This document outlines goals, definitions, challenges, monitoring, and medication options for sedation and analgesia in the pediatric intensive care unit (PICU). The goals of PICU sedation include patient comfort, pain control, anxiolysis, amnesia, and facilitating procedures. Common drugs utilized are opioids, benzodiazepines, chloral hydrate, barbiturates, ketamine, propofol, and neuroleptics. The document reviews dosing, administration, benefits, side effects and precautions for each class of medication.

1. SEDATION AND
ANALGESIA IN THE
PICU
Anand Bhutada
Pediatric Intensivist, Child Hospital, Nagpur

2. Outlines
 Introduction
 Goals
 Definitions
 The challenges of PICU sedation
 Sedation & Analgesia monitoring
 Medications options
 Suggested strategies
 Precautions
 Conclusion & key points

3. GOALS
 Patient comfort
 Control of pain
 Anxiolysis
 Amnesia
 Blunting adverse autonomic and hemodynamic
responses
 Facilitate nursing management
 Facilitate mechanical ventilation
 Avoid self-extubation or self injury
 Reduce oxygen consumption

4. SEDATION and ANALGESIA
 Inadequate analgesia and postsurgical
stress response is a metabolic, humoral,
and hemodynamic response following
injury or surgery
 This neuroendocrine cascade leads to
increased oxygen consumption,
increased carbon dioxide production,
and a generalized catabolic state with a
negative nitrogen balance

5. SEDATION/ANALGESIA
Sedation (seda/shun) [L. sedatio, to calm, allay].
The act of calming, especially by the
administration of a sedative, or the state of being
calm.
Analgesia (an-al-je/zi-ah) [G. insensibility, from an -
privative,negative + algesis, sensation of pain] A
condition in which nocioceptive stimuli are
perceived but are not interpreted as pain; usually
accompanied by sedation without loss of
consciousness.

6. IDEAL PICU
SEDATIVE/ANALGESIA
 Rapid onset
 Predictable duration
 No active metabolites
 Rapid recovery
 Multiple routes of delivery
 Easy to titrate
 Minimal cardiopulmonary effects
 Not altered by renal or hepatic disease
 No drug interactions
 Antidote available
 Wide therapeutic index

7. COMMON DRUGS UTILIZED
 Opiates (Narcotics)
 Benzodiazepines
 Chloral hydrate
 Barbiturates
 Ketamine
 Propofol
 Neuroleptics
 Paralytics

8. SITUATIONS REQUIRING
SEDATIVES/ANALGESIA
 MECHANICAL VENTILATION
 Respiratory failure
 Airway
 Neurological
 POST OPERATIVE
 HEAD INJURY
 PULMONARY HYPERTENSION
 PROCEDURES

25. FLACC (0-8 YR)

26. COMFORT SCALE SCORE
Intubated, Non paralysed patients (Target 17- 26)

31. OPIOIDS
 First line drugs
 Provide analgesia and sedation, NOT amnesia
 Act similarly as a class
 Produce delayed gastric emptying, decreased
intestinal peristalsis, and urinary retention
 Narcotic to be used:
 Morphine
 Fentanyl
 Methadone

32. OPIOIDS
ROUTE OF ADMINISTRATION
 IV
 Oral
 Transmucosal
 Transdermal
MODE OF ADMINISTRATION
 Intermittent/on demand (as necessary)
 Fixed interval
 Continuous infusion
 PCA

33. MORPHINE
 Gold standard
 Hepatic metabolism
 Depresses respiration by altering
chemoreceptor sensitivity to CO2
 Depresses rate over tidal volume
 Decreases sigh frequency
 Can cause hypotension due to histamine
mediated vasodilation
 Can block compensatory catecholamine
effect
 Prolonged clearance in neonates

34. MORPHINE
 IV intermittent
 0.1 mg/kg q 3 - 4
hrs
 IV continuous
 0.05 mg - 0.1
mg/kg/hr
 PO scheduled
 0.3 mg/kg q 3 - 4
hrs
 PCA dosing
 Initial dosing: 50
mcg/kg q 10 minutes
until comfortable
 Demand dose: 20 -
40 mcg/kg
 Lock-out period: 10
minutes
 4-hour limit: 0.25
mg/kg

35. FENTANYL
 Synthetic opiate, 100 x more potent than
morphine
 Rapid onset, highly lipophilic, rapidly crosses
BBB, redistributed to fatty tissue
 Short distribution t1/2, long elimination t1/2
 Minimal hemodynamic effect
 Blunts pulmonary vascular responses
 May produce “chest wall rigidity”, reversed with
relaxants or naloxone

36. FENTANYL
 IV intermittent dosing
 1-2 mcg/kg q 1-2 hrs
 IV continuous dosing
 1-2 mcg/kg/hr
 Transdermal delivery system available
 Not recommended in children less than 12
yrs
 25,50,75,100 mcg/hr
 25 mcg/hr is equivalent to 15 mg morphine
in a 24 hr period

37. METHADONE
 Equipotent to morphine
 Minimal hemodynamic effects
 Long half life
 Sedation and euphoric properties less
pronounced than morphine
 Useful for pain control and abstinence PO dosing
 0.1 mg/kg q 4-8 hrs
 50 % oral bioavailability
 Drug accumulation with repeated doses
caused by extensive protein binding

38. MODE OF ADMINISTRATION
 Intravenous bolus administration
 Common
 PRN - as needed
 Half-life of drug determines interval
 Disadvantage of pain breakthrough

39. IV BOLUS ADMINISTRATION

40. CONTINUOUS INFUSION
 Utilized when prolonged analgesia and
sedation needed
 Less labor intensive
 Better analgesia, initial bolus important
 Need for dedicated IV site

41. CONTINUOUS INFUSION

42. PCA
 Patient controlled analgesia
 Allows patient to administer a preset amount of
narcotic at preselected intervals
 Improved analgesia with decreased narcotic use
 Option to include low basal rate
 Nurse controlled analgesia
 Eliminates delay
 Allows delivery via a closed system

43. PCA

44. OPIATE SIDE EFFECTS
 RESPIRATORY DEPRESSION
 Reversal - Nalaxone (Narcan)
 Full reversal 0.1 mg/kg
 Partial reversal - titrate to effect
 Half life is less than narcotics
 IV,IM,Sub Q, ETT
 Abrupt reversal may result in nausea,
vomiting, sweating, tachycardia, increased
BP, and tremors

45. OPIATE SIDE EFFECTS
 Pruritis
 Individual variability and susceptibility,
alleviated by Benadryl
 Tolerance
 Need for increase in dose to achieve the
same effect
 Generally develops after 2-3 days of
frequent/continuous use
 Greater with fentanyl
 Treated by increasing the dose as needed

46. OPIATE SIDE EFFECTS
 DEPENDENCE
 Physiological state leading to abstinence
syndrome on withdrawal of the drug
 Generally develops after 7-10 days of
sustained use
 Symptoms include: mydriasis, tachycardia,
goose bumps, muscle jerks, vomiting, diarrhea,
seizures, fever, hypertension
 Treated with gradual withdrawal of the drug

47. OPIATE SIDE EFFECTS
 DEPENDENCE
 In general the longer the period of treatment the
longer the period of withdrawal needed
 A child is at risk for dependence if they have been on
narcotics for a week
 Finnegan scoring to monitor adequate weaning dose
 Weaning strategies can vary, typically 10% decrease
per day
 Do not spread the dosing interval beyond the
normal dosing interval, rather decrease the dose
 Can substitute methadone and wean q 48 hrs over
a longer time period

48. BENZODIAZEPINES
 First line agents for sedation
 Provide hypnosis, anxiolysis, antegrade amnesia,
and anticonvulsant activity
 NO ANALGESIA
 Can cause abstinence syndrome after prolonged
use
 Mechanism in the limbic system via the inhibitory
neurotransmitter, gamma aminobutyric acid
(GABA)

49. DIAZEPAM (VALIUM)
 Sedating, variable amnesia, anxiolytic
 Irritating to veins, pain in PIV
 Multiple active metabolites
 Advantage for prolonged sedation
 Disadvantage for rapid arousal
 Not recommended for continuous infusion
 Half-life 12-24 hrs
 Hepatic metabolism

50. LORAZEPAM (ATIVAN)
 Improved amnesia
 No active metabolites
 Half life 4-12 hours
 Metabolized by glucuronyl transferase
 Less influence from other drugs
 Better preserved in patients with liver
disease

51. MIDAZOLAM (VERSED)
 Rapid onset
 Rapid metabolism
 Good amnesia
 Water soluble, no pain
with injection
 Half life 2 -4 hours
 Hepatic metabolism with
renal excretion
 Active hydroxy-
metabolite may
accumulate
 Other routes of
administration
 Oral
 Nasal
 Rectal
 Sublingual
 Less absorption requiring
increase dosing

52. MIDAZOLAM
 Reports of dystonia and choreoathetosis
post infusion, greater risk in neonates
 Heparin decreases protein binding,
increases free drug
 Disadvantage cost
 20 kg patient
 80 $/day compared to Ativan = 30 $/day

53. BENZODIAZEPINES
SIDE EFFECTS
 RESPIRATORY DEPRESSION
 Less than narcotics, but potentiated with
narcotics
 Dose related
 Reversal
 Flumazenil - benzodiazepine receptor antagonist
 Contraindicated in patients with chronic benzo use
for seizures, mixed overdose, TCA’s - may result in
seizures

54. BENZODIAZEPINES
SIDE EFFECTS
 Choreoathetoid movement disorder
 Tolerance
 As with narcotics may need to increase dose
following 2-3 days use
 Dependence
 Withdrawal carefully and slowly if on greater
than 7-10 days
 Signs of withdrawal - tremor, tachycardia,
hypertension,
 Rapid withdrawal may promote seizures

55. CHLORAL HYDRATE
 Sedative hypnotic agent
 Metabolized in the liver to its active form,
trichlorethanol
 Half life 8-12 hours
 Oral or rectal administration
 Onset of action delayed
 Paradoxical reaction in some older children
 Not to exceed 100 mg/kg/day - i.e.: 25mg/kg/q 6 hrs
 Caution in children < 3 months or with hepatic
dysfunction

56. BARBITURATES
 Sedative
 Respiratory depression dose dependent
 Negative inotropic effects/vasodilation -
decreased cardiac output
 Decreased cerebral O2 consumption
 CBF
  ICP
 Anticonvulsant

57. BARBITURATES
 Useful in patients with increased ICP
 Short acting barbiturate useful for
sedation for procedure/imaging in
hemodynamically stable child
 Alkaline solution, often incompatible with
TPN or meds.

58. MAJOR TRANQUILIZERS
 Phenothiazine
 Thorazine
 Butyrophenones
 Droperidol
 Haloperidol
 Common in adult ICU, uncommon in PICU
 Side effects hypotension due to alpha blockade
and extrapyramidal effects
 At times useful in the difficult to sedate child

59. KETAMINE
 Dissociative IV anesthetic
 Good amnesia and somatic analgesia
 Anesthetic state classically described as a functional
and electrophysiological dissociation between the
thalamoneocortical and limbic system
 Chemically related to phencyclidine and
cyclohexamine
 Water and lipid soluble
 Quickly crosses blood-brain barrier, < 30 seconds

60. KETAMINE
 Redistribution half-life 4.7 minutes
 Elimination half-life 2.2 hours
 Clinical effects evident within one minute, resolution within
15 - 20 minutes of dose
 Bronchodilation
 Sialagogue -“promoting the flow of saliva”
 Administer with an anticholinergic
 Atropine or Robinol
 Minimal net hemodynamic effect
 Negative inotrope
 Central effect - HR, SVR
 Good choice in shock or status asthmaticus

61. KETAMINE
 Risk of laryngospasm
 Risk of emesis/aspiration
 Increases ICP , globe pressure
 Seizure inducing
 Emergent reactions, hallucinations
 Improved with administration of a benzodiazepine
 IM: 2 - 4 mg/kg dose q 30 minutes - 1 hour
 IV
 Intermittent dosing
 1 -2 mg/kg dose q 30 minutes to 1 hr
 Continuous dosing
 1 - 3 mg/kg/hr

62. PROPOFOL
 Sedative/hypnotic
 Dose dependent - conscious sedation to
general anesthesia
 Rapid onset (20-50 seconds)
 Quick recovery ( within 30 minutes of d/c)
 Lack of active metabolites
 Metabolized in liver
 Excreted in urine

63. PROPOFOL
 Lipid emulsion, reports of anaphylaxis
 Soybean oil, egg lecithin, and glycerol
 Decreased ICP, may lower CPP
 Decreased sympathetic tone
 Contraindicated in hemodynamically
unstable
 Moderate respiratory depression
 Pain with injection/infusion site
 Improved with use of 1% lidocaine
 0.5 mg/kg

64. PROPOFOL
 Neurologic sequela
 Opisthotonic posturing
 Myoclonic movements
 Metabolic acidosis reported with use > 24 hrs
 Contraindicated for long term use
 Doses
 1 - 3 mg/kg induction
 20 - 100 mcg/kg/min
 Increase infusion rate 5-10 mcg/kg/min increments
of 5 - 10 minutes