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Chest drain removal protocol in PICU - Analgesia

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Analgesia for chest drain removal

Chest drain removal in children can be distressing. Analgesia should be provided for all fully awake patients. To be rapidly and reliably effective, analgesia needs to be given intravenously. Intravenous ketamine is an good agent in that it provides intense analgesia and amnesia and some degree of immobility while not adversely affecting the airway or circulation BUT it will cause an increase in secretions and in older children may cause distressing dysphoria.

Beware of giving sedation to patients who are already obtunded with analgesics or sedatives. Patients who are heavily sedated due to prior sedatives and/or opioids should be reviewed by medical staff before further analgesia is given.


Age < 1 year
Do not cease feeding.
Give bolus of morphine (20mcg /kg) if required and remove drains.
Age > 1 year
If using Ketamine cease feeds - 6 hours food/formula. 2 hours clear fluid.
If using Fentanyl patient does not need to be NPO.
<10 years       Ketamine 0.5mg / kg IV
10 years +      Fentanyl 0.5mcg / kg IV

Documentation - All analgesia needs to be charted by medical staff on the drug chart and signed for when given. This includes boluses from infusion pumps.

Preparation and Equipment

Patients receiving ketamine should be NPO as follows:

  • Food/formula 6 hours
  • Breast milk     4 hours
  • Clear fluids     2 hours

This means that if the likelihood of drain removal is high in the morning do not give the patient their early morning feed/breakfast.

Child is on a continuous ECG and saturation monitor.

All emergency equipment available at bedside (suction and airway equipment available and working).

Medical officer informed and is available in PICU prior to giving ketamine.

Discharge to Ward

Child needs to be alert and rousable prior to discharge.

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Document Control

  • Date last published: 05 March 2015
  • Document type: Clinical Guideline
  • Services responsible: Paediatric Intensive Care Unit
  • Owner: Dave Buckley
  • Editor: John Beca
  • Review frequency: 2 years