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Sedation & Analgesia - procedural sedation in PICU

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Before undertaking sedation

Step One Before undertaking sedation, you need to have answered the following questions:
  1. What is the patients current level of sedation and analgesia?
2. Will the procedure be painful?
3. What sedation/analgesia will the patient require and will they tolerate it?
4. What is my plan for undersedation or oversedation?
Step Two Decide on what sedation/analgesia is appropriate for the patient and the planned procedure:
  No additional sedation/analgesia
Sedation only
Analgesia only
Combined sedation and analgesia
Step Three What level of sedation will the patient require? #
  None - distraction will suffice
Conscious sedation
Unconscious sedation/general anaesthesia
Step Four Assemble ALL personnel, drugs, and equipment required to carry out the procedure safely *


# Anaesthetists differentiate between unconscious sedation and general anaesthesia but in reality there is little difference between the two. Conscious sedation involves being able to communicate with the patient during the procedure and is most suitable for older children. No sedation may be applicable for some relatively painless, brief procedures if distraction is used.

* This will depend upon the level of sedation required.

Management of patients for Unconscious Sedation/General Anaesthesia

  • These patients should be fasted as per the PICU pre-op fasting guidelines.
  • Make sure there are no contraindications to the selected modality.
  • Prepare airway support equipment and appropriate CVS support drugs for all cases.
  • It may be preferable in some cases to give the patient a GA with intubation and ventilation

Ketamine

A good agent that produces dissociation and analgesia while maintaining CVS stability.

Small doses are given for minor procedures (0.5mg/kg IV) such as chest drain removal while larger doses (up to 2mg/kg) may be required for longer and more painful procedures eg chest drain insertion.

It has a short half-life (10 minutes) so you will need to give top up doses of 0.5mg/kg. It can be given IM or orally at a dose of 5mg/kg. (Orally it has a bitter taste and needs disguising with flavouring).

Precautions:

  • Do not use in children < 3 months as it can cause apnoea.
  • If using in older children (> 10yrs) ketamine can cause dysphoria ++ so it is best avoided.
  • Important ADRs are salivation, purposeless movement, laryngospasm, hypertension, dysphoria, raised ICP/IOP and occasionally hypotension.

Propofol

A short acting anaesthetic agent that is not an analgesic and can cause CVS instability due to vasodilatation and negative inotropy.

For minor procedures a bolus dose of 1mg/kg IV followed by an infusion of 1-4mg/kg/hr will provide sedation BUT NO analgesia. Local anesthesia plus propofol is a good combination. Propofol plus fentanyl or morphine can be used but beware apnoea. Repeat boluses can be given (e.g. 0.5mg/kg every 15mins) but this can create wild swings in the level of sedation so it is best given by infusion.

Precautions:

  • Do not use in shocked patients - can cause severe hypotension.
  • May cause apnoea even in small doses

Sevoflurane

Pleasant smelling volatile anaesthetic agent that is given by inhalation from a metered vaporiser.

Minimum Alveolar Concentration (MAC) = 2-3. Useful for PICU procedures. Should only be given by someone familiar with its use. No analgesic effect but depth of anaesthesia can be altered to account for painful stimuli. Rapid onset and offset.

Management of patients for Conscious Sedation

Useful agents are chloral hydrate, midazolam +/- morphine or fentanyl.

For non-painful procedures such as MRI, CTs, and echocardiograms:

Chloral hydrate (30-50mg/kg) is a good drug as it can be given orally and has been proved to be safe in small infants. Midazolam is less reliable but can be given orally at a dose of 0.5-0.75mg/kg up to a maximum of 15mg or IV 0.1-0.2mg/kg. It does have the advantage of producing profound amnesia.

Small infants may settle with a feed and swaddling and require no sedation.

MRIs take 40-60mins and do require that the patient stays very still. Some neonates will sleep through a scan. Older children often need a general anaesthetic.

For short but painful procedures:

Topical anaesthesia (+/- a dose of oral or intravenous analgesia) and distraction may suffice. Morphine can be given IV as per protocol. Fentanyl is shorter acting than morphine and can be given IV at a dose of 0.5mcg/kg.

Some patients may require sedation and analgesia - be wary of giving two agents as this increases the risk of adverse effects especially oversedation resulting in apnoea +/- loss of airway leading to desaturation.

Sucrose is widely used in neonates - it is effective but is not an analgesic. It is thought to work by distracting the patient

Dexmedetomidine

Unique central alpha-2 agonist with much high receptor affinity than clonidine. It is a powerful sedative with analgesic properties that does not depress respiration.

Can be used for procedural sedation but is very expensive.

Patients who are already on it may not require additional sedation for procedures. Major ADRs are hypertension and bradycardia.

Patient Needs Procedure Performed in PICU

Assess patient's current level of sedation and analgesia and need for additional sedation/analgesia for procedure

Unconscious Sedation Conscious Sedation +/- Analgesia No Sedation
Ketamine 0.5-1mg/kg
Propofol 1mg/kg
Sevoflurane
Chloral Hydrate 50mg/kg
Midazolam 0.1-0.2mg/kg
Fentanyl 0.5mcg/kg
Optimise Analgesia

Neonates:
Feed and wrap, +/- sucrose
Older:
Video, games, tablet, hypnosis
Be prepared to support airway, breathing and CV system.

If using propofol and procedure painful, add fentanyl 0.5mcg/kg. For prolonged procedures infuse propofol at 1-3mg/kg/hr (higher rate if using as general anaesthetic 6-12mg/kg/hr)

Ketamine 0.5mg/kg for minor procedures.
1mg/kg plus repeat doses Q10-20 mins for longer procedures.
Caution in older children as dysphoric reactions can be very distressing.
For brief painful procedures consider dose of opioid only, e.g. morphine per protocol OR fentanyl 0.5mcg/kg. Opioid can be added to the sedative for painful procedures BUT there is increased risk of airway and breathing problems. For repeat procedures in older children involve the child in what works and involve the Play Specialist.


References

  1. Cote CJ, Lerman J, and Anderson BJ; A Practice of Anesthesia in Infants and Children; eds 2013 Elsevier Saunders p993-1011.
  2. Cravero JP and Blike GT; Pediatric Sedation; Curr Opin Anaesth 2004; 17; p247-251.
  3. Kaynan Doctor et al; An update on pediatric hospital based sedation; Curr Opin Peds June 2013; 25 (3); p310-316.
  4. Krauss BS et al; Procedural Sedation and Analgesia in Children; NEJM Apr 10 2014; e23 (1-6).

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Document Control

  • Date last published: 06 March 2015
  • Document type: Clinical Guideline
  • Services responsible: Paediatric Intensive Care Unit
  • Editor: John Beca
  • Review frequency: 2 years