Critical Care Medicine

Sedation and analgesia approaches for children

Sedation and Analgesia Approaches for Critically Ill Children

1. Description of the problem

Sedation and analgesia are needed in critically ill children to minimize anxiety and pain. Most will do well with a combination of a benzodiazepine (most commonly midazolam or lorazepam) with opiates (most commonly fentanyl or morphine) via intermittent doses or continuous infusions.

Tolerance, dependency, and symptoms of withdrawal are concerns with long-term use.

Analgesia should be provided to treat painful or noxious stimuli (related to their disease and/or treatment) in all critically ill children. Assessment of pain and response to therapy should be performed regularly. Critically ill patients (and pediatric patients, in particular) may not be able to verbally communicate pain or response. As such, subjective observation of pain and physiologic parameters (heart rate [HR], blood pressure [BP], and respiratory rate [RR]) should be documented.

Fentanyl, hydromorphone, and morphine are recommended when intravenous (IV) analgesics are needed.

Sedation is considered of particular importance in the pediatric patient owing to added anxiety and fear that may be difficult to manage. Benzodiazepines (particularly midazolam and lorazepam) are the most commonly used sedatives. Dexmedetomidine is gaining increased use. Sedation should be started in conjunction with (not without) adequate analgesia. Propofol is not recommended for prolonged sedation use in pediatric patients.

Sedation and analgesia should be routinely monitored in a manner that is consistent across all caregivers. Regular assessment and modification of therapies is imperative. A validated assessment scale is highly recommended. A modification of the Ramsay scale is proposed in Table I.

Table I.

Modified Ramsay Scale for Intubated Pediatric Patients
Level Description Definition
0 Unresponsive Does not move with noxious stimuli.OR if on NMB: HR and MAP < baseline
1 Responsive to noxious stimuli Opens eyes or raises eyebrows or turns head toward stimulus, or moves limbs when noxious stimulus is applied.OR if on NMB: HR and MAP at baseline
2 Responsive to touch or name Opens eyes or raises eyebrows or turns head toward stimulus or moves limbs when touched or name is loudly spoken.OR if on NMB: HR and MAP at baseline
3 Calm and cooperative No external stimulus is required to elicit movement and patient is adjusting sheets or clothes purposefully and follows commands.OR if on NMB: HR and MAP with infrequent elevations 20% above baseline
4 Restless and cooperative No external stimulus is required to elicit movement and patient is picking at sheets or tubes or uncovering self and follows commands.OR if on NMB: HR and MAP with infrequent elevations >20% above baseline
5 Agitated No external stimulus is required to elicit movement AND attempting to sit up AND does not consistently follow commands.OR if on NMB: HR and MAP with frequent elevations 20% above baseline
6 Dangerously agitated and uncooperative No external stimulus is required to elicit movement AND patient is pulling at tubes or lines OR thrashing OR trying to climb out of bed AND does not calm down when asked.OR if on NMB: HR and MAP at sustained elevations >20% above baseline

Sedation and analgesia should be titrated to effect with a mechanism for tapering or providing daily interruptions to avoid over sedation and/or minimize physical dependence. The use of a sedation protocol is recommended. A protocol for sedation and analgesia of intubated pediatric patients is proposed in Figure 1.

Figure 1.

Intravenous sedation/analgesia protocol for intubated pediatric patients

Daily withholding of sedation/analgesia in intubated pediatric patients is recommended unless medically contraindicated. Contraindications include infusions started less than 24 hours, immediately perioperative or peri-procedure, critical airway, unstable respiratory or hemodynamic status, elevated intracranial pressure, or on NMB infusion. Once patient's sedation is above the desired level (as defined in modified Ramsay scale above) infusions are restarted at one half the prior infusion rate.

2. Emergency Management

Fentanyl (or alternatively, hydromorphone) is ideal for rapid onset of analgesia in the acutely distressed patient. It is also preferred in patients with hemodynamic instability or renal insufficiency. Morphine is preferred when intermittent therapy is required due to its longer duration of effect.

Midazolam or diazepam are effective for rapid sedation of acutely agitated patients.

Lorazepam is preferred for the sedation of most critically ill children via intermittent IV dosing or continuous infusion. Midazolam should be considered for infants younger than 6 months of age (due to concern for hepatic immaturity), when concern exists for the metabolism of propylene glycol (eg, hepatic dysfunction), or when the patient will be intubated for less than 48 hours. Midazolam results in unpredictable awakening and time to extubation when used as an infusion longer than 48 to 72 hours.

Drugs and dosages

Non-opioid Analgesics

- Acetaminophen: 10 to 15mg/kg (max 650mg) PO/PR q 4 h

- Ibuprofen: 5 to 10mg/kg (max 600mg) PO q 6 h

Opioid Analgesics

- Fentanyl: 0.5 to 2mcg/kg (max 100mcg) IV bolus every 0.5 to 2 h, or infusion rate 0.5 to 5mcg/kg/h (max 250mcg/h)

- Hydromorphone: 0.02mg/kg (max 1mg) IV bolus every 0.5 to 2 h, or infusion rate 0.004mg/kg/h (max 0.3mg/h)

- Morphine: 0.05 to 0.1mg/kg (max 5mg) IV bolus every 2 h, or infusion rate 0.025 to 0.3mg/kg/h (max 10mg/h)

Intermittent Sedative Dosing

- Midazolam 0.05 to 0.1 (max 5mg) IV q 2 to 4 h

- Lorazepam 0.05 to 0.1 (max 2mg) IV q 4 to 6 h

- Pentobarbital 0.5 to 1mg/kg

Common Sedative infusion Dosing Ranges

- Midazolam 0.05 to 0.2mg/kg/h

- Lorazepam 0.025 to 2mg/kg/h

- Pentobarbital 1 to 2mg/kg/h

- Dexmedetomidine 0.25 to 0.7mcg/kg/h

- Ketamine 0.5 to 2mg/kg/h.

What's the evidence?

Yaster, M, Easley, RB, Brady, KM, Nichols, DG. Rogers' textbook of pediatric intensive care. Wolters-Kluwer. 2008. pp. 136-55.

(Provides a thorough review of pain and sedation management in the critically ill child.)

Jacobi, J, Fraser, GL, Coursin, DB, Riker, RR, Fontaine, D, Wittbrodt, ET. "Clinical practice guidelines for the sustained use of sedatives and analgesics in the critically ill adult". Crit Care Med. vol. 30. 2002. pp. 119-41.

(The 2002 guidelines published in CCM provide an excellent review of the data with specific recommendations for management of analgesia, sedation, withdrawal, delirium, and sleep. Though the data and results are specific for adults, they provide an excellent template for development of a pediatric guideline.)

Kress, JP, Hall, JB. "Sedation in the mechanically ventilated patient". Crit Care Med. vol. 34. 2006. pp. 2541-6.

(The 2002 guidelines published in CCM provide an excellent review of the data with specific recommendations for management of analgesia, sedation, withdrawal, delirium, and sleep. Though the data and results are specific for adults, they provide an excellent template for development of a pediatric guideline.)]

Kress, JP. "Daily interruption of sedative infusions in critically ill patients undergoing mechanical ventilation". N Engl J Med. vol. 342. 2000. pp. 1471-7.

(This landmark study shows the benefit of daily sedative interruption in ventilated adult patients. Though controversial in pediatrics, our center adopted the routine use of daily interruptions in our ventilated pediatric patients in 2005.)
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