Managing pain and anxiety in children undergoing diagnostic or therapeutic procedures or to maintain comfort and safety while mechanically ventilated can be challenging.
Decisions regarding pain and sedation management must include a comprehensive evaluation of the child’s acute and chronic medical conditions, emotional and cognitive capabilities, and age, as well as inclusion of appropriate assessment data and comprehensive knowledge of agents and their potential risk factors.
Defined as an unpleasant, subjective, sensory, and emotional experience associated with actual or potential tissue damage.
Classification.
Nociceptive: acute pain defined as either somatic (e.g., skin, bone, or connective tissue) or visceral (e.g., internal organs).
Neuropathic: pain due to nerve damage.
Functional: pain due to the abnormal presence of, or inappropriate activation of, abnormal pain pathways within the nervous system.
Acute: short lived and occurs with an injury or near the injured tissue due to an adverse chemical, thermal, or mechanical stimulus.
Chronic: any pain (e.g., nociceptive, neuropathic, or functional) that lasts longer than 1 month.
Evaluation.
Critical to the management of pain in acutely and critically ill children.
Tools include self-report, observation, and physiologic-based instruments.
Examples include FACES and numeric rating scale self-report tools and the face, legs, activity, cry, and consolability (FLACC) behavioral scale.
Agents and reversal (Table 14.1).
Local anesthetics.
Topical.
Can be used for minor painful procedures or as adjunct medication for invasive procedures.
Allow 30 to 60 minutes for skin penetration with a duration of effect <4 hours.
Systemic absorption may occur; monitor for lidocaine toxicity if used over significant body surface area.
Examples include lidocaine/prilocaine (EMLA™) and lidocaine (LMX™) creams.
Intradermal.
Can be used for minor painful procedures or adjunct medication for invasive procedure.
Action is within 1 to 2 minutes with duration <1 hour.
Examples include intradermal lidocaine and buffered lidocaine 1% in jet injector.
Procedural pain management considerations.
Purpose: use of sedative, analgesic, and dissociative medications to provide anxiolysis, amnesia, analgesia, sedation, and motor control during painful or unpleasant diagnostic or therapeutic procedures.
Definitions.
Minimal sedation: state of sedation that provides anxiolysis.
Moderate sedation: drug-induced depressed consciousness, but patient is able to respond purposefully to verbal commands or light physical stimulation.
Deep sedation: drug-induced depressed consciousness from which patient is not easily aroused, and has partial or complete loss of protective reflexes.
General anesthesia: drug-induced loss of consciousness; patient is not arousable even to painful stimuli.
Presedation evaluation includes the following:
Length of procedure: influences choice of short-acting versus long-acting medications.
Painful versus nonpainful procedure: influences selection of agents (e.g., choosing a sedative for diagnostic study versus analgesic and sedative for painful procedure).
Location of procedure: Availability of resources influences choice of agents and number of doses administered.
TABLE 14.1 Sedatives, Analgesics, and Neuromuscular Blocking Agents and Available Reversal Agents
Medication
Dosing
Significant Side Effects
Sedatives
Midazolam
Anxiolysis or amnesia:
Neonatal:
IV/IM: 0.05-0.1 mg/kg/dose over 5 min.
Child:
IV: 0.025-0.15 mg/kg/dose.
IM: 0.1-0.15 mg/kg/dose, maximum dose 10 mg.
Intranasal: 0.2-0.3 mg/kg/dose.
Adult:
IM: 0.07-0.0.8 mg/kg/dose.
IV: 0.02-0.04 mg/kg/dose.
Procedural Sedation:
Neonatal:
IV/IM: 0.05-0.1 mg/kg/dose over 5 min.
Child:
IV: 0.025-0.15 mg/kg/dose.
IM: 0.1-0.15 mg/kg, maximum dose 10 mg.
Intranasal: 0.2-0.3 mg/kg/dose.
Adult: 0.5-2 mg IV.
Mechanical Ventilation:
Neonatal gestational age 32 wk:
IV continuous infusion: 0.03 mg/kg/hr
Neonatal gestational age >32 wk:
IV continuous infusion: 0.06 mg/kg/hr.
Child:
IV continuous infusion:
Load with 0.05-0.2 mg/kg/dose.
Infusion: 0.06-0.12 mg/kg/hr.
Adult:
IV continuous infusion:
Load with 0.01-0.05 mg/kg/dose.
Infusion: 0.02-0.1 mg/kg/hr.
Titrate medications to achieve goal sedation.
Hypotension, bradycardia, cardiac arrest, respiratory depression or arrest.
Lorazepam
Sedation:
Child:
IV/PO: 0.02-0.1 mg/kg/dose every 4-8 hr. Adult:
PO: 1-10 mg/day divided in 2-3 doses.
Preoperative:
IV: 0.04 mg/kg/dose, maximum dose 4 mg.
IM: 0.05 mg/kg/dose, maximum dose 4 mg.
Procedural sedation:
Child:
PO/IV/IM: 0.02-0.09 mg/kg/dose.
Adult:
PO: 1-10 mg/day divided in 2-3 doses.
Preoperative:
IV: 0.04 mg/kg/dose, maximum dose 4 mg.
IM: 0.05 mg/kg/dose, maximum dose 4 mg.
Mechanical Ventilation:
Child:
IV/PO: 0.02-0.1 mg/kg every 4-8 hr.
Infusion: 0.025-0.2 mg/kg/hr (Tobias, 1995).
Titrate medications to achieve goal sedation.
Respiratory depression, apnea, bradycardia, and circulatory collapse.
High dose or long-term use of parenteral formulation may result in toxicity (lactic acidosis, osmotic gap, and renal failure) as related to formulation with polyethylene glycol.
Diazepam
Procedural Sedation:
Child:
PO: 0.2-0.3 mg/kg/dose.
IV: 0.05-0.1 mg/kg/dose.
Sedation/anxiolysis:
PO: 0.12-0.8 mg/kg/day divided every 6-8 hr.
IV/IM: 0.04-0.3 mg/kg/dose to maximum 0.6 mg/kg within 8 hr.
Adolescent Sedation:
PO: 10 mg.
IV: 5 mg, may repeat 2.5 mg.
Adult Sedation:
PO/IV/IM: 2-10 mg/day 3-4 times per day.
Intubated patient:
IV: 0.03-0.1 mg/kg every 30 min to 6 hr.
Sudden hypotension, cardiac arrest, laryngospasm, and apnea or respiratory depression may result from rapid IV push.
Use with caution in neonates: parenteral and rectal gel formulations contain benzoic acid, benzyl alcohol, and sodium benzoate.
Etomidate
Procedural sedation:
Child:
IV: 0.1-0.3 mg/kg/dose.
Adult:
IV: 0.2-0.6 mg/kg/dose for anesthesia induction.
Apnea, laryngospasm, bradycardia, tachycardia, hypertension, hypotension, and myoclonus.
Adrenal suppression may result after a single dose.
Pentobarbital
Procedural sedation:
Child:
IM: 2-6 mg/kg/dose, maximum dose 100 mg/dose.
IV: 1-2 mg/kg/dose, repeat 1-2 mg/kg every 3-5 min until desired state to maximum 6 mg/kg.
Infant:
IV 1-3 mg/kg/dose to maximum of 100 mg until asleep.
PO:
<4 y/o: 3-6 mg/kg/dose, maximum dose 100 mg.
4 y/o: 1.5-3 mg/kg/dose, maximum dose 100 mg.
Adolescent:
IV: 100 mg prior to procedure.
Hypnotic:
Child:
IM: 2-6 mg/kg/dose.
Adult:
IV: 100 mg every 1-3 min, total dose 500 mg.
IM: 150-200 mg.
Failed sedation in intubated infants, children, and adolescents:
1 mg/kg/hr IV continuous infusion.
Respiratory depression, apnea, laryngospasm, arrhythmias, bradycardia, hypotension, syncope, and angioedema.
Analgesics
Morphine
Pain management:
Neonatal:
PO: 0.08 mg/kg/dose.
IV/IM: 0.05-0.1 mg/kg/dose.
Infants ≤6 mo:
PO: 0.08-0.1 mg/kg/dose.
IV: 0.025-0.03 mg/kg/dose.
Infants >6 mo, Child, and Adolescent:
PO: 0.2-0.5 mg/kg/dose every 4-6 hr PRN.
If patient weight >50 kg, dose 15-20 mg every 3-4 hr.
IV/IM/SQ: 0.05 mg/kg/dose: range, 0.1-0.2 mg/kg/dose.
If patient weight >50 kg, dose 5-8 mg every 3-4 hr.
Adults: 10-30 mg every 4 hr PRN (variable according to formulation).
IV continuous infusion:
Neonatal: 0.01 mg/kg/hr.
Child <50 kg: 0.01-0.04 mg/kg/hr, titrate as needed.
Child 50 kg: 1.5 mg/hr.
Adult: 0.8-10 mg/hr.
Epidural continuous infusion:
Child: 0.001-0.005 mg/kg/hr.
Adult: Dose varies based on specific medication.
May titrate to effect.
Respiratory depression, severe hypotension, syncope, peripheral vasodilation, orthostatic hypotension, noncardiogenic pulmonary edema, CNS depression, increased intracranial pressure, and histamine release.
Hydromorphone
Infants >6 mo and >10 kg:
PO: 0.03 mg/kg/dose every 4 hr PRN.
IV: 0.01 mg/kg/dose every 3-6 hr PRN.
IV continuous infusion: 0.003-0.005 mg/kg/hr.
Children and Adolescents <50 kg:
PO: 0.03-0.08 mg/kg/dose every 3-4 hr PRN.
IV: 0.015 mg/kg/dose every 3-6 hr PRN.
Children and Adolescents >50 kg:
PO: 1-2 mg/dose every 3-4 hr PRN.
IV: 0.2-0.6 mg/dose every 2-4 hr PRN.
IM/SQ: 0.8-1 mg every 4-6 hr PRN.
Rectal: 3 mg every 4-8 hr PRN.
Adults:
PO: 2-4 mg/dose every 4-6 hr PRN; may titrate dose to effect.
IV: 0.2-1 mg/dose every 2-3 hr PRN.
IM/SQ: 0.8-1 mg every 3-4 hr PRN.
Rectal: 3 mg every 6-8 hr PRN.
May titrate to effect.
Respiratory depression, especially in patients with preexisting respiratory conditions. Hypotension (may be exaggerated in patients with hypovolemia), orthostatic hypotension, peripheral vasodilation, CNS depression, increased intracranial pressure, and histamine release.
Fentanyl
Sedation/analgesia:
Neonates and young infants:
IV: 1-4 µg/kg/dose, may repeat every 2-4 hr.
IV continuous infusion:
0.5-1 µg/kg/hr; titrate to effect.
Children:
IV: 1-2 µg/kg/dose.
IV continuous infusion:
1-3 µg/kg/hr; titrate to effect.
Adolescent:
IV: 0.5-1 µg/kg/dose, may repeat at 30-60 min; or 25-50 µg, may repeat 4-5 times with 25 µg.
IV continuous infusion:
1-2 µg/kg/hr; titrate to effect.
Pain Management (unlabeled use):
Adult:
IV: 50-100 µg/dose every 1-2 hr PRN.
Intubated Adult:
IV continuous infusion: 50-700 µg/hr.
May titrate to effect.
May cause life-threatening respiratory depression and/or hypotension.
Chest wall rigidity, orthostatic hypotension, arrhythmia, syncope, bradycardia, and CNS depression.
Methadone
Pain management:
Children:
IV: 0.1 mg/kg/dose every 4 hr for 2-3 doses, titrate to every
6-12 hr as needed (weaning may be required with long-term therapy due to tissue accumulation).
PO/IM/SQ:
0.1 mg/kg/dose every 4 hr for 2-3 doses, titrate to every
6-12 hr as needed.
Maximum dose: 10 mg/dose.
Adult:
PO: 2.5-10 mg interval range every 8-12 hr.
IV/IM/SQ: 2.5 mg every 8-12 hr.
Iatrogenic narcotic dependency: individualize dosing for patient.
Life-threatening respiratory depression, prolonged QT interval or torsade de pointes, death, cardiac arrhythmias, increased intracranial pressure, and histamine release.
Dexmedetomidine
Sedation (ICU/Procedural):
Child:
IV load: 0.5-1 µg/kg/dose.
IV continuous infusion: 0.2-0.7 µg/kg/hr.
Use caution with continuous infusions >24 hr as no randomized controlled trial has been done evaluating this application in children.
ICU sedation:
Adult:
1 µg/kg IV load over 10 min with infusion 0.2-0.7 µg/kg/hr.
Procedural sedation:
Adult:
0.5-1 µg/kg IV load with 0.2-1 µg/kg/hr during procedure.
Respiratory acidosis, pulmonary edema, bradycardia, sinus arrest, hypotension, and hypertension.
Clonidine
Child
PO: 2 µg/kg/dose every 4-6 hr; increase over days as needed to range 2-4 µg/kg/dose.
Epidural: 0.5 µg/kg/hr; titrate to effect.
Transdermal: Convert oral dosing to patch.
When combined with stimulants, patients may suffer serious cardiovascular events or sudden death
Hypotension, CHF, and sedation.
Ketamine
Sedation:
Child:
PO: 6-10 mg/kg/dose 30 min preprocedure.
IM: 3-7 mg/kg/dose.
IV: 0.5-2 mg/kg/dose.
IV continuous infusion:
5-20 µg/kg/min; titrate to effect.
Adult:
IM: 2-4 mg/kg/dose.
IV: 0.2-0.75 mg/kg/dose.
IV continuous infusion: 2-7 µg/kg/min.
Respiratory depression, laryngospasm, hypersalivation, tachycardia, hypertension, hypotension, increased cerebral blood flow, and postanesthetic delirium.
Propofol
Anesthesia:
Child:
IV: 2.5-5 mg/kg/dose over 20-30 s, then 125-150 µg/kg/min for
10-15 min, decrease to goal level of sedation
(usual dose is 125-150 µg/kg/min).
Adult ICU sedation:
IV: 100-150 µg/kg/min or 0.5 mg/kg/dose, then continuous infusion 0.3-3 mg/kg/hr.
Continuous infusion of propofol in children has led to propofol infusion syndrome (severe metabolic acidosis, hyperkalemia, lipemia, rhabdomyolysis, hepatomegaly, cardiac failure, and kidney failure); not recommended to use this way.
Significant hypotension, bradycardia, hypothermia, and respiratory depression in the patient without an artificial airway.
Neuromuscular Blocking Agents
must be prepared for airway management when dosing
Succinylcholine
All age groups:
IM: 3-4 mg/kg/dose (not to exceed 150 mg)
Infants:
IV: 2 mg/kg/dose
Child:
IV: 1 mg/kg/dose
Adult:
IV: 0.6 mg/kg/dose
RSI:
Adult:
IV: 1-1.5 mg/kg/dose
Apnea, asystole, hypotension, arrhythmias, and myoglobinuria. Rhabdomyolysis when used in patients with undiagnosed myopathy.
May trigger malignant hyperthermia.
Cisatracurium
Children 1-23 mo:
IV: 0.15 mg/kg/dose over 5-10 s
Children 2-12 y/o:
IV: 0.1-0.15 mg/kg/dose over 5-10 s
IV continuous infusion: 1-4 µg/kg/min
Children >12 y/o:
IV: 0.15-0.2 mg/kg/dose
IV continuous infusion: 1-4 µg/kg/min
RSI:
Adults:
IV: 0.15-0.2 µg/kg/min
IV continuous infusion: 1-3 µg/kg/min
Bronchospasm, hypotension, and flushing.
May get acute quadriplegic myopathy syndrome or myositis ossificans with prolonged use.
Pancuronium
Neonates and infants:
IV: 0.1 mg/kg/dose
IV continuous infusion: 0.4-0.6 µg/kg/min
Children:
IV: 0.15 µg/kg/kg
Continuous infusion: 0.5-1.7 µg/kg/min
Adolescents and Adults:
IV: 0.15 mg/kg/dose every 30-60 min PRN
IV continuous infusion: 0.4-0.6 µg/kg/min
Bronchospasm, wheezing, increased blood pressure and cardiac output, tachycardia (use with caution in patients with baseline tachycardia or risk for tachyarrhythmias).
Excessive salivation and profound muscle weakness.
May get acute quadriplegic myopathy syndrome or myositis ossificans with prolonged use.
Rocuronium
RSI:
Children:
IV: 0.6-1.2 mg/kg/dose
IV continuous infusion: 7-12 µg/kg/min
Adult:
IV: 0.6-1.2 mg/kg/dose
IV continuous infusion: 4-16 µg/kg/min
Bronchospasm, increased pulmonary vascular resistance, hypertension, hypotension, tachycardia, and shock.
Vecuronium
Neonate:
IV: 0.1 mg/kg/dose
Infant (7 wk-1 y):
IV: 0.1 mg/kg/dose
IV continuous infusion: 1-1.5 µg/kg/min
Child:
IV: 0.1 mg/kg/dose
IV continuous infusion: 1.5-2.5 µg/kg/min
Adult:
IV: 0.1 mg/kg/dose
IV continuous infusion: 0.8-1.7 µg/kg/min
Bradycardia, circulatory collapse, and edema.
May get acute quadriplegic myopathy syndrome or myositis ossificans with prolonged use.
Reversal Agents
Flumazenil (benzodiazepine reversal agent)
Child:
Initial dose: 0.01 mg/kg over 15 s, may repeat 0.01 mg/kg after
45 s, then every minute for maximum cumulative dose 0.05 mg/kg for maximum dose 1 mg
Adult:
0.2 mg over 15 s, repeat 0.2 mg after 45 s, then every 60 s up to total 1 mg. Maximum dose 3 mg in 1 hr
Black Box Warning: High-risk patients (physically dependent on benzodiazepines, repeated doses of parenteral benzodiazepines, overdose, mixed-drug overdose, severe hepatic impairment) may have seizures when flumazenil is used.
May result in seizures in patients dependent on medication
Patients may experience resumption of sedation after flumazenil has worn off.
Naloxone (Narcotic reversal agent)
Total reversal of narcotic effect:
Infant, child 5 y/o:
IV: 0.1 mg/kg/dose
Child >5 y/o:
2 mg/dose
PALS guidelines recommend 2-3 times the IV dose via IM, SQ, or ET route
Adult:
0.4-2 mg/dose every 2-3 min
Post anesthetic narcotic reversal:
Infant, child, adolescent:
IV: 0.001-0.005 mg/kg/dose and titrate to effect
Adult:
IV 0.1-0.2 mg every 2-3 min
May precipitate withdrawal.
Hypertension, hypotension, ventricular arrhythmias, cardiac arrest.
Neostigmine (nondepolarizing neuromuscular blocking reversal agent)
Infant:
IV: 0.025-0.1 mg/kg/dose
Child:
IV: 0.025-0.8 mg/kg/dose
Adult: 0.5-2.5 mg (do not exceed total dose 5 mg)
Administer with atropine or glycopyrrolate to limit salivation
Bronchoconstriction, laryngospasm, dyspnea, respiratory arrest, bradycardia, asystole, AV block, agitation, seizures, and salivation.
PO, per os (oral); IV, intravenous; IM, intramuscular; SQ, subcutaneous; PR, per rectum; CHF, congestive heart failure; CNS, central nervous system; NMBA, neuromuscular blocking agent; RSI, rapid-sequence intubation; PALS, pediatric advanced life support
Data obtained from http://online.lexi.com except where cited.
Obtaining patient “AMPLE” history.
Allergies.
Medications: current medications, previous sedation/anesthetic history.
Past medical history: general health, risk factors for sedation, airway problems, hepatic or renal dysfunction. Last meal: NPO status, volume status.
Events leading up to scenario: reason for sedation.
Preprocedure NPO status: Table 14.2 presents the generally accepted fasting guidelines endorsed by the American Academy of Pediatrics (AAP) and American Association of Anesthesiologists (ASA).
Preprocedure physical examination: should include airway, lung sounds, heart sounds, and neurologic examination.
TABLE 14.2 Preprocedure Fasting Guidelines
Pre-procedure Fasting Guidelines
Diet
Minimal Fasting Time Period (hr)
Clear liquids
2
Human breast milk
4
Infant formula or milk
6
Solid food
8
From American Society of Anesthesiologists.
FIGURE 14.1 • The Mallampati Classification.
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