Sedation and analgesia for procedures in the pediatric emergency room<sup>,</sup>

Ramalho, Carlos Eduardo; Bretas, Pedro Messeder Caldeira; Schvartsman, Claudio; Reis, Amélia Gorete

doi:10.1016/j.jped.2017.07.009

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Review articles • J. Pediatr. (Rio J.) 93 (suppl 1) • 2017 • https://doi.org/10.1016/j.jped.2017.07.009 copy

Sedation and analgesia for procedures in the pediatric emergency room^☆ ☆ Please cite this article as: Ramalho CE, Bretas PM, Schvartsman C, Reis AG. Sedation and analgesia for procedures in the pediatric emergency room. J Pediatr (Rio J). 2017;93:2-18. ^,^☆☆ ☆☆ Study carried out at Universidade de São Paulo (USP), Faculdade de Medicina, Hospital das Clínicas, Instituto da Criança, São Paulo, SP, Brazil.

Authorship SCIMAGO INSTITUTIONS RANKINGS

Abstract

Objective:

Children and adolescents often require sedation and analgesia in emergency situations. With the emergence of new therapeutic options, the obsolescence of others, and recent discoveries regarding already known drugs, it became necessary to review the literature in this area.

Data sources:

Non-systematic review in the PubMed database of studies published up to December 2016, including original articles, review articles, systematic reviews, and meta-analyses. References from textbooks, publications from regulatory agencies, and articles cited in reviews and meta-analyses through active search were also included.

Data synthesis:

Based on current literature, the concepts of sedation and analgesia, the necessary care with the patient before, during, and after sedoanalgesia, and indications related to the appropriate choice of drugs according to the procedure to be performed and their safety profiles are presented.

Conclusions:

The use of sedoanalgesia protocols in procedures in the pediatric emergency room should guide the professional in the choice of medication, the appropriate material, and in the evaluation of discharge criteria, thus assuring quality in care.

KEYWORDS
Conscious sedation; Deep sedation; Analgesia; Child; Emergency service; Emergency medicine

Variable	0 points	1 point	2 points
Facial expression	Relaxed	Grimacing	-
Crying	Not crying	Whimpering	Vigorous
Breathing	Regular	Different from basal	-
Arms	Relaxed	Flexed/extended	-
Legs	Relaxed	Flexed/extended	-
State of alertness	Sleeping and/or peaceful	Restless and/or fussy	-

Categories	0 points	1 point	2 points
Face	No particular expression or smile	Occasional grimace or frown; withdrawn, uninterested	Frequent to constant frown, clenched jaw, quivering chin
Legs	Normal position or relaxed	Uneasy, restless, tense	Kicking or legs drawn up
Activity	Lying quietly, normal position, moves easily	Squirming, shifting back and forth, tense	Arched, rigid or jerking
Cry	No cry (awake or asleep)	Moans or whimpers, occasional complaint	Crying steadily, screams or sobs; frequent complains
Consolability	Content, relaxed	Reassured by occasional touching, hugging, or being talked to; distractible	Difficult to console or comfort

Class	Health status
I	A normal healthy patient
II	A patient with mild systemic disease
III	A patient with severe systemic disease
IV	A patient with severe systemic disease that is a constant threat to life
V	A moribund patient who is not expected to survive without the operation
VI	A patient declared brain-dead whose organs are being removed for donor purposes

Letter	Assessed item
S	Signs and symptoms of current pathology
A	Allergy to medication, food, or latex
M	Medication being taken, whether continuous or not
P	Past medical history - comorbidities, previous complications related to sedative agents
L	Liquids and solids - fasting time and which type of food ingested
E	Events related to the need for sedation

Type of food	Fasting time
Clear liquids^a a Water, fruit juice without pulp, carbonated drinks, light tea, and black coffee.	2 h
Breast milk	4 h
Infant formula and nonhuman milk	6 h
Light meal (toast and liquids)	6 h

Anamnesis	Physical examination	Monitoring	Discharge criteria
Signs and symptoms Allergy Medication Past medical history Liquids and solids Events	• Upper airway: mouth opening, jaw size • Neck flexion: ability to pull the chin to the chest (assess limitation), not applicable for victims with spinal cord trauma • Respiratory auscultation • Heart auscultation • Distal perfusion: pulse, skin temperature, capillary perfusion	• Heart rate and electrocardiogram tracing • Respiratory frequency • Blood pressure • Pulse oximetry • Level of consciousness • Pain scale • Capnography (moderate and deep sedation)	• Airway, vital signs and stable pulse oximetry and back to basal level • Able to obey commands appropriate for age • Hydrated patient and tolerating oral fluid intake • Awakened patient and at his/her basal level of verbal ability • Patient able to sit unassisted (if appropriate for age)

Type of procedure	Indications	Desired effect	Suggestion
Non-invasive procedures	Computed tomography	Motor control	Comfort measures Midazolam^a a Midazolam for EEG is not a good alternative. Dexmedetomidine
	Echocardiogram
	Electroencephalogram
	Ultrasonography

Procedures associated with light pain and high degree of anxiety	Tracheostomy exchange	Analgesia Sedation Motor control Reduction of anxiety	Comfort measures Midazolam^b b Consider association with analgesics, depending on the procedure. Ketamine Topical or local analgesia
	Gastrostomy exchange
	Dental procedures
	Nasofibroscopy
	Peripheral venous puncture
	Suture
	Lumbar puncture

Procedures associated with high level of pain, high level of anxiety, or both	Abscess drainage	Sedation Analgesia Motor control Reduction of anxiety Amnesia	Fentanyl Midazolam + Fentanyl Ketamine Ketamine + Propofol Propofol + Fentanyl Morphine
	Arthrocentesis
	Bone marrow aspiration
	Pericardial puncture
	Cardioversion
	Central venous puncture
	Burn debridement
	Reduction of fractures
	Hernia reduction
	Paraphimosis reduction
	Thoracentesis
	Thoracic drainage
	Paracentesis
	Physical examination of victims of sexual violence

Drug	Effects	Side effects	Indications	Dose	Onset of action	Duration of action
Sedative-hypnotic
Midazolam	Sedation, motor control, anxiety reduction, no analgesic effect	Hypotension, respiratory depression, paradoxical effect	Procedures that require sedation, Reduced anxiety or amnesia	IV (age 6 months-5 years): initial 0.05-0.1 mg/kg, maximum of 0.6 mg/kg IV (6-12 years): initial 0.025-0.05 mg/kg, maximum of 0.4 mg/kg IM: 0.1-0.15 mg/kg PO: 0.5-0.75 mg/kg IN: 0.2-0.5 mg/kg RR: 0.25-0.5 mg/kg	2-3 min 2-3 min 10-20 min 15-30 min 10-15 min 10-30 min	45-60 min 45-60 min 60-120 min 60-90 min 60 min 60-90 min
Diazepam	Sedation, motor control, anxiety reduction, no analgesic effect	Hypotension, respiratory depression, paradoxical effect	Seldom used due to long half-life	IV: initial 0.05-0.1 mg/kg, Max 0.25 mg/kg	2-3 min	45-60 min
Propofol	Fast and short sedation	May cause pain at infusion, hypotension, apnea and bradycardia	Short-term procedures, associated or unassociated with analgesics	IV: 1-2 mg/kg, may repeat 0.5 mg/kg every 3-5 min	1 min	5-15 min
Etomidate	Fast and short sedation	May cause local pain, myoclonus, transient adrenal suppression	Short-term procedures, associated or unassociated with analgesics	IV: 0.2-0.3 mg/kg	30-60 s	5-15 min
Dexmedetomidine	Sedation with respiratory drive maintenance Does not change EEG tracing Off-label use in pediatrics	May cause arrhythmia, hypotension, and hypertension	Imaging procedures (CT and MRI), endoscopy, EEG	IV: 2 mcg/kg IN/oral mucosa: 1-3 mcg/kg IM: 1-4.5 mcg/kg Oral: 5 mcg/kg	5-10 min	60-120 min

Analgesics
Fentanyl	Analgesia	Bradycardia, chest stiffness, respiratory depression	Procedures with moderate to severe pain	IV: 1.0 µg/kg/dose, may be repeated every 3 min IN: 1.5 µg/kg/dose	2-3 min 2-5 min	30-60 min 30-60 min
Morphine	Analgesia	Release of histamine, hypotension, nausea, reduction of gastrointestinal motility	Procedures with moderate to severe pain	IV: initial 0.05-0.15 mg/kg, may be repeated every 5 min	5-10 min	30-60 min
Ketamine	Dissociative agent with analgesic and sedative properties	Laryngospasm, hypersalivation, emergency reactions, vomiting	Short-term painful procedures or when amnesia is desired	IV: 1-2 mg/kg, may repeat 0.5-1 mg/kg every 5-10 min IM: 2-5 mg/kg, may repeat 2-4 mg/kg after 10 min IN: 1-9 mg/kg	IV: 1 min IM: 3-5 min	IV: 15 min (dissociation), 60 min (recovery) IM: 15-30 min (dissociation), 90-150 min (recovery)

Antidotes
Flumazenil	Benzodiazepine antagonist	Increased intracranial pressure, reduction of convulsive threshold	Reversal of unwanted effects	IV: 0.02 mg/kg/dose, may be repeated at each min up to a maximum of 1 mg	1-2 min	30-60 min
Naloxone	Opioid antagonist	Nausea, anxiety, sympathetic stimulation, hypertension, tachycardia, pulmonary edema, return of pain	Reversal of unwanted effects	IV or IM: 0.1 mg/kg/dose, maximum 2 mg/dose; can be repeated every 2 min if necessary^a a The dose for partial reversal is lower: 0.01-0.03 mg/kg.	IV: 2 min IM: 10-15 min	IV: 20-40 min IM: 60-90 min

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E-mail: jped@jped.com.br

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[1] * Corresponding author. E-mail:ameliareis30@gmail.com (A.G. Reis).