This document provides information on sedation and analgesia in the pediatric intensive care unit (PICU) and for procedures. It discusses pain and sedation assessment tools, pharmacology of commonly used drugs like midazolam, morphine, fentanyl, ketamine and propofol. It outlines strategies for administering sedation like using a combination of drugs titrated to specific endpoints and daily interruption of sedative infusions. Procedures requiring sedation and checklists for pre-sedation are also reviewed. Weaning, tolerance and dependence related to long-term sedation are discussed.

1. SEDATION AND ANALGESIA IN
PICU/PROCEDURE
DR.D.RASIKAPRIYA

2. OBJECTIVES
• Introduction
• Pain and sedation assessment
• Pharmacology
• Strategies for administering sedation.
• Procedure requiring sedation
• Drugs used in PICU

3. INTRODUCTION
• Pain, anxiety and agitation – major problem in
ICU.
• It causes increased endogenous
catecholamine activity with extreme
hypertension, tachycardia, tachypnea,
ventilator dysynchrony, hypoxemia and
unplanned extubation.

4. • Optimal level of sedation and analgesia –
important component of therapy of patients
with respiratory failure, raised intracranial
pressure and shock

5. ASSESSMENT
• Surrogate markers of pain – physiological
parameters( heart rate) or elicited behaviors
(facial expression).
• Visual analogue scale
• Ramsay scoring system
• Daily assessment of sedation - important

6. Visual analogue scale

7. Ramsay scoring system
AWAKE ASLEEP
1- Anxious or agitated 4- Quiescent with brisk response to light
glabelar tap or loud auditory stimulus
2- Co operative, oriented and tranquil 5- Sluggish response to light glabelar tap or loud
auditory stimulus
3- Responds to command 6- No response
Score – 4 in ventilated patients
Score – 3 in non ventilated patients

8. PHARMACOLOGY

9. • MIDAZOLAM:
For sedation and analgesic in procedure.
MOA- By acting on ɣ amino butyric acid
DOSE-0.1- 0.2mg/kg IV.
Peak at 2-3 min, duration – 45-60 min.
Respiratory depression – should be watched, hypotension
IV infusion in ventilated children.
Midazolam infusion = 6 mg/kg in 50 ml NS
1ml/hr= 2mcg/kg/hr
Undiluted = 60*b.wt*2/1000= ml/hr
1ml=1 mg availability

10. Opioids –
Acute pain in ICU.
Analgesia and some amount of sedation.
Commonly used- morphine and fentanyl
1. Morphine :
Prototype analgesic
Slower onset-20 mins and longer duration-2-6 hrs.
Dose - 0.1-0.2mg/kg/dose.
1 ml= 1mg
• Infusion -Morphine = 1 mg/kg in 50 ml NS
1ml/hr= 20mcg/kg/hr

11. 2. Fentanyl :
Rapid onset, short distribution half life and
long elimination [100 times more potent than
morphine]
Safe cardiovascular profile
Can be used in shock and unstable patients.
Rapid onset- < 30sec , peak at 2-3 min,
duration-20-60min
Infusion – 50mcg/kg in 50 ml NS
1ml/hr=1mcg/kg/hr

12. • Side effects:
Respiratory depression
Increased sphincter tone
Histamine release- itching, bronchoconstriction
Fentanyl – chest wall rigidity – too rapid
administration
Bradycardia

13. • KETAMINE:
Dissociative sedation – profound analgesia,
sedation, amnesia and immobilization.
Increase HR,BP and cardiac output.
Bronchodilation
Reflexes and spontaneous respiration
maintained.
IV 1-2 mg/kg over 1 min.
Preferred in acute onset hemodynamic
instability, intubation and severe asthmatics

14. Side effects:
Emergence phenomenon/agitation
Contraindicated in raised ICP.
PROPOFOL:
Ultra short acting- short term procedures.
Sedation and amnesia , no analgesic activity.
Dose – 2.5-3.5 mg/kg stat , 2-8mg/kg/hr IV
Side effects- hypotension , respiratory
depression, Propofol infusion syndrome.

15. • DEXMEDETOMIDINE:
Same group as clonidine- alpha 2 receptor.
Sedative anxiolytic agent.
Dose – 0.4mcg/kg/min followed by
0.2-0.7 mcg/kg/min
Adv: Can be used as both sedation and
analgesics as infusion
S/E: hypotension

16. • CHLORAL HYDRATE
Pure sedation without analgesic properties.
Dose – 30mg/kg
5ml= 500mg syrup
In higher dose- cause respiratory depression.

17. Comparative properties
DRUGS MORPHINE FENTANYL BZD KETAMINE PROPOFOL
Sedation Yes Yes Yes Yes Yes
Analgesia Yes Yes × Yes ×
H/D stability × Yes × Yes ×
Short T1/2 × Yes × Yes Yes
Prompt
recovery
× Yes × Yes Yes
Oral route - × Yes × ×
Antidote Yes Yes Yes × ×

18. Procedure requiring sedation
• Non invasive procedure:
MRI
CT scan
Other imaging studies
• Invasive procedure:
Bone marrow aspiration and biopsy
Lumbar puncture
ICD
Central line
Ultrasound guided aspiration
Sedation
Sedation and
Analgesic

19. Checklist
• Pre sedation assessment for procedure
-Preprocedure assessment [Identify high risk
patients – Mediastinal mass, floppy infants]
-Consent
• Equipment and emergency drugs
-Monitoring and reliable back up
-Age and body weight- resuscitation equipment
-Drugs –
Epinephrine, hydrocortisone,etc.

20. • Monitoring
Non invasive monitoring:-
ECG
BP
Pulse oximetry
RR.

21. DRUGS
• Step ladder pattern
• 3 Step approach for selecting drugs
• Mild to moderate pain- Acetaminophen
• Moderate to severe pain- Opioids

22. • Ideal agent:
Provide sedation
Analgesia
Maintain hemodynamic stability
Have short elimination half life
Have no unpleasant emergence reaction
Can be given oral route
Has an antidote

23. • Ketorolac :
Analgesic for minor procedure
Oral(10mg)/ IV injection(15 and 30mg/ml)
Dose – 0.5mg/kg every 6 hours
NSAID

24. Procedure
IV Midazolam 0.1mg/kg – dose up to 3 doses.
(0.5mg/kg)
IV Ketamine - 1-2 mg/kg
OR
IV Propofol – 2.5-3.5 mg/kg

25. ICU
• Midazolam
Midazolam infusion = 6 mg/kg in 50 ml NS
1ml= 2mcg/kg/hr
Undiluted = 60*b.wt*2
*1ml=1 mg availability.
• MORPHINE
• Infusion -Morphine = 1 mg/kg in 50 ml NS
1ml= 20mcg/kg/hr
*1ml= 1mg

26. • Asthmatics / Severe bronchiolitis in ventilator
Ketamine infusion can be used

27. In long time sedation:
• Tolerance
• Dependence
• Weaning

28. TOLERANCE:
Is the development of a need to increase the
dose of a drug to achieve the same effect.
Opioids – 10-21 days
Continuous infusion may produce tolerance
more rapidly than intermittent therapy.

29. DEPENDENCE:
Physiological dependence – an altered
physiologic state that requires continuous
drug administration to prevent the
appearance of an abstinence or withdrawal
syndrome.
Opioids- 2-3 weeks
Symptoms – within 24 hours of drug cessation
Peak – 72 hours

30. • Symptoms :
-Abdominal pain
-Vomiting
-Diarrhea
-Tachycardia
-Hypertension
-Diaphoresis
-Restlessness
-Insomnia
-Movement disorder
-Reversible neurological abnormalities
-Seizures

31. WEANING:
Important points in weaning-
1. Opioids/benzodiazepines used for 3-4 days reduce by
20% of pre taper dose every day.
2. Used for > 10 days- reduce more slowly by 10% of pre
taper dose daily.
3. If multiple agents- alternate btw agents for reduction,
effectively each agent every alternate day
4. Withdrawal symptoms develop – stop 24 hours.
5. Withdrawal symptoms don’t improve- increase to
previous dose

32. • Weaning benzodiazepine infusion:
Iv midazolam to oral lorazepam.
Total midazolam(mg) dose/8=lorazepam oral dose/day- divided
4-6 hours.
2 nd oral lorazepam reduce midazolam by 50%
3 rd dose- 50%
4 th dose- discontinue midazolam

33. STRATEGIES
• Combination of drugs, each titrated to specific
end points- more specific strategy.
1. Sedation and Analgesics can be administered
either by intermittent bolus or by continuous
infusion.
- Bolus – over sedation and under sedation
- Continuous infusion- more consistent level of
sedation with greater level of patient comfort.
- Eg- morphine and midazolam

34. 2. Daily interruption of sedative infusion reduce
complication of sedation
DRUG HOLIDAY
Allows a focused downward titration of sedative
infusion rate
Streamlining administration
Minimizing tendency for accumulation.

35. 3. Benzodiazepines produce dose dependent
depression of breathing and affect the
ventilatory response to both hypoxia and
hypercapnia.
- Hypoventilation – by decreasing tidal volume
and shallow breathing than decreased RR.

36. Sedation in newborn
• Non pharmacological methods
• Non nutritive sucking
• Local application - EMLA

37. THANK YOU