Sedation and Analgesia

Published on 24/03/2015 by admin

Filed under Emergency Medicine

Last modified 22/04/2025

Print this page

This article have been viewed 1116 times

Chapter 72 Sedation and Analgesia

Richard J. Scarfone, MD, FAAP

1 Why is the term conscious sedation considered obsolete?

In the past, conscious sedation has been defined as a medically controlled state of depressed consciousness in which:

Protective reflexes are maintained

The airway remains patent

The patient responds purposefully to physical or verbal stimuli

This term is now considered obsolete and has been replaced with the phrase moderate sedation and analgesia. For most clinical indications, emergency department (ED) physicians are attempting to achieve a deeper level of altered consciousness for their patients, referred to as deep sedation and analgesia. This state is characterized by:

Partial or complete loss of protective reflexes

An inability to independently maintain a patent airway

No purposeful response to stimulation

American Society of Anesthesiologists: Continuum of depth of sedation: Definition of general anesthesia and levels of sedation/analgesia: www.asahq.org/publicationsAndServices/standards/20.pdf

EMSC Grant Panel on Pharmacologic Agents Used in Pediatric Sedation and Analgesia in the Emergency Department: Clinical policy: Evidence-based approach to pharmacologic agents used in pediatric sedation and analgesia in the emergency department. Ann Emerg Med 44:342–377, 2004.

2 What are some reasons for the mismanagement of pain in children?

Lack of available data in children. The Food and Drug Administration studies and approves medications for use in adults. Physicians must extrapolate this information for pediatric patients. Until the past decade, few clinical trials assessed the safety and efficacy of sedatives or analgesics in children.

Fear of addiction from opioids. In both adult and pediatric patients, physicians have been overly concerned about inducing addiction with the use of opioid analgesics. In fact, addiction is a rare consequence of the legitimate use of opioids for medical purposes in children.

Belief that neonates and young children do not experience pain to the same degree as adults because of their immature nervous systems. Any physician who has attempted to intubate the trachea of an awake neonate or to perform a lumbar puncture in a struggling toddler can testify to the contrary. Young children cannot understand the purpose of a painful procedure or comprehend its time-limited nature. Therefore, they are likely to experience a greater degree of pain and anxiety compared to older children or adults and are more likely to benefit from the liberal use of procedural sedation and analgesia (PSA).

Berde CB, Sethna NF: Analgesics for the treatment of pain in children. N Engl J Med 347:1094–1101, 2004.

Lampell MS, Leder MS: Pediatric pain control. Pediatr Emerg Med Rep 4:73–84, 1999.

Zempsky WT, Cravero JP, Committee on Pediatric Emergency Medicine and Section on Anesthesiology and Pain Medicine: Relief of pain and anxiety in pediatric patients in emergency medical systems. Pediatrics 114:1348–1356, 2004.

3 What are tolerance, physical dependence, and addiction?

A child with sickle cell anemia who has been treated at home with acetaminophen and codeine for 2 weeks will probably require higher than usual doses of parenteral narcotics for management of a vaso-occlusive crisis. Such a child may have developed tolerance, diminished effectiveness of the drug with repeated administration. A child with leukemia and bony pain who abruptly discontinues daily oral morphine after 10 days may experience headaches, sweating, tachycardia, and tachypnea. Such a child may have developed physical dependence. In contrast, addiction is a psychological syndrome marked by compulsive drug-seeking behavior and associated with desire for euphoric effects.

4 Describe methods to reduce the pain of administration of local anesthetics

Local anesthetics administered through intact skin or into an open wound can cause considerable pain. Techniques that may be employed to reduce the pain of injection include using a needle of small caliber, buffering the lidocaine with bicarbonate, warming the drug, injecting slowly, and providing counterstimulation to the adjacent skin. Many physicians employ topical formulations, such as lidocaine, epinephrine, and tetracaine, either in a liquid or a gel form. This may be administered, without using a needle, to exposed mucosa. These drugs should not be used in any regions of the body in which epinephrine is contraindicated, such as fingertips or ears.

In addition, liposomal lidocaine (LMX) and a mixture of lidocaine and prilocaine (EMLA) may each be applied to intact skin to reduce the pain of venipuncture. Physicians have also found these topical mixtures to alleviate the pain associated with lumbar punctures incision of abscesses, and insertion of intravenous lines.

Berde CB, Sethna NF: Analgesics for the treatment of pain in children. N Engl J Med 347:1094–1101, 2002.

Eichenfield LF, Funk A, Fallon-Friedlander S, Cunningham BB: A clinical study to evaluate the efficacy of ELA-Max (4% liposomal lidocaine) as compared with eutectic mixture of local anesthetics cream for pain reduction of venipucture in children. Pediatrics 109:1093–1099, 2002.

Scarfone RJ, Jasani M, Gracey EJ: Pain of local anesthetics: Rate of administration and buffering. Ann Emerg Med 36:36–40, 1998.

5 Describe the key elements of the medical history for a child about to receive PSA

Aspects of the history that should be known before drug administration include time since last meal, current medications, allergies, pregnancy status, significant medical history, history of complications with sedation or general anesthesia, and a complete review of systems. If the child was transported from another institution, the clinician must know whether he or she received sedation or analgesia at the referring hospital and, if so, what was given and when. In addition, physicians should ask questions pertinent to the specific medication that one is about to give. For example, active laryngotracheobronchitis should be considered a contraindication to the use of ketamine.

6 Describe the key elements of the physical examination for a child about to receive PSA

Clinicians must monitor the patient’s vital signs (especially blood pressure), cardiac and pulmonary examinations, and mental status. Many agents cause hypotension and should be used cautiously or not at all for children with impending shock. Similarly, agents that may cause hypoventilation and hypoxemia are poor choices for any child with respiratory distress.

7 How much time should elapse between the last oral intake of food or liquid and PSA?

This is perhaps the area of greatest controversy in the administration of PSA to children. These are the published fasting guidelines for elective procedures developed by the American Society of Anesthesiologists (ASA):

Ingested Material	Minimum Fasting Period
Clear liquids	2 hr
Breast milk	4 hr
Infant formula, nonhuman milk, light meal	6 hr

8 What are the concerns about fasting guidelines for PSA?

Problems with these guidelines include:

They are arbitrary: For example, what evidence exists to support a longer fasting time after formula intake compared to breast milk? How does the age of the patient or the volume ingested influence these recommendations? In fact, the ASA states that “the literature does not provide sufficient evidence to test the hypothesis that preprocedural fasting results in a decreased incidence of adverse outcomes.”

They were written for fasting prior to general anesthesia.

Physicians working in busy EDs with time and space constraints find these guidelines prohibitively conservative and difficult to adhere to.

Aspiration following moderate or deep sedation is extremely rare.

Newer evidence suggests that prolonged fasting may not lead to fewer adverse events. In a recent report of over 1000 children receiving PSA, about half were not fasted as per the ASA guidelines. These children did not experience a greater incidence of aspiration or other adverse outcomes compared to the fasted group. A second study of over 2000 children and young adults found no correlation between preprocedural fasting time and adverse outcomes.

A recently published clinical practice advisory recommends weighing several factors when deciding what is the appropriate fasting for elective procedures. These factors include the overall health of the patient, the desired length and depth of sedation and analgesia, and the urgency of the procedure.

Agrawal D, Manzi SF, Gupta R, Krauss B: Preprocedural fasting state and adverse events in children undergoing procedural sedation and analgesia in a pediatric emergency department. Ann Emerg Med 42:636–646, 2003.

American Society of Anesthesiologists: Practice guidelines for sedation and analgesia by non-anesthesiologists. American Society of Anesthesiologists task force on sedation and analgesia by non-anesthesiologists. Anesthesiology 96:1004–1017, 2002.

Green SM.: Fasting is a consideration—not a necessity—for emergency department procedural sedation and analgesia. Ann Emerg Med 42:647–650, 2003.

Green SM, et al. Fasting and emergency department procedural sedation and analgesia: a consensus-based clinical practice advisory. Ann Emerg Med 49:454–461, 2007.

Roback, MG, Bajaj L, Wathen JE, Bothner J: Preprocedural fasting and adverse events in procedural sedation and analgesia in a pediatric emergency department: Are they related? Ann Emerg Med 44:454–459, 2004.

9 What is the ASA physical status classification?

This is a physical status classification based on the ASA recommendations. This status should be assigned before the initiation of sedation. There are five classes.

Class I: Normally healthy patient

Class II: Patient with mild systemic disease (e.g., mild asthma)

Class III: Patient with severe systemic disease (e.g., poorly controlled diabetes mellitus)

Class IV: Patient with severe systemic disease that is a constant threat to life

Class V: Moribund patient who is unlikely to survive without the operation

10 During PSA, which equipment is needed to monitor the patient and to be immediately available at the bedside?

The risks of sedating children are significant and include hypoventilation, apnea, airway obstruction hypotension, and aspiration. Equipment that should be immediately available at the bedside includes:

Cardiorespiratory monitor

Airway equipment, such as self-inflating breathing bags with masks, and oropharyngeal and nasopharyngeal airways

In addition, advanced airway equipment, such as laryngoscopes and endotracheal tubes, should be available in the ED.

American Academy of Pediatrics and American Academy of Dentistry: Guidelines for monitoring and management of pediatric patients during and after sedation for diagnostic and therapeutic procedures: an update. Pediatrics 118:2587–2602, 2006.

11 What is the optimal staffing for PSA?

Ideally, a physician experienced in pediatric advanced life support should administer the medications and closely observe the child’s response. The risk of respiratory depression is minimized by administering agents slowly, over about 60 seconds. The physician should remain at the bedside at least until the period of peak sedation and cardiorespiratory side effects has passed (typically about 20 minutes). A second physician should perform the procedure. In this way, a single physician is not dividing attention between two important tasks. A nurse should document the patient’s response to medications and be available to assist in suctioning or administering oxygen or reversal agents.

12 How frequently should the child be monitored? How should this be documented?

A sedation and analgesia flow chart should supplement the patient’s medical record, with a complete and accurate account of the encounter. Medications, times administered, doses, routes, and name of the person who gave the drugs should be recorded. The patient’s vital signs, oxygen saturation, and mental status should be monitored continuously, with recordings documented every 5 minutes for the first 30 minutes after drug administration. One-on-one clinical monitoring should continue until the child is well into the recovery phase. The frequency of monitoring beyond the initial half-hour and the duration of observation depend on which agents were given and depth of sedation.

14 What are the expected rates of success and complications for PSA in children?

Recent data has demonstrated that when PSA is provided to children by pediatric emergency medicine physicians in a tertiary care children’s hospital, success rates are very high and serious adverse outcomes are rare. In one report, over 1200 children received PSA in such a setting, with a variety of different medications being employed. For more than 98% of the children, the procedure was successfully completed while the patient remained minimally responsive. The rate of complications was 18%, with the most common complication being hypoxia. In a study assessing more than 30,000 pediatric sedation/anesthesia events, there were no deaths, cardiopulmonary resuscitation was required once, and oxygen desaturation was uncommon.

Cravero JP, et al. Incidence and nature of adverse events during pediatric sedation/anesthesia for procedures outside the operating room: report from the Pediatric Sedation Research Consortium. Pediatrics 118:1087–1096, 2006.

Newman DH, Azer MM, Pitetti RD, Singh S: When is a patient safe for discharge after procedural sedation? The timing of adverse effect events in 1,367 pediatric procedural sedations. Ann Emerg Med 42:627–645, 2003.

Pitetti RD, Singh S, Pierce MC: Safe and efficacious use of procedural sedation and analgesia by nonanesthesiologists in a pediatric emergency department. Arch Pediatr Adolesc Med 157:1090–1096, 2003.

15 What are the advantages and disadvantages of transmucosal drug administration?

The main advantage of transmucosal (oral, intranasal, rectal) compared to parenteral (IV, intramuscular) drug administration is its painless nature. It seems counterintuitive to cause pain with a needle puncture in an attempt to ultimately relieve pain. However, important disadvantages of transmucosal administration include delayed onset of action, less predictable results, and difficulties in titrating the dose to the desired effect. It can be frustrating to the child, parents, and doctor if the child is fully alert 40 minutes after an oral sedative has been administered. Thus, for most ED indications, the parenteral route of administration is preferred because it allows finer minute-to-minute control of depth of sedation and analgesia.

16 What are the advantages and disadvantages of chloral hydrate?

The main advantages of chloral hydrate are that it may be given orally and it has a relatively good safety profile. Its use in the ED is limited by a prolonged time to onset of sedation (30–60 minutes for peak plasma concentrations), prolonged recovery time (several hours), frequent gastric irritation and emesis, and inability to titrate the dose effectively.

17 Discuss the role of propofol for PSA

Propofol is a nonbarbiturate ultra–short-acting hypnotic agent. It has an extremely short onset (within 1 minute) of effect and duration of action, necessitating delivery by continuous IV infusion or frequent readministration for most procedures. Respiratory depression, hypoxemia, hypotension, and injection pain are common side effects. Its use requires vigilance on the part of physicians because of the likelihood of adverse effects. Its extremely rapid onset of action and potency make it difficult to titrate without inducing serious adverse effects. Unless physicians are experienced with its use, propofol would not be a good choice for sedating a child who will be leaving the ED, such as for a radiologic study. Even in the hands of practitioners experienced with its use, two thirds of children experienced decreases in systolic blood pressure below the fifth percentile and 12% had partial airway obstruction.

Bassett KE, Anderson JL, Pribble CG, et al: Propofol for procedural sedation in children in the emergency department. Ann Emerg Med 42:773–782, 2003.

Green SM, Krauss B: Propofol in emergency medicine: Pushing the sedation frontier. Ann Emerg Med 42:792–797, 2003.

Guenther E, Pribble CG, Junkins EP Jr, et al: Propofol sedation by emergency physicians for elective pediatric outpatient procedures. Ann Emerg Med 42:783–791, 2003.

Hertzog JH, Dalton HJ, Anderson BD, et al: Prospective evaluation of propofol anesthesia in the pediatric intensive care unit for elective oncology procedures in ambulatory and hospitalized children. Pediatrics 106:742–747, 2000.

18 Discuss the role of etomidate for PSA

Etomidate is a nonbarbituate hypnotic without analgesic properties that has been used extensively as an anesthetic induction agent. It has a very rapid onset of action, short duration of action, and minimal effects on cardiovascular status. Myoclonus and injection pain are common side effects. There is a growing experience with its use for PSA in children. In a recent study, it compared favorably to pentobarbital for sedating children for CT scans. Similarly, it has been shown to be superior to midazolam for fracture reductions.

Baxter AL, et al. Etomidate versus pentobarbital for computed tomography sedations: Report from the Pediatric Sedation Research Consortium. Pediatr Emerg Care 23:690–695, 2007.

Liddo LD, et al. Etomidate versus midazolam for procedural sedation in pediatric outpatients: A randomized controlled trial. Ann Emerg Med 48:433–440, 2006.

Miner JR, et al. Randomized clinical trial of etomidate versus propofol for procedural sedation in the emergency department. Ann Emerg Med 49:15–22, 2007.

KEY POINTS: SEDATIVE/HYPNOTIC AGENTS USED IN SEDATION

19 Can opioids be used safely in neonates?

The greatest experience with the use of opioids in neonates is with the use of morphine. Morphine may be indicated to reduce the pain associated with a strangulated inguinal hernia or resulting from an inflicted injury, such as a fracture. Because a smaller proportion of an administered dose of morphine is protein-bound in young infants compared to older children, the proportion of drug reaching the brain is increased and the elimination half-life is prolonged. Thus, very young infants are particularly susceptible to apnea and respiratory depression with morphine. For those < 6 months of age, a starting dose that is one-quarter to one-third the dose recommended for older infants and children should be used. Age from birth, rather than duration of gestation, determines how premature and full-term infants metabolize narcotics. Thus, a 4-month-old who was born at term metabolizes narcotics at the same rate as a 4-month-old who was born prematurely. The clinician must judge the infant’s facial expressions, heart rate, and blood pressure to determine whether to administer additional morphine for the desired effect.

Berde CB, Sethna NF: Analgesics for the treatment of pain in children. N Engl J Med 347:1094–1101, 2002.

20 A bead is located in the ear canal of an 8-year-old boy. Initial attempts to remove it cause considerable anxiety and discomfort, preventing successful removal. What are some sedation options for this patient?

Because the boy does not have an inherently painful condition and because he does not require an IV line for any other reason, a pure sedative hypnotic such as midazolam given orally may be a reasonable option. However, it will take about 30 minutes for the full effects to be realized, the depth of sedation after oral administration is not predictable, and midazolam alone does not offer him analgesia. Intranasal midazolam administrated with an atomizer is likely to result in more rapid and more reliable sedation than that given orally. Another option would be nitrous oxide, an odorless gas that patients inhale. Nitrous oxide causes mild analgesia, anxiolysis, sedation, and amnesia. Its ease of delivery and rapid onset of action makes it ideal for sedation before foreign-body removal. However, at a ratio of 50% nitrous oxide to 50% oxygen, it is not likely to be effective for more painful procedures, such as incision and drainage of an abscess.

21 A 3-year-old girl fell down five cement steps and struck her head on the pavement. She has vomited repeatedly since the injury but is fully alert and awake in the ED. You want to perform computed tomography of the head to rule out an intracranial injury. What are some sedation options for this patient?

Because the desired goal is to prevent the child from struggling and moving during the study, you wish to achieve sedation rather than analgesia. Pure sedative-hypnotics in common use in EDs include chloral hydrate, propofol, benzodiazepines, barbiturates, and etomidate. In addition to providing sedation before imaging studies, these drugs may also be useful as adjuncts to narcotics prior to painful procedures.

For this patient, midazolam or pentobarbital may be the best choices. The ability to titrate each drug offers an advantage over chloral hydrate. Their safety profiles and longer durations of action offer advantages over propofol and etomidate.

Midazolam may be administered by the IV, intramuscular, oral, nasal, or rectal routes. Its onset is within minutes after IV administration, and clinical effectiveness usually lasts about 30 minutes. One may expect mild reductions in blood pressure and dose-related respiratory depression. Significant hypoventilation is rare unless the drug is given concurrently with a narcotic or pushed too rapidly. Its effects may be reversed with the competitive antagonist flumazenil.

Pentobarbital is a short-acting barbiturate that produces sedation within 5 minutes, lasting 30–60 minutes. As with midazolam, hypoventilation may occur but responds readily to gentle stimulation. Hypotension is a common side effect, and the drug should not be used in children with possible cardiovascular compromise.

22 An adolescent girl needs a lumbar puncture to rule out aseptic meningitis. What agent(s) should be used for PSA?

For this procedure, an IV sedative alone does not provide analgesia for the painful local anesthetic that should be administered in the lumbar region. Topical anesthetics alone don’t provide a great enough depth of analgesia for this indication. In response to the injection of the local anesthetic, an anxious patient may arch her back and move enough that it will be nearly impossible to perform the lumbar puncture.

Some physicians have had success combining midazolam with fentanyl, which is 100 times more potent than morphine. Fentanyl’s onset and duration of action closely parallel that of midazolam, making this combination particularly potent. Fentanyl provides analgesia and potentiates the sedative effect of midazolam. Respiratory depression is common with this combination but may be minimized by administering each agent over 60 seconds with a 60-second interval in between and by titrating doses carefully. Gentle stimulation of the patient and supplemental oxygen almost always prevent hypoxemia.

Fentanyl has a more rapid onset and shorter duration of action than morphine, making it a better choice for most procedural analgesia. When more prolonged analgesia is desired (e.g., for vaso-occlusive crisis), morphine is the better choice. The combination of midazolam and fentanyl is also useful in the settings of laceration repair, burn care, and reduction of minimally displaced or angulated fractures.

23 A 10-year-old boy has displaced and angulated fractures to his ulna and radius that require closed reduction. What agent(s) should be used for PSA?

Clearly, the primary goal in this case is to achieve potent analgesia for what is anticipated to be a very painful procedure. With the midazolam/fentanyl combination it will be difficult to achieve the depth of analgesia required without producing significant hypoventilation. In this case, ketamine is a good choice. It causes dissociation between the cortical and limbic systems, resulting in potent sedation, analgesia, and amnesia. Unlike most other agents, it does not cause cardiovascular depression. In fact, patients typically experience an increased heart rate and blood pressure with its use. Onset of action after IV administration is 3–5 minutes, with return of coherence in 30–45 minutes. Because ketamine causes hypersalivation, concurrent administration of atropine or glycopyrolate is indicated. Two uncommon but potentially serious side effects are hallucinatory emergence reactions and laryngospasm. Many clinicians believe that the incidence of emergent reactions can be minimized with the concurrent administration of midazolam, but the results of recent studies have failed to prove this. In a study assessing the ED use of intramuscular ketamine among more than 1000 children, over 90% achieved acceptable sedation within 10 minutes and four young children experienced transient laryngospasm. The expected rate of laryngospasm with the use of ketamine is 1 in 250.

Green SM, Krauss B: Clinical practice guideline for emergency department ketamine dissociative sedation in children. Ann Emerg Med 44:1–21, 2004.

Green SM, Rothrock SG, Lynch EL, et al: Intramuscular ketamine for pediatric sedation in the emergency department: Safety profile in 1,022 cases. Ann Emerg Med 31:688–697, 1998.

Heinz P, et al. Is atropine needed with ketamine sedation? A prospective, randomized, double-blind study. Emerg Med J 23:206–209, 2006.

Roback MG, et al. A randomized, controlled trial of IV versus IM ketamine for sedation of pediatric patients receiving emergency department orthopedic procedures. Ann Emerg Med 48:605–612, 2006.

Sherwin TS, Green SM, Khan A: Does adjunctive midazolam reduce recovery agitation after ketamine sedation for pediatric procedures? A randomized, double-blind, placebo-controlled trial. Ann Emerg Med 35:239–244, 2000.

Wathen JE, Roback MG, Mackenzie T, Bothner JP: Does midazolam alter the clinical effects of intravenous ketamine sedation in children? A double-blind, randomized, controlled, emergency department trial. Ann Emerg Med 36:579–588, 2003.

24 What are the contraindications to the use of ketamine?

Absolute contraindications to the use of ketamine are age younger than 3 months (because of increased risk of laryngospasm) or psychosis. Other factors are considered to be relative contraindications because of the concern for laryngospasm, and physicians must weigh the risk/benefit ratio for individual patients. These factors include age younger than 12 months, intraoral procedures, upper airway problems (such as moderate upper respiratory tract infection, croup, tracheomalacia, active asthma, or anatomic abnormalities). Other relative contraindications include coronary artery disease, increased intracranial pressure, and glaucoma.

Green SM, Krauss B: Clinical practice guideline for emergency department ketamine dissociative sedation in children. Ann Emerg Med 44:1–21, 2004.

Lampell MS, Leder MS: Pediatric pain control. Pediatr Emerg Med Rep 4:73–84, 1999.

25 For what period of time should a child be observed in the ED after PSA before being discharged home?

A recent report of over 1300 sedation events in children found that 92% of adverse events occurred during the procedure and serious adverse events rarely occurred after 25 minutes from the final medication administration. In another study of over 1000 children who had received intramuscular ketamine, four experienced laryngospasm. Onset of this complication ranged from 15–25 minutes after ketamine administration.

Ideally, a child should return to his or her baseline verbal and motor skills and mental status before ED discharge. However, if the drugs are administered to a young child in the late evening or beyond, this state may not be achieved until the following morning. More practical endpoints are the ability to maintain normal spontaneous respirations and oxygen saturation for a period beyond the peak effect of the drugs and easy arousability. For most agents discussed above, the child will be ready for discharge 45–90 minutes after drug administration.

Green SM, Rothrock SG, Lynch EL, et al: Intramuscular ketamine for pediatric sedation in the emergency department: Safety profile in 1,022 cases. Ann Emerg Med 31:688–697, 1998.

27 What are the recommended starting doses for sedatives and analgesics commonly used in children?

See Table 72-1.

Table 72-1 Recommended Starting Dose *

Drug	Route	Dose (mg/kg)
Midazolam	IV	0.1
Midazolam	IM	0.2
Midazolam	IN	0.4
Midazolam	PO, PR	0.5
Pentobarbital	IM	4
Pentobarbital	IV	2
Chloral hydrate	PO	50–100
Propofol	IV	1–3 load, 25–100 μg/kg/min
Etomidate	IV	0.1–0.2
Ketamine	IV	1–2^†
Ketamine	IM	4^†
Morphine	IV	0.1^‡
Fentanyl	IV	1 μg

IM = intramuscular, IN = intranasal, IV = intravenous, PO = oral, PR = rectal.

* All drugs should be titrated to desired effect.

† Premix with atropine or glycopyrolate.

‡ Lower in neonates.

Pediatric Emergency Medicine Secrets

Recent Posts

Meta

Categories

Search Engine

Sedation and Analgesia

1 Why is the term conscious sedation considered obsolete?

2 What are some reasons for the mismanagement of pain in children?

3 What are tolerance, physical dependence, and addiction?

4 Describe methods to reduce the pain of administration of local anesthetics

5 Describe the key elements of the medical history for a child about to receive PSA

6 Describe the key elements of the physical examination for a child about to receive PSA

7 How much time should elapse between the last oral intake of food or liquid and PSA?

8 What are the concerns about fasting guidelines for PSA?

9 What is the ASA physical status classification?

10 During PSA, which equipment is needed to monitor the patient and to be immediately available at the bedside?

11 What is the optimal staffing for PSA?

12 How frequently should the child be monitored? How should this be documented?

13 Describe the characteristics of the ideal agent for sedation and analgesia

14 What are the expected rates of success and complications for PSA in children?

15 What are the advantages and disadvantages of transmucosal drug administration?

16 What are the advantages and disadvantages of chloral hydrate?

17 Discuss the role of propofol for PSA

18 Discuss the role of etomidate for PSA

19 Can opioids be used safely in neonates?

20 A bead is located in the ear canal of an 8-year-old boy. Initial attempts to remove it cause considerable anxiety and discomfort, preventing successful removal. What are some sedation options for this patient?

22 An adolescent girl needs a lumbar puncture to rule out aseptic meningitis. What agent(s) should be used for PSA?

23 A 10-year-old boy has displaced and angulated fractures to his ulna and radius that require closed reduction. What agent(s) should be used for PSA?

24 What are the contraindications to the use of ketamine?

25 For what period of time should a child be observed in the ED after PSA before being discharged home?

26 What are the top 10 pitfalls in administering sedation and analgesia to children in the ED?

27 What are the recommended starting doses for sedatives and analgesics commonly used in children?

Related

Recent Posts

Meta

Categories

Search Engine

Sedation and Analgesia

Share this:

Related

Related posts: