Sedation and Analgesia in the PCCU



Sedation and Analgesia in the PCCU

General Principles

Assessment

Thoughtful setting of sedation targets and careful assessment of the patient is more important than what particular medications or dosing strategies are used.

Non-pharmacological factors

Environmental factors, relaxation, sleep patterns and day/night orientation, communication, re-orientation, scheduled care, lightening and noise reduction must be considered for all patients BEFORE medications are considered and should be continued even when medication are used. Noxious stimuli such as a blocked urinary catheter or underventilation must also be considered and eliminated or reduced where possible.

Acute episodes of agitation or pain.

Treat with boluses, do not increase infusion. Boluses for acute episodes of agitation can be given more frequently than q1h and should be repeated until effective. Don’t forget to use non-pharmacological measures and assess for potentially noxious stimuli.

Short term intubations

If the anticipated duration of ventilation is short, intermittent prn doses are preferred.

When to move to the next step of the algorithm?

Consider moving to the next step of the algorithm when sedation scores are consistently not in target range. Add or increase infusions only after the target is met with boluses.

Tolerance

With prolonged exposure to benzodiazepines and opiates patients often develop tolerance, requiring gradually increasing doses to maintain the same level of sedation or analgesia. Don’t forget to increase the bolus doses if they are ineffective, as well as the infusions

Sedation “failures”

Some patients can be challenging to sedate. Remove noxious stimuli if possible, try to find a more comfortable mode of ventilation, assess for untreated pain and re-assess targeted level of sedation. Ensure targets are met with boluses before increasing infusions. Most patient require less than:

• midazolam 5 mcg/kg/min or 10 mg/h in older children adolescents

• morphine 100 mcg/kg/h

• fentanyl 5 mcg/kg/h

Some options for adjunctive pharmacological therapy:

• clonidine

• ketamine

• phenobarbital

• diphenhydramine

Usually best to add new drugs, once patient is stabilized try to decrease the original drug(s) if possible.

Sedation Vacations

Sedation vacation refers to the practice of holding any sedative infusions daily and restarting them at ½ the original dose. In adult ICUs this practice reduces the duration of ventilation and ICU stay. This practice has not been evaluated in children but is reasonable to consider sedation vacations in older children and adolescents. Younger children should be assessed daily for their readiness to wean from the ventilator and for the potential to decrease the dose of sedatives.

Delirium

The assessment of delirium in critically ill children is difficult. Low dose haloperidol or chlorpromazine may be considered to treat delirium.

Adverse Effects

Hypotension: Reduce dose, change morphine to fentanyl, avoid propofol.

Pruritis: Intravenous diphenhydramine, change morphine to fentanyl

Constipation: Start all patients on continuous opiates on regular laxatives (lactulose and/or senna) unless contraindicated.

Opiates

Choice of drug

Morphine is the PCCU standard. Use fentanyl if the patient is hemodynamically unstable or if patients experience adverse effects with morphine. Fentanyl usually causes less histamine release and usually causes less hypotension and pruritis. All opiates provide equivalent analgesia at equivalent doses. These drugs have not been compared in this population in any prospective trials. Both drugs accumulate in renal dysfunction.

Equivalent doses

▪ Bolus doses: 0.1 mg/kg morphine = 1-2 mcg/kg of fentanyl

▪ Infusions: little information, morphine 40 mcg/kg/h = approximately fentanyl 1-2 mcg/kg/h

Starting doses:

▪ morphine 20-40 mcg/kg/h or fentanyl 1-2 mcg/kg/h

▪ neonates: 10 mcg/kg/h

Benzodiazepines

Choice of drug:

Lorazepam a better choice for intermittent dosing and in patients with renal or hepatic dysfunction or patients on voriconazole. Midazolam is a better choice for acute agitation, procedures and for infusions. After single doses midazolam is shorter acting than lorazepam, but has active metabolites and is more likely to accumulate with continuous infusion.

Starting doses

▪ Lorazepam or midazolam: 0.05-1.1 mg/kg (lorazepam max 4 mg, midazolam max 5 mg). Midazolam infusion 1-2 mcg/kg/min

▪ Older children and adolescents often require lower doses (on a mcg/kg basis) than younger children. 0.5-1 mcg/kg/min is often a reasonable starting dose. Be aware of the dose in mg/h, most patients need less than 5 mg/h initially and rarely require more than 10 mg/h.

NSAIDs

All NSAIDs provide equivalent analgesia at appropriate doses. We used ibuprofen for enteral use and ketorolac if IV administration is required. Do not use in patients with coagulopathies, thrombocytopenia, gastrointestinal or other bleeding, recent orthopedic or spinal surgery, renal dysfunction or those at higher risk of renal dysfunction.

Chloral Hydrate

Because of its slow onset of action, chloral hydrate should be given regularly, not on an as needed basis. Adverse effects include bradycardia, arrhythmias and accumulation with prolonged use.

Propofol

Propofol can used for procedural or short term sedation, but is not appropriate for longer term sedation in the PCCU because of safety concerns. It can cause significant hypotension and is best avoided in hemodynamically unstable patients.

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