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Pain Management and Sedation

Pain Management and Sedation. Nightfloat Curriculum 2010-2011 LPCH Pediatric Residency Program. Teaching Goals. Be comfortable initiating pain medications Learn to assess pain and modify treatment strategies

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Pain Management and Sedation

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  1. Pain Management and Sedation Nightfloat Curriculum 2010-2011 LPCH Pediatric Residency Program

  2. Teaching Goals • Be comfortable initiating pain medications • Learn to assess pain and modify treatment strategies • Know how to choose appropriate sedation strategies based on patient age and procedure

  3. Pain Management • Pediatricians often under-treat children’s pain • When initiating pain medications, a standing regimen is preferable • PRN = Patient Not Receiving • Avoid combination products (i.e. Vicodin) at first • Constantly re-assess your pain plan • Is it working? • Any side effects?

  4. Assessing Pain • Infants • FLACC • Verbal Children • Scale of 1-10 (may use faces and/or numbers)

  5. FLACC

  6. Pain Medications • Acetaminophen • PO: 10-15 mg/kg every 4-6 hours • PR: Loading dose 35-50 mg/kg; Maintenance dose 20 mg/kg every 6 hours • NO MORE THAN 5 DOSES in 24 hours • Ibuprofen • PO: 5-10 mg/kg every 6-8 hours • MAX 40 mg/kg/day • Contraindicated in active GI bleeding, hypersensitivity to NSAIDs • Caution in severe asthmatics

  7. Pain Medications • OPIATE – If one doesn’t work, try another • AVOID Codeine • 1/3 of patients gain no analgesia • Morphine • PO: 0.2-0.5 mg/kg every 4-6 hours • IV: 0.05-0.2 mg/kg every 2-4 hours • PCA: 0.015 mg/kg/hr basal with 0.015 mg/kg PCA dose q10 min lockout

  8. Pain Medications • Oxycodone • PO: 0.1-0.2 mg/kg every 3-4 hours • Fentanyl • IV: 0.5-4 mcg/kg every 1-2 hours • Hydromorphone • PO: 0.03-0.08 mg/kg every 3-4 hours • IV: 0.015 mg/kg every 3-6 hours

  9. Moderate Sedation • Patient Assessment • ASA Class • Airway • Allergies • Informed Consent • Risks and benefits

  10. Moderate Sedation • Sedation certified nurse • Monitoring • Suction and bag-mask readily available • Reversal agents ordered and drawn up

  11. Moderate Sedation • Midazolam • PO: 0.5 mg/kg per dose, may repeat with 0.25 mg/kg; max 20 mg • IV: 0.05-0.1 mg/kg per dose, may repeat up to total of 0.2 mg/kg • Intranasal: 0.2-0.3 mg/kg per dose administered in 1 ml syringe over 15 seconds • Lorazepam • IV, PO: 0.05 mg/kg/dose every 4-8 hours; max 2 mg per dose

  12. Moderate Sedation • Chloral Hydrate • PO: 50 mg/kg as single dose, may repeat with 25 mg/kg after 20 minutes; max 100 mg/kg in 24 hours • Preferred in younger children and with painless procedures • Pentobarbital • PO, IM, IV: 4 mg/kg, may repeat with 2 mg/kg; max is 100 mg • May cause HYPERalgesia – avoid in painful procedures

  13. Reversal Agents • Flumenazil • IV: 0.01 mg/kg/dose given over 15 seconds, may repeat every minute; max TOTAL dose is 0.05 mg/kg or 1 mg • Naloxone • IV, IM, ET, SubQ: 0.001 mg/kg/dose, MINIMUM dose is 0.01 mg, may repeat every 1-2 minutes

  14. Case 1 • 15 month infant needs an urgent lumbar puncture. What agents would you use for sedation and analgesia? • What if she needed to get an MRI?

  15. Case 2 • A 4 year old has recently returned from having an abcess drained and has a painful JP drain in place. How would you treat his pain?

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