Analgosedation
Description Diagnostic criteria General and supportive measures Medicine treatment DESCRIPTION With respect to the comfort of critically ill children, the first priority is ensuring adequate analgesia, best assessed by validated pain assessment scales such as the revised FLACC (R-FLACC), Wong-Baker Faces, Numeric Pain Rating etc. However, sedation is routinely required to minimise anxiety and fac
General and supportive measures
DESCRIPTION
With respect to the comfort of critically ill children, the first priority is ensuring adequate analgesia, best assessed by validated pain assessment scales such as the revised FLACC (R-FLACC), Wong-Baker Faces, Numeric Pain Rating etc. However, sedation is routinely required to minimise anxiety and facilitate both the delivery of therapies, and performance of various invasive procedures associated with intensive care of children. To optimise the use of sedatives, it is essential to utilise age-appropriate sedation scales, e.g. COMFORT-B Scale or Richmond Agitation Sedation Scale, regularly (4–8 hourly). Please note that many sedatives may decrease blood pressure and prolonged usage is associated with delirium and other adverse outcomes.
DIAGNOSTIC CRITERIA
COMFORT-B Scale Score
| Alertness |
1 – Deeply asleep (eyes closed, no response to changes in environment). 2 – Lightly asleep (eyes mostly closed, occasional responses) 3 – Drowsy 4 – Awake & alert. 5 – Awake & hyper-alert. |
How responsive is the patient to the ambient light, sound and activity around them? Monitors, phones, talking.
|
| Calm/ Agitation |
1 – Calm 2 – Slightly anxious 3 – Anxious 4 – Very anxious 5 – Panicky |
How would you rate the patient’s level of anxiety?
|
| Respiratory response (intubated & ventilated) |
1 – No spontaneous respiration, no cough. 2 – Spontaneous breathing no resistance to ventilator. 3 – Occasional cough or resistance to ventilator. 4 – Actively breathes against ventilator or coughs. 5 – Fights ventilator coughing or choking. |
How comfortable and compliant is the patient with ventilation via ET tube?
|
| Respiratory response (crying & self- ventilated) |
1 – Quiet breathing, no crying sound. 2 – Occasional sobbing or moaning. 3 – Whining or monotonous sound. 4 – Crying 5 – Screaming or shrieking. |
How would you score the intensity of verbal response? (Significance should be given to the characteristics of the cry, not to the presence of tears.)
|
| Physical Movement |
1 – No movement. 2 – Occasional (3 or fewer) slight movements. 3 – Frequent, (> 3) slight movements. 4 – Vigorous movements limited to extremities. 5 – Vigorous movements include torso & head. |
What is the intensity & frequency of the patient’s movements?
|
| Muscle Tone |
1 – Muscles totally relaxed; no muscle tone. 2 – Reduced muscle tone; less than normal. 3 – Normal muscle tone. 4 – Increased muscle tone, increased flexion of fingers & toes. 5 – Extreme muscle rigidity & flexion of fingers & toes. |
How does the patient’s muscle tone compare to a normal awake & alert child of the same age/stage of development? Flex/extend limb. (Assess this section last.)
|
| Facial Muscles |
1 – Facial muscles totally relaxed. 2 – Normal facial tone. 3 –Tension evident in some muscles (not sustained). 4 – Tension evident throughout muscles (sustained). 5 – Facial muscles contorted and grimacing. |
How does the patient’s facial movement/tension compare to that of an awake & alert child of the same age/stage of development
|
Score uses 6 components; use only 1 respiratory score depending on whether the patient is intubated or not.
GENERAL AND SUPPORTIVE MEASURES
Pharmacotherapy is just part of the overall strategy to decrease the distress of critically ill children. It is crucial to also employ non-pharmacological strategies such as parental presence, calming music, distraction therapy, reduction of unnecessary alarms and environmental noise. Bundling of procedures also limits exposure to distressing situations.
MEDICINE TREATMENT
During continuous mechanical ventilation
| IV Bolus Dose | IV Infusion Dose | Comments | |
| Analgesic | |||
| Morphine | 0.05–0.3mg/ kg | 20–80µg/kg/ hour |
Significant vasodilator. Needs dose adjustment for renal failure. |
| Fentanyl | 1–5µg/ kg | 1–4µg/kg/ hour | Easier to titrate due to faster onset of action, but higher risk of tolerance/ tachyphylaxis. |
| Sedative | |||
| Midazolam | 0.05–0.2mg/ kg | 50–200µg/kg/ hour |
Significant vasodilator. Needs dose adjustment for renal failure. |
| Lorazepam | 0.05–0.1mg/ kg | 0.05– 0.15mg/kg/ hour |
Maximum daily dose 2 mg/kg or 100 mg. Useful for anticipated longer term sedation, t½ 10–20 hours. |
| Propofol | 0.5–1mg/ kg | 1.5–4 mg/kg/ hour | For maximum of 48 hours continuously, significant vasodilator. |
| Ketamine | 1–2mg/ kg | 5–40 µg/kg/ min | Currently recommended as an adjunctive sedative. |
Procedural Sedation
Take standard precautions for respiratory arrest.
| Drug | Dose | Comments |
| Ketamine |
0.25–1mg/kg, IV 2–4 mg/kg, IM 6–10 mg/kg, oral |
Both sedative and analgesic. |
| Midazolam |
0.025–0.1 mg/kg, IV 0.1–0.2 mg/kg, IM 0.25–0.5 mg/kg, oral 0.2–0.3 mg/kg, IN 0.3–0.5 mg/kg, PR |
Purely sedative, therefore, will need to combine with an analgesic (opioid) for painful procedures. |
| Fentanyl |
0.25 µg/kg, IV 1–2 µg/kg, IN |
For painful procedures. Administer slowly to reduce risk of chest wall rigidity. |
Standard Treatment Guidelines And Essential Medicines List For South Africa, Hospital Level, Paediatrics, 2023 Edition
Chapter 23: Paediatric Intensive Care, 23.2 Analgosedation