Analgesia and Procedural Sedation Module

See RCEM Pain in Children – Best Practice Guidance for a guide on how to assess pain.

Consider different assessment tools:

• FLACC (Face, legs, activity, cry, and consolability)
• Wong Baker Faces
• Visual analogue scale

See the analgesic ladder (RCEM guidance above and the WHO pain ladder).

Adjuvants should be considered in all steps of the ladder.

Bottom of the ladder is the most commonly used paracetamol (at 15mg/kg/dose) and non-steroidal anti-inflammatory drugs (NSAIDs). Paracetamol is an antipyretic and weak analgesic. It is used for the treatment of mild pain and fever associated with a sore throat or illness. But we should avoid oligo-analgesia and use the right drug for the right kind of pain.

Moving up the ladder are weak opioids like codeine. Codeine (an inactive compound of morphine) is no longer recommended for the management of acute moderate pain, particularly in children under 12 years with obstructive sleep apnoea or for post tonsillectomy procedures. Codeine must be metabolised by the cytochrome P450 enzyme 2D6 to the active compound, morphine, to relieve pain. Poor metabolisers of codeine may metabolise only up to 15% of the morphine concentration, receiving little or no analgesia from codeine. Ultra rapid metabolisers may metabolise up to 50% more morphine than normal metabolisers – which is potentially life threatening.

Children with moderate to severe pain should receive opioids together with non opioids. Morphine, oxycodone, hydromorphone are all active compounds that do not require the enzyme conversion to provide analgesia. Fentanyl, a synthetic opioid, has few, if any cardiovascular side effects. This is in contrast to morphine which may exacerbate hypotension with its vasodilatory effects. So in haemodynamically unstable children, fentanyl may be the preferred choice for acute pain management.

It’s easy to use, it’s needle-less, and decreases the overall need for utilisation of IV or IM routes which is a positive change in parent and patient satisfaction. It bypasses first pass metabolism permitting rapid and predictable bioavailability (compared with oral and intramuscular routes) and offers direct CSF delivery via the nose- brain pathway route

The maximum volume of IN medication permitted is 1ml per nostril and in cases of nasal trauma or septal defects, IN Fentanyl of course cannot be used. Rule of thumb, the IN dose is 2-3 times the IV dose.

Administer intranasal medications in the sniffing position. Lie the patient flat with occiput posterior, put patient in the sniffing position, seat the mucosal atomizing device cushion in the nostril, aim toward the pinna of the ear, and shoot fast – you have to push the drug as fast as you can to atomize the solution.

IN medication can be used for sedation, anxiolysis, pain control and seizure management. A 2014 Cochrane review on intranasal fentanyl concluded that it can be an effective analgesic for children aged 3 years and above with acute moderate to severe pain. Studies have demonstrated INF to result in decreased time to medication administration and equivalent pain control when compared to IV morphine, oral morphine or IV Fentanyl. IN Fentanyl (1.5mcg/kg) has become an excellent alternative to morphine in the ED, it has a greater safety profile and is easily available in the ED.

How does it compare to IN Fentanyl? One study demonstrated a similar pain reduction in children with moderate to severe pain from an isolated limb injury in the Paediatric ED, although the sample size was small and there was no comparator or placebo group. Adverse effects were more frequent with ketamine; however, these were all relatively mild (drowsiness and dizziness). Also, practically speaking, pain control doses for the IN Ketamine route at 1mg/kg mean that volumes for most children weighing above 10kg will exceed 1ml per naris if the ketamine concentration 10mg/ml is used.

An alpha-2 receptor agonist (like clonidine), does not markedly decrease blood pressure. Dexmedetomidine targets receptors in the CNS and spinal cord, and so it provides deep sedation, with very minimal blood pressure effects. It induces a sleep-like state. In fact, EEGs done under dex show the same pattern as seen in stage II sleep. Dexmedetomidine is safe, if titrated, and does not depress airway reflexes or respiration. Dose is 2.5 mcg/kg IN, and can add another 1 mcg/kg if needed. The downside is that it can last 30 minutes or more, but it may be a good choice for an abdominal ultrasound or CT head.Inflicting Pain with an IV to relieve pain is not something that makes sense to young children. IN medication offers pain relief prior to getting intravenous access and can even obviate the need for IV access if definitive care such as a cast, suturing, reduction of bony injuries can be done during the duration of action of the IN medication.

It is important these are thought about in conjunction with pharmacological techniques. These include:
Play specialists

• Distraction techniques
• Music
• Games
• Don’t forget the Bubbles

Immobilisation of injuries

Environment

• Right people
• Right place  
• Right time

Parental/carer anxiety

Sucrose, and non-nutritive sucking interventions exert analgesic effects independent of the opioid pathway. Swaddling/facilitated tucking (preterm) and skin to skin care significantly increase B-endorphin levels.

Rocking/holding neonates and breastfeeding during minor procedures have all been shown to decrease objective measures of pain such as heart rate and crying.

Pain should be assessed on arrival and then monitored throughout their time in the emergency department and if appropriate beyond. Children in moderate and severe pain should have their pain reassessed within 60 minutes of receiving analgesia.

• Unsuitable for under 1s
• Takes 20-30 minutes to work
• Skin will blanch when ready
• Max dose: 2 mls for 1 -3 year; 3 mls for >3 years
• Not for use on: mucous membranes; extremities; wounds >8 hours old
• Can be used in conjunction with local anaesthetic infiltration
• Max dose not to exceed 5mg/kg

• Inject slowly to reduce pain
• Small gauge needle to reduce pain
• Doses: 3mg/kg lidocaine

EMLA cream (lidocaine 2.5% and prilocaine 2.5%) is effective at numbing the tissue below intact skin to a depth of 6-7mm if left on for 30-60 min but does cause vasoconstriction which can be problematic if looking to cannulate.

LMX4, a topical liposomal 4% lidocaine cream like EMLA has full effectiveness by 30 minutes.

• Play specialist
  Distraction techniques appropriate to age
• Preparation of the child and area
• Quiet setting
• Parental/carer involvement
• Using appropriate language

Nitrous oxide provides anaesthesia, anoxiolysis and some mild amnesia but offers limited analgesia. Administration of analgesic supplements is recommended. Many papers including the FAN study demonstrate the safety and efficacy of co-administering intranasal fentanyl. Other analgesics can also be safely used.

There are two methods of delivering nitrous oxide, piped nitrous oxide and Entonox. Piped nitrous oxide can provide variable concentrations and can be titrated to response, whereas entonox is a fixed 50/50 mix of nitrous and oxygen and comes in canisters. The canister is set up with a demand value that needs to be overcome with a deep breath; this can be difficult for under 5’s.  You should see onset of effect in 30-60 seconds with the peak effect at 2-5 minutes. Offset of effects is similar at 2-5minutes, 100% oxygen should be applied during this time post procedure to avoid diffusion hypoxia.

Side effects are minor and transient but include:

• Nausea
• Vomiting (6-10% children receiving 50% dose). Increases incidence with higher dose, longer duration and concurrent opioid use. Consider prophylactic antiemetic if child has history of nausea or vomiting.
• Dizziness
• Nightmares

Nitrous oxide diffuses through tissues more rapidly than nitrogen alone and can expand in air containing spaces within the body, so it is contraindicated in:

• Pneumothorax
• Pneumocephalus
• After diving
• Gastrointestinal obstruction

Nitrous oxide inactivates the vitamin B12 dependent enzyme, methionine synthase and can deplete the B12 stores.  Therefore caution is advised in those at risk of vitamin B12 deficiency (vegetarians, patients with gastrointestinal disorders and those taking regular H2 receptors and proton pump inhibitors)

Despite the absence of use of intravenous sedative drugs, it is best practice to manage this patient in a high dependency setting, with monitoring including; respiratory rate, heart rate and oxygen saturations and at least 2 members of staff where one’s job is entirely focused on the sedation and monitoring of the child.

Guided imagery would work well in this setting with a trained practitioner.  This is a process where a variety of techniques can be used such as simple visualisation, story telling, direct suggestion imagery and fantasy exploration to elicit a physical response such as a reduction in pain, stress or anxiety.

Summary: procedure appropriate for sedation – post procedure simple airway issues due to obesity

Faculty required: operator/Voice of patient/Nurse in scenario

Vitals: HR 120, BP 105/60, Sats 99%, RR 20, ETCO2 4.2, ECG NSR

Neurovascular compromise of the foot, CRT delayed

PMH: nil

BH: term, nil complications

DH: nil

NKDA, UTD with immunisations

Last ate 2 hours prior

• Check full medical history
• ASA status
• Airway assessment (loose tooth, excess body fat)
• Ensure appropriate setting (RESUS)
• Appropriate equipment and monitoring (ECG, EtCO2, Sats, HR, RR, BP, suction, tilting table, resuscitation facilities)
• Describe consent
• WETFLAG calculations plus emergency drug calculations
• Choice of appropriate drugs and dosing for sedation
• Ensure appropriate staff
• Pre-oxygenation
• Checks patient during procedure

When should you assess a child’s pain and document a pain score in the emergency department when they present with an injury?

A: Wait until the child is seen by a doctor before assessing pain

B: At triage

C: Immediately after giving oral analgesia

D: Within 60 minutes of receiving analgesia for moderate and severe pain

E: When the child or the child’s parents informs you they are in pain

The correct answer is B + D.

A child’s pain should be assessed on arrival in the emergency department, and should be treated appropriately in a timely manner (within 20 minutes for moderate and severe pain). Pain should also be re-evaluated within 60 minutes of receiving analgesia for moderate and severe pain. This process should be repeated for all subsequent doses of analgesia. Reviewing pain should take into account peak of onset for the analgesia given; as such oral analgesics will not work immediately.

Which of the following predict possible airway difficulties in children?

A: C-spine immobilisation

B: Premature birth requiring NICU

C: Trisomy 21

D: Mouth breathing or frequent drooling

E: Reduced mouth opening

All are true.

A through pre assessment prior to sedation should be done to elicit any potential complications and also decide on appropriateness of sedation in the emergency department.

A formal airway assessment should include:

• Mouth opening
• Assessment of dentition for loose and protruding teeth
• Tongue size
• Presence of soft tissue masses in the mouth
• Mandible size
• Neck mobility
• Tempero-mandibular joint mobility

A review of the child’s medical history should also include, congenital abnormalities, birth complications, previous complications during anaesthetics or sedation, noisy breathing, sleep issues and concurrent upper respiratory tract infections.