Sedation and Analgesia for the Pediatric Intensivist: A Clinical Guide

Foreword
Preface
Contents
Contributors
Part I: Sedation and Analgesia for the Critically Ill Child
	Chapter 1: Introduction to Sedation and Analgesia
		Brief History of Pediatric Sedation and Analgesia
		Goal of Sedation and Analgesia in the Critically Ill Child
		Physiology of Pain
		Complexities of Sedation and Analgesia in the Critically Ill Child
		References
	Chapter 2: Safety and Monitoring During Pediatric ICU Sedation
		Assessment Tools
			Pain Assessment
			Self-Report Tools and Surrogate Reporting
			Observational Tools
			Agitation and Sedation Assessment
		Objective Monitoring Tools
			Processed EEG
			Conventional EEG
		Conclusions
		References
	Chapter 3: Analgesic Use in the Pediatric Intensive Care Unit
		Specific Agents
		References
	Chapter 4: Regional Analgesia and Its Role in the PICU
		Introduction
		History
		Safety and Risks of Regional Anesthesia
		Benefits of Regional Anesthesia
		Some Common Blocks
			Central Neuraxial Blocks
			Upper Extremity Blocks
			Truncal Blocks
			Lower Extremity Blocks
		Conclusion
		References
Part II: Sedative Agents
	Chapter 5: Sedative Agents (Benzodiazepines)
		Overview of Benzodiazepines and Mechanism of Action
		Pharmacokinetic and Pharmacodynamic Considerations
		Adverse Reactions, Drug-Drug Interactions, and Monitoring Parameters
		Benzodiazepine and Opioids
		Breastfeeding/Pregnancy Considerations
			Pregnancy Considerations
			Breastfeeding Considerations
		In Summary
		References
	Chapter 6: Alpha-Agonists in Pediatric Critical Care
		Introduction
		Pharmacology
		Clinical Applications
		Conclusion
		References
	Chapter 7: Barbiturates in the Pediatric ICU
		Introduction
		Pharmacology
		Clinical Applications
		References
Part III: Anesthetic Agents
	Chapter 8: Sedation and Analgesia for the Critically Ill Child: Ketamine
		Introduction
		Pharmacokinetics and Pharmacodynamics
			Mechanism of Action
			Dosing
		Uses of Ketamine in the Pediatric Intensive Care Unit
			Ketamine for Sedation
			Ketamine for Acute Pain
			Ketamine for Chronic Pain
		Ketamine Side Effects
		Conclusion
		References
	Chapter 9: Propofol for Sedation of the Critically Ill Child
		Introduction
		Pharmacology
			Mechanism of Action
			Pharmacokinetics
			Pharmacodynamics
		Clinical Considerations for Use
			Indications for Short-Term, Deep Sedation
			Propofol “Drug Washout”
			The Impact of Propofol on Sleep and Delirium in ICU Patients
			Palliative Sedation
			Propofol-Related Infusion Syndrome (PRIS)
				Pathophysiology
				Prevention and Treatment
			Consideration in Special Populations
				Mitochondrial and Metabolic Disorders
		Conclusions
		Bibliography
	Chapter 10: Inhalational Agents: What Volatile Inhalational Agents Are and How to Use Them in the ICU Setting
		Introduction
		Principles of Inhalational Agents
		Minimum Alveolar Concentration
		Uptake and Distribution
		Concentration Effect
		Delivery of the Agent
			Anesthesia Machine Direct Delivery
		Necessary Equipment and Preparation
		Clinical Effects of Inhalational Anesthetics
		Circulatory System
		Cerebral
		Hepatic
		Neuromuscular
		Pulmonary
		Biotransformation and Toxicity of Inhalational Anesthetic Agents
		Isoflurane
		Sevoflurane
		Desflurane
		Advantages of Inhalational Anesthetic Use in the PICU
			Status Epilepticus
		Bronchospastic Airway Disease and Status Asthmaticus
		Alternative Sedation Option for ICU Sedation
		Potential Myocardial and Lung Protection Properties
		Disadvantages of Inhalational Anesthetic Use in the PICU
		Specialized Equipment
		Cardiorespiratory Depression
		Adverse Effects of Inhalational Agents
		Malignant Hyperthermia (MH)
		Immunomodulatory Effects
		Neurocognition Effects
		Conclusions
		References
	Chapter 11: Tolerance and Withdrawal in Critically Ill Children
		Introduction
		Tolerance
		Dependence and Iatrogenic Withdrawal Syndrome
		References
	Chapter 12: Neuromuscular Blockade for the Critically Ill Child
		Introduction
		Neuromuscular Junction
		Pharmacology and Mechanism of Action
		Depolarizing
			Adverse Effects
		Competitive/Non-depolarizing
			Aminosteroid Compounds
				Rocuronium
				Vecuronium
				Pancuronium
			Benzylisoquinolines Compounds
				Atracurium
				Cisatracurium
				Mivacurium
		Other Adverse Effects
		Interactions with Other Compounds
		Monitoring
		Reversal
			Acetylcholinesterase Inhibitors
			Cyclodextrin Derivatives
		Indications for Sustained Neuromuscular Blockade in Critically Ill Children
			Acute Respiratory Distress Syndrome (ARDS)
			Traumatic Brain Injury (TBI)
			Sepsis
			Others
		Adverse Effects of Prolonged NMBA Administration
		Conclusion
		References
Part IV: Special Populations/Considerations
	Chapter 13: Sedation Considerations for Patients with Congenital and Acquired Heart Disease
		Introduction
		Congenital Heart Disease
		Acquired Heart Disease
		Pulmonary Hypertension
		Noncardiac Considerations
		Cardiac Sedation Physiology
		Contraindications to Sedation
		Presedation Considerations
		Specific Medications
			Propofol
			Ketamine
			Etomidate
			Fentanyl
			Midazolam
			Dexmedetomidine
		Sedation Recovery
		Summary
		Suggested Readings
	Chapter 14: Sedation Considerations for ECMO
		Overview
		Effect of ECMO Circuit
		Sedative Choice
		Approaches and Adjuncts in Difficult to Sedate Patients
		Neuromuscular Blockade
		Variations in Sedation Practice and Nurse-Driven Protocols
		Changing Paradigm: Transition to Awake ECMO
		Concluding Remarks
		References
	Chapter 15: Analgesia and Sedation in the Neonate
		Introduction
		Neonatal Pain and Sedation Assessment
		Analgesia and Sedation for Neonatal Procedures
			Endotracheal Intubation
				Opioids
				Sedatives/Hyponotics
					Midazolam
					Propofol
					Barbiturate
				Vagolytic Agents
					Neuromuscular Blocking Agents
			Mechanical Ventilation
				Opioids
					Morphine
					Fentanyl
					Methadone
				Benzodiazepines
					Midazolam
					Lorazepam
				Alpha-Adrenergic Agonists
					Dexmedetomidine
			Intercostal Drain Placement and Removal
			Endotracheal Suction
			Lumbar Puncture
			Peripherally Inserted Central Catheter (PICC)
			Intramuscular or Subcutaneous Injection
			Screening for Retinopathy of Prematurity
			Laser for ROP
			Circumcision
			Therapeutic Hypothermia
			Pre- and Post-Operative Sedation and Analgesia
			Skin Breaking Procedures
				Nonpharmacologic Methods of Pain Relief and Prevention in Neonates
					Oral Sucrose or Glucose
					Nonnutritive Sucking
					Breastfeeding/Breast Milk
					Swaddling and Skin-to-Skin Care
				Local Analgesia for Skin Breaking Procedures
					Lidocaine–Prilocaine Mixture (EMLA)
					Tetracaine Gel (Amethocaine)
			Other Options for Analgesia in the Neonate
				Nonsteroidal Anti-inflammatory Drugs (NSAIDs)
				Acetaminophen
			Adverse Effects of Medications Used for Analgesia and Sedation of the Neonate
		References
	Chapter 16: Sedation and Analgesia in Brain-Injured Children
		Role for Neuromonitoring During Sedation
			Interruption of Sedation Trials
			End-Tidal Carbon Dioxide
			Near-Infrared Spectroscopy
			Pupillometer
		Drug-Specific Considerations
			Propofol
			Benzodiazepines
			Opioids
			Barbiturates
			Dexmedetomidine
			Ketamine
			Neuromuscular Blockade
		References
	Chapter 17: Pediatric Anesthetic and Sedation Neurotoxicity in the Developing Brain
		Background
		Preclinical Studies
			What Are the Long-Term Consequences of Early Exposure to Anesthetic Agents?
			Human Studies
		Anesthesia/Sedation Exposures Outside the Operating Room
		Strategies to Decrease Potential Neurotoxicity from Anesthesia/Sedation Exposure
		References
	Chapter 18: Sedation and Analgesia for Endotracheal Intubation
		Indication for Tracheal Intubation in Pediatric ICU
			General Principles
			Typical Indications
		Factors Associated with Safety of Tracheal Intubation in Pediatric ICU
			Overall Description: Overall Safety Data and Association with Long-Term Outcomes
				Tracheal Intubation Procedural Outcomes
			Specific Factors Associated with Adverse Events and Oxygen Desaturation Events
				Patient Factors
				Provider Factors
				Practice Factors
		Role of Induction Medications for Tracheal Intubations
			Roles and Types of Anticholinergic and Other Adjunctive Medications
			Role and Type of Sedatives and Analgesics
			Roles and Types of Neuromuscular Blockade
		Special Considerations for High-Risk Tracheal Intubations in Pediatric ICU
			Patients with Hemodynamic Instability
			Patients with a Difficult Airway
			Patient with Increased Intracranial Pressure
			Other Special Considerations
		Summary
		References
Part V: PICU Environment and Sedation/Analgesia
	Chapter 19: Sleep in the Pediatric Intensive Care Unit
		Introduction
		The Importance of Sleep in Critically Ill Pediatric Patients
		The Study of Sleep
		Quantitative Measures of Sleep
			PSG and Sleep EEG
			Actigraphy
		Qualitative Measures of Sleep
			Brief Infant Sleep Questionnaire (BISQ)
			Anderson Behavioral State Scale
			Other Multidimensional Measures
		Risk Factors for Poor Sleep
		The Impact of Medications on Sleep
		Special Populations at Risk
			Mechanically Ventilated Patients
			Postsurgical Patients
		Delirium
		Sleep Promotion in the PICU
		Conclusion
		References
	Chapter 20: Delirium
		What Is Delirium?
		Clinical Presentation
		Etiology
		Epidemiology
		Outcomes
		Risk Factors
			Predisposing Factors
			Precipitating Factors
		Diagnosis
		Treatment
			Underlying Disease
			Iatrogenic Factors
			Environment
			Pharmacological Intervention
		Prevention
		Conclusions
		References
	Chapter 21: Mobility in the PICU
		The Consequences of Critical Illness
		The Benefits of Early Mobility Versus Bedrest: Unpacking the Evidence
		Barriers to Early Mobility in the PICU
		Safety and Feasibility of Early Mobility in the PICU
		Facilitating Early Mobility in the PICU
		Conclusions
		References
	Chapter 22: Palliative Sedation
		Introduction
		Ethical Considerations
		Symptom Management
		Guidelines and Protocols
		Moral Distress
		Final Considerations
		References
	Chapter 23: Child Life in the Pediatric ICU
		Child Life Profession Defined
			Role of Child Development
		General Principles of Child Life
			Procedure-Specific (Refer to “Child Life for Procedural Sedation”, Chap. 33)
				Diagnosis Education and Preparation
			Role and Value of Play
		Stress-Induced PICU Outcomes
			Environmental Stressors for Patients
			Developmental Stressors for Patients
			Early Mobility
			PICU Delirium
			Pain Management
			Positive Touch, Swaddling, and Infant Massage
			Communication
		Family Stressors
			Parents and Caregivers
			Siblings
		End-of-Life Care
			Death and Dying
			Memory Making and Legacy Building
			Post-intensive Care Syndrome
		Areas for Future Growth
		References
	Part VI: Procedural Sedation
		Chapter 24: Introduction to Procedural Sedation Within and Outside the ICU
			Overview of Pediatric Procedural Sedation
				The Sedation Continuum
				Standardized Monitoring
			Components of Quality Sedation Practice
				The Practitioner Skills and Competencies
				The Sedation Structure
				The Sedation Process and Work System
			Delivering High-Quality Procedural Sedation
			Conclusion
			References
		Chapter 25: Screening of Children for Procedural Sedation Outside the Operating Room
			Introduction
			Risk Factors Associated with Sedation-Related Adverse Events
				Previous Sedation History
				Airway and Breathing History
				Recent Illness
				Cardiac History
				Neurologic History
				Sleep-Disordered Breathing
				Genetic and Metabolic Conditions
				Premature Birth
				Obesity
			Contraindications for Sedation/Reasons to Refer to Anesthesiology
			Sedation of Hospitalized Patients
			Conclusions
			References
		Chapter 26: Choosing a Sedation Regimen
			Goals of Pediatric Procedural Sedation
			Pharmacological Considerations and the Therapeutic Window
				Pharmacodynamic Principles
				Pharmacokinetic Principles
				Pharmacodynamic-Pharmacokinetic Interactions
			Procedural Considerations
			Approaches to Choosing a Sedative Regimen
			References
	Part VII: Sedative and Analgesic Agents Available
		Chapter 27: Analgesic Agents
			Local Analgesics
				Injectable Local Anesthetics
				Topical Local Anesthetics
			Systemic Analgesics
				Non-opioid Systemic Analgesics
				Opioids
				Dexmedetomidine
				Ketamine
			References
		Chapter 28: Benzodiazepines and Barbiturates
			Benzodiazepines
				Mechanism of Action
				Pharmacokinetics
				Dosing and Clinical Effects: Shown in Table 28.1
				Midazolam
				Lorazepam
				Diazepam
				Adverse Effects
					Paradoxical Reactions
				Conclusion
			Barbiturates
				Mechanism of Action
				Pharmacokinetics
				Adverse Effects
				Conclusion
			References
		Chapter 29: Alpha-agonists in Pediatric Procedural Sedation
			Mechanism of Action
			Pharmacokinetics and Pharmacodynamics
			Adverse Events
			Uses in Sedation
			Dosing
			Summary
			References
Part VIII: Anesthetics
	Chapter 30: Procedural Sedation in Children: Ketamine
		Introduction
		Pharmacology
		Systemic Effects
		Indications
		Dosing and Routes of Administration
		Adjuncts to Use/Co-administration with Other Drugs
			Anticholinergics
			Antiemetics
			Benzodiazepines
			Ketamine and Propofol (“Ketofol”)
			Ketamine and Dexmedetomidine (“Ketadex”)
		Contraindications and Special Precautions
		Conclusion
		References
	Chapter 31: Propofol
		Background
		Use as an Anesthetic/Sedative Agent
		References
	Chapter 32: Nitrous Oxide
		Introduction
		History
		Nitrous Oxide: The Basics
		Nitrous Oxide Delivery: Nuts and Bolts
		Safety Features for Delivery of Nitrous Oxide
		Nitrous Oxide: From Theory to Practice
		Dental Procedures
			Cannulation for Peripheral Intravenous Placement or Blood Draw
		Lumbar Puncture
		Voiding Cystourethrography
		Other Considerations
		Conclusion
		References
Part IX: Special Circumstances
	Chapter 33: Child Life for Procedural Sedation
		Overview and Child Life Background
		Where to Begin
		Before the Procedure/Preparation
		During a Procedure/Support
		One Voice
		Positioning for Comfort
		Coping Plans/Strategies
		Coping Plans and Children with Autism
		Distraction
		Conclusion
		Appendix A
		Appendix B: Misconceptions in Health-Care Language for Children
		Appendix C: Positioning for Comfort
		Appendix D: Ideas on Questions to Ask in Creating a Coping Plan
		References
	Chapter 34: Risk Stratification for Procedural Sedation
		Overview
		Location of Procedure
		Procedure Type
		Chronic Conditions
		Acute Conditions
		References
	Chapter 35: Nursing Considerations
		Pre-procedure Nursing Considerations
			State Regulations
			Organizational Policies and Procedures
			Sedation Competency
		Setting
			Equipment
			Remote Locations
		Patient Preparation
			Prescreening
			Developmental Concerns
			Parent/Caregiver and Patient Education
		Intra-procedural Considerations
			Medication Administration
			Time-Out and Monitoring
		Post-procedural Considerations
			Recovery Phase
			Monitoring for Complications
			Discharge/Transfer/Discontinuation of Recovery Monitoring
			Discharge/Transfer Education
			Follow-Up
		References
Part X: Sedation Training
	Chapter 36: Simulation in Pediatric Procedural Sedation
		Introduction
		The Role of Simulation in PPS
		Debriefing
		Types of Simulators (Table 36.2)
		Institutional Application of Simulation in PPS (Clinical Training and Team Dynamics, System and Process Improvement, Quality and Safety Initiatives)
		Curriculum Development for Sedation-Analgesia and Clinical Training
		Sedation-Analgesia Team Dynamics
		Examples of Clinical Simulation Scenarios
			Case Scenario 1
			Case Scenario 2
			Case Scenario 3
			Case Scenario 4
			Case Scenario 5
			Case Scenario 6
		References
Index