THE SPECTRUM OF PAEDIATRIC SEDATION
1. Watchful waiting
*Combination of 1-9
1. Watchful Waiting
Sometimes its better to do nothing than to do something. Like that time when you saw a kids with a scalp lac that you brought back the next day for daylight sedation only to see a well opposed healing laceration? Pick your patients, pick their pathology and ask yourself if they deserve a 'trial of nothing'.
Parents will sometimes comment that the house could be burning down and their kids would still be glued to tv/i-device/computer. The psychological power of distraction should not be underestimated. It's infinitely low risk-benefit ratio is unmatched in the pharmacological universe!
Emla (topical lignocaine 25mg/g & Prilocaine 25mg/g) or
Laceraine (4% Lignocaine, 0.1% adrenaline, ).1% amethocaine)
If the opportunity exists, 1% lignocaine infiltrated into effected tissue is also an option.
Regional blocks and Bier's blocks are less likely to succeed in this population, but always worth keeping in the back of your head.
Never underestimate the mysteries of breast milk and/or sucrose in children < 3months (0.25ml prior to procedure and titrate with 0.25ml during the procedure to a max dose of 2ml - max 0.5ml if < 1.5kg).
The synergistic effects of simple analgesia should not be ignored. Appropriate doses of paracetamol & ibuprofen can go a long way.
Use 100mcg/2ml strength fentanyl solution (i.e. for intravenous use)
First dose - 1.5 mcg / kg dose
A second dose may be administered 10 minutes after the first to provide adequate analgesia - 0.75 - 1.5mcg/kg
After 2nd dose, if further analgesia is required, review and consider alternative or additional analgesia
Often used in combination with nitrous
Entenox (50/50 NO/O2) - Demand Valve
Requires co-operative child, onset within a few breathes and offset similar
Continuous Flow Meter (variable concentrations from 0-70% NO)
Start with 100% O2 and titrate to effect
Don't forget that inhalation anaesthetics are an option...a very last line option.
NB DO NOT use when concerned about air filled cavities e.g. PXT, Asthma, Middle ear infection
To some extent a level of restraint is applied to the paediatric patient (e.g. auricular examination). The potentially present and future consequences of restraint can make attempts at a procedure and future interactions infinitely more difficult. The level of restraint will need to be assessed on an experience and per child basis.
NEVER rely on a parent to restrain a child for a procedure. Firstly, they are (understandably) unreliable when their child is agitated and secondly, you should use "cuddles with mum or dad" as the 'reward' for enduring.
Now we're getting into true 'procedural sedation' territory
IM Ketamine is best used when there is a procedure to be done with a clear time-frame (e.g. fracture reduction or non-fiddly laceration).
The other indication for IM Ketamine is also in the case of the uncooperative child who needs IV titration of ketamine.
Suggested dose 4-5mg/kg with a 2-5 min onset (variable) & delayed offset
If needed you can titrate with a second dose of 2mg/kg once only.
The final frontier in emergency sedation.
Ketamine seems to be the drug of choice - maintain airway reflexes, triple whammy with amnesia/anaesthetic/analgesia effect and for the large part cardiorespiratory stable.
Suggested dose 1-1.5mg/kg slow push over 1-2min (any faster can induce larnygospasm) If needed you can titrate to effect with 0.5mg/kg slow pushes
Other things about Ketamine
And of course, in older kids don't forget about the sweet milk of Propofol!