SEDASI DAN ANALGESIA ANAK SAKIT KRITIS

Palembang 2014

SEDASI DAN ANALGESIA ANAK SAKIT KRITIS

Dadang Hudaya Somasetia UKK Gawat Darurat Pediatri, IDAI

Palembang 2014

DISCLOSURE

Dr Dadang Hudaya Somasetia certify that there is no conflict of interest in relation to this presentation.

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Sedasi dan Analgesia Anak Sakit Kritis Palembang 2014

TUJUAN PEMBELAJARAN 1.  Mengenal obat serta metode sedasi dan analgesia pada anak sakit kritis 2.  Memahami cara melakukan sedasi dan analgesia pada anak sakit kritis 3.  Menguasai teknik sedasi dan analgesia pada anak sakit kritis

Sedasi dan Analgesia Anak Sakit Kritis

PENDAHULUAN •  •  •  • 

Luaran fisiologis, neurologis & psikologis Sedatif mengurangi rasa cemas & gelisah Analgesia mengatasi rasa nyeri Kombinasi sedatif dan analgesia

Sedasi dan Analgesia Anak Sakit Kritis Sedasi dan analgesia tidak adekuat: à  Respons stres metabolik, à  humoral, à  hemodinamis Kaskade neuroendokrin à  konsumsi O2 ↑, produksi CO2 ↑, à  katabolisme, balans nitrogen (–)


Batasan Sedasi Tindakan untuk menenangkan, terutama dengan pemberian sedatif, atau upaya yang menenangkan Sensasi nyeri/rangsang hebat (-) Rasa takut dan kecemasan (-) Potensiasi dg analgesia, ingatan traumatis (-)

Analgesia Kondisi stimuli nosiseptif terasa tetapi tidak diinterpretasikan sebagai nyeri Biasanya diberikan bersama-sama dengan sedasi tanpa kehilangan kesadaran

Obat Sedatif dan Analgesik Ideal •  Onset cepat •  Durasi dapat diprediksi •  Tidak menghasilkan metabolit aktif •  Pulih cepat •  Rute masuk obat multipel •  Mudah dititrasi •  Efek kardiopulmonum minimal •  Tidak dipengaruhi oleh penyakit ginjal dan hati •  Tidak ada interaksi dengan obat lain •  Indikasi terapi luas

Pemakaian Sedasi - Analgesia Pertimbangan memilih obat: Indikasi Durasi yang diharapkan Farmakodinamik Indikasi kontra •  Hilang rasa nyeri, •  •  •  •  • 

Ventilasi Mekanis Pascaoperasi Cedera kepala (head injury) Hipertensi pulmonum Berbagai prosedur klinis

takut dan cemas •  Amnesia •  Kooperatif •  Kenyamanan •  Keamanan

Tingkatan Sedasi Sedasi Minimal (Ansiolisis) Masih berespons normal terhadap perintah verbal. Kognitif dan koordinasi baik Tidak memengaruhi sal. napas, ventilasi, kardiovaskuler

Sedasi Menengah (Sedasi Sadar [Conscious Sedation]) Masih merespons perintah verbal atau rangsang taktil minimal Tidak perlu intervensi sal. napas dan pernapasan, kardiovaskuler dipertahankan

Sedasi Disosiatif Kataleptis ~ kondisi ‘trans’ yg diinduksi ketamin, analgesia dalam dan amnesia, Retensi refleks protektif sal. napas, napas spontan & fungsi kardiopulmonum

Sedasi Dalam Depresi, sulit dibangunkan, respons rangsang nyeri (+) à perlu alat bantu patensi ventilasi & kardiovaskuler

Anestesia Umum Hilang kesadaran, tidak dapat dibangunkan. Ventilasi spontan terganggu à alat bantu patensi sal. napas & fungsi kardiovaskuler, VTP

Tabel 1. Berbagai Sistem Skoring Sedasi

Subjective Observer Rating

Visual analog scales Sedatif-Analgesik yang Sering Dipakai Steward Ramsay Harris Modified Glasgow Coma Scale Observer’s Assessment of alerness/Sedation Scale (OAA/S) Cambridge Bloomsbury Cook/Newcastle Neurobehavioral Assessment Scale (NAS) Sedation-Agitation Scale (SAS)

Patient Task Performance Digital symbol substitution test (DSST) Choice reaction time (CRT) Memory tests Visual analog scales

Physiologic Measures Included COMFORT Nisbet and Norris Heart rate variability Esophageal sphincter contractility PRST (Pressure, rate, sweat, tearing)

Sedasi dan Analgesia Tabel 2. Skala Ramsay untuk Penilaian Sedasi Tingkat

1 2 3 4 5 6

Deskripsi Sedasi Skala Ramsay

Sadar, cemas; gelisah atau tidur gelisah, atau keduanya Sadar, kooperatif, terorientasi, dan tenang Respons hanya terhadap perintah verbal Mengantuk, respons cepat thd ketukan ringan glabela atau rangsang suara keras Mengantuk, respons lambat thd ketukan ringan glabela atau rangsang suara keras Mengantuk, tidak ada respons thd ketukan ringan glabela atau rangsang suara keras

Tabel 3. Skala COMFORT untuk Menilai Sedasi Alertness Deeply asleep Lightly asleep Mengantuk Fully awake and alert Hyperalert Calmness/agitation Calm Slightly anxious Anxious Very anxious Panicky Heart rate Denyut jantung (HR) < baseline Denyut jantung sesuai baseline HR jarang >15% diatas baseline (1−3 selama periode observasi) HR sering >15% diatas baseline (>3 selama periode observasi) HR terus menerus sekitar >15%) Facial Tension Otot fasial relaksasi total Tonus otot fasial normal, tidak ada tegangan otot fasial yang jelas Tegangan jelas pd beberapa otot fasial Tegangan jelas pada seluruh otot fasial Otot fasial mengerut dan meringis

Mean arterial blood pressure (MAP) Tekanan darah MAP di bawah baseline Tekanan darah MAP pada baseline MAP jarang >15% di atas baseline MAPsering >15% di atas baseline (>3 selama periode observasi) MAP terus menerus >15% diatas baseline Respons respirasi Tidak ada batuk dan napas spontan Napas spontan, sedikit atau tidak ada respons ventilasi Sesekali batuk atau resistensi ventilator Bernapas aktif terhadap ventilator Batuk atau selalu melawan ventilator, batuk atau tersedak Tonus otot Relaksasi otot total, tidak ada tonus otot Penurunan tonus otot Tonus otot normal Tonus otot meningkat, fleksi jari tangan& kaki Rigiditas otot ekstrim Physical movement Tidak ada pergerakan Sesekali dan sedikit pergerakan Sering, sedikit pergerakan Pergerakan kuat pada ekstremitas Pergerakan kuat termasuk torso dan kepala

1 Sedatif-Analgesik yang Sering Dipakai 2 3 4 5 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5

1 2 3 4 5 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5

The COMFORT SCALE, 6 behavioral and 2 physiologic measures. The nurse observes the patient for 2 minutes during which the patient is scored on alertness, degree of calmness or agitation, respiratory response, physical movement and facial tension. The administrator observes the heart rate and mean arterial blood pressure every 15-20 seconds and determines whether these are within 15 % of the baseline. Total scores can range between 8 and 40. A score of 17-26 generally indicates adequate sedation and pain control.

The FLACC (Faces, Legs, Activity, Cry and Consolability) pain assessment tool to recognize pain and make the right analgesic choice. The use of this tool is appropriate in preverbal children in pain from surgery, trauma, cancer or other disease processes. Behavioral assessment tool for scoring postoperative pain in nonverbal patients This scale may also be helpful in the aphasic patient Indicators are divided in 5 categories : facial expression, movement (of legs), activity, cry and consolability. Each item is scored from 0 - 2. The total score is between 0 and 10. A score between 1 and 3 = no or mild pain, between 4 and 6 = moderate pain. A score of 7 or higher = serious pain.

Children with Cognitive Impairment •  Often unable to describe pain •  Altered nervous system and experience pain differently •  Use behavioral observation scales –  e.g. FLACC

•  Can apply to intubated patients

SEDATION LEVELS! Minimal! • General Description!

“Anxiolysis”!

Greg Hollman, MD, FAAP

“Appropriate”!

• Responsiveness!

Medical Director, Pediatric Sedation Program University of Wisconsin Children’s Hospital Madison, Wisconsin

!

! • Airway! • Ventilation!

Unaffected! Unaffected! Unaffected!

• Cardiovascular!

Risk! of! Adverse! Event!

Timothy E. Corden, MD, FAAP

Associate Professor of Pediatrics Associate Director, Pediatric Critical Care Medicine Medical College of Wisconsin Milwaukee, Wisconsin No" Sedation"

Mild" Sedation"

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SEDATION LEVELS! • General Description! • Responsiveness!

Minimal!

Moderate!

“Anxiolysis”!

“Conscious”!

“Appropriate”!

“Purposeful” to light stimulation! No intervention! Adequate! Maintained!

!



• Cardiovascular!

Risk! of! Adverse! Event!

No" Sedation"

Mild" Sedation"

Moderate" Sedation"

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SEDATION LEVELS! • General Description! • Responsiveness!

Minimal!

Moderate!

Deep!

“Anxiolysis”!

“Conscious”!

“Deep sleep”!

“Appropriate”!

“Purposeful” to light stimulation! No intervention! Adequate! Maintained!

“Purposeful” to pain stimulation!

!



• Cardiovascular!

(±) Intervention! (±) Inadequate! (±) Maintained!

Continuum Drug Induced - Level of Sedation American Society of Anesthesiologists (ASA) Risk! of! Adverse! Event!

No" Sedation"

Mild" Sedation"

Moderate" Sedation"

Deep" 18 Sedation"

Choosing a Moderate Sedation Plan Remember mnemonic AMPLE!! •  A llergies •  M edications •  P ast Medical History •  L ast Meal •  E vents leading to sedation

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Equipment & Supplies AAP recommends S O A P M E

q Suction – age/size-suction catheters and apparatus (Yankauertype) q Oxygen – adequate O2 supply, working flow/delivery devices q Airway – age/size-appropriate airway equipment (e.g., ET tubes, LMAs, oral and nasal airways, laryngoscope blades, stylets, bag mask) q Pharmacy – life-saving drugs, reversal agents (Naloxone, Flumazenil) q Monitors – pulse oximeter, BP, ECG, cardiac, EtCO2 q Equipment – special equipment/drugs (e.g., crash cart w/ defibrillator, respiratory box, IV access equipment) (Pediatric 2006;118:2587-2605)

MOST IMPORTANT

WELL TRAINED PERSONNEL IN ADVANCED LIFE SUPPORT! 20

Pre-Sedation Risk Assessment American Society of Anesthesiologists (ASA Class) 1941

Physical Status Classification I

A healthy patient

II

A patient with systemic disease, with no functional limitations

III

A patient with severe systemic disease which limits activity but is not incapacitating

*IV

A patient with an incapacitating disease that is a constant threat to life

*V

A patient not expected to survive 24 hours with or without an operation PFCCS 2008

* It is recommended that the patients receive sedation by appropriately trained anesthesiologists and intensivists

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IX!

X!

←inhibition→!

Nasal" Segment

Pharyngeal" Segment"

Tracheal" Segment P(-)!

P(O)!

THE UPPER AIRWAY! Pharyngeal collapse ! during sedation!

Greg Hollman, MD, FAAP Medical Director, Pediatric Sedation Program University of Wisconsin Children’s Hospital 22 Madison, Wisconsin

Physical Exam Mallampati - The Difficult Airway •  Mallampati/Samsoon Classification –  –  –  – 

Class I: soft palate, uvula, pillars Class II: soft palate, portion of uvula Class III: soft palate, base of uvula Class IV: hard palate only can be seen

•  Other predictors of difficult airway –  –  –  –  –  – 

Obesity with short neck Reduced neck movement Inability to protrude the lower teeth Reduced mouth opening Receding mandible Thyromental distance of less than 3 fingers 23

ASA NPO Guidelines for gastric emptying •  •  •  •  • 

Clear liquids Breast milk Infant formula Non-human-milk Light meal

− 2 hours − 4 hours − 6 hours − 6 hours − 6 hours

These guidelines apply to all ages These do not guarantee complete gastric emptying Meals that contain fried or fatty foods and meat may prolong gastric emptying

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Mod-Sed Scale/Scoring Tool Modified Ramsay Scale v  Provides a consistent method to document the child’s level of

sedation during and after a procedure

Indication

Modified Aldrete Score When a child can be safely discharged after undergoing sedation/analgesia?

Score*

1. Anxious, Agitated, Restless

1

2. Awake, cooperative, oriented, tranquil Accepts mechanical ventilation

2

3. Semi asleep but responds to commands

3

4. Brisk response to light glabellar tap or loud noise

4

5. Sluggish response to light glabellar tap or loud noise

5

6. No Response

6

*Desired score depends on indication for sedation

Score of NINE (9) is required for DISCHARGE 25

The Right Drug for the Right Pts •  There is no ideal drug or magic bullet…all drugs have potential complications •  Drugs to consider should fit your goals for sedation with minimum risk to the patient Considerations when choosing a drug

–  Route of administration –  Onset of action –  Duration of action –  Contraindications –  Therapeutic advantages All sedative drugs suppress the CNS 26

DRUG USED FOR MODERATE SEDATION First Generation Chloralhydrate Diazepam Morphine and Meperidine Pentobarbital Tiopental and Methohexital

Third Generation Etomidate Propofol

Second Generation Midazolam Fentanyl Ketamine Nitrous Oxide Krauss B, Green SM. Procedural sedation and analgesia in children. Lancet. 2006. 2006;367:766–80.

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The Favorite MOD-SED Drugs •  Anesthetics: –  Propofol, Ketamine, (Pentobarbital)

•  Analgesics: –  Fentanyl, Morphine, Paracetamol, Ibuprofen, Ketorolac, NO

•  Anxiolytics: –  Midazolam, (Lorazepam), Diazepam

•  Others: –  Dexmedetomidine, Etomidate, Clonidine –  Chloral Hydrate –  Nitrous Oxide –  Local anesthetics: Lidocaine, TAC, LET, EMLA

A new mixture of ketamine and propofol (KETOFOL), have also been reported. (Orlewicz MS et al. Procedural Sedation. MEDSCAPE Updated: May 28, 2013) 28

SKALA PENILAIAN NYERI FLACC – Preverbal children Skor Kategori 0 1 2 Tak ada ekspresi Terkadang Sering megernyitkan Face tertentu atau senyum

Legs

Posisi normal atau relaksasi

Activity

Tidur tenang, posisi normal, mudah bergerak Tidak menangis (terbangun/tertidur)

Cry Consolability

Santai

menyeringai atau menerutkan dahi, tidak tampak tertarik dengan sekitarnya Gelisah, tidak tenang, tegang

dahi, menggerakkan dagu, gerakan menggigit

Menggeliat-‐geliat, tegang

Melengkung, kaku, atau menyentak-‐ nyentak Menangis terus, menjerit / merintih, sering mengeluh Sulit untuk menenangkan diri

Menguap atau merengek, kadang mengeluh Perhatian mudah teralih, tenang bila disentuh,/dipeluk/ diajak bicara/main

Menendang-‐ nendangkan tungkai

The Visual Analogue Scales (VAS). The most widely used nonverbal self report scales- measure subjective complaints of pain. Although scientific research proved this type of scales to be a reliable assessment tool, many in the medical profession question the VAS scale because of its lack of reproducibility. Self-report scale for pain/mood. Can be used in large populations (adults and children > 3 years) Very easy and fast to use. Non-verbal. No specific training required

How severe is your pain today ? The visual analogue scale (VAS) unmarked line with extremes of pain where patients are asked to mark the point in the line that describes their pain.

The Numerical rating scale is similar to the VAS but uses numbers that indicate the severity of the pain.

What happen between the late famous Jacko with Propofol? Propofol infusion syndrome: a simple name for a complex syndrome. Propofol, a short-acting, intravenously administered sedative agent is what might have caused the cardiac arrest of the King of Pop, Michael Jackson.

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Propofol •  •  •  •  •  •  •  •  • 

Pure sedative, no analgesic or amnestic properties Quick onset: 30 sec – 1 min Short duration: 3-10 min, t1/2 30-90 minutes Dose: 0.5 -1 mg/kg IV bolus over 2 min, Continuous infusion: 50-150 mcg/kg/min Bolus followed by cont. infusion or repeated boluses Disadvantages: respiratory depression, hypotension, bradycardia, metab. acidosis with prolonged infusion Induction agent for GA, used for MRI’s, moderate (procedural) sedation and for prolong sedation in ICU Not recommended for PICU sedation “Propofol infusion syndrome” can cause CV collapse 32

Ketamine •  •  •  •  •  • 

Dissociative agent, produces a state of catalepsy Translike sedation, analgesia and amnesia Administered IV, IM, PO Onset: 30 sec - 1 min (IV), 3-4 min (IM) Duration: 5-10 min (IV), 15-30 min (IM) Dose: 0.5-1 mg/kg (IV), 4-5 mg/kg (IM) –  Infusion: 5-20 mcg/kg/min

•  Good safety profile, preserves airway protective reflexes, minimal effects on respiratory drive •  Good agent for asthma, potent bronchodilator

•  Disadvantages: excess secretions, increased ICP, sensitizes laryngeal reflexes, emergence reaction 33

Ketamine •  Anticholinergic added to reduce secretions –  Atropine 0.01- 0.02mg/kg (min 0.1 mg, max 0.5 mg)

•  Midazolam 0.05-0.1mg/kg added to reduce potential for emergence phenomenon

•  Ketamine, atropine and midazolam (KAM) can be given as single IM injection to avoid multiple sticks

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Barbiturates •  Sedative hypnotic, no analgesic properties •  Highly lipid soluble •  Administered w/ multiple routes (IV, IM, PO, PR) •  Function at GABA receptor complex •  Not reversible 35

Pentobarbital IV route •  Onset: 3-5 min (IV) •  Duration: 15-45 min (IV) •  Dose: 1-2 mg/kg (up to 2-5 mg/kg, max 100 mg) IM route: 20-30 minutes prior to study

•  Onset 10-20 minutes •  Duration 1-2 hours •  Dose: 2-6 mg/kg to maximum 100 mg Disadvantages: NO reversal agent, no analgesia (enhances pain perception) Can produce sedative effects for up to 24 hours •  Ensure fully awake prior to discharge

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Analgesics Non-narcotic ¨  Acetaminophen PO, PR, IV ¨  Ibuprofen PO ¨  Ketoralac PO, IM, IV ¨  No difference in effectiveness between ibuprofen and ketoralac

Narcotics ¨  Morphine IM, IV ¨  Demerol IM, IV ¨  Fentanyl IV, PO ¨  Codeine and analogs PO ¨  Morphine and demerol may cause nausea, vomiting, and histamine release

Nitrous oxide (NO) •  Inhaled analgesic •  Rapid onset and offset •  Requires special equipment •  Requires cooperative patient •  Does not work well for reduction of acute, sharp pain (fracture reduction)

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Opiates •  •  •  • 

Most commonly used Analgesia and sedation No anxiolysis or amnesia Natural derivatives of opium –  Morphine (gold standard) and codeine

•  Semi synthetic compounds –  Oxycodone and hydrocodone

•  Synthetic compounds –  Demerol, fentanyl and sufentanil

•  Reversal agent – Naloxone •  Hypotension, respiratory and CNS depression •  histamine release 38

Morphine Multiple routes (IV, IM, SQ)

Onset: 5-10 min (IV) Duration: 4-6 hours Dosage: 0.05-0.1mg/kg IV, IM, SQ Administer every 5-10 minutes in increments to achieve desired level. IV peak effect 15-30 minutes, IM peak 30-60 minutes 39

Fentanyl •  Short painful procedures •  Rapid onset: 2-3 min (<30 sec IV) •  Short duration: 30-60 min •  Dose: 1-5 mcg/kg IV (order in micrograms not µg) •  Synthetic opioid,100x more potent than morphine •  Reversal agent: Naloxone •  Lack of histamine release •  Disadvantages: no amnesia/ anxiolysis, tight chest syndrome - “steel chest” (when high dose 15 mcg/kg, rapid administration) 40

Benzodiazepines Therapeutic Effects •  Sedative hypnotic agents •  Anmestic, anxiolytic •  No analgesic properties •  Skeletal muscle relaxant •  Potentiate GABA neuroinhibition •  High safety profile •  Reversible with Flumazenil

Adverse Effects •  Respiratory depression •  CNS depression •  Potentiates hypotension in volume-depleted pts •  Tolerance and withdrawal effects *sedative-hypnotic dose Rodrigo. PFCCS 1998

Drug

* Dose (IV)

Midazolam

Onset

Peak

Duration

0.1 – 0.2 mg/kg <60 s

3-5 min

30-60 min

Lorazepam

0.05-0.1 mg/kg

2-3 min

26-30 min

2-6 h

Diazepam

0.1-0.2 mg/kg

<10 s

1-2 min

30-90 min 41

Midazolam

•  Multiple routes, IV, IM, oral, nasal, rectal •  Onset: 2-5 min (may <60 sec) IV •  Duration: 30-60 min IV •  IV dose: 6 mos-5 yrs: 0.05-0.2 mg/kg, max 0.6 mg/kg IV >5 yrs: 0.025-0.05 mg/kg, max 0.4 mg/kg IV •  Oral dose is 0.5-0.75 mg/kg to max dose 20 mg •  Intranasal dose is 0.2-0.5mg/kg •  Reversal agent: Flumazenil •  Retrograde amnesia •  Disadvantages: NO analgesia, paradoxical reactions 42

Diazepam •  Onset: <10 sec (IV), 1-1.5 hours (oral) •  Duration: variable but LONG 30-90 min (oral) •  Dose: 0.1-0.2 mg/kg (IV) 0.1-0.8 mg/kg/day (oral) •  Useful for tapering •  Disadvantages: accumulation, long halflife, avoid rapid IV push 43

Lorazepam •  •  •  •  • 

Onset:2-3 min (IV) Duration: 2-6 hrs (up to 12 hrs) Dose: 0.05-0.1 mg/kg Medium acting benzo Disadvantages: mixed with propylene glycol –  Anion gap metabolic acidosis, osmolar gap –  Avoid infusions 44

Clonidine •  •  •  •  •  • 

Centrally acting alpha-2 agonist Onset: 30-60 min (oral) Duration: 6-10 hours Dose: 0.05 mg/day (oral) Can convert to transdermal patch Eases withdrawal & decreases anesthetic requirements 45

Dexmedetomidine •  Alpha-2 agonist –  1700x more selective for alpha 2 (compared to clonidine)

•  Onset: 15-30 min •  Duration: 60-120 min •  Dose: load with 0.5-1 mcg/kg –  Infusion of 0.3 – 1.5 mcg/kg/hr

•  Disadvantages: bradycardia, only approved for 24 hrs infusions 46

Etomidate •  Ultra short acting agent –  IV onset 1 minute, –  Duration 10-15 minutes

–  Dose 0.3 mg/kg IV –  Minimal cardiovascular effects –  Reduces intracranial pressure –  Can interfere adrenocortical function –  Uncommon in pediatric sedations –  Drug of choice for rapid sequence intubation in hemodynamically unstable with increased ICP 47

Chloral Hydrate 1.  Pure sedative hypnotic with no analgesic properties 2.  Used primarily for outpatient radiologic proc.s and EEG’s. 3.  Administered PO/PR, dose range from 50-100 mg/kg not to exceed 2 grams. May be repeated in 30 minutes within dose ranges. 4.  Long onset of action (40 minutes) and duration (1-2 hours) 5.  Low success rate when age >2 years (>3 yrs)

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Most Useful Drug for Pediatric Emergencies •  Ketamin: Sedative analgesic of choice for intubating with hemodynamic instability of any etiology and those with severe bronchospasm •  Fentanyl: Analgesic of choice in the presence hemodynamic instability and severe bronchospasm •  Midazolam: adjunct to above in a small titrated dose but doesn’t have any analgesic effect Continuous infusions for prolonged sedation: - Midazolam at 0,1 mg/kg/h/ IV - Fentanyl at 1-2 mcg/kg/h IV - Dexmedetomidine at 0.3-0.7 mcg/kg/h IV 49

Emergency Intubation “Cocktail” KAM - VR •  •  •  • 

Ketamine 1-2 mg/kg IV Atropine 0.02 mg/kg up to 1 mg IV/IM/IO Midazolam 0.025 to 0.05 mg/kg IV Rocuronium 1 mg or Vecuronium 0,2 mg/ kg IV -  If not IV/IO can use IM succinylcholine unless contraindicated by history -  Anecdotal reports of effective use of IM non depolarizing agent 50

Neuromuscular Blocking Agents •  Never give neuromuscular blockade to patient you cannot bag-mask ventilate •  Never use neuromuscular blockade alone since these agents do not provide sedation, amnesia, or analgesia Non depolarizing Agent

Dose (iv)

Onset

Duration

Rocuronium

0.6-1.2 mg/kg

30-60 s

30-40 min

Vecuronium

0.1-0.2 mg/kg

1-3 min

30-40 min

Pancuronium

0.05-0.1 mg/kg

1-3 min

40-60 min

Depolarizing Agent

Dose IV

Onset

Duration

Succinylcholine

1.0-1.5 mg/kg (2 mg/kg for infants)

30-40 s

3-5 min 51

Adjuncts to Sedation Establish rapport with child and parents, if applicable Calm environment Imagery Preemptive analgesia Local anesthetics Prepare for Unexpected Emergencies •  Oxygen, bag and mask, and suction (SOAPME) •  Use volume or fluid resuscitation •  Have advanced airway equipment, intubation, medications, and appropriate staff to monitor the patient 52

Antagonists Naloxone Pure antagonist, reverses sedative and analgesic properties of narcotics. Will not reverse hypotension. Short t1/2 (1-2 hours) result in repeated doses with longer acting narcotics.

Dose Children <5 years and < 20 kg: 0.1 mg/kg IV, IM, SQ, ETT Children > 5years or > 20 kg: 2 mg May repeat Q 2-3 min - desired affect 1/10 of standard dose to reverse respiratory but not analgesic effects

Naloxone Opiate antagonist

Flumazenil Benzo. antagonist Flumazenil Very short duration of action need repeated doses Dose 0.02 mg/kg IV May repeat every min. to achieve max dose of 1 mg Can precipitate seizures in chronic benzodiazepine use and TCA overdose 53

Therapeutic Advantages •  Not all side effects are harmful •  Considerations for choice of drug –  Ketamine à bronchodilator –  Pentobarbital or Midazolam à anti-convulsant –  Diazepam à muscle relaxation

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Contraindications •  All drugs should be used judiciously!!! •  Commonly seen relative contraindications and adverse effects

–  Ketamine à increased ICP, excess salivation, emergence reaction –  Propofol à hypotension, acidosis –  Dexmedetomidine à bradycardia, arrhythmia –  Benzodiazepine à hypotension

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Sedation-Analgesia Non-pharmacologic Strategies •  •  •  •  •  •  • 

Parental presence during procedure Distraction, Parent rub adjacent area to decrease local pain Externally oriented play Guided imagery Sucrose 24% Pacifier

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Safe Mod-Sed Prepare for Unexpected Emergencies

•  Optimize your patient prior to sedation –  Correct acidosis –  Keep euvolemic –  Know your pts “AMPLE”

•  Anticipate difficulties and be prepared (SOAPME) –  Bag, mask, oxygen, +/- airway app. box –  Suction app. –  Normal saline/Lactated Ringer’s

•  Monitors: O2, CO2, CR monitor, and BP •  Appropriate staff to monitor the patient

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Mod-Sed Documentation Before Sedation: •  Presedation health •  (Aldrete score) •  Confirm staff privileges & universal procedures (i.e., “time out”) •  Drug calculations (include reversal agents and local anesthetics) •  Informed consent •  Instructions to family

During Sedation: •  •  •  •  • 

Drug name(s) &calculations Route Site Time Dosage (titrated to desired effect)

During administration: •  •  •  • 

FiO2 & duration of sedating/ analgesic agents Level of consciousness Heart rate, respiratory rate, SpO2 Adverse events and corrective intervention/treatment given

Document at least once every 5 minutes until child reaches predetermined discharge criteria

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Goals of Moderate Sedation “Hipocrates Oath - Primum nonnocere” (Do no harm)

•  To relieve the anxiety and pain •  To choose sedatives and analgesics that fits the procedures with lightest degree of sedation •  Attempt non-pharmacologic approach •  Qualified personnel and correct equipment •  Monitor the patient condition until fully awake in baseline state for a safe discharge •  Patient’s safety and welfare 59

Mod-Sed Discharge Criteria •  Airway, vital signs, and pulse oximetry have returned to baseline •  Patient follows commands (age-appropriate) •  Patient is hydrated and tolerates oral fluids •  Patient is arousable and has baseline level of verbal ability •  Patient can sit unaided (age appropriate) 60

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ModSed Quality Improvement (QI) indicators ü SpO2 ≤ 90% requiring O2 ü Any complications; need for emergency interventions ü Aspiration; airway obstruction ü Inability to complete the procedure as planned ü Long recovery time; unplanned admission ü Hypotension ü Use of reversal agents ü Proper documentation ü Death 61

Take Home Message •  Many situations require sedation, its component including anesthesia, analgesia, anxiolysis, & amnesia •  There are several levels of sedation •  Remember mnemonic “AMPLE” for sedation •  Choosing the right drug(s) for the right patients •  Always anticipate possible complications & be prepared •  Sedation may be indicated for the benefit of the child, the family, and the caregivers but must be done with careful consideration of the risks.

62

INDONESIAN PEDIATRIC ASSOCIATION DEDICATED TO ALL INDONESIAN CHILDREN THROUGH MODERATE SEDATION

Patient evaluation

Monitoring

Rescue Skills 63

Palembang 2014

OR F OU TION Y K N N E A T H T T A R U YO

IDAI DEDICATED TO THE HEALTH OF ALL INDONESIAN CHILDREN

64

Anak Usia 3-8 tahun •  Usually have a word for pain •  Can articulate more detail about the presence and location of pain; less able to comment on quality or intensity •  Contoh: –  Color scales –  Faces scales

Sedasi dan Analgesia

The Wong-Baker Faces Pain Rating Scale consists of a horizontal line with 6 faces, representing pain complaints on a scale of 0 (no pain at all) to 10 (worst pain you have ever felt). The patient is asked to choose the face that best describes how he feels. It is advised to be specific about time and location of the pain. Gambar 1 Wong-Baker FACES Pain Rating Scale Dikutip dari: Atkinson dkk.

Children older than 8 years •  Use the standard visual analog scale •  Same used in adults

Neonatal Infant Pain Scale (NIPS)

Sedatif-Analgesik Sering Dipakai 1.  Opiat (narkotik) 2.  Benzodiazepin 3.  Kloral-hidrat 4.  Barbiturat 5.  Ketamin 6.  Propofol 7.  Neuroleptik 8.  Paralitik

Prinsip Umum Tatalaksana Nyeri 1.  Antisipasi & cegah nyeri 2.  Nilai nyeri secara adekuat 3.  Berbagai cara/pendekatan 4.  Libatkan orang tua 5.  Rute aman Pediatrics in Review 2003; 24 (10)

Sedasi dan Analgesia Anak Sakit Kritis Prosedur yang memerlukan sedasi Prosedur noninvasif Magnetic resonance imaging (MRI) Computerized tomographic scan (CT-scan) Prosedur pencitraan Terapi radiasi Elektroensefalografi (EEG) Prosedur invasif Aspirasi sumsum tulang dan biopsi Pungsi lumbal atau pengobatan intratekal Biopsi hati, ginjal atau tulang Ganti balutan, perawatan luka atau debridement luka bakar Endoskopi, bronkoskopi Ekokardiografi transesofageal Torakosentesis atau pemasangan selang dada (chest tube) Parasentesis, perikardiosentesis Pemasangan kateter vena sentral Reduksi fraktur atau pemasangan balutan gips Aspirasi cairan tubuh dengan panduan USG


Amnesia

Sedasi

Hipnotik

Analgesik

NSAIDs

Gambar 2. Spektrum Obat Sedasi dan Analgesia

Sedasi dan Analgesia Opioid dan benzodiazepin pilihan utama untuk sedasi. Obat alternatif: anestesi inhalasi, nitrous oxide, ketamin, propofol, dan barbiturat The Analgesic Ladder Strategi tatalaksana nyeri WHO mengatasi rasa nyeri secara rasional I.  Analgesik nonopioid (anti inflamasi nonsteroid/NSAIDs) - nyeri ringan II. Opioid lemah, dgn/tanpa NSAIDs - nyeri menengah/sedang III. Opioid kuat, dgn/tanpa NSAIDs - nyeri sangat kuat

Rute obat S&A: Pilih oral dan i.v.. Hindari i.m.


NSAIDs

Gambar 3. Pemilihan Obat Analgesik

Obat

Dosis Obat analgesik dan sedatif

Catatan

Morfin

Bolus iv: <60 kg; 100−200 µg/kg, >60 kg; 5−10 mg, Infus i.v.: <60 kg: 10−60 µg/kg/jam,

Potensial pelepasan histamin, pertimbangkan penurunan dosis pada gangguan ginjal dan hati


>60 kg: 0.8−3 mg/jam Fentanil Bolus iv: <60 kg; 1−2 µg/kg, >60 kg; 50−200 µg/jam Infus iv: <60 kg;4−10µg/kg/jam, >60 kg; 25−100µg/jam Parasetamol

Ibuprofen

Midazolam

Klonidin

Onset cepat, waktu paruh panjang, terutama bila penggunaan lama

Dapat p.o., p.r. ( rektum) <60 kg:10−15 mg/kg/4jam, >60 kg: 650−1000 mg/4jam atau i.v. Dosis harian maks.: <3 bulan: 60 mg/kg/hari, 3 bl−12 th: 90 mg/kg/hari, >12 th: 4 gr/hari Hati-hati pada penyakit ginjal, retensi air, <60 kg: 6−10 mg/kg/6 jam, >60 kg: 200−600 mg/6 jam perdarahan GI Dosis harian maks.: <60 kg: 30 mg/kg/hari >60 kg: 2,4 g/hari Toleransi dan withdrawl Bolus i.v.: <60 kg: 0,1−0,2 mg/kg, >60 kg: 5 mg syndrome, dapat p.o., Infus i.v.: <60 kg: 2−10 µg/kg/menit p.r., bukal, i.m., i.v. >60 kg: 5−15 mg/jam Withdrawl syndrome; Infus i.v.: 0,1−2 µg/kg/jam, NG; 1−5 µg/kg/8 jam hindari henti tiba-tiba

Kloralhidrat NG; 20−50 mg/kg/4−6 jam, maks. 2 gram per dosis Dosis harian maksimal; 200 mg/kg/hari Prometazin

Sedikit iritasi lambung Hati-hati pada neonatus

Parasetamol

<60 kg:10−15 mg/kg/4jam, >60 kg: 650−1000 mg/4jam Dosis harian maks.: <3 bulan: 60 mg/kg/hari, 3 bl−12 th: 90 mg/kg/hari, >12 th: 4 gr/hari

Ibuprofen

<60 kg: 6−10 mg/kg/6 jam, >60 kg: 200−600 mg/6 jam Dosis harian maks.: <60 kg: 30 mg/kg/hari >60 kg: 2,4 g/hari

Midazolam

Bolus i.v.: <60 kg: 0,1−0,2 mg/kg, >60 kg: 5 mg Infus i.v.: <60 kg: 2−10 µg/kg/menit >60 kg: 5−15 mg/jam

Morfin

Bolus iv: <60 kg; 100−200 µg/kg, >60 kg; 5−10 mg, Infus i.v.: <60 kg: 10−60 µg/kg/jam, >60 kg: 0.8−3 mg/jam

Fentanil Bolus i.v.: <60 kg; 1−2 µg/kg,

>60 kg; 50−200 µg/jam Infus i,.v.: <60 kg;4−10µg/kg/jam, >60 kg; 25−100µg/jam

Klonidin

Infus i.v.: 0,1−2 µg/kg/jam, NG; 1−5 µg/kg/8 jam

Kloralhidrat NG; 20−50 mg/kg/4−6 jam, maks.2 gr per dosis Dosis harian maksimal; 200 mg/kg/hari

Prometazin NG; 1−2 mg/kg/6 jam, maks. 50 per dosis

Sedasi dan Analgesia Peralatan Emergensi untuk Prosedur Sedasi Analgesia (depresi kardiorespirasi )

Peralatan intravena Sarung tangan, torniquet, kasa alkohol, kasa steril, kateter i.v., selang i.v. cairan i.v., jarum suntik dengan ukuran yang tepat, selotip Peralatan dasar talaksana jalan napas Sumber O2, sumber alat hisap, kateter penghisap, yankauer-type suction, self-inflating breathing bag-valve set, oral and nasal airway, pelumas Peralatan lanjutan talaksana jalan napas (untuk klinisi mampua intubasi) Laryngeal mask airways, laryngoscope ,selang endotrakeal, stylet Antagonis farmakologi Nalokson – antidotum narkotik/opioid Flumazenil – antidotum benzodiazepin Obat emergensi Epinefrin, efedrin, vasopresin, atropin, nitrogilserin, aniodaron, lidokain G 50% (10% atau 25%), difenhidramin, hidrokrortison, metilprednisolon, deksametason Diazepam atau midazolam

Tabel 6 Sistem Skor Aldrete Recovery – Dimodifikasi (Pascaprosedur Sedasi Analgesia) Kriteria Nilai Kriteria


Tanda Vital Stabil

1 0

Tidak stabil Pernapasan Normal Dangkal/takipnea Apnea Tingkat kesadaran Sadar, terorientasi/pulih ke asal Kesadaran berkabut, agitasi Tidak responsif

2 1 0 2 1 0

Skor Sedasi >8 7−8 4−6 0−3

Nilai

Saturasi Oksigen 90−100% 90−94% <90% Warna Kulit Pink/kembali ke asal Pucat Sianosis Aktivitas Bergerak menurut perintah/kembali ke asal Bergerak hanya ekstremitas, berjalan tidak terkoordinasi Tidak ada gerak spontan

Tindakan

Pulang bila semua skor >0, skor total 8 Monitor tanda vital tiap 20 menit Monitor tanda vital tiap10 menit Monitor tanda vital tiap 5 menit, dan evaluasi lebih lanjut sesuai kebutuhan

2 1 0 2 1 0 2 1 0

Analgesik Non-opioid •  Nyeri ringan sampai sedang •  Tidak menyebabkan depresi respirasi •  Sangat efetif bila dikombinasi dg opioid •  •  •  • 

Asetaminofen/parasetamol NSAIDs COX-2 inhibitors Aspirin & pirazolon –  Tidak dipakai lagi pada pediatri

Acetaminofen/parasetamol •  •  •  • 

Antipiretik Analgesik ringan Rute PO or PR Dosis oral 10-15 mg/kg/dosis tiap 4 jam –  Dosis bayi 10-15 mg/kg/dosis tiap 6-8 jam –  Dosis dewasa 650 mg-1000 mg/dosis

•  Onset 30 menit

Asetaminofen/parasetamol •  Per rektum 40 mg/kg diikuti 20 mg/kg/dosis tiap 6 jam –  Uptake is delayed and variable –  Peak absorption is 60-120 minutes –  Unreliable to cut suppositories –  Non physiologis, not hygienis route –  Thinks psychologic effects

•  Dosis harian maksimum –  Bayi: 60-75 mg/kg/hari –  <60 kg: 100 mg/kg/hari –  >60 kg: 4 gram/hari

!


OPIOID RUTE

–  IV –  Oral –  Transmukosa –  Transdermal

MODE

–  Intermiten/on demand (sesuai kebutuhan) –  Interval tetap –  Infus kontinyu –  PCA (patient controlled analgesia)

Sedasi dan Analgesia Anak Sakit Kritis MORFIN •  Gold standard •  Metabolisme di hepar •  Depresi respirasi - mengubah sensitivitas kemoreseptor terhadap CO2 •  Depresi laju napas > volume tidal •  Depresi frekuensi napas •  Hipotensi akibat vasodilatasi - dimediasi histamin •  Memblokir efek kompensasi katekolamin •  Klirens panjang pada neonatus


MORFIN •  IV intermiten 0.1 mg/kg tiap 3 - 4 jam •  IV kontinyu 0.05 mg - 0.1 mg/kg/jam •  PO terjadwal 0.3 mg/kg tiap 3 - 4 jam

Dosis PCA •  Dosis awal: 50 mcg/kg tiap 10 menit sampai penderita merasa nyaman •  Dosis on demand: 20 - 40 mcg/kg •  Lock-out period: 10 menit •  Limit 4 jam: 0.25 mg/kg

Sedasi dan Analgesia Anak Sakit Kritis FENTANIL •  Opiat sintetis, 100 x lebih poten dp morfin •  Onset cepat, sangat lipofilik, cepat lewati sawar darah otak, redistribusi ke jaringan lemak •  Distibusi singkat t1/2, eliminasi panjang t1/2 •  Efek hemodinamis minimal •  Respons vaskuler paru rendah •  Dapat menimbulkan “rigiditas dinding dada”, yang dapat diatasi dengan relaksans atau nalokson DOSIS: IV intermiten :1-2 mcg/kg tiap 1-2 jam IV dosis kontinyu: 1-2 mcg/kg/jam

Sedasi dan Analgesia Anak Sakit Kritis METADON •  •  •  •  • 

Potensi sama dengan morfin Efek hemodinamis minimal Waktu paruh panjang Efek sedasi dan euforia lebih rendah dari morfin Untuk kontrol nyeri dan abstinensia

Dosis per oral: 0.1 mg/kg tiap 4-8 jam 50 % bioavailabilitas oral Akumulasi obat dengan dosis berulang dapat disebabkan oleh pengikatan protein ekstensif


BOLUS I.V. Biasa dilakukan Sesuai kebutuhan Waktu paruh menentukan interval Kelemahan: pain breakthrough

INFUS KONTINYU Digunakan bila analgesia dan sedasi diperlukan Less labor intensive Analgesia lebih baik, perlu bolus inisial Perlu jalur I.V.

Sedasi dan Analgesia Anak Sakit Kritis EFEK SAMPING OPIAT

Depresi napas

Ketergantungan

Antidotum - Nalaxone (Narcan)

•  Menyebabkan abstinence syndrome bila dilakukan withdrawal obat •  Umumnya muncul setelah penggunaan 7-10 hari •  Midriasis, takikardia, tersentak otot, muntah, diare, kejang, demam, hipertensi •  Diobati dengan penarikan bertahap dari obat

•  Reversal penuh 0.1 mg/kg •  Reversal sebagian : dosis titrasi sampai menimbulkan efek •  Waktu paruh kurang daripada narkotik •  Pemberian: IV, IM, Sub Q, ETT •  Reversal mendadak dapat menyebabkan mual, muntah, berkeringat, takikardia, peningkatan BP, dan tremor

Toleransi •  Umumnya muncul setelah 2-3 hari pasca penggunaan terus menerus •  Lebih besar dengan fentanil •  Meningkatkan dosis untuk mencapai efek yang sama •  Meningkatkan dosis sesuai kebutuhan

Penyapihan •  Biasanya 10% penurunan per hari •  Jangan menyebar interval dosis melampaui interval pemberian dosis normal •  Dapat menggantikan metadon dan menyapih tiap 48 jam selama periode waktu yg lebih lama

Sedasi dan Analgesia Anak Sakit Kritis BENZODIAZEPIN

•  Lini pertama obat sedasi •  Menyebabkan hipnosis, ansiolisis, amnesia antegrad, dan aktivitas antikonvulsi •  Tidak ada efek analgesia Dapat menyebabkan abstinence syndrome setelah penggunaan jangka panjang •  Mekanisme dalam sistem limbik melalui neurotransmiter inhibisi, gamma aminobutyric acid (GABA)

Sedasi dan Analgesia Anak Sakit Kritis DIAZEPAM •  Sedasi, amnesia variabel, ansiolitik •  Iritasi terhadap vena, nyeri pada PIV •  Metabolit aktif multipel •  Keuntungan untuk sedasi berkepanjangan Kerugian untuk rapid arousal Tidak dianjurkan untuk infus kontinyu Waktu paruh12-24 jam Metabolisme hepatik

Sedasi dan Analgesia Anak Sakit Kritis LORAZEPAM (ATIVAN) •  Memperbaiki amnesia •  Tidak ada metabolit •  Waktu paruh 4-12 jam •  Dimetabolisme oleh glukoronil transferase –  Sedikit pengaruh dari obat lain –  Baik diberikan pada pasien dengan penyakit hati

Sedasi dan Analgesia Anak Sakit Kritis MIDAZOLAM •  •  •  •  • 

Onset cepat Metabolisme cepat Amnesia Larut dalam air Tidak nyeri saat disuntikkan •  Waktu paruh 2-4 jam •  Metabolisme hepatik, eksresi renal

•  Akumulasi hydroxymetabolite aktif dapat terakumulasi

•  Rute lainnya: –  Oral –  Nasal –  Rectal –  Sublingual •  Absorbsi kurang seiring peningkatan dosis

Sedasi dan Analgesia Anak Sakit Kritis EFEK SAMPING BENZODIAZEPIN DEPRESI NAPAS Kurang dibanding narkotik, namun berpotensiasi dengan narkotik. Dose related Reversal: Flumazenil – antagonis reseptor benzodiazepin Kontraindikasi untuk pasien dengan pemakaian kronik benzodiazepin untuk kejang, mixed overdose, TCA’s – dapat menyebabkan kejang KOREOATETOID Toleransi: Dosis dapat ditingkatkan setelah pemakaian 2-3 hari Ketergantungan Lakukan withdrawal secara hati-hati dan perlahan jika pemakaian >7-10 hari Gejala withdrawal: tremor, tachycardia, hypertension, Withdrawal cepat dapat meyebabkan kejang

Sedasi dan Analgesia Anak Sakit Kritis KLORALHIDRAT •  Hipnotik sedatif •  Dimetabolisme di hati à bentuk aktif: trichlorethanol •  Waktu paruh: 8-12 jam •  Administrasi oral atau rektal •  Onset of action terlambat •  Reaksi paradoksikal pada anak usia yang sama •  Tidak lebih dari 100 mg/kg/hari, contoh: 25mg/kg/6 jam •  Hati-hati pada anak < 3 bulan dengan disfungsi hati

Sedasi dan Analgesia Anak Sakit Kritis BARBITURAT •  Sedatif •  Respiratory depression dose dependent •  Efek inotropik negatif /vasodilatasi menurunkan cardiac output •  Menurunkan konsumsi O2 otak –  ↓ aliran darah otak •  Bermanfaat untuk pasien dengan –  ↓ tekanan intrakranial peningkatan tekanan intrakranial •  Barbiturat kerja cepat •  Antikonvulsan

•  Bermanfaat untuk sedasi prosedur/ imaging pada anak dengan hemodinamik stabil •  Larutan alkali, seringkali inkompatibel dengan TPN atau obat

Sedasi dan Analgesia Anak Sakit Kritis MAJOR TRANQUILIZER •  Fenotiazin –  Torazin •  Butirofenon –  Droperidol –  Haloperidol •  Umum dipakai pada dewasa di ICU, jarang di PICU •  ES: hipotensi karena blokade alfa dan efek ekstrapiramidal •  Dipakai untuk anak yang sulit disedasi

Sedasi dan Analgesia Anak Sakit Kritis KETAMIN •  Anastetik disosiatif i.v. •  Amnesia baik dan analgesia somatik •  Status anastetik secara klasik digambarkan sebagai disosiasi fungsional dan elektrofisiologi diantara talamoneokortek dan sistem limbik •  Secara kimia berkaitan dengan phencyclidine dan cyclohexamine •  Larut dalam air dan lemak •  Cepat melalui sawar darah otak, <30 detik

Sedasi dan Analgesia Anak Sakit Kritis KETAMIN •  •  •  •  • 

Waktu paruh redistribusi 4.7 menit Waktu paruh eliminasi 2.2 jam Efek klinis dalam 1 menit, resolusi dalam 15-20 menit Bronkodilatasi Sialagogue -“menimbulkan aliran saliva” –  Diberikan dengan antikolinergik •  Atropin •  Efek net hemodinamik minimal –  Inotrop negatif –  Efek sentral - ↑HR, ↑SVR •  Pilihan baik untuk syok atau status asmatikus

Sedasi dan Analgesia Anak Sakit Kritis KETAMIN •  •  •  •  • 

Risiko laringospasme Risiko emesis/aspirasi Meningkatkan tekanan intrakranial, intraokuler Menginduksi kejang Reaksi emergensi, halusinasi –  Perbaikan dengan administrasi benzodiazepin

Dosis: IM: 2 - 4 mg/kg per dosis tiap 30 menit- 1 jam I IV: Dosis intermiten 1 -2 mg/kg per dosis tiap 30 menit-1 jam Dosis kontinyu 1 - 3 mg/kg/jam

Sedasi dan Analgesia Anak Sakit Kritis PROPOFOL

•  Sedatif/hipnotik –  Dose dependent - conscious sedation sampai anestesia umum –  Onset cepat (20-50 detik) –  Pulih cepat (dalam 30 menit) –  Metabolit aktif kurang –  Dimetabolisme di hati –  Dieksresikan dalam urin

Sedasi dan Analgesia Anak Sakit Kritis PROPOFOL •  Emulsi lemak, •  Menurunkan tekanan intrakranial dan CPP •  Menurunkan tonus simpatis –  Kontraindikasi bila hemodinamik tidak stabil –  Depresi napas moderat •  Nyeri pada tempat injeksi –  Perbaikan dengan lidokain 1% 0.5 mg/kg

Sedasi dan Analgesia Anak Sakit Kritis PROPOFOL •  Sekuele neurologi –  Opistotonus –  Gerakan mioklonik •  Asidosis metabolik pada penggunaan >24 jam •  Kontraindikasi untuk penggunaan jangka panjang •  Dosis: –  Induksi 1 - 3 mg/kg –  20 - 100 mcg/kg/menit –  Infus naik 5-10 mcg/kg/menit setiap 5 - 10 menit

Sedasi dan Analgesia Anak Sakit Kritis DEXMEDETOMIDINE •  Alfa-2 agonis (seperti KLONIDIN) – short acting •  Dosis: –  Load 1 mcg/kg i.v. dalam 10 menit, –  Diikuti dg 20,2 – 0,7 mcg/kg/jam

•  Efek samping: hipotensi (vasodilatasi), bradikardia relatif

Sedasi dan Analgesia Anak Sakit Kritis PCA •  Patient controlled analgesia •  Pasien mengontrol sendiri pemberian obat narkotik analgesia, dosis telah ditentukan sebelumnya •  Memperbaiki analgesia ttp menurunkan dosis narkotik •  Low basal rate •  Nurse controlled analgesia –  Eliminates delay –  Allows delivery via a closed system

Sedasi dan Analgesia Anak Sakit Kritis PCA


TERIMA KASIH TELAH MEMBERI SEDASI DAN ANALGESI YANG TEPAT

KASUS 1 •  •  •  •  •  •  •  •  •  •  • 

Anak 2 tahun, BB 10 kg Gagal napas akut - asma Intubasi Ventilator Atropin, Benzodiazepin: Diazepam, midazolam, fentanil, Barbiturat: Fenobarbital, pentobarbital, tiopental Lidokain Opioid: Fentanil Profopol Pelumpuh otot: Suksinilkolin, vekuronium


NSAIDs

Gambar 3. Pemilihan Obat Analgesik

7 P’S – RSI 1. Preparasi 2. Preoksigenasi 3. Pramedikasi/Pretreatment Atropin Lidokain à TBI/TTIK Benzodiazepin: Dia/Midazolam Opioid Fentanil 4. Paralisis: NMBA - Suksinilkolin - Rocuronium 5. Proteksi 6. Placement with proof 7. Post intubation management Sedasi jangka panjang

Status asmatikus

Tatacara penggunaan ventilator pasien ASMA: 1.  Bronkodilator atau steroid tetap dilanjutkan 2.  Sebelum intubasi (beri Atropin) 3.  Isap lendir: hindari bronkospasme (beri Lidokain) 4.  Relaksasi otot dan sedasi untuk mencegah asinkronisasi dan untuk pasien tidak kooperatif (Diazepam, Midazolam, Pancuronium) 5.  Mode ventilator : awal menggunakan kontrol selanjutnya sesuai fisiologi dan keadaan klinis, sering digunakan volume-cycled : Assist control atau IMV 6. Monitoring kejadian auto PEEP dan barotrauma.

Sedasi dan Analgesia Anak Sakit Kritis FENTANIL •  Opiat sintetis, 100 x lebih poten dp morfin •  Onset cepat, sangat lipofilik, cepat lewati sawar darah otak, redistribusi ke jaringan lemak •  Distibusi singkat t1/2, eliminasi panjang t1/2 •  Efek hemodinamis minimal •  Respons vaskuler paru rendah •  Dapat menimbulkan “rigiditas dinding dada”, diatasi dengan relaksans atau nalokson DOSIS: IV intermiten :1-2 mcg/kg tiap 1-2 jam IV dosis kontinyu: 1-2 mcg/kg/jam

Syok Sepsis

How to intubate a Septic Shock Patient. (Yamamoto LG Textbook Ped Emerg Med 2000)

•  Volume load, begin peripheral or if available central ino/pressor •  Premedication: 0.01-0.02 mg/kg atropine •  Ketamine 1-2 mg/kg bolus •  Rocuronium 1 mg/kg •  Intensive Care Medicine and Anesthesia recommend against the use of etomidate! (Editorials 2005)

Head Injury •  Lidokain •  Pentobarbital

Pascaoperasi Laparatomi •  Analgetik •  Sedatif


Gambar 1 Wong-Baker FACES Pain Rating Scale Dikutip dari: Atkinson dkk.


TERIMA KASIH TELAH MEMBERI SEDASI DAN ANALGESI YANG TEPAT

Obat-‐obatan yang digunakan pada sedasi dan analgesi dosis mg/kg

rute

dosis maks (mg)

interval durasi antara dosis 9trasi

10-‐15

oral/rektal

1000

4 jam

5-‐10

oral

ketorolak

0,5

im/iv

morfin

0,1

im/iv

fentanil

0,01

obat asetaminofen (parasetamol) ibuprofen

remifentanil

800 6 jam 30 mg iv 4-‐6 jam 60 mg im 10

12 mcg/ kg/jam

meperidin

1-‐1,8

im/iv

100 im

hidromorfon

0,01

im/iv

2

hidrocodone

0,2

oral

10

1

oral

60

2-‐5

iv

200

4

im/iv

methohexital

0,5-‐1

iv

100

18-‐25

rektal

kodein pentobarbital

30 menit im depresi pernafasan. Pengeluaran histamin 15 menit iv 0,5-‐1 jam 10 menit iv kaku dada, muntah, dosis yang lebih rendah pada bayi 3-‐4 jam

iv 0,05 transmukosa 0,005-‐0,015 400 mcg 0,5-‐1 jam l 0,0015 intranasal 100 mcg 0,15 mcg/kg/ 0,2 mcg/ mnt (10 mcg/ iv 5 menit kg/mnt kg/jam)

perha9an

2 menit depresi pernafasan

30 menit im gunakan dosis rendah untuk parenteral, kejan, iritabilitas 10 menit iv 30 menit im 3-‐4 jam 10 menit iv 4-‐6 jam haH-‐haH bila dikombinasi dengan parasetamol gangguan saluran cerna, muntah bila dikombinasi dengan 4-‐6 jam parasetamol Htrasi pemberian parenteral, hindari semua golongan barbiturat 0,5-‐1,5 jam pada anak dengan porphyria 20 menit im 20-‐60 depresi saluran nafas, hindari semua golongan barbiturat pada 5 menit iv menit anak dengan porphyria 3-‐4 jam

2,5-‐5

iv

300

20-‐60 menit

5 menit iv

25

rektal

midazolam

0,05-‐0,2

im/iv

0,3-‐0,7

oral

kloralhidrat

50-‐100

oral/rektal

1000

6-‐24 jam

hindari pada penyakit liver

0,5-‐1

iv bolus

100

1-‐6 mg/kg/jam

infus

0,1-‐0,23

iv bolus

20

15-‐20 menit

1-‐2.

iv

4

im

1-‐2 jam 20 menit im

0,005-‐0,01 (parHal reversal)

im/iv

2

20 menit

antagonis opiat

0,1 (total reversal)

flumazenil

0,01

iv

0,2

30 menit

hindari pada penderita kejang

lidokain (lignokain)

infiltrated

4,5 mg/ kg

30-‐120 menit

lidokain (lignokain) + epinefrin

infiltrated 7 mg/kg

1 jam

bufipakain

infiltrated

2-‐8 jam

Hopental

propofol ethomidate ketamin nalokson

2,5 mg/ kg

depresi pernafasan, hindari semua golongan barbiturat pada anak dengan porphyria

1-‐2 jam 10 menit iv depresi pernafasan, agitasi

6-‐10 menit 5 menit iv depresi saluran nafas

10 menit iv gerakan mioklonik

0,5-‐2 jam 5 menit iv hipersekresi saluran napas

Pilihan Sedasi Potensial Skenario

Pilihan

trauma ekstrimitas (minor) opioid oral

asetaminofen (parasetamol) atau ibuprofen dengan atau tanpa opioid

trauma ekstrimitas (mayor) opioid oral atau parenteral

propofol

pasien mendapat analgesi

etomidat

anestesi regional

nitrousoxide

ketamine

luka bakar ringan

opioid oral


opioid im

anestesi lokal

anestesi topikal

luka bakar luas

opioid iv

ketamin

anestesi regional

remifentanil

pasien mendapat analgesi

trauma minor mulHpel

opioid parenteral


hipnoHs

opioid oral

distraksi

trauma mulHpel dislokasi sendi

opioid iv ketamine etomidate propofol nitrousoxide opioid iv/ sedaHf diazepam etomidate

krisis nyeri akibat penyakit sumbatan pembuluh darah (ringan)

lidokain intraarHkular (lignokain) remifentanil asetaminofen atau kombinasi opioid (po) dapat dikombinasi dengan ibuprofen (po)

krisis nyeri akibat penyakit sumbatan pembuluh darah (berat) morfin iv hidromorfon iv nyeri abdomen opioid parenteral ketorolak (untuk kolik renal/ bilier) nyeri pelvis (Hdak hamil) opioid parenteral oral NSAIDS ketorolak

pasien dalam pengaruh analgesik fentanyl remifentanil

opioid harus dikombinasi dengan ibuprofen (po) ketorolak (iv)

nyeri non obstetrik pada ibu hamil nyeri gigi

opioid oral asetaminofen dan opioid opioid im/sk anestesi regional opioid oral asetaminofen atau ibuprofen dengan atau tanpa opioid anestesi lokal hipnoHs

laserasi pada anak yang kooperaHf lidokain bupivakain laserasi pada anak yang Hdak midazolam oral dan anestesi kooperaHf lokal fentanil dan midazolam propofol dan anestesi lokal ketamin dan anestesi lokal pungsi lumbal propofol ketamin fentanil dan midazolam pentobartbital anestesi lokal

CT san (MRI) pasien rawat jalan yang menjalani pemeriksaan yang Hdak nyeri (mis. EKG, echo) sepsis work up prosedur minor mulHpel

pentobartbital propofol fentanil atau remifentanil midazolam difenhidramin kloralhidrat ketamin

midazolam po kloralhidrat pentobartbital difenhidramin sukrosa oral ketamin im nitrousoxide opioid tranmukosal ketamin im nitrousoxide opioid tranmukosal

SKALA PENILAIAN NYERI FLACC Kategori 0

Skor 1

2

Face

Tak ada ekspresi tertentu Terkadang menyeringai atau senyum atau menerutkan dahi, tidak tampak tertarik dengan sekitarnya

Sering megernyitkan dahi, menggerakkan dagu, gerakan menggigit

Legs

Posisi normal atau relaksasi

Gelisah, tidak tenang, tegang

Menendang-‐nendangkan tungkai

Activity

Tidur dengan tenang, posisi normal, mudah bergerak

Menggeliat-‐geliat, tegang Melengkung, kaku, atau menyentak-‐nyentak

Cry

Tidak menangis (terbangun/tertidur)

Menguap atau merengek, Menangis terus-‐menerus, terkadang mengeluh menjerit atau merintih, sering mengeluh

Consolability

Santai

Perhatiannya mudah teralihkan, tenang bila disentuh, dipeluk atau diajak bicara/bermain

Sulit untuk menenangkan diri

Sedasi dan Analgesia Tabel 2. Skala Ramsay untuk Penilaian Sedasi Tingkat

1 2 3 4 5 6

Deskripsi Sedasi Skala Ramsay

Sadar, cemas; gelisah atau tidur gelisah, atau keduanya Sadar, kooperatif, terorientasi, dan tenang Respons hanya terhadap perintah verbal Mengantuk, respons cepat thd ketukan ringan glabela atau rangsang suara keras Mengantuk, respons lambat thd ketukan ringan glabela atau rangsang suara keras Mengantuk, tidak ada respons thd ketukan ringan glabela atau rangsang suara keras

Tabel 3. Skala COMFORT untuk Menilai Sedasi Alertness Deeply asleep Lightly asleep Mengantuk Fully awake and alert Hyperalert Calmness/agitation Calm Slightly anxious Anxious Very anxious Panicky Heart rate Denyut jantung (HR) < baseline Denyut jantung sesuai baseline HR jarang >15% diatas baseline (1−3 selama periode observasi) HR sering >15% diatas baseline (>3 selama periode observasi) HR terus menerus sekitar >15%) Facial Tension Otot fasial relaksasi total Tonus otot fasial normal, tidak ada tegangan otot fasial yang jelas Tegangan jelas pd beberapa otot fasial Tegangan jelas pada seluruh otot fasial Otot fasial mengerut dan meringis

Mean arterial blood pressure (MAP) Tekanan darah MAP di bawah baseline Tekanan darah MAP pada baseline MAP jarang >15% di atas baseline MAPsering >15% di atas baseline (>3 selama periode observasi) MAP terus menerus >15% diatas baseline Respons respirasi Tidak ada batuk dan napas spontan Napas spontan, sedikit atau tidak ada respons ventilasi Sesekali batuk atau resistensi ventilator Bernapas aktif terhadap ventilator Batuk atau selalu melawan ventilator, batuk atau tersedak Tonus otot Relaksasi otot total, tidak ada tonus otot Penurunan tonus otot Tonus otot normal Tonus otot meningkat, fleksi jari tangan& kaki Rigiditas otot ekstrim Physical movement Tidak ada pergerakan Sesekali dan sedikit pergerakan Sering, sedikit pergerakan Pergerakan kuat pada ekstremitas Pergerakan kuat termasuk torso dan kepala

1 Sedatif-Analgesik yang Sering Dipakai 2 3 4 5 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5

1 2 3 4 5 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5

N/M blocking agents pediatr Emerg Care 2000;16(6):441

Pain Assessment in Neonates & Infants •  Challenging •  Combines physiologic and behavioral parameters •  Many scales available –  NIPS (Neonatal Infant Pain Scale) –  FLACC scale (Face, Legs, Activity, Cry Consolability)

Neonatal Infant Pain Scale (NIPS)

Children between 3-8 years •  Usually have a word for pain •  Can articulate more detail about the presence and location of pain; less able to comment on quality or intensity •  Examples: –  Color scales –  Faces scales

Children older than 8 years •  Use the standard visual analog scale •  Same used in adults

Children with Cognitive Impairment •  Often unable to describe pain •  Altered nervous system and experience pain differently •  Use behavioral observation scales –  e.g. FLACC

•  Can apply to intubated patients

FLACC scale

3: Multi-modal Approach •  Cognitive-behavioral –  Education –  Relaxation, imagery –  Psychotherapy, counseling –  Hypnosis –  Biofeedback –  Music, literature, art, play –  Prayer, meditation

•  Physical Approach –  Massage –  Acupuncture –  Acupressure –  Heat or Cold –  TENS –  Therapeutic exercise

Sucrose for Infants •  Sucrose 24% oral solution •  Can be used for procedures such as heel stick, venipuncture, catheterization, etc. •  Effective analgesic in preterm and term infants –  Not effective beyond 3 months old

•  Dip pacifier in sucrose solution or give 0.2 mL to buccal area –  May repeat but be cautious with many doses to younger infants

SEDASI DAN ANALGESIA ANAK SAKIT KRITIS

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