Pharmacology - UNC School of Medicine ppt 4.12.pdf · Pharmacology • Regardless of medication,...
Transcript of Pharmacology - UNC School of Medicine ppt 4.12.pdf · Pharmacology • Regardless of medication,...
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Pediatric Procedural Sedation Course
Pharmacology
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Pharmacology
• Regardless of medication, dose or route of administration, adherence to the pediatric procedural sedation policy is required.
• When choosing drugs for procedural sedation the provider must consider
• Pharmacodynamics • Pharmacokinetics • Dose Response
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Pharmacodynamics Pharmacodynamics refers to the action of a drug
• Drugs used for procedural sedation may be divided into two general groups: 1) Those which provide sedation 2) Those which provide primarily analgesia
• Use of drugs that provide analgesia should be determined by whether the procedure is associated with pain or discomfort
• Use of drugs that provide only sedation should be considered for non-painful procedures such as MRI or CT scans
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Pharmacokinetics
Pharmacokinetics affects the onset & duration of action of the drug and is affected by the route of administration • Drugs for procedural sedation may be given orally, IV, or
intra-nasally • Providers must be familiar with routes of administration,
dosages, and effects of medications typically used for procedural sedation
• Combinations of medications must be used with caution: increased potency compared to individual medications • IV administration of combinations of medications is
the leading cause of respiratory depression in children undergoing procedural sedation
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Pharmacokinetics
Routes of Administration: • Oral medications may have a bitter taste that may
not be tolerated • Consider mixing with flavored syrup to mask the
bitterness • Condition of the nasal mucosa can effect intranasal
absorption • Presence of mucus • Epistaxis • Destruction from surgery • Use of nasal vasoconstrictors
• The advantage of IV administration is the ability to titrate medications to the desired effect
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Dose Response Dose response is affected by titration and synergy
• The amount of effect achieved for a given dose of medication is referred to as the dose-response curve for that drug
• Most sedative and analgesic medications have non-linear dose-response curves
• Non-linear curves result in initial doses having little or no effect until a certain point, followed by clear incremental effect for each dose Dose Response Curve
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• The ideal manner in which to administer a medication is to titrate that drug to achieve the desired effect.
• An appropriate "loading dose" should be administered followed by smaller doses with adequate time between doses to evaluate effect
• Starting with small doses then escalating the dose due to a lack of initial effect, will lead to overdose during medication titration
Dose Response
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Question 1 Which of the following is the most appropriate method
of administering medication to children for procedural sedation:
Administer a loading dose followed by smaller dose allowing adequate time between doses to evaluate effect
Start with a small dose then escalate the dose if you do not see an initial effect
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You are correct!
• The ideal manner in which to administer a medication is to titrate that drug to achieve the desired effect.
• An appropriate "loading dose" should be administered followed by smaller doses with adequate time between doses to evaluate effect
• Starting with small doses then escalating the dose due to a lack of initial effect will lead to overdose during medication titration
Next
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Try again.
• That is not the best choice for administering sedation to children.
Click here to return to the question and choose another answer
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Dose Response Dose Stacking Administration of medications before the peak effect of a previous dose has been reached will result in an excessive total drug effect over time (dose stacking)
Synergy • Combinations of medications are more potent than an
individual medication leading to increase risk of complications
• An example of synergy is the increased risk of respiratory depression when opioids are administered with benzodiazepines
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Dose Calculation and Documentation
• Special attention must be paid to the accurate calculation of dosage based on the child’s weight in kilograms
• Documentation on the Sedation/Analgesia Assessment and Procedure Record must include: • Name of medication • Dose and time including duration of administration • Route and site of administration • Patient response including adverse effects
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Medications Frequently Used During Procedural Sedation
Fentanyl - analgesia and mild sedation Chloral Hydrate - sedative hypnotic, no analgesia Midazolam - sedation, anxiolysis, amnesia, no analgesia Pentobarbital - sedation, no analgesia Narcan - opioid agonist reversal agent for fentanyl Flumazenil - reversal agent for midazolam Ketamine - restricted use Propofol - restricted use Dexmedetomidine - restricted use
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Question 2 Which of the following medications frequently used
for procedural sedation is best known for its anxiolytic and amnesic properties?
chloral hydrate midazolam
naloxone pentobarbital
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You are correct!
Midazolam is best know for decreasing anxiety and producing amnesia.
Next
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Try again.
That is not the best answer.
Click here to return to the question and choose another answer
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Mild Analgesia
Sucrose Pacifier: • Pacifier dipped in sugar water or sucrose solution for
infants under 2 months of age provides mild analgesia • Sucrose solution may also be applied underneath tongue
• Consider use in neonates undergoing brief painful procedures such as blood draws and lumbar punctures
• Studies demonstrated decrease in crying time
Does not require strict adherence to pediatric procedural sedation policy
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Procedural Sedation
Oral Chloral Hydrate: • Sedative hypnotic with NO analgesic effects • Used for pediatric patients during painless
procedures such as diagnostic radiology • Advantage: lack of associated respiratory
depression when used as a single agent Requires strict adherence to monitoring and
observation requirements of the pediatric procedural sedation policy
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Procedural Sedation Oral Chloral Hydrate: • Respiratory depression likely when combined with
opioids or other sedatives • Long half-life can result in prolonged sedation,
especially in infants • requires prolonged observation and monitoring prior to
discharge
• Ensure that children are at pre-sedation baseline prior to discharge • Risk for airway obstruction should the head fall forward while
child is secured in car seat • Respiratory arrests have occurred during transport home for
children in car seats
• Inform parents of potential safety risks associated with prolonged sedative effects
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Procedural Sedation
Oral Chloral Hydrate: • Dose: 50 – 75 mg/kg/dose orally (Max 1 g/dose)
May repeat 30 minutes after initial dose to maximum of: 120 mg/kg total or 1 g total for infants and 2 g total for
children • Onset: 10 – 20 minutes • Peak effect: Up to 60 minutes
• Increased in infants • Elimination half-life: 4 – 12 hours • Duration: 4 – 8 hours • Contraindications: GFR < 50
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Procedural Sedation Midazolam: • Water soluble benzodiazepine devoid of analgesic
properties • Causes skeletal muscle relaxation, amnesia, and
anxiolysis • Can be used:
• to achieve anxiolysis and cooperation • as a single agent for non-painful procedures • in combination with an analgesic or local
anesthetic for painful procedures
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Procedural Sedation Midazolam: • Advantages:
• Short duration • Predictable onset • Lack of active metabolites • Low risk of respiratory depression when used alone • Anterograde and retrograde (less frequent) amnesia
Requires strict adherence to monitoring and observation requirements of the pediatric procedural sedation policy
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Procedural Sedation Oral Midazolam: • Dose: 0.25 – 0.5 mg/kg (MAX 20 mg dose)
• Onset: 10 – 20 minutes • Peak effect: 30 minutes • Elimination half-life: 3 – 4.5 hours • Duration: 2 hours
• Availability • Syrup 10mg/5ml
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Intranasal Midazolam: • Dose: 0.2 – 0.3 mg/kg (MAX 7 mg initial dose) • Use is limited by:
• Burning upon application to the nasal mucosa • Most children will only accept this route of
administration once • Onset: Within 5 minutes • Peak effect: 10 minutes • Elimination half-life: 2 – 4.5 hours • Duration: 30 – 60 minutes • Availability:
• Use the 5 mg/ml IV concentration
Procedural Sedation
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Procedural Sedation
Intravenous Midazolam: • Slow IV administration recommended with close observation
for respiratory depression • Potent sedative effect when combined with intravenous
opioids for painful procedures • Pronounced anterograde amnesia and (at times) retrograde
amnesia with IV administration • Slurred speech coincides with onset of anterograde
amnesia • The value of amnesia and anxiolysis can not be
underestimated in the performance of painful procedures in children
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Intravenous Midazolam: • Effects of midazolam may be altered by underlying
medical conditions or medications • Cimetidine, carbamazepine, phenobarbital,
phenytoin, and valproic acid • Children may require higher dose due to altered metabolism
through p450 enzymes
• Heparin • Children may require lower dose due to increase in the
available drug
• Renal failure • Children may require lower dose due to an increase in the
available drug
Procedural Sedation
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Intravenous Midazolam: • Dose: 0.05 – 0.1 mg/kg (MAX 2 mg initial dose)
• May repeat 3 – 4 minutes after initial dose to a total dose of 0.2 mg/kg
• A maximum IV dose of 0.05 mg/kg is recommended when combining with narcotics
• Onset: Within 1 – 5 minutes • Peak effect: 5 – 7 minutes • Elimination half-life: 1 - 4 hours • Duration: mean 2 hours
Procedural Sedation
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Flumazenil: • Reverses effects of benzodiazepines
• Should be immediately available when using benzodiazepines for sedation
• Dose: 0.01mg/kg (MAX 0.2 mg initial dose) • May be repeated 5 times as needed • Patients > 50 kg – doses up to 1 mg may be used
• Resedation may occur requiring additional flumazenil doses • Monitor children receiving flumazenil for a minimum of one
hour prior to discharge, regardless of Aldrete score
Use of reversal agents is discouraged and must never be used to expedite discharge
Procedural Sedation
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Procedural Sedation Fentanyl: • Very potent synthetic opioid, ideal for painful procedures in
children • As a sole agent offers:
• analgesia • mild sedation • short duration of action
• Bradycardia may occur from vagal nerve stimulation • Drug metabolism may be prolonged in neonates and
children with hepatic dysfunction Requires strict adherence to monitoring and observation
requirements of the pediatric procedural sedation policy
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Fentanyl: Respiratory depression:
• Significant risk • may outlast opioid effects by 60-90 minutes
• Markedly increased when combined with midazolam or other sedatives; IV access recommended
Chest wall rigidity: • May occur with rapid intravenous fentanyl dosing • If chest wall rigidity occurs:
• call for help immediately • support respirations • be prepared to administer a neuromuscular blocker
Procedural Sedation
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Intranasal Fentanyl: • Dose: 2 µg/kg/dose (MAX 50 µg) • Onset: Almost immediate • Peak effect: Maximal analgesic and respiratory
depressant effect occurs in 5 minutes
Procedural Sedation
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Intravenous Fentanyl: • Dose: 0.5 – 1 µg/kg/dose (MAX 50 µg)
• May be titrated to a total dose of 4 – 5 µg/kg • Onset: Almost immediate • Peak effect: Maximal analgesic and respiratory
depressant effect occurs within 5 minutes • Elimination half-life:
• Terminal half-life 16 hours
• Duration: 30 – 60 minutes
Procedural Sedation
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Naloxone: • Opioid antagonist: reverses opioids’ depressive effects • Administer intravenously, intramuscularly, or intratracheally
• Preferred route of administration is intravenous • Abrupt effect
• Sedated children will often be quite disturbed when awakened by naloxone administration
• Administer by slow titration when possible • Most common side effect: nausea • Unusual catastrophic events (such as sudden death)
described in adults – not reported in children
Procedural Sedation
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Naloxone: • Dose for oversedation
• 0.01 mg/kg IV, maximum dose 0.4mg IV • May repeat after 2 minutes for a total of 2 doses
• Dose for respiratory arrest • 0.1 mg/kg, maximum dose 2 mg
• Availability: 0.4 mg/ml
Procedural Sedation
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Fentanyl + Midazolam Dosing Recommendation
• Midazolam 0.05 mg/kg IV every 3 minutes to achieve desired level of sedation • Max dose 2 mg • Total maximum dose 0.2 mg/kg
• Fentanyl 1 mcg/kg IV every 5 minutes to achieve desired level of sedation • Max dose 50 mcg • Total maximum dose 5 mcg/kg or total of 5 doses
• Administer each drug separately, allow sufficient time to reach full effect before administering another dose
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Question 3
Which medication is used to reverse the effects of benzodiazepines?
naloxone
chloral hydrate flumazenil
fentanyl
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You are correct!
• Flumazenil is given to reverse the effects of benzodiazepines and should be immediately available when using benzodiazepines for sedation.
• Resedation may occur requiring additional doses therefore children who receive flumazenil for oversedation/respiratory depression should be monitored for a minimum of one hour prior to discharge, regardless of Aldrete score
Next
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Try again.
That medication is not used to reverse the effects of benzodiazepines.
Click here to return to the question and choose another answer
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Procedural Sedation Pentobarbital: • Oxybarbiturate • Used for nonpainful procedures requiring immobility • Effectiveness enhanced when combined with midazolam • Respiratory depression can occur
• ~5% rate of oxygen desaturation • Excitatory phase can occur prior to sedative effect • Agitation can occur during recovery
• Occurs more frequently when children are aroused before the sedative effects wear off
Requires strict adherence to monitoring and observation requirements of the pediatric procedural sedation policy
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Procedural Sedation Pentobarbital: • Dose: 2 mg/kg IV (MAX 50mg)
• May repeat at 1 mg/kg IV every 3 minutes to achieve desired level of sedation
• May be titrated to a total dose of 7 mg/kg or 200 mg
• Onset: within 1-3 minutes • Elimination half-life: 25 hours +/- 16 hours • Duration: 15 minutes per drug insert, but clinical
effects last 30-90 minutes when titrated
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Question 5 Which of the following medications provide
analgesia and sedation?
chloral hydrate
fentanyl
midazolam
pentobarbital
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You are correct!
Fentanyl provides both analgesia and a mild sedative effect
Next
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Try again.
That medication does not produce both analgesia and sedation.
Click here to return to the question and choose another answer
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Medications for Restricted Use Medications listed here are restricted to administration by
the following providers: Ketamine
• ICU physicians, Anesthesiologists, Emergency physicians
Propofol • ICU physicians, Anesthesiologists, Emergency physicians • Separate LMS training and credentialing is required
Dexmedetomidine • ICU physicians, Anesthesiologists, Emergency physicians,
and nurses with Pediatric PSC Service • Separate LMS training and credentialing is required
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Ketamine: • Derivative of PCP • Binds to opioid receptors providing intense
analgesic, sedative, and amnestic effects • Useful in painful procedures
• Demonstrated to be safe for children • Spontaneous respirations and airway reflexes are
maintained • Eyes remain open with a slow nystagmic gaze, intact
corneal and light reflexes
Procedural Sedation
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Ketamine: • Causes increases in heart rate, blood pressure, cardiac
output, and intracranial pressure • Slowly redistributes into the peripheral tissues (average
15 minutes) • Decrease in CNS levels correlate with return of
coherence • Refer to nursing policy Management of the Pediatric
Patient Receiving Ketamine-NURS 0519 for additional information
Procedural Sedation
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Dexmedetomidine: • Alpha 2 agonist • Provides sedation and anxiolysis via receptors in the locus
ceruleus • Provides analgesia via receptors in spinal cord • Decreases stress response • No significant respiratory depression
• Enhanced effect when administered with anesthetics, sedatives, hypnotics and opioids
• May require reduced doses when combined with other agents
• Please refer to nursing policy Management of the Patient Receiving Dexmedetomidine for Non-Painful Procedural Sedation for additional information
Procedural Sedation
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Procedural Sedation
Propofol: • Ultra short-acting sedative-hypnotic agent • Causes global depression of the central nervous
system by binding to a different ץ-aminobutyric acid (GABA) receptor site than benzodiazepines
• Some amnestic and anti-emetic effects • NO analgesic effect • Used for induction and maintenance of general
anesthesia • Can only be administered by an attending physician • Please refer to the Pediatric Sedation Policy for Non-
Anesthesiologists – ADMIN 0160, appendix D for additional information
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Question 6
Registered nurses who have successfully completed all procedural sedation credentialing requirements may administer ketamine or propofol to children
undergoing procedural sedation
true
false
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You are correct!
• While nurses may administer ketamine under the direction of a credentialed attending physician, administration of propofol is restricted to attending physicians only.
• An attending physician must be present at the patient’s bedside throughout the sedation and is responsible for the sedation, not the procedure.
Next
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Try again.
Click here to return to the question and choose another answer
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You have successfully completed the Pharmacology module.
Congratulations!
Pediatric Procedural Sedation Course