Pediatric emergency medicine trisk 4293 4293
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to reach a desired depth of sedation, and therefore potentially decrease the
risk of sedative adverse effects. One should take into account the choice of
sedative when deciding to also administer an analgesic. Certain sedatives,
such as ketamine, have analgesic properties, and additional analgesia may
not be necessary when this drug is used. Other sedatives do not offer any
pain control and patients could benefit from concomitant use of an analgesic
agent. One must be aware that some analgesic medications, in particular
opiates, can potentiate the respiratory depression experienced after
administration of sedatives. Table 129.6 summarizes the advantages and
disadvantages of several analgesics used in PSA.
Sucrose
Sucrose is safe and effective in managing pain for infants younger than 6
months of age. The effect of sucrose is strongest in the newborn and
decreases gradually over the first 6 months of life. It is recommended to use
a 25% sucrose solution and administer 2 mL orally by allowing the infant to
suck on a pacifier. Alternatively, use a syringe and apply 1 mL orally to each
cheek. There are almost no side effects and the dose can be repeated. The
sucrose should be administered no more than 2 minutes before beginning the
painful procedure and it is usually most effective when given for short
painful procedures such as heel stick or venipuncture. Some clinicians note
that an infant may be calmed during a lumbar puncture while sucking
continuously on a pacifier dipped in sucrose.
Opioids
Opioid medications are extremely important for treating moderate to severe
pain and can be an important adjunct in procedural sedation. Most opioids
can cause important adverse effects (primarily respiratory depression and
hypotension) that are dose related and may be reversed with naloxone if
necessary, remembering that reversal of the narcotic-induced side effect will
also reverse pain control. For this reason, naloxone may be dosed according
to level of reversal needed (e.g., mild respiratory depression can be reversed
with 1 to 10 mcg/kg) to preserve some level of pain control. Because of
pharmacokinetic differences in young infants that may predispose them to
respiratory depression, these drugs should be used with caution and with
reduced doses in infants younger than 3 months of age who are not
ventilated mechanically.
