Sedation for intensive care procedures

ICU SEDATION, NEONATE

DESCRIPTION

Sedation is required for various procedures and situations in newborns in an intensive care setting to decrease discomfort and suffering, and to improve the management outcomes of the procedure/care that is being given.

GENERAL AND SUPPORTIVE MEASURES

In all situations, appropriate control of the environment, provision of normal physiological requirements, monitoring of vital signs and provision of comforting care should be incorporated into the care of neonates in order to minimise stress on the child.

MEDICINE TREATMENT

  1. For controlled endotracheal intubation for ventilation

This skill should have been learnt in an appropriate learning situation.
If not, endotracheal intubation should take place under supervision of a specialist.

Pre-oxygenate with bag-mask and reservoir, T-piece or equivalent ventilator.
Maintain pre-ductal (right hand or ear lobe) oxygen saturation between 88–92% by adjusting the FᵢO₂.

  • Ketamine, IV, 1–2 mg/kg. (Acts within 60 seconds. Effect lasts 5-10 minutes.)

OR

  • Propofol, IV, titrate up to 2.5 mg/kg. Titrate as necessary to achieve required sedation. (Acts within 30 seconds. Effect lasts 3-10 minutes.)

LoEIII [1]

OR

  • Midazolam, IV, 0.1–0.2 mg/kg. (Acts within 1-5 minutes. Effect lasts 20-30 minutes.) Avoid in preterm babies. In term babies, use in combination with fentanyl. Fentanyl, IV, 1-4 mcg/kg. (Acts immediately. Effect lasts 30-60 minutes.)

LoEIII [2]

THEN

  • Suxamethonium, IV, 2 mg/kg. (Produces 5–10 minutes of neuromuscular blockade within 30-60 seconds.) Causes paralysis and apnoea.
    • Note: Avoid Suxamethonium in patients with or at risk of developing hyperkalaemia, neuromuscular disease and a family history of malignant hyperthermia.

LoEIII [3]

PLUS

Atropine should be readily available in the case of bradycardia or ketamine hypersecretion:

  • Atropine, IV, 0.02 mg/kg.

If it is an emergency with no IV line, consider:

  • Ketamine, IM, 5–10 mg/kg. (Effect lasts 12-25 minutes.)
  1. During continuous mechanical ventilation
    For pain and sedation when indicated but not routinely:
  • Fentanyl, IV, 1–5 mcg/kg bolus.
    If necessary, follow with IV infusion, 5–10 mcg/kg/hour, i.e. 50 mcg/mL at 0.1–0.2 mL/kg/hour.

LoEIII [5]

OR

  • Morphine, IV, 10–30 mcg/kg/hour infusion.
    • i.e. Morphine 1 mg/kg mixed with 50 mL dextrose 5% or sodium chloride 0.9% at 0.5–1.5 mL/hour.
    • Do not use routinely in preterm infants.

OR

  • Sucrose 24% solution, onto the infant’s tongue, as needed for minor procedures.
    • Preterm infants: 0.5–1 mL.
    • Term infants: 2 mL.

LoEIII [4]

REFERRAL

  • Inability to provide appropriate care.

ICU SEDATION, INFANT AND CHILD

DESCRIPTION

Sedation is required for various procedures and situations in infants and children in an intensive care setting to decrease discomfort and suffering, and to improve the management outcomes of the procedure/care that is being given.

GENERAL AND SUPPORTIVE MEASURES

In all situations, appropriate control of the environment, provision of normal physiological requirements, monitoring of vital signs and provision of comforting care should surround the care of infants and children in order to minimise the stress on the child.

MEDICINE TREATMENT

Endotracheal intubation should be learnt in an appropriate learning situation.
If not, endotracheal intubation should take place under supervision of an experienced health practitioner.

  1. For endotracheal intubation
    Pre-oxygenate with bag-mask and reservoir, T-piece or equivalent ventilator.
    Maintain oxygen saturation > 90%.
    Consider conditions that will determine appropriate medication options and prepare equipment.
  • Ketamine, IV, 1–2 mg/kg. (Acts within 60 seconds. Effect lasts 5-10 minutes.)

OR

  • Propofol, IV, titrate up to 2.5 mg/kg. Titrate as necessary to achieve required sedation. (Acts within 30 seconds. Effect lasts 3-10 minutes).

LoEIII [1]

THEN

If muscle relaxant is necessary:

  • Suxamethonium, IV, 1-2 mg/kg. (Produces 5–10 minutes of neuromuscular blockade within 30-60 seconds). Use the lower dose in older children and the higher dose in younger children. Causes paralysis and apnoea.
    • Note: Avoid Suxamethonium in patients with or at risk of developing hyperkalaemia, neuromuscular disease and a family history of malignant hyperthermia.

PLUS

If bradycardia occurs or if using ketamine:

  • Atropine, IV, 0.02 mg/kg (not less than 0.1 mg/dose).
    • Maximum dose: 0.6 mg.

If it is an emergency with no IV line, consider:

  • Ketamine, IM, 5–10 mg/kg. (Effect lasts 12-25 minutes.)
  1. During continuous mechanical ventilation
  • Midazolam, IV, 1–4 mcg/kg/minute.
    • i.e. Midazolam 3 mg/kg mixed with 50 mL dextrose 5% at 1–4 mL/hour.

PLUS

  • Fentanyl, IV, 1–5 mcg/kg bolus.
    • If necessary, follow with IV infusion, 5–10 mcg/kg/hour, i.e. 50 mcg/mL at 0.1–0.2 mL/kg/hour.

LoEIII [5]

OR
PLUS

  • Morphine, IV, 20–80 mcg/kg/hour infusion.
    • i.e. Morphine 1 mg/kg mixed with 50 mL dextrose 5% or sodium chloride 0.9% at 1–4 mL/hour.
  1. For procedures (not ventilated)

Take standard precautions for respiratory arrest.

For painful procedures:

  • Ketamine, oral, 5 mg/kg (Acts within 30 minutes. Effect lasts 60 minutes.) or IV, 1–2 mg/kg. (Acts within 60 seconds. Effect lasts 5-10 minutes.)

For non painful procedures

  • Midazolam, oral, 0.5 mg/kg (Acts within 20 minutes. Effect lasts 60-90 minutes.) or intranasal, 0.2 mg/kg or IV, 0.1–0.2 mg/kg. (Acts within 1-5 minutes. Effect lasts 20-30 minutes.) (Has no analgesic effect.)
    • Maximum dose: 15 mg.

LoEIII [6]

REFERRAL

  • Inability to provide appropriate care.