Sedation and Analgesia

6 Sedation and Analgesia

State Behavioral Scale:

The State Behavioral Scale (SBS) is an assessment tool used to ensure appropriate sedation for intubated patients. A goal SBS score is decided upon during rounds, and sedation is adjusted based on the nursing assessment of the actual SBS score achieved.

It is scored by assessing the patients response to voice, then touch, then noxious stimuli.

Scale	Description	Definition
-3	Unresponsive	No spontaneous respiratory effort No cough or coughs only with suctioning No response to noxious stimuli Unable to pay attention to care provider Does not distress with any procedure (including noxious)Does not move
-2	Responsive to Noxious Stimuli	Spontaneous yet supported breathing Coughs with suctioning/repositioning Responds to noxious stimuli Unable to pay attention to care provider Will distress with a noxious procedure Does not move/occasional movement of extremities or shifting of position
-1	Responsive to Gentle Touch or Voice	Spontaneous but ineffective non-supported breaths Coughs with suctioning/repositioning Responds to touch/voice Able to pay attention but drifts off after stimulation Distresses with procedures Able to calm with comforting touch or voice when stimulus removed Occasional movement of extremities or shifting of position
0	Awake and Able to Calm	Spontaneous and effective breathing Coughs when repositioned/Occasional spontaneous cough Responds to voice/No external stimulus is required to elicit response Spontaneously pays attention to care provider Distresses with procedures Able to calm with comforting touch or voice when stimulus removed Occasional movement of extremities or shifting of position/increased movement(restless, squirming)
+1	Restless and Difficult to Calm	Spontaneous effective breathing/Having difficulty breathing with ventilator Occasional spontaneous cough Responds to voice/ No external stimulus is required to elicit response Drifts off/ Spontaneously pays attention to care provider Intermittently unsafe Does not consistently calm despite 5 minute attempt/unable to console Increased movement (restless, squirming)
+2	Agitated	May have difficulty breathing with ventilator Coughing spontaneously No external stimulus required to elicit response Spontaneously pays attention to care provider Unsafe (biting ETT, pulling at lines, cannot be left alone) Unable to console Increased movement (restless, squirming or thrashing side-to-side, kicking legs)

Cornell Assessment of Pediatric Delirium (CAPD):

The score most commonly used to assess ICU delirium in our PICU is the CAPD score. Often, delirium is often misinterpreted as agitation, causing the medical team to give the patient more sedation. This can make the delirium worse. If the patient is determined to be delirious, treatment strategies include weaning of the sedative medications, particularly benzodiazepines; attempts to return to a normal day/night cycle by setting a schedule for waking up, turning on the lights, opening the blinds, meals, activities, TV time, and finally, blinds down and lights off at bedtime; providing the child with familiar objects like their favorite music, toys, or pet therapy; as well as psychotropic medications.

The CAPD score of 9 or greater is considered a positive test for delirium. The score is generated by asking the following questions:

	Never 4	Rarely 3	Sometimes 2	Often 1	Always 0
Does the child make eye contact with the caregiver?
Are the child’s actions purposeful?
Is the child aware of his/her surroundings?
Does the child communicate needs and wants?
	Never 4	Rarely 3	Sometimes 2	Often 1	Always 0
Is the child restless?
Is the child inconsolable?
Is the child underactive – very little movement while awake?
Does it take the child a long time to respond to interactions?

Medications for pain and sedation:

Drug	Dose (IV)	Comment
Dexmedetomidine	Bolus 0.5–1 mcg/Kg over 10 minutes Infusion: 0.25–1 mcg/ Kg/hr	Avoid in patients with heart block
Etomidate	0.3 mg/Kg/dose	Avoid in septic shock Adrenal suppression
Fentanyl	1 mcg/Kg/dose IV q 30–60 minutes Max dose: 300 mcg total Continuous: 1 mcg/Kg/hr	Rigid chest with rapid administration
Ketamine	1 mg/Kg/dose	Bronchodilator – consider with asthma
Lorazepam	0.05–0.1 mg/Kg/dose q 4–6 hours Max dose: 4 mg
Midazolam	0.1 mg/Kg	Avoid in hemodynamically unstable patient
Morphine	0.1– 0.15 mg/Kg IV q 3–4 hours Continuous: 10 –30 mcg/Kg/hr	Ventilated patients may receive larger doses, more frequent intervals Avoid in asthma patients
Pentobarbital	1–3 mg/Kg (max 100 mg) –– sedation 10–15 mg/Kg load (< 5 mg/Kg/hr), then 1–5 mg/ Kg/hr–– therapeutic coma	Avoid in hemodynamically unstable patient
Propofol	25–100 mcg/Kg/min (short term use only)	Avoid in hemodynamically unstable patient

Medications for pharmacologic paralysis:

Drug	Dose (IV)
Rocuronium*	1 mg/Kg/dose
Succinylcholine*	1 mg/Kg/dose
Vecuronium	0.1 mg/Kg/dose

* Preferred for Rapid Sequence Intubation (RSI)

6 Sedation and Analgesia

State Behavioral Scale:

Cornell Assessment of Pediatric Delirium (CAPD):

Medications for pain and sedation:

Medications for pharmacologic paralysis:

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