Download Pain Management and Dosing Guide

Pain Management
and Dosing Guide
Updated
Updated April
April 2016
2016
Pain Management and Dosing Guide Includes:
1. Principles
Principles of
of Pain
Pain Management,
Management, Discharge
Discharge and
and Patient
Patient Safety
Safety
1.
Considerations,
Analgesic
Ladder
Considerations, Analgesic Ladder
2. Non-opioid
Analgesics, Opioid
Opioid Prescribing
Prescribing Guidelines
Guidelines and
and
2.
Non-opioid Analgesics,
Equianalgesic Chart,
Chart, Opioid
Opioid Cross-Sensitivities,
Cross-Sensitivities, Intranasal
Intranasal
Equianalgesic
Medications
Medications
3. Nerve
Blocks, Neuropathic
Neuropathic Pain
Pain Medications,
Medications, Muscle
Muscle Relaxer
Relaxer
3.
Nerve Blocks,
Medications, Ketamine
Ketamine Indications
Indications
Medications,
4. Topical
and Transdermal
Transdermal Medications
Medications
4.
Topical and
5.
Procedural
Sedation
and
Analgesia (PSA)
(PSA) Medications
Medications
5. Procedural Sedation and Analgesia
6. Stepwise
Approach to
to Pain
Pain Management
Management and
and PSA
PSA
6.
Stepwise Approach
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Funding
Principles of Pain Management
Establish realistic
realistic pain
pain goals
goals
Establish
Will vary
vary depending
depending on
on patient
patient and
and type
type of
of
Will
pain -- goal
goal of
of zero
zero may
may not
not be
be feasible
feasible
pain
Analgesic Ladder
Ladder and
and Treatment
Treatment Basics
Basics
Pain Management Considerations Analgesic
Type of
of pain:
pain: nociceptive,
nociceptive, neuropathic,
neuropathic, inflammatory
inflammatory
••Type
Acutevs.
vs.chronic
chronicvs.
vs.acute
acuteon
onchronic
chronicpain
painexacerbation
exacerbation
••Acute
Pain medication
medication history:
history: OTC,
OTC, Rx
Rx and
and herbal
herbal
••Pain
Patient factors:
factors: genetics,
genetics, culture,
culture, age,
age, previous
previous
••Patient
pain experiences,
experiences, comorbidities
comorbidities
pain
Verify dosing
dosing for
for << 66 mo
mo and
and >> 65
65 yo
yo
••Verify
Treatment Options
Options
Treatment
Educate patient/caregivers
patient/caregivers on
on pain
pain
Educate
management
goals
and
regimen
management goals and regimen
Pharmacotherapy: systemic,
systemic, topical,
topical, transdermal
transdermal -••Pharmacotherapy:
nerve blocks
blocks
nerve
Non-pharmacologic modalities
modalities
••Non-pharmacologic
Refer to
to pain,
pain, palliative
palliative or
or other
other specialists
specialists for
for
••Refer
advanced treatment
treatment
advanced
Consider pharmacologic
pharmacologic and
and
Consider
non-pharmacologic treatment
treatment options
options and
and
non-pharmacologic
initiate therapy
therapy
initiate
Continually reassess
reassess patient’s
patient’s pain
pain
Continually
and monitor
monitor for
for medication
medication efficacy
efficacy and
and
and
side effects
effects
side
same scale
scale to
to reassess
reassess pain
pain
••Use
Use same
scale that
that isis age
age and
and cognitively
cognitively appropriate
appropriate
••Use
Use scale
no improvement,
improvement, adjust
adjust regimen
regimen
••If
If no
Step 1:
1: Mild
Mild Pain
Pain
Step
and counsel
counsel regarding
regarding falls,
falls, driving,
driving, work
work
••Assess
Assess and
safety, and
and medication
medication interactions
interactions
safety,
regimen for
for opioid
opioid induced
induced constipation
constipation
••Bowel
Bowel regimen
signs and
and oral
oral intake
intake before
before discharge
discharge
••Vital
Vital signs
all pain
pain medications
medications administered
administered and
and
••Document
Document all
response at
at time
time of
of discharge
discharge or
or disposition
disposition
response
OTC and
and non-pharmacologic
non-pharmacologic options
options
••Consider
Consider OTC
patient implement
implement pain
pain management
management plan?
plan?
••Can
Can patient
-- insurance
insurance coverage,
coverage, transportation,
transportation, etc.
etc.
Non-Opioid Analgesics*
Analgesics*
Non-Opioid
(Brand)
(Brand)
Adult
Adult
Pediatric
Pediatric
(<12yo)
yo)
(<12
325-650mg
mg
15mg/kg
mg/kg
325-650
15
Acetaminophen
Acetaminophen
POqq4-6
4-6hh
POqq4-6
4-6hh
PO
(Tylenol®) Max:PO
(Tylenol®)
Max:90
90mg/kg/d
mg/kg/d
g/dor
or11qq44hh Max:
Max: 44g/d
<50kg
kg
<50
Acetaminophen
Acetaminophen
IV qq 66 hh
15mg/kg
mg/kgIV
IVqq66hh
11 gg IV
15
IV (Ofirmev®)
(Ofirmev®) Max:
IV
or12.5
12.5mg/kg
mg/kg
g/d or
or 650
650 or
44 g/d
Use only
only ifif not
not Max:
Use
IV
q
4
h
prn
pain
mg
q
4
h
prn
pain
IV q 4 h prn pain
tolerating PO
PO mg q 4 h prn pain Max:
tolerating
75mg/kg/d
Max: 75mg/kg/d
100-200 mg
mg
100-200
>2 yo
yo
Celecoxib
>2
Celecoxib
PO daily
daily to
to qq 12
12 hh 50 mg
PO BID
BID
(Celebrex®) PO
mg PO
(Celebrex®)
Max: 400
400 mg/d
mg/d 50
Max:
10mg/kg
mg/kg
10
400-800 mg
mg
400-800
Ibuprofen
POqq66to
to88hh
Ibuprofen
PO
PO qq 66 to
to 88 hh Max:
PO
(Motrin®)
40
mg/kg/d
(Motrin®)
Max:
40
mg/kg/d
Max: 3200
3200 mg/d
mg/d or 2400
Max:
mg/d
or 2400 mg/d
1-2 mg/kg
mg/kg
1-2
25-50 mg
mg
PO qq 66 to
to 12
12 hh
25-50
PO
Indomethacin
Indomethacin
PO qq 66 to
to 12
12 hh
>6 mo
mo
PO
>6
(Indocin®)
(Indocin®)
Max:
200
mg/d
Max:
4
mg/kg/d
Max: 200 mg/d Max: 4 mg/kg/d
or 200
200 mg/d
mg/d
or
0.5-1
mg/kg/
0.5-1
mg/kg/
15-30 mg
mg IV/IM
IV/IM
15-30
dose IM/IV
IM/IV
dose
Ketorolac†
Ketorolac†
qq 66 hh
66 hh
(Toradol®)
Max: 120
120 mg/d
mg/d Max:qq15-30
(Toradol®)
Max:
mg
Max: 15-30 mg
xx 55 dd
qq 66 hh xx 55 dd
250-500 mg
mg PO
PO
mg/kgPO
PO
250-500
55mg/kg
Naproxen
Naproxen
to 12
12 hh
12hh
qq 88 to
qq12
(Naprosyn®) Max:
(Naprosyn®)
1500 mg/d
mg/d Max:
Max:1000
1000mg/d
mg/d
Max: 1500
7.5-15mg
mgPO
POdaily
daily
Meloxicam 7.5-15
Meloxicam
—
—
Max: 15
15 mg/d
mg/d
(Mobic®)
Max:
(Mobic®)
*Doses can
can be
be scheduled
scheduled or
or PRN
PRN pain.
pain. Avoid
Avoid NSAIDs
NSAIDs inin renal
renal
*Doses
dysfunction, PUD,
PUD, CHF,
CHF, and
and ifif << 66 mo
mo of
of age.
age. Use
Use with
with caution
caution
dysfunction,
elderlypatients.
patients.
ininelderly
†Forpatients
patients<<65
65yo,
yo,60
60mg
mgIM
IMor
or30
30mg
mgIV
IVxx1,
1,followed
followedby
by30
30
†For
mgIV/IM
IV/IMqq66hhPRN
PRNup
upto
toaamax
maxdaily
dailydose
doseof
of120
120mg
mgfor
for55days.
days.
mg
For patients
patients >65
>65 yo,
yo, <50
<50 kg,
kg, and/or
and/or with
with renal
renal impairment,
impairment, 30
30
For
mgIM
IMor
or15
15mg
mgIV
IVxx1,
1,followed
followedby
by15
15mg
mgIV/IM
IV/IMqq6h
6hPRN
PRNup
upto
to
mg
maxdaily
dailydose
doseof
of60
60mg
mgfor
for55days.
days.
aamax
Step 2:
2: Moderate
Moderate Pain
Pain
Step
Step 11 Strategy
Strategy ++ Intermittent
Intermittent Dose
Dose of
of Opioid
Opioid
Step
Analgesics (PO,
(PO, IV)
IV) +/+/Analgesics
Interventional (Blocks
(Blocks &
& Procedures)
Procedures)
Interventional
Non-pharmacological modalities
modalities
Non-pharmacological
Splinting, distraction,
distraction, hot/cold
hot/cold therapy,
therapy,
Splinting,
exercise, massage,
massage, imagery,
imagery, and
and others
others
exercise,
Discharge and
and Patient
Patient Safety
Safety Considerations
Considerations
Discharge
Generic
Generic
Step 3:
3: Severe
Severe Pain
Pain
Step
Step 11 and
and Step
Step 22 Strategies
Strategies +/+/- Scheduled
Scheduled
Step
Opioid
Analgesics
Opioid Analgesics
Non-opioid Analgesic
Analgesic (APAP,
(APAP, NSAIDs,
NSAIDs, COX-2
COX-2
Non-opioid
Inhibitors) +/+/- Local/Topical
Local/Topical Anesthetics
Anesthetics
Inhibitors)
Ladder Basics
Basics
Ladder
1.Use
oral route
route when
when possible
possible
1.
Use oral
2.Give
analgesics at
at regular
regular intervals
intervals
2.
Give analgesics
3.Prescribe
according to
to pain
pain intensity
intensity
3.
Prescribe according
4.Dosing
must be
be adapted
adapted to
to individual
individual
4.
Dosing must
5.Analgesic
plan must
must be
be refined
refined and
and
5.
Analgesic plan
communicated with
with patient
patient and
and staff
staff
communicated
Opioid Prescribing
Prescribing Guidelines
Guidelines and
and Equianalgesic
Equianalgesic Chart
Chart
Opioid
Onset (O)
(O) and
and
Onset
Duration (D)
(D)
Duration
Oral
IV
Oral
IV
Generic (Brand)
(Brand)
Generic
Recommended STARTING
STARTING
Approximate
Recommended
Approximate
Equianalgesic Dose
Dose
dose for
for ADULTS
ADULTS
Equianalgesic
dose
Oral
IV
Oral
IV
Oral
IV
Oral
IV
O:30-60
30-60min
min O:
O:5-10
5-10min
min 30 mg
O:
Morphine (MSIR®)
(MSIR®) [CII]
[CII]
30 mg
Morphine
D:3-6
3-6hh
D:3-6
3-6hh
D:
D:
O:
30-90
min
Morphine
extended
release
O:
30-90
min
Morphine extended release
—
30mg
mg
—
30
(MS Contin®)
Contin®) [CII]
[CII]
D:8-12
8-12hh
(MS
D:
O:15-30
15-30min
min O:
O:15
15min
min 7.5 mg
Hydromorphone (Dilaudid®)
(Dilaudid®) [CII]
[CII] O:
7.5 mg
Hydromorphone
D:4-6
4-6hh
D:4-6
4-6hh
D:
D:
Hydrocodone/APAP 325
325 mg
mg
Hydrocodone/APAP
O:30-60
30-60min
min
O:
—
30mg
mg
(Norco 5,
5, 7.5,
7.5, 10®)
10®) [CII]
[CII]
—
30
(Norco
D:4-6
4-6hh
Hycet (7.5
(7.5 mg/325
mg/325 mg
mg per
per 15
15 mL)
mL) D:
Hycet
Transdermal
Transdermal
Fentanyl[CII]
[CII]
Fentanyl
O:immediate
immediate
O:12-24
12-24hh O:
O:
(Sublimaze®Duragesic®)
Duragesic®)
—
(Sublimaze®
—
D:72
72hhper
per D:
D:30-60
30-60min
min
Patchfor
foropioid
opioidtolerant
tolerantpatients
patientsONLY
ONLY D:
Patch
patch
patch
O:30-60
30-60min
min
Methadone (Dolophine®)
(Dolophine®) [CII]
[CII] O:
Methadone
D:>8
>8hh
—
Variable
D:
—
Variable
Opioid tolerant
tolerant patients
patients ONLY
ONLY
Opioid
(chronic
use)
(chronic use)
Oxycodone5,5,15,
15,30
30mg
mg(Roxicodone®),
(Roxicodone®),
Oxycodone
O:10-15
10-15min
min
Oxycodone5,5,7.5,
7.5,10
10mg/
mg/APAP
APAP325
325mg
mg O:
Oxycodone
—
20-30mg
mg
—
20-30
(Percocet®),
D:4-6
4-6hh
(Percocet®),
D:
ER=Oxycontin®[CII]
[CII]
ER=Oxycontin®
O:11hh
O:
—
300mg
mg
Tramadol (Ultram®)
(Ultram®) [CIV]
[CIV]
—
300
Tramadol
D:3-6
3-6hh
D:
Codeine* 15,
15, 30,
30, 60
60 mg/APAP
mg/APAP
Codeine*
300 mg
mg
300
O:1-2
1-2hh
O:
D:4-6
4-6hh
D:
—
—
200mg
mg
200
Recommended STARTING
STARTING
Recommended
dose for
for CHILDREN
CHILDREN (>
(> 66 mo)
mo)
dose
Oral
Oral
IV
IV
0.1mg/kg
mg/kg
0.1
2-4hh
qq2-4
0.5-2mg
mg
0.5-2
2-4hh
qq2-4
0.3mg/kg
mg/kg
0.3
qq44hh
0.3-0.6mg/kg
mg/kg
0.3-0.6
12hh
qq12
0.06mg/kg
mg/kg
0.06
qq44hh
0.015mg/kg
mg/kg
0.015
qq44hh
5-10mg
mg
5-10
qq66hh
—
—
0.1-0.2mg/kg
mg/kg
0.1-0.2
4-6hh
qq4-6
—
—
100mcg
mcg
100
(0.1mg)
mg)
(0.1
Transdermal
Transdermal
12-25mcg/h
mcg/h
12-25
72hh
qq72
50mcg
mcg
50
1-2hh
qq1-2
Transdermal
Transdermal
12-25mcg/h
mcg/h
12-25
72hh
qq72
1-2mcg/kg
mcg/kg
1-2
1-2hh
qq1-2
(max50
50mcg/dose)
mcg/dose)
(max
Variable
Variable
5-10mg
mg
5-10
8-12hh
qq8-12
—
—
0.7 mg/kg/d
mg/kg/d PO/SC/IM/IV
PO/SC/IM/IV divided
divided
0.7
4-6 hh prn
prn severe
severe chronic
chronic pain
pain
qq 4-6
—
—
0.05-0.15mg/kg
mg/kg
0.05-0.15
4-6hh
qq4-6
—
—
1.5mg
mg
1.5
15-30mg
mg
15-30
2-4hh
qq2-4
15-30 mg
mg
15-30
12 hh
qq 12
2-4mg
mg
2-4
qq44hh
—
—
10mg
mg
10
10mg
mg
10
—
—
—
—
—
—
5-10mg
mgqq66hh
5-10
ER10
10mg
mgqq12
12hh
ER
2-10mg
mg
2-10
2-4hh
qq2-4
—
—
—
—
50-100mg
mgqq66hh
50-100
Max:400
400mg/d
mg/d
Max:
—
—
—
—
—
—
30-60mg
mg
30-60
qq44hh
—
—
0.5-1mg/kg
mg/kgqq66hh
0.5-1
or3-6
3-6yo
yo==12mg
12mg
or
7-12yo
yo==15-30mg
15-30mg
7-12
—
—
*Codeineisisoften
oftenineffective.
ineffective.Use
Usefor
forcough
coughand
andcold
coldisiscontraindicated
contraindicatedininchildren.
children.Not
Notrecommended
recommendedfor
for<<12
12yo
yoor
or12-18
12-18yo
yowith
withrespiratory
respiratorycondition
conditionor
ornursing
nursingmothers.
mothers.
*Codeine
Opioid Cross-Sensitivities
Cross-Sensitivities
Opioid
Phenanthrenes(related
(relatedto
tomorphine):
morphine):morphine,
morphine,
Phenanthrenes
codeine,oxycodone,
oxycodone,hydrocodone,
hydrocodone,hydromorphone
hydromorphone
codeine,
Phenylpiperidines(related
(relatedto
tomeperidine):
meperidine):
Phenylpiperidines
meperidine,fentanyl
fentanyl
meperidine,
Riskof
ofcross-sensitivity
cross-sensitivityininpatients
patientswith
withallergies
allergiesisis
Risk
greaterwhen
whenmedications
medicationsfrom
fromthe
thesame
sameopioid
opioid
greater
family
are
administered.
family are administered.
Generic
Generic
Fentanyl
Fentanyl
Dose
Dose
Intranasal Medications*
Medications*
Intranasal
Max Dose
Dose
Max
Comments
Comments
1.5-2mcg/kg
mcg/kgqq1-2
1-2hh 33mcg/kg
mcg/kgor
or100
100mcg
mcg Divide
Dividedose
doseequally
equallybetween
betweeneach
eachnostril
nostril
1.5-2
10mg
mgor
or11mL
mLper
per Divide dose equally between each nostril
10
Midazolam55mg/mL
mg/mL
0.3mg/kg
mg/kg
Midazolam
0.3
Divide
dose
equally
between
each
nostril
nostril
(total
2
mL)
nostril (total 2 mL)
0.5-1.0mg/kg
mg/kgLarge
Largerange
range
Limiteddata
data
Usewith
withcaution
cautionuntil
untilfurther
furtherstudied
studied
Ketamine+
0.5-1.0
Limited
Use
Ketamine+
*Usethe
theMOST
MOSTconcentrated
concentratedform
formavailable
availablewith
withan
anatomizer.
atomizer. ++Dosing
Dosingnot
notwell
wellestablished.
established.Studies
Studieshave
haveused
used0.5-9
0.5-9mg/kg.
mg/kg.
*Use
Neuropathic Pain Medications
nerve blocks
Generic (Brand)
Beginning Dose
Max Dose
Gabapentin* (Neurontin®)
Pregabalin* (Lyrica®)
SNRIs: Duloxetine (Cymbalta®)
Venlafaxine ER (Effexor XR®)
TCAS: Amitriptyline (Elavil®)
Nortriptyline (Pamelor®)
300 mg PO QHS to TID
50 mg PO TID
30 mg PO daily†
37.5 mg PO daily
25 mg PO QHS
25 mg PO QHS
3600 mg/d
300 mg/d**
60 mg/d**
225 mg/d
200 mg/d
150 mg/d
Type of Block
General Distribution of Anesthesia
Interscalene Plexus Block
Shoulder, upper arm, elbow and forearm
Supraclavicular Plexus Block
Upper arm, elbow, wrist and hand
Infraclavicular Plexus Block
Upper arm, elbow, wrist and hand
Axillary Plexus Block
Forearm, wrist and hand. Elbow if including musculocutaneous nerve
Median Nerve Block
Hand and Forearm
Radial Nerve Block
Hand and Forearm
Ulnar Nerve Block
Hand and Forearm
Femoral Nerve Block
Anterior thigh, femur, knee and skin over the medial aspect below the knee
Popliteal Nerve Block
Foot and ankle and skin over the posterior lateral portion, distal to the knee
Tibial Block
Foot and ankle
Deep Peroneal Block
Foot
(Flexeril®)
Saphenous Nerve Block
Foot
Methocarbamol
Sural Nerve Block
Foot
Local Anesthetics†
Onset
†30 mg daily for at least 7 days to decrease nausea
*Requires dose adjustment based on renal function **Varies depending on indication
Beginning Dose
Max Dose
Baclofen (Lioresal®)
Cyclobenzaprine
5 mg PO TID
80 mg/d
5 mg PO TID
30 mg/d
1-1.5 g PO TID to 4x/day x 48-72 h,
then 500-750 mg PO TID to 4x/day
8 g/d
(Robaxin®)
Duration
Duration
without Epi (h) with Epi (h)
Max Dose
without Epi,
mg/kg
Max Dose
with Epi,
mg/kg
Lidocaine (1%)
Rapid
0.5–2
1–6
4.5 (300 mg)
7 (500 mg)
Bupivicaine (0.5%)*
Slow
2-4
4-8
2.5
3
Mepivicaine (1.5%)
Rapid
2-3
2-6
5
7
2-Chloroprocaine (3%)
Rapid
0.5-1
1.5-2
10
15
Ropivicaine (0.5%)
Medium
3
6
2-3
2-3
*Most cardiotoxic
Muscle Relaxer Pain Medications
Generic (Brand)
Adult: 2-10mg PO TID-QID;
Ped: 0.6 mg/
5-10mg IV/IM
Ped: (6-12yo): 0.12-0.8 mg/kg/day PO kg/8h IV/IM to
divided q 6-8 h; 0.04-0.2 mg/kg IV/IM
adult max
q 2-4 h prn;
Diazepam
(Valium®)
Ketamine (Ketalar®) Indications
Indications
Starting Dose
IV: Adult 0.5-1.0 mg/kg, Ped 1-2mg/kg;
IM: 4-5 mg/kg
IV: 0.1 to 0.3 mg/kg, max initial dose ≤ 10 mg
Sub-dissociative Analgesia
IM: 0.5-1.0 mg/kg; IN*: 0.5-1.0 mg/kg
Excited Delirium Syndrome
IV: 1 mg/kg; IM: 4­‐5 mg/kg
Procedural Sedation
†1% = 10mg/ml, 0.5% = 5mg/ml
*Dosing not well established. Studies have used 0.5-9 mg/kg.
Topical and Transdermal Medications*
Generic (Brand)
Indications
Diclofenac sodium 1.5%, 2% w/w
topical solution (Pennsaid)
Onset (O) and Recommended STARTING Recommended STARTING
Duration (D)
dose for ADULTS
dose for CHILDREN
Osteoarthritis
Variable
1% gel (Voltaren gel)
1.5% soln: 40 drops QID
2% soln: 2 pumps (40mg) BID
to affected knee
Maximum Dose
—
1.5% soln: 40 drops QID
2% soln: 2 pumps (40mg) BID
1% gel (2g): 8 g/d to single joint of upper
extremity; 1% (4g): 16 g/d to single joint of
lower extremity
1% gel: 2 or 4g QID
Diclofenac epolamine 1.3% patch
(Flector patch)
Acute pain from sprains,
strains, contusion
Variable
1 patch (180 mg) BID
—
1 patch BID
Lidocaine 5% patch
(Lidoderm patch)
Postherpetic neuralgia
Variable
1-3 patches applied once daily,
remove after 12 h
—
3 patches in a 12 h period per day
Fentanyl (Duragesic®)
Persistent moderate to severe
chronic pain
O: 12-24 h
D: 72 h per patch
Capsaicin cream (Theragen®, Zostrix®,
backache or
Salonpas) Exists as several OTC formulations Strains, sprains,
arthritis
in combination with camphor and menthol
Variable
12-25 mcg/h q 72 h
Apply a thin layer to the
affected area and gently
massage up to QID
Variable
>12 yo: Apply a thin layer to
the affected area and gently
massage up to QID
Lidocaine 4% (L.M.X.4®)
Minor cuts, scrapes, burns,
sunburn, insect bites, and minor
skin irritations
O: 20-30 min
D: 60 min
Apply externally
LET (Lidocaine Epinephrine Tetracaine)
(gel or liquid)
Wound repair (non-mucosal)
O: 10 min
D: 30-60 min
Topical
4% Lidocaine, 1:2,000 Epinephrine, 0.5% Tetracaine
EMLA (2.5% Lidocaine 2.5% Prilocaine)
Cover with occlusive dressing
Maximum application time 4 hours
Dermal analgesic (intact skin)
O: 60 min
D: 3-4 h
20 gm
Pain-Ease®
Vapocoolant/Skin Refrigerant
Cooling intact skin and mucus
membranes and minor open
wounds
O: immediate
D: few sec to
1 min
—
Lidocaine
Foley catheter and nasogastric
tube insertion; intubation; nasal
packing; gingivostomatitis
O: 2-5 min
D: 30-60 min
3-12 mo (>5 kg): 2 gm
1-6 yo (>10kg): 10 gm
7-12 yo (>20kg): 20 gm
Up to QID
Externally 3-4 times per day. Apply in area less
than 100cm2 for children less than 10kg. Apply
in area less than 600cm2 for children between
10 and 20kg
3 mL
(not to exceed maximal Lidocaine
dosage of 3-5 mg/kg)
3-12 mo max area 20cm2
1-6 yo max area 100cm2
7-12 yo max area 200cm2
Spray for 4-10 sec from distance
of 8-18 cm.
Stop when skin turns white to avoid frostbite
Not recommended for < 3 yo
2% topical gel/jelly, 5% topical ointment, 2% oropharyngeal
viscous topical solution
3-5 mg/kg
*Dosages are guidelines to avoid systemic toxicity in patients with normal intact skin and with normal renal and hepatic function
Procedural Sedation and Analgesia Medications
Generic (Brand)
Adult
Pediatric
Comments
Ketamine
(Ketalar®)
IV 0.5-1.0 mg/kg
IM 4-5 mg/kg
>3 mo: IV 1-2 mg/kg;
additional doses 0.5 mg/kg
IV q 10-15 min prn;
IM 4 - 5 mg/kg
Risk of laryngospasm increases with active upper respiratory
infection and procedures involving posterior pharynx; vomiting
common - consider premedication with Ondansetron (Zofran).
Not recommended in patients <3 mo.
Midazolam
(Versed®)
IV 0.05-0.1 mg/kg
IV slow push over 1-2 min
IV 0.05-0.1 mg/kg
IN 0.2-0.3 mg/kg
(IN max 10 mg)
Initial max dose 2 mg. Max total dose in >60 yo is 0.1 mg/kg
Decrease dose by 33-50% when given with opioid
Propofol
(Diprivan®)
Etomidate
(Amidate®)
Ketamine + Propofol
Dexmedetomidine
(Precedex®)
IV 0.5-1 mg/kg slow push
IV 1 mg/kg slow push (1-2 min); Risk of apnea, hypoventilation, respiratory depression, rapid changes
(1-2 min); additional doses 0.5
additional doses 0.5 mg/kg
in sedative depth, hypotension; provides no analgesia
mg/kg
IV 0.1 - 0.2mg/kg; additional doses 0.05mg/kg
—
IV ketamine 0.75 mg/kg +
propofol 0.75 mg/kg. Additional
doses: ketamine 0.5 mg/kg,
propofol 0.5-1 mg/kg
IV 1 mcg/kg loading dose (over IV 0.5–2 mcg/kg loading dose
10 min) followed by 0.5 to 2 mcg/ (over 10 min) followed by 0.5 to
kg/h continuous infusion. Use 2 mcg/kg/h continuous infusion
0.5 mcg/kg for geriatric patients
IN 2-3 mcg/kg
Nitrous oxide
—
50% N2O/50% O2 inhaled
Morphine
IV 0.05-.0.1 mg/kg or
5-10 mg
IV 0.1-0.2 mg/kg,
titrated to effect
IV 0.5-1 mcg/kg
1-3 yo: 2 mcg/kg;
3-12 yo 1-2 mcg/kg
Fentanyl
Risk of myoclonus (premedication w/ benzo or opioid can decrease),
pain with injection, nausea and vomiting, risk of adrenal suppression;
provides no analgesia
See ketamine and propofol comments respectively
Risk of bradycardia, hypotension, especially with loading dose or
rapid infusions, apnea, bronchospasm, respiratory depression
Do not use if acute asthma exacerbation, suspected pneumothorax/other
trapped air or head injury with altered level of consciousness
Monitor mental status, hemodynamics, and histamine release. Requires
longer recovery time than fentanyl. Difficult to titrate during procedural
sedation due to slower onset and longer duration of action. Reduce
dosing when combined with benzodiazepines (combination increases risk
of respiratory compromise)
100 times more potent than morphine; Rapid bolus infusion may
lead to chest wall rigidity. Reduce dosing when combined with
benzodiazepines and in elderly. Preferred agent due to rapid onset
and short duration.
Stepwise Approach to Pain Management
and Procedural Sedation Analgesia (PSA)
http://pami.emergency.med.jax.ufl.edu/resources/
educational-materials/procedural-sedation/
1. Situation Checkpoint
What are you trying to accomplish?:
analgesia, anxiety, sedation, procedure, etc.
2. Developmental/Cognitive Checkpoint
What is the patient’s development stage?
3. Family Dynamic Checkpoint
Who is caring for the patient?
What are the family dynamics?
4. Facility Checkpoint
Type of staffing and setting, team
experience, facility policies, etc.
5. Patient Assessment Checkpoint
Review patient’s risk factors and history.
6. Management Checkpoint
Choose your “ingredients” for pharmacologic
and non-pharmacologic “recipe.”
7. Monitoring & Discharge Checkpoint
Joint Commission standards, reassessments,
facility policies, discharge and transportation
considerations.