1 Sedasi Dan Analgesia Pada Anak Sakit Kritis-Dadang Hudaya PDF

SEDASI DAN ANALGESIA
Palembang 2014 ANAK SAKIT KRITIS
Dadang Hudaya Somasetia

UKK Gawat Darurat Pediatri, IDAI
Palembang 2014
DISCLOSURE
Dr Dadang Hudaya Somasetia

certify that there is no conflict of interest
in relation to this presentation.
2
Sedasi dan Analgesia Anak Sakit Kritis
Palembang 2014
TUJUAN PEMBELAJARAN
1.  Mengenal obat serta metode sedasi dan
analgesia pada anak sakit kritis
2.  Memahami cara melakukan sedasi dan
analgesia pada anak sakit kritis
3.  Menguasai teknik sedasi dan analgesia
pada anak sakit kritis
PENDAHULUAN
•  Luaran fisiologis, neurologis & psikologis

•  Sedatif mengurangi rasa cemas & gelisah
•  Analgesia mengatasi rasa nyeri
•  Kombinasi sedatif dan analgesia
Sedasi dan analgesia tidak adekuat:

à  Respons stres metabolik,
à  humoral,
à  hemodinamis
Kaskade neuroendokrin
à  konsumsi O2 ↑, produksi CO2 ↑,
à  katabolisme, balans nitrogen (–)
Batasan
Sedasi
Tindakan untuk menenangkan, terutama dengan
pemberian sedatif, atau upaya yang menenangkan
Sensasi nyeri/rangsang hebat (-)
Rasa takut dan kecemasan (-)
Potensiasi dg analgesia, ingatan traumatis (-)
Analgesia
Kondisi stimuli nosiseptif terasa
tetapi tidak diinterpretasikan sebagai nyeri
Biasanya diberikan bersama-sama dengan sedasi
tanpa kehilangan kesadaran
Obat Sedatif dan Analgesik Ideal
•  Onset cepat
•  Durasi dapat diprediksi
•  Tidak menghasilkan metabolit aktif
•  Pulih cepat
•  Rute masuk obat multipel
•  Mudah dititrasi
•  Efek kardiopulmonum minimal
•  Tidak dipengaruhi oleh penyakit ginjal dan hati
•  Tidak ada interaksi dengan obat lain
•  Indikasi terapi luas
Pemakaian Sedasi - Analgesia
Pertimbangan memilih obat:
Indikasi
Durasi yang diharapkan
Farmakodinamik
Indikasi kontra
•  Hilang rasa nyeri,
•  Ventilasi Mekanis
takut dan cemas
•  Pascaoperasi
•  Amnesia
•  Cedera kepala (head injury)
•  Hipertensi pulmonum •  Kooperatif
•  Berbagai prosedur klinis •  Kenyamanan
•  Keamanan
Tingkatan Sedasi
Sedasi Minimal (Ansiolisis)
Masih berespons normal terhadap perintah verbal. Kognitif dan koordinasi baik
Tidak memengaruhi sal. napas, ventilasi, kardiovaskuler
Sedasi Menengah (Sedasi Sadar [Conscious Sedation])
Masih merespons perintah verbal atau rangsang taktil minimal
Tidak perlu intervensi sal. napas dan pernapasan, kardiovaskuler dipertahankan
Sedasi Disosiatif
Kataleptis ~ kondisi ‘trans’ yg diinduksi ketamin, analgesia dalam dan amnesia,
Retensi refleks protektif sal. napas, napas spontan & fungsi kardiopulmonum
Sedasi Dalam
Depresi, sulit dibangunkan, respons rangsang nyeri (+)
à perlu alat bantu patensi ventilasi & kardiovaskuler
Anestesia Umum
Hilang kesadaran, tidak dapat dibangunkan. Ventilasi spontan terganggu
à alat bantu patensi sal. napas & fungsi kardiovaskuler, VTP
Tabel 1. Berbagai Sistem Skoring Sedasi
Subjective Observer Rating
Sedatif-Analgesik
Visual analog scales yang Sering Dipakai
Steward
Ramsay
Harris
Modified Glasgow Coma Scale
Observer’s Assessment of alerness/Sedation Scale (OAA/S)
Cambridge
Bloomsbury
Cook/Newcastle
Neurobehavioral Assessment Scale (NAS)
Sedation-Agitation Scale (SAS)
Patient Task Performance
Digital symbol substitution test (DSST)
Choice reaction time (CRT)
Memory tests
Visual analog scales
Physiologic Measures Included
COMFORT
Nisbet and Norris
Heart rate variability
Esophageal sphincter contractility
PRST (Pressure, rate, sweat, tearing)
Sedasi dan Analgesia
Tabel 2. Skala Ramsay untuk Penilaian Sedasi
Tingkat

Deskripsi Sedasi Skala Ramsay
1 Sadar, cemas; gelisah atau tidur gelisah, atau keduanya
2 Sadar, kooperatif, terorientasi, dan tenang
3 Respons hanya terhadap perintah verbal
4 Mengantuk, respons cepat thd ketukan ringan glabela
atau rangsang suara keras
5 Mengantuk, respons lambat thd ketukan ringan glabela
6 Mengantuk, tidak ada respons thd ketukan ringan glabela
Tabel 3. Skala COMFORT untuk Menilai Sedasi
Alertness Mean arterial blood pressure (MAP)
Deeply asleep Sedatif-Analgesik
1 yang Sering Dipakai
Tekanan darah MAP di bawah baseline 1
Lightly asleep 2 Tekanan darah MAP pada baseline 2
Mengantuk 3 MAP jarang >15% di atas baseline 3
Fully awake and alert 4 MAPsering >15% di atas baseline 4
Hyperalert 5 (>3 selama periode observasi)
Calmness/agitation MAP terus menerus >15% diatas baseline 5
Calm 1 Respons respirasi
Slightly anxious 2 Tidak ada batuk dan napas spontan 1
Anxious 3 Napas spontan, sedikit atau tidak ada respons 2
Very anxious 4 ventilasi
Panicky 5 Sesekali batuk atau resistensi ventilator 3
Heart rate Bernapas aktif terhadap ventilator 4
Denyut jantung (HR) < baseline 1 Batuk atau selalu melawan ventilator, batuk 5
Denyut jantung sesuai baseline 2 atau tersedak
HR jarang >15% diatas baseline 3 Tonus otot
(1−3 selama periode observasi) Relaksasi otot total, tidak ada tonus otot 1
HR sering >15% diatas baseline 4 Penurunan tonus otot 2
(>3 selama periode observasi) Tonus otot normal 3
HR terus menerus sekitar >15%) 5 Tonus otot meningkat, fleksi jari tangan& kaki 4
Facial Tension Rigiditas otot ekstrim 5
Otot fasial relaksasi total 1 Physical movement
Tonus otot fasial normal, tidak ada 2 Tidak ada pergerakan 1
tegangan otot fasial yang jelas Sesekali dan sedikit pergerakan 2
Tegangan jelas pd beberapa otot fasial 3 Sering, sedikit pergerakan 3
Tegangan jelas pada seluruh otot fasial 4 Pergerakan kuat pada ekstremitas 4
Otot fasial mengerut dan meringis 5 Pergerakan kuat termasuk torso dan kepala 5
The COMFORT SCALE, 6 behavioral and 2 physiologic measures.
The nurse observes the patient for 2 minutes during which the patient is scored on
alertness, degree of calmness or agitation, respiratory response, physical
movement and facial tension.
The administrator observes the heart rate and mean arterial blood pressure every
15-20 seconds and determines whether these are within 15 % of the baseline.
Total scores can range between 8 and 40.
A score of 17-26 generally indicates adequate sedation and pain control.
The FLACC
(Faces, Legs, Activity, Cry and
Consolability) pain assessment tool
to recognize pain and make the right
analgesic choice.
The use of this tool is appropriate in
preverbal children in pain from
surgery, trauma, cancer or other
disease processes.
Behavioral assessment tool for
scoring postoperative pain in non-
verbal patients
This scale may also be helpful in the
aphasic patient
Indicators are divided in 5 categories : facial expression, movement (of legs), activity,
cry and consolability.
Each item is scored from 0 - 2. The total score is between 0 and 10.
A score between 1 and 3 = no or mild pain, between 4 and 6 = moderate pain.
A score of 7 or higher = serious pain.
Children with Cognitive Impairment
•  Often unable to describe pain
•  Altered nervous system and experience
pain differently
•  Use behavioral observation scales

–  e.g. FLACC
•  Can apply to intubated patients
SEDATION LEVELS!
Minimal!
• General Description! “Anxiolysis”!
Greg Hollman, MD, FAAP
• Responsiveness! “Appropriate”! Medical Director, Pediatric
! ! Sedation Program
University of Wisconsin
• Airway! Unaffected! Children’s Hospital
• Ventilation! Unaffected! Madison, Wisconsin
• Cardiovascular! Unaffected!
Risk!
of!
Adverse!
Event!
Timothy E. Corden, MD, FAAP
Associate Professor of Pediatrics
Associate Director, Pediatric Critical
Care Medicine
Medical College of Wisconsin
Milwaukee, Wisconsin
No" Mild" 16
Sedation" Sedation"
SEDATION LEVELS!
Minimal! Moderate!
• General Description! “Anxiolysis”! “Conscious”!
• Responsiveness! “Appropriate”! “Purposeful” to light
! ! stimulation!
• Airway! Unaffected! No intervention!
• Ventilation! Unaffected! Adequate!
• Cardiovascular! Unaffected! Maintained!
Risk!
of!
Adverse!
Event!
No" Mild" Moderate" 17

Sedation" Sedation" Sedation"
SEDATION LEVELS!
Minimal! Moderate! Deep!
• General Description! “Anxiolysis”! “Conscious”! “Deep sleep”!
• Responsiveness! “Appropriate”! “Purposeful” to light “Purposeful” to pain
! ! stimulation! stimulation!
• Airway! Unaffected! No intervention! (±) Intervention!
• Ventilation! Unaffected! Adequate! (±) Inadequate!
• Cardiovascular! Unaffected! Maintained! (±) Maintained!
Continuum
Drug Induced - Level of Sedation
American Society of Anesthesiologists (ASA)
Risk!
of!
Adverse!
Event!
No" Mild" Moderate" Deep"

18
Sedation" Sedation" Sedation" Sedation"
Choosing a Moderate Sedation Plan
Remember mnemonic AMPLE!!

•  A llergies
•  M edications
•  P ast Medical History
•  L ast Meal
•  E vents leading to sedation
19
38
Equipment & Supplies

AAP recommends S O A P M E
q Suction – age/size-suction catheters and apparatus (Yankauer-
type)
q Oxygen – adequate O2 supply, working flow/delivery devices
q Airway – age/size-appropriate airway equipment (e.g., ET
tubes, LMAs, oral and nasal airways, laryngoscope blades,
stylets, bag mask)
q Pharmacy – life-saving drugs, reversal agents (Naloxone,
Flumazenil)
q Monitors – pulse oximeter, BP, ECG, cardiac, EtCO2
q Equipment – special equipment/drugs (e.g., crash cart w/
defibrillator, respiratory box, IV access equipment)
(Pediatric 2006;118:2587-2605)
MOST IMPORTANT WELL TRAINED PERSONNEL IN ADVANCED LIFE SUPPORT!
20
Pre-Sedation Risk Assessment
American Society of Anesthesiologists (ASA Class) 1941
Physical Status Classification
I A healthy patient
II A patient with systemic disease, with no functional
limitations
III A patient with severe systemic disease which
limits activity but is not incapacitating
*IV A patient with an incapacitating disease that is a
constant threat to life
*V A patient not expected to survive 24 hours with or
without an operation PFCCS 2008
* It is recommended that the patients receive sedation by
appropriately trained anesthesiologists and intensivists 21
IX! X!
←inhibition→!
Pharyngeal"
Segment"
Nasal" Tracheal"
Segment Segment
P(O)! P(-)!
THE UPPER AIRWAY! Greg Hollman, MD, FAAP

Medical Director, Pediatric
Pharyngeal collapse ! Sedation Program
University of Wisconsin
during sedation! Children’s Hospital 22
Madison, Wisconsin
Physical Exam
Mallampati - The Difficult Airway
•  Mallampati/Samsoon Classification
–  Class I: soft palate, uvula, pillars
–  Class II: soft palate, portion of uvula
–  Class III: soft palate, base of uvula
–  Class IV: hard palate only can be seen
•  Other predictors of difficult airway
–  Obesity with short neck
–  Reduced neck movement
–  Inability to protrude the lower teeth
–  Reduced mouth opening
–  Receding mandible
–  Thyromental distance of less than 3 fingers
23
ASA NPO Guidelines
for gastric emptying
•  Clear liquids − 2 hours
•  Breast milk − 4 hours
•  Infant formula − 6 hours
•  Non-human-milk − 6 hours
•  Light meal − 6 hours
These guidelines apply to all ages

These do not guarantee complete gastric emptying
Meals that contain fried or fatty foods and meat may
prolong gastric emptying
24
85
Mod-Sed Scale/Scoring Tool

Modified Ramsay Scale Modified Aldrete Score
v  Provides a consistent method to
document the child’s level of When a child can be safely
sedation during and after a discharged after undergoing
procedure sedation/analgesia?
Indication Score*
1. Anxious, Agitated, Restless 1
2. Awake, cooperative, oriented, 2
tranquil
Accepts mechanical ventilation
3. Semi asleep but responds to 3
commands
4. Brisk response to light glabellar 4
tap or loud noise
5. Sluggish response to light 5
glabellar tap or loud noise
6. No Response 6
*Desired score depends on indication for sedation Score of NINE (9) is required for DISCHARGE
25
The Right Drug for the Right Pts
•  There is no ideal drug or magic bullet…all drugs have
potential complications
•  Drugs to consider should fit your goals for sedation
with minimum risk to the patient
Considerations when choosing a drug
–  Route of administration
–  Onset of action
–  Duration of action
–  Contraindications
–  Therapeutic advantages
All sedative drugs suppress the CNS
26
DRUG USED FOR MODERATE SEDATION
First Generation Third Generation
Chloralhydrate Etomidate
Diazepam Propofol
Morphine and
Meperidine
Pentobarbital
Tiopental and
Methohexital
Second Generation
Midazolam
Fentanyl
Ketamine
Nitrous Oxide
Krauss B, Green SM. Procedural sedation and analgesia in children. 27
Lancet. 2006. 2006;367:766–80.
The Favorite MOD-SED Drugs
•  Anesthetics:
–  Propofol, Ketamine, (Pentobarbital)
•  Analgesics:
–  Fentanyl, Morphine, Paracetamol, Ibuprofen,
Ketorolac, NO
•  Anxiolytics:
–  Midazolam, (Lorazepam), Diazepam
•  Others:
–  Dexmedetomidine, Etomidate, Clonidine
–  Chloral Hydrate
–  Nitrous Oxide
–  Local anesthetics: Lidocaine, TAC, LET, EMLA
A new mixture of ketamine and propofol (KETOFOL), have also been
reported. (Orlewicz MS et al. Procedural Sedation. MEDSCAPE Updated: May 28, 2013)
28
SKALA PENILAIAN NYERI FLACC – Preverbal children
Kategori Skor
0 1 2
Face Tak ada ekspresi Terkadang Sering megernyitkan
tertentu atau menyeringai atau dahi, menggerakkan
senyum menerutkan dahi, dagu, gerakan
tidak tampak tertarik menggigit
dengan sekitarnya
Legs Posisi normal atau Gelisah, tidak Menendang-‐
relaksasi tenang, tegang nendangkan tungkai
Activity Tidur tenang, posisi Menggeliat-‐geliat, Melengkung, kaku,

normal, mudah tegang atau menyentak-‐
bergerak nyentak
Cry Tidak menangis Menguap atau Menangis terus,
(terbangun/tertidur) merengek, kadang menjerit / merintih,
mengeluh sering mengeluh
Consolability Santai Perhatian mudah Sulit untuk
teralih, tenang bila menenangkan diri
disentuh,/dipeluk/
diajak bicara/main
The Visual Analogue Scales (VAS). The most widely used non-
verbal self report scales- measure subjective complaints of pain.
Although scientific research proved this type of scales to be a reliable
assessment tool, many in the medical profession question the VAS scale
because of its lack of reproducibility. Self-report scale for pain/mood.
Can be used in large populations (adults and children > 3 years)
Very easy and fast to use. Non-verbal. No specific training required
How severe is your pain today ?
The visual analogue scale (VAS) unmarked line with extremes of pain where
patients are asked to mark the point in the line that describes their pain.
The Numerical rating scale is similar to the VAS but uses numbers
that indicate the severity of the pain.
What happen
between the late
famous Jacko
with Propofol?
Propofol infusion syndrome:
a simple name for a complex syndrome.
Propofol, a short-acting, intravenously
administered sedative agent is what might
have caused the cardiac arrest of the King
of Pop, Michael Jackson. 31
Propofol
•  Pure sedative, no analgesic or amnestic properties
•  Quick onset: 30 sec – 1 min
•  Short duration: 3-10 min, t1/2 30-90 minutes
•  Dose: 0.5 -1 mg/kg IV bolus over 2 min,
Continuous infusion: 50-150 mcg/kg/min
•  Bolus followed by cont. infusion or repeated boluses
•  Disadvantages: respiratory depression, hypotension,
bradycardia, metab. acidosis with prolonged infusion
•  Induction agent for GA, used for MRI’s, moderate
(procedural) sedation and for prolong sedation in ICU
•  Not recommended for PICU sedation
•  “Propofol infusion syndrome” can cause CV collapse
32
Ketamine
•  Dissociative agent, produces a state of catalepsy
•  Translike sedation, analgesia and amnesia
•  Administered IV, IM, PO
•  Onset: 30 sec - 1 min (IV), 3-4 min (IM)
•  Duration: 5-10 min (IV), 15-30 min (IM)
•  Dose: 0.5-1 mg/kg (IV), 4-5 mg/kg (IM)
–  Infusion: 5-20 mcg/kg/min
•  Good safety profile, preserves airway protective reflexes,
minimal effects on respiratory drive
•  Good agent for asthma, potent bronchodilator
•  Disadvantages: excess secretions, increased ICP,

sensitizes laryngeal reflexes, emergence reaction
33
Ketamine
•  Anticholinergic added to reduce secretions
–  Atropine 0.01- 0.02mg/kg (min 0.1 mg, max 0.5 mg)
•  Midazolam 0.05-0.1mg/kg added to reduce
potential for emergence phenomenon
•  Ketamine, atropine and midazolam (KAM)
can be given as single IM injection to
avoid multiple sticks
34
Barbiturates
•  Sedative hypnotic, no analgesic
properties
•  Highly lipid soluble
•  Administered w/ multiple routes (IV, IM, PO,
PR)
•  Function at GABA receptor complex
•  Not reversible
35
Pentobarbital
IV route
•  Onset: 3-5 min (IV)
•  Duration: 15-45 min (IV)
•  Dose: 1-2 mg/kg (up to 2-5 mg/kg, max 100 mg)
IM route: 20-30 minutes prior to study
•  Onset 10-20 minutes
•  Duration 1-2 hours
•  Dose: 2-6 mg/kg to maximum 100 mg
Disadvantages: NO reversal agent, no analgesia
(enhances pain perception)
Can produce sedative effects for up to 24 hours
•  Ensure fully awake prior to discharge 36
Analgesics
Narcotics
Non-narcotic
¨  Morphine IM, IV
¨  Acetaminophen PO, PR, IV
¨  Demerol IM, IV
¨  Ibuprofen PO
¨  Fentanyl IV, PO
¨  Ketoralac PO, IM, IV
¨  Codeine and analogs PO
¨  No difference in
effectiveness between ¨  Morphine and demerol
ibuprofen and ketoralac may cause nausea,
vomiting, and histamine
release
Nitrous oxide (NO)
•  Inhaled analgesic
•  Rapid onset and offset
•  Requires special equipment
•  Requires cooperative patient
•  Does not work well for reduction of
acute, sharp pain (fracture reduction) 37
Opiates
•  Most commonly used
•  Analgesia and sedation
•  No anxiolysis or amnesia
•  Natural derivatives of opium
–  Morphine (gold standard) and codeine
•  Semi synthetic compounds
–  Oxycodone and hydrocodone
•  Synthetic compounds
–  Demerol, fentanyl and sufentanil
•  Reversal agent – Naloxone
•  Hypotension, respiratory and CNS depression
•  histamine release
38
Morphine
Multiple routes (IV, IM, SQ)
Onset: 5-10 min (IV)

Duration: 4-6 hours
Dosage: 0.05-0.1mg/kg IV, IM, SQ

Administer every 5-10 minutes in increments
to achieve desired level.
IV peak effect 15-30 minutes,
IM peak 30-60 minutes
39
Fentanyl
•  Short painful procedures
•  Rapid onset: 2-3 min (<30 sec IV)
•  Short duration: 30-60 min
•  Dose: 1-5 mcg/kg IV (order in micrograms not µg)
•  Synthetic opioid,100x more potent than morphine
•  Reversal agent: Naloxone
•  Lack of histamine release
•  Disadvantages: no amnesia/ anxiolysis, tight
chest syndrome - “steel chest” (when high dose 15
mcg/kg, rapid administration)
40
Benzodiazepines
Therapeutic Effects
•  Sedative hypnotic agents Adverse Effects
•  Respiratory depression
•  Anmestic, anxiolytic
•  CNS depression
•  No analgesic properties •  Potentiates hypotension
•  Skeletal muscle relaxant in volume-depleted pts
•  Potentiate GABA neuroinhibition •  Tolerance and
•  High safety profile withdrawal effects
•  Reversible with Flumazenil *sedative-hypnotic dose
Rodrigo. PFCCS 1998
Drug * Dose (IV) Onset Peak Duration
Midazolam 0.1 – 0.2 mg/kg <60 s 3-5 min 30-60 min
Lorazepam 0.05-0.1 mg/kg 2-3 min 26-30 min 2-6 h
Diazepam 0.1-0.2 mg/kg <10 s 1-2 min 30-90 min 41

Midazolam
•  Multiple routes, IV, IM, oral, nasal, rectal
•  Onset: 2-5 min (may <60 sec) IV
•  Duration: 30-60 min IV
•  IV dose:
6 mos-5 yrs: 0.05-0.2 mg/kg, max 0.6 mg/kg IV
>5 yrs: 0.025-0.05 mg/kg, max 0.4 mg/kg IV
•  Oral dose is 0.5-0.75 mg/kg to max dose 20 mg
•  Intranasal dose is 0.2-0.5mg/kg
•  Reversal agent: Flumazenil
•  Retrograde amnesia
•  Disadvantages: NO analgesia, paradoxical
reactions
42
Diazepam
•  Onset: <10 sec (IV), 1-1.5 hours (oral)
•  Duration: variable but LONG 30-90 min
(oral)
•  Dose: 0.1-0.2 mg/kg (IV)
0.1-0.8 mg/kg/day (oral)
•  Useful for tapering
•  Disadvantages: accumulation, long half-
life, avoid rapid IV push
43
Lorazepam
•  Onset:2-3 min (IV)
•  Duration: 2-6 hrs (up to 12 hrs)
•  Dose: 0.05-0.1 mg/kg
•  Medium acting benzo
•  Disadvantages: mixed with propylene
glycol
–  Anion gap metabolic acidosis, osmolar gap
–  Avoid infusions
44
Clonidine
•  Centrally acting alpha-2 agonist
•  Onset: 30-60 min (oral)
•  Duration: 6-10 hours
•  Dose: 0.05 mg/day (oral)
•  Can convert to transdermal patch
•  Eases withdrawal & decreases anesthetic
requirements
45
Dexmedetomidine
•  Alpha-2 agonist
–  1700x more selective for alpha 2
(compared to clonidine)
•  Onset: 15-30 min
•  Duration: 60-120 min
•  Dose: load with 0.5-1 mcg/kg
–  Infusion of 0.3 – 1.5 mcg/kg/hr
•  Disadvantages: bradycardia,
only approved for 24 hrs infusions
46
Etomidate
•  Ultra short acting agent
–  IV onset 1 minute,
–  Duration 10-15 minutes
–  Dose 0.3 mg/kg IV
–  Minimal cardiovascular effects
–  Reduces intracranial pressure
–  Can interfere adrenocortical function
–  Uncommon in pediatric sedations
–  Drug of choice for rapid sequence intubation in
hemodynamically unstable with increased ICP
47
Chloral Hydrate
1.  Pure sedative hypnotic with no analgesic properties
2.  Used primarily for outpatient radiologic proc.s and EEG’s.
3.  Administered PO/PR, dose range from 50-100 mg/kg
not to exceed 2 grams.
May be repeated in 30 minutes within dose ranges.
4.  Long onset of action (40 minutes) and duration (1-2 hours)
5.  Low success rate when age >2 years (>3 yrs)
48
Most Useful Drug for
Pediatric Emergencies
•  Ketamin: Sedative analgesic of choice for intubating with
hemodynamic instability of any etiology and those with
severe bronchospasm
•  Fentanyl: Analgesic of choice in the presence
hemodynamic instability and severe bronchospasm
•  Midazolam: adjunct to above in a small titrated dose but
doesn’t have any analgesic effect
Continuous infusions for prolonged sedation:

- Midazolam at 0,1 mg/kg/h/ IV
- Fentanyl at 1-2 mcg/kg/h IV
- Dexmedetomidine at 0.3-0.7 mcg/kg/h IV
49
Emergency Intubation “Cocktail”
KAM - VR
•  Ketamine 1-2 mg/kg IV

•  Atropine 0.02 mg/kg up to 1 mg IV/IM/IO
•  Midazolam 0.025 to 0.05 mg/kg IV
•  Rocuronium 1 mg or Vecuronium 0,2 mg/
kg IV
-  If not IV/IO can use IM succinylcholine
unless contraindicated by history
-  Anecdotal reports of effective use of IM
non depolarizing agent
50
Neuromuscular Blocking Agents
•  Never give neuromuscular blockade to patient you
cannot bag-mask ventilate
•  Never use neuromuscular blockade alone since these
agents do not provide sedation, amnesia, or analgesia
Non depolarizing Dose (iv) Onset Duration
Agent
Rocuronium 0.6-1.2 mg/kg 30-60 s 30-40 min
Vecuronium 0.1-0.2 mg/kg 1-3 min 30-40 min
Pancuronium 0.05-0.1 mg/kg 1-3 min 40-60 min
Depolarizing Agent Dose IV Onset Duration
Succinylcholine 1.0-1.5 mg/kg 30-40 s 3-5 min

(2 mg/kg for infants)
51
Adjuncts to Sedation
Establish rapport with child and parents, if applicable

Calm environment
Imagery
Preemptive analgesia
Local anesthetics
Prepare for Unexpected Emergencies

•  Oxygen, bag and mask, and suction (SOAPME)
•  Use volume or fluid resuscitation
•  Have advanced airway equipment, intubation, medications,
and appropriate staff to monitor the patient
52
Naloxone
Antagonists Opiate antagonist
Naloxone Flumazenil
Pure antagonist, reverses sedative and Benzo. antagonist
analgesic properties of narcotics.
Will not reverse hypotension. Flumazenil
Short t1/2 (1-2 hours) result in repeated Very short duration of
doses with longer acting narcotics. action need repeated
Dose doses
Children <5 years and < 20 kg: Dose 0.02 mg/kg IV
0.1 mg/kg IV, IM, SQ, ETT May repeat every min. to
Children > 5years or > 20 kg: 2 mg achieve max dose of 1 mg
May repeat Q 2-3 min - desired affect Can precipitate seizures in
1/10 of standard dose to reverse chronic benzodiazepine
respiratory but not analgesic effects use and TCA overdose
53
Therapeutic Advantages
•  Not all side effects are harmful
•  Considerations for choice of drug
–  Ketamine à bronchodilator
–  Pentobarbital or Midazolam à anti-convulsant
–  Diazepam à muscle relaxation
54
Contraindications
•  All drugs should be used judiciously!!!
•  Commonly seen relative contraindications and
adverse effects
–  Ketamine à increased ICP, excess salivation,
emergence reaction
–  Propofol à hypotension, acidosis
–  Dexmedetomidine à bradycardia, arrhythmia
–  Benzodiazepine à hypotension
55
Sedation-Analgesia
Non-pharmacologic Strategies
•  Parental presence during procedure
•  Distraction,
•  Parent rub adjacent area to decrease local pain
•  Externally oriented play
•  Guided imagery
•  Sucrose 24%
•  Pacifier
?
56
Safe Mod-Sed
Prepare for Unexpected Emergencies
•  Optimize your patient prior to sedation
–  Correct acidosis
–  Keep euvolemic
–  Know your pts “AMPLE”
•  Anticipate difficulties and be prepared
(SOAPME)
–  Bag, mask, oxygen, +/- airway app. box
–  Suction app.
–  Normal saline/Lactated Ringer’s
•  Monitors: O2, CO2, CR monitor, and BP
•  Appropriate staff to monitor the patient
57
Mod-Sed Documentation
During Sedation:
Before Sedation:
•  Drug name(s) &calculations
•  Presedation health •  Route
•  (Aldrete score) •  Site
•  Confirm staff privileges & •  Time
universal procedures •  Dosage (titrated to desired effect)
(i.e., “time out”) During administration:
•  Drug calculations (include •  FiO2 & duration of sedating/
reversal agents and local analgesic agents
anesthetics) •  Level of consciousness
•  Informed consent •  Heart rate, respiratory rate, SpO2
•  Adverse events and corrective
•  Instructions to family
intervention/treatment given
Document at least once every 5 minutes

until child reaches predetermined discharge criteria 58
Goals of Moderate Sedation
“Hipocrates Oath - Primum nonnocere”
(Do no harm)
•  To relieve the anxiety and pain
•  To choose sedatives and analgesics that fits
the procedures with lightest degree of
sedation
•  Attempt non-pharmacologic approach
•  Qualified personnel and correct equipment
•  Monitor the patient condition until fully awake
in baseline state for a safe discharge
•  Patient’s safety and welfare
59
Mod-Sed Discharge Criteria
•  Airway, vital signs, and pulse oximetry have

returned to baseline
•  Patient follows commands (age-appropriate)
•  Patient is hydrated and tolerates oral fluids
•  Patient is arousable and has baseline level of
verbal ability
•  Patient can sit unaided (age appropriate)
60
51
ModSed
Quality Improvement (QI) indicators
ü SpO2 ≤ 90% requiring O2

ü Any complications; need for emergency interventions
ü Aspiration; airway obstruction
ü Inability to complete the procedure as planned
ü Long recovery time; unplanned admission
ü Hypotension
ü Use of reversal agents
ü Proper documentation
ü Death
61
Take Home Message
•  Many situations require sedation, its component including

anesthesia, analgesia, anxiolysis, & amnesia
•  There are several levels of sedation
•  Remember mnemonic “AMPLE” for sedation
•  Choosing the right drug(s) for the right patients
•  Always anticipate possible complications & be prepared
•  Sedation may be indicated for the benefit of the child, the
family, and the caregivers but must be done with careful
consideration of the risks.
62
INDONESIAN PEDIATRIC ASSOCIATION
DEDICATED TO ALL INDONESIAN CHILDREN
THROUGH MODERATE SEDATION
Patient evaluation
Monitoring Rescue Skills

63
Palembang 2014
FOR
Y OU TION
AN K E N
TH AT T
U R
YO
IDAI
DEDICATED TO THE HEALTH OF
ALL INDONESIAN CHILDREN
64
Anak Usia 3-8 tahun
•  Usually have a word for pain

•  Can articulate more detail about the
presence and location of pain; less
able to comment on quality or intensity
•  Contoh:
–  Color scales
–  Faces scales
The Wong-Baker Faces Pain Rating Scale consists of a

horizontal line with 6 faces, representing pain complaints on a scale of
0 (no pain at all) to 10 (worst pain you have ever felt).
The patient is asked to choose the face that best describes how he feels.
It is advised to be specific about time and location of the pain.
Gambar 1 Wong-Baker FACES Pain Rating Scale

Dikutip dari: Atkinson dkk.
Children older than 8 years
•  Use the standard visual analog scale
•  Same used in adults
Neonatal Infant Pain Scale (NIPS)
Sedatif-Analgesik Sering Dipakai
1.  Opiat (narkotik)
2.  Benzodiazepin
3.  Kloral-hidrat
4.  Barbiturat Prinsip Umum Tatalaksana Nyeri
5.  Ketamin 1.  Antisipasi & cegah nyeri
2.  Nilai nyeri secara adekuat
6.  Propofol
3.  Berbagai cara/pendekatan
7.  Neuroleptik
4.  Libatkan orang tua
8.  Paralitik
5.  Rute aman
Pediatrics in Review 2003; 24 (10)
Prosedur yang memerlukan sedasi
Prosedur noninvasif
Magnetic resonance imaging (MRI)
Computerized tomographic scan (CT-scan)
Prosedur pencitraan
Terapi radiasi
Elektroensefalografi (EEG)
Prosedur invasif
Aspirasi sumsum tulang dan biopsi
Pungsi lumbal atau pengobatan intratekal
Biopsi hati, ginjal atau tulang
Ganti balutan, perawatan luka atau debridement luka bakar
Endoskopi, bronkoskopi
Ekokardiografi transesofageal
Torakosentesis atau pemasangan selang dada (chest tube)
Parasentesis, perikardiosentesis
Pemasangan kateter vena sentral
Reduksi fraktur atau pemasangan balutan gips
Aspirasi cairan tubuh dengan panduan USG
Amnesia Sedasi Hipnotik Analgesik
NSAIDs
Gambar 2. Spektrum Obat Sedasi dan Analgesia

Opioid dan benzodiazepin
pilihan utama untuk sedasi.
Obat alternatif: anestesi inhalasi, nitrous
oxide, ketamin, propofol, dan barbiturat
The Analgesic Ladder
Strategi tatalaksana nyeri WHO
mengatasi rasa nyeri secara rasional
I.  Analgesik nonopioid Rute obat S&A:
(anti inflamasi nonsteroid/NSAIDs) Pilih oral dan i.v..
- nyeri ringan
II. Opioid lemah, dgn/tanpa NSAIDs
Hindari i.m.
- nyeri menengah/sedang
III. Opioid kuat, dgn/tanpa NSAIDs
- nyeri sangat kuat
NSAIDs
Gambar 3. Pemilihan Obat Analgesik

Obat Dosis Obat analgesik dan sedatif Catatan
Morfin Bolus iv: <60 kg; 100−200 µg/kg, Potensial pelepasan
>60 kg; 5−10 mg,
Infus i.v.: <60 kg: 10−60 µg/kg/jam,
histamin, pertimbangkan
penurunan dosis pada
gangguan ginjal dan hati
>60 kg: 0.8−3 mg/jam
Fentanil Onset cepat, waktu
paruh panjang, terutama
Bolus iv: <60 kg; 1−2 µg/kg, >60 kg; 50−200 µg/jam bila penggunaan lama
Infus iv: <60 kg;4−10µg/kg/jam, >60 kg; 25−100µg/jam
Parasetamol Dapat p.o., p.r. ( rektum)
<60 kg:10−15 mg/kg/4jam, >60 kg: 650−1000 mg/4jam atau i.v.
Dosis harian maks.: <3 bulan: 60 mg/kg/hari,
3 bl−12 th: 90 mg/kg/hari, >12 th: 4 gr/hari Hati-hati pada penyakit
Ibuprofen ginjal, retensi air,
<60 kg: 6−10 mg/kg/6 jam, >60 kg: 200−600 mg/6 jam perdarahan GI
Dosis harian maks.: <60 kg: 30 mg/kg/hari
Midazolam >60 kg: 2,4 g/hari Toleransi dan withdrawl
Bolus i.v.: <60 kg: 0,1−0,2 mg/kg, >60 kg: 5 mg syndrome, dapat p.o.,
Infus i.v.: <60 kg: 2−10 µg/kg/menit p.r., bukal, i.m., i.v.
>60 kg: 5−15 mg/jam
Klonidin Withdrawl syndrome;
Infus i.v.: 0,1−2 µg/kg/jam, NG; 1−5 µg/kg/8 jam hindari henti tiba-tiba
Kloralhidrat
NG; 20−50 mg/kg/4−6 jam, maks. 2 gram per dosis Sedikit iritasi lambung
Dosis harian maksimal; 200 mg/kg/hari
Prometazin Hati-hati pada neonatus
Parasetamol <60 kg:10−15 mg/kg/4jam, >60 kg: 650−1000
mg/4jam
Dosis harian maks.: <3 bulan: 60 mg/kg/hari,
3 bl−12 th: 90 mg/kg/hari, >12 th: 4 gr/hari
Ibuprofen <60 kg: 6−10 mg/kg/6 jam, >60 kg: 200−600

mg/6 jam
Dosis harian maks.: <60 kg: 30 mg/kg/hari
>60 kg: 2,4 g/hari
Midazolam Bolus i.v.: <60 kg: 0,1−0,2 mg/kg, >60 kg: 5 mg

Infus i.v.: <60 kg: 2−10 µg/kg/menit
>60 kg: 5−15 mg/jam
Morfin Bolus iv: <60 kg; 100−200 µg/kg,
>60 kg; 5−10 mg,
Infus i.v.: <60 kg: 10−60 µg/kg/jam,
>60 kg: 0.8−3 mg/jam
Fentanil Bolus i.v.: <60 kg; 1−2 µg/kg,

>60 kg; 50−200 µg/jam
Infus i,.v.: <60 kg;4−10µg/kg/jam,
>60 kg; 25−100µg/jam
Klonidin Infus i.v.: 0,1−2 µg/kg/jam, NG; 1−5 µg/kg/8 jam
Kloralhidrat NG; 20−50 mg/kg/4−6 jam, maks.2 gr per dosis

Dosis harian maksimal; 200 mg/kg/hari
Prometazin NG; 1−2 mg/kg/6 jam, maks. 50 per dosis

Peralatan Emergensi untuk Prosedur Sedasi Analgesia (depresi kardiorespirasi )
Peralatan intravena
Sarung tangan, torniquet, kasa alkohol, kasa steril, kateter i.v., selang i.v.
cairan i.v., jarum suntik dengan ukuran yang tepat, selotip
Peralatan dasar talaksana jalan napas
Sumber O2, sumber alat hisap, kateter penghisap, yankauer-type suction,
self-inflating breathing bag-valve set, oral and nasal airway, pelumas
Peralatan lanjutan talaksana jalan napas (untuk klinisi mampua intubasi)
Laryngeal mask airways, laryngoscope ,selang endotrakeal, stylet
Antagonis farmakologi
Nalokson – antidotum narkotik/opioid
Flumazenil – antidotum benzodiazepin
Obat emergensi
Epinefrin, efedrin, vasopresin, atropin, nitrogilserin, aniodaron, lidokain
G 50% (10% atau 25%), difenhidramin, hidrokrortison,
metilprednisolon, deksametason
Diazepam atau midazolam
Tabel 6 Sistem Skor Aldrete Recovery – Dimodifikasi
(Pascaprosedur Sedasi Analgesia)
Kriteria Nilai Kriteria Nilai
Tanda Vital Saturasi Oksigen
Stabil 1 90−100% 2
Tidak stabil 0 90−94% 1
Pernapasan <90% 0
Normal 2 Warna Kulit
Dangkal/takipnea 1 Pink/kembali ke asal 2
Apnea 0 Pucat 1
Tingkat kesadaran Sianosis 0
Sadar, terorientasi/pulih ke asal 2 Aktivitas
Kesadaran berkabut, agitasi 1 Bergerak menurut 2
Tidak responsif 0 perintah/kembali ke asal
Bergerak hanya ekstremitas, 1
berjalan tidak terkoordinasi
Tidak ada gerak spontan 0
Skor Sedasi Tindakan
>8 Pulang bila semua skor >0, skor total 8
7−8 Monitor tanda vital tiap 20 menit
4−6 Monitor tanda vital tiap10 menit
0−3 Monitor tanda vital tiap 5 menit, dan
evaluasi lebih lanjut sesuai kebutuhan
Analgesik Non-opioid
•  Nyeri ringan sampai sedang

•  Tidak menyebabkan depresi respirasi
•  Sangat efetif bila dikombinasi dg opioid
•  Asetaminofen/parasetamol
•  NSAIDs
•  COX-2 inhibitors
•  Aspirin & pirazolon
–  Tidak dipakai lagi pada pediatri
Acetaminofen/parasetamol
•  Antipiretik
•  Analgesik ringan
•  Rute PO or PR
•  Dosis oral 10-15 mg/kg/dosis tiap 4 jam
–  Dosis bayi 10-15 mg/kg/dosis tiap 6-8 jam
–  Dosis dewasa 650 mg-1000 mg/dosis
•  Onset 30 menit
Asetaminofen/parasetamol
•  Per rektum 40 mg/kg

diikuti 20 mg/kg/dosis tiap 6 jam
–  Uptake is delayed and variable
–  Peak absorption is 60-120 minutes
–  Unreliable to cut suppositories
–  Non physiologis, not hygienis route
!
–  Thinks psychologic effects
•  Dosis harian maksimum
–  Bayi: 60-75 mg/kg/hari
–  <60 kg: 100 mg/kg/hari
–  >60 kg: 4 gram/hari
OPIOID
RUTE
–  IV
–  Oral
–  Transmukosa
–  Transdermal
MODE
–  Intermiten/on demand (sesuai kebutuhan)
–  Interval tetap
–  Infus kontinyu
–  PCA (patient controlled analgesia)
MORFIN
•  Gold standard
•  Metabolisme di hepar
•  Depresi respirasi - mengubah sensitivitas
kemoreseptor terhadap CO2
•  Depresi laju napas > volume tidal
•  Depresi frekuensi napas
•  Hipotensi akibat vasodilatasi - dimediasi histamin
•  Memblokir efek kompensasi katekolamin
•  Klirens panjang pada neonatus
MORFIN
•  IV intermiten Dosis PCA
0.1 mg/kg tiap 3 - 4 jam •  Dosis awal: 50 mcg/kg
tiap 10 menit sampai
•  IV kontinyu penderita merasa nyaman
0.05 mg - 0.1 mg/kg/jam •  Dosis on demand:
20 - 40 mcg/kg
•  PO terjadwal •  Lock-out period:
0.3 mg/kg tiap 3 - 4 jam 10 menit
•  Limit 4 jam: 0.25 mg/kg
FENTANIL
•  Opiat sintetis, 100 x lebih poten dp morfin
•  Onset cepat, sangat lipofilik, cepat lewati sawar darah otak,
redistribusi ke jaringan lemak
•  Distibusi singkat t1/2, eliminasi panjang t1/2
•  Efek hemodinamis minimal
•  Respons vaskuler paru rendah
•  Dapat menimbulkan “rigiditas dinding dada”, yang dapat
diatasi dengan relaksans atau nalokson
DOSIS: IV intermiten :1-2 mcg/kg tiap 1-2 jam

IV dosis kontinyu: 1-2 mcg/kg/jam
METADON
•  Potensi sama dengan morfin
•  Waktu paruh panjang
•  Efek sedasi dan euforia lebih rendah dari morfin
•  Untuk kontrol nyeri dan abstinensia
Dosis per oral: 0.1 mg/kg tiap 4-8 jam

50 % bioavailabilitas oral
Akumulasi obat dengan dosis berulang dapat
disebabkan oleh pengikatan protein ekstensif
BOLUS I.V. INFUS KONTINYU

Biasa dilakukan Digunakan bila analgesia dan sedasi
Sesuai kebutuhan diperlukan
Waktu paruh menentukan interval Less labor intensive
Analgesia lebih baik, perlu bolus inisial
Kelemahan: pain breakthrough
Perlu jalur I.V.
EFEK SAMPING OPIAT
Depresi napas Ketergantungan

Antidotum - Nalaxone (Narcan) •  Menyebabkan abstinence syndrome bila
•  Reversal penuh 0.1 mg/kg dilakukan withdrawal obat
•  Reversal sebagian : dosis titrasi sampai •  Umumnya muncul setelah penggunaan 7-10
menimbulkan efek hari
•  Waktu paruh kurang daripada narkotik •  Midriasis, takikardia, tersentak otot, muntah,
•  Pemberian: IV, IM, Sub Q, ETT diare, kejang, demam, hipertensi
•  Reversal mendadak dapat menyebabkan •  Diobati dengan penarikan bertahap dari obat
mual, muntah, berkeringat, takikardia,
peningkatan BP, dan tremor
Penyapihan
Toleransi •  Biasanya 10% penurunan per hari
•  Umumnya muncul setelah 2-3 hari pasca •  Jangan menyebar interval dosis melampaui
penggunaan terus menerus
interval pemberian dosis normal
•  Lebih besar dengan fentanil
•  Dapat menggantikan metadon dan menyapih
•  Meningkatkan dosis untuk mencapai efek
tiap 48 jam selama periode waktu yg lebih
yang sama
lama
•  Meningkatkan dosis sesuai kebutuhan
BENZODIAZEPIN
•  Lini pertama obat sedasi
•  Menyebabkan hipnosis, ansiolisis, amnesia antegrad,
dan aktivitas antikonvulsi
•  Tidak ada efek analgesia
Dapat menyebabkan abstinence syndrome setelah
penggunaan jangka panjang
•  Mekanisme dalam sistem limbik melalui neurotransmiter
inhibisi, gamma aminobutyric acid (GABA)
DIAZEPAM
•  Sedasi, amnesia variabel, ansiolitik
•  Iritasi terhadap vena, nyeri pada PIV
•  Metabolit aktif multipel
•  Keuntungan untuk sedasi berkepanjangan
Kerugian untuk rapid arousal
Tidak dianjurkan untuk infus kontinyu
Waktu paruh12-24 jam
Metabolisme hepatik
LORAZEPAM (ATIVAN)
•  Memperbaiki amnesia
•  Tidak ada metabolit
•  Waktu paruh 4-12 jam
•  Dimetabolisme oleh glukoronil transferase
–  Sedikit pengaruh dari obat lain
–  Baik diberikan pada pasien dengan penyakit hati
MIDAZOLAM
•  Onset cepat •  Rute lainnya:
•  Metabolisme cepat –  Oral
•  Amnesia
–  Nasal
•  Larut dalam air
•  Tidak nyeri saat –  Rectal
disuntikkan –  Sublingual
•  Waktu paruh 2-4 jam •  Absorbsi kurang seiring
•  Metabolisme hepatik, peningkatan dosis
eksresi renal
•  Akumulasi hydroxy-
metabolite aktif dapat
terakumulasi
EFEK SAMPING BENZODIAZEPIN
DEPRESI NAPAS
Kurang dibanding narkotik, namun berpotensiasi dengan narkotik.
Dose related
Reversal:
Flumazenil – antagonis reseptor benzodiazepin
Kontraindikasi untuk pasien dengan pemakaian kronik
benzodiazepin untuk kejang, mixed overdose,
TCA’s – dapat menyebabkan kejang
KOREOATETOID
Toleransi: Dosis dapat ditingkatkan setelah pemakaian 2-3 hari
Ketergantungan
Lakukan withdrawal secara hati-hati dan perlahan jika pemakaian
>7-10 hari
Gejala withdrawal: tremor, tachycardia, hypertension,
Withdrawal cepat dapat meyebabkan kejang
KLORALHIDRAT
•  Hipnotik sedatif
•  Dimetabolisme di hati à bentuk aktif: trichlorethanol
•  Waktu paruh: 8-12 jam
•  Administrasi oral atau rektal
•  Onset of action terlambat
•  Reaksi paradoksikal pada anak usia yang sama
•  Tidak lebih dari 100 mg/kg/hari, contoh: 25mg/kg/6 jam
•  Hati-hati pada anak < 3 bulan dengan disfungsi hati
BARBITURAT
•  Sedatif
•  Respiratory depression dose dependent
•  Efek inotropik negatif /vasodilatasi
menurunkan cardiac output
•  Menurunkan konsumsi O2 otak
–  ↓ aliran darah otak
•  Bermanfaat untuk pasien dengan
–  ↓ tekanan intrakranial peningkatan tekanan intrakranial
•  Antikonvulsan •  Barbiturat kerja cepat
•  Bermanfaat untuk sedasi prosedur/
imaging pada anak dengan
hemodinamik stabil
•  Larutan alkali, seringkali inkompatibel
dengan TPN atau obat
MAJOR TRANQUILIZER
•  Fenotiazin
–  Torazin
•  Butirofenon
–  Droperidol
–  Haloperidol
•  Umum dipakai pada dewasa di ICU, jarang di PICU
•  ES: hipotensi karena blokade alfa dan efek ekstrapiramidal
•  Dipakai untuk anak yang sulit disedasi
KETAMIN
•  Anastetik disosiatif i.v.
•  Amnesia baik dan analgesia somatik
•  Status anastetik secara klasik digambarkan sebagai
disosiasi fungsional dan elektrofisiologi diantara
talamoneokortek dan sistem limbik
•  Secara kimia berkaitan dengan phencyclidine dan
cyclohexamine
•  Larut dalam air dan lemak
•  Cepat melalui sawar darah otak, <30 detik
KETAMIN
•  Waktu paruh redistribusi 4.7 menit

•  Waktu paruh eliminasi 2.2 jam
•  Efek klinis dalam 1 menit, resolusi dalam 15-20 menit
•  Bronkodilatasi
•  Sialagogue -“menimbulkan aliran saliva”
–  Diberikan dengan antikolinergik
•  Atropin
•  Efek net hemodinamik minimal
–  Inotrop negatif
–  Efek sentral - ↑HR, ↑SVR
•  Pilihan baik untuk syok atau status asmatikus
KETAMIN
•  Risiko laringospasme
•  Risiko emesis/aspirasi
•  Meningkatkan tekanan intrakranial, intraokuler
•  Menginduksi kejang
•  Reaksi emergensi, halusinasi
–  Perbaikan dengan administrasi benzodiazepin
Dosis: IM: 2 - 4 mg/kg per dosis tiap 30 menit- 1 jam

I IV: Dosis intermiten
1 -2 mg/kg per dosis tiap 30 menit-1 jam
Dosis kontinyu
1 - 3 mg/kg/jam
PROPOFOL
•  Sedatif/hipnotik
–  Dose dependent
- conscious sedation sampai anestesia umum
–  Onset cepat (20-50 detik)
–  Pulih cepat (dalam 30 menit)
–  Metabolit aktif kurang
–  Dimetabolisme di hati
–  Dieksresikan dalam urin
PROPOFOL
•  Emulsi lemak,
•  Menurunkan tekanan intrakranial dan CPP
•  Menurunkan tonus simpatis
–  Kontraindikasi bila hemodinamik tidak stabil
–  Depresi napas moderat
•  Nyeri pada tempat injeksi
–  Perbaikan dengan lidokain 1% 0.5 mg/kg
PROPOFOL
•  Sekuele neurologi
–  Opistotonus
–  Gerakan mioklonik
•  Asidosis metabolik pada penggunaan >24 jam
•  Kontraindikasi untuk penggunaan jangka panjang
•  Dosis:
–  Induksi 1 - 3 mg/kg
–  20 - 100 mcg/kg/menit
–  Infus naik 5-10 mcg/kg/menit setiap 5 - 10 menit
DEXMEDETOMIDINE
•  Alfa-2 agonis (seperti KLONIDIN) – short acting

•  Dosis:
–  Load 1 mcg/kg i.v. dalam 10 menit,
–  Diikuti dg 20,2 – 0,7 mcg/kg/jam
•  Efek samping: hipotensi (vasodilatasi),
bradikardia relatif
PCA
•  Patient controlled analgesia
•  Pasien mengontrol sendiri pemberian obat narkotik
analgesia, dosis telah ditentukan sebelumnya
•  Memperbaiki analgesia ttp menurunkan dosis narkotik
•  Low basal rate
•  Nurse controlled analgesia
–  Eliminates delay
–  Allows delivery via a closed system
PCA
TERIMA KASIH
TELAH MEMBERI
SEDASI DAN ANALGESI
YANG TEPAT
KASUS 1
•  Anak 2 tahun, BB 10 kg
•  Gagal napas akut - asma
•  Intubasi
•  Ventilator
•  Atropin,
•  Benzodiazepin: Diazepam, midazolam, fentanil,
•  Barbiturat: Fenobarbital, pentobarbital, tiopental
•  Lidokain
•  Opioid: Fentanil
•  Profopol
•  Pelumpuh otot: Suksinilkolin, vekuronium
NSAIDs
Gambar 3. Pemilihan Obat Analgesik

7 P’S – RSI
1. Preparasi
2. Preoksigenasi
3. Pramedikasi/Pretreatment
Atropin
Lidokain à TBI/TTIK
Benzodiazepin: Dia/Midazolam
Opioid Fentanil
4. Paralisis: NMBA
- Suksinilkolin
- Rocuronium
5. Proteksi
6. Placement with proof
7. Post intubation management
Sedasi jangka panjang
Status asmatikus
Tatacara penggunaan ventilator pasien ASMA:
1.  Bronkodilator atau steroid tetap dilanjutkan

2.  Sebelum intubasi (beri Atropin)
3.  Isap lendir: hindari bronkospasme (beri Lidokain)
4.  Relaksasi otot dan sedasi untuk mencegah
asinkronisasi dan untuk pasien tidak kooperatif
(Diazepam, Midazolam, Pancuronium)
5.  Mode ventilator :
awal menggunakan kontrol selanjutnya sesuai
fisiologi dan keadaan klinis, sering digunakan
volume-cycled : Assist control atau IMV
6. Monitoring kejadian auto PEEP dan barotrauma.
FENTANIL
•  Opiat sintetis, 100 x lebih poten dp morfin
•  Onset cepat, sangat lipofilik, cepat lewati sawar darah otak,
redistribusi ke jaringan lemak
•  Distibusi singkat t1/2, eliminasi panjang t1/2
•  Respons vaskuler paru rendah
•  Dapat menimbulkan “rigiditas dinding dada”, diatasi dengan
relaksans atau nalokson
DOSIS: IV intermiten :1-2 mcg/kg tiap 1-2 jam

IV dosis kontinyu: 1-2 mcg/kg/jam
Syok Sepsis
How to intubate a Septic Shock Patient.
(Yamamoto LG Textbook Ped Emerg Med 2000)
•  Volume load, begin peripheral or if

available central ino/pressor
•  Premedication: 0.01-0.02 mg/kg atropine
•  Ketamine 1-2 mg/kg bolus
•  Rocuronium 1 mg/kg
•  Intensive Care Medicine and Anesthesia
recommend against the use of etomidate!
(Editorials 2005)
Head Injury
•  Lidokain
•  Pentobarbital
Pascaoperasi Laparatomi
•  Analgetik
•  Sedatif
Gambar 1 Wong-Baker FACES Pain Rating Scale

Dikutip dari: Atkinson dkk.
TERIMA KASIH
TELAH MEMBERI
SEDASI DAN ANALGESI
YANG TEPAT
Obat-‐obatan yang digunakan pada sedasi dan analgesi
dosis interval
obat dosis mg/kg rute maks durasi antara dosis perha9an
(mg) 9trasi
asetaminofen
10-‐15 oral/rektal 1000 4 jam
(parasetamol)
ibuprofen 5-‐10 oral 800 6 jam
30 mg iv
ketorolak 0,5 im/iv 4-‐6 jam
60 mg im
30 menit im
morfin 0,1 im/iv 10 3-‐4 jam depresi pernafasan. Pengeluaran histamin
15 menit iv
fentanil 0,01 iv 0,05 0,5-‐1 jam 10 menit iv kaku dada, muntah, dosis yang lebih rendah pada bayi
transmukosa
0,005-‐0,015 400 mcg 0,5-‐1 jam
l
0,0015 intranasal 100 mcg
0,15 mcg/kg/
0,2 mcg/
remifentanil mnt (10 mcg/ iv 5 menit 2 menit depresi pernafasan
kg/mnt
kg/jam)
12 mcg/

kg/jam
30 menit im
meperidin 1-‐1,8 im/iv 100 im 3-‐4 jam gunakan dosis rendah untuk parenteral, kejan, iritabilitas
10 menit iv
30 menit im
hidromorfon 0,01 im/iv 2 3-‐4 jam
10 menit iv
hidrocodone 0,2 oral 10 4-‐6 jam haH-‐haH bila dikombinasi dengan parasetamol
gangguan saluran cerna, muntah bila dikombinasi dengan
kodein 1 oral 60 4-‐6 jam
parasetamol
Htrasi pemberian parenteral, hindari semua golongan barbiturat
pentobarbital 2-‐5 iv 200 0,5-‐1,5 jam
pada anak dengan porphyria
4 im/iv 20 menit im
20-‐60 depresi saluran nafas, hindari semua golongan barbiturat pada
methohexital 0,5-‐1 iv 100 5 menit iv
menit anak dengan porphyria
18-‐25 rektal
20-‐60 depresi pernafasan, hindari semua golongan barbiturat pada
Hopental 2,5-‐5 iv 300 5 menit iv
menit anak dengan porphyria
25 rektal
midazolam 0,05-‐0,2 im/iv 1-‐2 jam 10 menit iv depresi pernafasan, agitasi
0,3-‐0,7 oral
kloralhidrat 50-‐100 oral/rektal 1000 6-‐24 jam hindari pada penyakit liver
propofol 0,5-‐1 iv bolus 100 6-‐10 menit 5 menit iv depresi saluran nafas
1-‐6 mg/kg/jam infus
15-‐20
ethomidate 0,1-‐0,23 iv bolus 20 10 menit iv gerakan mioklonik
menit
ketamin 1-‐2. iv 0,5-‐2 jam 5 menit iv hipersekresi saluran napas

4 im 1-‐2 jam 20 menit im
0,005-‐0,01
nalokson (parHal im/iv 2 20 menit antagonis opiat
reversal)
0,1 (total

reversal)
flumazenil 0,01 iv 0,2 30 menit hindari pada penderita kejang

lidokain 4,5 mg/ 30-‐120
infiltrated
(lignokain) kg menit
lidokain
(lignokain) + infiltrated 7 mg/kg 1 jam
epinefrin
2,5 mg/
bufipakain infiltrated 2-‐8 jam
kg
Pilihan Sedasi Potensial
Skenario Pilihan
trauma ekstrimitas (minor) opioid oral
asetaminofen (parasetamol) atau ibuprofen dengan atau tanpa opioid
trauma ekstrimitas (mayor) opioid oral atau parenteral propofol
pasien mendapat analgesi etomidat
anestesi regional nitrousoxide
ketamine
luka bakar ringan opioid oral
opioid im
anestesi lokal
anestesi topikal
luka bakar luas opioid iv ketamin
anestesi regional remifentanil
pasien mendapat analgesi
trauma minor mulHpel opioid parenteral
hipnoHs
opioid oral
distraksi
trauma mulHpel opioid iv pasien dalam pengaruh analgesik
ketamine fentanyl
etomidate remifentanil
dislokasi sendi propofol
nitrousoxide
opioid iv/ sedaHf
diazepam
etomidate
lidokain intraarHkular (lignokain)

remifentanil
krisis nyeri akibat penyakit
sumbatan pembuluh darah asetaminofen atau kombinasi
(ringan) opioid (po)
dapat dikombinasi dengan
ibuprofen (po)
krisis nyeri akibat penyakit
sumbatan pembuluh darah opioid harus dikombinasi dengan
(berat) morfin iv ibuprofen (po) ketorolak (iv)
hidromorfon iv
nyeri abdomen opioid parenteral
ketorolak (untuk kolik renal/
bilier)
nyeri pelvis (Hdak hamil) opioid parenteral
oral NSAIDS
ketorolak
nyeri non obstetrik pada ibu
hamil opioid oral
asetaminofen dan opioid
opioid im/sk
anestesi regional
nyeri gigi opioid oral
asetaminofen atau ibuprofen
dengan atau tanpa opioid
anestesi lokal
hipnoHs
laserasi pada anak yang
kooperaHf lidokain
bupivakain
laserasi pada anak yang Hdak midazolam oral dan anestesi
kooperaHf lokal
fentanil dan midazolam
propofol dan anestesi lokal
ketamin dan anestesi lokal
pungsi lumbal propofol
ketamin
fentanil dan midazolam
pentobartbital
anestesi lokal
CT san (MRI) pentobartbital
propofol
fentanil atau remifentanil
midazolam
difenhidramin
kloralhidrat
ketamin
pasien rawat jalan yang
menjalani pemeriksaan
yang Hdak nyeri (mis.
EKG, echo) midazolam po
kloralhidrat
pentobartbital
difenhidramin
sepsis work up sukrosa oral
ketamin im
nitrousoxide
opioid tranmukosal
prosedur minor mulHpel ketamin im
nitrousoxide
opioid tranmukosal

SKALA PENILAIAN NYERI FLACC
Kategori Skor
0 1 2
Face Tak ada ekspresi tertentu Terkadang menyeringai Sering megernyitkan
atau senyum atau menerutkan dahi, dahi, menggerakkan
tidak tampak tertarik dagu, gerakan menggigit
dengan sekitarnya
Legs Posisi normal atau Gelisah, tidak tenang, Menendang-‐nendangkan

relaksasi tegang tungkai
Activity Tidur dengan tenang, Menggeliat-‐geliat, tegang Melengkung, kaku, atau

posisi normal, mudah menyentak-‐nyentak
bergerak
Cry Tidak menangis Menguap atau merengek, Menangis terus-‐menerus,

(terbangun/tertidur) terkadang mengeluh menjerit atau merintih,
sering mengeluh
Consolability Santai Perhatiannya mudah Sulit untuk menenangkan

teralihkan, tenang bila diri
disentuh, dipeluk atau
diajak bicara/bermain
Tabel 2. Skala Ramsay untuk Penilaian Sedasi
Tingkat

Deskripsi Sedasi Skala Ramsay
1 Sadar, cemas; gelisah atau tidur gelisah, atau keduanya
2 Sadar, kooperatif, terorientasi, dan tenang
3 Respons hanya terhadap perintah verbal
4 Mengantuk, respons cepat thd ketukan ringan glabela
5 Mengantuk, respons lambat thd ketukan ringan glabela
6 Mengantuk, tidak ada respons thd ketukan ringan glabela
Tabel 3. Skala COMFORT untuk Menilai Sedasi
Alertness Mean arterial blood pressure (MAP)
Deeply asleep Sedatif-Analgesik
1 yang Sering Dipakai
Tekanan darah MAP di bawah baseline 1
Lightly asleep 2 Tekanan darah MAP pada baseline 2
Mengantuk 3 MAP jarang >15% di atas baseline 3
Fully awake and alert 4 MAPsering >15% di atas baseline 4
Hyperalert 5 (>3 selama periode observasi)
Calmness/agitation MAP terus menerus >15% diatas baseline 5
Calm 1 Respons respirasi
Slightly anxious 2 Tidak ada batuk dan napas spontan 1
Anxious 3 Napas spontan, sedikit atau tidak ada respons 2
Very anxious 4 ventilasi
Panicky 5 Sesekali batuk atau resistensi ventilator 3
Heart rate Bernapas aktif terhadap ventilator 4
Denyut jantung (HR) < baseline 1 Batuk atau selalu melawan ventilator, batuk 5
Denyut jantung sesuai baseline 2 atau tersedak
HR jarang >15% diatas baseline 3 Tonus otot
(1−3 selama periode observasi) Relaksasi otot total, tidak ada tonus otot 1
HR sering >15% diatas baseline 4 Penurunan tonus otot 2
(>3 selama periode observasi) Tonus otot normal 3
HR terus menerus sekitar >15%) 5 Tonus otot meningkat, fleksi jari tangan& kaki 4
Facial Tension Rigiditas otot ekstrim 5
Otot fasial relaksasi total 1 Physical movement
Tonus otot fasial normal, tidak ada 2 Tidak ada pergerakan 1
tegangan otot fasial yang jelas Sesekali dan sedikit pergerakan 2
Tegangan jelas pd beberapa otot fasial 3 Sering, sedikit pergerakan 3
Tegangan jelas pada seluruh otot fasial 4 Pergerakan kuat pada ekstremitas 4
Otot fasial mengerut dan meringis 5 Pergerakan kuat termasuk torso dan kepala 5
N/M blocking agents
pediatr Emerg Care 2000;16(6):441
Pain Assessment in Neonates & Infants
•  Challenging
•  Combines physiologic and behavioral
parameters
•  Many scales available
–  NIPS (Neonatal Infant Pain Scale)
–  FLACC scale (Face, Legs, Activity, Cry
Consolability)
Neonatal Infant Pain Scale (NIPS)
Children between 3-8 years
•  Usually have a word for pain
•  Can articulate more detail about the
presence and location of pain; less
able to comment on quality or intensity
•  Examples:
–  Color scales
–  Faces scales
Children older than 8 years
•  Use the standard visual analog scale
•  Same used in adults
Children with Cognitive Impairment
•  Often unable to describe pain
•  Altered nervous system and experience
pain differently
•  Use behavioral observation scales

–  e.g. FLACC
•  Can apply to intubated patients
FLACC scale
3: Multi-modal Approach
•  Cognitive-behavioral •  Physical Approach
–  Education –  Massage
–  Relaxation, imagery –  Acupuncture
–  Psychotherapy, –  Acupressure
counseling –  Heat or Cold
–  Hypnosis –  TENS
–  Biofeedback –  Therapeutic exercise
–  Music, literature, art,
play
–  Prayer, meditation
Sucrose for Infants
•  Sucrose 24% oral solution
•  Can be used for procedures such as heel stick,
venipuncture, catheterization, etc.
•  Effective analgesic in preterm and term infants
–  Not effective beyond 3 months old
•  Dip pacifier in sucrose solution or give 0.2 mL to
buccal area
–  May repeat but be cautious with many doses to
younger infants

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SEDASI DAN ANALGESIA

Palembang 2014 ANAK SAKIT KRITIS

Dadang Hudaya Somasetia

Dr Dadang Hudaya Somasetia

• Luaran fisiologis, neurologis & psikologis

Sedasi dan analgesia tidak adekuat:

• Use behavioral observation scales

No" Mild" Moderate" 17

No" Mild" Moderate" Deep"

Remember mnemonic AMPLE!!

Equipment & Supplies

THE UPPER AIRWAY! Greg Hollman, MD, FAAP

These guidelines apply to all ages

Mod-Sed Scale/Scoring Tool

Activity Tidur tenang, posisi Menggeliat-­‐geliat, Melengkung, kaku,

How severe is your pain today ?

• Disadvantages: excess secretions, increased ICP,

Onset: 5-10 min (IV)

Dosage: 0.05-0.1mg/kg IV, IM, SQ

Midazolam 0.1 – 0.2 mg/kg <60 s 3-5 min 30-60 min

Lorazepam 0.05-0.1 mg/kg 2-3 min 26-30 min 2-6 h

Diazepam 0.1-0.2 mg/kg <10 s 1-2 min 30-90 min 41

Continuous infusions for prolonged sedation:

• Ketamine 1-2 mg/kg IV

Vecuronium 0.1-0.2 mg/kg 1-3 min 30-40 min

Pancuronium 0.05-0.1 mg/kg 1-3 min 40-60 min

Depolarizing Agent Dose IV Onset Duration

Succinylcholine 1.0-1.5 mg/kg 30-40 s 3-5 min

Establish rapport with child and parents, if applicable

Prepare for Unexpected Emergencies

Document at least once every 5 minutes

• Airway, vital signs, and pulse oximetry have

ü SpO2 ≤ 90% requiring O2

• Many situations require sedation, its component including

Monitoring Rescue Skills

• Usually have a word for pain

The Wong-Baker Faces Pain Rating Scale consists of a

Gambar 1 Wong-Baker FACES Pain Rating Scale

Gambar 2. Spektrum Obat Sedasi dan Analgesia

Gambar 3. Pemilihan Obat Analgesik

Ibuprofen <60 kg: 6−10 mg/kg/6 jam, >60 kg: 200−600

Midazolam Bolus i.v.: <60 kg: 0,1−0,2 mg/kg, >60 kg: 5 mg

Fentanil Bolus i.v.: <60 kg; 1−2 µg/kg,

Kloralhidrat NG; 20−50 mg/kg/4−6 jam, maks.2 gr per dosis

Prometazin NG; 1−2 mg/kg/6 jam, maks. 50 per dosis

• Nyeri ringan sampai sedang

• Per rektum 40 mg/kg

DOSIS: IV intermiten :1-2 mcg/kg tiap 1-2 jam

Dosis per oral: 0.1 mg/kg tiap 4-8 jam

BOLUS I.V. INFUS KONTINYU

EFEK SAMPING OPIAT

Depresi napas Ketergantungan

• Waktu paruh redistribusi 4.7 menit

Dosis: IM: 2 - 4 mg/kg per dosis tiap 30 menit- 1 jam

• Alfa-2 agonis (seperti KLONIDIN) – short acting

Gambar 3. Pemilihan Obat Analgesik

1. Bronkodilator atau steroid tetap dilanjutkan

DOSIS: IV intermiten :1-2 mcg/kg tiap 1-2 jam

• Volume load, begin peripheral or if

Gambar 1 Wong-Baker FACES Pain Rating Scale

ketamin 1-­‐2. iv 0,5-­‐2 jam 5 menit iv hipersekresi saluran napas

ﬂumazenil 0,01 iv 0,2 30 menit hindari pada penderita kejang

lidokain intraarHkular (lignokain)

•  Luaran fisiologis, neurologis & psikologis

•  Use behavioral observation scales

Activity Tidur tenang, posisi Menggeliat-‐geliat, Melengkung, kaku,

•  Disadvantages: excess secretions, increased ICP,

•  Ketamine 1-2 mg/kg IV

•  Airway, vital signs, and pulse oximetry have

ü SpO2 ≤ 90% requiring O2

•  Many situations require sedation, its component including

•  Usually have a word for pain

•  Nyeri ringan sampai sedang

•  Per rektum 40 mg/kg

•  Waktu paruh redistribusi 4.7 menit

•  Alfa-2 agonis (seperti KLONIDIN) – short acting

1.  Bronkodilator atau steroid tetap dilanjutkan

•  Volume load, begin peripheral or if

ketamin 1-‐2. iv 0,5-‐2 jam 5 menit iv hipersekresi saluran napas

Legs Posisi normal atau Gelisah, tidak tenang, Menendang-‐nendangkan

Activity Tidur dengan tenang, Menggeliat-‐geliat, tegang Melengkung, kaku, atau

Cry Tidak menangis Menguap atau merengek, Menangis terus-‐menerus,

•  Use behavioral observation scales