Severe Pediatric Traumatic Brain Injury (TBI), PICU — Sedation Recommendations — Clinical Pathway: Emergency, ICU and Inpatient

Traumatic Brain Injury (TBI) Clinical Pathway — Emergency Department and ICU

Sedation Recommendations

  • AVOID HYPOTENSION — use the smallest dose and/or infusion to achieve effect.
  • DO NOT use a continuous infusion of Propofol.
  • If the patient has intracranial hypertension, goal SBS should be -2 or -3.

Intubated Patients ≤ 50 kg

Medication Infusions – Initial Doses Opioid (Fentanyl or Hydromorphone) and Benzodiazepine (Midazolam)
(If midazolam contraindicated — consider Dexmedetomidine)
Fentanyl 1 mcg/kg/hr
Hydromorphone 0.005 mg/kg/hr
Midazolam 0.05 mg/kg/hr
Incremental Infusion Change
Fentanyl 0.5 mcg/kg/hr
Hydromorphone 0.002 mg/kg/hr
Midazolam 0.02 mg/kg/hr
Assess/Titration Use SBS and State Behavioral Scale (SBS) Scores Procedure
Assess both every 4 hrs, at minimum
Assess 30 minutes after IV PRN doses
PRN Doses PRN dose matches hourly infusion dose for Fentanyl and Midazolam
Selection of PRN agent is based on pain score
Pain present Opioid (Fentanyl or Hydromorphone)
Agitation present Benzodiazepine (Midazolam)

Intubated Patients > 50 kg

Medication Starting Dose Frequency of Titrations Titration Amount Usual Max
Fentanyl 50 mcg/hr* Every 2 hrs 25-50 mcg/hr 300 mcg/hr
Hydromorphone 0.1-0.2 mg/hr Every 6 hrs 0.1-0.2 mg/hr 3 mg/hr
Morphine 2 mg/hr Every 4 hrs 0.5-1 mg/hr 15 mg/hr
Midazolam 2 mg/hr Every 4 hrs 0.5-1 mg/hr —
*Starting bolus is recommended: Give I.V. bolus 25-100 mcg/dose, some patients may require up to 100 mcg/dose