Neuropharmacology and Sedation/Analgesia
Principles
Understand that analgesia and sedation are distinct goals, that untreated pain and agitation raise ICP and oxygen demand, and that oversedation masks neurologic change and prolongs ventilation. Know common agents: opioids (fentanyl, morphine) for analgesia; benzodiazepines (midazolam) for sedation and seizures; propofol for short-term sedation with infusion-syndrome risk; dexmedetomidine for cooperative sedation with bradycardia and hypotension risk; ketamine with hemodynamic stability and ICP considerations. Know reversal agents (naloxone, flumazenil) and when they are dangerous.
Special considerations
Recall that children have age-dependent pharmacokinetics: immature hepatic and renal clearance, higher water content, and altered protein binding. Tolerance and withdrawal occur with prolonged infusions; use validated sedation scales and daily interruption where safe. Avoid polypharmacy and drug interactions, especially with antiseizure medications (enzyme induction, protein binding).
Traps
Questions test that sedation scales must be appropriate for the age and ventilator status, that propofol is not for prolonged pediatric sedation, and that abrupt cessation of infusions causes withdrawal (agitation, tachycardia, diaphoresis).
Rule of thumb
Treat pain first, then titrate sedation to a target score, reassess the neurologic exam regularly, and taper rather than stop abruptly.