prn sedation for children?

[brownbook]

I have a temporary summer vacation relief assignment helping a family with a disabled 5 year old. He is non verbal, mentally disabled.

He used to be easy going, self stimulating, happy. About a year ago he started having episodes of agitation. He has been through all kinds of tests to find out why he is agitated, the thinking is some kind of stomach GI pain. He has been worked up by a GI peds specialist but just vague maybe this and that diagnosis.

The various doctors have mentioned "okay we don't know what is wrong lets just treat the symptoms for now." His episodes occur every 4 - 6 weeks, several days of agitation upset, non consolable, not sleeping. But so far no doctor has ordered any PRN for agitation for the parents to give, just q HS trazadone for sleep that does not work during these episodes.

What could, would, should, I suggest they ask for in the way of PRN for agitation for a disabled 5 year old?

[brownbook]

brkndoll18 your reply very insightful. It is such a difficult situation.

This child pushes caregivers and parents away and squirms out of their arms during these episodes. I keep thinking if somehow we can just gently physically restrain him to calm him down, but he fights so much, that was what made me think of asking about "chemical" restraints.

The parents and doctors do feel there is a strong GI component to this, but the last episode went along with a bout of diarrhea! Other times it has been related to constipation.

[yuzzamatuzz]

To me it sounds like this kid might just be having a hard time expressing his discomfort (probably related to constipation, stomach ache, etc). It's hard to know over the internet what your patient really needs. If it is behavioral then I don't think chemical restraints are a good idea, unless he is a harm to himself or others. Keep in mind that chemical restraints won't help to correct his behavior and he will just continue to have this problem. Does he see a therapist at all? An occupational therapist would be able to help him figure out ways to express himself without language.

The problem with drugs for agitation is that we don't really know what is causing his agitation. Patients with very severe CP/mental disabilities will sometimes have a prn ativan order. I've rarely given it because it is reserved for situations of very bad agitation. Ativan is not meant to be used as a quick fix and it is much better to decrease agitation in other ways. Maybe you could suggest they see a pediatric palliative care specialist who would be able to answer more of their questions about symptom management.

[brownbook]

Your answer is greatly appreciated. These episodes have been going on for over a year, lasting several days, happen every 3 - 4 weeks. Finally a GI pediatric specialist said "we don't know what is causing the agitation, let's treat the symptoms." But that was just to give motrin and two other GI OTC meds when the episodes happen.

I will mention the idea of a pediatric palliative care specialists if I get the chance to interact with the parents again. They are seeing a lot of "specialists," OT, PT, speech, GI, neurology, etc. Everyone is trying to help, and concerned, but can't seem to come up with a diagnosis or solution!

It is doubly hard because the specialists that don't know him well just see it as "well....that is just how he is. it's his disability." They don't appreciate that when he is not having these episodes he is a compliant, quiet, likes hugs and snuggling, boy.