taking the pain out of pediatric pain management

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Objectives. Be able to effectively assess pain in the pediatric patientReview therapeutic rationale and selection of analgesic medicationsDescribe non-pharmacologic techniques of pain managementRecognize the benefits of regional analgesia in the pediatric patient. What is Pain?. Pain is whatever the experiencing person says it is, existing whenever they say it does (McCaffery, 1972)Pain is an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or d224

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1. Taking the Pain Out of Pediatric Pain Management Denise Strasser, MSN, APRN, FNP-BC Pain Management Coordinator Shriners Hospitals for Children Greenville, SC

3. What is Pain? Pain is whatever the experiencing person says it is, existing whenever they say it does (McCaffery, 1972) Pain is an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage (International Association for the Study of Pain [IASP] 1979, p. 249)

4. Pain Characteristics Somatic Pain - Pain originating from bone, joint, muscle, skin, or connective tissue Visceral Pain - Pain originating from visceral organs Neuropathic Pain - Pain originating from peripheral or central nervous system

5. Introduction to Pediatric Pain Children experience pain the same way an adult experiences pain; it should be assumed that if it is painful for an adult, it will be painful for a child Many children are not routinely asked about their pain, even when they suffer from a disease or condition with a known pain process (Fanurik, Koh, Schmitz, Harrison, & Conrad, 1999; Malviya et al., 2001)

7. Introduction to Pediatric Pain Cultural differences and language barriers can make pediatric pain assessment difficult and must be considered in assessment and management Children must be given an age-appropriate explanation of pain and let know it’s not a form of punishment Infants, young children and children with developmental delay have varying levels of communicating their pain and therefore their pain may go unrecognized and untreated (American Pain Society [APS], 2003; Fanurik et al., 1999; Malviya et al., 2001; Oberlander, O’Donnell, & Montgomery, 1999)

8. Key Misconceptions About Pain in Children Infants do not feel as much pain as adults Infants cannot feel pain because of an immature nervous system Young children cannot indicate where pain is located Active children are not in pain A child engaged in playing activities cannot be in pain Sleeping children cannot be in pain

9. Consequences of Unrelieved Pain Rapid shallow breathing (hypoxemia/alkalosis) Inadequate expansion of lungs/poor cough (atelectasis) Increased HR, BP and myocardial requirements (ischemia) Increased stress hormones (decrease immune function and impede healing) Slowing or stasis of gut and urinary systems (n/v, ileus, urinary retention)

10. Consequences of Unrelieved Pain Muscle tension, spasm, and fatigue leading to reluctance to move (delaying recovery) Behavioral disturbances Fear Anxiety Reduced Coping Developmental Regression (Managing Pain in Children, 2009)

11. Pain Management Applying the stages of the nursing process Practice should be based on scientific facts or agreed best practice Everyone is responsible

12. Pain Scoring Tools Because pain is subjective, it is measured best by self-report (APS, 2003) Nurses need to use age-appropriate validated pain scoring tools The lower age limit for successful use of a self-report pain scale is generally 3-4 years old (Hicks et al., 2001; Wong & Baker, 1988) When discussing pain scales with children explain it is to let the nurse know how they hurt 22

13. Pain Assessment Tools By Age Toddlers-can point to area and nonverbal cues more important than language Preschoolers-some can use easier self report scales (i.e., Faces) and those who can’t need assessment via observational scales School-age (7-12 years)-abstract thought and can use verbal numerical scale or visual analogue scale

14. Self-Report Tools Verbal Rating Scales Faces Pain Scale Numerical Rating Scales Visual Analog Scales Graphic Rating Scales

15. Faces Pain Rating Scale Point to each face using the words to describe the pain intensity. Ask the child to choose the face that best describes the child’s own pain, and record number.Point to each face using the words to describe the pain intensity. Ask the child to choose the face that best describes the child’s own pain, and record number.

16. Numerical Rating Scale

17. Oucher Pain Scale This scale consists of 6 photos of a childs face representing no hurt to biggest hurt. Scales for black and hispanic children children have been developed.This scale consists of 6 photos of a childs face representing no hurt to biggest hurt. Scales for black and hispanic children children have been developed.

18. Poker Chip Tool

19. Visual Analog Scale

20. Observational or Behavioral Tools Too young to understand and use self-report scales (less than 3-4 years old) Too distressed to use self-report scales Impaired in cognitive or communicative abilities Very restricted by bandages, surgical tape, mechanical ventilation or paralyzing drugs Self-report ratings are considered to be exaggerated , minimized, or unrealistic (von Baeyer and Spagurd, 2007)

21. Children’s Hospital of Eastern Ontario Pain Scale (CHEOPS) Intended for use in children 1-7 years but has been used in children 4 months to 17 years Crying, facial expression, verbalizations, torso activity, wound touching, leg position Each indicator scored on 4-point scale Lengthy and confusing scoring system make complicated in everyday practice

22. FLACC Scale

23. Individualized Numeric Rating Scale (INRS)

24. Individualized Numeric Rating Scale INRS

25. Choosing the Right Tool Reliable Valid Responsive Feasible Practical

26. Pharmacological Interventions Use of the WHO (World Health Organization) analgesic ladder is based on child’s level of pain; if pain control is inadequate move up to the next level

27. Acetaminophen Most commonly used analgesic drug for children Antipyretic activity but minimal anti-inflammatory effects Highly effective as sole analgesic for mild to moderate pain Enhances analgesia when used in combo w/NSAIDs, opioids or tramadol Opioid sparing effects Probably underused in patients with moderate pain with many clinicians relying on opioids

28. Aspirin (acetylsalicylic acid) Pediatric use declined since early 1980’s Link between Reye Syndrome and use of Aspirin Standard dosing 10-15 mg/kg q 4-6 hrs NSAIDs preferred for JRA

29. Non-steroidal anti-inflammatory drugs (NSAIDs) Used for treatment of mild to moderate pain, especially inflammatory-mediated conditions In children used for pain and fever management Juvenile Rheumatoid Arthritis (JRA) Have antipyretic, anti-inflammatory, and analgesic activities Significant opioid-sparing effect

30. NSAIDs Ibuprofen used commonly in children and labeled for children >6 months; dose is 10 mg/kg q 6 hrs Ketorolac dosing 0.5 mg/kg IV q 6 hrs; do not use more than 5 days, and… 30 mg provides the analgesia comparable to 12 mg morphine and 100 mg meperidine

31. Opioid or Narcotic? Opioid refers to any substance with morphine-like actions including natural, semi-synthetic and synthetic opioids (Preferred Term) Narcotic is an obsolete term for opioids because governments, law enforcement, and media use the term to refer to drugs of addiction and other illicit drugs including opioids, cocaine, and amphetamines ..

32. Opioids Used for treating moderate to severe pain Come in different levels of potency and efficacy Can be given in reduced doses without loss of analgesic effect when used in combination with non-opioids Have no ceiling effect (except codeine) In acute pain management , one opioid is not better than another

33. Weak Opioids Manage mild-to-moderate pain with or without a non-opioid and includes such medications as codeine and nalbuphine If child has inadequate pain control, change medication to a strong opioid AA

34. Strong Opioids Manage moderate to severe pain; dose limited by side effects…remember, no defined upper dose due to tolerance Morphine Hydromorphone Meperidine Methadone Oxycodone

35. Morphine Gold standard Widely studied in infants and children Use in infants younger than 2 months should be monitored in ICU Continuous infusion will avoid peaks and troughs

36. Hydromorphone Five times more potent than morphine Useful when child experiences excessive side effects to morphine Renal impairment Large interpatient variability

37. Fentanyl 80-100 times more potent than morphine Great choice for short procedures For continued pain more appropriate to administer by continuous infusion High lipid solubility with rapid entry into the brain

38. Meperidine 10 times less potent than morphine Principal metabolite is normeperidine; when accumulates may cause central nervous system excitation i.e.: tremors, hyperactive reflexes, and seizures Oral form not recommended Consider other opioids with same analgesic effect and fewer disadvantages

39. Methadone Used when weaning off long-term opioids Can be effective in severe pain situations when PCA not an option Respiratory depressant effect lasts longer than analgesic effect When comfort level is achieved, usually after a few doses, lower the dose

40. Oxycodone Typically first line post-op orthopedics No injectable dose available Give with food as nausea is common Formulations available with or without acetaminophen

41. Adjuvant Analgesic Medications Not analgesics in true pharmacological sense Contribute significantly to pain relief Used alone or in combination

42. Anticonvulsants Gabapentin used most often Carbamazepine Reduce neuronal excitability Physiology of pain and epilepsy similar; good for analgesia Neuropathic pain

43. Tricyclic Antidepressants Analgesia may be provided by blocking re-uptake of neurotransmitters Rapid onset of analgesic effects Improved sleep and mood elevation Neuropathic pain

44. Alpha-2 Agonists Work by reducing central sympathetic output and increasing firing of inhibitory neurons Clonidine Sedation and analgesia w/o respiratory compromise Can be used as an anxiolytic Improves post-op analgesia PO, IV, Epidural, Transdermal

45. Non-Pharmacologic Techniques Useful in addition to medication in the acute setting and often the cornerstone for treatment of may types of chronic pain (Core Curriculum Pain Management Nursing, 2009) Cognitive-behavioral therapies increase feelings of control; restructuring negative thinking that often leads to pain-amplifying behaviors (Clark & Odell, 2000) Do not require an order

46. Parental Presence Feel secure and safe when parents are present Children describe parental presence as being an excellent distracter from things which hurt (Woodgate & Kristjanson, 1996; Polkki et al., 2003). Parents who are taught how to distract their children experience less anxiety and pain (Greenberg et al., 1999; Mainimala et al., 2000; Kleiber et al., 2001; Walker et al., 2006).

47. Distraction and Relaxation Redirect the child’s attention Distraction is a proven effective psychological intervention (Kleiber & Harper, 1999) Best method for relaxation is deep breathing

48. Rocking/Swaddling & Massage Held in comfortable well-supported position Rocked in rhythmic motion Provides security when wrapping infants in blanket Manipulation of body using tactile stimulation in purposeful application

49. Guided Imagery Focus on pleasant experiences Concrete objects for younger children Older children can benefit from more abstract

50. Music Therapy Infants respond best to repetitive songs such as nursery rhymes Music that you may like may not work for your patient Live music

51. Heat and Cold The underlying mechanisms of pain relief from heating and cooling are uncertain (McCaffery & Pasero, 1999) Topical applications of both heat and cold appear to help alleviate pain and promote comfort

52. Regional Analgesia Provides superior analgesia compared to systemic opioids (Liu & Wu, 2007) Central and peripheral techniques Single shot or continuous

53. Epidural Analgesia Solution of local anesthetic, opioid, or both into epidural space Manages pain after major surgeries of chest, abdomen and limbs Typically left in place 2-3 days

54. Patients with Epidural Infusions Close monitoring Dermatome levels Plan in place for discontinuation

55. Dermatome Map

56. Peripheral Nerve Blocks Local anesthetic solution delivered directly to peripheral nerve sheath Target is the nerve that controls pain to specific region of the body Benefit is analgesia to affected region without unwanted side effects seen with opioids Peripheral nerve stimulator Ultrasound guided

57. Axillary Nerve Block Used in surgery of elbow, forearm or hand

58. Interscalene Block Used for shoulder and upper arm procedures

59. Infraclavicular Nerve Block Used in surgery of elbow, forearm, hand and wrist

60. Femoral Nerve Block Surgery of the knee or medial part of the leg or pain management after operations on the femur, patella, knee and ankle

61. Sciatic Nerve Block Lower extremity surgeries

62. Peripheral Nerve Block Highlights Single shot or continuous Continuous usually left in 2-3 days Additional analgesia may be needed Ropivacaine or bupivacaine Protection of insensate limb “We don’t know how long it will last….”

63. Take Home Points Selecting the right delivery technique is key The way you give the med is often more important than the med itself Oral mode is ideal Rectal mode is unreliable PCA is safe and effective in pediatric patients (Monitto et al., 2000)

64. Take Home Points Use your Child Life Specialists Pain is a personal experience; so promoting comfort should be personalized too Use the stepwise approach in selecting the analgesic for your patient Be patient with your pain service….

65. Questions/Comments

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