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Emerging Therapies in
Pediatric Pain Management
Wendy Mosiman, DNP, APRNPNP-BC, CNS, RN-BC
Clinical Nurse Specialist
Pediatrics/PICU
Via Christi Hospitals
Wichita, Kansas
Barriers
• Belief children, especially infants, don’t feel pain
• Belief unable to assess pediatric patient painBelief unable to assess pediatric patient pain
• Belief it is just a stick w/ no long term effect
• Belief managing pain takes too much time
• Belief pain treatment for kids doesn’t exist
Professional Perception
1968
“Pediatric patients seldom need medications for relief of pain. They tolerate pain well.”
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We know now!
Substantial evidence shows that even the smallest of preterm infants not only perceives but remembers pain and demonstrates recognizable pain behaviors.
Age Perception of Pain
Pre-termBy mid/late gestation has anatomical/functional ability to process pain; sensitivity to pain >term infants or children
Age/Perception of Pain
NewbornResponse to pain is inborn; newborns respond to pain with behaviors such as grimacing, crying, moving body
Infants older than one month
Metabolize analgesics/anesthesia effectively; Caregiver recognized as comforter
Age Perception of Pain
Toddlers andPreschoolers
Pain description of location/intensity possible; anger, crying, sadness response; may think pain punishment; may hold someone accountable for pain and remember
Age/Perception of Pain
y pexperiences, i.e. IV RN!
School-age children
When facing painful procedure may try to be brave; developmental regression to earlier stage common; seeks to understand reasons for pain
AdolescentsMay try to avoid acknowledging pain; showing signs of pain may be considered weak; regression to earlier stages of development common with persistent pain
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Pain doesn’t just hurt!
• Stress hormones released– Systemic changes
• Increased heart rate, BP, ICP, ,
• Increased oxygen consumption and hypoxemia
• Reduced tidal volume/abnormal respirations
• Weakened immune function → delayed healing
– Lengthened hospital stay
Pain doesn’t just hurt!
• Maladaptive response development to future painful procedures
– ↑ pain intensities + fear/non compliance↑ p p
– Procedural conditioned anxiety
– Significant anticipatory stress/anxiety
– Analgesic effectiveness diminished
– Needed medical care avoided or postponed
– Chronic pain more likely as an adult
Needle Pain
• It isn’t JUST A STICK!
• Two most common sources of pain in hospitalized childrenhospitalized children– Venipuncture
– Intravenous (IV) cannula insertion• 2nd most common cause of worst pain in hospital
• 1st is underlying disease!
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… Just because the patient is unable to scream the words ‘That HURTS’ doesn’t mean there is no way to tell they are
ff i d ’t d ’t t l tsuffering and can’t mean we don’t at least try treatment!…
FLACCFace
0 = No particular expression or smile
1 = Occasional grimace/frown; withdrawn or disinterested; appears sad or worried
2 = Consistent grimace or frown; frequent/constant quivering chin, clenched jaw; distressed-looking face;
expression of fright or panic
Individualized behavior:___________
Legs
0 = Normal position or relaxed; usual tone & motion to limbs
1 = Uneasy, restless, tense; occasional tremors
2 = Kicking, or legs drawn up; marked increase in spasticity, constant tremors or jerking
Individualized behavior:________
Activity
0 = Lying quietly, normal position, moves easily; Regular, rhythmic respirations
1 = Squirming, shifting back and forth, tense or guarded movements; mildly agitated (e.g. head back and forth, aggression); shallow,1 Squirming, shifting back and forth, tense or guarded movements; mildly agitated (e.g. head back and forth, aggression); shallow, splinting respirations, intermittent sighs.
2 = Arched, rigid or jerking; severe agitation; head banging; shivering (not rigors); breath holding, gasping or sharp intake of breaths, severe splinting
Individualized behavior:__________
Cry
0 = No cry/verbalization
1 = Moans or whimpers; occasional complaint; occasional verbal outburst or grunt
2 = Crying steadily, screams or sobs, frequent complaints; repeated outbursts, constant grunting
Individualized behavior:_________
Consolability
0 = Content and relaxed
1 = Reassured by occasional touching, hugging or being talked to. Distractible.
2 = Difficult to console or comfort; pushing away caregiver, resisting care or comfort measures
Individualized behavior:___________
©2002, The Regents of the University of Michigan—Permission granted
Wong-Baker FACES Pain Rating Scale
Brief word instructions: Point to each face using the words to describe the pain intensity. Ask the child to choose face that best describes own pain and record the appropriate number.
From Hockenberry MJ, Wilson D: Wong’s essentials of pediatric nursing, ed. 8, St. Louis, 2009, Mosby. Used with permission. Copyright Mosby.
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Presumed Pain
• Knowing what you know now, ask yourself, if this was happening to me, would I think it hurt?– If the answer is yes or even maybe, you
need to make sure the child is adequately treated.
Painful procedure in Neonates
• >10,000 infants in NICU across USAuthors # Painful Procedure in NICU
Johnston et al, 1997 2-10 per day
• Pre-emptive analgesia <35%
• Nearly 40% had NO analgesia
Benis & Suresh, 2001 6 per day
Simons et al, 2003 14 per day
Carbajal et al, 2008 16 per day
Painful procedures in older children
• Kids undergo many painful procedures
*14-20 separate immunization injections by age 2
*Venipuncture, IV start, laceration repair
• Children interviewed 7 years after pediatric cancer stated procedural pain (lab draws, IV start) worse than cancer pain
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Procedural Pain
So we are all
convinced they hurt.
What should we do?
Ethically? Morally?
• Nurses obligated to relieve children's pain– ANA code of ethics
• Right behavior, right knowledge, compassion
– Immanuel Kant duty based perspective• When the knowledge/tools exist, poor
management is wrong
– Relational ethics• Nurses “are the healthcare system”
• Child depends on nurses to protect from pain
Procedural Pain
• Plan ahead—we almost always have time to provide pain management before sticks
• TJC considering 2 new standards• Involving parents in identifying signs of pain
• Intervening before the procedure• Pharmacologically
• Non pharmacologically
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Intramuscular - IM
• Painful administration and for days
• Sterile abscesses
• Fibrosis of muscle and soft tissue
Just plain mean!!
• Absorption erratic
• Titration not possible
• Respiratory depression more likely
• ↑↑ expense over oral meds
• Needle stick risk to care providerAmerican Pain Society, Principles of Analgesic Use in the Treatment of Acute Pain and Cancer Pain, 6th ed., American Pain Society, Skokie, IL, 2008. AAP 2001
DO NOT USE
DEMEROLDEMEROLDevil Drug
PLAN AHEAD• Develop standard protocols
• Develop standard orders
Develop staff expectations• Develop staff expectations
• Develop education for parents
• Organize needed equipment
• Make it easy to do the right thing
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Environment– Child friendly
– May or may not be the child's room
Comfort HoldSaint Joseph's Children's Hospital, Marshfield, Wi
• Comfort positioning purpose is to increase the comfort of infants and children as well as parents and medical staff.– Invites the presence of the parent/caregiver
– Prepares the child/parent for procedure and their role
– Gives the option of the treatment room
– Positions child in a that allows control and comfort
– Maintain a calm, positive atmosphere
• Youtube video from Dell Children’s Medical Center
Comfort HoldSaint Joseph's Children's Hospital, Marshfield, Wi
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Side Sitting PositionSaint Joseph's Children's Hospital, Marshfield, Wi
IV Start Sitting PositionSaint Joseph's Children's Hospital, Marshfield, Wi
Distraction– Child Life Specialist
• Trained professional not causing pain
– Distraction• Infant: pacifier, bubbles, toys
• Toddler: bubbles, songs, pop-up books, party blower, kaleidoscope, toys
• School-age: videos, video games, search for objects in pictures, stories, jokes, counting, nonprocedural conversation
• Adolescent: music by headphones, video games, nonprocedural conversation, focusing on objects
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Non Pharm with some effect but incomplete
• Pre term Infants– Skin to skin contact
– Sucking related i t ti
• Neonates– Sucking related
interventions
R ki /h ldiinterventions
– Swaddling/facilitated tucking
– Rocking/holding
Older infants – the latest Cochrane review did not find sufficient evidence for any of the above (sucrose, breast feeding and music were excluded from the review)
Sucrose solution 24%Neonates >28 days Infants>4kg up to 6 months of age
•0.1 mL of solution at a time on anterior section of infant’s tongue PRN painsection of infant s tongue PRN pain, irritability, or prior to a procedure.
•For optimal effect, begin 2 minutes before procedure.
•Maximum volume of 24% sucrose is 0.5mL per procedure or 2 mL in 24 hours
NON-NUTRITIVE SUCKING
NNS shown to reduce pain behavior.
Offer dummy (pacifier) at least 2Offer dummy (pacifier) at least 2 minutes before minor procedure.
May be dipped in sucrose solution or offered after sucrose.
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L·M·X·4
• Topical 4% liposomal Lidocaine cream
• Intact skin needed, cover with clear occlusive dressing
• Available over the counter
• May be applied by parent
• Effective from 30 minutes– Longer is better, up to 5 hours is safe
LIDOCAINE/PRILOCAINE CREAM EMLA
Age up to 3 months or weight < 5 kg:
Apply a maximum of 1 gram to affected area x 1, 60 mins prior to procedure. Maximum application area = 10 cm2, p p pp ,Maximum application time = 1 hour, Cover with clear occlusive dressing
• Example only, please develop your own procedures based on your population
EMLA CREAM For LP and implanted port access
Age and Body WeightRequirements
Max. TotalDose ofEMLA Cream
MaximumApplicationArea
MaximumApplication Time
0 up to 3 months or < 5 kg 1 g 10 cm2 1 hour
3 up to 12 months and > 5 2 g 20 cm2 4 hours
Please note: If a patient greater than 3 months old does not meet the minimum weight requirement, the maximum total dose of EMLA Cream should be restricted to that which corresponds to the patient’s weight. From AstraZenac package insert—Demonstration purposes only
3 up to 12 months and > 5 kg
2 g 20 cm2 4 hours
1 to 6 years and > 10 kg 10 g 100 cm2 4 hours
7 to 12 years and > 20 kg 20 g 200 cm2 4 hours
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Lidocaine/TetracaineSYNERA is a peel-and-stick procedural topical anesthetic patch with a novel heating technology designed to enhance the delivery of the anesthetic. The anesthetic formulation is a eutectic mixture of equal parts lidocaine and tetracaineequal parts lidocaine and tetracaine.
Iontophoresis
• 10-20 minutes
• Use in kids older than age 5
• Non Invasive• Non Invasive
• Small electrical charge– Tingling
• Unbroken skin needed
• Application to contoured skin difficult
J - TIP
• Needle free lidocaine by jet of compressed CO2
A th i i 1 3 i t• Anesthesia in 1-3 minutes
• Popping noise
• Can be prefilled or filled at facility
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J - TIP
http://www.jtip.com/injection_for_anesthesia.html
Injection Pain Management
• Warm Hands
• Warm Medication
• Buffer if needed• Buffer if needed
• Ask yourself if the medication
can be given any other way
Buzzy
• Decrease injection pain relief by use of vibration, cold and distraction
• See on YouTube and WebSee on YouTube and Web
• http://www.buzzy4shots.com/
• Data on effectiveness for IV starts >4
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Vapocoolant Pain Ease
• Ethyl vinyl chloride skin refrigerant
• Spray onto intact skin
• Lasts for up to one minute• Lasts for up to one minute
Opiates
• Mu Agonist (Morphine Like)– Morphine, Hydromorphone, Oxycodone, Fentanyl
N ili d (NSAIDS/APAP d !)No ceiling dose (NSAIDS/APAP do!)Do NOT cause end organ damage (NSAIDS/APAP do!)
Safe for childrenUtilize weight based dosingSmall frequent dosesPre printed orders for post op pain, sedation, PCA
Opiates
• Opiates safe for children
• Weight based dosing
• Utilize pre printed orders sedation PCA• Utilize pre printed orders sedation, PCA
• IV small frequent dose safest way
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Pediatric Morphine IVP Dose
• All <3 months .025 - 0.05 mg/kg
(start low 0.012 mg/kg titrate up)
• Infants/Children 0.1 - 0.2 mg/kg g g
(start low 0.05 mg/kg titrate up)
• You can always give more;
harder to suck it back out!
• IV peak 20 minutes, Duration 3-5 hoursPlease develop your own reference, recommendations vary
Morphine MaximumSingle Dose
–Neonate 0.1 mg/kg/dose
–Infants 2mg/dose
–Children 1-6 yr 4mg/doseChildren 1 6 yr 4mg/dose
–Children 7-12 yr 8mg/dose
–Adolescents 15mg/doseSTART LOW GO SLOW
YOU CAN ALWAYS GIVE MORE
HARD TO SUCK IT BACK OUT
Please develop your own reference, recommendations vary.
IV Acetaminophen
• Offirmev
• Mild to moderate pain or adjunct
• Generally post op• Generally post op
• > age 2
• 15 mg/kg over 15 minutes
• Don’t use if you wouldn’t use oral
• May mask fever
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May need sedation
• If you are giving a medication so you can do something (a procedure, a test, a treatment) to a child then thata treatment) to a child, then that medication is considered sedation and must be monitored as such.
Sedation for Procedures
Sedative hypnotic medication may be required to bring pain/stress levels under adequate control for many procedures.y p
Even those you may consider painless with the use of a topical or local anesthetic.
Sedation for Procedures
Current guidelines from AAP, ASA and ACEEP require structured evaluation of children’s risk before beginning sedation.
A critical component of any sedation protocol is a trained observer to be solely responsible for monitoring the patient while the procedure is being performed.
Physicians administering sedation and analgesia must have proven training and skills and ongoing training in the management of pediatric airways and resuscitation.
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Believe!
Infants and children feel at least as much pain as adults.
There are harmful effects, both physical and h l i l f li d ipsychological of unrelieved pain.
There are reasonable behavioral, non pharmacological and pharmacological solutions to pain management that every child deserves.
Be known for excellent pain management!
Questions?
Dedicated to Dr. Donna Wong (1948Dedicated to Dr. Donna Wong (1948--2008) 2008) for her devotion to assessment and for her devotion to assessment and Management of children's painManagement of children's painManagement of children s pain.Management of children s pain.
Contact me @Contact me @wmosiman@[email protected]
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