Pain Management in Infants and Children Lynette Thacker Clinical Nurse Specialist Paediatric...
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Transcript of Pain Management in Infants and Children Lynette Thacker Clinical Nurse Specialist Paediatric...
Pain Pain Management in Management in
Infants and Infants and ChildrenChildren
Lynette ThackerLynette Thacker
Clinical Nurse Specialist Clinical Nurse Specialist
Paediatric Palliative CarePaediatric Palliative CareDisclaimer: Whilst every effort has been made to ensure that the information in this presentation is accurate and referenced the author does not accept any responsibility for the use by any third parties.
Operational Definition of Operational Definition of PainPain
“Pain is whatever the experiencing person says it is, existing whenever he says it does.”
BELIEVE THE PATIENT! Ref: McCaffery and Pasero: Pain: Clinical
Manual, 1999).
Myths About Pain in ChildrenMyths About Pain in Children• Infants are neurologically immature and
therefore cannot conduct pain impulses.• Infants do not remember pain, because of
cortical immaturity.• Children do not report pain while playing or
sleeping so they must get over it quickly or not be experiencing it.
The Golden RuleThe Golden Rule
What is painful to an adult is painful to an infant and
child unless proven otherwise.
Types of PainTypes of Pain• Nociceptive
– Somatic• Well-localized• Pain receptors in soft tissue, skin, skeletal muscle, bone
– Visceral• Vague• Visceral organs
• Neuropathic• Damaged sensory nerves
Classification of pain• Many different systems
– e.g. based on:• Duration – acute/chronic/persistent• Intensity – mild/moderate/severe• Location• Presumed pathophysiology – visceral, somatic,
sympathetic• Sensitivity to opioids – sensitive/insensitive/partially
insensitive• Pragmatic
Pragmatic classification of pain• Neuropathic
– Disordered sensation– Responds to anticonvulsants and antidepressants
• Bone– Intense and focal– Responds to NSAIDs and bisphosphonates
• Muscle spasm– Responds to muscle relaxants and antispasmodics
• Cerebral irritation– Caused by brain injury– Signs of anxiety– Responds to benzodiazepines
QUESTTQUESTT
• Question the patient/parent/carer• Use pain rating scale• Evaluate behavior & physiologic
signs• Secure family’s involvement• Take cause of pain into account• Take action and assess
effectiveness
Pain AssessmentPain Assessment• What is the policy for pain assessment and
documentation in your area?• Methods of assessment vary according to age and
cognitive level of child– Patient report– Numerical scale – 1 to 10– FACES – can be used at all ages– FLACC used on infants
Physiological Indications Physiological Indications of of
Acute PainAcute Pain
• Dilated pupils• Increased perspiration• Increased rate/ force of heart rate• Increased rate/depth of respirations• Increased blood pressure• Decreased urine output• Decreased peristalsis of GI tract• Increased basal metabolic rate
Infant Response to PainInfant Response to Pain• Forcefully closed eyes• Lowered brows• Deepened furrow between nose and outer
corner of lip.• Square mouth• Cupped tongue
Toddler and Pre-schoolToddler and Pre-school• Limited in their cognitive abilities in localizing
and expressing pain intensity, and understanding reasons for pain.
• Find out word they use to express pain• Point to pain• Faces is a good tool for them.
School-ageSchool-age• Increased ability to communicate pain in more
abstract terms.• They can describe pain: squeezing, stabbing or
burning• Respond well to direct questioning.• Tools: body outline, faces scale, visual analog.
Acute IllnessAcute Illness• Middle ear infection, pharyngitis, meningitis,
abdominal pain, fractures• Treatment determined by severity of pain
– Paracetamol– Non-steroidal – Opioids– Locally applied medications– Relaxation and distraction
Pre-procedural PainPre-procedural Pain• Key to managing procedural –related pain is
anticipation• Anticipated intensity and duration• Child / parent receive appropriate information
to minimize distress
Operative PainOperative Pain• Morbidity and mortality can be reduced by
good pain treatment• Plans for postoperative pain should be
discussed before surgery• Goal is to control the pain as rapidly as
possible
Post-Operative PainPost-Operative Pain• Oral administration is preferred for mild to moderate
pain.• IV is indicated for immediate pain relief. • Persistent moderate to severe pain – continuous
around the clock dosing at fixed intervals is recommended.
• PCA – patient-controlled analgesia – used only when patient can use pump on their own.
Non-pharmacologic Pain Non-pharmacologic Pain ManagementManagement
• Physical– Massage– Heat and cold– Acupuncture
• Behavioral– Relaxation– Art and play therapy– Biofeedback
• Cognitive– Distraction– Imagery and Hypnosis
Case Study 1Case Study 1Alex is a 6 year old, admitted for osteotomy as treatment for bilateral dislocated hips from quadriplegic dystonic cerebral palsy. He is non-verbal, gastrostomy fed and as epilepsy.
Present analgesia consists of Buprenorphine patch 15micrograms and Oromorphine 3.5milligrams as required for pain.
Using the holistic approach of physical/psychological/social/spiritual aspects how would you manage Alex pain in the post-operative period.
Case Study 2Case Study 2Bobby is a 14 year old, admitted with a fractured radius and ulna. He is has a Lawrence Moon Biedal Barr Syndrome. He has chronic renal failure, visual impairment, mild learning disability and is verbal. Present analgesia consists of Paracetamol 500milligrams as required for pain.Bobby’s younger brother died 3 years ago from a more severe form of Lawrence Moon Biedal Barr Syndrome.Using the holistic approach of physical/psychological/social/spiritual aspects how would you manage Bobby’s pain in the post-operative period.
WHO analgaesic ladder
Golden RulesOral meds if possible
NB – adjuvants at all stages
Do not rotate within a step, move up
Major opioids should always be regular
Adjuvant AnalgesicsAdjuvant’ = not primarily analgesic but can improve pain in certain
circumstances
• Neuropathic - anticonvulsants (carbamazepine, gabapentin), antidepressants (amitriptyline), NMDA receptor antagonists (methadone, ketamine)
• Bone - NSAIDs, bisphosphonates, RTx, chemo
• Muscle spasm - Benzodiazepines, baclofen, tizanidine, botox
• Cerebral irritation- Benzodiazepines, phenobarbitone
• Inflammatory/Oedema – Steroids
• Non-pharmacological - Physio, Psychology…..
Initiating strong opioid therapy
• What drug?Morphine - short acting formulation (Oramorph, Sevredol)By mouth if possible
• What dose?1mg/kg/day = total daily dose = 30mg30mg ÷ 6 = 4 hourly dose = 5mg
• And for breakthrough pain?
• Give the 4 hourly dose (5mg) as required
Titration phase
Aim – to match the amount of analgesia given with the degree of pain experienced
• Add up all doses taken in 24 hours so if 6 doses x 5mg30mg + 30mg = 60mg60mg ÷ 6 = 10mg
Prescribe 10mg 4hrly and 10mg prn for breakthrough pain
Maintenance phase
• More convenient opioid preparations– MST
• Total daily Oramorph requirement: 60mg• Appropriate MST dose: 30mg bd
– Diamorphine SCI• Total Oramorph requirement: 60mg• Appropriate Diamorphine dose: 20mg/24hrs= 60mg/3 as Diamorphine 1/3rd stronger than Oral morphine
• Prescribe breakthrough analgesia
Side EffectsSide Effects
• Nausea, vomiting and puritus are common side effects
• Drowsiness• Respiratory Depression• Constipation with prolonged use of opioids
MonitoringMonitoring• What monitoring is required per hospital
policy?• A cardiac / respiratory monitor is used for
infants less than 7 months • Oximetry monitors for other patients during use
of IV opioids – Unstable respiratory status– History of difficult airway management– Neurologically impaired
DocumentationDocumentation• The assessment and measure of pain intensity
and quality, appropriate to the patient’s age, are recorded in a way that facilitates regular re-assessment and follow-up according to criteria developed by the organization.
Take Home PointsTake Home Points• Assess pain using an age appropriate tool.• Consider starting an around the clock regimen.• Continually assess pain and modify medication regimen
appropriately.• When to call for medical assistance:
– Patient has persistent or worsening pain despite appropriate analgesic regimen.
• When to transfer to a higher level of care:– Patient develops respiratory depression with opiates
• Control airway and ventilation• Order opioid antagonist (Naloxene)while calling for
help
Narcotics Narcotics Are No More Dangerous Are No More Dangerous for Children Than Adultsfor Children Than Adults
• Addiction from narcotics (opioids) used to treat pain is extremely rare in adults; no reports substantiate this fear in children; reports of respiratory depression in children are rare.