Pain Management: Pediatric Chronic Illness

Pain Management: Pediatric Chronic Illness

Gregory Kirkpatrick, MD

Pediatric Hematology/Oncology

Childhood Chronic Pain

Position Statement from the American Pain Society

Significance of the problem:Affects 15% to 20% of children (Goodman & McGrath, 1991).

Creates significant emotional and social consequences.

Financial costs, healthcare utilization and indirect costs are high

Impact child’s overall health and may predispose for adult chronic pain (Campo et al., 1999; Walker, Garber, Van Slyke, & Greene, 1995).

Defining Pain

Pain means an unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage.

Acute pain signals a specific nociceptive event and is self-limited

Chronic pain has been defined as pain that lasts longer than 3 (6) months and continues beyond the normal time expected for resolution of the problem or persists or recurs for other reasons.

Defining Pain

Acute Pain Classification

Somatic Pain: Result of activation of nociceptors

(sensory receptors) sensitive to noxious stimuli in

cutaneous or deep tissues. Experienced locally and

described as constant, aching and gnawing. The most

common type in cancer patients.

Visceral Pain: Mediated by nociceptors. Described as

deep, aching and colicky. Is poorly localized and often is

referred to cutaneous sites, which may be tender. In cancer

patients, results from stretching of viscera by tumor growth.

Defining Pain

Chronic Pain Classification

Nociceptive pain: Visceral or somatic.stimulation of pain receptors by tissue inflammation, mechanical deformation, ongoing tissue injury. Responds well to common analgesic medications and nondrug strategies.

Neuropathic Pain:Involves the peripheral or central nervous system. Does not respond predictably to conventional analgesics. May respond to adjuvant analgesic drugs.

Mixed or undetermined pathophysiology:Treatment is unpredictable; requires various approaches.

Psychologically based pain syndromes:Traditional analgesia is not indicated.

Assessing Pain

QuickTime™ and aTIFF (Uncompressed) decompressor

are needed to see this picture.

Assessing Pain

Age variations in abilty to identify

Location

Quality

Time element

Source

Assessing Pain

• Wong/Baker FACES Pain Rating Scale

• FLACC

• Pain Intensity Rating



Assessing Pain



Managing Pain

General Treatment Principles:Ask about pain regularly.

Believe the patient's and family's reports of pain and what relieves it.

Choose appropriate pain control options.

Deliver interventions in a timely, logical, and coordinated fashion.

Empower patients and their families.

Managing Pain

Opioid Medications



Managing Pain

Non-steroidal Anti-inflammatory



Managing Pain

Adjuvant Medication for PainCorticosteroids

DecadronPrednisone

Most specific indication for brain metastasis and spinal cord compression. May add benefit for painassociated with inflammatory process.

Side effects common: hunger and weight gain,stretch marks, muscle weakness

Managing Pain

Adjuvant Medication for PainAnticonvulsants

CarbamazepimeGabapentin

Neuropathic pain:

May be helpful as antidepressant

Managing Pain

Adjuvant Medication for PainAntidepressants

AmytriptylineDoxepin Trazadone

Serotonin re-uptake inhibitorsMay be helpful as antidepressant

Neuropathic pain ofperipheral nerve injury

Managing Pain

Adjuvant Medication for PainDiphenhydramineTransdermal clonidine (0.1 to 0.2 mg/day)

Managing Pain

Wisconsin Cancer Pain Initiative

Managing Pain

Physical Pain ManagementExercise regimen

Cutaneous stimulation techniques: superficial heat and cold, massage, pressure or vibration

Physical therapy: active and passive range-of-motion exercises to prevent joint contracture, muscle atrophy, cardiovascular deconditioning

Managing Pain

Rehabilitation Treatment Modalities

Physical Therapy

Occupational Therapy

Alternative Interventions: Acupuncture, reflexology,

aroma therapy, music therapy, dance therapy, yoga,

hypnosis, relaxation and imagery, distraction and

reframing, psychotherapy, peer support group,

spiritual, chiropractic, magnet therapy, bio-feedback,

meditation, relaxation techniques

Managing PainNonpharmacologic Interventions: Invasive Procedures

With rare exception, noninvasive treatments should precede invasive palliative approaches

Palliative radiation therapy: treatment of symptomatic metastasis where tumor has caused pain, obstruction, or compression. Radiation should be administered in the fewest fractions possible to promote patient comfort during and after treatment.

Neurolytic blockade of peripheral nerves should be reserved with rare exception for instances in which other therapies (palliative radiation, TENS, pharmacotherapy) are ineffective, poorly tolerated, or clinically inappropriate.

Intraspinal medication (Ommya resevoir)

Managing Pain

Psychological Intervention

Managing Pain

Painful Procedures

Perceived Pain

Specific Disease States

Sickle Cell AnemiaBone Infarction

Pneumonia

Abdominal Crisis


Cancer Bone PainPrimary Bone Tumors

Bone Metastasis

Bone Marrow Metastasis


Cancer Nerve PainSpinal Cord Compression

Increased Intracranial Pressure

Peripheral Nerve Compression/Injury

Pain Management: Pediatric Chronic Illness

Documents

Transcript of Pain Management: Pediatric Chronic Illness