Pain Perception in Pediatrics & Geriatrics (1) · Pain Perception in Pediatrics (7) Male...
Transcript of Pain Perception in Pediatrics & Geriatrics (1) · Pain Perception in Pediatrics (7) Male...
Pain Perception in
Pediatrics and Geriatrics
M. S. El Ansary
• Prof. of Pain Medicine, Al Azhar University
• President of Egyptian Pain Society for Pain Medicine
• President of African Pain Association
• S. General of AUPM
• Former Council Member of IASP
Pediatric Pain in Ancient Civilizations
• Greeks, Romans and Spartans.
– Infanticide the father’s right
– Infant care A.D, Soranus and Galen
• A.E suspend the dead infant for 3 days (milk nurse)
• Babylonians Hammurabi Code
– Amputation of the milk nurse’s breast
• Arabs female infanticide (slave and heritage).
History of Pediatric Pain
• (Moses Pbuh) The Egyptian pharaoh killed all the newborn Jew males
• (Jesus Christ Pbuh) Saint Marry fled to Egypt for fear of killing him.
• Judaism, Christianity and Islam 1. Gave an early message for the children rights.
2. This issue still a matter of debate to the preparation of this work.
Pediatric Care in Holly Koran and Hadith
1. And when the girl child that was buried alive is made to ask for what crime she had been slain
At-Takwir, 81(8,9)
2. (Feed) or Play with him 7 years, correct him 7 years, a friend of him 7 years and then leave the cord loose.
3. Praying and carrying Imam Al-Hassan & Al- Hussein. (grand children)
4. To embrace the children and orphans. The off springs of the martyrs.
-وإذا انًىئىدح سئهت ثأي ذَت قتهت 1. (9و 8) 81سىرح انتكىير
سجع و أدثه سجع و ( اطعًه)العجه 2.صبدقه سجع ثى اترك نه انحجم عهي
انغبرة
كبٌ يصهي حبيالحفيديه األيبييٍ 3. انحسٍ و انحسيٍ
يعبَق األطفبل و األيتبو يٍ أثُبء 4. انشهداء
Al Canon of Medicine (Ibn Sina) 11th. Century Gregorian, 6th. Century Hejri
• Handle gently by the finger tips
• While asleep don’t twist:
– Any part of body (neck, arms, legs or trunk)
– Clean (eyes and body) with soft cloths
– Put sweet oil in the nose
• Good sedation
– Very clean Mother’s Nipple + rocking
– Movements are good for the body
– Music is good for the soul and mind
• Most of the studies on middle age group
• Pediatrics special case
They have different
`
Pain Perception in Pediatrics (1)
Anatomy & Physiology
Pathology, Measurement
and Pharmacology
Pain Perception in Pediatrics (2)
• Pain in Neonates & Infants (ICU)
• Present in pre & full term, neonate & infant
Causes STRESS
1. Separation from mother or father
2. Exposure to light & sounds
3. Variable thermal environment
4. Poor nutritional support
5. Invasive (Diagnostic & Monitoring)
Pain Perception in Pediatrics (3)
Pain is under estimated & under treated ?
• Pre and full term can not self report pain,
and (mentally & verbally handicapped)
• Weak and ill neonate can not express his
pain properly or to PROTEST
• wrong assumption that the CNS is
underdeveloped
Pain Perception in Pediatrics (4)
Stimulus (heal steak) Physio. Response
• High O2 consumption, limb withdrawal
• Kicking other limb
• Writhing body movements
• High pitched crying, specific facial
expression
• Stress BP, HR, ICT, RR
Pain Perception in Pediatrics (5)
Continuous Pain: Passive behavior
FLAT RESPONSE to circumcision (shock)
• Passive response
• Limited body movements
• Expressionless face
• Low HR, RR, ICT, O2 consumption
Pain Threshold in Pre term Neonates (6)
Proportional in pain threshold from pre full term.
Pre-term:
1.Immature descending inhibitory control
2.High activity of DHN Trans. Release
3. Non painful (handling, change napkins) Painful
4. Pre term males ♂ more susceptible than females♀
5.High doses of analgesics and anesthetics /s. area
Pain Perception in Pediatrics (7)
Male circumcision without anesthesia :
• Irritability (2-7 days)
• Attentiveness & orientation (2-7 days)
• Poor regulation of behavioral state(2-7 days)
• Change in pattern of feeding and sleep(2-7 days)
• Repeated pain in pre term pain threshold
in late adult life.
Female mutilation present but crime
Painful Circumcision
•This operation was
performed in young adults
just before marriage and
without local analgesia.
•The operator says to the
assistant “Hold him well do
not let him fall down”
Pain would induce
syncope.
Health and Healing in Ancient Egypt,
Ghalioungi P, Chapt.III., Fig. 87-89, 1965
Ancient Egypt
Pharaonic Medicine
Painless Circumcision
The surgeon rubs in with
an ovoid instrument, while
the patient says: “rub well
the part”. The operator
answers : “I shall make it
so that it is agreeable”.
They used Stone of
Memphis = Ca carbonate
+ Acetic Acid.
Co2 local cooling
analgesia Health and Healing in Ancient Egypt,
Ghalioungi P, Chapt.III., Fig. 87-89,
1965
Ancient Egypt
Pharaonic Medicine
Female Genital Mutilation
• It is performed without anesthesia
• Girls aged between 2-12 years.
• Occasionally later before marriage
• Seen as an act of passage to womanhood
• Deeply rooted cultural tradition
• No religious basis
• Can have serious health consequences
• WHO –violation of human rights
Dar al-Ifta stopped Female Genital Mutilation
Pain Perception in Pediatrics (8)
Repeated pain:
• Loss of hypocampal neurons
• Hypoth. Pituit. Aden. Axis (HPA) response to
emotions.
• Tendency for alcohol and drug addiction
• Rapid formation of neuronal plasticity and high
C- fos protein in the sensory cortex
Follow up in Ex Pre term Neonates (10)
• Mental retardation
• Poor motor performance
• Visual and auditory deficits
• Learning curves
• Impaired learning processing
Follow up in Ex Pre term Neonates (11)
• low activity and attention
• Low social control and inability to cope
with new situations and poor adaptive
behavior
• Increased somatization in relation to
duration of stay in the (N.ICU)
• More score to develop psychosis
Pain in Geriatrics (1)
Pain in geriatrics is different from
young adults and pediatrics
They have special
Anatomy, physiology
Pathology and Pharmacology
Pain In Geriatrics (3)
Classification of the WHO
• 60 - 74 Yrs. Young old
• 75 - 84 Yrs. Old old
• 85 Yrs. and above Oldest old
Pain In Geriatrics (4)
Less pain in spite of arthritis due to:
– Sensory discriminative pathway
– Affection, motivation and interpretation of pain
– High threshold of pain (20%)
Why ??
Pain In Geriatrics (5)
• Loss of activity of A- fibers
(sharp rapid discrimination of pain)
• Active C fibers
(Slow dull prolonged poorly localized)
• Cerebral Event Related Potential (CERP)
Low response to thermal CO2 laser
Pain In Geriatrics (6)
Geriatrics have higher incidence of :
• Arthritic pain
• Cancer pain
• Post herpetic & Trigeminal Neuralgias
• Post stroke (central) pain
• Depression more than anxiety
Pain In Geriatrics (7)
• Pharmacokinetics:
Delayed absorption, distribution,
metabolism and excretion
• Pharmacodynamics:
Exaggerated response to drug action
Pain In Geriatrics (8)
• Pain processing in Geriatrics is delayed
than in young adults.
But • It has more harmful effects on border
line vital body systems (C.V.S, R.S,
Kidney, Liver, Blood coagulation)