4/9/2012

Emerging Therapies in Pediatric Pain Management Wendy Mosiman, DNP, APRN PNP-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 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 Age

Perception of Pain

Pre-term

By mid/late gestation has anatomical/functional ability to process pain; sensitivity to pain >term infants or children

Newborn

Response to pain is inborn; newborns respond to pain with behaviors such as grimacing, crying, moving body

Infants older Metabolize analgesics/anesthesia effectively; than one month Caregiver recognized as comforter

Age/Perception of Pain Age

Perception of Pain

Toddlers and Preschoolers

Pain description of location/intensity possible; anger, crying, sadness response; may think pain punishment; y hold someone accountable for p pain and remember may experiences, 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

Adolescents

May 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

– ↑ ppain intensities + fear/non compliance 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 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 suffering ff i and d can’t’t mean we d don’t’t att lleastt try treatment!…

FLACC

Face 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, 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 US Authors Johnston et al, 1997

# Painful Procedure in NICU 2-10 per day

Benis & Suresh, 2001

6 per day

Simons et al, 2003

14 per day

Carbajal et al, 2008

16 per day

• Pre-emptive analgesia 28 days Infants>4kg up to 6 months of age

•0.1 mL of solution at a time on anterior section of infant’s infant s tongue PRN pain 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 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 p p procedure. Maximum application pp area = 10 cm2, 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 Weight Requirements

Max. Total Maximum Dose of Application EMLA Cream Area

Maximum Application Time

0 up to 3 months or < 5 kg

1g

10 cm2

3 up to 12 months and > 5 kg

2g

20

cm2

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

1 hour 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

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Lidocaine/Tetracaine SYNERA 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 tetracaine tetracaine.

Iontophoresis • • • •

10-20 minutes Use in kids older than age 5 Non Invasive Small electrical charge – Tingling

• Unbroken skin needed • Application to contoured skin difficult

J - TIP • Needle free lidocaine by jet of compressed CO2 • Anesthesia A th i iin 1 1-3 3 minutes i t • 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 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 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

Opiates • Mu Agonist (Morphine Like) – Morphine, Hydromorphone, Oxycodone, Fentanyl No ceiling N ili d dose (NSAIDS/APAP d do!) !) Do NOT cause end organ damage (NSAIDS/APAP do!) Safe for children Utilize weight based dosing Small frequent doses Pre printed orders for post op pain, sedation, PCA

Opiates • • • •

Opiates safe for children Weight based dosing Utilize pre printed orders sedation sedation, PCA IV small frequent dose safest way

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Pediatric Morphine IVP Dose • All 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 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 manyy procedures. 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 psychological h l i l off unrelieved li d pain. i 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 (1948 (1948--2008) for her devotion to assessment and Management of children's children s pain. pain Contact me @ [email protected] wmosiman@via

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