pain management in peds

Pain Management

Aola H. Al Duhaim RN, BScN

Pain Management CNC

AolaH.Duhaim@kfsh.med.sa

Pediatrics

The IASP defines Pain as:

“An unpleasant sensory and emotional experience

associated with actual or potential tissue damage, or

described in terms of such damage“

King Fahad Specialist Hospital

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The IASP defines Pain as:

"Pain is whatever the experiencing person says it is and

exists whenever he says it does."

Margo McCaffery

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▫ Motivates us to withdraw from damaging or

potentially damaging situations.

▫ Protect the damaged body part while it heals, and

avoid those situations in the future.

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Pain Pathway:

Children are at Risk of Inadequate Pain

Management

▫ Age-Related Factors

Neurobiological

Physiological

Psychological

▫ Misconceptions

Inadequate analgesia

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Developmental Neurobiology

• Sensory fibers are abundant by 20 weeks

• Functional spinal reflex is present by 19 weeks

• Connection to the thalamus are present by 20 weeks

Lee SJ, Ralston H, Drey EA, Partridge J, Rosen MA. Fetal Pain: A Systematic

Multidisciplinary Review of the Evidence.

JAMA. 2005;294(8):947-954

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Developmental Neurobiology

• Connection to the subplate neurons are present by 17

weeks e` intensive differentiation by 25 weeks

• Mature thalamocortical projections not present till

29-30 weeks

Lee SJ, Ralston H, Drey EA, Partridge J, Rosen MA. Fetal Pain: A Systematic

Multidisciplinary Review of the Evidence.

JAMA. 2005;294(8):947-954

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NOW well accepted by Neuroscientists and Pain Specialists that..

The nervous system is sufficiently developed before birth.

Children experience pain from birth onward

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NOW well accepted by Neuroscientists and Pain Specialists that..

Infants and young children may experience a greater

neural response more pain sensation and pain-related

distress

The impact of painful experience on the young

long-term effects can occur

i.e. lowered pain tolerance

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Physiological Changes

• CNS (BBB)

• Liver ( Hepatic blood flow Vs. Immaturity)

• Protein Bindings (Albumin Vs. AAG)

• Kidney (Protein load , Excretion Capability)

• Volume of distribution (water Vs. Fat compartments)

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Physiological Changes

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Cognitive Factors

• Understanding the pain source

• Ability to understand what happen

• Expectation regarding the quality or strength of pain

• Previous experience

• Knowledge of pain control strategies

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Behavioral Factors

• Distress responses (child and family)

▫ May initiate, maintain or exacerbate a child’s pain.

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Emotional Factors

• Vary widely & include:

▫ Neutral acceptance

▫ Anxiety

▫ Fear

▫ Anger

▫ Frustration

▫ sadness

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Developmental Stages

Neonateup to 1 mth

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Misconceptions

• The myth that infants and children do not feel pain, or

suffer less from it than adults.

• Lack of routine pain assessment in children.

• Lack of knowledge regarding newer modalities and

proper dosing strategies for the use of analgesics in

children.

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The American Academy of Pediatrics and

the American Pain Society

• Fears of respiratory depression or other adverse effects

of analgesic medications.

• The belief that preventing pain in children takes too

much time and effort.

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The American Academy of Pediatrics and

the American Pain Society

Misconceptions

Classification of Pain

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Sharp & well localized.

Reproduce by touching &

moving the affected area

Somatic1-Nociceptive

Noxious stimulation of

specific pain receptors

Thermal, Mechanical or

Chemical

Deep or Superficial

Stretch, Inflammation &

Ischemia

Poorly localized, cramping,

colicky in nature & may feel like

vague deep ache

2-Non-Nociceptive

within PNS / CNS

Nerve cell dysfunction.

No specific receptors for pain

Neuropathic

AKA: Pinched/ Trapped Nerve

Degeneration, Pressure,

Inflammation ..

it becomes electrically unstable,

firing off signals randomly

Sympathatic

Over-Activity of Sympathetic

Nervous System, and CNS/ PNS

More Commonly After Fractures or

Soft Tissue Injuries

may lead to Complex Regional

Pain Syndrome (CRPS).

Partially Sensitive to:

Paracetamol

NSAIDs

Opioids.

More Sensitive to:•Anti-Depressants

•Anti-Convulsants

•Anti-Arrhythmics

•NMDA Antagonists

•Topical Capsaicin may be helpful

Acute Pain:

• More common

• Begins suddenly

• Sharp in quality

• Serves as a warning of disease/threat

• Caused by ..▫ Procedures

▫ Surgery

▫ Broken bones

▫ Dental work

▫ Burns or cuts

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Chronic Pain:

• Longer than 3-6 months

• Despite the fact that an injury has healed

• Pain signals remain active in the nervous system for

weeks, months, or years.

Such as:• Cancer pain

• Arthritis pain

• Neurogenic pain (pain resulting from damage to nerves)

• Psychogenic pain (pain not due to past disease or injury or any visible sign

of damage inside)

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Breakthrough pain:

A sudden Flare-up of pain that “break through” the

around the clock medication used for persistent pain.

Up to 86% of the patients

3 – 30 min & require different Tx.

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Overtreatment

Increased around the clock

medication

Increased side Effects

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BTP Medications may not act

quickly enough

Patient suffer pain up to 30 min

or more

Undertreatment

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Quick onset BTP medication

Last as long as the BTP (30min)

Easily used

Has manageable Side Effects

Preferred Treatment

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Why Should we Treat Pain?

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Pain Assessment:

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When ..?

• On admission

• After any known pain- producing event

• With each new report of pain

• Routinely at regular intervals

• After intervention

▫ at appropriate time (e.g. 15-30 min P` IV , 1 hr P` PO);

Follow-up assessment is crucial

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• To assess pain adequately we must consider..

▫ The developmental stage

▫ Age

▫ Experience

▫ Family Culture/Belief

▫ Language

▫ Severity of Illness

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Neonates and Infants

▫ They communicate distress by crying

▫ Should involve the parents

Notice changes in the infant not obvious to the health care

provider

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Neonates and Infants

Observational pain scales (unable to verbalize)

These scales, though essential, also respond to distress

from causes other than pain, such as hunger, fear or

anxiety

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Preschool and School Age Children

Simple self-report scales using facial expressions or

small objects

To allow more accurately description of their pain

intensity.

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Pain Scales:

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Observational Pain Scales

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NIPS0 – 1 Y

CRIESKing Fahad Specialist Hospital

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0 – 1 Y

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FLACC2M – 3 Y

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2- Poker Chip Scale “pieces of hurt,”

1- Oucher Scale (ethnic versions) well accepted in children over 6 years of age

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3- Wong-Baker

Faces Scale (free to

(available in 30 languages) 4-

5- VAS , NRS 8 years and older

without difficulty

Pain Assessment in Pediatrics

Adult Pediatrics

Pain receptors are the same in the pediatric patient compared to the adult.

But Children do have increased fear and anxiety.

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Pain control must be based on scientific fact, not on

personal beliefs or opinions

Optimal pain management is the right of all patients

and the responsibility of all health professionals

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Treatment should include

▫ Pharmacological - Appropriate Multi-Modal

▫ Non-Pharmacological

▫ Sympathetic Nerve Blocks – as needed

▫ Intensive Rehabilitation

Occupational and Physiotherapy.

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Pharmacologic Pain Management

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• Special Considerations in Treating Infants and

Children.

• Although most of the major organ systems in infants

are well developed at birth, their functional maturity

is often delayed.

• In the first months:

▫ These systems rapidly mature similar to adults before 3

months of age.

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Multi-Modal Medications

• Inhibition of peripheral inflammatory response to tissue injury (NSAIDs)

• Blocking the pain receptors (Opioids)

• Neural blockade of transmission of pain impulses (Regional Tech./Neuraxial blocks)

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Multi-Modal Medications

• Prevention of “Central Sensitization” before tissue injury (Preemptive analgesia)

• Prevention & treatment of anxiety accompanying acute pain.

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Preemptive analgesia

• Treatment that ..

▫ Starts before surgery

▫ Prevent the establishment of Central Sensitization caused by Injury/Inflammatory responses.

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Drugs used for pain management

• Non-Steroidal Anti-Inflammatory Drugs (NSAIDS)

• Acetaminophen

• Opioids

• Adjuvant

• Others

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Analgesics (Opioids/L.A)

Most are conjugated in the liver.

Newborns, and especially premature infants, have

delayed maturation of the enzyme systems involved

in drug conjugation

▫ Several of these hepatic enzyme systems mature at varying

rates over the first 6 months of life.

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Glomerular filtration rates :

▫ Diminished in the first week of life, especially in premature

infants

▫ but sufficiently mature to clear medications and metabolites

by 2 weeks of age.

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Newborns

have a higher percentage of body weight as water and

less as fat

Water soluble drugs often have larger volumes of

distribution.

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Newborns

• Have reduced plasma concentrations of both albumin

and alpha-1 acid glycoprotein may lead to higher concentrations of unbound drug (active), and

thereby greater drug effect or drug toxicity.

• Have diminished ventilatory responses to hypoxemia

and hypercarbia - especially premature infants

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Acetaminophen

• Excellent safe profile and lack of significant side

effects

• commonly used

• mild to moderate pain,

• often combined with opioid (for more severe pain)

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Acetaminophen

• Can results in Hepatotoxicity

• Infants and children produce high levels of GSH as a

part of hepatic growth may provide some

protection

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Acetaminophen

• Still acetaminophen toxicity are highest in pediatric

patients.

▫ Analysis of Poison Control Center data, FDA adverse

event reports, and clinical trial reports indicate that

therapeutic doses of <75 mg/kg daily are safe with

respect to hepatotoxicity.

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NSAIDs

• Pharmacodynamics and pharmacokinetics are not

much different than in adults.

• Potential for GI, renal and other toxicities exist

but less than in adults.

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NSAIDs

• Ibuprofen

▫ frequently chosen

▫ mild to moderate pain

▫ liquid form easy administration

▫ fever reduction

▫ pain relief

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Patient Controlled Analgesia

• Widely used for postoperative pain relief

• Appropriate preoperative teaching and

encouragement

• As young as 6 to 7 years of age can independently

use the PCA

• 4 and 6, however, require encouragement from their

parents and nurses

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Local Anesthetics and Regional Anesthesia

• Topical Anesthetics (EMLA)

• provide pain relief prior to needle-stick procedures

• requires 30 to 60 minutes to become fully effective after application.

• must be applied in a thick layer

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• Clinical trials have shown effectiveness of EMLA in

reducing the pain or distress of a number of common

pediatric procedures including:

▫ venous cannulation

▫ Venipuncture

▫ lumbar puncture,

▫ Circumcision

▫ urethral meatotomy

▫ Immunizations

▫ dermatologic procedures … etc.

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Nonpharmacologic Pain Management

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Comfort Methods:

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RepositioningSinging

or soft music

Gentle stroking

Rocking with the child

in a rocking chair

Swaddling

Comfort Methods:

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Watching a movie

Reading a book

Other methods used at home

to comfort the child

Psychological strategies:

For children undergoing repeated painful procedures,

cognitive-behavioral therapy

▫ decrease anxiety and distress

▫ help children master a distressing situation.

▫ take time to learn and master

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Psychological strategies:

• Distraction techniques ▫ divert attention away from painful stimuli

• positive incentive techniques

▫ provide a small reward (e.g., stickers or prizes)

Decrease anxiety but not adequate as the sole means of

pain relief.

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Persistent Pain in Children

• Children with chronic medical disease can

experience:

▫ a significant amount of pain associated with both their

underlying disease and the procedures that are performed to

treat it.

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Persistent Pain in Children

• Children with chronic medical disease can

experience:

▫ They deserve not only access to adequate pain medication,

but also psychological support to help them continue to

learn and grow as they should.

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SUMMARY

• The pediatric nervous system is fully developed and

able to respond to Nociceptive stimuli even in pre-

term neonates

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SUMMARY

• Pain can have lasting physiological and

developmental consequences if not appropriately

managed

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SUMMARY

• Regular pain assessment is fundamental to good pain

management but is often poorly performed

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SUMMARY

• A variety of pain assessment tools are available and

should be utilized according to a patient’s age and

developmental stage

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SUMMARY

• Multi-modal therapy is appropriate for managing all

forms of pediatric pain and should utilize

combinations of local anesthetic, paracetamol,

NSAIDs and opioids as appropriate

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SUMMARY

• Adequate monitoring, safety equipment and

resuscitation skills are needed to safely manage

patients requiring combinations of sedation and

analgesia for painful procedures

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SUMMARY

• The pharmacokinetic and pharmacodynamic profile

of commonly used analgesics can be variable

depending on the age and development

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THANK YOU

Aola H. Al Duhaim RN, BScN

Pain Management CNC

AolaH.Duhaim@kfsh.med.sa

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pain management in peds

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