Paediatric Pain

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Paediatric Pain
Susie Lord FFPMANZCA John Hunter Childrens
Hospital Anaesthesia, IC Pain Management
Newcastle, NSW
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Curriculum Framework

• Pain Management
• Understand the hierarchy of therapies and options
  for pain control
• Appreciate that pain therapies need to be matched
  to patients analgesia requirements
• Develop, implement and evaluate a plan of timely
  pain control
• Skills and procedures ? Sedation

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Outline

• Background
• Pain Assessment ? Management
• Sedation Planning ? Management

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NOT SO CORDLESS...
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When does pain start?
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Long-term Consequences

• Plasticity
• 20 wks PCA ? synapto- genesis is at least in
  part dependent on sensory stimulation
• Programming
• Noxious insult in a critical phase ? permanent
  effects on structure, physiology, metabolism

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Long-term Consequences

• Evidence from human studies
• Circumcision ? Taddio, Lancet 1997
• Prematurity ? Buskila, Arch Ped Adol Med 2003
• Thoracic Sx ? Schmelzle-Lubieki, IASP 2005

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Long-term Consequences

• Evidence from human studies
• Circumcision ? Taddio, Lancet 1997
• Prematurity ? Buskila, Arch Ped Adol Med 2003
• Thoracic Sx ? Schmelzle-Lubieki, IASP 2005
• Neonatal pain is association with
• - altered pain processing
• - poor cognitive development
• atypical behaviors during childhood

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Long-term Consequences

• Evidence from human studies
• Circumcision ? Taddio, Lancet 1997
• Prematurity ? Buskila, Arch Ped Adol Med 2003
• Thoracic Sx ? Schmelzle-Lubieki, IASP 2005
• Neonatal pain is association with
• - altered pain processing
• - poor cognitive development
• atypical behaviors during childhood
• Childhood pain experiences influence responses to
  future care and pain

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Pain Assessment
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Goals of Assessment

• Pain severity / distress? ? How urgent is
  this?
• Is the cause known / unknown? ? Further Ix
  and specific Mx?
• Relevant health concurrent drugs? ? Check for
  drug CIs/interactions

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Components of Assessment

• Interview with child and parent
• Physical examination
• Developmentally-appropriate pain scale

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Paediatric Pain Scales

• Physiological measures
• Behavioural measures
• Self-report measures
• Neonates PIPP
• Infants FLACC
• Children gt 3yo Faces
• Children gt 7yo VAS

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How often?

• On admission
• Daily if pain is not a feature
• 4th hourly on oral analgesics
• 2nd hourly on PCA / NCA / infusions
• AND whenever a child appears distressed or
  complains of pain ? and then after your
  intervention

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Daniel

• 1½ yo boy pulled cup of coffee onto himself

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Daniel

• Great first aid, analgesia by ambos
• No pain score in ED ? paracetamol
• Inadequate analgesia ? IPS opioid infusion but
  not started and no pain scores done
• Next morning I was asked to assess for a dressing
  change under sedation

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Daniel

• Slept poorly
• Too agitated to drink much
• Being rubbed down in preparation for dressing
  removal

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FLACC Infants 2 mo 7 years
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Assessment summary

• Using a pain score does make a difference to the
  care a child receives, and improves family and
  staff satisfaction
• Use a scale appropriate to each child
• Use the team including child / parents
• Use repeated measures to guide management
  automatic responsive

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JHCH Guideline for Managing Acute Pain in Children
HNE Health Intranet ? Kaleidoscope ?
Professionals ? Guidelines
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General Considerations

• At any stage consider
• Could non-drug strategies be helpful?
• Can the Play Therapist help me?
• Can the Pain Team help me?
• Can the Pharmacist help me?
• Are anti-neuropathic drugs indicated?
• Additional stuff for painful procedures?

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Non-drug strategies

• Oral sucrose for neonates
• Good psychological preparation, parent education
  and involvement
• Cognitive behavioral techniques and hypnosis
• Distraction (play, music, VR games)
• May be provided by a Recreational therapist
• or any member of the team including parents

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Sucrose Story

• Stevens B et al, Clin J Pain 200521543
• Lefrak L et al, Pediatrics 2006118S197
• Endogenous opioid-mediated effect?
• Actual benefit only 2 PIPP points

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Specific considerations

• Analgesia Prescribing Guide
• Choose route
• Choose drug and dosing
• Assess response
• Amend prescription

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1) Choosing the Route

• Speed Access Patient acceptance
• PO mild-mod pain or if IV access is
  delayed
• IM hurts and is not faster that PO use only
  as an interim measure
• IV severe pain or if GIT access is not
  possible

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2b) Choosing the Drug
Paracetamol first line simple analgesic
Ibuprofen - if family or physician prefer
OR
Add NSAID
Add Codeine (?)
Add full opioid agonist First line PO / IV
Morphine Second line PO Oxycodone Second
line IV Fentanyl
OR
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2b) Choose Dosing

• Mistakes happen be vigilant
• To calculate doses, use the least of
  real wt vs ideal wt vs 50 kg maximum
• Administer IV loading doses in increments
• Use standard solutions whenever possible

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3) Assess response

• Benefit?
• Adverse-effects?
• seriousness
• treatment
• monitoring

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4) Return to or amend
Regular assess-ment of pain

• Inadequate benefit ? increase dose
• Dose-limiting side-effects ? contact IPS

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Ask for advice Page 2101 (24 hours)
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Special delivery techniques

• Opioid infusions
• Patient-controlled analgesia (PCA)
• Nurse-controlled analgesia (NCA)
• Continuous regional blocks
• Epidurals

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Analgesia Sedation for Painful Procedures in
Children
HNE Health Intranet ? Kaleidoscope ? Education
Packages HNE Skills Simulation Centre
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Procedure-related pain is common

• Medical procedures are a frequent and distressing
  component of medical care for many children
• Repeated interventions are often required eg.
  bone marrow aspirates, port access, dressings

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its variable

• Between different children
• Between different occasions
• Between different procedures
• Minor venepuncture, cannulation, laceration
• Moderate LP, bone marrow aspiration
• Major fracture reduction, burns dressings
• Between brief vs prolonged procedures
• Variable post-procedure pain

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and it has consequences

• Pain is not just a warning or an unpleasant
  experience it can be harmful
• short-term
• long-term
• Level of pain and memory of the first procedure
  affect the pain and distress associated with
  subsequent procedures

Weisman 1998, Chen 2000
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Aims of procedural pain Mx

• ? Analgesia
• ? Amnesia
• ? Activity modification
• ? Without compromising safety

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Approaches

• Child-friendly environment
• Parental involvement (prep / during)
• Non-drug strategies
• Non-sedating analgesics / LA
• Sedating analgesics
• (Other sedating drugs)
• (GA)

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Approaches

• Child-friendly environment
• Parental involvement
• Non-drug strategies
• Non-sedating analgesics / LA
• Sedating analgesics
• (Other sedating drugs)
• (GA)

• Matched to
• child
• procedure
• expected intensity and duration of pain
• treatment environment and available resources

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Levels of Sedation

• Minimal spontaneously awake without stimulus,
  anxiolysis
• Moderate drowsy but rouses to consciousness
  with verbal or light tactile stimulus
• Deep drowsy, rouses somewhat with repeated
  tactile or painful stimulus, purposeful
• Anaesthesia unconscious, reflex response to
  pain

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Levels of Sedation

• Minimal spontaneously awake without stimulus,
  anxiolysis
• Moderate drowsy but rouses to consciousness
  with verbal or light tactile stimulus
• Deep drowsy, rouses somewhat with repeated
  tactile or painful stimulus, purposeful
• Anaesthesia unconscious, reflex response to
  pain

?
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Levels of Sedation

• Minimal spontaneously awake without stimulus,
  anxiolysis
• Moderate drowsy but rouses to consciousness
  with verbal or light tactile stimulus
• Deep drowsy, rouses somewhat with repeated
  tactile or painful stimulus, purposeful
• Anaesthesia unconscious, reflex response to
  pain

Drugs Pain Senses Anxiety Sleep-wake
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Facilities and equipment

• To deliver analgesia and sedation
• To manage paediatric emergencies
• Needs to be immediately available

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Personnel

• With knowledge, skills and experience
• The role of proceduralist and sedationist may be
  merged but the proceduralist should not be the
  person responsible for monitoring the child
  during the procedure
• Sedationist must be able to manage and recover a
  patient who enters deeper levels of sedation
• A medically qualified person should hold
  responsibility for the sedated child until
  discharge

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Patient selection

• Need a full pre-procedure clinical assessment
• Caution when sedating children under 5 yo and
  only anaesthetists should sedate lt1 yo
• Children with contra-indications to sedation
  should not be sedated
• Remember GA is an option

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Contra-indications

• A abnormal airway including large tonsils,
  snoring
• B active resp infection, sleep apnoea, resp
  failure
• C pulmonary hypertension, cardiac failure,
  shock

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Contra-indications

• A abnormal airway including large tonsils,
  snoring
• B active resp infection, sleep apnoea, resp
  failure
• C pulmonary hypertension, cardiac failure,
  shock
• Neuro risk ? ICP, ? LOC, neuromuscular disease
• Reflux risk known, not fasted, bowel
  obstruction

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Contra-indications

• A abnormal airway including large tonsils,
  snoring
• B active resp infection, sleep apnoea, resp
  failure
• C pulmonary hypertension, cardiac failure,
  shock
• Neuro risk ? ICP, ? LOC, neuromuscular disease
• Reflux risk known, not fasted, bowel
  obstruction
• Additional ones for nitrous any contained air
  space
• Allergy or previous adverse reaction to sedation
• Informed refusal

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Patient preparation

• Child and parental education, medical play
• Consent for procedure PLUS analgesia/sedation
• Fasting
• 6 hours for solids
• 4 hours for breast milk
• 2 hours for clear fluids
• Except if nitrous is the only agent used

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Techniques - Principles

• Non-Rx techniques for painless procedures if
  possible
• For painful procedures provide analgesia before
  considering sedation

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Techniques - Principles

• Non-Rx techniques for painless procedures if
  possible
• For painful procedures provide analgesia before
  considering sedation
• Integrate non-Rx and Rx (preference to
  non-sedating methods)
• Use the least distressing route

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Techniques - Principles

• Non-Rx techniques for painless procedures if
  possible
• For painful procedures provide analgesia before
  considering sedation
• Integrate non-Rx and Rx (preference to
  non-sedating methods)
• Use the least distressing route
• Individualise dose and always double-check
  prescription
• Avoid combinations of sedatives that depress
  respiration and airway reflexes ? deeper sedation
  and increased adverse effects

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Techniques - Novices

• NonRx / topical / non-sedating
• Single agent in healthy children gt 2yo
• Common sedative agents
• Midazolam
• Chloral hydrate
• Nitrous oxide

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Management

• Must have a person to monitor child
• Oximetry with sound and alarms
• SOBA suction, oxygen, bag-mask, airway (guedel)
  must be present throughout
• Person capable of establishing an airway and PPV
  present or immediately available

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