Acute Pain Management in Children

Presenter : Ranjith Nelluri( 2nd yr MD)

Moderator : Dr.Govardhani

(Asst.Professor)

• International Association for the Study of Pain

– An unpleasant sensory and emotional experience

arising from actual or potential tissue damage or

described in terms of such damage

– Sensory, emotional, cognitive, and behavioral

components that are interrelated with environmental,

developmental, socio-cultural, and contextual factors

DIFFICULTIES• Belief that children, especially infants, do not feel pain the

way adults do

• Lack of routine pain assessment

• Lack of knowledge in pain treatment

• Fear of adverse effects of analgesics, especially respiratory depression and addiction

• Belief that preventing pain in children takes too much time and effort

• Parental understanding of pain

• Personal values and beliefs; i.e. pain builds character

• AAP 2001 Task Force on Pain in Infants, Children and Adolescents

• Historically children and infants received less post-

operative analgesia than adults

• Well documented that children are often undertreated for

pain

• Specifically in neonates:

– Recent studies show that neonates can experience pain by 26

weeks of gestation

• Mature afferent pain transmission

– Untreated pain in neonates lead to increased distress and altered

pain response in the future

Acute Pain in Children

• Acute illness

• Procedural pain

• Surgical pain

• Postoperative pain

• Exacerbation of chronic pain

Effects of Acute Pain

• Physiologic

• Metabolic

• Behavioral

Physiologic Response

• Increased heart rate

• Increased respiratory rate

• Increased blood pressure

• Decrease in oxygen saturation

Metabolic Response

• Increased secretion of catecholamine, glucagon, and corticosteroids.

• Delayed wound healing

• Poor intake

• Impaired mobility

• Sleep disturbances

• Irritability

General Principles ofPain Management

• Anticipate & prevent pain

• Adequately assess pain

• Use multi-modal approach

• Involve parents

• Use non-noxious routes

Anticipate & Prevent Pain

• Prepare patient and parent on what to expect

• Guide them on ways to minimize pain and anxiety

• Utilize quiet environment

• Distraction , parental presence

• Treat pain prophylactically when anticipated

– E.g. Following surgery or local anesthetic for lumbar puncture

– Takes more medication to treat pain than to prevent its

occurrence

Pain Assessment

• Obtain a detailed assessment of pain

– description of pain, experience with pain medications, use of non-

pharmacologic techniques, parent experience with pain

– Quality, location, duration, intensity, radiation, relieving & exacerbating

factors, & associated symptoms

• Use age appropriate tool

– Scales for neonate, infant, children ages 3-8, >8 years, and children with

cognitive impairments

• Directly ask child when possible

• Pain can be multi-dimensional and therefore, tools can be limited

PQRSTU mnemonic

• Provocative/Palliative factors (For example, "What makes your pain better or

worse?")

• Quality (For example, use open-ended questions such as "Tell me what your

pain feels like," or "Tell me about your 'boo-boo'.")

• Region/Radiation (For example, "Show me where your pain is," or "Show me

where your teddy hurts.")

• Severity: Ask child to rate pain, using a pain intensity scale that is appropriate

for child's age, developmental level, and comprehension. Consistently use the

same pain intensity tool with the same child.

• Timing: Using developmentally appropriate vocabulary, ask child (and family) if

pain is constant, intermittent, continuous, or a combination. Also ask if pain

increases during specific times of the day, with particular activities, or in specific

locations.

• How is the pain affecting you (U) in regard to activities of daily living (ADLs),

play, school, relationships, and enjoyment of life?

Goal of Pain Rating Scale

Identify characteristics of pain

Establish a baseline assessment

Evaluate pain status

Effects of intervention

Assessment in Neonates & Infants

• Challenging

• Combines physiologic and behavioral parameters

• Many scales available

– NIPS (Neonatal Infant Pain Scale)

– FLACC scale (Face, Legs, Activity, Cry ,Consolability)

CRIES scale

FLACC scale

Neonatal Infant Pain Scale (NIPS)

Children between 3-8 years

• Usually have a word for pain

• Can articulate more detail about the presence and location of pain; less able to comment on quality or intensity

• Examples:– Color scales

– Faces scales

Children older than 8 years

• Use the standard visual analog scale

• Same used in adults

Children with Cognitive Impairment

• Often unable to describe pain

• Altered nervous system and experience pain differently

• Use behavioral observation scales

– e.g. FLACC

• Can apply to intubated patients

4: Patient & Parental Involvement

• Parent– Excellent sources of information on child

– Learn techniques to help coach through pain

– Reduces anxiety

• Patient– Age & developmentally appropriate

– Gives them control in their pain experience

– Learn techniques to help with pain control

– Reduces anxiety

Multi-modal Approach

• Pharmacological therapy

• Interventional therapy

• Non pharmacological therapy

Non-pharmacologic Therapy

• Physical

– Massage

– Heat and cold

– Acupuncture

• Behavioral

– Relaxation

– Art and play therapy

– Biofeedback

• Cognitive

– Distraction

– Imagery and Hypnosis

World Health Organization (WHO)

Principles of

Pediatric Acute Pain Management

• By the clock

• With the child

• By the appropriate route

• WHO Ladder of Pain Management

By the Clock

• Regular scheduling ensures a steady blood level

• Reduces the peaks and troughs of PRN dosing

• PRN = as little as possible???

With the Child

Analgesic treatment should be

individualized according to:

• The child’s pain

• Response to treatment

• Frequent reassessment

• Modification of plan as required

Correct Route

Oral

Nebulized

Buccal

Transdermal

Sublingual

Intranasal

IM

IV / SC

Rectal

Pharmacological intervention

Non-opioid Analgesics

• Mild to moderate pain

• No effects of respiratory depression

• Highly effective when combined with opioids

• Acetaminophen

• NSAIDs

• COX-2 inhibitors

• Aspirin

– No longer used in pediatrics

Acetaminophen

• Antipyretic

• Mild analgesic

• Administer PO or PR

• Pediatric Oral dose 10-15 mg/kg/dose every 4 hr

– Infant dose is 10-15 mg/kg/dose every 6-8 hr

• Onset 30 minutes

Acetaminophen

• Per rectum dose

• 35-50mg/kg once followed by 20 mg/kg/dose every 6 hours– Uptake is delayed and variable

– Peak absorption is 60-120 minutes

– Unreliable to cut suppositories

• Maximum daily dosing– <2yrs : 60-75 mg/kg/day

– >2yrs kg : 90-100 mg/kg/day

Side Effects of Acetaminophen

• Generally a good safety profile

– Do not use in hepatic failure

• Causes hepatic failure in overdose

– Infant drops are MORE concentrated than the

children’s suspension

• Infant’s Acetaminophen 80 mg/0.8 mL

• Children’s Acetaminophen 160 mg/5 mL

NSAIDs

• Antipyretic

• Analgesic for mild to moderate pain

• Anti-inflammatory

– COX inhibitor Prostaglandin inhibitor

• Platelet aggregation inhibitor

NSAIDs: Ibuprofen

• Dose 5-10 mg/kg/dose every 6 hours

– Adult dose 400-600 mg/dose every 6 hours

• Onset 30-45 minutes

• Maximum daily dosing

– <60 kg: 40 mg/kg

– >60 kg: 2400 mg

• May use higher doses in rheumatologic disease

NSAIDs: Ketorolac

• Intravenous NSAID (also available P.O.)

• Dose every 6 hours

• < 2 years: 0.25 mg/kg i.v.

• > 2 years: 0.5 mg/kg i.v., max. 30mg, max of 5 days)

• Onset 10 minutes

• Maximum I.V. dose 30 mg every 6 hours

• Monitor renal function

• Do not use more than 5 days– Significant increase in side effects after 5 days

Side Effects of NSAIDs

• Gastritis

– Prolonged use increases risk of GI bleed

– Still rare in pediatric patients compared to adults

– NSAID use contraindicated in ulcer disease

• Nephropathy (ATN)

• Bleeding from platelet anti-aggregation

– Increased risk versus benefit post-tonsillectomy

– NSAID use contraindicated in active bleeding

• Delayed bone healing?

COX-2 inhibitors

• Selectively inhibits Cyclooxygenase-2 which reduces risk of gastric irritation and bleeding

• Same risk for nephropathy as non-selective COX inhibitors

• Shown to have increased cardiovascular events in adults

• More studies needed in pediatric patients

– COX-2 inhibitors used in rheumatologic diseases

Opioids

• Codeine

• Oxycodone

• Morphine

• Fentanyl

• Hydromorphone

• Methadone

Opioids Analgesics

• Moderate to severe pain

• Various routes of administration

• Different pharmacokinetics for different age

groups

– Infants younger than 3 months have increased risk of

hypoventilation and respiratory depression

• Low risk of addiction among children

Codeine

• Oral analgesic (also anti-tussive)

• Weak opioid

– Used often in conjunction with acetaminophen to increase analgesic effect

• Metabolized in the liver and demethylated to morphine

– Some patients ineffectively convert codeine to morphine so no analgesia is achieved

• Dose 0.5-1 mg/kg every 4-6 hours

Oxycodone

• Oral analgesic

• Mild to moderate pain

• Hepatic metabolism to noroxycodone and oxymorphone

• Can be given alone or in combination with acetaminophen

• Dose 0.05-0.15 mg/kg every 4-6 hours

• Maximum 5-10 mg every 4-6 hours

Morphine• Available orally, sublingually, subcutaneously, intravenous, rectally,

intrathecally

• Moderate to severe pain

• Hepatic conversion with renally excreted metabolites

– Use in caution with renal failure

• Duration of I.V. analgesia 2-4 hours

– Oral form comes in an immediate and sustained release

• Dose dependent on formulation

• I.V. Dose 0.05-0.2 mg/kg/dose every 2-4 hours

• Onset 5-10 minutes

• Side effect of significant histamine release

Fentanyl

• Available intravenous, buccal tab, lozenge and transdermal

patch

• Severe pain

• Rapid onset, brief duration of action

– With continuous infusion, longer duration of action

• I.V. Dose 1 mcg/kg/dose every 30-60 minutes

• Side effect of rapid administration may produce glottic and

chest wall rigidity

• Careful observation, CRM and immediate availability of airway

equipment

Ketamine

Analgesic dose : 0.1-0.5mg/kginfusion - 4µg/kg/min

Patient/Parent Controlled Analgesia (PCA)

• Programmable pump that allows patient control of

intravenous analgesia

• Patient can choose when to deliver a dose of opioid and

achieve relief quickly

• Inherent safety in the PCA: patient will fall asleep when

over sedated and is unlikely to administer too much

drug

• Teaching is integral and essential

PCA

• Useful for sickle cell vaso-occlusive episodes,

postoperative pain, cancer pain, palliative care

• Take patient’s age, maturity, and medical condition into

the decision

PCA• Loading dose if patient is in pain so that there is a therapeutic serum level to start

• Basal infusion rate can deliver continuous background dose of opioid to maintain

therapeutic level

• Patient demand dose is the dose administered with each patient activation of the

pump (usually small)

• Lockout interval (5-10 min) prevents a second PCA dose before the previous bolus

has taken effect (important to prevent overdosing)

• Maximum hourly limit can be set based on the average hourly use of morphine

• Sedation and vital sign assessment is mandatory

Naloxone

• Opioid antagonist

• 1 ampule = 0.4 mg/mL

• Use when unresponsive to physical stimulation, shallow respirations

(<8 breaths/min), pinpoint pupils

• Stop Opioid

– For <40 kgs: Naloxone ¼ ampule with NS 9 mL = 10 mcg/mL

• Administer slowly and observe response

– 1-2 mcg/kg/min

• Discontinue naloxone as soon as patient responds

• Duration 30-45 minutes

– Monitor the patient; repeat doses may be needed

Local Anesthetics

• For IV cannulation, suturing, lumbar puncture, etc.

• Topical or infiltration

• Acts by blocking nerve conduction at Na-channels

• If administered in excessive doses, can cause systemic effects

– CNS effects of perioral numbness, dizziness, muscular twitching, seizures &

cardiac toxicity

– Aspirate back before injecting to avoid direct injection into blood vessels

– Calculate maximum mg/kg dose to avoid overdose

Anesthesia

• Regional

– Blocks afferent pathways to CNS

– Good for post-operative pain relief

– Epidural and caudal anesthesia

– Peripheral nerve blocks

• General

Caudal anaesthesia The armitage regime:

• O.5 ml/kg- all sacral dermatomes blocked

• 1 ml/kg- sacral and lumbar dermatomes blocked

• 1.25 ml/kg- upto midthoracic levels blocked

Bupivacaine in Concentration Dose Possible additives

Single dose caudal

0.175%- 0.5% 0.75- 1.25 ml/kg (max. 3 ml/kg)

Epinephrine 2.5- 5 µg/kgClonidine 1- 2 µg/kgMorphine 30- 70 µg/kg

Continuous caudal

0.1%- 0.25% 0.4 ml/kg Fentanyl 2- 5 µg/kg

Epidural Block

• Epidural space more superficial in children than

adults

• Guideline for determining epidural depth:

– 1mm/kg of body weight

– Depth (cm) = 1 + 0.15 X age (years)

– Depth (cm) = 0.8 + 0.05 X weight (kg)

• Use shorter needles and extreme care

Epidural Block

• Dosing:

– Depends on upper level of analgesia required

– > 10 years of age:

• Volume to block one spinal segment

– V (in ml) = 1/10 X (age in years)

– < 10 years old:

• 0.04ml/kg/segment

Maximum dosage

Sucrose for Infants

• Sucrose 24% oral solution

• Can be used for procedures such as heel stick,

venipuncture, catheterization, etc.

• Effective analgesic in preterm and term infants

– Not effective beyond 3 months old

• Dip pacifier in sucrose solution or give 0.2 mL to buccal

area

– May repeat but be cautious with many doses to younger infants

• Anesthesiologists are like no other physicians: we are experts at controlling the

airway and at emergency resuscitation;

• we are real-time cardio pulmonologists achieving hemodynamic and

respiratory stability for the anesthetized patient;

• we are pharmacologists and physiologists, calculating appropriate doses

and desired responses;

• we are gurus of postoperative care and patient safety;

• we are internists performing perianesthetic medical evaluations;

• we are the pain experts across all medical disciplines and apply specialized

techniques in pain clinics and labor wards;

• we manage the severely sick and injured in critical care units;

• we are neurologists, selectively blocking sympathetic, sensory, or motor functions

with our regional techniques

THANK YOU