Slide 1

Mohanad Shukry, MD Associate Professor in Anesthesiology Director, Pediatric Pain Management Service The Childrens Hospital 1 Slide 2 Objectives Name pain assessment tools Choose the appropriate pain assessment tool Appropriately reassess pain scores Discuss new advancements from the past 5 years in Pediatric Pain Management 2 Slide 3 3 Slide 4 2009 JCAHO Standards for Pain The organization respects the patient's right to pain management. "The organization plans, supports, and coordinates activities and resources to ensure that pain is recognized and addressed appropriately and in accordance with the care, treatment, and services provided including the following: Assessing for pain, Educating all relevant providers about assessing and managing pain, Educating patients and families, when appropriate, about their role in managing pain and the potential limitations and side effects of pain treatments." Chapter: Rights and Responsibilities of the Individual patient: Standard #8 4 Slide 5 Assessment of Pain Optimal pain management begins with accurate and thorough pain assessment Pain assessment should be carried out at regular intervals Disease process and influencing factors change Permits measurement of the efficacy of different treatments Pain assessment process includes child, caregiver, and health-care providers 5 Slide 6 Effective Pain Management Requirements Pain intensity/relief is assessed/reassessed Preferences respected Children cannot/will not report pain High suspicion Evaluate effectiveness of pain assessment 6 Slide 7 Pain Assessment Detailed medical history: Previous pain experiences Previous analgesia Treatment Current pain experience Non-verbal language Developmental level Activity level (sleep, play, feed) Physical examination 7 Slide 8 8 Slide 9 Expression of Pain Depends on: Age Cognitive development Sociocultural context Sedatives or hypnotics may blunt behaviors Physiological measures such as heart rate and blood pressure are neither sensitive nor specific 9 Slide 10 Behavioral Indicators of Pain Facial expression Body movement Body posture Inability to be consoled Crying Groaning 10 Slide 11 Criteria for Pain Assessment Tool Appropriate for age, developmental level, and sociocultural context Easy to understand and explain Process of scoring is easy, short, and quick The data obtained is recordable and easy to interpret Readily available and inexpensive Require minimal material or equipment Easy to carry Evidence based 11 Slide 12 Effective Pain Management Principles Negative physical and psychological if untreated Need aggressive pain prevention and control Prevention is better than treatment Established pain difficult to control Positive relationship between HCP Information welcome to discuss preferences Actively involved both children and families May not eliminate all pain Reduction to acceptable levels 12 Slide 13 Neonates as young as 24- weeks feel pain Ascending nerve tracts develop earlier than the pain inhibiting nerve tracts Neonates exposed to repeated painful stimuli show increasing sensitivity No understanding of pain and unable to self report Neonatal/Infant Pain Scale (NIPS) Birth-2 Years 13 Slide 14 NIPS 14 Slide 15 2 - 4 years CNS fully developed Development of autonomy continues Significant language development Limited logic and reasoning Three levels of pain expression (little, some, a lot) Visual analog (Wong-Baker Faces) 15 Slide 16 FLACC Scale 16 Slide 17 Faces Pain Scale Wong, 2001 17 Slide 18 18 Slide 19 19 Slide 20 7 - 11 Years Logic and reasoning far more developed Imagination and creativity Finalism and concept of death Number pain scale (scale 1-10) 20 Slide 21 Adolescents (11+ years) Cognitively adults Same pain assessment methods as adults Abstract thinking and understanding hypo Situations Emotional needs Include them in the process Respect their privacy Respect their pain reports 21 Slide 22 Numeric & Visual Scale 22 Slide 23 The Word-Graphic Rating Scale Point the finger where there is no pain and run your finger to the worst possible pain! USA DHHS 23 Slide 24 Pediatric Pain Assessment Tools Neonatal Infant Pain Score (NIPS) FLACC Scale (< 5 years old) FACES Pain Scale (5-13 years old) Verbal rating (older than 13 years old) Numeric scale Visual analogue scale 24 Slide 25 Pain Assessment Hospitals should use a standard pain scale for various age groups to allow continuity Self report scores (e.g. numerical rating scale) can be misleading Pain can be worsened by anxiety, depression, spiritual crisis 25 Slide 26 26 Slide 27 Top 5 1. Release of the 2012 WHO pediatric pain guidelines; particularly the removal of codeine from the step ladder 2. FDA approval and availability of IV Acetaminophen 3. Methadone to manage chronic and complex pain 4. Topical anesthetics prior to painful procedures 5. Comfort measures 27 Slide 28 Removal of Codeine from the Step Ladder Codeine is a weak opioid previously recommended for moderate pain Codeine is converted into active metabolite morphine Poor metabolizers = poor pain control Over metabolizers = increased risk for over sedation and respiratory depression One of the most constipating opioids 28 Slide 29 FDA Approval & Availability of IV Acetaminophen Approved in November 2010 for management of mild to moderate pain, moderate to severe pain with adjuvants, and reduction of fever Approved in patients 2 years and older Helpful because sometimes PO, RC routes are not an option IV route has faster onset time (~15mins) Infuses over 15 minutes 29 Slide 30 Methadone to Manage Chronic & Complex Pain Rediscovered to treat moderate to severe non cancer and persisting pain 1940s first synthesized as an analgesic 1960s used for treatment of opioid addicted patients Dosage needs to be titrated clinically and patient monitored closely Prescribed for pediatric patients who have inadequate responses or contraindications to first line opioids 30 Slide 31 Methadone to Manage Chronic & Complex Pain Potent analgesic properties Good oral bioavailability Long duration of action Low cost 31 Slide 32 Topical Anesthetics Prior to Painful Procedures J-Tip Maxilene Pain Ease Buzzy 32 Slide 33 Comfort Measures Great way to get multi-disciplinary team involved Call Child Life Specialist Positions of Comfort for painful procedures Allowing parent/caregiver to stay with child during a painful procedures with an active role in distraction and positioning 33 Slide 34 Thank you! 34 Slide 35 References Bieri D, Reeve RA, Champion GD, Addicoat L, Ziegler JB. Faces Pain Scale for the self-assessment of the severity pain experienced by children: development, initial valid and preliminary investigation for ratio scale properties. 1990; 41 (2): 139-50. Friedrichsdorf SJ, Kang TI. The management of pain in children with life-limiting illnesses. Pediatric clinics of North American. 2007;54: 645-672. Tomlinson D, Baeyer CL, Stinson JN, Sung LA system review of Faces scales for the self-report of pain intensity in children. Pediatrics. 2010; 126:e1168. 35