Download Pain Assessment and Management for Children

Pediatric Pain Management:
Meeting the Challenges
Linda Oakes RN MSN C CCNS
Pain Clinical Nurse Specialist
St Jude Children’s Research Hospital
November 2006
Greetings from St Jude Children’s Research
Hospital: Memphis, Tennessee
To advocate for a patient in regards
to pain is to……
• Believe the basic assumptions about pain
assessment and management
• Know how to assess pain including
awareness of the challenges
• Demonstrate how to ask for what the patient
needs, provide it safely including teaching
the patient and family
Being A Pain Advocate
• Topic of pain  values within yourself and
your co-workers
• Even if you are clear about how to manage
pain, your patients, families, and colleagues
will not always have the same perceptions
• Pain management is saturated with:
– Misinformation
– Misled intentions (“quick fixes”)
Pain
• An unpleasant sensory and emotional
experience associated with actual or
potential tissue damage, or described in
terms of such damage
• International Association of Pain
(1979)
Pain Assessment
• Whatever the experiencing person
says it is, existing whenever the
person says it does
» McCaffery (1968, 1999)
Assumptions
• All persons with pain deserve prompt
recognition and treatment
• Pain should be routinely monitored,
assessed, reassessed, and documented
clearly to facilitate treatment and
communication among health care
clinicians
• Nurses are well positioned as patient
advocates to something about the pain
– Independent interventions
– Interdependent interventions
Ingredients to be Advocate
• Recognition of pain
• Courage to be present
• Ability to “do battle” using the absolute best
of their interpersonal skills
• Empathy more than a judgmental attitude
• Willingness to become educated about pain
management
American Society of Pain Management Nursing (ASPMN), 2002
What are the Challenges?
• What is the right method?
• How do we factor in the additional challenges of
caring for:
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Different developmental stages?
Individuality of pain expression: verbal and nonverbal?
Different types of pain?
Different cultures?
• How do we use the pain assessment information?
• Should assessment be the same for acute and
chronic pain?
Do patients experience pain,
including infants and children?
• By 24 weeks gestation the pain pathways
are able to provide sensory input regarding
pain
• First encounter with pain is the vitamin K
injection ongoing pain experiences
throughout life
– Pain is usually helpful serving as a warning
Pain Literature
• Wolfe et al, 2000, NEJM
– 90% of children dying of cancer
experience pain or other symptoms
– Less than 40% had pain relief before they
died
– Dying children exposed to multiple
painful procedures/therapies even as they
are dying
– Interviewed parents of children who died
between 1990-1997 in credible
teaching/children’s hospital
Advocacy in Assessment
• Patient is the authority on his pain
– Accept the report
– Take appropriate action (avoiding an
adversarial relationship)
• Recognize that pain thresholds and levels of
thresholds are variable
• Patients will creatively adapt to pain in order to
cope with its intensity and interference with
function
• Avoid “expected responses” for interventions
Assessment: What is Known?
• Children experience the pain as adults…if it is painful for
adult, it is painful for child
• Children are at risk for under treatment of pain because
they do not have verbal skills to report pain  pain may
be overlooked
• Children may fear reporting pain
– Results in an injection
– Have to stay in hospital longer
– May be reluctant to complain (“disappoint their
parents”)
• Discrepancies in surrogate ratings of pain
Zisk, 2003
Developmental Aspects of Pain
Expression
• Infant: intense cry, unable to sleep or eat
• Toddler: verbal or physical aggression or
withdrawal, guarding the site or pain
• Preschooler: can verbalize but much “magical
thinking”, see pain as punishment
• School-age: can verbalize but very influenced
by cultural behaviors associated with pain
• Adolescent: can verbalize but may choose to be
“tough” in front of peers; regression
Why treat pain?
• Health care providers value providing comfort
“as the right thing to do”
• Barriers:
• Lack of education about pain medication
– Need handy resources for
» Dosing
» Treatment of side effects
• Lack of understanding that a person may not
“look like” he is in pain
• Misunderstanding of risks of use of opioids
Fear of addiction
Fear of respiratory depression
Today…..the Reality is Our Patients’
Pain is often….
• Untreated
• Under-treated
• Inappropriately
Treated
Assessment of Pain
Needs to be comprehensive, more than a Pain Intensity
Scale
– Intensity: asking from 0-10 to rate amount of pain
– Location of the pain
– Type of pain: describe the pain in terms of adjectives such as
“burning”, “cramping”
– Duration: when did it start? Patterns?
– What makes pain better? Worse?
– Previous/current medications
– How is the pain interfering with
• Normal activities (play, school, being with friends, eating, sleep)
• Not adequate to just assess current pain levels…..need to ask about
what happens which children are active
Self-Report of Pain
• The single most reliable indicator, using a valid
and reliable scale when possible
• Select an age-appropriate scale
• Ask in trusting environment
– Assumption is that the number the child reports will be
believed by the health care provider
Numerical Pain Scale (NRS)
• Ask the patient (usually > age 12 years to
rate their pain from 0 to 10
• Requires the understanding that increasing
ordinal numbers mean pain at a higher
intensity
Faces Pain Scale
Useful for children age 5-12 years
Some children 3-5 years of age can use it
Need to ask in terms of the “worst pain you can think of”
Wong, 2001
How can pain intensity be assessed in
children who cannot self-report?
• Random observation of factors may not indicate pain
• Needed are research-based indicators of pain based
on developmental stage
• Observational pain scales can facilitate the
quantification and evaluation of pain behaviors for
clinical decision making
– Do such scales only tell us whether pain is present or not?
Pain Behaviors
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Noisy breathing
Negative vocalizations
Lack of facial expression
Sad facial expression
Frightened facial expression
Lack of relaxed body relaxation
Tense body language
Fidgeting
Pain Assessment
• Under age 5 years or the patient cannot self
report: need a behavioral scale
• How a person expresses pain (pain behaviors)
FLACC
(Merkel, 1997)
Warning about Behavioral Pain
Assessment Methods
• No way we can accurately know how persons are
feeling if they can not speak or report their pain
level themselves
• Clinicians then must use
– Research-based behaviorally-based pain scales
• But also must include
– Critical thinking (“Does what I see make sense for this
patient?”)
– Input of family members
– Rational decision making (“trial of analgesic to see if
behaviors of child improve”
Assume Pain Present (APP)
• What if the child cannot self-report or display
pain behaviors, yet has reason to be feeling
pain? Too ill or paralyzed
• Implication: have patient on pain medications
– Opioid infusion
• Titrate with clinical signs of pain and vital
signs
• Use for any age when only pathology or
potentially painful procedure and patient
cannot self-report or move to indicate pain
Credit to Margo McCaffery
Challenges in Assessment:
The Gap
• Development of tools for preterm and term
neonates with ongoing or chronic pain
• Exposure to prolonged or severe pain may
increase neonatal morbidity; long term
effects of neonatal pain
– Longitudinal studies involving infants < 1000
grams at 10 years of age
AAP, 2000
What is Pain Assessment?
• It is NOT just a pain score.
• A Pain Intensity Score is just a screening
– Tells you whether the patient is having pain or
not
– Tells you whether further evaluation needs to
be done if the patient is in pain
• Assumption is that you will ask the patient
if he is pain and, if so, believe the patient
• Severe pain: scales may oversimplify the
amount of pain the person is feeling
Assessment of Pain
Needs to be comprehensive
– Location of the pain
– Type of pain: describe the pain in terms of adjectives
such as “burning”, “cramping”
– Duration: when did it start? Patterns?
– What makes pain better? Worse?
– Previous/current medications
– How is the pain interfering with
• Normal activities (play, school, being with friends, eating,
sleep)
• Not adequate to just assess current pain levels…..need to
ask about what happens which children are active
When to offer an intervention?
• Assumed that acute pain, threshold for
treatment is at least “moderate” level
– None, mild, moderate, severe
• “What is moderate?”
– Is it > 3/10?
• What is severe?
– Is it  5,  6, or  7/10?
• Should it be individualized such as a “pain
goal”? What is an “acceptable pain level?”
Cheng et al, 2003
What is a Meaningful Response
to an Intervention?
• What is tolerable? Is it 3/10?
• What is pain relief? < 5/10, 50% reduction
with an intervention? How to balance with
the side effects of interventions? Cost of
interventions?
• What makes an analgesic effective?
Approach to Acute & Chronic Pain
Complex Problem
Physiological
Factors
Psychological
Factors
Social Factors
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MDs
RNs
Psychologists
Pharmacists
Physical therapists
Social workers
Chaplains
Art/music therapists
Child Life Specialists
Goals of Pain Management
• Provide maximum pain relief with minimal side
effects and maximal function
• How?
– Identify the cause(s) of the pain
– Prevent pain (preemptive strategies)
– Treat the pain: NOT JUST BY DRUGS
• Provide the simplest method of analgesic
delivery
• If drugs, minimize the side effects
Savvy Pain Management
• How do we ask for what the patient needs?
• Know the pharmacological options including a
guideline for dosages
– Regimen needs to be
• Least invasive
• Within capability of the child/family
• Consider costs of plan
• Know the nonpharmacological options to “make
the pain medications work better”
• Have the data available to communicate to the
prescribing clinician
Make immediately
accessible to
bedside caregivers
•Pocket cards
•Wall charts
Need to know how
to calculate the dose
which is usually
referenced in mg or
mcg/kg
Not guesswork!!!!!!!!!!!!!!!!!!!!!!!!
Free at www.nccn.org
www.nccn.org
Position Statements
• ASPMN
– Neonatal Circumcision Pain
Relief
– Pain Management at the End of
Life
– Use of Placeboes in Pain
Management
– Authorized Agent use of
Analgesic Pumps
– Pain Assessment in the Nonverbal Patient
Non-steroidal
Anti-inflammatory Drugs (NSAIDS)
• Ibuprofen (Motrin®)
• Naproxen (Naprosyn®)
• IV Toradol (Ketoralac®)
• Advantages:
• Effective anti-inflammatory
and treatment for bone pain
• Avoid side effects of opioids
• Disadvantages:
• Inhibit platelet function
• Renal and
gastrointestinal toxicity
Acetaminophen
• Advantages:
• Does not interfere
with platelet function
• No gastrointestinal
toxicity
• No renal toxicity
• Readily available
• Inexpensive
• Disadvantages:
• Weak anti-inflammatory
• Liver toxicity
• Dose: 15 mg/kg PO q4h
with max of 4000
mg/day
Opioids: Mainstay of Treatment
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Morphine: PO, IV
Oxycodone: PO
Hydromorphone (Dilaudid®): PO and IV
Fentanyl: IV and transdermal
Codeine: PO
• Do not give meperidine (Demerol®) in
repeated doses: has metabolite that is
neurotoxic
Opioid Doses for Infants
• Because of immature responses to hypoxia
and hypercarbia and
• Longer elimination half-life and slower
clearance rates
• Doses for infants < 6 months of age of
opioids should be reduced by 20-50% on a
per kilogram basis relative to dosing older
children
Methods
of Opioid Administration
• Oral: preferred
– Long-acting for continuous pain
– Short-acting/immediate release for intermittent
pain or breakthrough pain while on continuous
• Intramuscular: not recommended
• Intravenous:
– Intermittent scheduled or continuous infusion
(basal) for continuous pain
– PRN doses only for intermittent pain
– Patient controlled analgesia (PCA)
Long-acting Opioids
Opioid/route
SR Preparation
Dose frequency
Morphine/PO
Oramorph®
Every 12 hrs
Kadian®
Every 12 or 24 hrs
MS Contin®
Every 12 hrs
Oxycodone/PO Oxycontin®
Every 12 hrs
Fentanyl/transd Duragesic®
ermal
patches
Every 72 hrs
Equianalgesic Doses
Drug
Morphine
Equianalgesic Dose (in mg)
IV
Oral
10
30
Hydromorphone
1.5
7.5
0.1-0.2
Not available
Not available
15-30
Fentanyl
Oxycodone
Use of Opioids
• Dosages in guidelines are given as starting doses
(for opioid naïve)
– in mg (or mcg)/kg
• All other dosing is “Titration, titration, titration”
• No maximum dose for any opioid
• Always want to benefit the patient (effective
analgesia) with the least amount of risk (minimize
opioid side effects)
Opioid Doses To Relieve Suffering:
Boston Children’s
• Retrospective review of 12 patients who required high
dosages of opioids during terminal care
– found that ranges from 3.8 to 518 mg/kg/hr of morphine (or
equivalent) were needed
• Conclusions: standard dosing of opioids adequately
treats most cancer pain in children; however, a
significant group requires more extensive management.
– Seen more often in solid tumors metastatic to spine
and major nerves
» Collins, J Pediatri, 1995
Addiction
• A pattern of compulsive drug use
characterized by a continued craving for a
drug and the need to use it for effects other
than relief of symptoms such as pain
Physiological Dependence
• The patient has developed a physical need
for the drug such that rapid withdrawal will
manifest as a specific set of symptoms
– yawning, tearing and rhinorrhea
– sweating, restlessness and irritability
– tremors, dilated pupils
• May progress to:
– nausea, vomiting and, diarrhea
– chills, muscle spasm and increased irritability
Side Effects of Opioids
• Constipation
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Senna or bisacodyl
Docusate (only stool softener)
Magnesium citrate
Lactulose
Miralax® (polyethalene glycol)
• Pruritus: use an alternative opioids
– Diphenhydramine (Benedryl): 0.5-1 mg/kg
Weaning of opioids
• Calculate the total amount of opioid
received 24 hours
• Reduce this amount by 20% the first
day
• Wean subsequent doses by 10% per
day as tolerated
Neuropathic Pain Medications
• Anti-convulsants: Gabapentin (Neurontin®)
– 5 mg/kg or 100 mg TID up to 70 mg/kg/day or 1200 mg
TID
• Tri-cyclic Anti-depressants (TCAs) : Amitriptyline
(Elavil®)
– 0.1 mg/kg PO or 25 mg at bedtime increased to 1 mg/kg
bedtime
• Need to teach patients
– To give as directed (not PRN and not to skip doses)
– Treatment may not be effective for several days
– May need to increase dose before effective
• Opioids may help especially the first few days of
treatment
What about Chronic Pain?
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Really is persistent pain
“a sensory,emotion, and cognitive experience…”
Cannot always promise “No Pain”
Need to achieve the level of pain that is needed to
be able to conduct activities with the least amount
of side effects from the analgesics or other
interventions
• Defined as a “pain goal”
Slatkin, City of Hope
Pain Goal
• Pain Goal: what number do you need to have as a
maximum before the pain interferes with:
– Sleep
– Normal activities for developmental age and limitations
of illness
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Going to school
Playing
Sleeping
Eating
What if the patient needs more
that what is ordered?
• Know the pain score and
other assessment data
• Know the current
analgesic dosages
• Know the overall medical
condition of the patient
including rehabilitation
and discharge plan
• Morphine 10 mg PO q 3
hours PRN
• Took dose at 0830,
asking for dose at 1030
• Yesterday used 6 doses
• Could a sustained-release
preparation be used?
Advocacy = Planning
• Patient is using IV
morphine 3 mg every
3 hours
• Discussion of the
patient going home
tomorrow needing
months of
rehabilitation for
extensive surgery
• Need to know 6 doses of
morphine IV (18 mg) = 54
mg PO
• Should Oramorph 15 mg PO
BID be started the day
before?
• Teach the family to know
how to dose for
breakthrough pain
(morphine 10 mg PO q 2
hours PRN)
Case Study
• 6 year old (15 kg) patient who had
extensive orthopedic surgery
• Day of surgery: needs morphine IV
available on scheduled basis
– Recommendation is 0.1 mg/kg every 2-4 hours
• Day following surgery
– Pain scores < 3/10 with 10 doses of 1.5 mg
morphine IV
– Consider morphine infusion of 1 mg/hr with
careful reassessment
Case Study
• Also complains of “burning pain” in leg
• Consider gabapentin 100 mg every 8 hours
• To plan for discharge: convert to oral
morphine tablets using 1 mg of IV
morphine = 3 mg oral morphine
• Patient’s infusion = 24 mg plus the patient
had additional doses of 1.5 mg for dressing
change and physical therapy (total of 6 mg)
– Total of 30 mg IV = 90 mg oral
Case Study
• Then gradually reduce the opioid but still
control the pain “around-the-clock”
• Use long-acting morphine:
– 30 mg every 12 hours
– With immediate-release doses of 5-10 mg every
2 hours as needed
– Continue gabapentin and increase to 200 mg
every 8 hours if neuropathic pain is still present
• Return to outpatient clinic
– Evaluate doses of immediate-release morphine
Case Study
• As patient takes less immediate-release
morphine, reduce the long-acting to 15 mg
every 12 hours and then discontinue
• Patient may need immediate-release and
gabapentin for weeks, especially for
physical therapy
• Require parent to write down doses on
“pain diary” to monitor use of all analgesics
Children are the living
messages we send to a time we
will not see.
John W Whitehead, The Stealing of
America, 1983
References 1
• Anghelescu D & Oakes L: Working toward better cancer
pain management for children, Canc Prac 10(supp ):
S52-S57, 2002
• Anghelescu, D, Oakes, L, Popenhagen, M: Management
of pain due to cancer in neonates, children, and
adolescents. In: de Leon-Casasola OA, ed. Cancer Pain:
Pharmacologic, Interventional, and Palliative Care
Approaches, Philadelphia, Elsevier Science, 2006
• Collins JJ et al: Control of severe pain in children with
terminal malignancy, J Pediatr 126: 4, 653, 1995
• Collins JJ et al: Management of pain in childhood
cancer. In Schecter NL et al: Pain in Infants, Children,
and Adolescents, 2nd ed, 2003, 517-538
References 2
• International Association for the Study of Pain,
Subcommittee on Taxonomy: Pain terms: a list
with definitions and notes on usage, Pain 6: 249252, 1979
• McCaffery M et al: Pain management: problems
and progress. In McCaffery M & Pasero C, eds:
Pain: Clinical Manual, 2nd ed, Mosby, 1999
• Merkel et al: The FLACC: a behavioral scale for
scoring postoperative pain in young children,
Pediatr Nurs 23: 293-297, 1997
References 3
• Wolfe J et al: Symptoms and suffering at the
end of life in children with cancer. N Engl J
Med 342: 326-333, 2000
• Wong DL et al. Essentials of Pediatric Nursing,
6th ed, 2001
• World Health Organization: Cancer Pain Relief
and Palliative Care in Children, 1998 (to order
internationally, email to [email protected])