Download Pediatric Grand Rounds: Pain Management in the Pediatric

Pain Management in the
Pediatric Emergency Department
Veronica Carullo, MD
Chief, Pediatric Pain Management Service
Cohen Children’s Medical Center
March 16, 2011
Disclosures
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I have no financial relationships or
affiliations to disclose.
I do not intend to discuss any off-label
or investigational use of drugs or
products in my presentation.
Objectives
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Overview of pain in children
Pediatric pain assessment
Pharmacologic and nonpharmacologic
approaches to pain management in the
ED
• Injuries
• Procedural pain
Background
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Historically, children and infants received
less post-operative and procedural analgesia
than adults
Well documented that children are often
undertreated for pain
•
Kids were half as likely as adults to receive pain
medications in the ED for painful conditions (i.e.
fractures, burns, sickle cell pain crises)
• 30% kids vs. 60% adults got pain meds
Selbst & Clark, Ann Emerg Med, 1990
What distinguishes pain in childhood
from adult pain?
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IASP: “An unpleasant sensory or emotional experience
associated with actual or potential tissue damage, or
described in terms of such damage.”
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The inability to communicate pain verbally in no way negates the
possibility that an individual is experiencing pain and in need of
treatment.
In pediatrics, pain is an “inherent quality of life that
appears early in development and serves as a signaling
system for tissue damage.”
Pain may be modulated by developmental stage, affective
state, cognitive state, prior pain experiences, distress or
suffering.
Cassell. NEJM 306:639,1994
Anand KJS and Craig KD Pain 67: 3, 1996
Barriers to Pediatric Pain Control
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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
Pediatrics, 18 (3) 2001
Jeffrey Lawson, 1985
Landmark seminar paper
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Pain and its effects in the human
neonate and fetus, 1987, NEJM.
Anand & Hickey.
• Called into question the widely held belief that
neonates do not have the neurophysiologic
apparatus required to experience pain
Developmental Anatomy of Pain
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Cutaneous nociception: sensory
terminals are present in the perioral area
at 7 wks GA, with spread to all body areas
by 20 wks GA
Dorsal horn: A fibers enter the spinal
cord prior to C fibers at 8-12 wks; A and C
fiber territories overlap at birth in the
developing substantia gelatinosa
Developmental Anatomy of Pain
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Ascending pain pathways: completely
myelinated in the spine and brainstem
between 22 and 30 wks GA; myelination
extends to thalamus at 30 wks; to cortex at
37 wks-term
Descending inhibition: develops post term
• Pain sensitivity may be more profound  Nervous system less
effective at blocking painful stimuli
Pain in children is still undertreated
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By health care professionals
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By parents
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Fear of adverse effects - inadequate knowledge of drug
dosing and safety across the spectrum of ages
Legal concerns about diversion or abuse
Inadequate assessment and patient disbelief
Costs and availability of medication
Lack of adequate instruction by health care
professionals
Fear of addiction and tolerance
By patients themselves
•
“Suffer in silence”
Pediatric Pain Assessment
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Pain assessment = the crucial first step in
managing pain
Pain is multidimensional
• Includes sensory, affective, cognitive,
behavioral, sociocultural, and physiologic
dimensions
• Interactions of above components explain
variations that exist in patients’ response to pain
and perception of pain
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Frequent reassessment just as important
Pain Scoring Tools
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Health care providers need to use ageappropriate validated pain scoring tools
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Child self-report = gold standard
• Must use an age-appropriate, reliable, and valid pain
tool
Infant or young child
• May be assessed with behavioral pain tools coupled
with a parent report
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The lower age limit for successful use of a selfreport pain scale is generally 3-4 years old
(Hicks et al., 2001; Wong & Baker, 1988)
Physiologic measures
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Provide information about general
distress levels but are not sensitive or
specific indicators of a child’s pain
Should only be used as adjuncts to selfreport and behavior ± parental report
Pain in the ED
Injuries: contusions, strains,
sprains, and fracture
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Rest and splinting
Oral analgesics
• Acetaminophen
• NSAIDs
• Aspirin
• Opioids (i.e. Hydrocodone / Oxycodone)
• Intravenous analgesics for moderate to
severe pain as with displaced fractures
Acetaminophen
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Most commonly used analgesic drug in pediatric practice
Centrally-acting prostaglandin synthetase inhibitor
Antipyretic and analgesic activity but minimal antiinflammatory effects
Highly effective as sole analgesic for mild to moderate
pain
Synergistic when used in combination with NSAIDs and
opioids for moderate to severe pain
Oral dosing: 15 mg/kg q 4 hours
Rectal dosing: 30-40 mg/kg, followed by 20 mg/kg 6
hours later
Daily max: 90 mg/kg children, 80 mg/kg neonates, 60
mg/kg premature infants
Non-steroidal anti-inflammatory
drugs (NSAIDs)
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Nonselective inhibitors of peripheral cyclooxygenase (COX)
Provide excellent analgesia with good safety margin
Children appear to have lower incidence of renal and GI side
effects than adults even with chronic administration
Except in newborn period, when t1/2 after administration is
significantly longer, the pharmacodynamics and
pharmacokinetics in children similar to that of adults
Dosing guidelines:
• Ibuprofen PO 6-10 mg/kg q6h
• Naproxen PO 5-6 mg/kg q12h
• Ketorolac IV 0.5 mg/kg q6h
• Comparable with opiates for treatment of postoperative pain
and orthopedic injuries with less sedation and fewer side
effects
Opioids
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Most commonly used analgesic for moderate to
severe acute pain
Marked individual variation in opioid dose
requirements; therefore doses must be titrated to
effect
Come in different levels of potency and efficacy
Combined with acetaminophen for synergistic
effect
Oral dosing guidelines:
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Hydrocodone: 0.1-0.2 mg/kg/dose q4h
Oxycodone 0.05-0.1 mg/kg/dose q4h
Codeine
Codeine
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Phenanthrene alkaloid derived from morphine
• Change in the methyl group on 3 position (substituted for the hydroxyl group)
One tenth the potency (analgesic properties) of morphine
Prodrug – has very little to no analgesic properties in and
of itself
• Metabolized in liver by CYP2D6 to become an active morphine metabolite
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Commonly administered orally in combination with acetaminophen
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At least 10% of American population does not have enzyme
necessary for conversion (genetic polymorphisms)
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Not all enzyme systems are turned on at birth
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Newborns do not have CYP2D6; therefore, no analgesic properties with
codeine, only vomiting
Very narrow therapeutic window, so genetic variability in
metabolism is more likely to have a relevant clinical effect
Morphine
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Gold standard
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Metabolized by liver, excreted by kidney
Histamine release can lead to decreased peripheral
vascular resistance and hypotension
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Only of concern if child has severe injury and showing signs of
hypovolemia
Full term infants < 3 months have decreased morphine
clearance (reduce starting dose by 25-50%)
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Widely studied in infants and children
10-20 hrs in preterm infants and 1-2 hrs in young children
Continuous pulse oximetry recommended
Children < 11 yrs have higher clearance and larger
volume of distribution for morphine and and its
glucoronides
Dosing: 0.05-0.1 mg/kg IV/SQ q3h
Fentanyl
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Synthetic opioid which is 50-100 times more potent than
morphine
Highly lipid-soluble with rapid entry into the brain  very rapid
onset (2-5 minutes) and short duration of action (30-45
minutes)
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Eliminated almost entirely by hepatic metabolism
Rarely causes hypotension
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Excellent choice for injured children with severe pain
Can rarely cause chest wall rigidity at high doses (>15
micrograms/kg)
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Ideal choice for ED
Reversible with naloxone, but succinylcholine may be required
Dosing: 2-3 micrograms/kg IV q1h
Procedural Pain
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Patients seldom
remember how great
a clinician you are,
but they DO
remember how much
or how little they hurt
when you were
treating them.
Procedural Pain
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Consider the type of procedure, expected
duration of pain, the patient and parents
involved, and child’s pain history
Educate the parents and patients on what to
expect
Utilize combination of non-pharmacologic
and pharmacologic methods maximizing
topical/local anesthetics
Calm environment
Consider anxiolytic/sedation
Topical Analgesics
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Widely used for pain
associated with
needle pricks, IV
placements, lumbar
punctures, laceration
repairs, and
procedures on
superficial skin
lesions
LET
Lidocaine Infiltration –
Decreasing Pain
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Buffer with bicarbonate (9:1 mixture)
• Decreases pain of injection by neutralizing
acidic pH of lidocaine
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Warm to body temperature
Inject slowly!
Use smallest gauge needle (30-gauge)
Inject directly into wound rather than
through intact dermis
Anxiolytic + Analgesic Combination
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Benzodiazepine (Midazolam) + Opiate
(Fentanyl or Morphine)
• Amnesia, sedation and muscle relaxation
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Safe and effective in children
Likelihood of respiratory depression
increases with use of a sedative
• Proper precautions to protect the airway must
be taken
Nitrous Oxide-Oxygen Analgesia
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Advantages
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Painless delivery
Odorless, tasteless
Rapid onset, short
duration of action
Produces sedation,
amnesia and
dissociation
May be used in young
children
Safe when mixed with
oxygen
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Disadvantages
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Fail-safe system
required
Equipment expensive
Scavenger device
needed
Requires patient
cooperation
Increased incidence of
vomiting
Greater personnel
demands
N2O Self-Administration by a
3-year-old
Ketamine hydrochloride
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PCP derivative; NMDA receptor antagonist
Analgesic, amnesic, and sedative properties
without loss of protective airway reflexes
Causes dissociative amnesia
Rapid onset (IV: 1 min, IM: 5-10 min)
Dosing: 0.5-2 mg/kg IV or 4-5 mg/kg IM
Adverse reactions: Laryngospasm, emergence
reactions (less common in children than adults)
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Atropine (0.01 mg/kg) or Glycopyrrolate (0.005 mg/kg)
to prevent excess salivation
Benzodiazepine may decrease likelihood of
emergence reaction
Propofol
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Non-opioid, nonbarbiturate sedative-hypnotic given
intravenously for sedation during short procedures
Potent sedative with amnesic properties; no analgesic
properties
Rapid onset of action (3 sec - 1 min) and rapid recovery
phase (5-10 minutes)
Use outside of OR by non-anesthesiologists controversial
Low complication rate comparable to midazolam in one
pediatric ED study, but advantage of shorter recovery
time with propofol (small sample size)1
Dosing: Initial bolus 1-2 mg/kg, followed by maintenance
infusion of 60-100 microgram/kg/min
1Havel
et al. Acad Emerg Med 1999
Propofol for ED PSA - Concerns
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Difficult to titrate to desired sedation endpoints
without overshooting to apnea and hypotension
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Loss of protective airway reflexes during apneic
periods likely places patients at increased risk of
pulmonary aspiration, especially if positive
pressure ventilation administered
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Gastric insufflation likely induces passive regurgitation
Propofol for ED PSA – Concerns
(continued)
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Patients must be carefully screened for “full
stomachs” and difficult airways.
Propofol should only be used by providers with
in-depth knowledge of its adverse effects and
skilled in airway assessments and positive
pressure ventilation.
When propofol is administered, an experienced
provider must be dedicated to administering the
sedation, managing the airway and
cardiorespiratory status of the patient, and not
involved with the procedure being performed.
Propofol in ED– future research
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Prospective, randomized studies of pediatric
patients undergoing procedural sedation with
propofol in the ED needed to better clarify:
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Risks of adverse events
Effectiveness of distress reduction, amnesia
Recovery and post-recovery experiences
Etomidate
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Rapidly-acting intravenous sedative-hypnotic; no analgesic
properties
Fast onset (15-45 seconds), short duration of action (5-10
minutes)
Advantage of maintaining cardiovascular stability
Minimal effects on ventilation when used alone, although rapid
administration can lead to transient apnea
Common side effects: nausea, vomiting, myoclonus
Dosing: 0.1-0.2 mg/kg IV
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Three reports of use in pediatric ED for procedural sedation:
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Dickinson: Acad Emerg Med,2001
Ruth: Acad Emerg Med, 2001
Vinson: Ann Emerg Med, 2002
Etomidate – future research
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Prospective, randomized studies of
pediatric patients undergoing procedural
sedation with etomidate in the ED needed
to better clarify:
• Standardized protocol
• Dose (titrated to effect?)
• Analgesic adjunct
• Procedure specific
• Impact of myoclonus on CT scans, suturing?
• Elucidation of risk of apnea, aspiration
Dexmedetomidine
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Selective alpha-2-agonist with analgesic and
sedative properties and minimal effect on
respiratory drive or cardiac function
Preliminary studies in pediatric patients
demonstrate it is a safe and effective
alternative for children undergoing diagnostic
imaging
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Associated with a much shorter recovery time and less
need for adjuvant sedatives
Nonpharmacologic Techniques
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Effect of environment itself must be
considered
Presence of child life therapists who are
trained in nonpharmacologic techniques for
reducing pain is vital
Three broad categories:
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Cognitive
Behavioral
Physical
General Principles of
Pediatric Pain Management
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Anticipate & prevent pain
Assessment is a continuous process
Reverse the reversible: treat the underlying
cause
Use multi-modal approach
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Nonpharmacologic
Pharmacologic
Involve parents
Use non-noxious routes
Address associated psychosocial distress
Pediatrics in Review 2003; 24 (10)
Questions??