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Pediatric Pain:Assessment & Interventions
Pediatric Pain:Assessment & Interventions
Lori McKenna, CRNP
Debbie Wolf, RN, CNSKeeley Harding, CRNP
Cincinnati Children’s Hospital Medical CenterDivision of Pain Management
Department of Anesthesia
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Pain Service: The Acute TeamCensus: Approximately 1700 patients seen per year
APNs: Lori McKenna Debbie WolfKeeley Harding
Attendings: Ken Goldschneider Norb WeidnerMark Meyer Senthil SadhasivamAlex Szabova Deborah Vermaire
Psychologists: Michelle Ernst Carrie Piazza-Waggoner
Contacting Us: On-call pager # 303-2019 available 24/7APN # 6-7768, opt 3Mobile Phone #s available in Centerlink
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Chronic Pain Service (750 pt visits per yr)
Attendings: Ken Goldschneider & Alex SzabovaAPNs: Debbie Wolf, Keeley Harding, Lori McKennaPsychologists: Anne Lynch & Susmita Kashikar-ZuckPhysical Therapist: Julie Badylak
Pediatric Palliative and Comfort Care Team (PACT) (50+ pts/yr)
APN: Suzanne BlackSocial Worker: Debby PalmisanoAttendings: Norb Weidner & Mark MeyerPager #: 736-6301Office #: 6-5479
Pain Service: The Chronic Team
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Definition of Pain“Pain is whatever the experiencing person says it is. It exists whenever they say it does.”
McCaffery 1968
“Unpleasant sensory and emotional experience associated with actual/potential tissue damage.”
IASP 1979
Pain is highly personal and subjective.
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JCAHO Standards• Patients have right to appropriate assessment &
management of pain
• Initial assessment • Identify patients with pain
• Comprehensive assessment• Intensity• Quality (pain character, frequency, location,
duration)• Assessment (appropriate to patient’s age)• Reassessment
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Myths• If sleeping, not in pain
• If able to distract, not in pain
• Use of narcotics causes addiction
• Children are more prone to respiratory depression
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Assessment• Pain tool just one piece of assessment
• Self report best: GOLD STANDARD
• Parent/family input
• Physiologic Response
• Behavioral Response/Function• Daily Activities
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Reassessment
• Reassess in response to interventions• PO meds – 20 min• IV/PCA meds – 10 min
• REMEMBER: Document Reassessment
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Children’s Hospital of East Ontario Pain Scale: CHEOPS
• Behavioral (six behaviors assessed)
• Ages 1 to 7 years• Scores range 4-13
• Original design PACU
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Oucher
• Self Report Scale• Ages 5-10 years (some as young as 3 years)• 3 cultures (all male)• Avoid happy/sad, use age appropriate words• Range 0-10
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Visual Analog Scale: VAS
• Self Report Scale• Ages 8 to adult• Describe scale• Ask what level is acceptable to patient
0 1 2 3 4 5 6 7 8 9 10
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Comfort Scale
• Measures psychological and physiologic distress behaviors in mechanical ventilated infants, children and adolescents. Not designed for premature infants.
• Score is derived from the total score of 8 specific dimensions
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Assessment of Children with Developmental Delays
• No scale currently adopted by CCHMC
• Behavioral or physiological measure utilized
• Family input of KEY importance
• Evaluate• Objective data: increased HR, RR, BP• Subjective clues: guarding, rigidity, crying, facial
expressions, activity changes, eating & appetite pattern changes, c/o pain
• Documentation• Narrative Assessment Screen in ICIS
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Pharmacological Interventions
• Topical Anesthetics
• Oral Medications
• Intravenous/PCA Medications
• Epidurals
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Topical Anesthetics
ELA-Max cream• 4% lidocaine
EMLA cream• 2.5% lidocaine + 2.5% prilocaine
Lidoderm• Lidocaine patch 5%
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NSAIDS: Non-Steroidals
Non-opioid Analgesics• Non-steroidals
• Acetaminophen• Ibuprofen• Naproxen• Ketorolac- Only IV Form
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Opioids: What is enough?
The amount that maximally relieves pain with minimal side effects.
NO CEILING EFFECT
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Oral Combinations with Opioids
• Mild to moderate pain
• Used along with non-opioid
• Examples• Oxycodone = Percocet / Roxicet• Hydrocodone = Vicodin 5/500 mg• Codeine = Tylenol #3, 30/325 mg
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• Tablets: OxyContin®, MS Contin®,
• Do NOT crush, chew, cut or score these meds
• SA (sustained action) = CR (controlled release) = SR (sustained release)
ALL LONG ACTING
• Other forms:• Liquid ? Methadone• Capsule ? Kadian• Patch ? Fentanyl
Long-Acting Opioids
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PCA
• ≥ 7 y.o.
• Only patient allowed to push button
• Better analgesia with less sedation
• No delay between pain and response
• PCA lockout usually 7 minutes
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PCA + Continuous
• Generally first 24 hours post-op
• Prevents patient from waking up in pain
• Hem/Onc population or prolonged recovery
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Parent or Nurse Controlled Analgesia (NCA)
• < 7 yrs
• Developmentally delayed
• Parent Education • Safety
• Lock-out 10-15 min• When to use:
• Prior to painful procedures• Ambulation/chair• Incentive spirometer
DO NOT USE when patient is sleeping
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Caring for the Patient on a PCA• Continuous pulse ox
• VS Q 1 x 1st 4 hrs then Q 4 (RR Q2 while asleep)
• PCA button within reach at all times
• Activity—OOB unless contraindicated by primary service
• 2nd IV line necessary if vasoactive drug drips or blood started
• Change syringe Q 24 hrs, tubing Q 72 hours
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Caring for the Patient on a PCA Q4 Assessments
• Response to Analgesic?
• Respiratory Status? (Q2 while asleep)
• Hypotension?
• Pruritis?
• Urinary Retension?
• Nausea/Vomiting?
• IV Site Burning?
• Constipation?
2 Nurse Documentation in ICIS: Initial Set Up Order changeVial/syringe change Hand off of care (Yellow Card)
1 Nurse Only:24 hr Totals (Pump cleared daily at 0600)
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Documentation• Q 8 hours: Volume on I/O
• Yellow Controlled Substance Pharmacy Sheet document volume of med w/ 2nd RN:
• At initial set up• Hand off of care• Any Waste/Loss • Change of syringe
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Epidurals
• Placed under general analgesia
• Lumbar or caudal placement
• Indications• Thoracic• Abdominal• GU• Lower extremity procedures
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Epidural Analgesia
Typical Medications/Dosing
• Bupivicaine: 0.1%• Chloroprocaine:1.5%(neonates)• Morphine: 50 mcg/ml• Dilaudid: 10 mcg/ml• Fentanyl: 2 mcg/ml• Stadol: 4 mcg/ml• Clonidine: 1-2 mcg/ml
****Common Dosing Ranges: 0.2-0.4 ml/kg/hr****
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Epidural Advantages
• Improved pain control
• Improved pain assessment ability (awake patient)
• Decreased Apnea/Bradycardia in Neonates
• Decreased respiratory suppression if local anesthetic only(i.e. bupivacaine injection)
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Care of the Patient w/ an EPIDURAL• Is Patient comfortable?
• Shoulder dressing intact?
• Back Dressing intact?
• Heel Protectors?
• Incentive Spirometer/Bubbles Q 1hr
• Turn/reposition Q 4
• OOB as allowed by primary service
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Care of the Patient w/ an EPIDURAL
• VS q4h with appropriate pain assessment scale
• HR, RR, pulse ox monitoring continuously w/ alarms set
• LE mobility/numbness check Q 4 hrs
• If a “BOLUS” dose given• VS @ 10 & 20 minutes• Call APS if abnormal
• At least once/shift → unless + then more often assessment for:• Pruritis• Urinary retention • Constipation• Nausea & Vomiting• Seizures
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Other Information• Option of PCEA
• Usually reserved for adolescents/Fetal Care Unit Patients• Longer onset (~20-30 min) than IV dose
• Reassessment after 30 minutes
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Side Effects of Opioids
Pruritus• Benadryl
Urinary Retention
Nausea• Reglan/Zofran
Burning at IV site
Constipation• Miralax/Colace
Respiratory Depression• Narcan
2 Nurse Documentation in ICIS: Initial Set Up Order change
Solution bag change Hand off of care (Yellow Card)
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PCA & Epidural Transport
• RN transport to & from the OR
• RN transport off the unit is required 24 hrs after any of the following:• A new order• An increase in dosage• Medication changed
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Adjuvant Pain Medications: Anticonvulsants
Gabapentin (Neurontin®)
• Indicated for treatment of partial seizures
• Effective in neuropathic pain
• Mechanism of action unknown
• Titrate to avoid side effects
• Other anticonvulsants commonly used: trileptal, topamax, tegretol
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Adjuvant Pain Medications: Antidepressants
Tricyclics (Elavil®)• Used in neuropathic pain
• Lower doses for analgesia vs depression
• Initially improves sleep• 10 days 2 weeks analgesia
• Other antidepressants commonly used: Doxepine, Celexa
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Adjuvant Pain Medications: Skeletal Muscle Relaxants
• Baclofen• Dose: 2-7 years old—10-15 mg/day q 8 hrs then titrate up
to effect(max 40 mg/day)
>/= 8 years old—max 80 mg/day
• Side Effects: hypotension, drowsiness, ataxia, nausea
• Must not be abruptly discontinued - withdrawal
• Other skeletal muscle relaxants: flexeril, skelaxin, robaxin, valium
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Addiction
Definition• A psychological phenomenon
• A behavioral pattern of drug use characterized by compulsive use of an opioid
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Physical Dependence
Definition• A physiological phenomenon
• A physiological state that results from taking increasing amount of opioids & is manifested by the development of withdrawal