Dr Farah Jafri

Pediatric Acute pain DEPARTMENT PROTOCOL

Al Razi Hospital

INTRODUCTION

Pain management practice in children has not kept pace with that in adults.

The provision of effective pain relief to children has been hindered by the many myths

PEDIATRIC PAIN MYTHS

-Children experience less pain than adults

-Neonates don’t experience or remember pain

-Opioids are addictive or otherwise too dangerous to use in children

-Children cannot localise or describe their pain

The truth....

Achieving good pain management is of equal importance in children as it is in adults and failure to do so may have long term detrimental effects.

The truth....

Research on early childhood pain experiences suggests that

Long lasting behavioural and physiological effects occur as a result of permanent structural and functional changes in the central nervous system partly due to central sensitisation

(after Fitzgerald and Andrews, Stevens, Taddio, Johnson, Anand and

Hickey and others)

Anand KJ, McIntosh N, Lagercrantz H, et al. Arch Ped Adol Med

1999;153:331-338.

DEFINING PEDIATRIC PAIN

Assessment factors to consider.

x Cognitive development

x Previous experience

x Differentiate between pain and anxiety

x Age

x Behavioural observation

x Socio-cultural and environmental issues

x Parent/family perception

5 General Principles of Pain Management

• Anticipate & prevent pain.

• Adequately assess pain

• Use multi-modal approach

• Involve parents

• Use non-noxious routes

Anticipate pain

Prepare patient and parent on what to expect

Guide them on ways to minimize pain and anxiety

Utilize quiet environment

Treat pain prophylactically when anticipated

Pediatric pain scales

FLACC for acute procedural and post-

operative pain ( 2 months- 7 years, cognitively impaired)

FACES-revised (adults and children >3)

VAS (> 8 years old)

PAIN ASSESSMENT TOOLS

Wong & Baker Face Scale

Facial expressions are acceptable and the use of cartoon-based pictures is appealing to children

-allowing them to relate to simple pictures and move towards verbalising their pain.

For older children

Able to verbalise their pain more easily using either the VAS 0-10 visual analogue scale or the scale below. Patient Reports:

• No pain ‘0’

• No pain at rest, mild on movement ‘1’

( VAS = 1 to 3)

• Intermittent pain at rest, moderate on movement ‘2’ ( VAS = 4-7)

• Continuous pain at rest, severe on movement ‘3’ (VAS = 8- 10)

Using the scales

Use the same scale each time with the same patient.

Use age and cognitive function compatible scale

Take feedback from family caregiver and childlife specialists

Starting with the simple changes

Premedication

Intraoperative plan

Post op plan

Pre-medication

Premptive analgesia-

Premedicate- ? Adol syp

? Adol PR

Sedation PO - inj dormicam with juice

(1 ml/kg ; 0.5mg/kg)

- tab valium ( 0.2- 0.3 mg/kg)

INTRAOPERATIVELY

Use opioids as indicated

PR/IV paracetamol

Local infiltration

Caudal /epidurals Nerve blocks

Post operatively

In recovery-

Control pain – reassurance

-opioids –

- inj morphine ( 0.025- 0.1 mg/kg)

- inj pethidine ( 0.2- 0.5 mg/kg)

- IV/ PR paracetamol ( 15mg/kg)

Keep in recovery 20 mins post opioid administration

Perfalgan for kids < 10 kg, term baby

7.5 mg/kg per administration i.e. 0.75 mL solution per kg

One IV infusion of 7.5mg/kg (0.75 mL/ kg)

up to four times a day, with a minimum interval

Of 4 hours between each administration.

Perfalgan for kids > 10 kg

Children weighing >10 kg and <33 kg

15 mg/kg per administration i.e. 1.5 mL solution per kg

One IV infusion of 15mg/kg (1.5 mL per kg) up to four times a day with a minimum interval of 4 hours between each administration.

Pediatric local anaesthesia & blocks

Start simple - local infiltration

Lower limb surgery-

• Caudal single shot

• Caudal with catheter threaded up

• Lumber epidural

Upper limb-

• axillary approach brachial plexus block- safest

• Para scalene approach

Locating lumbar epidural space

As a general rule the epidural space will be found at 1 mm/kg of body weight, however, there is considerable individual variation.

Dose for caudal & other epidurals

In pediatric population, body weight is a better correlate than age in predicting spread of local anesthetic following a caudal block.

For caudal use, the optimum concentration of bupivacaine is 0.125-0.25%.

For continuous epidural infusion, bupivacaine

0.2 - 0.4 mg/kg/h for older children is often used.

CAUDAL BLOCK

Volume of LA

Volume of LA required depends on the level of blockade desired, ranging from 0.5 ml/kg for a sacral block to 1.25 ml/kg form mid thoracic block.

Single-shot injections generally last 4- 12 hr. median of 4- 6 h.

Kiddy caudals

Single shot caudal epidural blockade (‘kiddy caudals’) is widely used to provide perioperative analgesia in pediatric practice.

As a single injection, it offers a reliable and effective block for patients undergoing urological, general and orthopedic surgery involving the lower abdomen and lower limbs.

Caudal needles

20- 22 g cannula

advancement of these catheters into the caudal space may indicate proper positioning

There is also indications that it is easier to detect intravascular placement and interosseous placement with angiocatheters.

Perpheral nerve block in children

Current used - to maintain the motor response at 0.4-0.2 mA .

Objective monitoring of the injection pressures during injection of local anesthetic to decrease the risk of intraneural injection

Surface mapping

Surface stimulation or surface mapping-

use Higher current amperage and/or current duration is required (usually about 5 mAmps/1 msec) in order to percutaneously stimulate.

A relative moist surface either using alcohol swabs or lubricating jelly allows for better contact of the negative electrode.

Perpheral nerve block in children

Volume of local anesthetic for common blocks

Axillary block – 0.2-0.6 mL/kg

Interscalene block – 0.33 mL/kg

Femoral block – 0.5 mL/kg

Sciatic block – 0.15-0.2 mL/kg

Continous infusion- 0.1-0.4 ml/kg/hr of

(0.1- 0.125 % inj marcaine )

ANALGESIC TECHNIQUES in the ward

As with adults a combination of pharmacological [based on the analgesic ladder] and where appropriate non- pharmacological methods are recommended.

NON PHARMACOLOGICAL Physical Strategies:

massage; positioning, application of heat or cold; mother holding the child, reduction of stimuli (noise control, dim lights )

Cognitive Strategies: reassurance; distract by using art, play, child life activities, and music

NON PHARMACOLOGICAL

Child Life Specialist for consultation to assist

with coping strategies and/or diversional activities.

Psychological Evaluation to assess if patient is

a candidate for psychological interventions.

PARACETAMOL

Children - PO > 1year of age-

Suggested loading dose 30mg/kg

Then 20mg/kg 6 hourly

Available as syrup: 120mg/5ml, 250mg/5ml

- PR Loading dose 40mg/kg

Followed by 20mg/kg QD Available as- suppositories 120mg/200mg/250mg-

PARACETAMOL

Useful as a mild analgesic following minor op.

Conjunction with NSAIDs and opioids following intermediate and major surgery.

Take care

Review after 48 hrs & taper dose after 72 hrs.

DONT USE MORE THAN 5 DAYS

Beware of hepatotoxicity in the critically ill child. .

Pharmacological techniques

Ibuprofen- can be used in children over 7Kg and over 6 months of age

10mg/kg PO 8 hourly

Available as: Syrup 100mg/5ml

NSAIDs used with care in children with asthma,

Should not be used in children with renal failure/hepatic failure, salicylate sensitivity or coagulopathy.

Patient Controlled Analgesia (PCA)

• Suitable for children from the age of 6 years upwards who require parenteral opioid

analgesia.

• A detailed pre-operative briefing of both child and parents is required prior to PCA use in children.

PCA morphine

For children up to 50 kg:

Morphine make up 1mg/kg in 50mls normal saline (20micrograms/kg/ml)

Bolus 0.02 mg/kg ( 0.5mg for a 25 kg child)

Lockout 15 minutes

PLUS/minus Background Infusion 0.004 mg/kg/hr ( 0.1mg/hr for a 25 kg child) , must have close monitoring

4 hour limit 0.4

PCA for children

A background infusion is an integral part of

PCA in children, giving children confidence in

the technique and providing a better sleep

pattern, especially during the first post

-operative night.

SIDE EFFECT MANAGEMENT- Nausea and Vomiting

Identify cause and treat i.e. dehydration, hypotension, hypoglycaemia, hypothermia etc.

1) Ondansetron- 1st choice ( >1 month ) 0.1mg/kg (maximum 4mg), 8 hourly, po/iv

2) Metaclopramide- 0.15-0.25 mg/kg/dose IV q6hr/PRN (max 10 mg/dose)

May be alternated with zofran

3 )Dexamethasone- 0.15mg/kg single dose

COMPLICATION

b) Respiratory Depression +/- Sedation

Naloxone - Opioid Antagonist

4 micrograms/kg I/V titrated to effect

Remember naloxone can wear off before morphine – continued close observation is mandatory

Safety – PCA in children

- Widely used in many centres for children as young as 5 years

-A safe and effective form of analgesia provided that guidelines are followed.

- Careful monitoring of the child receiving PCA essential.

-Nursing observations of respiratory rate, level of sedation, pain scores, nausea and vomiting should be recorded regularly

PCA in children

The main contraindications include:

-inability to understand or operate the machine

-head injury

-upper airway obstruction

Continous peripheral nv block care in ward

– Identification of LA toxicity by staff and parents

- Patent i.v canullas,

- labelling of the pump, to indicate site of block

– staff training - resusitation equip, knowledge of drug doses used in ped resusitation

Continous peripheral nv block care in ward

– Care of the blocked limb

Sling for upper limbs

Avoid pressure on the limb, change position, padding etc

– Monitor for signs of pressure on the skin (e.g. redness, blanching)

toes and heel of the affected leg OR

fingers palms for upper limb

CONCLUSION

AREAS FOR IMPROVEMENT-

• Preemptive analgesia

• Local infiltrations

• Caudals, use them.

• Peripheral nerve blocks tutorials and practice

• Ward staff orientation and training.