Managing pain & distress in children brief diagnostic therapeutic procedures Flashcards
Examples of common medical procedures that can cause significant pain and distress, particularly in children?
- IV cannulation
- Blood draws
- Heel lances
- LPs
- Urethral catheterizations
- Wound repair
- Medical imaging of fractures and dislocations
_______ is reported by children, especially the very young, to be the worst pain they experience while in hospital.
Needle-related pain
Under treated pain has short and long-term negative consequences for both children and families, and can result in _____________.
Avoidance of medical care
What reasons are often reported for limiting the use of effective strategies for pain management?
- Time constraints
- Lack of material resources, personnel or knowledge
- Safety concerns
Recommend combining three different approaches: _____, ______ and ______ - to minimize pain and distress.
- Physical
- Psychological
- Pharmacological
Physical strategies?
Comfort positioning
- Siting upright–> increases sense of control
- Secure, comforting, or ‘hugging’ holds
- Caregivers can also support by distracting and using soothing words
- Family presence encouraged
Infant focused strategies
- Breastfeeding
- -Simultaneously offers skin-to-skin contact, comfort of sucking and rocking, and (likely) transfers endogenous opiates in breastmilk
- Sucrose
- -Recommended dose: 0.5ml-2ml of 24-33% sucrose
- -Most effective when part of dose given 2 minutes prior to procedure and rest given during
- Non-nutritive sucking (i.e. pacifier use)
- Rocking or holding
- Skin-to-skin or ‘kangaroo’ care
- Swaddling and facilitated tucking in prems
Choosing less painful approaches
- Batch IV inserts and blood tests; group bloodwork
- Experienced phlebotomist
- Avoid heel lances
- Do not prescribe daily bloodwork in automatic, routine fashion
- –If required for critical situations, restrict to short period of time and reassess daily
Psychological strategies?
- Preparation
- Distraction
- Deep breathing
- Hypnosis
- Music Therapy
How to prepare child for a procedure?
- Children over the developmental age of 4 years generally benefit from simple information regarding what to expect.
- -Explaining the steps of a procedure
- -Receiving sensory information about what they might feel (e.g., cold, wet)
- -Seeing the medical supplies that will be used
- -Offering realistic choices or roles related to the procedure helps children to feel more in control
- Parents also need preparation of what to except, how they can help (position, distraction), and what’s best to say
- -Avoid false or premature reassurance (i.e. “this won’t hurt”, “it’s all over”, “this is the last stitch”) as this may not be able to be predicted reliably
- -Saying ‘I’m sorry’ can confuse a child and should be avoided in the context of performing painful procedures.
- Health care providers – prepare appropriately for procedure
What is the most widely studied cognitive strategy for needle-related procedural pain and distress in >/= 2 years old?
Distraction
Methods of distraction?
- Bubbles
- Reading a story
- Offering animated video, interactive game
- Tablet, phone, favourite blanket or toy from home
- Older children
- -Focus on empowerment by asking about and attending to their preferences
- -Engage in non-procedure related conversation
- -When appropriate, humour to alleviate tension
Pharmacological interventions before needle procedures?
- Topical local anesthetic creams
- -Liposomal lidocaine (Maxilene) – effective for IV procedures; Shorter procedure time for IV cannulations; Higher success rates on first attempts; Earlier onset of action than EMLA
- -Ametop (amethocaine) – earlier onset and reported to be more effective than EMLA (lidocaine-prilocaine) in reducing pain
- When patients are stable enough to wait 30 minutes, using either liposomal lidocaine (Maxilene) or Amethocaine (Ametop) recommended - have earlier onset of action compared with lidocaine-prilocaine
- Other novel methods: vibration/cold devices, needle-free jet injection of 1% buffered lidocaine – promising but limited studies; neither available in Canada
- Vapocoolant sprays (e.g. Pain Ease) – an alternative to anesthesia cream
- -Immediately effective, limited duration of action
- -Mild discomfort upon application (cold sensation)
If still remain distressed after all that, then consider mild analgesia and sedation can be used with nitrous oxide (50% nitrous oxide and 50% O2)
- -Nitrous oxide – safe and easy in cooperative children; rapid onset and offset of action
- -Sedation – only with trained personnel adequate staffing, proper equipment, access to appropriate medication and reversal agents, and monitoring
Reported cases of _________ in infants with EMLA cream appear to be mainly related to the ______ component.
Methemoglobinemia, prilocaine
Pharmacologic interventions before LP?
-Topical local anesthetic creams, and then injected lidocaine (if non-urgent)
–Success in managing pain and improve procedural success
-When urgency does not permit applying cream, about 1 mL of injected 1% lidocaine without epinephrine should still be used.
-Oral sucrose for infants can be added
-Nitrous oxide can be a helpful adjunct for older patients
±procedure sedation
Pharmacologic interventions for urine collection?
- Clean catch increasingly used in non-toilet trained children
- Bladder stimulation with gentle tapping or cold ± paravertebral massage
- Sucrose helpful for cath urine in neonates but not older infants
- Can use topical for suprapubic cath
Pharmacologic interventions for NG?
- Oral sweet solution in newborns to reduce pain
- Sitting upright, offering water through a straw (often offered in adults)
- Topical lidocaine supported in adult literature
