Pain and Seduction in Children

Question 1

What are barriers to pain management in children

Answer 1

Fear of side effects, miconseption that babies don’t feel pain, lack of trained healthcare providers, difficulty of assessment

Question 2

What are the consequences of not adequately treating pain in babies

Answer 2

Long-term changes in the developing nervous system, alteration in later perception and reaction to pain

Question 3

What is the gold standard for pain, physiological changes

Answer 3

Self report, increase in blood pressure heart rate and oxygen consumption

Question 4

What is the tool used to asses pain in 3 to 7 year olds

Answer 4

Wong-baker FACES

Question 5

When self reporting is not possible how can pain be assessed

Answer 5

Physiological changes, behavioral changes, facial expressions, change in cry

Question 6

What are two different behavioral observation scales

Answer 6

FLACC: full term neonates and no verbal children
NIPS: Premature and full term neonates

Question 7

What are behavioral AND physicological tools used to assess pain used in infants and nonverbal children

Answer 7

CRIES: 0 to 6 months, PIPP: term and premature infants, NPASS: preterm and term infants(assess pain AND sedation), COMFORT: 0-18 (assess pain AND sedation)

Question 8

What are the management goals for pain in children

Answer 8

Decrease pain, decrease anxiety, decrease short term and long term effects of exposure to pain

Question 9

What are the nonpharmacological techniques that should always be used with pharmacological agents

Answer 9

Distraction techniques, allow parents to stay, pacifiers, hypnosis, soft music, breathing techniques, swaddling, decrease light and noise

Question 10

What nonpharmacological techniques can aid in handling newborn pain

Answer 10

Skin to skin care (Kangaroo care), swaddling, sucrose, pacifier

Question 11

What happens in a baby brain when giving a pacificer

Answer 11

Releases serotonin leading to modulating the transmission of pain stimuli

Question 12

How much sucrose should be given and when should it be given to aid in infant pain, when does it lose its effect, when is it useful

Answer 12

1 to 2 ml of 24% sucrose two minutes prior to painful stimuli (heel lance), After 6 months of life/ blood draws, heel sticks and line insertions

Question 13

What are the options in order to treat mid and moderate pain,moderate to severe

Answer 13

Acetaminophen, NSAIDs, non-opioid analgesics/ opioids

Question 14

For severe pain which opiods are most commonly used

Answer 14

Morphine, Fentanyl, and Hydromorphone

Question 15

What is the gold standard for severe pain management, cautions

Answer 15

Morphine/ caution for decreased renal function, must be hemodynamically stable, in neonates doses should be reduced 25 to 50 percent with longer intervals

Question 16

Which opioid is 100 times more potent than morphine, what is its use in children

Answer 16

Fentanyl, commonly used as continous infusion in PICU/NICU setting in mechanically ventilated patients

Question 17

Which opioid is 5 to 6 times stronger than morphine, when should it be used

Answer 17

Hydromorphone, good in renal insufficiency (less nausea and itchness than morphine)

Question 18

What are the options for moderate pain

Answer 18

Acetaminophen plus codeine, Acetaminophen plus hydrocodone, tramadol

Question 19

Why hydrocodone plus codeine no longer used as frequently anymore, BBW

Answer 19

Variability in the metabolism of codeine (CYP2D6)/ Contraindicated use in ages less than 12 year old and post-tonsillectomy and/or adeindectomy

Question 20

What is the BBW regarding tramadol

Answer 20

Contraindicated use in ages less than 12 years old, tonsillectomy/adenoidectomy, sleep apnea, obesity, chronic lung disease, people prone to seizures

Question 21

What is PCA, when is it used, what opioids are associated, who does not use it , lockout interval

Answer 21

Patients self-administer small doses of opioid analgesics IV at frequent intervals, Moderate to sever pain, morphine fentanyl and hydromorphone/ kids less than 6 years, cognitively/physically impaired/ 6 to 10 minutes

Question 22

What are the side effects of opioids

Answer 22

Respiratory depression (lower the dose or naloxone), nausea (metoclopramide or ondansetron), constipation (docusate or sennosides, pruritus (diphenhydramine), urinary retention(lower dose)

Question 23

What is the first choice for mild pain

Answer 23

Acetaminophen

Question 24

What are the NSAIDs that are used for pain in children, benefit when used with opiods

Answer 24

Ibuprofen and Naproxen (tablets and oral suspension), Ketorolac (IV/IM)/ may decrease opioid use by 30%

Question 25

What are the side effects of NSAIDs, caution

Answer 25

GI bleeding and Nephropathy/ dehydration and hypovolemia, renal and hepatic dysfunction, coagulation disorders, peptic ulcer disease, concomittant use with anticoagulants and nephrotoxic drugs, post operative with a high risk of bleeding`

Question 26

What are controversies that makes it so patients may or may not use NSAIDs

Answer 26

Tonsillectomy: increased risk of bleed but can be used except Ketorolac, orthopedic surgery: impaired bone healing but also inconclusive so use is limited especially in spinal fusion or limb lengthening

Question 27

What are the perioperative opioid-strategies that have been used to reduce the use of opioids

Answer 27

IV/PR acetaminophen and NSAIDs, Dexamethasone, low dose ketamine, clonidine an dexmedetomidine, gabapentin and pregablin

Question 28

Why is it important to control anxiety if a patient is having pain as well

Answer 28

Anxiety enhances pain perception

Question 29

What are the benefits of sedation in mechanically ventilated patients

Answer 29

Promotes ventilator synchrony, improves oxygenation, prevents inadvertent extubation, alleviates discomfort and anxiety

Question 30

T/F: Paralyzed patients receiving NMBAs have a mandatory use of sedation

Answer 30

True

Question 31

What are the assessment for sedation

Answer 31

State behavioral scale (SBS), COMFORT B scale

Question 32

What medication classes are used for sedation and anxiolysis

Answer 32

BZDs, Alfa 2 agonists,

Question 33

What are non-pharmacological intervention to reduce anxiety

Answer 33

Reduction of noise and light, skin care, baths, music

Question 34

What are the BZDs used in children

Answer 34

Midazolam, Lorazepam, Diazepam

Question 35

What is the alpha 2 adrenoreceptor agonist, clinical applications

Answer 35

Dexmedetomidine/ sedation in the PICU in ventilated and non ventilated patients, procedural sedation, treatment of latrogenic withdrawal

Question 36

What is the main advantage of dexmedetomidine

Answer 36

Lack of significant respiratory depression, may reduce the requirement for other sedative/analgesic agents, rapid onset and duration of action

Question 37

What are the common side effects of dexmedetomidine

Answer 37

Bradycardia, hypotension, dry mouth

Question 38

What sedative drug is contraindicated in kids and why

Answer 38

Propofol is contraindicated for continuous sedation in pediatric patients due to metabolic acidosis and death (PRIS)

Question 39

What is seen with longer lengths of stay and morbidity along with no responding in pain/anxiolysis, pediatric assessment tools

Answer 39

Delirium/ pCAM-ICU, CAP-D, SOS-PD

Question 40

What are the risk factors for delirium risk factors

Answer 40

Age less than 2 years, development delay, severity of illness, mechanical ventilation, immobilization, Prolonged ICU stay, Restraints

Question 41

What medications can be given for delirium

Answer 41

Benzodiazepines, Anticholinergics, steroids

Question 42

What are ways to prevent delirium

Answer 42

Assess infection, manage hypoxemia and metabolic abnormalitites, minimize sedation, assess for iatrogenic withdrawal, stabilize a daily schedule with normal sleep and wake cycles