Pediatric Pain Management Flashcards
What is pain?
pain is whatever the patient says it is and exists whenever the patient says it does
Pain in kids is multi-dimensional, subjective, physiological and behavioral
Eland & Anderson 1977
similar surgical procedures- traumatic amputations, malignant neck mass, repair of ASD
25 children- 24 pain meds
18 adults- 671 pain meds
13/25 kids received no pain meds
Perry & Heidrich, 1982
Burn Unit
surveyed nurses medicating prior to tanking
6 nurses would not pre-medicate an adult
24 nurse would not medicate a child
Beyer, DeGood, Ashley, & Russell, 1983
compared 50 adults/50 children matched for diagnosis - cardiac surgery
70% of the total analgesics were given to the adults
12 infants/toddlers received no analgesics
Broome, et al 1996
27% insititions did not use self report tools
IMs given “sometime often” 48%
DPT- “Sometimes-often” 50%
Effectiveness of pain control significantly better for school age & adolescents than younger kids
96% major obstacles- knowledge deficit, attitudes, stated skills, lack of resources
Rieman & Gordon 2007
295 pediatric RNs 8 Shriners hospitals Peds pain assessment and management Mean score was 74% More experienced nurses scored higher Nurses who belonged to a professional organization scored higher
What is the first myth?
Nervous system of the neonate is too immature to feel pain
pain receptors are fully developed & functional at birth
complete myelinization is not necessary for pain perception
What is the second myth?
children, infants in particular dont feel pain
“Whatever is painful in the adult is painful in the infant & child until proven otherwise”
Wongs Golden Rule
1993
What is the third myth?
children cant tell you where they hurt
even infants show signs of pain in facial expressions, posture, cry, & body movements
young children can point to where they hurt and effectively use pictorial pain assessment tools
older children can tell in words and drawings where they hurt
what is the fourth myth?
children who do not report pain or request medication for pain, are not in pain
children are egocentric & believe that others know how they feel
they perceive adults to be the “care providers”. if they needed it you would provide it
What is the fifth myth?
children cry during procedures because they do not like to be restrained
What is the sixth myth?
narcotics cause respiratory depression in children
What is the seventh myth?
pain will have no lasting effect on children- they wont remember it anyway
recent research indicates that memory for pain & behavioral changes may begin as early as the neonatal period
may change the way an individual perceives/copes with pain
What is the eighth myth?
narcotic pain meds administered to children increase the risk of addiction particularly in adolescents
Sucrose
- Painful procedures infants birth- 6 months: venipuncture, heel stick, LPs/circs
- 24-28% sucrose
- Dripped on anterior third of tongue- absorbed by receptors- not swallowed
- pacifier dipping
- 1cc 2 min prior to procedure
- another cc during procedure
Aspirin
- analgesic/ anti-pyretic/ anti-inflammatory/ antiplatelet
- restricted to selected used in pediatrics (risk of Reyes Syndrome)- Rhematic Fever, Kawasakis Disease
Acetaminophen
analgesic/antipyretic
-Dose: 10-15mg/kg every 4-6 hours not to exceed 5 doses in 24 hrs
Ibuprophen (motrin)
analgesic/ anti-inflammatory/ antipyretic/ anti-platelet
-dose 10mg/kg every 6-8 hours
Ketorolac (toradol)
- NSAID Analgesic- IV, IM, or oral
- 0.5-1.0 mg/kg
- short term use- 5 days
- side effects: acute renal failure, elevation liver enzymes, prolonged bleeding time. Dose lower with renal dysfunction
- black box warning
Narcotics- Opiates
- MS, Fentanyl (100 x more potent than MS), Dilaudid, Codeine
- Mu receptors
- No ceiling on analgesic effect
- Narcan antagonist
- Common side effects- respiratory depression, hypotension, constipation, euphoria, histamine release- itching
Morphine Opiate Analgesic
- analgesic effect, sedation, some immobility
- IV loading dose- 0.05-0.1 mg/kg slowly
- dilute in peds- titrate to effect
- peak for respiratory depression 20 minutes
- causes histamine release– itching, flushing, rash/hives
- Respiratory depression; hypotension
- antidote- nalaxone
Fentanyl Opiate Analgesic
- analgesia, sedation, some immobility
- 100 times more potent than morphine
- oralet, IM, IV
- 1-2micrograms/kg to begin-titrate to effect
- rapid IV onset- 1-5 minutes;
- duration- 1/2-1 hour
- antidote- nalaxone
- give slowly-may cause skeletal muscle or chest wall rigidity
Hydromorphone (Dilaudid)
- can be given PO, IM, IV, R
- about 7 x more potent than MS
- IV onset almost immediate
- Half life= 2.5 hrs
- Dosage- .015 mg/kg every 4-6 hrs
Reversal Agent- Nalaxone/Narcan (opiates)
- displaces opioid drugs at the opioid receptor site
- what do you want to reverse
- give IV slowly until desired response
- Onset- 2 minutes, may repeat every 2-3 minutes
- duration 15-60 minutes- beware- re sedation
Benzodiazepines Biazepam (Valium)
- induces sedation, antianxiety, some immobility, some amnestic properties, great muscle relaxant, no analgesia
- requires ability to support airway
- respiratory depression/apnea
- painful IM or IV
- doesnt mix well with other drugs/fluids
- re sedation effects with oral med 6-8 hours
Benzodiazepines Midazolam (Versed)
- midazolam (versed)
- immobility +sedation +amnesia +antianxiolytic
- unpredictable as primary agent particularly in young children- usually secondary agent
- often requires cardiac monitoring
- variety of routes
- IV- burns (10-15 min)
- Requires ability to support airway
- Antidote- Flumazenil
Reversal Agent- Flumazenil (Romazicon) (Benzodiazepines)
- Reverses induced sedation and amnesia. May not effectively reverse hypoventilation
- Rapid onset; Duration < 1 hour
- Painful IV; give slowly 1/2-1 minute
- may cause seizures
Coanalesics- Tricyclic antidepressants (TCAs)
- neuropathic pain shingles
- Lower doses avoid some common TCA SEs-sedation, dry mouth, urinary retention
- Beward the overdose
Coanalgesics Gabapentin (Neurontin)
- Gabapentin (Neurontin) anticonvulsant- good for neuropathic pain-primarily affects C fibers
- Gluccocorticoids- reduce edema in tumor and nerve tissue, bone mets
- 5% Lidocaine patches-postherpetic neuraligia- on 12 hrs off 12 hrs
EMLA LMX4 Synera (topical)
EMLA- lidocaine/prilocaine combination 45-60 min application, Rx required, patch or cream
- LMx4- 4% Lidocaine- 15 min application, over the counter, cream transparent drsg.
- Synera- Lidocaine (70)/Tetracaine (70) patch
- some blanching of skin
- contraindications: methemoglobinemia (EMLA), allergy to lidocaine
Topical Anesthetics TAC/LAT (LET)
- tetracaine/adrenaline/cocaine
- Lidocaine/adrenaline/tetracaine
- apply to wound with gauze
- 15-20 minute onset
- Do not use on mucous membranes
- No adrenaline on end arterioles
J Tip Compressed Gas Driven Syringe
- Needle Free
- Med Delivered under pressure from compressed gas (Co2)
- Buffered (Sodium Bicarb) Lidocaine
- Delivers SQ 5-8 mm in 2 seconds
- Advantages- no needle, short wait time, no vasoconstriction/blanching
Tissue Adhesives Histoacryl Blue/Cyanoacrylate
- minor laceration repair
- relatively painless
- Decreased time of repair
- Negates need for follow-up
- Cosmetic- as good as if not better
