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Advanced Principles of Anesthesia > Week 10 - Pediatric Chronic and Acute Pain > Flashcards

Week 10 - Pediatric Chronic and Acute Pain Flashcards

1
Q

What are the three types of pain?

A
  1. Nociceptive: somatic (well localized in soft tissue, bone, muscle, skin) and visceral (vague, visceral organs)
  2. Neuropathic: burning, shooting, tingling – damaged sensory nerves
  3. Functional Pain: chronic pain that impacts everyday functioning
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2
Q

What are the four stages of pain processing?

A

Transduction
Transmission
Modulation
Perception

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3
Q

What is the Transduction stage of pain processing?

A

Painful stimulus activates nociceptors

  • mechanoreceptors (ruffini, meissner, pacinian, merkel)
  • thermoreceptors (krause endings)
  • free nerve endings

Damaged tissues release bradykinin, serotonin, histamine, substance P, prostaglandins – generates an electrical impulse along an axon
*going from mechanical stimulus to electrical impulse

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4
Q

What is the Transmission stage of pain processing?

A
  • Electrical stimulus is propagated along axons from the PNS to the CNS
  • Stimulus transmitted by A-delta (glutamate) and C-fibers (substance P)
  • Nociceptors/Free nerve endings –> Peripheral Nerves –> Dorsal Horn (1st order)
  • Spinothalamic Tract –> Thalamus –> Cerebral Cortex (2nd order)
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5
Q

What is the Modulation stage of pain processing?

A
  • Alters incoming noxious stimuli
  • Involves humoral and neural events (endogenous opioid systems, NMDA receptors, serotonin and norepi)
  • Occurs between the thalamus and the brainstem interneurons of the dorsal horn, and descending inhibitory pathways (serotonin and norepinephrine)
  • occurs between the 1st order and 2nd order neurons
  • Descending inhibition
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6
Q

What is the Perception stage of pain?

A
  • Patient “feels” pain
  • Mediated by the cerebral cortex
  • Most variable component of pain pathway – heavily influenced by behavioral, cognitive, affective, sensory, and emotional factors
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7
Q

What is the gold standard to acute pain management in pediatric patients?

A

A multimodal approach

  • maximal analgesic benefit
  • minimal adverse effects

*utilize medications with different mechanisms of action

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8
Q

Explain the pain pathway development for pediatric population

A
  • Nociceptive pathways in the PNS and CNS develop in the 2nd and 3rd trimesters
  • By 26 weeks the fetus responds to tissue injury and inflammation through withdrawal reflexes, ANS arousal, and hormonal stress responses
  • Preterm infants are MORE sensitive to painful stimuli (reduced threshold for withdrawal to noxious stimuli, immature descending inhibitory pathways)
  • Opioid receptors are present at birth, but inflammatory mechanisms are immature (may imply NSAIDs are ineffective in neonates)
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9
Q

What are the long term consequences of untreated neonatal pain?

A

Depression, anxiety, hyperalgesia, allodynia

-BUT… neonates who undergo painful procedures are commonly those who have chronic medical conditions — very difficult to correct for variables in the literature

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10
Q

What are the barriers to pediatric pain management?

A
  • Historically pain undertreated – slow development of reliable and valid assessment tools, myth that infants don’t feel pain
  • Fear of opioid side effects and addiction
  • Lack of evidence-based pain management protocols
  • Inadequate staff education regarding pain assessment and management
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11
Q

How do you assess pain in the pediatric population?

A
  • Requires age appropriate assessment tool – must consider cognitive and developmental level
  • Assessment of postop pain is greatly facilitated by preop introduction of assessment tool
  • For children to understand magnitude and ordinal positions, they must be 7 years old (ie. 0-10 scale)
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12
Q

What is the FLACC behavioral pain scale? What age is it appropriate for?

A

Observational behavioral measure
Ages 2 months to 7 years old

Five behaviors have been shown to be reliable, specific, and sensitive when prediction analgesic requirements: facial expressions, vocalization or cry, leg posture, body posture, and motor restlessness

Indicated for use in medical procedures and postop pain

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13
Q

What is the comfort pain scale? What age is it appropriate for?

A

Developed for use in an ICU setting
0-18 years old

Assesses alertness, calmness/agitation, respiratory response, physical movement, blood pressure, muscle tone, facial tension, and heart rate

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14
Q

What are the Faces Pain Scales? What age are they appropriate for?

A

Wong Baker and Bieri Faces Pain Scales

Reliable and valid for children 3-18 years old

*do not require the concept of magnitude or serration and can be used by preschool aged children

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15
Q

What is the numerical rating pain scale? What age is it appropriate for?

A
  • Self report metrics in which a pt is asked to quantify the severity of pain between 0-10
  • Most accurately reflect ACUTE pain

Good reliability and validity for pts 7-17

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16
Q

How do you assess pain in cognitively impaired children?

A

Revised FLACC for pain assessment in the cognitively impaired

  • children who are cognitively impaired experience pain more frequently because of many inherent conditions
  • difficulty with pain assessment in this population has led to exclusion from research studies/clinical drug trials adding to the deficits in our knowledge
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17
Q

What “number” demands pain intervention?

A

Must consider pain score, behavioral signs, nature of the procedure, parental input, and overall clinical context to direct treatment decisions

18
Q

What is the definition of acute pain?

A

Nociceptive pain resulting from tissue injury, inflammation, or infection

  • most prominent immediately following injury –> gradual improvement over time with tissue repair
  • responds to opioids, non-opioids, neuraxial anesthesia, peripheral nerve blocks, and non-pharmacologic measures
  • rarely progresses to chronic pain

**Plan for addressing acute postop pain during preop period

19
Q

Where can pain be treated?

A

Peripheral Level: local anesthetics, peripheral nerve blocks, NSAIDs, antihistamines or opioids

Spinal Cord Level: local anesthetics, neuraxial opioids, a2 agonists, NMDA receptor antagonists

Cortical Level: opioids, a2 agonists, voltage gated calcium channel agonists

20
Q

What pain therapies are ideal for preterm infants with impaired central respiratory drive?

A

Acetaminophen
NSAIDs
Local Anesthetics

21
Q

When are non-opioid analgesics used in the pediatric population?

A
  • Sole agents for mild pain and as
  • Adjuncts for moderate to severe pain
  • limited by a ceiling effect
  • ideally delivered on a scheduled basis for at least the first few days postop (supplemented with opioids PRN)
22
Q

What is the max dose of acetaminophen for children, neonates, and preterm neonates?

A

Children: 75 mg/kg max

Neonates (32-44 weeks): 60 mg/kg max

Preterm (28-32 weeks): 40 mg/kg

  • 3000mg overall max
  • important to confirm w/ parents in tylenol containing products have been given preop
23
Q

What is the recommended dose schedule for oral administration of acetaminophen in pediatrics?

A

10 mg/kg every 4 hours or 15 mg/kg every 6 hours for a total of 60 mg/kg

24
Q

What are pediatric specific considerations for NSAIDs?

A
  • NSAIDs do not cause increased risk of bleeding
  • Combination therapy with acetaminophen and NSAIDs have a synergistic effect (should be admin at the same time, not alternating)
  • May impair bone healing in pediatric spinal fusion pts

*avoid NSAIDs in kids w/ severe asthma or hyperreactive airways

25
Q

What is the dosing for Precedex in pediatrics?

A

0.5 mcg/kg IV for maximal benefit

26
Q

What is the most commonly used opioid in pediatrics?

A

Morphine

  • dosing is very important due to M6 glucuronide formation (kidney function ok?)
  • < 6 months are at greater risk for opioid-induced respiratory depression
27
Q

What opioid is a better choice for children with hemodynamic instability?

A

Fentanyl

  • avoid histamine release as with morphine
  • commonly admin in 5mcg boluses (1mcg/kg total admin)
28
Q

What age is appropriate for use of a PCA?

A

Most cognitively intact children age 7+

-gives sense of control back to the child

29
Q

What are the benefits of regional anesthesia in the pediatric population?

A

Excellent pain control in children who may not tolerate large doses of opioids

Opioid sparing

Preemptive analgesia prevents “wind up” phenomenon

30
Q

What are contraindications of regional anesthesia in the pediatric population?

A
  • Anatomic anomalies
  • Sepsis
  • Coagulopathy
  • Thrombocytopenia
  • Surgical assessment postop
31
Q

What are regional anesthesia considerations in the pediatric population?

A
  • Will not see sympathectomy with neuraxial anesthesia as in adults
  • Regional anesthesia is performed AFTER pt is alseep
  • <6 months requires VERY careful attention to dosing (decreased protein binding –> increased risk of toxicity)
32
Q

What are local anesthetic considerations for the pediatric population?

A

Neonates and young infants have decreased plasma proteins (a1aG) –> increased free fraction of LA

33
Q

What is the max dose of lidocaine?

A

5 mg/kg plain

7 mg/kg with epi

34
Q

What is the max dose of Bupivacaine?

A

2.5 mg/kg plain

3 mg/kg with epi

35
Q

What is the max dose of ropivacaine?

A

2.5 mg/kg plain

36
Q

What are the neuraxial anesthesia techniques used in the pediatric population?

A

Caudal: most common – analgesia of lower extremities and lower abdomen

Epidural: catheter left in <3 days to minimize infection risk – standard of care for pain management of open abdominal surgery

Spinal: provides surgical anesthesia, no other sedation needed, commonly used for urology procedures and other procedures of the lower extremity

37
Q

When can a pediatric patient go home after neuraxial anesthesia?

A

Whenever they show spontaneous movement of the lower extremities

-need to show evidence of the block wearing off prior to discharge

38
Q

What are non-pharmacologic pain interventions for the pediatric population?

A

Cognitive: distraction, imagery hypnosis

Behavioral: relaxation, play therapy, biofeedback

Physical: massage, heat/cold, acupuncture

39
Q

What is the definition of chronic pain?

A

Pain that persists beyond the expected time of tissue healing – 3-6 months

  • may begin as acute pain and transition to chronic
  • may continue due to re-injury or the persistence of noxious stimuli
  • may exist in the absence of identifiable pathology

*multidisciplinary approach to chronic pain management is essential

40
Q

What are the risk factors for pediatric chronic pain development?

A
  • Underlying depression and anxiety
  • History of abuse
  • Female
  • Family dynamics
  • Certain medical conditions (Sickle cell anemia, Cystic fibrosis, Epidermolysis bullosa, Cancer)
  • Pain as the primary pathology (Abdominal pain, Headaches, Back pain)
41
Q

How do you treat acute on chronic pain in the pediatric population?

A

Patients with chronic pain presenting to the OR

  • identify their current treatment plan and continue throughout the perioperative period – add medications on top of current treatment to treat the acute pain
  • consult institutional pain service for recommendations

Advanced Principles of Anesthesia (31 decks)

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