how to manage acute pain klas internasional

7/27/2019 How to Manage Acute Pain Klas Internasional

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How to Manage Acute Pain in

Neonate and Infant

Elizeus Hanindito

Dept. of Anesthesiology & Reanimation

Medical Faculty of Airlangga University dr.Soetomo General

Hospital

S U R A B A Y A


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Definition of Pain

Nyeri adalah rasa inderawi dan pengalaman emosional

yang tidak menyenangkan akibat adanya kerusakan

jaringan yang nyata atau yang berpotensi rusak atau

sesuatu yang tergambarkan seperti itu


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Proportion of NICUs Treating Pain During Invasive

Procedures *

* Pain management in NICU , Lago P. J Ped Anesthesia 2005


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60% of adult patients in the ED received

analgesia for burns & fractures compared

with 28% of pediatric patients.Selbst & Clark . Sedation & Analgesia in the ED 1990.

Pain is not recognized

Misconception of pediatric pain

Fear of respiratory depression & hypotensionFear of masking symptoms

Unfamiliarity with analgesics,doses

Inadequate training of medical professional


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CommonMisconceptions(Myths)

Myth 1 : the neural & endocrine systems of the

newborn infant are not developed to the

stage that allow for transmission of pain-

ful stimuli. That they cannot feel pain.Myth 2: newborn infants cannot remember pain

and therefore,there can be no sequelae.

Myth 3 : pain cannot be assessed in the newborninfants.

Myth 4 : newborn infants are easily comforted

without analgesics.


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CommonMisconceptions(Myths)

Myth 5 : it is unsafe to administer opioids to infants

and that infants often suffer respiratory

depression following administration of

opoids.

Limited clinical information.

Limited available research and acces.


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Neonates experience pain evenmore than older infants !

Adaptive mechanisms do not

develop until 32-36 weeks ofpostconceptional age


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Why treat pain ?

Treatment & alleviation of pain

are a basic human right !

regardless of age

Fishman SM. Recognizing Pain Management as a Human Right: A First StepAnesthesia Analgesia 2007.


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Neuroanatomy& Neurophysiology

Density of cutaneous nociceptive nerve endings~ adults.

Nociceptive tracts have completed by the end of

third trimester.Substance P and its receptors are detectable inthe fetal dorsal horn at 12 to 16 wks.

Concentration of beta-endorphin increase in

response to stress.A marked release of catecholamines, growthhormone, cortisol and glucagon occurs.

Andrews KA. The Human Developmental Neurophysiology of Pain.

Pain in Infants,Children and Adolescents 2nd Ed 2003.


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Short-term effects

Adverse short-term consequences:

Physiologic & biochemical sequelae:

hyperglycemia,protein catabolism,oxygen

consumption,gut motility,heart rate,bloodpressure.(Barker DP et al. Arch Dis Child Fetal Neonatal Ed. 1996; 75:F187)

Exposure of preterm neonates torepetitive pain and stress leads to clinicalinstability and complications(KJS Anand. Crit Care Med 1993; 21: S358)


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Long-term effects

Adverse long-term consequences:

Circumcision (without analgesia) increases

pain response to subsequent vaccination

(Taddio A et al: Lancet 1997;349: 599)

Permanent structural and functional

changes may occur in infants exposed tomultiple painful and stressful events(Porter FL et al: J Dev Behav Pediatr 1999;20:253)


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Sustained physiologic,anatomic & behavioural changes result

from repetitive or prolonged exposure to noxious stimuli.

Consequence 25 wk

PCAFull term 4-6 mo 1-2 yr 4 yr 10 yr

Hyperalgesi :

Sensitization:

Physiologic

destabilsation:

Behavioural

changes :

Personality

effects :

Yes

yes

Yes

Yes

?

Yes

Yes

Yes

Yes

?

Probably

?

?

Yes

?

?

?

?

Probably

Probably

?

?

?

Possibly

Possibly

?

?

?

?

Possibly

Anand KJ,Kenneth RG.Longterm Consequences of Pain in Neonates.

Pain in Infants Children and Adolescents 2ndEd 2003


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Pain management begins with an assessmentof the childwith pain .

Not only the explicit pain features but also the situational factors

that modulate pain-measurement of infant pain is just oneaspect ofcomprehensive pain assessment.

Pain is private & subjective, can only be accessed & measured

by indirect method.

Health care facilities now identify pain assessment as the 5th

vital signs.

Pediatric Pain Assessment

Gaffney A et al. Measuring Pain in Children: Developmental & Instrument Issues.

Pain in Infants,Children and Adolescents 2nd Ed 2003.


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Pediatric Pain Assessment

Behavioural parameters

Physiological parameters

Biochemical parameters

Self-Reporting measures

Unidimensional tool

Multidimesional tool

Anand KJS.Pain and Pain Management during Infancy.Research and Clinical Forum 1998


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Behavioural Parameters

Crying characteristics.

Facial expressions.

Simple motor responses.

Complex behavioural responses.

More specific and consistent thanphysiological measurements.


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Facial Expression of Physical

Distress

NASO-

LABIAL FOLD

deepened


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Physiological Parameters

Heart rate.

Respiratory rate.

Blood pressure.Palmar sweating.

Vagal tone.

Oxygen saturation.Transcutaneous O2/CO2.

Intracranial pressure.

Objective,Precise , but

Not specific for pain


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Biochemical Parameters

Catecholamines : Epinephrine, Norepinephrine.

Cortisol : blood, saliva, or urine.

b-EndorphinGrowth hormone, glucose, glucagon, renin,

aldosterone, and lactate have also been noted

to increase with pain.

Insulin secretion is usually suppressed.


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Newborn Pain Assessment Tools

FLACC (Face,Legs,Activity,Cry,Consolability).

PIPP (Premature Infant Pain Profile).

CRIES (Crying,oxygen Requirement,Increased vitalsigns,Expression and Sleeplessness).

NIPS (Neonatal Infant Pain Scale).

N-PASS (Neonatal Pain Agitation and SedationScale).

NFCS (Neonatal Facing Coding System).


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Childrens Hospital of Eastern Ontario Pain Scale

(CHEOPS)

Score 0 1 2

Cry

Facial

Verbal

Torso

Legs

smile

+

neutral

neutral

+

composed

shifting/tense

kick/squirm

scream

grimace

pain complaint

restraint

restraint


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Self-Report Measures

Self-report measures.

Poker Chip Tool (Hester)

Faces Scale (Bieri)Visual Analog Scale (VAS)

Oucher Scale (Beyer & Wells)

Pain Diary

Anne G,Patrick JM. Measuring Pain in Children:Developmental & Instrument Issues

Pain in Infants,Chidren and Adolescents 2ndEd 2003


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Validity & Reliability

Validity :

the ability of the pain tool to measure pain as an

isolated condition differentiated from other condition,

such as distress and agitationReliability :

the tools ability to consistently score pain each time the

tool is used (test-retest reliability) and when different

people use the tool (interrater reliability).

Easy to administer at the bedside.

appropriate for the gestational age.


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Procedural Pain in NICU

> 10/day several hundred in the course

of a prolonged admission.

Procedural intervention :

*tracheal suctioning

* heel lancing

* venepuncture

* lumbar puncture

* chest tube insertion

* tracheal intubation

* Pain management in NICU , Lago P. J Ped Anesthesia 2005


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Prevention of pain is the best approach to pain

management :

*suctioning the infant on an as needed basis

*limiting the number of painful procedure

*skilled person to perform painful procedure

*method by which we performs the procedure

(venipuncture vs heel stick)

Pharmacologic and nonpharmacologic approach.

Neonatal pain management


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Pharmacologic Intervention

Nonsteroidal antiinflammatory drugs.

Intermittent/continuous narcotic.

Patient-controlled analgesia.Peripheral nerve block.

Regional anesthetic techniques.

American Academy of Pediatric,Canadian Paediatric Society,Committee on

Drugs,Committee on Fetus and Newborn and Section on Anesthesiology

Prevention and Management of Pain and Stress in the NeonatePediatrics 2000


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Nonpharmacologic Intervention

Oral sucrose,non-nutritional sucking

Minimal handling protocols

Lowering noise levels in NICUAvoiding exposure to bright lights

Swaddling , nesting.

American Academy of Pediatric,Canadian Paediatric Society,Committee on

Drugs,Committee on Fetus and Newborn and Section on Anesthesiology

Prevention and Management of Pain and Stress in the NeonatePediatrics 2000


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Pain in pediatric trauma

Trauma Pediatric Morbidity & Mortality

(USA : 500.000 hospitalization 15.000 20.000

deaths/year).

Pain management :

* Emergency phase.

* Healing phase.

* Rehabilitation phase.

The first priority is preservation of life and

stabilization.

Rose JB. Pain Management for the Pediatric Trauma

Revista Mexicana de Anestesiologia 2004


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Ideal Analgesic in the ED

Rapid onset.

Short duration of effect.

Easily administered.Effective analgesia.

Minimal side effects.


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NSAIDs

Minimal sedation , emetic effect.

Mild-moderate pain.

Analgetic ceiling effect.Opioid sparing effect.

Contraindication:

coagulation disorder.asthma.

renal/liver disease.


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DRUG LOADING

DOSE

(mg/kg)

MAINTENANCE

DOSE

(mg/kg)

INTERVAL

(hours)

DAILY MAX

DOSE

(mg/kg)

KetoprofenIbuprofen

Naproxen

Diclofenac

Ketorolac

210

10

2

0.5

110

5

1

0.25

6-86-8

8-12

6-8

6-8

540

15

3

2

NSAID Doses in Children

Ketoprofen continuous : Loading dose 1 mg/kg in 15 minutes,infusion 3-5 mg/kg/24 h

Kokki H. Use.Abuse and Misuse of NSAIDS in Children

European Journal of Anesthesiology 2005


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Paracetamol Dosing in Children

Orally :

20 mg/kg loading dose.

15 mg/kg 4-8 hourly.

Rectally :

30-45 mg/kg loading dose.

20 mg/kg 6-8 hourly.

Maximum 90 mg/kg/day (neonate 60mg/kg/day).


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Ketorolac tromethamine

Effective for moderate postoperative pain.

Has a significant opioid-sparing effect.

Not recommended for < 1 year.


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Recommended dosage & duration of

ketorolac therapy in children

Intravenous :Initial dosage 0.5 mg/kg.

Subsequent dosage 1.0 mg/kg q6h.

I.V. infusion 0.17 mg/kg/h.

Maximum daily dosage 90 mg.

Maximum duration 2 days.

Oral :

Oral dosage 0.25 mg/kg q6h.Maximum daily dosage 1 mg/kg.

Maximum duration 7 days.

Use of intravenous ketorolac in the neonate and premature


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Use of intravenous ketorolac in the neonate and premature

babies.

Papacci P et al. pediatric Anesthesia 2004.


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Opioids

Morphine or Fentanyl most often used.

Avoid Demerol (Meperidine)

Requires frequent and thorough

assessment of adequacy of pain relief

and possible side effects

< 6 months continuous respiratory

monitoring:

* < 1 month : 9 hours

* 1-6 months : 4 hours

After the last

administraton


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Estimated Values for Vd t1/2 CL

of Morphine

Vd

(L/kg)

t1/2

(h)

CL

(ml/min/kg)

Preterm 2.8 + 2.6 9.0 + 3.4 2.2 + 0.7

Term 2.8 + 2.6 6.5 + 2.8 8.1 + 3.2

Infants &children 2.8 + 2.6 2.0 + 1.8 23.6 + 8.5

Kart T, Lona L. Recommended Use of Morphine in Neonates,Infants and Children Based on Literature

Review : Part 1 Pharmacokinetics.Pediatric Anesthesia 1997.


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Morphine Dosing

Infusion :

* 100 g/kg/hour for 2 hours.

* Followed by 10-30 g/kg/hour.Intermittent Dosing :

* 50-200 g/kg/dose i.v. slowly.

* repeat as required usually 4 hourly.Fentanyl 1-2 g/kg/hour


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Recommended Starting Setting for

PCA in Children

Recommended drug concentration is morphine

1 mg/kg in 0.9% saline 50 ml.

Bolus dose 0.02 mg/kg ; maximum 1 mg.

Lock-out time 5-10 minutes.Frequency range 5 boluses/hour.

Background infusion 4 ug/kg/h.


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Opioids Side Effects

Morphine :

Respiratory depression apnea

HypotensionUrinary retension

Fentanyl :

Bradycardia hypotensionChest-wall rigidity

Naloxone : 0.1-0.2/kg/dose (antidote)


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Check patient before administering

Rousable to voice or light touch.

Respiratory rate >20(infant) ,>30(neonate)

Heart rate is appropriate.


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Sedatives: benzodiazepines

Benzodiazepines : NOT analgesics.

sedative-hypnotic, amnesic, anxiolytic, muscle relaxant,and anti-epileptic properties.

Midazolam :

short half-life and is approved by the FDA for neonataluse. Although an effective sedative, it can causeabnormal movements and adverse hemodynamiceffects .

Dose: 0.1 mg/kg IV over 5 min q2-4h. Can also beused continuous IV (10-50 mcg/kg/h), intranasal,sublingual, oral.

Diazepam not recommended due to long half-life.

Flumazenil 0.01 mg/kg/dose (antidote)


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Precaution Needed for Use of

Sedation/Analgesia in the ED

Appropriate personnel

MonitoringEquipment

Medication

Selbst SM,Zempsky WT. Sedation & Analgesia in the ED.

Pain in Infants Children and Adolescents 2nd Ed 2003.


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Caudal epidural analgesia

Most popular central block

Easiest & safest approach

Excellent analgesia-painfree awakening

Applicable to children of all ages


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Caudal epidural catheter

Easier to place than lumbar

Easily passed cephalad

Never forcibly advance the catheter against

resistance


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Caudal Bupivacaine + Clonidine

1-2 ug/kg.

Prolonged the duration of caudal block.

Postoperative sedation + .Favorable analgesia-to-side effect profile.


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Caudal Bupivacaine + Opioids

Morphine : 20-40 ug/kg ; 75 -100 ug/kg.

Fentanyl : 0.5-1.0 ug/kg.

Postoperative sedation + .Respiratory depression,nausea/vomiting,

urinary retention.


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Peripheral Nerve Block

Penile block.

Ilioinguinal nerve block.iliohypogastric nerve block.


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Brachial Plexus Block

Interscalene approach.

Parascalene approach.

Subclavian approach.

Supraclavicular approach.

Axillary approach.


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Axillary approach


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how to manage acute pain klas internasional

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