procedural pain mangement in children

8/14/2019 procedural pain mangement in children

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Procedural Pain Management

in Children

Janlyn RozdilskyRN MN CNCCP(C)

Clinical Nurse Educator

PICU Royal University Hospital

Saskatoon, Sask

When do we inflict pain? Needle Pokes -Venupuncture,IV starts

Lumbar punctures Fracture examination,reduction, casting

Laceration repair

Dressing changes

Tube Insertion-Foley catheter,Gastric

tube, endotracheal tube

Key Definitions

Analgesic-reduces or eliminates theperception of pain

ex: opiods, NSAIDS

Sedation-reduces awareness: it doesnot relieve pain.

May causes hypnosis (sleep)

ex: benzodiazapines

Amnesic-inability to remember an event

or experience

Most analgesics have somesedative properties, but manysedatives lack analgesiceffects.

Levels of ProceduralAnalgesic/Sedation

Minimal Sedation Antiolysis

Does not effect respiratory or

cardiovascular functions

Patients respond to verbal commandsbut may have impaired cognitive

function and coordination


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Narcotics Narcotics remain gold standard for

treatment of moderate to severe pain

Do not give IM!!

Use for invasive & painful proceduressetting fracture, burn dressing, chesttube, intubation

Morphine Dose: 0.05-0.1 mg/kg

Onset: 5-10 minutes Duration: 2-4 hrs.

Safe medication in most children.

May have some hemodynamic compromise

in hypotensive child due to histaminerelease

Fentanyl 50-100 times more potent than morphine with

less sedation, less respiratory depression &less hypotensive side effects

Dose: 1-2 mcg/kg IV

Onset: 2-3 minutes

Duration 20-60 minutes

Rarely produces chest wall rigidity requiringassisted ventilation

Consider continuous infusion if using for more

than procedure

Other Narcotics

Codeine

has to be converted

Ineffective in 1/3 of people

No IV form

Remifentanyl-very short acting so usefulfor short, painful procedures

ex: fracture reduction

Sufentinil-used primarily in OR

Narcotic Reversal-Naloxone Provide respiratory assistance first, then

consider if reversal needed.

Titrate Narcan in small aliquots (0.001-0.01

mg/kg) until respiratory efforts satisfactory Complete, sudden reversal will result in acute

pain that can trigger sudden hypertension andpulmonary edema

May have to repeat doses as not as long

acting as some narcotics

Ketamine Dissociate anesthetic agent providing

analgesia, sedation, and amnesia

Dose 1-2 mg/kg IV

Duration 15-20 minutes Use with atropine to diminish oral

secretions & small dose Midazolam toreduce hallucinations

Contraindicated with braininjury/inflammation


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Nitrous Oxide- Laughing Gas

Antiolytic, analgesic, amnesic

Give for 3-4 minutes prior to procedure Often augmented with local anesthetic,

narcotics, or acetaminophen

Recover with oxygen


Inhaled mixed 1:1with oxygen

Self administeredby demand valve,scented mask, orwhistle device


Best effects in children over 3 years asmore compliant with inhalation technique

Not for use with asthma, pneumothorax,head injury or ocular problems

Worker protection required


Used extensively in UK, Europe, &Australia by non-Anesthesiologists

Minor side effects only-nausea, vomiting,hallucinations, euphoria, restlessness

Putting it all together:Case Study

Tommy, a 8 year old boy, arrives at

your ER with his father. He is holdinghis left wrist against his body. Tears arerolling down his cheeks and he lookspale. His parents tell you they think hiswrist is broken. He fell whilesnowboarding down the neighborhood

hill with his friends. How do youproceed?

Assessment

Airway, Breathing, Circulation

Disability-alert and orientated, obvious

deformity of Left wrist but pulse, color,sensation good. Tommy crys outwhenever limb moved or touched. Herates pain 10 out of 10 with movement oflimb and 7 out of 10 when limb not

moved.


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Focused history: AMPLE

No allergies, no regular medications, nocomplex medical history, last ate atnoon (2 hrs ago), slipped backward onsnowboard and put hand down forsupport, was wearing helmet. Walkedhome about 2 blocks. Incidenthappened about 20 minutes ago.

Non-pharmacological Methods

Involve Tommy & his Dad in care Explain what is going to happen

Support limb/limit movement-let childcontinue to splint. Remove clothing afterpain medication given

Elevation

Cold packs

Pharmacological

Start IV with topical anesthetic

Examine for ease of IV start

Get history from child if has had IV

Give Tommy choice as IV with or withouttopical preparation as fracture pain rated assevere

Nitrous oxide administration for IV start

Give Morphine as ordered as soon as IV in(prior to removing clothing, x-ray &extensive exam)

Advocate for gentle examinations, allowingchild to move and position limb

Give Morphine regularly until wristreduction/casting complete

Teach family to manage pain at home withibuprofen/acetomenophren , elevation, cold

packs, sling & to return if pain uncontrolled

What can we do tomake it better?

Anticipate the procedure and advocate

for the child!

Differentiate between analgesic &sedation

Attend to environmental comfort-temp,lighting, too many people

Let parents/caregiver have choice aboutbeing present and show them how tohelp

What can we do tomake it better?

Treat pain first-anxiety often comes from beingin pain

Provide maximum treatment for the firstprocedure to build trust

Combine pharmacological and non-pharmacological techniques for synergisticeffects

Teach families how to assess & manage painfollowing procedure


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References Annequin, D., Carbajal, R., Chauvin P., Gall O., et al. 2000. Fixed 50% nitrous

oxide oxygen mixture for painful procedures: A French survey. Pediatrics 105(4)

http://pediatrics.aappublications.org/cgi/content/full/105/4/e47

Burnweit, C, Diana-Zerpa, J. A., Nahmad, M. H., Lankau C, A., et al. 2004.

Nitrous oxide analgesia for Minor pediatric surgical procedures: An effective

alternative to conscious sedation? Journal of Pediatric Surgery 39(3) 495-499

Cattell, V. 2005, October. Pediatric Pain Management in the ER. Presentation to

Pediatrics 2005 Conference, Saskatoon.

Mattick, A. 2002. Use of tissue adhesives in the management of paediatric

lacerations. Emergency Medicine Journal 19, 382-385.

Prodedural Sedation 2001. PALS Provider Manual . American Heart and Stoke

Foundation

Razzi, M. 2006, Februrary. Pediatric Anesthesia: Whats New? Unpublished

presentation at PICU Education Day, Royal University Hospital, Saskatoon

Young, K. D. 2005. Pediatric procedural pain. Annals of Emergency Medicine 42

(2) 160-171.

procedural pain mangement in children

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