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© The Children's Mercy Hospital, 2015
Kimberly Hartman, MDAssistant Professor of Pediatrics
Department of Pediatric Rehabilitation MedicineChildren’s Mercy Hospital
Kansas City, MO
Procedure-related Pain
Objective
Recognize methods to manage procedural pain
Pain + anxiety distress
2
3
Common Procedures
Chemodenervation
Botulinum toxin
Phenol
Intrathecal Baclofen Pump refill
EMG
Trigger point injections
4
Why?
Needle-based procedures induce high levels of distress:
83% toddlers (2.5-6yo)
51% children (7-12yo)
28% adolescents (≥12yo)
ED: IM injections reported in top 5 most painful and distressing procedures
Inpatients: procedural pain reported as greater than disease-related and surgical pain
Humphrey 1992; Babl 2008; Shomaker 2015
5
Acute Implications
Increased distress:
Patient
Parent
Providers
Inability to perform procedure accurately or completely
Increased time spent in procedure
Walco 2008; Smith 2007; Kennedy 2008
6
Memory
Memory can shape future reactions to painful events
Stressful experience recalled up to years later
Adults report distress based on childhood experiences
Painful event
Remembered pain
Walco 2008; von Baeyer 2004; Noel 2002; Pate 1996
7
Remembered Pain
von Baeyer 2004
• Decreased reaction over time• Milder pain, more mature copingHabituation
• Increased reaction over time ± reduced pain threshold
• More severe pain, younger kids, less mature coping
Sensitization
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Long-term Implications
Increased anticipatory anxiety
Increased pain perception
Diminished analgesic effectiveness
Adults: Needle fear (25%) or phobia (10%)
Avoidance of medical care
Walco 2008; Taddio 1997; von Baeyer 2004; Weisman 1998; Hamilton 1995; Rocha 2003
Quality >> Quantity
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Clinical Scenario
3yo male with cerebral palsy presents for toxin procedure.
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Factors to Consider
Developmental age
Patient temperament
Parental anxiety
Culture
Prior patient experiences with procedure
Type of procedure
Procedure duration
Bearden 2012; Kristjansdottir 2012
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Management
Procedural
Physical
Psychological
Pharmacological
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> 60 minutes
30-60 minutes
1-2 minutes
At time of procedure
Procedural
Physical
Psychological
Pharmacological
Preparation
Taddio 2012
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Procedural
Needle size
Injection volume
Simultaneous injections
No evidence higher Gauge is better
Patients need to be aware of pressure sensation
Taddio 2009; Goodenough 2000; Beirne 2015; Price 2009; Hanson 2010
May have decreased pain behaviors
14
Procedural
No aspiration and rapid injection speed
Less painful formulation injected first
Sitting up or holding (vs. supine)
Less pain and no negative effects (for IM imms)
Similar to less painful site first?
Safety concerns? Access to site?
Taddio 2009; Goodenough 2000; Beirne 2015; Price 2009; Howard 2012
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Physical
Stroking skin
Pressure
Cold
Vibration
Vibration + cold
Swaddling, tucking, kangaroo care (infants)
Decreased pain with IM immunizations unknown if translates to Rehab procedures
Taddio 2009; Sahiner 2015; Howard 2012; Pillai Riddell 2012
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Physical
• Sucrose 24%
• Glucose 30%
• Breast-feeding
• Non-nutritive sucking
Non-nutritive sucking (≤ 3 years)
No benefit:
Sweet gum
Lollipop
Sucrose
Infants ˂12 months Children ˃ 12 months
Harrison 2010; Kassab 2012; Harrison 2015
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Vapocoolant
Rapidly cools skin slows initiation & conduction of impulses in sensory nerves and increase refractoriness
Mixed results
IM: in 4-6yo, can increase pain
IV: no significant pain reduction in children
EMG (adults): more effective than EMLA cream or no treatment
Cohen 2009; Hogan 2014; Moon 2013; MacLaren 2007; Howard 2012; Zempsky 2012
Fast and cheap
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Psychological: Preparation
What will happen
How it will feel
What will be done for pain
How child can help
Demonstration
Taddio 2012; Slifer 2011
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Parent Preparation
• Calm
• Coaching to cope
• Distraction
Anxious
Apologizing
Criticizing
Reassuring
Empathizing
Positive strategies Negative strategies
Jones 2005; Taddio 2012
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Distraction
Distraction more beneficial than reassurance
Parent involvement
Specialist involvement (i.e., Child Life, Music)
No/low tech vs. high tech
Interactive vs. passive
Child choice vs. no child choice
McMutry 2010; Birnie 2014; Uman 2013
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Reframing Memory
Recall of positives:
– Portions of procedure (“You held really still”)
– Positive coping strategies (“You did a great job taking deep breaths”)
May be able to create more adaptive memories
Chen 2000
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Pharmacological
Topical
Enteral
Sedation
Anesthesia
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Local Anesthetic
Anesthetic Dosage forms
Application time (minutes)
Lidocaine 2.5% - prilocaine 2.5%
CreamGelPatch
60-90
Liposomal lidocaine 4%
Cream 30
Lidocaine 7% - tetracaine 7%
Heat patch
20-30
Occlusive dressing helps permeate
Inject within 1h of removal
Does not treat anxiety or pressure sensation
Main side effects are local
Methemoglobinemia at high doses
Things to consider
Taddio 2012;Zempsky 2012
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Enteral Analgesic
Few studies with decreased local reaction (acetaminophen)
No studies for acute pain during procedure
? Benefit for soreness after procedure
Taddio 2012
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Sedation
Minimal sedation
Moderate sedation
Deep sedation
General anesthesia
Patient response
Normal Purposeful response
Cannot be easily aroused
Not arousable
Protective airway reflexes
Maintained Maintained Partial or complete loss
Partial or complete loss
Ventilation Spontaneous Spontaneous May be impaired
Impaired
CV function Maintained Maintained Usually maintained
May be impaired
Cote 2006
26
ASA Physical Status Classification
Class I A normally healthy patient
Class II A patient with mild systemic disease (eg, controlled reactive airway disease)
Class III A patient with severe systemic disease (eg, a child who is actively wheezing)
Class IV A patient with severe systemic disease that is a constant threat to life (eg, a child with status asthmaticus)
Class V A moribund patient who is not expected to survive without the operation (eg, a patient with severe cardiomyopathy requiring heart transplantation)
Cote 2006
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Midazolam
Short-acting benzo
Effects
Skeletal muscle relaxation
Amnesia
Anxiolysis
No analgesic properties
Enteral Intranasal Intravenous
Dose 0.3-0.75 mg/kg
0.2-0.4 mg/kg 0.05-0.1 mg/kg repeated q3-4 minutes (total 0.5-0.7 mg/kg)
Onset 15 min 10-15 min 2-3 min
Zempsky 2012
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Nitrous Oxide
Analgesic
Anxiolytic
Weak sedative
Onset: minutes
Offset: rapid when gas discontinued
Minimal CV or respiratory effects alone
Zempsky 2012; Pedersen 2013; Brochard 2009
29
Nitrous Oxide + EMLA
Prospective
N = 51 sessions (4-8 sites)
Ave age: 5.94 years
In 49%, CHEOPS was above threshold of 9
Four children had “major cognitive problems;” average CHEOPS 12.5 ± 2.1
No predictive factors
Brochard 2009
30
Midazolam vs. Nitrous Oxide
RCT
N = 50
Ages 1-17yo
Range of GMFCS
All: topical anesthetic and verbal distraction
All equally sedated at time of BoNTA procedure
Midazolam group: longer sedation after
NO group:
decreased FLACC scores
decreased parental and nurse report of pain
Zier 2008
31
Moderate Sedation & Beyond
• Pentobarbital
• IV Propofol
• IV Dexmedetomidine
Fentanyl
Ketamine
Sedatives Analgesics
Zempsky 2012
32
Anesthesia Risks
Increase in programmed cell death
Rodents:
Impaired memory
Behavioral abnormalities
Primates:
Slower response speed
Poorer performance in learning
Lower motivation
Ing 2012; Sanders 2013
33Sanders 2013
34
QI Data
N = 311
LMX or Vapocoolant in clinic
Mean pain score (FACES):
During 3.6 (max 10)
After 0.47 (max 9)
23 patients (7%) went to sedation due to high pain score
35
Standard of Care?
Howard 2012
36
Summary
Untreated procedure-related pain & anxiety has short- and long-term consequences
Treatment needs to be based on individual characteristics and developmental age
Procedural and physical adaptations can help but may not be feasible
Distraction helps
Topical anesthetic helps
Sedation/anesthesia: weigh risks & benefits
Questions: [email protected]
37
Future Directions
More research on toxin procedures and procedural pain in children with neurodevelopmental disabilities
Consensus on toxin procedure distress management: what is the standard of care?
39
Discussion