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© The Children's Mercy Hospital, 2015 Kimberly Hartman, MD Assistant Professor of Pediatrics Department of Pediatric Rehabilitation Medicine Children’s Mercy Hospital Kansas City, MO Procedure-related Pain

© The Children's Mercy Hospital, 2015 Kimberly Hartman, MD Assistant Professor of Pediatrics Department of Pediatric Rehabilitation Medicine Children’s

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Page 1: © The Children's Mercy Hospital, 2015 Kimberly Hartman, MD Assistant Professor of Pediatrics Department of Pediatric Rehabilitation Medicine Children’s

© 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

Page 2: © The Children's Mercy Hospital, 2015 Kimberly Hartman, MD Assistant Professor of Pediatrics Department of Pediatric Rehabilitation Medicine Children’s

Objective

Recognize methods to manage procedural pain

Pain + anxiety distress

2

Page 3: © The Children's Mercy Hospital, 2015 Kimberly Hartman, MD Assistant Professor of Pediatrics Department of Pediatric Rehabilitation Medicine Children’s

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Common Procedures

Chemodenervation

Botulinum toxin

Phenol

Intrathecal Baclofen Pump refill

EMG

Trigger point injections

Page 4: © The Children's Mercy Hospital, 2015 Kimberly Hartman, MD Assistant Professor of Pediatrics Department of Pediatric Rehabilitation Medicine Children’s

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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

Page 5: © The Children's Mercy Hospital, 2015 Kimberly Hartman, MD Assistant Professor of Pediatrics Department of Pediatric Rehabilitation Medicine Children’s

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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

Page 6: © The Children's Mercy Hospital, 2015 Kimberly Hartman, MD Assistant Professor of Pediatrics Department of Pediatric Rehabilitation Medicine Children’s

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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

Page 7: © The Children's Mercy Hospital, 2015 Kimberly Hartman, MD Assistant Professor of Pediatrics Department of Pediatric Rehabilitation Medicine Children’s

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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

Page 8: © The Children's Mercy Hospital, 2015 Kimberly Hartman, MD Assistant Professor of Pediatrics Department of Pediatric Rehabilitation Medicine Children’s

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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

Page 9: © The Children's Mercy Hospital, 2015 Kimberly Hartman, MD Assistant Professor of Pediatrics Department of Pediatric Rehabilitation Medicine Children’s

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Clinical Scenario

3yo male with cerebral palsy presents for toxin procedure.

Page 10: © The Children's Mercy Hospital, 2015 Kimberly Hartman, MD Assistant Professor of Pediatrics Department of Pediatric Rehabilitation Medicine Children’s

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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

Page 11: © The Children's Mercy Hospital, 2015 Kimberly Hartman, MD Assistant Professor of Pediatrics Department of Pediatric Rehabilitation Medicine Children’s

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Management

Procedural

Physical

Psychological

Pharmacological

Page 12: © The Children's Mercy Hospital, 2015 Kimberly Hartman, MD Assistant Professor of Pediatrics Department of Pediatric Rehabilitation Medicine Children’s

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> 60 minutes

30-60 minutes

1-2 minutes

At time of procedure

Procedural

Physical

Psychological

Pharmacological

Preparation

Taddio 2012

Page 13: © The Children's Mercy Hospital, 2015 Kimberly Hartman, MD Assistant Professor of Pediatrics Department of Pediatric Rehabilitation Medicine Children’s

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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

Page 14: © The Children's Mercy Hospital, 2015 Kimberly Hartman, MD Assistant Professor of Pediatrics Department of Pediatric Rehabilitation Medicine Children’s

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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

Page 15: © The Children's Mercy Hospital, 2015 Kimberly Hartman, MD Assistant Professor of Pediatrics Department of Pediatric Rehabilitation Medicine Children’s

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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

Page 16: © The Children's Mercy Hospital, 2015 Kimberly Hartman, MD Assistant Professor of Pediatrics Department of Pediatric Rehabilitation Medicine Children’s

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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

Page 17: © The Children's Mercy Hospital, 2015 Kimberly Hartman, MD Assistant Professor of Pediatrics Department of Pediatric Rehabilitation Medicine Children’s

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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

Page 18: © The Children's Mercy Hospital, 2015 Kimberly Hartman, MD Assistant Professor of Pediatrics Department of Pediatric Rehabilitation Medicine Children’s

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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

Page 19: © The Children's Mercy Hospital, 2015 Kimberly Hartman, MD Assistant Professor of Pediatrics Department of Pediatric Rehabilitation Medicine Children’s

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Parent Preparation

• Calm

• Coaching to cope

• Distraction

Anxious

Apologizing

Criticizing

Reassuring

Empathizing

Positive strategies Negative strategies

Jones 2005; Taddio 2012

Page 20: © The Children's Mercy Hospital, 2015 Kimberly Hartman, MD Assistant Professor of Pediatrics Department of Pediatric Rehabilitation Medicine Children’s

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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

Page 21: © The Children's Mercy Hospital, 2015 Kimberly Hartman, MD Assistant Professor of Pediatrics Department of Pediatric Rehabilitation Medicine Children’s

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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

Page 22: © The Children's Mercy Hospital, 2015 Kimberly Hartman, MD Assistant Professor of Pediatrics Department of Pediatric Rehabilitation Medicine Children’s

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Pharmacological

Topical

Enteral

Sedation

Anesthesia

Page 23: © The Children's Mercy Hospital, 2015 Kimberly Hartman, MD Assistant Professor of Pediatrics Department of Pediatric Rehabilitation Medicine Children’s

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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

Page 24: © The Children's Mercy Hospital, 2015 Kimberly Hartman, MD Assistant Professor of Pediatrics Department of Pediatric Rehabilitation Medicine Children’s

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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

Page 25: © The Children's Mercy Hospital, 2015 Kimberly Hartman, MD Assistant Professor of Pediatrics Department of Pediatric Rehabilitation Medicine Children’s

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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

Page 26: © The Children's Mercy Hospital, 2015 Kimberly Hartman, MD Assistant Professor of Pediatrics Department of Pediatric Rehabilitation Medicine Children’s

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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

Page 27: © The Children's Mercy Hospital, 2015 Kimberly Hartman, MD Assistant Professor of Pediatrics Department of Pediatric Rehabilitation Medicine Children’s

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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

Page 28: © The Children's Mercy Hospital, 2015 Kimberly Hartman, MD Assistant Professor of Pediatrics Department of Pediatric Rehabilitation Medicine Children’s

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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

Page 29: © The Children's Mercy Hospital, 2015 Kimberly Hartman, MD Assistant Professor of Pediatrics Department of Pediatric Rehabilitation Medicine Children’s

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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

Page 30: © The Children's Mercy Hospital, 2015 Kimberly Hartman, MD Assistant Professor of Pediatrics Department of Pediatric Rehabilitation Medicine Children’s

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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

Page 31: © The Children's Mercy Hospital, 2015 Kimberly Hartman, MD Assistant Professor of Pediatrics Department of Pediatric Rehabilitation Medicine Children’s

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Moderate Sedation & Beyond

• Pentobarbital

• IV Propofol

• IV Dexmedetomidine

Fentanyl

Ketamine

Sedatives Analgesics

Zempsky 2012

Page 32: © The Children's Mercy Hospital, 2015 Kimberly Hartman, MD Assistant Professor of Pediatrics Department of Pediatric Rehabilitation Medicine Children’s

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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

Page 33: © The Children's Mercy Hospital, 2015 Kimberly Hartman, MD Assistant Professor of Pediatrics Department of Pediatric Rehabilitation Medicine Children’s

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Page 34: © The Children's Mercy Hospital, 2015 Kimberly Hartman, MD Assistant Professor of Pediatrics Department of Pediatric Rehabilitation Medicine Children’s

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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

Page 35: © The Children's Mercy Hospital, 2015 Kimberly Hartman, MD Assistant Professor of Pediatrics Department of Pediatric Rehabilitation Medicine Children’s

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Standard of Care?

Howard 2012

Page 36: © The Children's Mercy Hospital, 2015 Kimberly Hartman, MD Assistant Professor of Pediatrics Department of Pediatric Rehabilitation Medicine Children’s

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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]

Page 37: © The Children's Mercy Hospital, 2015 Kimberly Hartman, MD Assistant Professor of Pediatrics Department of Pediatric Rehabilitation Medicine Children’s

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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?

Page 38: © The Children's Mercy Hospital, 2015 Kimberly Hartman, MD Assistant Professor of Pediatrics Department of Pediatric Rehabilitation Medicine Children’s

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References

See handouts or email: [email protected]

Page 39: © The Children's Mercy Hospital, 2015 Kimberly Hartman, MD Assistant Professor of Pediatrics Department of Pediatric Rehabilitation Medicine Children’s

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Discussion