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1 Pediatric Pain: Assessment & Interventions Lori McKenna, CRNP Debbie Wolf, RN, CNS Keeley Harding, CRNP Cincinnati Children’s Hospital Medical Center Division of Pain Management Department of Anesthesia

1 Pediatric Pain: Assessment & Interventions Lori McKenna, CRNPDebbie Wolf, RN, CNS Keeley Harding, CRNP Cincinnati Children’s Hospital Medical Center

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Pediatric Pain:Assessment & Interventions

Pediatric Pain:Assessment & Interventions

Lori McKenna, CRNP

Debbie Wolf, RN, CNSKeeley Harding, CRNP

Cincinnati Children’s Hospital Medical CenterDivision of Pain Management

Department of Anesthesia

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Pain Service: The Acute TeamCensus: Approximately 1700 patients seen per year

APNs: Lori McKenna Debbie WolfKeeley Harding

Attendings: Ken Goldschneider Norb WeidnerMark Meyer Senthil SadhasivamAlex Szabova Deborah Vermaire

Psychologists: Michelle Ernst Carrie Piazza-Waggoner

Contacting Us: On-call pager # 303-2019 available 24/7APN # 6-7768, opt 3Mobile Phone #s available in Centerlink

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Chronic Pain Service (750 pt visits per yr)

Attendings: Ken Goldschneider & Alex SzabovaAPNs: Debbie Wolf, Keeley Harding, Lori McKennaPsychologists: Anne Lynch & Susmita Kashikar-ZuckPhysical Therapist: Julie Badylak

Pediatric Palliative and Comfort Care Team (PACT) (50+ pts/yr)

APN: Suzanne BlackSocial Worker: Debby PalmisanoAttendings: Norb Weidner & Mark MeyerPager #: 736-6301Office #: 6-5479

Pain Service: The Chronic Team

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Definition of Pain“Pain is whatever the experiencing person says it is. It exists whenever they say it does.”

McCaffery 1968

“Unpleasant sensory and emotional experience associated with actual/potential tissue damage.”

IASP 1979

Pain is highly personal and subjective.

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JCAHO Standards• Patients have right to appropriate assessment &

management of pain

• Initial assessment • Identify patients with pain

• Comprehensive assessment• Intensity• Quality (pain character, frequency, location,

duration)• Assessment (appropriate to patient’s age)• Reassessment

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Myths• If sleeping, not in pain

• If able to distract, not in pain

• Use of narcotics causes addiction

• Children are more prone to respiratory depression

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Assessment• Pain tool just one piece of assessment

• Self report best: GOLD STANDARD

• Parent/family input

• Physiologic Response

• Behavioral Response/Function• Daily Activities

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Reassessment

• Reassess in response to interventions• PO meds – 20 min• IV/PCA meds – 10 min

• REMEMBER: Document Reassessment

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Neonatal Infant Pain Scale: NIPS

• Behavioral scale

• Birth to 1 year

• Range 0-7

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Children’s Hospital of East Ontario Pain Scale: CHEOPS

• Behavioral (six behaviors assessed)

• Ages 1 to 7 years• Scores range 4-13

• Original design PACU

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Oucher

• Self Report Scale• Ages 5-10 years (some as young as 3 years)• 3 cultures (all male)• Avoid happy/sad, use age appropriate words• Range 0-10

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Visual Analog Scale: VAS

• Self Report Scale• Ages 8 to adult• Describe scale• Ask what level is acceptable to patient

0 1 2 3 4 5 6 7 8 9 10

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Comfort Scale

• Measures psychological and physiologic distress behaviors in mechanical ventilated infants, children and adolescents. Not designed for premature infants.

• Score is derived from the total score of 8 specific dimensions

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FLACC• Ages 2 months-7 yo

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Assessment of Children with Developmental Delays

• No scale currently adopted by CCHMC

• Behavioral or physiological measure utilized

• Family input of KEY importance

• Evaluate• Objective data: increased HR, RR, BP• Subjective clues: guarding, rigidity, crying, facial

expressions, activity changes, eating & appetite pattern changes, c/o pain

• Documentation• Narrative Assessment Screen in ICIS

Narrative Assessment Documentin

g

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Pharmacological Interventions

• Topical Anesthetics

• Oral Medications

• Intravenous/PCA Medications

• Epidurals

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Topical Anesthetics

ELA-Max cream• 4% lidocaine

EMLA cream• 2.5% lidocaine + 2.5% prilocaine

Lidoderm• Lidocaine patch 5%

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NSAIDS: Non-Steroidals

Non-opioid Analgesics• Non-steroidals

• Acetaminophen• Ibuprofen• Naproxen• Ketorolac- Only IV Form

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Opioids: What is enough?

The amount that maximally relieves pain with minimal side effects.

NO CEILING EFFECT

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Oral Combinations with Opioids

• Mild to moderate pain

• Used along with non-opioid

• Examples• Oxycodone = Percocet / Roxicet• Hydrocodone = Vicodin 5/500 mg• Codeine = Tylenol #3, 30/325 mg

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IV Opioids

• Morphine

• Dilaudid

• Fentanyl

• Stadol

• Demerol

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• Tablets: OxyContin®, MS Contin®,

• Do NOT crush, chew, cut or score these meds

• SA (sustained action) = CR (controlled release) = SR (sustained release)

ALL LONG ACTING

• Other forms:• Liquid ? Methadone• Capsule ? Kadian• Patch ? Fentanyl

Long-Acting Opioids

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Patient Controlled Analgesia – PCA

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PCA

• ≥ 7 y.o.

• Only patient allowed to push button

• Better analgesia with less sedation

• No delay between pain and response

• PCA lockout usually 7 minutes

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PCA + Continuous

• Generally first 24 hours post-op

• Prevents patient from waking up in pain

• Hem/Onc population or prolonged recovery

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Parent or Nurse Controlled Analgesia (NCA)

• < 7 yrs

• Developmentally delayed

• Parent Education • Safety

• Lock-out 10-15 min• When to use:

• Prior to painful procedures• Ambulation/chair• Incentive spirometer

DO NOT USE when patient is sleeping

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Caring for the Patient on a PCA• Continuous pulse ox

• VS Q 1 x 1st 4 hrs then Q 4 (RR Q2 while asleep)

• PCA button within reach at all times

• Activity—OOB unless contraindicated by primary service

• 2nd IV line necessary if vasoactive drug drips or blood started

• Change syringe Q 24 hrs, tubing Q 72 hours

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Caring for the Patient on a PCA Q4 Assessments

• Response to Analgesic?

• Respiratory Status? (Q2 while asleep)

• Hypotension?

• Pruritis?

• Urinary Retension?

• Nausea/Vomiting?

• IV Site Burning?

• Constipation?

2 Nurse Documentation in ICIS: Initial Set Up Order changeVial/syringe change Hand off of care (Yellow Card)

1 Nurse Only:24 hr Totals (Pump cleared daily at 0600)

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Documentation• Q 8 hours: Volume on I/O

• Yellow Controlled Substance Pharmacy Sheet document volume of med w/ 2nd RN:

• At initial set up• Hand off of care• Any Waste/Loss • Change of syringe

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Epidurals

• Placed under general analgesia

• Lumbar or caudal placement

• Indications• Thoracic• Abdominal• GU• Lower extremity procedures

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Epidural Placement

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Epidural Analgesia

Typical Medications/Dosing

• Bupivicaine: 0.1%• Chloroprocaine:1.5%(neonates)• Morphine: 50 mcg/ml• Dilaudid: 10 mcg/ml• Fentanyl: 2 mcg/ml• Stadol: 4 mcg/ml• Clonidine: 1-2 mcg/ml

****Common Dosing Ranges: 0.2-0.4 ml/kg/hr****

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Epidural Advantages

• Improved pain control

• Improved pain assessment ability (awake patient)

• Decreased Apnea/Bradycardia in Neonates

• Decreased respiratory suppression if local anesthetic only(i.e. bupivacaine injection)

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Care of the Patient w/ an EPIDURAL• Is Patient comfortable?

• Shoulder dressing intact?

• Back Dressing intact?

• Heel Protectors?

• Incentive Spirometer/Bubbles Q 1hr

• Turn/reposition Q 4

• OOB as allowed by primary service

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Care of the Patient w/ an EPIDURAL

• VS q4h with appropriate pain assessment scale

• HR, RR, pulse ox monitoring continuously w/ alarms set

• LE mobility/numbness check Q 4 hrs

• If a “BOLUS” dose given• VS @ 10 & 20 minutes• Call APS if abnormal

• At least once/shift → unless + then more often assessment for:• Pruritis• Urinary retention • Constipation• Nausea & Vomiting• Seizures

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Other Information• Option of PCEA

• Usually reserved for adolescents/Fetal Care Unit Patients• Longer onset (~20-30 min) than IV dose

• Reassessment after 30 minutes

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Side Effects of Opioids

Pruritus• Benadryl

Urinary Retention

Nausea• Reglan/Zofran

Burning at IV site

Constipation• Miralax/Colace

Respiratory Depression• Narcan

2 Nurse Documentation in ICIS: Initial Set Up Order change

Solution bag change Hand off of care (Yellow Card)

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PCA & Epidural Transport

• RN transport to & from the OR

• RN transport off the unit is required 24 hrs after any of the following:• A new order• An increase in dosage• Medication changed

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Adjuvant Pain Medications: Anticonvulsants

Gabapentin (Neurontin®)

• Indicated for treatment of partial seizures

• Effective in neuropathic pain

• Mechanism of action unknown

• Titrate to avoid side effects

• Other anticonvulsants commonly used: trileptal, topamax, tegretol

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Adjuvant Pain Medications: Antidepressants

Tricyclics (Elavil®)• Used in neuropathic pain

• Lower doses for analgesia vs depression

• Initially improves sleep• 10 days 2 weeks analgesia

• Other antidepressants commonly used: Doxepine, Celexa

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Adjuvant Pain Medications: Skeletal Muscle Relaxants

• Baclofen• Dose: 2-7 years old—10-15 mg/day q 8 hrs then titrate up

to effect(max 40 mg/day)

>/= 8 years old—max 80 mg/day

• Side Effects: hypotension, drowsiness, ataxia, nausea

• Must not be abruptly discontinued - withdrawal

• Other skeletal muscle relaxants: flexeril, skelaxin, robaxin, valium

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Addiction

Definition• A psychological phenomenon

• A behavioral pattern of drug use characterized by compulsive use of an opioid

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Physical Dependence

Definition• A physiological phenomenon

• A physiological state that results from taking increasing amount of opioids & is manifested by the development of withdrawal

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Goal of Pain Management A Child like this … … Or a child like this…