Pain Management 06

8/11/2019 Pain Management 06

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Pain Management in Children

Dr.Mumtaz Ahmed Qureshi

Department of Pediatric

Surgery LUMHS Jamshoro.


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Pain Management in Children


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Different age Groups

Neonates- 0 to 30 days.

Infants- Birth to 1 year.

Toddlers- 1 to 3 years.

Preschoolers- 3 to 5 years.

School Age- 6 to 12 years. Adolescent- 13 to 18 years.


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Pain in Children

Infants are neurologically immature

and therefore cannot conduct pain

impulses. Infants do not remember pain,

because of cortical immaturity.

Children do report pain while playingor sleeping.


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Effects of Acute Pain

Physiologic

Metabolic

Behavioral


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Physiologic Response

Increased heart rate

Increased respiratory rate

Increased blood pressure

Decrease in oxygen saturation


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Metabolic Response

Increased secretion of catecholamine,

glucagon, and corticosteroids.

Delayed wound healing

Poor intake / anorexia

Impaired mobility

Sleep disturbances

Irritability


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Behavioral Response

Facial expression of pain.


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Infant Response to Pain

Forcefully closed eyes

Lowered brows

Deepened furrow between nose andouter corner of lip.

Square mouth

Cupped tongue


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Toddler and Pre-school

Limited in their cognitive abilities in

localizing and expressing pain

intensity, and understanding reasonsfor pain.

Find out word they use to express pain

Point to pain

Faces is a good tool for them.


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School-age

Increased ability to communicate pain

in more abstract terms.

They can describe pain: squeezing,stabbing or burning

Respond well to direct questioning.

Tools: body outline, faces scale, visual

analog.


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Pre-procedural Pain

Key to managing proceduralrelated

pain is anticipation

Anticipated intensity and duration

Child / parent receive appropriate

information to minimize distress


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Child / Parent Preparation

Quiet environment

Calm nurse

Clear confident instructions

Pain management according to cause

or underlying disease.

Localized anesthetics

Systemic agents

Sedatives


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Types of Pain

Procedural pain

Post-operative pain

Sickle cell pain

Neuropathic pain

Cancer pain Pain in palliative care


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Operative Pain

Morbidity and mortality can be reduced

by good pain treatment

Plans for postoperative pain should bediscussed before surgery

Goal is to control the pain as rapidly as

possible


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Post-Operative Pain

Oral administration is preferred for mild tomoderate pain.

IV is indicated for immediate pain relief. Persistent moderate to severe pain

continuous around the clock dosing at fixedintervals is recommended.

PCApatient-controlled analgesiausedonly when patient can use pump on theirown.


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Side Effects

Nausea, vomiting and puritus are

common side effects

Constipation with prolonged use ofopioids


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Pain Assessment

Methods of assessment vary

according to age and cognitive level of

child Patient report

Numerical scale1 to 10

FACEScan be used at all ages FLAC used on infants


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FACES


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Monitoring

A cardiac / respiratory monitor is used

for infants less than 7 months

Oximetry monitors for other patientsduring use of IV opioids

Unstable respiratory status

History of difficult airway management Neurologically impaired


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Principles of Pharmacology

Consider patients age, associated

medical problems, type of pain, &

previous experience with pain Choose type of analgesia

Choose route to control pain as rapidly

and effectively as possible Titrate further doses based on initial

response

Anticipate side effects


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NSAIDs

Antipyretic

Analgesic for mild to moderate pain

Anti-inflammatory

COX inhibitorProstaglandin inhibitor

Platelet aggregation inhibitor


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Side Effects of NSAIDs

Gastritis

Prolonged use increases risk of GI bleed

Still rare in pediatric patients compared to adults NSAID use contraindicated in ulcer disease

Nephropathy (ATN)

Bleeding from platelet anti-aggregation

Increased risk versus benefit post-tonsillectomy

NSAID use contraindicated in active bleeding

Delayed bone healing?


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Opioids Analgesics

Moderate to severe pain

Various routes of administration

Different pharmacokinetics for different

age groups

Infants younger than 3 months have

increased risk of hypoventilation andrespiratory depression

Low risk of addiction among children


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Side Effects of Opioids

All opioids have side effects that

should be anticipated & managed

Respiratory depression

Nausea, vomiting

Constipation

Pruritis Urinary retention


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Key Points

Treat pain

Adhere to general principles of painmanagement Anticipate & prevent pain Adequately assess pain

Use multi-modal approach

Involve parents & patients

Use non-noxious routes Understand the pharmacology of non-opioid

and opioid analgesics

Approach and treat different types of pain

accordingly


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Documents

Pain Management 06