อ.พ.ญ. สหสา หมนด

ภาควชาวสญญวทยา

คณะแพทยศาสตรศรราชพยาบาล

Pain Management In Pediatric Patient

Pain: What is it?

•Pain: “unpleasant sensory and emotional experience associated with actual or potential tissue damage”

•Pain is subjective

•Pain is both a sensory and emotional experience:

ดงนนการประเมนควรใหครอบคลมทกดาน

Pain in Pediatric patient Often under-medicated

Often cannot tell you how they feel

May be difficult to assess (under-rating, atypical behavior)

Deserve protection (social responsibility)

Short-term effects may have long-term consequences

Taddio et al.: Lancet 1995, 1997; NEJM 1997 Page et al. – Pain 2001; 90:191-9 Brain Behav Immun 2005; 19:78-87

Barriers to Pediatric Pain Control Belief that children, especially infants, do not feel pain the

way adults do Lack of routine pain assessment Lack of knowledge in pain treatment Fear of adverse effects of analgesics, especially respiratory

depression and addiction Belief that preventing pain in children takes too much time

and effort

Pediatrics, 18 (3) 2001

Adverse Physiologic effects of Postoperative Pain

Pulmonary system - atelectasis - V/Q mismatching - hypoxemia - pneumonia CVS system - hypertesion - tachycardia - myocardial ischemia - cardiac dysrhythmias

Adverse Physiologic effects of Inadequate Pain Control

Endocrine system

- hyperglycemia

- sodium and water retention

- Protein catabolism

Immune system

Coagulation system

- increase platelet adhesiveness

- decreased fibrinolysis

- hypercoagulation

- DVT

Adverse Physiologic effects of Inadequate Pain Control

GI system

- ileus

GU system

- urinary retention

Good pain control requires

accurate and detailed assessment, and reassessment, of each pain

‘ make the pain visible’ knowledge of the different types of pains a different therapeutic approach to pain knowledge of which treatment modalities to use knowledge of the actions, adverse effects and pharmacology

of analgesics multidisciplinary assessment and treatment of other aspects

of suffering that may aggravate pain - physical, psychological, social, cultural and spiritual distress.

Type of Pain

Acute / Chronic Pain

Cancer pain/ Chronic non cancer pain

Mechanism

: nociceptive pain : autonomic, somatic

neuropathic pain

mixed pain

Classification of Pain: By mechanism Nocioceptive Somatic

Bone, joint, muscle, skin, or connective tissue

Well localized Aching & throbbing

Visceral Visceral organs such as GI tract Poorly localized Cramping

Neuropathic Central

Injury to peripheral or central nervous system causing phantom pain

Dysregulation of the autonomic nervous system (e.g. Complex regional pain syndrome)

Peripheral Peripheral neuropathy due to

nerve injury Pain along nerve fibers

http://www.med.umich.edu/PAIN/pediatric.htm

5 General Principles of Pain Management

คาดประเมนความปวดและปองกน (Anticipate & prevent pain)

ประเมนความปวดอยางเหมาะสม(Adequately assess pain)

ใชหลกการรกษาแบบผสมผสาน(multi-modal approach)

ควรใหพอแมมสวนรวมในการรกษา(Involve parents)

เลอกใชวธทไมเจบปวดในการใหยา (Use non-noxious routes )

Pediatrics in Review 2003; 24 (10)

1: คาดประเมนความปวดและปองกน (Anticipate & Prevent Pain) เตรยมผ ปวยและพอแม ถงการทาหตถการตางๆ

ใหการรกษา และปองกนความปวดอยางเหมาะสม Following surgery or local anesthetic for lumbar puncture Pre-emptive analgesia : pre incision infiltration topical analgesia

ควรคานงถงพฒนาการตามวย

ควรเลอกใชเครองมอทเหมาะสมกบวยของผ ปวย

2. ประเมนความปวดอยางเหมาะสม (Adequately assess pain)

การประเมนความเจบปวดในผปวยเดก

Pain assessment : History, physical exam Location, type, severity, characteristics Assessment tools : depend on age and condition

- Self report measures of pain - behavioral measures of pain - Physiological measures of pain

….. รวมกบการสงเกตอาการทางคลนกของผปวยรวมไปดวยเสมอ

Age related measures

Age(y) Physio. Behavior. Self-report < 3 + + - 3-5 + + +/- > 5 - +/- +

การประเมนทางสรรวทยา อาการแสดงของการกระตนประสาท sympathetic เชน HR, RR, BP,

SaO2 Stress hormone เพมขน

ไว(sensitive)แตไมจาเพาะ (specific)

มประโยชนในผปวยทไมสามารถบอกความปวดของตนได

การประเมนทางพฤตกรรม

สหนา (facial expression)

การรองไห

การแสดงออกทางรางกาย

(body language)

ควรใชเมอผปวยไมสามารถบอกความปวด

ของตนเองได

สหนา

0 = เฉยๆ สบาย

1=แสยะ ปากเบะ จมก

ยน หวควยน ปดตา

แนน

รองไห

0=ไมรอง

1=รองคราง

2=กรดรอง

การหายใจ

0=สมาเสมอ

1=หายใจเรวขน

หรอชาลงหรอ

กลนหายใจ แขน

0=วาง

สบายๆ

1=งอ

ขา

0=วางสบายๆ

1=งอ / เหยยด

ระดบการตน

0=หลบ / ตน

1=กระสบกระสาย วนวาย

Neonatal Infant Pain Scale (NIPS)

1-6 ป

CHEOPS รองไห 1=ไมรอง

2=คราง,รองไห

3=หวดรอง

สหนา 0=ยม 1=เฉย 2=เบ

การสงเสยง 0=พดสนกราเรง หรอไมพด 1=บนอนๆเชนหว,หาแม 2=บนปวด+ บนอนๆ

CHEOPS ทาทาง(ลาตว) 1=ธรรมดา สบายๆ 2=ดน/เกรง/สน /ยน/ดนจนถก จบตรงไว

สมผสแผล 1=ไมสมผส 2=เออมมอมา/ แตะเบาๆ/ตะปบ/ เออมมอมาจนตอง จบมอหรอแขนไว

ขา 1=ทาสบาย 2=บดตว/ เตะ/ดงขาหน/ เกรง/ยน/ดน จนถกจบหรอ ตรงไว

สหนา

0=เฉย, ไมย ม

1=หนาตาเบะ หรอขมวดคว ถอยหนไมสนใจ

สงแวดลอมเปนบางครง

2=คางสน, กดฟนแนนเปนบอยๆหรอตลอดเวลา

ขา

0=อยในทาปกตสบายๆ

1=อยในทาไมสบาย, กระสบกระสาย, เกรง

2=เตะ หรองอขาขน

การเคลอนไหว

0=นอนเงยบๆ, ทาปกต, เคลอนไหวสบายๆ

1=บดตวไปมา, แอนหนาแอนหลง, เกรง

2=ตวงอ เกรงจนแขงหรอสนกระตก

รองไห

0=ไมรอง (ตนหรอหลบกได)

1=ครางฮอๆ หรอครางเบาๆ บนเปนบางครง

2=รองไหตลอด หวดรอง สะอกสะอน บนบอยๆ

การสนองตอการปลอบโยน

0=เชอฟงด, สบายๆ

1=สามารถปลอบโยนดวย การสมผสโอบกอด พดคย

เพอดงดดความสนใจเปนระยะๆ

2=ยากทจะปลอบโยนหรอทาใหสบาย

FLACC

อาย 6 ป

การประเมนความปวดจากตวผปวยเอง

Gold standard เดกพดคาวาปวดหรอเจบไดตงแตอาย 18 เดอน

บอกระดบความปวดไดตงแตอาย 3-4 ป

บอกความรนแรง ลกษณะและตาแหนงของความ

ปวดไดตงแตวยเขาเรยน

Pain Assessment Self report

1. Verbal descriptor scales

___0. None

___1. Mild / a little

___2. Moderate / some

___3. Severe / a lot

___4. Worst pain imaginable

2. Visual analogue scale

3. Numerical rating scale

Self - report measure

Color analogue scale Worst pain No pain

Visual analogue scale

0 100

Self - report measure

Poker Chip tool Verbal rating scale 0 = no pain

1 = mild pain

2 = moderate pain

3 = severe pain

4 = worst pain

FACES scale

Faces Pain Scale - Revised (FPS-R)

0 (neutral) means “no pain”. The faces show “more and more pain”. The right hand one means “very much pain” (or “the worst pain”). Ask the child to point to “the face which shows how much you hurt right now”.

www.painsourcebook.ca - Hicks et al. [Pain 2001; 93: 173-183]based on Bieri et al. [Pain 1990; 41: 139-50]

ในคาชแจงตอไปนใหใชคาวา “เจบ” หรอ“ปวด” ตามความเหมาะสมแกผปวยเดกแตละคน

“รปหนาตอไปนจะแสดงใหเหนวามความปวดมากเทาไร

รปหนาน (ซายสด) แสดงวาไมปวดเลย

รปหนาถดมาแสดงวาปวดมากขนมากขน (ชรปหนาจากซายมาขวา)

จนถงรปหนาน(ชรปขวาสด) แสดงวาปวดมากๆ

ใหหนชรปหนาทแสดงวาหนปวดมากแคไหน (ตอนน)”

ใหคะแนนตามรปหนาทเลอก 0, 2, 4, 6, 8, 10 ตามลาดบจากซายไปขวา

คะแนน 0 = ไมปวดเลย คะแนน10 = ปวดมากๆ ไมควรใชคาวา“สข” หรอ“เศรา”

การใหคะแนนนมจดประสงคเพอวดวาผปวยเดกมความปวดมากแคไหน

ไมใชการใหคะแนนจากการดลกษณะสหนาของเดก Translation credit: Wimonrat Krisanaprakornkit & Duenpen Horatanaruang Dept of Anesthesiology, Srinagarind Hospital, Khon Kaen University, Khon Kaen, Thailand Instructions for administering the Faces Pain Scale – Revised in languages other than English. 4th Ed. – August 2005. Pediatric Pain Sourcebook, www.painsourcebook.ca

0 2 4 6 8 10

Faces Pain Scale – Revised (FPS-R) Hicks CL, et al. Pain 2001;93:173-83.

3: ใชหลกการรกษาแบบผสมผสาน

Multi-modal Approach

Multiphasic = pre-intra-post-operative

Mutimodal = LA+ opioids+NSAIDs

4: ใหผปวยและผปกครองมสวนรวมในการรกษา

ผปกครอง เปนผ รขอมล ลกษณะนสยของเดกมากทสด ชวยลดความตงเครยดของผ ปวยได

ผ ปวย เลอกใชวธใหเหมาะสมตามวยและพฒนาการ อาจใหมสวนรวมในการเลอกวธระงบปวดไดตามความเหมาะสม

5: เลอกวธระงบปวดทไมเจบปวด

Non-noxious Routes Administer analgesia through most painless route Avoid IM injections Oral and Intravenous routes are preferred Oral route for mild to moderate pain Intravenous route for immediate pain relief and severe

pain

ชนดของความเจบปวดทพบไดบอยในผปวยเดก

Acute Pain

Procedure related pain : LP, MBA, ICU care

post-operative pain

Pain in Life limiting Patient Childhood malignancy Neurodegenerative disorders Cystic fibrosis Cerebral palsy Chromosomal abnormalities congenital malformations HIV

Acute Pain Management

Neonates and Infants

•Barriers to treatment of pain in infants and neonates

•The myth that infants do not feel pain

•Lack of pain assessment &reassessment tools

•Lack of knowledge of pain treatment

•Notion that addressing pain in children takes too much time and effort

•Fears of adverse effects of analgesic medications

NICU Pain

•Diagnostic procedures: Arterial punctures, heel lancing, lumbar puncture, ROP exams

•Therapeutic procedures: bladder catheterization, peripheral IV and central line insertion, dressing changes,OG/NG tube insertion, IM injections, mechanical ventilation, removal of adhesive tape, tracheal suctioning

•Localized infections/inflammation

•Post-operative pain

•Burns or abrasions from probes, leads & topical agents

Pharmacologic Pain Control

Sucrose for analgesia Non-pharmacological analgesia : kangaroo bag, pacifier Pharmacological analgesia should be chosen carefully based on

patient, medication and environment Subsequent doses should be modified based on cause of the pain,

previous response, clinical condition, concomitant drug use, and pharmacodynamics of the drugs used

WHO 3-Step Ladder for Pain

Step 1 - Mild

Step 2 - Moderate

Step 3 - Severe

Non-opioids

Weak opioids

Strong opioids

Always consider adding an adjuvant Rx

Morphine Available orally, subcutaneously, intravenous Moderate to severe pain

Hepatic conversion with renally excreted metabolites

Use in caution with renal failure

Duration of I.V. analgesia 2-4 hours Oral form comes in an immediate and sustained release

Side effect of significant histamine release

Fentanyl Available intravenous, transdermal patch

Severe pain

Rapid onset, brief duration of action With continuous infusion, longer duration of action

I.V. Dose 1 mcg/kg/dose every 30-60 minutes Side effect of rapid administration may produce glottic and

chest wall rigidity

Level II and III Medications

Parenteral route

Morphine 0.1 mg/kg IV bolus, prn. 1-2hr .05 mg/ kg/hr, CI - IV or SQ , PCA

Hydromorphone (Dilaudid) Approximately 6 times stronger than morphine

Fentanyl Approximately 10 times stronger than morphine Wide dosing range 1-2 mcg/kg IV slow push 0.5-1.0 mcg/kg/hr, CI - IV or SQ Total hourly dose as a transderm patch

Level II and III Medications

Enteral route Codeine 1 mg/kg, Q 2-4 hrs, PO

Tramadol 0.7 - 2.0 mg/kg/dose PO Q 4-6 hours Morphine immediate release 0.3 mg/kg PO Q 2-4hr

Morphine SR (MS Contin) : acute pain 0.5 mg/kg, BID, PO (Do not crush)

Patient Controlled Analgesia : PCA

PCA : Patient Controlled Analgesia สามารถใชไดตงแตอาย 6 ปขนไป

การตง background infusion ชวยเสรมประสทธภาพในการระงบปวดในผปวยเดกได

การตง lockout period ปกตตงประมาณ 5 นาท

การตง 4-hourly dose limit เพอประเมนความเหมาะสมการใหยาระงบปวดขณะน

Acetaminophen

Antipyretic

Mild analgesic

Administer PO or PR

Pediatric Oral dose 10-15 mg/kg/dose every 4-6 hr

Infant dose is 10-15 mg/kg/dose every 6-8 hr Maximum dose in children> 6mo = 90mg/ka/day Maximum dose in children< 6mo = 60mg/ka/day

Onset 30 minutes

Acetaminophen Per rectum dose 40 mg/kg once followed by 20

mg/kg/dose every 6 hours Uptake is delayed and variable Peak absorption is 60-120 minutes Contraindication in neutropenic patient

Side Effects of Acetaminophen Generally a good safety profile Do not use in hepatic failure

Causes hepatic failure in overdose Infant drops are MORE concentrated than the children’s

suspension Infant’s Acetaminophen 80 mg/0.8 mL Children’s Acetaminophen 160 mg/5 mL

Ketorolac Intravenous NSAID Dose 0.5-1 mg/kg/dose every 6 hours Onset 10 minutes Maximum I.V. dose 30 mg every 6 hours

Monitor renal function Do not use more than 5 days Significant increase in side effects after 5 days

Contraindication to the use of NSAIDS in children

Hypersensitivity or allergy to aspirin or NSAIDs

Peptic ulcer

Bleeding diatheses

Severe asthma, especially if aspirin sensitive of corticosteriod dependent

Nasal polypitis

Renal dysfunction, hypovolemia, diuretic therapy

Planed major surgery

Codeine Oral analgesic (also anti-tussive) Weak opioid Used often in conjunction with acetaminophen to increase

analgesic effect Metabolized in the liver and demethylated to morphine Some patients ineffectively convert codeine to morphine

so no analgesia is achieved Dose 0.5-1 mg/kg every 4-6 hours

Tramadol

weak receptor

Inhibit serotonin และ nor-epinephrine reuptake

Local Anesthetics For needle procedures, suturing, etc.

Topical or infiltration

Acts by blocking nerve conduction at Na-channels

If administered in excessive doses, can cause systemic effects

CNS effects of perioral numbness, dizziness, muscular twitching, seizures & cardiac toxicity

Aspirate back before injecting to avoid direct injection into blood vessels Calculate maximum mg/kg dose to avoid overdose

Buffering lidocaine can help with pain of infiltration 9 mL lidocaine mixed with 1 mL sodium bicarbonate

Dosing of oral medication commonly use in children Paracetamol paracetamol : 10-15 mg/kg orally q 4-6 hr. 40 mg for 1st dose then 20 mg/kg rectally q 6 h

NSAIDs diclofenac 1 mg/kg orally q 8 hr 20 mg/kg rectally q 6 hr

(max 3mg/kg/day) ibuprofen 5-10 mg/kg orally q 8 hr indomethacin 1 mg/kg orally q 8 hr naproxen 5 mg/kg orally q 12 hr

Dosing of oral medication commonly use in children

Weak Opioids codeine 0.5-1 mg /kg orally q 4-6 hr

(max 3mg/kg/day)

tramadol 1-2 mg /kg orally q 8 hr

(max 6mg/kg/day)

Pain in Life limiting Patient

Pediatric principles and practice

Advanced disease in pediatric palliative care

Childhood malignancy Neurodegenerative disorders Cystic fibrosis Cerebral palsy Chromosomal abnormalities and congenital malformations

Pediatric patients with cancer Pain in a cancer patient can result from

tumor invasion

procedures

therapy : mucositis, neuropathy, surgical incisions, corticosteroid

other causes unrelated to cancer

How to assess pain in patients Pain assessment : Location, type, severity Assessment tools : depend on age and condition

- Self report measures of pain : gold standard - behavioral measures of pain - Physiological measures of pain ….. combined with clinical observation

For chronic pain changing in pain behavior

In palliative care

the analgesic program should be kept simple, even for patients in severe pain

oral medication is the mainstay of treatment and should only be abandoned if the patient is unable to take or retain oral preparations

WHO 3-Step Ladder for cancer pain

Step 1 - Mild

Step 2 - Moderate

Step 3 - Severe

Aspirin

Acetaminophen

NSAIDs

Codeine

Hydrocodone

Oxycodone

Tramadol

Morphine

Hydromorphone

Methadone

Levorphanol

Fentanyl

Always consider adding an adjuvant Rx

Non pharmacological approach for managing procedure pain in children Distraction

Infants : toys, dummy, bubble blower

Preschool children : songs, books, toys

School age children : stories, counting, DVDs

Rewards

etc…

What about when the pain seem intractable?

Intractable pain

Combination of clinical factors and patient factors.

Need review pathology

: Fracture? Cord compression?

Neuropathic pain?

Neuropathic pain symptoms and signs

Radicular/dermatomal distribution

Quality of pain : burning, pins and needles, electrical shock-like, pain in numb area, phantom pain

Associated features : numbness, weakness, abnormal reflexes

Allodynia : pain cause by light touch

Hyperalgesia

Wind up: rapidly escalating pain with decreasing opioid responsiveness

Management for Neuropathic pain

Pharmacological therapy : Acetaminophen, NSAIDs Tricyclic antidepressants Anticonvulsant (carbamazepine, phenytoin, gabapentin)

systemic local anesthetics

opioids (morphine, methadone given PO or IV or through a regional technique especially in cancer patients)

Ketamine infusion

Regional blockades Non-pharmacological treatment

: hypnosis, biofeedback,TENS, physical

therapy etc.

Management for Severe Bone Pain

Medication

-Regular paracetamol

-NSAIDS

-Opioids : background around the clock

dosing and breakthrough doses.

- Bisphosphanate

Management for Severe Bone Pain Anesthetic Procedures Epidural anesthetics Nerve Block

Radiotherpy Neurosurgical Procedures Neurolysis

Orthopedic Procedures Stabilization of pathologic fractures

Management of Visceral pain

Should respond to increased doses of opioids

Paracetamol

Dexamethasone : decrease peri-tumor edema

Avoid co-administration steroid with NSAIDS

Opioid side effects

Respiratory depression

Nausea and vomiting

Pruritus

Urinary retention

Constipation

sedation

Pain and the Reticular Activating System “The respiratory depressant effect of opioid agonists can be demonstrated easily in volunteer studies. When the dose of morphine is titrated against a patient’s pain, however, clinically important respiratory depression does not occur. This appears to be because pain acts as a physiological antagonist to the central depression effects of morphine.”

Wall, R.D., ed. Textbook of Pain. Churchill Livingstone

Opioid Side Effects : respiratory depression

ความพรอมของอปกรณและยาแกไข

Monitoring system

: Pulse oximetry : aged less than 6 month or co-existing disease

Appropriate protocol for resuscitation, oxygenation, contracting appropriate personel

Infusion pump

Syringe pump

PCA

Naloxone : 5 mcg /kg (up to max 100 mcg) IV,

repeated if necessary q 2 min

Respiratory rate Sedation score Pain score Adverse effect monitoring pruritus nausea vomiting urinary retention

Monitoring

Clinical Indicators of Respiratory Depression

Sedation score

0 = none

1 = mild, occasionally drowsy, easy to arouse

2 = moderate, constantly or frequently drowsy, easy to arouse

3 = severe, somnolent, difficult to arouse

S = normally asleep, easy to arouse

Respiratory rate 0-1 ป < 30 ครง 3-6 ป < 20 ครง 1-3 ป < 25 ครง 6-13 ป < 15 ครง

Oxygen saturation

may also unreliable, esp. receiving supplemental oxygen

Medications commonly used to treat opioid side effects

Respiratory depression :

Naloxone 10 mcg/kg (max 100 mcg / dose

q 2-3 min)

Naloxone (5-20mcg/kg/hr)

Pruritus : Diphenhydramine (0.5mg/kg/dose)

Naloxone (0.5-2mcg/kg/hr)

Nausea : Ondansetron (0.15mg/kg/dose)

Naloxone (0.5-2mcg/kg/hr)

Somnolence : methylphenidate (0.1mg/kg/dose)

Naloxone (0.5-2mcg/kg/hr)

A belief that morphine hastens death

morphine may be used for months or years and, correctly administered, is compatible with a normal lifestyle

used properly, it does not hasten death

The fear of respiratory depression

used properly, morphine should not cause respiratory depression, although care must be taken with patients who are at risk of respiratory depression for other reasons

A belief that "Morphine doesn't work"

Morphine will be ineffective in controlling pain if

it is incorrectly administered

it is used for morphine-insensitive pain

matters of psychosocial concern have not been addressed

The belief that morphine causes unacceptable side effects

side effects should not be severe

respiratory depression is uncommon

constipation occurs inevitably and requires explanation and advice about diet and laxative therapy

somnolence and nausea usually improve after several days

That means I'm going to die soon

requires explanation that morphine can be used for months or years and is entirely compatible with a normal lifestyle

“I'll become an addict”

requires explanation and reassurance about physical and psychological dependence

Morphine may not relieve pain if the dose was too low it was given too infrequently there were no instructions for breakthrough pain it was given for insensitive pain matters of psychosocial concern have not been addressed

Take Home messages

Good pain control needs pain assessment and reassessment. Pain can be well controlled in most patients. Opioids are safe if titrated to effect. Pain must be consider along with other symptoms. Patients need regular and as required medications for pain. Families need information and support. Multidisciplinary is required for providing the good care.