Support I I I

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  • 1. Symptom Control for Pediatric Patients
    • A guide to the management of pain, nausea, and other symptoms in seriously ill children, with a focus on the social and medical aspects of end-of life care.

Sponsored by -- The Jason Program creating a community of care 2. 3. Why Are You Here?

  • Be the caregiver you would want if you were in pain.

4. Outline

  • Social Aspects
  • Cure vs. Palliation
  • Accepting end-of-life care
  • Maintenance of active medical care
  • Managing death - Home or Hospital?
  • Medical Care
  • Pain Control
  • Other Common Symptoms
  • Nebulized Everything
  • Last Hours of Life

5. Cure vs. Palliation

  • Cure
  • -- fundamental hope is eradication of
  • disease to achieve longevity
  • -- assumes cure is worth a sacrifice
  • Palliation
  • -- fundamental hope is comfort
  • -- consequences of any interventionthat relieves suffering are acceptable

6. Curative / Life-Prolonging Therapy Relieve Suffering - Palliative Care Presentation Death A Better Viewpoint 7. Accepting End-of-Life Care

  • Hope is never lost
  • MD must accurately understand the medicalsituation and estimate the chance for cure
  • With the family, level of support is determined
    • Previously established trust is helpful
    • Clear communication and truth are necessary
    • Shift towards increased family control
    • Identify goals
    • Situation is dynamic

8. Maintain Active Medical Care

  • Socially Important
    • Families need to know what is happening
    • Families need to plan and adapt
    • Feelings of security fostered
    • Fears of abandonment eliminated
  • Medically Important
    • Symptom relief necessary
    • Maintain dignity
    • Accomplish desired goals
    • PRO active rather thanRE active

9. Death at Home vs. Hospital

  • Positive Home Death --(Ida Martinson)
    • More control over daily activities
    • Medical care often better than in hospital
    • Home is a safe, comfortable place
    • Usually requires well functioning family
    • Staff support of the home death concept helpful
  • Positive Hospital Death --
    • Family does not need to take a medical role
    • Death at home may leave greater scars
    • For some, sibling issues are easier
    • Make hospital room feel like home

10. Medical Care Issues

  • Pain
  • Other Common Symptoms
  • Venous Access
  • Neonatal Pain
  • Terminal Care
  • Case Studies

11. Oncologic Emergencies Immediate Intervention Required Common Less Common Pain Fever with Neutropenia or Splenectomy Airway Compression Spinal Cord Compression Brain Herniation Hyperleukocytosis 12. Pain Management

  • Freedom From Pain: A Matter of Rights?
    • T. Patrick Hill, M.A.Ca. Invest., 12 (4), 1994
  • Pain Isolates: We are probably never more alone than when severe pain invades us.
  • Pain is Elusive: Despite the fact that it is the result of biochemical processes, it is also ... a subjective experience, felt only within the confines of our individual minds.

13. A Matter of Attitude

  • Pain is unlike disease, and that to treat its symptoms clinically, physicians need above all to understand how the ravages of pain can reach beyond the body to the soul of the person, assaulting its very integrity.
  • There exists a principle on which rests the human right to be free of pain and the corresponding obligation of health-care professionals to honor it. All patients are vulnerable, but none is more vulnerable than the patient in severe pain. The measure of medicine in general and of a physician in particular is ultimately their respect for the patients right to be freeof pain.

14. Barriers to Pain Control

  • ... the most pervasive and difficult to overcome relate to the fears among patients, families, and health professionals of opioid analgesics, which are the cornerstone of drug therapy for moderate to severe pain.
  • These fears include an exaggerated estimation of opioid addictionand tolerance, fear of opioid side effects -- most notably respiratory depression -- and ethical and regulatory concerns about using opioids.
    • Weissman, David E.Home Health Care ConsultantVol. 2, No. 5, Sept. 1995

15. Treatment Principles

  • Correctly Assess Degree and Cause of Pain
  • Consider Psychosocial Factors
  • Consider 24 hour Coverage
    • Children
    • Severe or Chronic Pain
    • Patient- Controlled Analgesia
  • Opioids Are Safe
    • Respiratory Depression Overestimated
    • Pharmacologic Dependence With Chronic Use
  • Neveruse a placebo

16. Pediatric Pain Assessment

  • Infant
    • HR, Resp, BP
    • fever, sweating
  • Child
    • Irritability, esp. paradoxical
    • Refusal to walk or use a painful limb
    • Functional changes (school, sports, etc.)
    • May be able to use pain scale
  • Adolescent
    • Generally accurate reporter
    • May be reluctant to participate

17. WHO 3-Step Ladder 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 18. Level I Medications

  • Acetaminophen
    • 12 - 15 mg/kg, Q 4hr, PO or PR
  • NSAIDs
    • Ibuprofen
      • 10 mg/kg, max 40mg/kg/day, Q 6hr, PO
    • Ketorolac (variable efficacy)
      • 0.5 mg/kg IV/IM, 5-10 mg PO, Q 6hr
    • Cox 2 Inhibitors
      • Vioxx, oral solution, 0.5 mg/kg QD (effective)
      • Occasional sedation
      • Celebrex has better GI safety profile

19. Level II and III Medications Pain Control Using Narcotics 20. Principles of Narcotic Dosing

  • The Right Dose is the Dose that Works
  • 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 patients pain, however, clinically important respiratory depression does not occur. This appears to be becausepain acts as a physiological antagonist to the central depression effects of morphine .
      • Wall, R.D., ed.Textbook of Pain . Churchill Livingstone
  • Naive Pts. vs. Tolerance

21. Enteral Narcotics

  • Codeine
    • 1 mg/kg, Q 2-4 hrs, PO
    • Ineffective for age >~10-12 years
  • Hydrocodone(Lortab)
    • 0.1 mg/kg PO q 2-4 hours (very good for moderate pain)
  • Oxycodone5 - 10 mg/ dose PO q 2-4 hours (Tylox)
  • Tramadol(Ultram)
    • 0.7 - 2.0 mg/kg/dose PO Q 4-6 hours (variable efficacy)
  • Morphine(the gold standard)
    • 0.3 mg/kgPOQ 2-4hr
  • Morphine SR(MS Contin)
    • 0.5 mg/kg, BID, PO (Do not crush)

22. Parenteral Narcotics

  • Morphine
    • 0.1 mg/kgIV bolus, Q 1-2hr
    • .05 mg/ kg/hr, CI - IV or SQ
  • Hydromorphone(Dilaudid)
    • Approximately 6 times stronger than morphine
  • Fentanyl
    • Approximately 10 times stronger than morphine
    • Wide dosing range
    • 1-2 mcg/kg IVslow push