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<ul><li> 1. Symptom Control for Pediatric Patients <ul><li>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.</li></ul></li></ul> <p>Sponsored by -- The Jason Program creating a community of care 2. 3. Why Are You Here? </p> <ul><li>Be the caregiver you would want if you were in pain. </li></ul> <p> 4. Outline </p> <ul><li>Social Aspects </li></ul> <ul><li>Cure vs. Palliation </li></ul> <ul><li>Accepting end-of-life care </li></ul> <ul><li>Maintenance of active medical care </li></ul> <ul><li>Managing death - Home or Hospital? </li></ul> <ul><li>Medical Care </li></ul> <ul><li>Pain Control </li></ul> <ul><li>Other Common Symptoms </li></ul> <ul><li>Nebulized Everything </li></ul> <ul><li>Last Hours of Life </li></ul> <p> 5. Cure vs. Palliation </p> <ul><li>Cure </li></ul> <ul><li>-- fundamental hope is eradication of</li></ul> <ul><li>disease to achieve longevity </li></ul> <ul><li>-- assumes cure is worth a sacrifice</li></ul> <ul><li>Palliation </li></ul> <ul><li>-- fundamental hope is comfort </li></ul> <ul><li>-- consequences of any interventionthat relieves suffering are acceptable </li></ul> <p> 6. Curative / Life-Prolonging Therapy Relieve Suffering - Palliative Care Presentation Death A Better Viewpoint 7. Accepting End-of-Life Care </p> <ul><li>Hope is never lost </li></ul> <ul><li>MD must accurately understand the medicalsituation and estimate the chance for cure </li></ul> <ul><li>With the family, level of support is determined </li></ul> <ul><li><ul><li>Previously established trust is helpful </li></ul></li></ul> <ul><li><ul><li>Clear communication and truth are necessary </li></ul></li></ul> <ul><li><ul><li>Shift towards increased family control </li></ul></li></ul> <ul><li><ul><li>Identify goals </li></ul></li></ul> <ul><li><ul><li>Situation is dynamic</li></ul></li></ul> <p> 8. Maintain Active Medical Care </p> <ul><li>Socially Important</li></ul> <ul><li><ul><li>Families need to know what is happening </li></ul></li></ul> <ul><li><ul><li>Families need to plan and adapt </li></ul></li></ul> <ul><li><ul><li>Feelings of security fostered </li></ul></li></ul> <ul><li><ul><li>Fears of abandonment eliminated </li></ul></li></ul> <ul><li>Medically Important</li></ul> <ul><li><ul><li>Symptom relief necessary </li></ul></li></ul> <ul><li><ul><li>Maintain dignity </li></ul></li></ul> <ul><li><ul><li>Accomplish desired goals </li></ul></li></ul> <ul><li><ul><li>PRO active rather thanRE active </li></ul></li></ul> <p> 9. Death at Home vs. Hospital </p> <ul><li>Positive Home Death --(Ida Martinson) </li></ul> <ul><li><ul><li>More control over daily activities </li></ul></li></ul> <ul><li><ul><li>Medical care often better than in hospital </li></ul></li></ul> <ul><li><ul><li>Home is a safe, comfortable place </li></ul></li></ul> <ul><li><ul><li>Usually requires well functioning family</li></ul></li></ul> <ul><li><ul><li>Staff support of the home death concept helpful </li></ul></li></ul> <ul><li>Positive Hospital Death -- </li></ul> <ul><li><ul><li>Family does not need to take a medical role </li></ul></li></ul> <ul><li><ul><li>Death at home may leave greater scars </li></ul></li></ul> <ul><li><ul><li>For some, sibling issues are easier </li></ul></li></ul> <ul><li><ul><li>Make hospital room feel like home </li></ul></li></ul> <p> 10. Medical Care Issues </p> <ul><li>Pain </li></ul> <ul><li>Other Common Symptoms </li></ul> <ul><li>Venous Access </li></ul> <ul><li>Neonatal Pain </li></ul> <ul><li>Terminal Care </li></ul> <ul><li>Case Studies </li></ul> <p> 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 </p> <ul><li>Freedom From Pain: A Matter of Rights? </li></ul> <ul><li><ul><li>T. Patrick Hill, M.A.Ca. Invest., 12 (4), 1994 </li></ul></li></ul> <ul><li>Pain Isolates: We are probably never more alone than when severe pain invades us. </li></ul> <ul><li>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. </li></ul> <p> 13. A Matter of Attitude </p> <ul><li> 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. </li></ul> <ul><li>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. </li></ul> <p> 14. Barriers to Pain Control </p> <ul><li>... 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. </li></ul> <ul><li>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. </li></ul> <ul><li><ul><li>Weissman, David E.Home Health Care ConsultantVol. 2, No. 5, Sept. 1995 </li></ul></li></ul> <p> 15. Treatment Principles </p> <ul><li>Correctly Assess Degree and Cause of Pain </li></ul> <ul><li>Consider Psychosocial Factors </li></ul> <ul><li>Consider 24 hour Coverage </li></ul> <ul><li><ul><li>Children </li></ul></li></ul> <ul><li><ul><li>Severe or Chronic Pain</li></ul></li></ul> <ul><li><ul><li>Patient- Controlled Analgesia </li></ul></li></ul> <ul><li>Opioids Are Safe </li></ul> <ul><li><ul><li>Respiratory Depression Overestimated </li></ul></li></ul> <ul><li><ul><li>Pharmacologic Dependence With Chronic Use </li></ul></li></ul> <ul><li>Neveruse a placebo </li></ul> <p> 16. Pediatric Pain Assessment </p> <ul><li>Infant </li></ul> <ul><li><ul><li>HR, Resp, BP </li></ul></li></ul> <ul><li><ul><li>fever, sweating </li></ul></li></ul> <ul><li>Child </li></ul> <ul><li><ul><li>Irritability, esp. paradoxical </li></ul></li></ul> <ul><li><ul><li>Refusal to walk or use a painful limb </li></ul></li></ul> <ul><li><ul><li>Functional changes (school, sports, etc.) </li></ul></li></ul> <ul><li><ul><li>May be able to use pain scale </li></ul></li></ul> <ul><li>Adolescent </li></ul> <ul><li><ul><li>Generally accurate reporter </li></ul></li></ul> <ul><li><ul><li>May be reluctant to participate </li></ul></li></ul> <p> 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 </p> <ul><li>Acetaminophen </li></ul> <ul><li><ul><li>12 - 15 mg/kg, Q 4hr, PO or PR </li></ul></li></ul> <ul><li>NSAIDs </li></ul> <ul><li><ul><li>Ibuprofen </li></ul></li></ul> <ul><li><ul><li><ul><li>10 mg/kg, max 40mg/kg/day, Q 6hr, PO </li></ul></li></ul></li></ul> <ul><li><ul><li>Ketorolac (variable efficacy) </li></ul></li></ul> <ul><li><ul><li><ul><li>0.5 mg/kg IV/IM, 5-10 mg PO, Q 6hr </li></ul></li></ul></li></ul> <ul><li><ul><li>Cox 2 Inhibitors </li></ul></li></ul> <ul><li><ul><li><ul><li>Vioxx, oral solution, 0.5 mg/kg QD (effective) </li></ul></li></ul></li></ul> <ul><li><ul><li><ul><li>Occasional sedation </li></ul></li></ul></li></ul> <ul><li><ul><li><ul><li>Celebrex has better GI safety profile </li></ul></li></ul></li></ul> <p> 19. Level II and III Medications Pain Control Using Narcotics 20. Principles of Narcotic Dosing </p> <ul><li>The Right Dose is the Dose that Works </li></ul> <ul><li>Pain and the Reticular Activating System </li></ul> <ul><li><ul><li> 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 .</li></ul></li></ul> <ul><li><ul><li><ul><li>Wall, R.D., ed.Textbook of Pain . Churchill Livingstone </li></ul></li></ul></li></ul> <ul><li>Naive Pts. vs. Tolerance </li></ul> <p> 21. Enteral Narcotics </p> <ul><li>Codeine </li></ul> <ul><li><ul><li>1 mg/kg, Q 2-4 hrs, PO </li></ul></li></ul> <ul><li><ul><li>Ineffective for age &gt;~10-12 years </li></ul></li></ul> <ul><li>Hydrocodone(Lortab) </li></ul> <ul><li><ul><li>0.1 mg/kg PO q 2-4 hours (very good for moderate pain) </li></ul></li></ul> <ul><li>Oxycodone5 - 10 mg/ dose PO q 2-4 hours (Tylox) </li></ul> <ul><li>Tramadol(Ultram) </li></ul> <ul><li><ul><li>0.7 - 2.0 mg/kg/dose PO Q 4-6 hours (variable efficacy) </li></ul></li></ul> <ul><li>Morphine(the gold standard) </li></ul> <ul><li><ul><li>0.3 mg/kgPOQ 2-4hr </li></ul></li></ul> <ul><li>Morphine SR(MS Contin) </li></ul> <ul><li><ul><li>0.5 mg/kg, BID, PO (Do not crush) </li></ul></li></ul> <p> 22. Parenteral Narcotics</p> <ul><li>Morphine </li></ul> <ul><li><ul><li>0.1 mg/kgIV bolus, Q 1-2hr</li></ul></li></ul> <ul><li><ul><li>.05 mg/ kg/hr, CI - IV or SQ</li></ul></li></ul> <ul><li>Hydromorphone(Dilaudid) </li></ul> <ul><li><ul><li>Approximately 6 times stronger than morphine </li></ul></li></ul> <ul><li>Fentanyl </li></ul> <ul><li><ul><li>Approximately 10 times stronger than morphine </li></ul></li></ul> <ul><li><ul><li>Wide dosing range </li></ul></li></ul> <ul><li><ul><li>1-2 mcg/kg IVslow push </li></ul></li></ul> <ul><li><ul><li>0.5-1.0 mcg/kg/hr, CI - IV or SQ </li></ul></li></ul> <ul><li><ul><li>Total hourly dose as a transderm patch </li></ul></li></ul> <p> 23. Patient-Controlled Analgesia </p> <ul><li>Age &gt; 4 years (if able to play computer games) </li></ul> <ul><li>Home or Hospital </li></ul> <ul><li>Adequate observation </li></ul> <p>Medication Base Rate Bolus Dose Lockout Max/Hr Morphine.03 mg/kgSame6-10 min.15 mg/kg Dilaudid5 mcg/kgSame6-10 min25 mcg/kg Fentanyl1 mcg/kgSame6-10 min4 mcg/kg 24. Equianalgesic Narcotic Dosing Source : McCaffery M, Pasero C. PAIN : Clinical Manual,2nd Edition, Harcort Health Sciences Website, 2000.www.harcourthealth.com/PAIN/index.html Oral/Rectal Dose (mg) Analgesic Parenteral Dose (mg) 3 Morphine 1 20 Codeine 12 3 Hydrocodone -- 0.75 Hydromorphone 0.15-(0.3 w/ PCA) 2 Oxycodone -- 2 Methadone 1 25 mcg/hrFentanyl Patch = 1 mg/hr IV MSO 4 -- Fentanyl 10-20 mcg 30 Meperidine 7.5 25. Common Uncommon Constipation Bad dreams / hallucinations Dry mouth Dysphoria / delirium Nausea / vomiting Myoclonus / seizures Sedation Pruritus / urticaria Sweats Respiratory depression Urinary retention Opioid Side Effects Demerolis not recommended due to its side effects Addictionis NOT a sideeffect 26. CNS Excitation </p> <ul><li>Eliminate primary cause </li></ul> <ul><li>Medications </li></ul> <ul><li><ul><li>Haldol (drug of choice) </li></ul></li></ul> <ul><li><ul><li><ul><li>Age 3-12: Agitation: 0.01-0.03 mg/kg/day div QD - TID </li></ul></li></ul></li></ul> <ul><li><ul><li><ul><li>Age 3-12: Psychosis: 0.05-0.15mg/kg/day div BID-TID </li></ul></li></ul></li></ul> <ul><li><ul><li><ul><li>Age &gt;12: Acute agitation: 2-5 mg IM or 1-15 mg PO, Q1h PRN </li></ul></li></ul></li></ul> <ul><li><ul><li><ul><li>Age &gt;12: Psychosis: same doses, IM Q 4-8 hr; PO div BID-TID</li></ul></li></ul></li></ul> <ul><li><ul><li>Benzodiazepenes (may exacerbate delirium) </li></ul></li></ul> <ul><li><ul><li>Dantrium - muscle spasms </li></ul></li></ul> <ul><li><ul><li><ul><li>4-8 mg/kg/day, PO, div QID </li></ul></li></ul></li></ul> <ul><li><ul><li><ul><li>2.5 mg/kg by slow IV per dose, to effect </li></ul></li></ul></li></ul> <ul><li><ul><li>Narcotics are generally not indicated as these symptoms are usually uncomfortable, but not painful. </li></ul></li></ul> <p> 27. Myoclonus </p> <ul><li>Melatonin in treatment of non-epileptic myoclonus in children </li></ul> <ul><li><ul><li>Developmental Medicine &amp; Child Neurology 1999, 41: 255-259 </li></ul></li></ul> <ul><li>Melatonin - pineal hormone regulates sleep </li></ul> <ul><li><ul><li>Absenceseizures; MLT is anticonvulsant </li></ul></li></ul> <ul><li><ul><li>1.25 /kg IV MLT causes EEG slowing and sleep </li></ul></li></ul> <ul><li><ul><li>Half-life &lt; 1 hour </li></ul></li></ul> <ul><li>Case Reports: </li></ul> <ul><li><ul><li>Three children with severe sleep disorders due to myoclonus </li></ul></li></ul> <ul><li><ul><li>1 had epilepsy, 2 without epilepsy </li></ul></li></ul> <p> 28. Case I </p> <ul><li>15 month-old boy with holoprosencephaly &amp; spastic quadriplegia; no epilepsy </li></ul> <ul><li><ul><li>Prolonged clusters of myoclonus only before sleep </li></ul></li></ul> <ul><li><ul><li>Lasted several hourscrying and exhaustion </li></ul></li></ul> <ul><li><ul><li>No change in sensorium </li></ul></li></ul> <ul><li><ul><li>Benzodiazepenes failed </li></ul></li></ul> <ul><li><ul><li>5 years of age:2.5 mg oral FR MLT QHS </li></ul></li></ul> <ul><li><ul><li>Myoclonus stopped after 2 days; returned if MLT stopped </li></ul></li></ul> <ul><li><ul><li>8 years of age: developed AM myoclonus; 4mg CR MLT (replacing 5mg FR MLT) successful </li></ul></li></ul> <p> 29. Addiction </p> <ul><li> neurobehavioral syndrome with genetic &amp; environmental influences that results in psychological dependence on the use of substances for their psychic effects.</li></ul> <ul><li><ul><li>ME Board of Licensure in Medicine </li></ul></li></ul> <ul><li>Compulsive use </li></ul> <ul><li>Loss of control over drugs </li></ul> <ul><li>Loss of interest in pleasurable activities </li></ul> <ul><li>Continued use of drugs in spite of harm </li></ul> <ul><li>A rare outcome of pain management </li></ul> <p> 30. Pseudoaddiction </p> <ul><li> Pseudoaddiction is a pattern of drug-seeking behavior of pain patients who are receiving inadequate pain management that can be mistaken for addiction. </li></ul> <ul><li><ul><li>Department of Professional &amp; Financial Regulation,Board of Licensure in Medicine, a joint chapter with the Board of Osteopathic Medicine,Chapter 11: Use of Controlled Substances for Treatment of Pain </li></ul></li></ul> <p> 31. Tolerance </p> <ul><li>Reduced effectiveness of a given dose over time </li></ul> <ul><li>Not clinically significant with chronic dosing </li></ul> <ul><li>If dose is increasing, suspect disease progression </li></ul> <p> 32. Physical dependence </p> <ul><li>A process of neuroadaptation </li></ul> <ul><li>Abrupt withdrawal mayabstinence syndrome </li></ul> <ul><li>If dose reduction required, reduce by 50% every 23 days </li></ul> <ul><li>Avoid antagonists </li></ul> <p> 33. Substance Abusers </p> <ul><li>Can have real pain </li></ul> <ul><li>Treat with compassion</li></ul> <ul><li>Create protocols and contracts </li></ul> <ul><li>Consider a consultation with pain or addiction specialists </li></ul> <ul><li>More Options </li></ul> <p> 34. Adjunctive Pain Treatments </p> <ul><li>Radiotherapy </li></ul> <ul><li><ul><li>External beamor brachytherapy </li></ul></li></ul> <ul><li><ul><li>Bone Metastases :</li></ul></li></ul> <ul><li><ul><li><ul><li>NSAIDs </li></ul></li></ul></li></ul> <ul><li><ul><li><ul><li>Hemibody XRT </li></ul></li></ul></li></ul> <ul><li><ul><li><ul><li>Radioisotopes </li></ul></li></ul></li></ul> <ul><li>Anesthetic Procedures </li></ul> <ul><li><ul><li>Epidural anesthetics </li></ul></li></ul> <ul><li><ul><li>Nerve Block </li></ul></li></ul> <ul><li>Neurosurgical Procedures </li></ul> <ul><li><ul><li>Neurolysis </li></ul></li></ul> <ul><li>Orthopedic Procedures </li></ul> <ul><li><ul><li>Stabilization of pathologic fractures </li></ul></li></ul> <p> 35. Complimentary Interventions </p> <ul><li>Acupuncture </li></ul> <ul><li>Relaxation Therapy </li></ul> <ul><li>Spiritual Assistance </li></ul> <ul><li>Hypnosis / Biofeedback / Massage </li></ul> <ul><li>Art Therapy </li></ul> <p>Summary 36. NIH Consensus Statement 21 The introduction of acupuncture into the choice of treatment modalities that are readily available to the public is in its early stages. Issues of training, licensure, and reimbursement remain to be clarified. There is sufficient evidence, however, of acupuncture's value to expand its use into conventional medicine and to encourage further studies of its physiology and clinical value. 37. ShotBlocker </p> <ul><li>Thin plastic device designed to reduce the pain of minor injections </li></ul> <p> 38. Use of the ShotBlocker In my office, using the ShotBlocker on over 100 patients, ages ranging from 4-18 years, I have noticed a significant reduction in the perceived pain from my patients receiving minor injections and immunizations. Although anecdotal, the response has been striking. -- James Hunter, MD, PhD 39. Scientific Results Ordering Information Bionix Medical Technologies Phone: 1-800-551-7096 Fax: 800-455-5678 Web: www.bionix.com Pricing 25 per box . $23.75 100 per box $85.00 40. Other Common Symptoms </p> <ul><li>Neurologic Pain </li></ul> <ul><li>Anxiety </li></ul> <ul><li>Depression </li></ul> <ul><li>Breathlessness </li></ul> <ul><li>When All Else Fails </li></ul> <ul><li>Nausea </li></ul> <ul><li>Constipation </li></ul> <p> 41. Narcotic Pruritus </p> <ul><li>Due to mast cell destabilization </li></ul> <ul><li>Routine skin care </li></ul> <ul><li>? Reduce dose or change narcotic </li></ul> <ul><li>Antihistamines </li></ul> <ul><li><ul><li>Claritin (or other non-sedating antihistamines) </li></ul></li></ul> <ul><li><ul><li><ul><li>1- 6 years 5 mg PO QD </li></ul></li></ul></li></ul> <ul><li><ul><li><ul><li>&gt;6 years 10 mg PO QD </li></ul></li></ul></li></ul> <ul><li><ul><li>Benadryl </li></ul></li></ul> <ul><li><ul><li><ul><li>1 mg/kg, IV or PO, Q 4-6 hr </li></ul></li></ul></li></ul> <ul><li><ul><li>H 2Blockers may be effective </li></ul></li></ul> <ul><li>Narcotic receptor blockade </li></ul> <ul><li><ul><li>Narcan, 0.005 mg/kg/hr, IV or SQ </li></ul></li></ul> <p> 42. Sedation </p> <ul><li>Distinguish from exhaustion due to pain </li></ul> <ul><li>Tolerance develops within days </li></ul> <ul><li>Treatment Stimulants </li></ul> <ul><li><ul><li>Ritalin, start @ 5-10 mg PO BID </li></ul></li></ul> <ul><li><ul><li>Consider SR, 20 mg BID </li></ul></li></ul> <ul><li><ul><li>Maximum20 mg QID </li></ul></li></ul> <ul><li><ul><li>Adderall is an alternative </li></ul></li></ul> <p> 43. Physiology of Nausea </p> <ul><li>CTZ </li></ul> <ul><li>All transmitters </li></ul> <p>CorticalAnticipation </p> <ul><li>GI Tract </li></ul> <ul><li>Serotonin--vagal </li></ul> <ul><li>ACH- peristalsis </li></ul> <ul><li>?Dopamine </li></ul> <ul><li>Other CNS </li></ul> <ul><li>VestibularACH, histamine </li></ul> <ul><li>ICP </li></ul> <p>Vagal acetylcholine 44. Pharmacologic Management </p> <ul><li>Serotonin Blockage-- Wonder Drugs </li></ul> <ul><li><ul><li>Zofran(Ondansetron) </li></ul></li></ul> <ul><li><ul><li><ul><li>0.15 mg/kg PO or IV Q 4-8 Hr </li></ul></li></ul></li></ul> <ul><li><ul><li><ul><li>Oral forms: Solution: 4mg/5ml, Disintegrating tab: 4, 8 mg, Tabs, 4, 8, 24 mg </li></ul></li></ul></li></ul> <ul><li><ul><li>Approved for chemo, post-op, gastroenteritis </li></ul></li></ul> <ul><li><ul><li>No significant adverse effects </li></ul></li></ul> <ul><li><ul><li>Less effective with delayed nausea </li></ul></li></ul> <ul><li><ul><li>Kytril(Gran