The 3 Ps of Control

1
????? ????? ?????? ???? ????? ??????
?"? ???? ???? ??"? "?????" ?????? ???? ????? ???"?
1
2
Do we really need to treat Pediatric pain and
anxiety?(Ethics?)
3
Treat the disease ?
patient ?
4
Children are not just the people of tomorrow,
they are people today (Janusch Korchak)
5
There is no ethical justification to withhold
analgesia when a child is clearly in pain
6

• The Ethics of pain control in Infants and
  children. Walco GA, Cassidy RC, Schechter NL,
  NEJM, 1994331(8)541-43
• The assessment and treatment of pain in
  children are important parts of Pediatric
  practice, and failure to provide adequate control
  of pain amounts to substandard and unethical
  medical practice

7
AAP APS policy statement, 09/2001

• The concepts of pain and suffering go well
  beyond that of a simple sensory experience. It
  has emotional, cognitive, and behavioral
  components as well as developmental,
  environmental and sociocultural aspects
• It is important that Pediatricians expand
  their knowledge and advocate for the use of
  effective pain management in children

8
????? ????? - ???? ??????? ?????? ??????? ??????
13 ???? 2003
????? ?????
????? ????? ?????? ?? ??? ???? ????? ????? "...
?? ?? ???? ??? ????? ????? ?? ???? ??????? ??????
??? ??????? ??????? ??????...."
9
Pain is an Emergency
Relieving
pain
anxiety
are an ED task!!
(todays standard of
care)
10
We create pain (Procedural pain)
11
Myths related to Pediatric pain

• Myth 1 Babies dont feel pain
• Myth 2 Babies dont remember
• Myth 3
  My son doesnt
  need pain killers
  No pain
  no gain,
  Pain is character building

12
Myth 1 Neonates dont feel pain...
Neonates do experience pain!
13

• By 29 wks of gestation, pain pathways and
  cortical sub-cortical centers involved in the
  perception of pain are well developed, as are the
  Neurological systems for the transmission and
  modulation of pain sensation
• Pain sensitivity in neonates may be more profound
  that that of older individuals their nervous
  system may be less effective at blocking painful
  stimuli than those of adults

14
Myth 2 They dont remember...
Babies do remember pain!
15

• Effect of neonatal circumcision on pain response
  during subsequent routine vaccination. 1997,
  Lancet. Taddio, Kats, Ilersich, Koren
• Does neonatal circumcision alter pain response at
  4-month or 6-month vaccination compared with the
  response of uncircumcised infants?
• Prospective. cohort design. 87 patients.
• 3 groups uncircumcised infants, circumcised
  infants who had randomly pretreated with either
  EMLA cream or Placebo for circumcision in a
  previous clinical trial

16

• All infants were videotaped during vaccination in
  a primary care clinic. Videotapes were blindly
  scored by a trained research assistant. The score
  measured 3 behavioral pain measures facial
  action, cry duration and visual analogue scale

3 specific facial actions brow bulge,
nasolabial furrow, and eyes squeezed shut -
present or absent for each 1 s period of the 20 s
before the vaccination (baseline), and the first
20s during and after the vaccination
(expressed in ). Cry duration, VAS
17
Results

• The pain itself may not be consciously remembered
  but the painful experience does

18
Myth 3 Pain is character building
Pain is not character building, it has a
negative influence on children !
19

• This statement is unfair. It legitimizes pain and
  takes away the childs right for pain relief
• Children younger than 8 years are not able to
  understand that short term pain may have long
  term benefit
• Adolescents who had poorly managed pain
  procedures show increased level of anxiety in
  subsequent pain situations
• Pain is a subjective experience and is
  incomparable. There is no direct relationship
  between pain experience and pain intensity or
  between physical pathology and pain intensity

20
Anxiety decreases pain threshold (Fear makes
every pain greater)
21
????? ??? ?????? ???? ?? ????
22

• Sedation reduces the state of awareness
• Analgesia reduces or eliminates the
  perception of pain
• Amnesia Inability to remember an event or
  experience (babies do remember the painful
  experience!)

23
Children are different
24
????? ?? ???????

• Parental distraction techniques
• Quite environment

Hei Doc, tell me whats going on.Hei, dont
take my mom away
25
Indications for sedation in children

• Painful procedures (lac. Repair, BMA)
• (I dont want you to feel pain)
• Prolonged procedures (bone scan, CT scan)
• (Id like you to sleep)
• Unpleasant procedures (VCUG)
• (I need you to lie down without moving)

26
PSA - Medications
Dissociative agent
Inhalational agent
Analgesic agents
Sedative/Hypnotics
Etomidate Propofol
Opioids
Benzodiazepins
Barbiturates
Nitrous Oxide
Ketamine
Non-opioid
Fentanyl
Midazolam
Methohexital
Ibuprofen
Nurofen Advil
Monitoring devices
Morphine
Oxycode
Topical Analgesia
Tramadol (Atypical opioid)
Meperidine?
Emla, AmetopGel, LET, TAC
27

• Safe environment
  resuscitation space, resuscitation equipment

Trained Personnel
PALS Pediatric sedation course
trained, at least 2 personnel - one is
responsible for sedation only
Documented accepted hospital protocol Recording
Informed consent
28
You are going to do what to my penis?