Pain%20management%20in%20the%20Pediatric%20%20%20Emergency%20Department

1
Pain management in the Pediatric Emergency
Department

• Itai Shavit, MD
• Alberta Childrens Hospital November 2001

2
Objectives

• 1. Pain in children Perception, Myths, Attitudes
  and Ethics
• 2. Pediatric pain assessment
• 3. Pediatric Procedural Sedation and Analgesia
  (PSA)
• 4. Narcotic analgesia in acute abdomen
• 5. Topical analgesia
• 6. Neonatal Sucrose analgesia
• 7. AAP, September 2001 guidelines
• 8. Summary

3
Pain in children Perception, Myths, Attitudes
and Ethics
4
The definition of pain

• An unpleasant sensory or emotional experience
  associated with actual or potential tissue
  damage, or described in terms of such damage
  (International Association for the study of Pain
  IASP,1979)
• Does the human neonate capable of perceiving pain
  ????

5
The concept of pain perception

• In the eighties, Premature infants who had major
  surgeries were treated with minimal anesthesia
  during and after the surgery (normal standard)
• Pain and its effects in the human neonate and
  fetus.1987, NEJM. Landmark seminar paper. Anand
  and Hickley Called into question the widely
  held belief that neonates do not have the
  Neurophysiologic apparatus required to experience
  pain

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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
  (AAP and American Pain
  Society policy statement, September, 2001)

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Myths

• 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

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Myth 1 Babies dont feel pain...
Babies do experience pain!
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• 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

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Myth 2 They dont remember...
Babies do remember pain!
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• 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

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• All infants were videotaped during vaccination in
  a primary care clinic. Videotapes were blindly
  scored by a trained research assistant. The score
  measured facial action, cry duration and visual
  analogue scale
• Results Circumcised infants showed a stronger
  pain response to subsequent routine vaccination
  than uncircumcised infants. Among the circumcised
  group, preoperative treatment with EMLA
  attenuated the pain response to vaccination
• The pain itself may not be consciously remembered
  but the painful experience does

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• Consequences of inadequate Analgesia during
  painful procedures in childen. 1998, Arch Ped
  Adolesc Med. Weisman, Bernstein, Schechter
• How does inadequate Analgesia for painful
  procedures (BMA, ST) effect pain response in
  subsequent procedures?
• Cohort study, randomized, placebo control
  (Placebo vs Oral Transmucosal Fentanyl), small
  sample
• Young children (lt8y) who received placebo in
  previous procedure had consistently higher pain
  scores than children who had proper analgesia

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Myth 3 Pain is character building
Pain is not character building, it has a
negative influence on children !
15

• 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

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Our fear of Analgesia...

• Masking of symptoms and signs
• Changes in the exam
• Side effects and complications

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Ethics

• 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

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Short term effects of inadequate pain management

• Significant fluctuations in HR, BP, ICP, Oxygen
  level, and stress hormones level
• Sleep disturbances, agitation, crying

Long term effects of inadequate pain management

• Inadequate surgical pain management has more
  clinical complications, prolonged hospitalization
  time and higher mortality rates
• Behavioral and Psychological sequaela

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Pediatric pain assessment
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• Weve all experienced pain
• Anxiety decreases pain threshold

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Pediatric pain assessment scales

• Inability to verbalize pain appropriately under 2
  years of age. At age 3-7 most children are
  competent to provide accurate information (using
  assessment tools)
• Pain is a subjective experience therefore
  individual self report is favored (AAP
  recommendation)
• Behavioral pain measures are more useful than
  physiological parameters. Physiologic parameters
  are unreliable

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Pediatric pain assessment scales
Pain Assessment tools

• 0-2 Years Neonatal Infant Pain Scale, Premature
  Infant Pain Profile, Neonatal Infant Pain Scale,
  DAN score
• 3-7 years old FACES pain rating scale, OUCHER
  Scale
• 7lt years old Verbal Report Scale, Visual Analog
  Scale

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Neonatal pain assessment
Facial expression Eyes squeeze Brow
bulge Nasolabial furrow Vocal expression
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Circumcision
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DAN score Acute pain rating scale in neonates
(Douleur Aigue du Nouuveau-ne, 1997)
Facial expression Calm (0), Snivels and
alternates gentle eye openining and closing (1),
Determine intensity of one or or more of eyes
squeeze, brow bulge, nasolabial furrow Mild,
intermittent with return to calm (2), Moderate
(3), Very pronounced, continuous (4)
Limb movements Calm or gentle movements (0),
Determine intensity of one or more of the
following signspedals, toes spread, legs tensed
and pulled up, agitation of arms, withdrawal
reaction Mild, intermittent with return to calm
(2), Moderate (3), Very pronounced, continuous
(4)
Vocal expression No complaints (0), Moans
briefly for intubated child, looks anxious or
uneasy (1), Intermittent crying for intubated
child, gesticulations of intermittent crying (2),
Long lasting crying, continuous howl, for
intubated child, gesticulations of continuous
crying
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FACES pain rating scale (3-7 years)

The Wong Baker Scale
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OUCHER scale (3-7 years)
Categorical

• Available in versions for males and females and
  in multicultural forms. The child is asked to
  point to the picture that best shows how he or
  she feels

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Verbal Report Scale (gt7 years)
Categorical

• On a scale of 0 to 10, with 0 being no pain
  and 10 being the worst pain ever, how would you
  rate your pain?

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Visual Analog Scale (gt7 years)
Non categorical

• A straight line. The left end of the line
  representing no pain and the right end of the
  line representing the worst pain. Patients are
  asked to mark on the line where they think their
  pain is

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Visual Analog Scale (gt7 years)
Non categorical
The greatest pain imaginable
No pain
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Pediatric procedural analgesia
32
Guidelines for Pediatric procedural sedation and
analgesia

• Sedation and Analgesia for procedures in children
  2001,NEJM. Krauss, Green
• Management of acute pain and anxiety in children
  undergoing procedures in the Emergency
  Department. 2001, Pediatric Emergency Care.
  Krauss
• Pharmacological Management of pain and anxiety
  during Emergency procedures in children. 2001,
  Paediatric Drugs. Kennedy, Luhmann

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Terminology

• 12 different definitions for state of sedation.
  Most of them are based on the degree of sedation
  induced rather than the specific indication for
  sedation
• Only 4 are applicable for children

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Conscious Sedation, AAP, 1992

• A medically controlled state of depressed
  consciousness that 1. Allows protective reflexes
  to be maintained. 2.
  Retains the patient ability to maintain a patient
  airway independently and continuously
  
  3. Permits appropriate response by the patient
  to physical stimulation or verbal command, e.g.,
  open your eyes.

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Deep Sedation, AAP, 1992

• A medically controlled state of depressed
  consciousness or unconsciousness from which the
  patient is not easily aroused. It may be
  accompanied by a partial or complete loss of
  protective reflexes, and includes the inability
  to maintain a patent airway independently and
  respond purposefully to physical stimulation or
  verbal command.

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General Anesthesia, AAP, 1992

• A medically controlled state of depressed
  consciousness accompanied by a loss of reflexes
  including the inability to maintain a patent
  airway independently and respond purposefully to
  physical stimulation or verbal command

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Procedural Sedation and Analgesia (PSA),
ACEP, 1998

• A Technique of administering sedatives or
  dissociative agents with or without analgesics to
  induce a state that allows the patient to
  tolerate unpleasant procedures while maintaining
  cardiorespiratory function. Procedural sedation
  and analgesia is intended to result in a
  depressed level of consciousness but one that
  allows the patient to maintain airway control
  independently and continuously. Specifically, the
  drugs, doses, and techniques used are not likely
  to produce a loss of protective airway reflexes.
• Significant improvement over the traditional AAP
  terminology

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Precautions

• Midazolam
  
  Reduce dose when used in combination with Opioids
  
• Ketamine
  
  Higher risk for hallucinations gt 15y, may be
  blunted with Midazolam . Adding Midazolam to
  Ketamine in children younger than 15y appears to
  be unnecessary (Sherwin et al, Ann Em Med, 2000)
• Hypersalivation can be minimized with Atropine
  (poor evidence)
• Fentanyl
  
  Reduce dose when combined with Midazolam

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Ultra-Short acting medications

• Propofol
  Currently not
  (yet) recommended for PSA in children. High risk
  for apnea and loss of airway reflexes. No
  analgesic effect. Insufficient data (only one
  study in children)
• Etomidate, Methohexital
  Insufficient data in
  children for safety and reliability

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Oral/Intranasal medications for PSA

• Oral Transmucosal Fentanyl (lozengens)
  High rate of emesis
  (gt30)
• Intranasal Sufentanyl
  Insufficient
  data on safety and efficacy in children. 7 times
  more potent than Fentanyl. With Midazolam for
  lacerations. The nasal delivery is painless, no
  vomiting . Mean time to sedation 20 min,
  discharge time 54 min. Expensive.
• Oral Ketamine
  Insufficient
  data. Optimum oral dose for safe and reliable
  sedation for PSA has to be determined.
  Long discharge time
  (100 min)

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Antagonists

• Naloxon
  
  Introduced in 1960, proven to be safe in
  children. Opioid
  antagonist of choice for PSA
• Flumazenil
  
  Introduced in 1987, proven to be safe in children
  
• Nalmefen
  
  New Opioid antagonist, Introduced in 1995,
  proven to be useful in adults. Long acting
  (3.5h).
• Only one study in children (Nov 2001, Ann Em
  Med) Patients who had PSA with
  Fentanyl/Midazolam received Nalmefen after the
  procedure. Sedation reversal parameters were
  improved, no side effects, no cardiorespiratory
  changes, no resedation phenomena. Nalmefen seems
  to be effective in children. (small sample)

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Narcotic analgesia in the pediatric acute abdomen
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Narcotic analgesia in acute abdomen

• The Ethical dilemma of withholding analgesia
  while awaiting surgical evaluation
• 4 prospective randomized controlled double blind
  studies in adults, no studies in children
• All 4 studies use Morphine sulfate or Morphine
  derivatives

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Narcotic analgesia in acute abdomen

• In all studies, opiates didnt change management
  and were not found to be associated with
  increased morbidity or mortality. None of the
  trials was able to identify even one patient in
  which analgesia led to a poor outcome
• In adults the use of narcotic analgesia doesnt
  mask symptoms or change the physical exam
  findings
• In children there is no data

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Topical analgesia
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Needlephobia

• Topical anesthetics do not reduce needlephobia
  
• Coping strategies used by parents proved to
  significantly reduce stress (e.g. favorite toy,
  books, singing songs)
• Both child and parents have to be fully aware of
  what is going to occur and the reasons why

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EMLA

• For IV cannulation and lumbar puncture. Not
  recommended for IM injection or heel prick in
  neonates
• Mixture of 2.5 lidocaine and 2.5 prilocaine in
  a cream base. The specific concentration gradient
  promote penetration of intact skin
• Application under an occlusive dressing. Depth of
  anesthesia ranges from 3mm after 60 min (onset to
  pick effect), to 5 mm after 90

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EMLA

• Should be placed on skin for at list 60 min.
  Changing Triage protocols?
• Safe. Recently been approve to for use in
  newborns.
• Single dose does not cause Methemoglobinemia
  (Prilocaine side effect)

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Tetracaine cream
Ametop Gel (Smith Nephew 1997)

• 4 Tetracaine cream (Amethocaine)
• Applied under occlusive dressing
• Rapid onset of action (30 to 40 min)
• Provide anesthesia for up to 4 hours
• Should not be used in neonates (irritation, even
  blistering)

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Lidocaine injection

• Subcutaneously injected buffered lidocaine 1
  (1/10 with Bicarbonate solution of 1meq/ml) using
  30-gauge needle, reduces struggling during LPs
  in newborns
• EMLA or Ametop (gt1mo) prior the procedure if
  possible
• Buffering decreases onset time for analgesia
  without affecting efficacy or duration
• To reduce pain Distract the patient, use
  buffered lidocaine, use 30 (for infants) or 27
  gauge needle, warm the anesthetic to body
  temperature prior administration, avoid
  intradermal injection

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Neonatal analgesia
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Analgesia for minor invasive procedures in
neonates
(Neonates usually suffer more than one poke)

• Acetaminophen?
• Not effective in controlling neonatal procedural
  pain
• Ibuprofen?
• Its safety under 6 months of age hasnt been
  established
• Codeine?
• Codeine requires the conversion to its active
  component, Morphine. This enzymatic conversion
  activity is lt10 of that seen in adults

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Sucrose analgesia
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• Since 1991, 14 RO,CO,BL studies were published
  
• All studies found sucrose to be safe and
  effective in reducing neonatal procedural pain
  (using various neonatal pain rating scales)
  
  
• most studies used 24 sucrose, 30 sucrose or 30
  glucose

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• Sucrose elicits analgesia in neonates when
  administered prior to a painful procedure

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The phenomenon of sucrose analgesia

• Infant rats showed attenuated pain response when
  given intraoral infusions of sugar (1987, Blass
  et al,Pharmacol Biochem Behav)
• 1991, Blass Hoffmeyer, Pediatrics. First report
  in neonates. 24 Sucrose solution proved to
  attenuate pain, especially when given with
  pacifier (Circumcision, small sample, only of
  crying time was measured)

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Theoretical Mechanism

• Endogenous Opioid release? The animals analgesia
  was reversible with the administration of opiate
  antagonist
• Perception of sweet taste signaling pain pathways
  ?
• How does pacifier elicit analgesia? Pacifier may
  promotes sucking and calming that increase pain
  threshold by reducing stress/anxiety

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DAN score during venepuncture in 150 newborns
Carbajal et al, BMJ, 1999
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Practical considerations

• Optimal sugar solution ? Optimal dose ?
• The suggested solution for practical purposes is
  sucrose 25 gram dissolved in 100cc of sterile
  water, or D25W

• Technique
• 1. Two minutes prior procedure, put the pacifier
  soaked with sugar solution in babys mouth. Coat
  the pacifier with the solution repeatedly during
  the procedure Or
• 2. Two minutes prior procedure, Slowly (30 sec)
  administer 2cc of the solution to the tongue,
  then allow him to suck the pacifier during the
  procedure

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Practical considerations

• Treatment of infants older than 1 month with
  sucrose solution?
• Insufficient data. One study showed improved pain
  response when given to children at 2-4 months
  prior immunization

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AAP / APS policy statement September 2001
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The assessment and management of Acute pain in
Infants, Children, and Adolescent
Policy Statement, 09/2001 American Academy of
Pediatrics American Pain Society

• The AAP and APS jointly issued this general
  statement to emphasize the responsibility and the
  obligation of Physicians to treat acute Pain in
  children
• Discusses myths about pain in children, the
  importance of pain assessment, procedure related
  pain and recommends using guidelines for PSA

63
The assessment and management of Acute pain in
Infants, Children, and Adolescent
Policy Statement, American Academy of
Pediatrics American Pain Society

• Because of the diversity and complexity of the
  clinical issues present pain treatment,
  including choice of drug, dosage, and route, must
  be tailored to the individual patient, and
  analgesic given in the overall context of
  what is best
  for the patient

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Summary

• Pain has short and long term effects on children
• Assessment of pain should be part of the PE
• Pain is a subjective experience, Treat the
  individual !
• Use PSA guidelines
• Insufficient data to support narcotic analgesia
  in Pediatric acute abdomen
• EMLA (60 min), Ametop (30 min), Buffered
  lidocaine
• 2001, AAP policy statement
• Just stick the sweetened soother in!

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PED-EM-L_at_LISTSERV.BROWN.EDUPediatric Emergency
Medicine Discussion List
2001

• Would you give analgesia to a child with a
  fracture, prior to obtaining parental consent?

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PED-EM-L_at_LISTSERV.BROWN.EDUPediatric Emergency
Medicine Discussion List
2001

• Pain is an emergency. It should be treated
  regardless of parental consent Bill Zempsky,
  Connecticut