Transcript Oxford Textbook of Paediatric Pain.

Procedure-related Pain
Kimberly Hartman, MD
Assistant Professor of Pediatrics
Department of Pediatric Rehabilitation Medicine
Children’s Mercy Hospital
Kansas City, MO
© The Children's Mercy Hospital, 2015
Objective
• Recognize methods to manage procedural
pain
• Pain + anxiety  distress
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Common Procedures
• Chemodenervation
– Botulinum toxin
– Phenol
• Intrathecal Baclofen Pump
refill
• EMG
• Trigger point injections
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Why?
• Needle-based
procedures induce high
levels of distress:
– 83% toddlers (2.5-6yo)
– 51% children (7-12yo)
– 28% adolescents (≥12yo)
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• ED: IM injections
reported in top 5 most
painful and distressing
procedures
• Inpatients: procedural
pain reported as greater
than disease-related
and surgical pain
Humphrey 1992; Babl 2008; Shomaker 2015
Acute Implications
• Increased distress:
– Patient
– Parent
– Providers
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• Inability to perform
procedure accurately or
completely
• Increased time spent in
procedure
Walco 2008; Smith 2007; Kennedy 2008
Memory
• Memory can shape
future reactions to
painful events
• Stressful experience
recalled up to years
later
• Adults report distress
based on childhood
experiences
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Painful event
Remembered
pain
Walco 2008; von Baeyer 2004; Noel 2002; Pate 1996
Remembered Pain
Habituation
• Decreased reaction over time
• Milder pain, more mature coping
Sensitization
• Increased reaction over time ± reduced
pain threshold
• More severe pain, younger kids, less
mature coping
von Baeyer 2004
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Long-term Implications
• Increased anticipatory
anxiety
• Increased pain
perception
• Diminished analgesic
effectiveness
• Needle phobia (10% of
adult population)
• Avoidance of medical
care
Quality >> Quantity
8
Walco 2008; Taddio 1997; von Baeyer 2004; Weisman 1998;
Hamilton 1995; Rocha 2003
Factors to Consider
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•
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Patient temperament
Developmental age
Parental anxiety
Culture
• Prior patient
experiences with
procedure
• Type of procedure
• Procedure duration
Bearden 2012; Kristjansdottir 2012
Management
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•
•
•
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Procedural
Physical
Psychological
Pharmacological
Procedural
• Needle size
No evidence higher Gauge
is better
• Injection volume
Patients need to be aware
of sensation
• Simultaneous
injections
11
May have decreased pain
behaviors
Taddio 2009; Goodenough 2000; Beirne 2015; Price 2009; Hanson
2010
Procedural
• No aspiration and rapid
injection speed
Less pain and no negative
effects (for IM imms)
• Less painful formulation
injected first
Similar to less painful site
first?
• Sitting up or holding (vs. Safety concerns? Access
supine)
to site?
12
Taddio 2009; Goodenough 2000; Beirne 2015; Price 2009;
Howard 2012
Physical
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•
•
•
•
•
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Stroking skin
Pressure
Cold
Vibration
Vibration + cold
Swaddling, tucking,
kangaroo care (infants)
Decreased pain with IM
immunizations 
unknown if translates to
Rehab procedures
Taddio 2009; Sahiner 2015; Howard 2012; Pillai Riddell 2012
Vapocoolant
•
•
•
•
Mixed results
IM: in 4-6yo, can increase pain
IV: no significant pain reduction in children
EMG (adults): more effective than EMLA
cream or no treatment
Fast and cheap
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Cohen 2009; Hogan 2014; Moon 2013; MacLaren 2007;
Howard 2012
Physical
Infants ˂12 months
Children ˃ 12 months
• Sucrose 24%
• Non-nutritive sucking (≤ 3
years)
• Glucose 30%
• Breast-feeding
• Non-nutritive sucking
• No benefit:
– Sweet gum
– Lollipop
– Sucrose
Harrison 2010; Kassab 2012; Harrison 2015
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Psychological: Preparation
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What will happen
How it will feel
What will be done for pain
How child can help
Demonstration
Taddio 2014; Slifer 2011
Parent Preparation
Positive strategies
Negative strategies
• Calm
• Anxious
• Coaching to cope
• Apologizing
• Distraction
• Criticizing
• Reassuring
• Empathizing
Jones 2005; Taddio 2014
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Distraction
• Distraction more
beneficial than
reassurance
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• Parent involvement
• Specialist involvement
(i.e., Child Life, Music)
• No/low tech vs. high
tech
• Interactive vs. passive
• Child choice vs. no child
choice
McMutry 2010; Birnie 2014; Uman 2013
Reframing Memory
• Recall of positives:
– Portions of procedure (“You
held really still”)
– Positive coping strategies
(“You did a great job taking
deep breaths”)
• May be able to create more
adaptive memories
Chen
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Pharmacological
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•
•
•
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Topical
Enteral
Sedation
Anesthesia
Topical
Anesthetic
Dosage
forms
Application
time
(minutes)
Lidocaine
2.5% prilocaine
2.5%
Cream
Gel
Patch
60-90
Liposomal
lidocaine 4%
Cream
30
Lidocaine 7% tetracaine 7%
Heat
patch
20-30
Things to consider
• Occlusive dressing helps
lido/prilo permeate
• May not need occlusive
dressing with liposomal lido
• Main side effects are local
• Methemoglobinemia at high
doses
Taddio 2014; Zempsky 2014
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Enteral
• Few studies with decreased local reaction
(acetaminophen)
• No studies for acute pain during procedure
• ? Benefit for soreness after procedure
22
Taddio 2014
Sedation
Minimal
sedation
Moderate
sedation
Deep
sedation
General
anesthesia
Patient
response
Normal
Purposeful
response
Cannot be
easily
aroused
Not arousable
Protective
airway
reflexes
Maintained
Maintained
Partial or
complete loss
Partial or
complete loss
Ventilation
Spontaneous
Spontaneous
May be
impaired
Impaired
CV function
Maintained
Maintained
Usually
maintained
May be
impaired
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Cote 2006
ASA Physical Status Classification
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Class I
A normally healthy patient
Class II
A patient with mild systemic disease (eg, controlled
reactive airway disease)
Class III
A patient with severe systemic disease (eg, a child
who is actively wheezing)
Class IV
A patient with severe systemic disease that is a
constant threat to life (eg, a child with status
asthmaticus)
Class V
A moribund patient who is not expected to survive
without the operation (eg, a patient with severe
cardiomyopathy requiring heart transplantation)
Cote 2006
Midazolam
• Short-acting benzo
• Effects
– Skeletal muscle
relaxation
Enteral
Intranasal
Dose
0.3-0.75
mg/kg
0.2-0.4 mg/kg 0.05-0.1
mg/kg
repeated q34 minutes
(total 0.5-0.7
mg/kg)
Onset
15 min
10-15 min
– Amnesia
– Anxiolysis
• No analgesic
properties
Zempsky 2014
Intravenous
2-3 min
25
Nitrous Oxide
• Analgesic
• Anesthetic
• Weak sedative
• Onset: minutes
• Offset: rapid when gas
discontinued
• Minimal CV or respiratory
effects
Zempsky 2014; Pedersen 2013; Brochard 2009
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Other Medications
Sedatives
Analgesics
• Pentobarbital
• Fentanyl
• IV Propofol
• Ketamine
• IV Dexmedetomidine
Zempsky 2014
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Anesthesia Risks
• Anesthetic-induced neuro-toxicity
• Exposure < 3 years old:
– Deficits in language
– Deficits in reasoning
28
Ing 2012; Sanders 2013
Summary
• Untreated procedurerelated pain & anxiety
has short- and longterm consequences
• Treatment needs to be
based on individual
characteristics and
developmental age
29
• Procedural and physical
adaptations can help
but may not be feasible
• Distraction helps
• Topical anesthetic helps
• Sedation: weigh risks &
benefits
• Need more research!
Questions: [email protected]
References
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Babl FE, Mandrawa C, O’Sullivan R, Crellin D. Procedural pain and distress in young children as perceived
by medical and nursing staff. Pediatric Anesth. 2008;18:412-419.
Baxter AL, Cohen LL, McElvery HL, Lawson ML, von Baeyer CL. An integration of vibration and cold relieves
venipuncture pain in a pediatric emergency department. Ped Emer Care. 2011;27(12):1151-1156.
Bearden DJ, Feinstein A, Cohen LL. The influence of parent preprocedural anxiety on child procedural pain:
mediation by child procedural anxiety. J Pediatr Psychol. 2012;37(6):680-686.
Beirne PV, Hennessy S, Cadogan SL, Shiely F, Fitzgerald T, MacLeod F. Needle size for vaccination
procedures in children and adolescents. Cochrane Database of Systematic Reviews. 2015;6(Art. No:
CD010720:1-118.
Birnie KA, Noel M, Parker JA et al. Systematic review and meta-analysis of distraction and hypnosis for
needle-related pain and distress in children and adolescents. J Pediatric Psychol. 2014;39(8)783-808.
Brochard S, Blajan V, Lempereur M et al. Effectiveness of nitrous oxide and analgesic cream (lidocaine and
prilocaine) for prevention of pain during intramuscular botulinum toxin injections in children. Ann Phys
Rehab Med. 2009:52(10):704-716.
Cote CJ, Wilson S. Guidelines for monitoring and management of pediatric patients during and after
sedation for diagnostic and therapeutic procedures: an update. Pediatrics. 2006;118(6):2587-2602.
Cravero JP. Procedural sedation. In: McGrath PJ et al., ed. Oxford Textbook of Paediatric Pain. Oxford, UK:
Oxford University Press; 2014:194-204.
Cummings EA, Reid GJ, Finley GA, McGrath P, Ritchie JA. Prevalence and source of pain in pediatric
inpatients. Pain. 1996;68:25-31.
Hanson D, Hall W, Mills LL et al. Comparison of distress and pain in infants randomized to groups receiving
standard versus multiple immunizations. Inf Beh Dev. 2010;33:289-296.
30
•
•
•
•
•
•
•
•
•
•
Harrison D, Stevens B, Bueno M et al. Efficacy of sweet solutions for analgesia in infants between 1 and 12
months of age: a systematic review. Arch Dis Child. 2010;95:406-413.
Harrison D, Yamada J, Adams-Webber T, OhlssonA, Beyene J, Stevens B. Sweet tasting solutions for
reduction of needle-related procedural pain in children aged one to 16 years (review). Cochrane Database
of Systematic Reviews. 2015;5(Art No:CD008408).
Hogan M, Smart S, Shah V, Taddio A. A systematic review of vapocoolants for reducing pain from
venipuncture and venous cannulation in children and adults. J Emer Med. 2014;47(6):736-749.
Horn MI, McCarthy AM. Children’s responses to sequential versus simultaneous immunization injections. J
Pediatr Health Care. 1999;13:18-23.
Howard R, Carter B, Curry J et al. Good practice in postoperative and procedural pain management, 2nd
edition, 2012. Pediatric Anesthesia. 2012;22(Suppl. 1):1-79.
Humphrey GB, Boon CMJ, van Linden van den Huevell GFEC, van de Wiel HBM. The occurrence of high
levels of acute behavioral distress in children and adolescents undergoing routine venipunctures.
Pediatrics. 1992;90:87-91.
Ing C, DiMaggio C, Whitehouse A et al. Long-term differences in language and cognitive function after
childhood exposure to anesthesia. Pediatrics. 2012;130(3):e476-e485.
Jones M, Qazi M, Young KD. Ethnic differences in parent preference to be present for painful medical
procedures. Pediatrics.2005;116(2):e191-e197.
Kassab M, Foster JP, Foureur M, Fowler C. Sweet-tasting solutions for needle-related procedural pain in
infants one month to one year of age (review). Cochrane Database of Systematic Reviews. 2012;12(Art No:
CD008411). Kazak AE, Penati B, Brophy P, Himelstein B. Pharmacologic and psychologic interventions for
procedural pain. Pediatrics. 1998;102(1):59-66.
Kennedy RM, Luhmann J, Zempsky WT. Clinical implications of unmanaged needle-insertion pain and
distress in children. Pediatrics. 2008;122(3):S130-S133.
31
•
•
•
•
•
•
•
•
•
•
•
•
Kristjansdottir O, Unruh AM, McAlpine L, McGrath PJ. A systematic review of cross-cultural comparison
studies of child, parent, and health professional outcomes associated with pediatric medical procedures. J
Pain. 2012;13(3):207-219.
Lee GY, Yamada J, Kyololo O, Shorkey A, Stevens B. Pediatric clinical practice guidelines for acute
procedural pain: a systematic review. Pediatrics. 2014;133(3):500-515.
MacLaren JE, Cohen LL. Interventions for paediatric procedure-related pain in primary care. Paediatr Child
Health. 2007;12(2):111-116.
McCarthy AM, Kleiber C, Hanrahan K, Zimmerman MB, Westhus N, Allen S. Factors explaining children’s
responses to intravenous needle insertion. Nurs Res. 2010;59(6): 407-416.
Noel M, Chamgers CT, McGrath PJ, Klein RM, Stewart SH. The influence of children’s pain memories on
subsequent pain experience. Pain. 2012;153:1563-1572.
Pillai Riddell RR, Racine NM, Turcotte K et al. Non-pharmacological management of infant and young child
procedural pain (review). Cochrane Database of Systematic Reviews. 2012;10(Art No.: CD006275)
Pedersen RS, Bayat A, Steen NP, Bouchy Jacobsson ML. Nitrous oxide provides safe and effective analgesia
for minor paediatric procedures—a systematic review. Dan Med J. 2013;60(6):1-8.
Price KM, Williams ZY, Woodward JA. Needle preference in patients receiving cosmetic botulinum toxin
type A. Dermatol Surg. 2010;36:109-112.
Rocha EM, Prkachin KM, Beaumont SL, Hardy CL, Zumbo BD. Pain reactivity and somatization in
kindergarten-age children. J Pediatric Psychol. 2003;28(1):47-57.
Sahiner NC, Inal S, Akbay AS. The effect of combined stimulation of external cold and vibration during
immunizations on pain and anxiety levels in children. J PeriAnesth Nurs. 2015;30(3):228-235.
Sanders RD, Hassell J, Davidson AJ, Roberston NJ, Ma D. Impact of anaesthetics and surgery on
neurodevelopment: an update. Br J Anesth. 2013;110(S1);i53-i72.
Shah V, Taddio A, Rieder MJ. Effectiveness and tolerability of pharmacologic combined interventions for
reducing injection pain during routine childhood immunizations: systematic review and meta-analyses.
Clin Thera. 2009;31(Supplement B):S104-151.
•
•
•
•
•
•
•
•
•
•
•
•
•
Shomaker K, Dutton S, Mark M. Pain prevalence and treatment patterns in a US children’s hospital. Hosp
Peds. 2015;5(7):363-370.
Slater R, Cornelissen L, Fabrizi L et al. Oral sucrose as an analgesic drug for procedural pain in newborn
infants: a randomized controlled trial. Lancet. 2010;376:1225-1232.
Slifer KJ, Hankinson JC, Zettler MA et al. Distraction, exposure therapy, counterconditioning, and topical
anesthetic for acute pain management during needle sticks in children with intellectual and
developmental disabilities. Clin Pediatrics. 2011;50(8):688-697.
Taddio A, Katz J, Ilersich AL, Koren G. Effect of neonatal circumcision on pain response during subsequent
routine vaccination. Lancet. 1997;349:599-603.
Taddio A, Manley J, Potash L, Ipp M, Sgro M, Shah V. Routine immunization practices: use of topical
anesthetics and oral analgesics. Pediatrics. 2007;120(3):e637-e643
Taddio A, Ilersich AL, Ipp M, Kikuta A, Shah V. Physical interventions and injection techniques for reducing
injection pain during routine childhood immunizations: systematic review of randomized controlled trials
and quasi-randomized controlled trials. Clin Therap. 2009;31(Suppl B):S48-S76.
Taddio A, Appleton M, Bortolussi R et al. Reducing the pain of childhood vaccination: an evidence-based
clinical practice guideline. CMAJ. 2010;182(18):E843-E855.
Taddio A. Needle procedures. In: McGrath PJ et al., ed. Oxford Textbook of Paediatric Pain. Oxford, UK:
Oxford University Press; 2014:184-193.
Uman LS, Birnie KA, Noel M et al. Psychological interventions for needle-related procedural pain and
distress in children and adolescents. Cochrane Database of Systematic Reviews. 2013;10(Art. No.
CD005179).
Von Baeyer CL, Marche TA, Rocha EM, Salmon K. Children’s memory for pain: overview and implications
for practice. J Pain. 2004;5(5):241-249.
Walco GA. Needle pain in children: contextual factors. Pediatrics. 2008;122(Suppl 3):S125-S129.
Zepmsky WT. Topical anaesthetics and analgesics. In: McGrath PJ et al., ed. Oxford Textbook of Paediatric
Pain. Oxford, UK: Oxford University Press; 2014:486-494.
Zier JL, Rivard PF, Krach LE, Wendorf HR. Effectiveness of sedation using nitrous oxide compared with
enteral midazolam for botulinum toxin A injections in children. Dev Med Child Neuro. 2008;50:854-858.