Transcript Pediatric pain management

By:
Dr. Gamal Adel
Under supervision
Prof Dr. Hany Elzahaby
 Pain as an unpleasant sensation that originates in traumatized tissue and
warns of injury
 An unpleasant sensory and emotional experience normally associated with
tissue damage or described in terms of such damage
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 Nociceptive pain
 Neuropathic pain
 is pain in which normal nerves
transmit information to the central
nervous system about trauma to tissues
 is pain in which there are structural
and/or functional nervous system
adaptations secondary to injury
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 Cutaneous pain
 Somatic pain
 Neuropathic pain
 Phantom limb pain
 Visceral pain
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Spinal
cord
Higher
centers
nociceptor
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 Impulses in C fibers or A delta fibers travels to the spinal cord (Peripheral
Nerve Sensitivity)
 To the dorsal horn (central sensitization )
 Competition by encephalin-producing descending fibers from the brain stem
interact with both pre-synaptic and post-synaptic cells to inhibit transmission
“pain gate”
 Incoming signals in the A beta fibers of a peripheral nerve can alter
sensitivity of the post-synaptic cells to painful stimuli arriving in C and A
delta fibers
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 Supraspinal pain modulating loops exist that can increase or decrease the
amount of pain
 Reticular formation, cortico-reticular signals
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The dorsolateral pontine tegmentum
The rostral ventral medulla
The dorsal medulla
The caudal medulla
The lateral hypothalamus
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 Descending Pain Modulating Pathways
 Periaqueductal grey matter
 locus ceruleus
raphe nuclus
to
dorsal horn
 Spinocerebral Ascending Pathways
 The spinothalamic pathway
 The spinoreticular pathway
 Areas of the brain
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Sensory and motor cortex areas
Premotor cortex ( for planning of movement)
Other parts of the parietal cortex and frontal cortex
Cingulate cortex
Insula
Occipital cortex
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Wrong beliefs
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 Children tolerate pain better than adults
 Children become accustomed to pain or painful procedures under pain
recognition
 Children’s behavior reflects their pain intensity.
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 Pain is less harmful than the side effects of analgesic therapy
 Health care providers frequently have limited knowledge regarding state of
the art pain management
 Limited verbal communication in the younger children population
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Pain
Assessment
Self Report
Physical
Behavioral
Examination
Observation
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 Appropriate age related tool is used to asses and document level of pain.
 < 3 years old .... Behavioral observation or FACES tool or FLACC scale
 3-7 years old .... FACES or visual analog scale
 8-14 years old .. Visual analog scale and numeric scale or oucher scale or
pocker chip scale
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 Children < 3 years and Children with Developmental disabilities
Face
Legs
Activity
0
1
2
No particular
Occasional grimace or
Frequent to constant
expression or smile
frown, withdrawn,
frown, clenched jaw,
disinterested
quivering chin
Normal or relaxed
Uneasy, restless,
Kicking, or legs drawn Up
position
tense
Lying quietly, normal
Squirming, tense,
Arched, rigid, or
position, moves easily
shifting back and forth
jerking
Moans or whimpers;
Cries steadily,
occasional complaint
screams, sobs,
Cry
No cry
(awake or asleep)
Consolability
Content, relaxed
frequent complaints
Assured talking or hugging;
distractible
Difficult to console or
Comfort
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Non-pharmacologic
Strategies
Regional blocks
Systemic
analgesics
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 Non-pharmacologic strategies play an important role in pain management
and can be combined with analgesics to minimize the pain experience
 Non-pharmacologic approaches for the treatment of pain in children include
psychological strategies, education and parental support
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 According to type:
1-Rehabilitative:
heat, cold, ultrasound, holding, mobilization or immobilization
2-Psychological:
Education, relaxation, imagery, psychotherapy, counseling, music, swaddling and rocking
3-Complementary and Alternative:
Acupuncture ,TENS and massage
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Mechanism of action of complementary methods :
 Activation and stimulation of large-diameter non-noxious fibers and inhibit
transmission of nociceptive information from the periphery to the brain.
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Topical anesthesia
Systemic analgesics
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 Topical local anaesthesia of the skin should be routine before all needle
procedures in children
 The eutectic mixture of local anesthetics (EMLA cream) is very effective
when applied for 60–90 min, while tetracaine gel has a slightly more rapid
onset of action (40 min) and produces vasodilatation.
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 Vapocoolant spray.
 It was found that all pain measures and cry duration were similar for EMLA and the
Vapocoolant. The Vapocoolant spray is much less expensive than EMLA cream and
significantly faster acting
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 Opioid Analgesics
Opioids produce analgesia by acting on both central and peripheral mu,
kappa and delta Opioid receptors to inhibit the transmission and perception
of nociceptive input.
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 Morphine clearance in term infants greater than 1 month old is comparable
with children from 1 to 17 yr old.
 In neonates aged 1–7 days, the clearance of morphine is one-third that of
older infants and elimination half-life approximately 1.7 times longer.
 Morphine sulphation is efficient and effective in the early neonatal period
while glucuronidation maturity is some weeks later.
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 Titrated loading dose of i.v. morphine 50 µg kg-1 increments, repeated up to ·4 times
while I.V. or s.c. morphine infusion10–40 µg kg-1 h PCA with morphine
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Bolus dose 20 µg kg-1
Lockout interval 5 min
Background infusion 4 µg kg- h-1
(especially first 24 h)
 Nurse controlled analgesia (NCA) with morphine
 Bolus dose 20 µg kg-1
 Lockout interval 30 min
 Background infusion 20 µg kg-1 h-1
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Routes of administration
 Subcutaneous cannula
 subcutaneous cannula can be sited while the child is anaesthetized or under topical local anaesthetic
cream and nurse-administered bolus doses can be highly effective.
 A 24-gauge cannula can be inserted easily into the subcutaneous tissue of the anterior abdominal
wall or the deltoid area of the upper outer arm
 The pharmacokinetics and dynamics are similar to the i.v. route provided peripheral tissue perfusion
is stable and adequate
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Other opioids
 Fentanyl, sufentanil, alfentanil, and remifentanil may have a role after major
surgery and in intensive care practice.
 Opioids with low context-sensitive half time are of extremely rapid recovery
because of esterase clearance are best delivered by target controlled infusion
devices.
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 (PCA) is now widely used in children as young as 5 yr.
 improve sleep pattern without increasing the adverse effects.
 Children have control over their own analgesia, which has considerable
psychological benefits.
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 Child less than 5 yr of age
 Child with learning difficulties
 Child physically unable to operate demand button
 Increased intracranial pressure
 Depressed conscious level
 Airway obstruction
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 Respiratory depression and sedation
 depressing central respiratory drive and also causing a partially obstructed upper
airway as a result of oversedation
 If a child is noted to be oversedated. have a consistent pulse oximetry reading of
less than 94%
 ventilatory frequency less than 20 bpm in an infant or less than 12 bpm in an
older child.
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 Support the airway and give high flow oxygen
 Assist breathing if hypoventilation severe
 Discontinue opioid administration
 Give i.v. naloxone 2–4 µgkg–1
 Repeat naloxone 2–4 µgkg–1 up to 10 µgkg–1
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 Cause: opioid stimulation of the chemoreceptor trigger zone in the medulla of the brain
 Management
 reduce the dose of drug given.Antiemetics: but may cause extrapyramidal signs in children if given
frequently(e.g. metoclopramide and prochlorperazine).
The 5-HT3 antagonist ondansetron does not produce sedation or extrapyramidal problems.
 Transdermal hyoscine has also been used as there is often a component of motion sickness to opioidinduced nausea. Low-dose droperidol is another alternative.
 changing to a different opioid decreases the incidence of nausea and vomiting
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The cause of pruritus induced by opioids is unclear
common when spinal opioids are used common when spinal opioids are used
Antihistamine drugs (Chlorpheniramine) but they increase the level of sedation
It may be safer to use a small dose of naloxone which does not affect the analgesic
properties of the opioid
 Ondansetron 0.1 mg kg–1 may be effective in reducing pruritus caused by epidural or
spinal opioids
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 In small babies, gentle suprapubic pressure allows bladder emptying but it
may be necessary to catheterize older patient
 low dose of naloxone0.5–2 µg kg–1
 Laxatives, suppositories and micro-enemas may be required.
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 chest wall rigidity particularly with fentanyl
 adductor muscle spasms may be caused by accumulation of stimulatory
metabolites such as morphine-3-glucuronide specially if used in orthopedic
surgeries for long periods.
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 Pharmacokinetic studies of NSAIDs have revealed a higher than expected
dose from adult doses
 NSAIDs should be avoided in:
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infants less than 6 months of age.
Children with aspirin or NSAID allergy
dehydration or hypovolaemia
renal or hepatic failure
coagulation defects
significant risk of haemorrhage
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The most commonly reported adverse
effects are
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 Bleeding, gastrointestinal, skin
 Hepatic, and renal toxic effects.
 Edema,bone marrow suppression,Stevens– Johnson syndrome
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The COX-2 inhibitors available at
present meloxicam, nimesulide,
celecoxib,
 etoricoxib,lumaricoxib,valdecoxib
 Parecoxib(rofecoxib having been
withdrawn recently)
 By sparing physiological tissue prostaglandin production while inhibiting
inflammatory prostaglandin release, COX-2 inhibitors offered the potential
of effective analgesia with fewer side effects than the NSAID
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 Acetaminophen inhibits prostaglandin synthesis in the hypothalamus probably via
inhibition of cycloxygenase-3
 This central action produces both antipyretic and analgesic effects.
 Acetaminophen also reduces hyperalgesia mediated by substance P
 reduces nitric oxide generation involved in spinal hyperalgesia induced by
substance P or NMDA.
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 Oral and rectal dosage 15-20 mg kg-1 and maintenance 15 mg kg-1 every 812hours according to age
 Total daily doses of paracetamol should not exceeed approximately 90 mg
kg–1 day–1 for up to 72 h
 Peak analgesia even after i.v. administration is between 1 and 2 h.
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 The novel i.v. formulation pro-paracetamol is cleaved by plasma esterases to
produce half the mass of acetaminophen. Recently, mannitol solubilized
paracetamol (PerfalganTM) has become available for i.v. use.
 therapeutic plasma concentration’ of 10–20 mg ml-1
 I.V. acetaminophen (PerfalganTM) (15 mg kg-1) as slow i.v. infusion over 15
min children older than 1 year.
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 Suggested benefits include decreased intraoperative requirement for general
anesthetics in acute pain management
 less of a need for parenteral opioids limiting the incidence of side effects
limitation of stress hormone responses Improved postoperative analgesia
shortened recovery for outpatient surgery
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 In younger children, particularly infants, nerves have a thinner myelin
sheath, a smaller fiber diameter, and a shorter internodal distance.
 lack of hypotensive response from a sympathectomy produced by the local
anesthetic increased risk of toxicity
 Neonates and infants have a lower AAG concentration in serum as compared
with adults; therefore, their free fraction of local anesthetics is increased
accordingly
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 The intrinsic clearance of bupivacaine is only one-third of that in adults at 1
month of age, and two-thirds at 6 months
 Infants also have decreased levels of plasma pseudocholinesterase that
theoretically could increase the risk of toxicity with ester local anesthetics
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 Most famous axillary and parascalene blocks
 Dose: 0.3–0.5 ml/kg bupivacaine 0.25% or ropivacaine 0.2% in children younger than five–
eight years.
 In older children, the larger concentrations may be required, i.e., 0.3–0.5 mL/kg
bupivacaine 0.5% or ropivacaine 0.5%.
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 The needle is inserted immediately superior to
the artery high in the axilla. The needle
should be at a 45 degree angle pointing
cephalad toward the midpoint of the clavicle
and advanced until there is evidence of nerve
stimulation seen distally
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 The needle should be inserted perpendicular to
the skin at the junction of the upper two
thirds and lower one third of this line near the
external jugular vein. A nerve stimulator is
used to determine the depth of the brachial
plexus, which should be 7 to 30 mm below the
skin
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 Lower extremity blocks include those of the lumbar plexus (L1-L4) and
sciatic (L4-S3) nerves and are generally used for orthopedic and plastic
surgery procedures.
 Dosing requirements for lower extremity blocks are 0.5–1 mL/kg of 0.25%
bupivacaine or 0.2% ropivacaine in children younger than five to eight
years.Higher range reserved for lumbar plexus anesthesia
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 The needle is inserted with a slight cephalad
angle to the skin at 0.5–1 cm below the
inguinal ligament and 0.5–1 cm lateral to the
artery
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 Two lines are drawn: 1) between the
two iliac crests, and 2) parallel to the
spinous processes and through the
ipsilateral posterior superior iliac spine.
The needle should be inserted at 90
degrees to the skin at the intersection
of these lines and will traverse through
the quadratus lumborum
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 The point of needle insertion in
children is at the midpoint of a line
drawn between the tip of the coccyx
and the greater trochanter of the
femur. The needle should be
perpendicular to the skin and advanced
medially and upward toward the lateral
border of the ischial tuberosity until a
muscle twitch is seen in the foot
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 The point of needle insertion is 1
cm lateral to the line , 1 to 2 cm
proximal to the popliteal crease,
and lateral to the popliteal
arterydirected perpendicular to the
skin or with a slight cephalad
angle
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 A 3F polyethylene catheter can be placed over a 0.018-inch wire that has
been passed through a 22-gauge insulated needle or a 4F catheter can be
placed over a 0.021-inch wire that has been passed through a 20-gauge
insulated needle
 continuous infusions of local anesthetics in children have recommended a
starting rate of 0.15 ml kg-1 h-1 of bupivacaine 0.25%
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 Blockade of these nerves is
generally performed simultaneously
bylocating a point 1 cm superior
and 1 cm medial to the anterior
superior iliac spine
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 Subcutaneous ring block
 1–5 mL of local anesthetic is
required bupivacaine 0.25%–0.5%
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 a needle or intravenous catheter
(18–23 gauge) is advanced at a 45°
angle cephalad until a pop is felt
as the needle pierces the
sacrococcygeal lig.
 Maximum dose: Bupivacaine 3
mg/kg, Lidocaine 10 mg/kg
 Dosage by ml? Adding
morphine: 30µ/kg
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 The lumbar space is usually
encountered at 2.2–2.5 cm
 Infusion regimens:
 Loading: 0.5-1 ml/seg
 Maintanance: 0.125% plain 0.2–0.4
ml kg-1 h-1 to 0.25–0.5 mgaccording
to age with same max. dosages kg-1 h-
 Clonidine, an alpha-adrenoceptor
agonist,in a dose of 1–2mg kg-1
 ketamine, in its preservative-free
form at a dose of 0.5 mg kg-1
 Fentany and clonidine in the dose
1µg kg-1
1
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 Side effects include:
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urinary retention
leg weakness
tachyphylaxis
epidural haematoma
epidural infection
risk of i.v. and subarachnoid injection
Pressure sores may occur in analgesic skin
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26-27G needle
 Dosage:
 bupivicaine 0.5–1 mg/kg
 adiitminister an extra 0.1–0.2cc to
compensate needle dead space
 From: 0-5 kg 0.1ml/kg
5-10 kg 0.08 ml/kg
> 15kg 0.06 ml/kg
Morphine : 10µg/kg
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 The multi-modal approach is considered to be the best for good pain cotrol
 Examples
 Tosillectomy
 Cong.ing hernia
 Talipus
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