Lesson 308: PreAnesthetic Assessment of the Pediatric Patient With Pain: Part 1

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1 Lesson 308: PreAnesthetic Assessment of the Pediatric Patient With Pain: Part 1 Page 1 of 12 Lesson 308: PreAnesthetic Assessment of the Pediatric Patient With Pain: Part 1 Written by: Orvil Luis Ayala, MD, Pediatric Pain Medicine Fellow, Cincinnati Children s Hospital Medical Center, Department of Anesthesia, Cincinnati, Ohio Reviewed by: Alexandra Szabova, MD, Pediatric Pain Medicine Fellowship, Program Director Cincinnati Children s Hospital Medical Center, Department of Anesthesia, Cincinnati, Ohio REVIEW DATE: December, 2013 Read this article, reflect on the information presented, then go online and complete the lesson post-test and course evaluation before the termination date below. (CME credit is not valid past this date.) You must achieve a score of 80% or better to earn CME credit. TIME TO COMPLETE ACTIVITY: 2 hours RELEASE DATE: February 1, 2014 TERMINATION DATE: January 31, 2015 COPYRIGHT: This material is subject to copyright 2014 Icahn School of Medicine at Mount Sinai. All rights reserved. Professional Gaps Although most anesthesiologists appreciate the need to provide perioperative pain relief for their patients, perioperative pain in children remains undertreated. Part 1 of this 2-part series examines the barriers to treatment of pain in children and presents the means of assessing pain as well as other factors affecting acute pain management in the pediatric population. Learning Objectives At the end of this activity, the participant should be able to: 1. Recognize some of the barriers to treating pediatric pain. 2. Discuss the developmental anatomy of nociception. 3. Present the controversies involved with perception of pain. 4. Highlight the development of understanding and reporting of pain by a pediatric patient. 5. Recognize the different tools used to assess pain in the pediatric population. 6. Discuss self-reporting measures used in the assessment of pain in the pediatric population. 7. Discuss the usefulness of observational scales used in the assessment of the nonverbal pediatric patient. 8. Understand other factors affecting the treatment of pain. 9. Discuss some of the techniques available to decrease perioperative anxiety. 10. Present general guidelines for the use of age-appropriate nonpharmacologic techniques in reduction of perioperative anxiety. Case History An 8-year-old boy with a past medical history significant for anorectal malformation and fecal incontinence was scheduled for a continent neo-appendicostomy under general anesthesia. The patient was otherwise healthy. He lived with his parents and had recently completed the third grade.

2 Lesson 308: PreAnesthetic Assessment of the Pediatric Patient With Pain: Part 1 Page 2 of 12 He weighed 25 kg, and his vital signs and physical examination were normal. The surgeon noted that postoperative pain could be significant. The surgeon and the parents asked that a plan for postoperative pain relief be in place and explained to them ahead of time The assessment and treatment of pain in the pediatric population present many challenges for perioperative physicians, especially the anesthetic care provider. Since the 1980s, several reports have indicated that pediatric patients in the perioperative setting are undertreated for pain compared with their adult counterparts. 1 Many advances in the care of pediatric patients have occurred, including evidence-based practice guidelines for the treatment of pediatric pain to mitigate gaps in clinical practice. 2 However, excessive pain in the perioperative setting can lead to worse patient outcomes and development of chronic pain syndromes. 3-5 The role of the perioperative physician is to understand and address barriers in pediatric pain management, and to improve pain management and thus patient outcomes (Table 1). 6 Development of Pain Perception Pain, as defined by the International Association for the Study of Pain (IASP), is an unpleasant sensory and emotional experience associated with actual or potential tissue damage. The IASP also acknowledges that the inability to communicate verbally does not negate the possibility that an individual is experiencing pain and is in need of appropriate pain-relieving treatment. 7 Some experts have postulated that neonates are born with the ability to perceive pain, given that the neuroanatomical system for pain is considered to be complete by 26 weeks of gestation. 8 Others have argued that the perception of pain requires an actual conscious recognition of noxious stimuli, which has been thought to exist once the thalamocortical pathways have matured and begun to function at around 30 weeks of gestation A brief overview of the developmental anatomy of nociception and pain perception pathways is presented in Table 2. These arguments and findings are relevant when one considers the need for anesthesia for midand end-gestational fetal surgeries in which fetuses are actively treated with opioids to prevent any negative consequences that exposure to pain at such a young age might have. Advances in the field of perinatology have led to an increase in the survival of preterm neonates in neonatal ICUs. 1 Many

3 Lesson 308: PreAnesthetic Assessment of the Pediatric Patient With Pain: Part 1 Page 3 of 12 studies have demonstrated that failure to provide adequate analgesia to these patients can lead to negative sequelae, including motor and cognitive deficits, changes in sensory processing, and high susceptibility to growth retardation. 11,14-16 It also is considered substandard and unethical care. Assessment of Perioperative Pain in the Pediatric Population The initial step in successful treatment of perioperative pain in the pediatric population is assessment. Preoperative assessment may elucidate confounding factors, such as the presence of developmental delay, which may make the treatment of pain challenging. It also may provide a platform for discussion between the physician, health care staff, parents, and patients as to what can be expected during the perioperative period. The assessment of pain in the pediatric population has been approached through the use of selfreporting scales, observational scales, and/or physiologic measures. Becoming familiar with the available age-appropriate pediatric pain assessment tools may significantly improve patient care and outcomes (Table 3). 17,18 Self-Reporting Scales The self-reporting scales used in the assessment of pain in the pediatric population rely on the patient s ability to understand and express his or her pain, and thus have to reflect various developmental stages. Success and ease of use of a self-reporting scale depends on how well the implications of the child s understanding of pain are incorporated in the assessment tool. It is important to note that between 36 and 60 months of age, children begin to report both the intensity of their pain and the emotions associated with it. This is the youngest age for which self-reporting scales have been developed, validated, and widely used in pain assessment. In our institution, we use a FACES rating for the younger age group and the numeric rating scale (NRS) for older children and adolescents (Figure). Self-reporting scales are regarded as the gold standard of pain assessment. We recommend choosing 1 or 2 scales, training the medical center staff well, and using the scales

4 Lesson 308: PreAnesthetic Assessment of the Pediatric Patient With Pain: Part 1 Page 4 of 12 consistently throughout the perioperative period (Table 4). 19,20 Observational Scales Validated observational scales have been used in the perioperative setting for assessment of pain in the pediatric population (Table 5). 11,19

5 Lesson 308: PreAnesthetic Assessment of the Pediatric Patient With Pain: Part 1 Page 5 of 12 Some of these scales are detailed, labor-intensive, and not practical for routine use, although they work well for intubated and sedated patients in the ICU, such as the Neonatal Infant Pain Scale (NIPS) or COMFORT Scale. For awake patients aged 0 to 18 years, we adopted the FLACC (faces, legs, activity, cry, consolability) scale, whose numeric value correlates with NRS, making interpretation meaningful to all users. A challenge of observational scales is the lack of ability to differentiate between other forms of distress, including hunger, thirst, or anxiety. 19 Physiologic Measures The physiologic measures are not as well validated as other methods of assessing pain but may provide some insight about the body s response to pain. Measures may include heart rate, blood pressure, transcutaneous oxygen, respiratory rate, sweating, and stress response (Table 6). 19 When using physiologic measures, it is important to note that these signs are not specific to pain and they work best when used in conjunction with other methods. Other Factors Affecting Pain Assessment and Treatment in the Pediatric Population Even with the use of age-appropriate pain assessment tools, the potential for failure and complications persists. Factors such as anxiety or medication side effects may alter the treatment of pain in the pediatric population. Perioperative anxiety has been shown to predict higher pain scores and analgesic consumption postoperatively Perioperative anxiety also can lead to long-term maladaptive behaviors. As a result, many studies have focused on interventions to reduce perioperative anxiety in children and their parents. Various pharmacologic and nonpharmacologic techniques have been shown to reduce anxiety, ranging from patient reassurance, distraction, 25 and preoperative videos, 26 as well as complementary and alternative medical therapies such as hypnosis, music therapy, and laughter therapy (Table 7). 27 Parental presence in the induction room is a well-researched technique for reducing anxiety in the pediatric population. 28 It has its limitations, 29 but is most effective when combined with noninstrumental talk between patient and health care providers compared with parental presence alone or in combination with anxiolytics. 30 Distraction is an effective and inexpensive technique to counteract anxiety that can be applied across the age groups. 31 This method probably works through cognitive and motor absorption, as children tend to be oblivious or have a decreased regard for their surroundings. 32 Such tools may include but are not limited to pacifiers, blankets, medical play, video games, and clowns. 30,32

6 Lesson 308: PreAnesthetic Assessment of the Pediatric Patient With Pain: Part 1 Page 6 of 12 Table 8. General Guidelines for Nonpharmacologic Techniques Used for Reduction of Perioperative Anxiety in the Pediatric Population Age and Developmental Barriers Techniques Emotional Support Common Reactions Infants (0-1 y) Attachment Basic trust Sensitivity to physical environment Preoperatively: Provide parents with information about the procedure (eg, pamphlets, reading materials, etc) During: Child distraction Music Massage Parental presence Items of comfort (eg, pacifier, blanket) Crying Problems with sleep Generalized increase in irritability Pain Toddlers (1-3 y) Separation anxiety Loss of autonomy Preoperatively: Parental information Child therapeutic play Medical play During: Child distraction Music Massage Same as infants, plus Home routines Simple explanations Pain Verbal responses to pain usually are not reliable When restrained, patient often responds to painless procedures Invasive procedures tend to cause a lot of anxiety Resistance Aggression Regression Preschoolers (4-5 y) Separation anxiety Moral reasoning Good vs bad Allow child to pick coping strategies Provide follow-up to procedures Music distraction Medical play Same as toddlers, plus Choices Positive reinforcement Fears intensified with age/experience Fear of abandonment Guilt Anger/aggression Regression Breaks in schedule, loss of control, and unfamiliar place and people tend to cause more anxiety

7 Lesson 308: PreAnesthetic Assessment of the Pediatric Patient With Pain: Part 1 Page 7 of 12 Age and Developmental Barriers Techniques Emotional Support Common Reactions School-aged (6-12 y) Altered body image Loss of privacy Loss of independence Preoperatively: Therapeutic play Medical play Procedure-based images During: Distraction Music Massage Hypnosis Allow child to make more choices Actively involve child in procedure Discuss potential changes in physical appearance Same as preschoolers, plus Positive reinforcement Encourage parental presence Increased ability to identify and localize pain Lack of abstract thinking may cause patient to feel guilt Past experiences/caregiver response can affect pain reactions Capability to exaggerate pain Acting out Aggression Depression Regression Adolescence (13-17 y) Loss of autonomy Loss of privacy Altered body image Preoperatively: Procedure-based instructions During: Distraction Music Guided imagery Hypnosis Discuss possible psychological and physical changes postprocedure Increase chances for involvement in decision making for medical care Same as school children, plus Encourage active participation Can locate and describe pain accurately Increased desire to participate in medical decision making Can be hyper-responsive to pain Has a better understanding of the concept of death May become rebellious to treatment and medical care Depression Regression Aggression Modified from reference 11. Perioperative pain management sometimes can be described as walking a fine line between comfort and medication-related side effects, such as sedation. The risk for adverse drug reactions may double in an overly sedated patient, 21 which is a distressing situation for all involved. Further administration of opioids or other medications under such circumstances should be withheld or tapered. 11 To prevent such incidents, many institutions have implemented routine assessment of sedation in patients on opioids. We use a modified Ramsay Sedation Scale in the assessment of sedation in the perioperative pediatric patient (Table 9). For safety reasons, if the Ramsay score is greater than 3, the administration of opioids or other sedation-enhancing medications is stopped regardless of the patient s pain score. 23

8 Lesson 308: PreAnesthetic Assessment of the Pediatric Patient With Pain: Part 1 Page 8 of 12 Conclusion When assessing pain in the pediatric population, the perioperative physician should have a consistent approach to evaluating the patient and to modifying the plan according to confounding factors throughout the perioperative course. Use of age-appropriate pain assessment tools, education of the medical staff on their use, and the creation of treatment guidelines based on assessment, all lead to improved pain management, patient satisfaction, fewer complications, and better outcomes.

9 Lesson 308: PreAnesthetic Assessment of the Pediatric Patient With Pain: Part 1 Page 9 of 12 REFERENCES 1. Schechter NL, Allen DA, Hanson K. Status of pediatric pain control: a comparison of hospital analgesic usage in children and adults. Pediatrics. 1986;77(1): MacLaren J, Kain ZN. Research to practice in pediatric pain: what are we missing? Pediatrics. 2008;122(2): Gauthier JC, Finley GA, McGrath PJ. Children s self-report of postoperative pain intensity and treatment threshold: determining the adequacy of medication. Clin J Pain. 1998;14(2): Roth-Isigkeit A, Thyen U, Stoven H, et al. Pain among children and adolescents: restrictions in daily living and triggering factors. Pediatrics. 2005;115(4): Porter FL, Grunau RE, Anand KJ. Long-term effects of pain in infants. J Dev Behav Pediatr. 1999;20(4): Golianu B, Krane EJ, Galloway KS, et al. Pediatric acute pain management. Pediatr Clin North Am. 2000;47(3): Goldschneider KR. Long-term consequences of pain in infancy. In: Berde CB, Rowbotham MC, eds. International Association for the Study of Pain: Technical Corner. IASP Newsletter. July/August Lee SJ, Ralston HJP, Drey EA, et al. Fetal pain: a systematic multidisciplinary review of the evidence. JAMA. 2005;294(8): Derbyshire SW. Can fetuses feel pain? BMJ. 2006;332(7546): Lowery CL, Hardman MP, Manning N, et al. Neurodevelopmental changes of fetal pain. Semin Perinatol. 2007;31(5): Gold JI, Townsend J, Jury DL, et al. Current trends in pediatric pain management: from preoperative to the postoperative bedside and beyond. Semin Anesth Periop Med Pain. 2006;25(3): Fitzgerald M. Development of pain pathways and mechanisms. In: Anand KIS, McGrath PJ, eds. Pain Research and Clinical Management. Vol. 5. Pain in Neonates. Amsterdam: Elsevier; 1993: Fitzgerald M. The neurobiology of chronic pain. In: McClain BC, Suresh S, eds. Handbook of Pediatric Chronic Pain: Current Science and Integrative Practice. New York, NY:Springer; 2011: Simons SHP, van Djik M, Anand KS, et al. Do we still hurt newborn babies? A prospective study of procedural pain and analgesia in neonates. Arch Pediatr Adolesc Med. 2003;157(11): Walco GA, Cassidy RC, Schechter NL. Pain, hurt, and harm. The ethics of pain control in infants and children. N Engl J Med. 1994;331(8): Fabrizi L, Slater R. Commentary: exploring the relationship of pain and development in the neonatal intensive care unit. Pain. 2012;153(7): McGrath PJ, Craig KD. Developmental and psychological factors in children s pain. Pediatr Clin North Am. 1989;36(4): Treadwell MJ, Franck LS, Vichinsky E. Using quality improvement strategies to enhance pediatric pain assessment. Int J Qual Health Care. 2002;14(1): McGrath PJ, Unruh AM. Measurement and assessment of pediatric pain. In: Wall & Melzack s Textbook of Pain, 6 th Ed. Philadelphia, PA: Saunders; McGrath PJ. Pain measurement in children. International Association for the Study of Pain, Clinical Updates. 1995;3(2): Vila H, Smith RA, Augustyniak MJ, et al. The efficacy and safety of pain management before and after implementation of hospital-wide pain management standards: is patient safety compromised by treatment based solely on numerical pain ratings? Anesth Analg. 2005;101(2); Lentschener C, Tostivint P, White PF, et al. Opioid-induced sedation in the postanesthesia care unit does not insure adequate pain relief: a case-control study. Anesth Analg. 2007;105(4): Ramsay MAE. How to use the Ramsay score to assess the level of ICU sedation. edation.htm. Accessed September 8, Kain ZN, Mayes LC, Caldwell-Andrews AA, et al. Preoperative anxiety, postoperative pain, and behavioral recovery in young children undergoing surgery. Pediatrics. 2006;18(2): Lee J, Lee J, Lim H, et al. Cartoon distraction alleviates anxiety in children during induction of anesthesia. Anesth Analg. 2012;115(5): McEwen A, Moorthy C, Quantock C, et al. The effect of videotaped preoperative information on parental anxiety during anesthesia induction for elective pediatric procedures. Paediatr Anaesth. 2007;17(6): Evans S, Tsao JC, Zeltzer LK. Complementary and alternative medicine for acute procedural pain in children. Altern Ther Health Med. 2008;14(5): Powers KS, Rubenstein JS. Family presence during invasive procedure in the pediatric intensive care unit: a prospective study. Arch Pediatr Adolesc Med. 1999;153(9): Cameron JA, Bond MJ, Pointer SC. Reducing the anxiety of children undergoing surgery: parental presence during anesthetic

10 Lesson 308: PreAnesthetic Assessment of the Pediatric Patient With Pain: Part 1 Page 10 of 12 induction. J Paediatr Child Health. 1996;32(1): Vagnoli L, Caprilli S, Messeri A. Parental presence, clowns or sedative premedication to treat preoperative anxiety in children: what could be the most promising option? Paediatr Anaesth. 2010;20(10): Kleiber C, Harper DC. Effects of distraction on children s pain and distress during medical procedures: a meta-analysis. Nurs Res. 1999;48(1): Patel A, Schieble T, Davidson M, et al. Distraction with a hand-held videogame reduces pediatric preoperative anxiety. Paediatr Anaesth. 2006;16(10):

11 Lesson 308: PreAnesthetic Assessment of the Pediatric Patient With Pain: Part 1 Page 11 of 12 Visit today for instant online processing of your CME post-test and evaluation form. There is a registration fee of $15 for this non industry-supported activity. For assistance with technical problems, including questions about navigating the Web site, call toll-free customer service at (888) or send an to Customer.Support@ProCEO.com. For inquiries about course content only, send an to ram.roth@mssm.edu. Ram Roth, MD, is director of PreAnesthetic Assessment Online and assistant professor of anesthesiology at The Icahn School of Medicine at Mount Sinai, New York, NY. Post-test 1. Which of the following is an example of an observational measure used to assess pain in a pediatric patient? a. Poker Chips b. Visual analog scale c. FLACC Scale d. FACES Scale 2. Which of the following scales may be used to assess pain in sedated patients? a. COMFORT Scale b. Numeric Rating Scale c. The Oucher scale d. Poker Chips 3. Which of the following is an example of the nonpharmacologic techniques involved in the treatment of pediatric patients? a. Massages b. Blowing bubbles c. Music therapy d. All of the above 4. Examples of barriers to the treatment of pain in the pediatric population include all of the following except. a. lack of familiarity with appropriate assessment tools b. lack of familiarity with drug options and dosing c. lack of parental/patient education d. presence of child life specialist on an inpatient unit 5. The treatment of pain should be withheld in which of the following scenarios? a. A 3-month-old boy undergoing elective circumcision b. A 13-year-old boy s/p pectus excavatum repair with patient-controlled analgesia and respiratory rate of 6 who requires supplemental oxygen to maintain saturation above 94% c. A 6-month-old girl undergoing congenital cystic adenomatoid malformation repair d. An 18-month-old boy undergoing pyeloplasty

12 Lesson 308: PreAnesthetic Assessment of the Pediatric Patient With Pain: Part 1 Page 12 of Which of the following is not part of the FLACC Scale? a. Face b. Labs c. Activity d. Cry 7. What Ramsay Sedation Scale (RSS) score does the following patient have: a 6-year-old boy s/p left inguinal hernia repair currently in the postanesthesia care unit, who is asleep but awakens to voice commands? a. RSS 6 b. RSS 8 c. RSS 1 d. RSS 3 8. Which of the following are some of the consequences of administering opioids or other sedation-inducing medications to an overly sedated person? a. Severe hypercarbia b. Hypoxia c. Respiratory arrest d. All of the above 9. High levels of parental anxiety may lead to higher anxiety levels in the pediatric patient during the perioperative period. a. Almost always b. It is unrelated c. Never d. Depends entirely on the preoperative mental condition of the child 10. Which of the following will help reduce anxiety during the perioperative period in an adolescent patient? a. Involving patient in decision making b. Hypnosis c. Procedure-based instructions d. All of the above