Pain in the Pediatric Population

Transcription

1 Objective Pain in the Pediatric Population Noor Daghistani, Pharm.D. Define and discuss types of Discuss barriers in the treatment of in the pediatric population Describe age appropriate strategies and assessment tools for measuring in the pediatric population Review non-pharmacological and pharmacological treatment modalities for in the pediatric population Describe specific pharmacokinetic characteristics of commonly used medications in pediatric patients Definition Pain Pathway An unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage Noxious stimuli Physiological transmission of Sensory perception of Overall experience of Pain The inability to communicate verbally does not negate the possibility that an individual is experiencing Changes in Behavior Behavioral Dimensions of Pain Cognitive Beliefs, attitudes, spiritual, and cultural attitudes Emotions Affective Classification of Pain Pathophysiological Classification Pathophysiological Mechanism of Pain Duration of Pain Etiology of Pain Anatomic Location of Pain Nociceptive Pain Protective Tissue injury activates nociceptors Divided into Somatic vs Visceral Neuropathic Harmful Structural damage and nerve cell dysfunction Mixed Pain Neuropathic with nociceptive 1

2 Duration of Pain Secondary Classifications Acute Chronic Episodic Breakthrough Incidental End of dose Sudden onset Short-lasting Continuous Negatively affects all aspects of life Intermittent Intensity, quality, and frequency fluctuate Temporary increase in severity Pain due to simple movements Pain due to medication blood levels falling below minimum effective analgesic level Etiology of Pain Little relevance to mechanism and treatment of Based on underlying disease Malignant Non-malignant Anatomic Location Body location or anatomic function of affected tissue Does not offer bases for clinical management of Barriers to Myth that children & infants do not feel the way adults do Lack of assessment & reassessment Belief that addressing in children takes too much time and effort Difficulty with understanding & quantifying a subjective experience Fears of adverse effects of analgesic medications Lack of knowledge of treatment The American Academy of Pediatrics and the American Pain Society-The Assessment and Management of Acute Pain in Infants, Children, and Adolescents General Pain Assessment Principles Gather information on the usual behavior of the child when not in Asses cognitive developmental level Tools used depend on child s age and cognitive level. Can use self-report, behavioral observation, & physical measures Assess regularly Inquire aboutthe character, location, intensity, & duration of the Pain Expression Behavioral/Physiologic Scales Neonates & Infants Toddlers (1-2 years) Early Childhood (2-5 years) Middle Childhood (6-11 years) Adolescents (12-18 years) Inability to verbally express or discomfort Rely on behavioral features and vital signs Limited ability to differentiate types of May have limited knowledge of numbers and colors Ability to indicate presence of verbally Gradually learn to distinguish levels of, and by 5 years can describe and intensity At 6 years: can clearly differentiate levels of intensity 7-10 years: can explain why it hurts Have the highest capacity to describe Recommended Age: premature to full-term infants Neonatal Facial Coding System (NFCS) Neonatal Infant Pain Scale (NIPS) Premature Infant Pain Profile (PIPP) 2

3 Behavioral/Physiological Scales Face Legs Activity Cry Consolability(FLACC) Recommended Age: 2 months 7 years Categories Face Legs Activity Cry No particular expression or smile Normal position or relaxed Lying quietly, normal position, moves easily No cry,(awake or asleep) Scoring Occasional grimace or frown, withdrawn, disinterested Uneasy, restless, tense Squirming, shifting back and forth, tense Moans or whimpers, occasional complaint Consolability Content, relaxed Reassured by occasional toughing, hugging, or being talks to, distractible Frequentto constant quivering chin, clenched jaw Kicking, or legs drawn up Arched, rigid or jerking Crying steadily, screams or sobs, frequent complaint Difficult to console or comfort Self-Report Scales FACES Scales (3 years and older) Wong-Baker Faces Pain Scale- Revised (FSP-R) Recommended Poker Chip tool/pieces of Hurt tool (3-12 years) Self-Report Scales Other Parameters to Assess Visual Analogue Scale ( 8 years) Numerical Rating Scale ( 8 years) The OucherPhotographic (3-12 years) The extent of the child s restriction in physical and social activities Emotional disturbances Fear Anxiety Emotional stress Sleeping difficulties Coping skills Management of Acute Pain Nonpharmacologic Management Acetaminophen Non-opioid Pharmacological NSAIDs of Pain Opioid Non-Pharmacological Neonates & Infants: Cognitive strategies are visual or auditory Behavioral strategies: Swaddling, facilitated tucking, rocking, pacifier use, and positioning Toddlers & Preschoolers Explain procedure using age appropriate vocabulary Distraction: Active: bubbles, therapeutic play, distracting conversations, deep breathing Passive: television, read age appropriate books 3

4 Nonpharmacologic Management Principles of Pharmacologic Pain Management School-Aged Children Provide with age-appropriate information regarding procedure Give children choices Educate on passive and active distraction techniques Adolescents Ensure a private setting for procedure Give power to chose type of distraction and who can be present for procedure Mild Pain By the clock By the mouth Acetaminophen Ibuprofen By the individual Moderate to severe Pain Consider Opioids Special Considerations capacity to metabolize medications glomerular filtration and tubular secretion Thinner stratum corneumand greater hydration to the epidermis Topical medications Higher % of body weight as water concentrations of albumin & alpha-1 acid glycoprotein Special Considerations Children < 50 kg and < 18 years: Use weight-based dosing Children 50 kg Single-dose medications: use weight-based dosing unless patient s dose or dose per day exceeds adult dose for indication Continuous intravenous medication: avoid weightbased dosing strategies and use adult dosing strategies Premature infants, have ventilatory responses Teething Pain Non-pharmacologic treatment: Teething ring chilled in refrigerator Gently rub or massage gums with finger Pharmacologic treatment Acetaminophen or ibuprofen FDA does NOT recommend: Benzocaine- methemoglobinemia OTC: Anbesol, Hurricaine, Orajel Lidocaine 2%- seizures, brain injury, heart problems Procedural-Related Pain Key to management: anticipation Multimodal approach Use of local anesthetics and strategies to soothe, even in simple procedures, like venipuncture's Eutectic Mixture of Local Anesthetics (EMLA) Ionotophoresis Liposomal lidocaine Vapocoolant spray Use systemic agents for procedures which usually cause severe, such as bone marrow aspirations Do not use sedatives or anxiolytics alone 4

5 Acetaminophen Most common due to safety profile Available in many formulations (eg: tabs, caps, oral liquids, sup, IV) Beware of concentrated solutions General dosing principles PO: 10-15mg/kg Rec: 20mg/kg Loading dose needed: 30-40mg/kg IV: 15mg/kg Not FDA approved for use in children < 2 years MAX: 3G or 4G? Hepatically cleared Nonsteroidal Anti-inflammatory Drugs (NSAIDs) Most common NSAIDs in hospital settings: ibuprofen, naproxen, ketorolac FDA indication: Ibuprofen & ketorolac Exceptions: Neoprofen-PDA; Caldalor only approved for 17 years Ketorolac- only single dose in < 2 years WHO only recommends the use of ibuprofen NSAIDs Adverse Events: Increased incidence of bleeding Gastrointestinal bleeding Nephropathy Edema Caution in children with: Asthma Orthopedic injuries Mainstay of treatment for moderate to severe Golden Standard: Morphine Gradual titration needed No ceiling analgesic effect Respiratory depression Administration: PO or IV Intravenous route of administration is favored for acute onset of severe Bolus Continuous infusion Patient/Nurse Controlled Analgesia Morphine Most common opioid prescribed Safety: Hypotension Histamine release Hydromorphone 5 times more potent than morphine Preferred for intermittent dosing in patients with renal failure Fentanyl times more potent than morphine More lipophilic and quicker onset Structurally similar to meperidine Shorter half-life in children: ~2h Methadone Long-acting opioid Same potency as morphine Safety: Bradycardia, hypotension, cardiac arrythmias 5

6 Hydrocodone Oral administration Used for moderate Oxycodone Oral administration Used for moderate to severe Safety: Acetaminophen overdose in combination products Meperidine No longer recommended for treatment of acute Codeine Weak opioid Should not be routinely recommended 2013 BW: respiratory depression in children following tonsillectomy and/or adenoidectomy Tramadol May have role in some types of in adolescents Use is limited in children Safety: seizures and drug-interaction with serotonin reuptake inhibitors Opioid Dosing Medication Initial IV Initial PO < 40 kg 40 kg < 40 kg 40 kg Morphine B: mg/kg/dose q 2-4h; B: 5-10mg q 2-4h mg/kg/dose q 4-6h 10-30mg q 4h IR max15 mg/dose CI: mg/h CI: mg/kg/h B: 0.015mg/kg/dose q Hydromorphone 3-6h B: 1-2mg q 2-4h mg/kg/dose q 3-4h; 2-4 mgq 3-4h CI: mg/kg/h CI: mg/h max 5 mg/dose Fentanyl B: 1-2mcg/kg/dose q 1-2h B: mcg q 1-2h CI: 1-2 mcg/kg/h CI: mg/h Methadone B: not recommended 0.1mg/kg/dose q 4h x two or 5-10mg q 4-12h not recommended CI: three doses; then 0.1 mg/kg/dose q 6-12h; max 10 mg/dose Oxycodone mg/kg/dose q 4-6h; 1-2 tabs (5mg of max 5mg/dose of oxycodone oxycodone) q 4-6h Hydrocodone 0.2 mg/kg/dose q4-6h 1-2 tabs (5mg of hydrocodone) q 4-6h Summary Pediatric patients feel, even neonates Comprehensive management is multidisciplinary Pain assessments should be done regularly, using self-report scales when possible Appropriate analgesic dosing is based on patient s weight and/or age B= bolus, CI= continuous infusion, h= hours, IV= intravenous, max= maximum, PO= oral, q= every, Assessment: True or False? References FALSE FALSE TRUE Infants and children suffer less from than adults. Self-Report Scales, when possible, are the preferred strategy for gathering information about levels in the pediatric population. Preterm and term infants clear acetaminophen faster than older children and therefore require a higher dosing frequency. 1. American Society of Anesthesiologists Task Force on Acute Pain Management: Practice guidelines for acute management in the perioperative setting: An updated report by the American Society of Anesthesiologists Task Force on Acute Pain Management. ANESTHESIOLOGY 2004; 100: American Academy of Pediatrics and American Pain Society. The assessment and management of acute in infants, children, and adolescents. Pediatrics. 2001; 108: Johnson PN. Chapter 53: Pain Management. In: Benavides S & NahataMC, Eds. Pediatric Pharmacotherapy. Lenexa, Kansas: American College of Clinical Pharmacy; 2013: Lavonas EJ, Reynolds KM, and Dart RC. Therapeutic acetaminophen is not associated with liver injury in children: a systematic review. Pediatrics. 2010; 126: Srouji R, Ratnapalan S, Schneeweiss S. Pain in Children: Assessment and Nonpharmacological Management. International Journal of Pediatrics 2010;2010: doi: /2010/ US Food and Drug Administration. Drug Safety Communications: FDA recommends not using lidocaine to treat teething and requires new boxed warning Available at: 7. WHO guidelineson the pharmacological treatment of persisting in children with medical illnesses. Available at: 6