Inspiration. Trauma. Minimizing Pain 7/17/16

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1 Pain-free Dermatology: Minimizing Discomfort in Procedures for Children and Adults Peter A. Lio, MD, FAAD Assistant Professor Clinical Dermatology & Pediatrics Northwestern University Feinberg School of Medicine Inspiration Pediatrics vs. Dermatology Alisa McQueen, MD, FAAP, FACEP Associate Professor of Pediatrics The University of Chicago Comer Children s Hospital Trauma Minimizing Pain Me > Patient! Everybody wins: The patient has less pain The parents have less stress The dermatologist has a smoother procedure! 1

2 Outline Procedural Distress The History and Science of Pain A Model for Ensuring Procedure Success Pharmacologic Non-pharmacologic Practical Take Home Points Pain Distress Fear Attention Baxter A. Best Practices for Outpatient Procedural Sedation. Pediatric Annals 2012; 41: Pain 2

3 Fear Anxiolysis Anxiolysis Anxiolysis Attention Distraction 3

4 Anxiolysis Distraction Suffering so great as I underwent cannot be expressed in words, and thus fortunately cannot be recalled. The particular pangs are now forgotten; but the blank whirlwind of emotion, the horror of great darkness, and the sense of desertion by God and man, bordering close upon despair, which swept through my mind and overwhelmed my heart, I can never forget, however gladly I would do so. Patient to Sir James Simpson mid 19 th century. Definitions an unpleasant sensory and emotional experience associated with actual or potential tissue damage International Association of the Study of Pain Nociception perception of injury or painful stimuli by nerve endings, spinal tract, midbrain, and cortex and does not involve the affective or evaluative components of pain Nociception + OUCH = PAIN 4

5 Pain Transmission Theory A delta fibers 2-5 mm in diameter and myelinated have a fast conduction velocity (5-40 meters/sec) localized pain sensations, sharp pain C fibers mm in diameter and unmyelinated slow conduction velocity ( meters/sec) transmit dull, poorly localized pain sensation 70 % of all noxious pain transmission Melzack R, Wall PD: Pain mechanisms: a new theory. Science 150: , 1965 Taddio A et al. Effect of neonatal circumcision on pain response during subsequent routine vaccination. The Lancet 1997;349: Uncircumcised Circumcised with EMLA Circumcised with placebo Facial action score All videotaped during routine vaccination 4-6 months later Videotapes scored by blinded investigator Taddio A et al. Effect of neonatal circumcision on pain response during subsequent routine vaccination. The Lancet 1997;349: Taddio A et al. Effect of neonatal circumcision on pain response during subsequent routine vaccination. The Lancet 1997;349:

6 Cry duration Neural Pathways Taddio A et al. Effect of neonatal circumcision on pain response during subsequent routine vaccination. The Lancet 1997;349: % Occurrence During Heel Stick Skin-to-skin is analgesic 100 P = < P = < % Grimace % Cry Gray L, et al. Skin-to-skin contact is analgesic in healthy newborns. Pediatrics 2000;105(1) e14. Control Contact HR (bpm) Skin-to-skin is analgesic Heart Rate CONTROL 170 CONTACT Heel Stick Recovery Gray L, et al. Skin-to-skin contact is analgesic in healthy newborns. Pediatrics 2000;105(1) e14. 6

7 Breastfeeding is analgesic % Occurrence During HS Control Breastfeeding P = < P = < A sucker consisting of a sponge dipped in some sugar water will often suffice to calm a baby. % Cry % Grimace HR (bpm) Breastfeeding Control Modern Surgical Technique, HS REC Gray L, et al. Breastfeeding is analgesic in healthy newborns. Pediatrics 2002; 109(4), Harrison D et al. Analgesic effects of sweet-tasting solutions for infants: current state of equipoise. Pediatrics;2010: Harrison D et al. Analgesic effects of sweet-tasting solutions for infants: current state of equipoise. Pediatrics;2010:

8 Sucrose is an effective analgesic in newborns for single, limited procedures Sucrose likely works on opioid receptors Optimal dose is unclear but 24% does the trick (1 packet of table sugar to 10 cc sterile water) Baxter A et al. An integration of vibration and cold relieves venipuncture pain in a pediatric emergency department. Pediatric Emergency Care 2011;27:

9 Anxiolysis Distraction Topical Anesthetics There are many different topical anesthetics available Act via a numbing effect : reversible block in nerve conduction for minutes to hours Very safe overall Lander JA, Weltman BJ, So SS. EMLA and amethocaine for reduction of children's pain associated with needle insertion. Cochrane Database Syst Rev. 2006;3:CD Topical Anesthetics 1:1 mixture of 2.5% lidocaine and 2.5% prilocaine (EMLA: eutectic mixture of local anesthetics) They melt at a lower temperature than they do separately à a liquid at room temperature The combination is more effective than using both drugs together Mathew PJ, Mathew JL. Assessment and management of pain in infants. Postgrad Med J Aug;79(934): Topical Anesthetics Applied about 60 minutes before the intended procedure, it penetrates up to a depth of 10 mm Penetration can be increased with occlusion Possible side effects: methemoglobinemia Usually concern in < 3 months of age and when using large amounts (>2 g per 10 cm 2 ) Mathew PJ, Mathew JL. Assessment and management of pain in infants. Postgrad Med J Aug;79(934):

10 Topical Anesthetics A review of 8 trials (n = 458 children) of painful procedures compared tetracaine to EMLA Both were comparable for pain relief with 60 min application for EMLA and 30 min for tetracaine Topical Anesthetics Liposomal lidocaine is newer anesthetic Appears to have superior effect with faster onset (30 min) A trial of liposomal lidocaine vs. tetracaine found no significant difference in pain scores An Evidence-Based Approach to Minimizing Acute Procedural Pain in the Emergency Department and Beyond.Ali S, McGrath T, Drendel AL.Pediatr Emerg Care Jan;32(1): An Evidence-Based Approach to Minimizing Acute Procedural Pain in the Emergency Department and Beyond.Ali S, McGrath T, Drendel AL.Pediatr Emerg Care Jan;32(1): Pearl Cryotherapy pain has both immediate and delayed component Applying a topical anesthetic (e.g., 4% lidocaine cream) right after freezing can render the lesion painless within 30 seconds! Theory: ice crystals during freezing damage epidermal barrier, thus increasing penetration Benedetto AV. A novel use of topical anesthetics to alleviate the pain of cryotherapy. Skinmed Sep-Oct;2(5): Local Anesthetics Injectable anesthetics are the mainstay of dermatologic procedures They are very safe, work rapidly, and are very cost effective There can be significant discomfort as they are injected, however, both from the needle and the infiltration An Evidence-Based Approach to Minimizing Acute Procedural Pain in the Emergency Department and Beyond.Ali S, McGrath T, Drendel AL.Pediatr Emerg Care Jan;32(1):

11 For the Needle Pain Consider a topical anesthetic first Dr. McQueen will talk about distraction techniques shortly that are fantastic For the Infiltration Pain ph of lidocaine solution is between The acidity is thought to be responsible for the pain Alkalinization of the lidocaine can reduce this pain An Evidence-Based Approach to Minimizing Acute Procedural Pain in the Emergency Department and Beyond.Ali S, McGrath T, Drendel AL.Pediatr Emerg Care Jan;32(1): Buffer A systematic review of 23 studies determined that pain from injection of buffered lidocaine was less than from unbuffered lidocaine Buffering is generally achieved by adding 1 ml of 8.4% sodium bicarbonate to 9 ml of 1% or 2% lidocaine An Evidence-Based Approach to Minimizing Acute Procedural Pain in the Emergency Department and Beyond.Ali S, McGrath T, Drendel AL.Pediatr Emerg Care Jan;32(1): Buffer Theoretical issues with adding sodium bicarbonate: Causing precipitation Decreasing potency Reducing shelf life None of these found in the studies reviewed An Evidence-Based Approach to Minimizing Acute Procedural Pain in the Emergency Department and Beyond.Ali S, McGrath T, Drendel AL.Pediatr Emerg Care Jan;32(1):

12 A little out there In a mouse model of post-op pain: Inhalation of atlantic cedar oil markedly reduced mechanical hypersensitivity to painful stimulus This effect was prevented by pretreatment with naloxone Odors may activate the descending pain modulation pathway Inhalation of Cedrus atlantica essen tia l o il a llevia tes p a in b ehavio r thro ugh activatio n o f descending pain modulation pathways in a mouse model of postoperative pain. Martins DF, Emer AA, BatistiAP, Donatello N, Carlesso MG, Mazzardo-Martins L, Venzke D, Micke GA, PizzolattiMG, Piovezan AP, Dos Santos AR.J Eth n o p h a rma co l Dec 4;175:30-8. doi: /j.jep Ep u b 2015 Sep 4. Closer to home Aromatherapy may help with the autonomous response to pain 73 children with type 1 diabetes Orange and lavender oil were dispersed with an aromatherapy device vs. placebo Lower ΔHR% was associated with essential oil application (p=0.0252) Małachowska B, Fendler W, Pomykała A, Suwała S, Młynarski W. Es s en t ia l oils reduce autonomous response to pain sensation during self-monitoring of blood glucose among children with diabetes. J Pediatr En d o crin o l Metab Jan 1;29(1): Cooling Cooling the skin may decrease nerve conduction velocity of C and A[delta] fibers, thus decreasing the transmittance of pain A study of 60 subjects found no significant difference between buffered anesthetic and skin cooling in reducing pain of infiltration Suggests that cooling could be as effective as the pharmacologic effect of buffering SchlieveT, MiloroM. Topical refrigerant sprayfor pediatric venipuncturefor outpatient surgery. Oral andmaxillofacialsurgerycases. 2015; 1(2), Al Shahwan MA. Prospectivecomparison between buffered1%lidocaine-epinephrinean dskin coolingin reducingthepain oflocalanestheticinfiltration. DermatolSurg. 2012Oct;38(10): More Cooling A study randomized 39 patients before injecting anesthesia to skin cooling (termed cryo-preparation ) or no skin cooling They found significant reduction in injection pain with cryo-preparation 24.6% reduction in pain score that was statistically significant (p = 0.039) Goel S, ChangB, Bhan K, El-HindyN, et al. Cryoanalgesicpreparation beforelocalanesthetic injection for lidsurgery. Orbit, 2006; 25:

13 Many Ways to Cool Evaporative refrigerant sprays such as ethyl chloride to a simple ice pack One study compared ice cubes wrapped in latex or latex-like glove material to cubes wrapped in aluminum foil and found that the aluminum foil wrapping was more effective at reducing skin temperature before neurotoxin injection After 120 seconds of exposure, only the aluminum foil wrap was able to achieve a 2 C skin temperature--thought to be necessary to reduce nerve conduction and increase the pain threshold AlgaflyAA, GeorgeKP. Theeffectofcryotherapyon nerveconduction velocity, pain thresholdandpain tolerance. BrJ SportsMed. 2007; 41: Good Vibrations Application of vibration to the skin proximal to the procedure site has been shown to decrease pain perception during procedures More than simple distractin, vibration physiologically mediates the transmission of painful stimuli under Melzack and Wall s Gate Control Theory of pain KatzJ, Rosenbloom BN. Th e g o ld en a n n iversa ry o f Melzack and Wall s gate control theory of pain: celebrating 50 years of pain research and management. Pain Res Manag. 2015Nov-Dec;20(6): Vibration A study of 20 neonates found application of vibration during heel stick reduced pain (measured by the Neonatal Infant Pain Scale) In adults, at least one study demonstrates vibration outperforming vapocoolant for pain reduction during venipuncture Baba LR, McGrath JM, LiuJ. Th e ef f ica cyo f mechanical vibration analgesia for relief of heel stick pain in neonates: a novel approach. J Perinat Neonata lnurs. 2010Jul-Sep;24(3): Baxter AL, Leong T, Mathew B. Extern a l th ermo mech a n ica l stimu la tio n versu s vapocoolant for adult venipuncture pain: pilot data on a novel device. Clin J Pain Oct;25(8): Vibration + Cooling Vibration + Cooling may be even more effective Numerous studies demonstrate statistically and clinically significant reduction in pain perception when both are applied proximal to the painful procedure A randomized prospective trial of 81 children who received standard therapy versus use of a device combining cooling and vibration lower pain scores and improved venipuncture success Baxter AL, Cohen LL, McElvery HL, Lawson ML, von Baeyer CL. An integration of vibration and cold relieves venipuncture pain in a pediatric emergency d epartment. Pediatric Emerg en cy Ca re Dec;27(12):

14 Anxiolysis What about Parents? Distraction Use verbal reassurance with caution, especially for kids under 6 years. Krauss B et al. Current concepts in management of pain in children in the emergency department. Lancet 2016;387:

15 Instead of: The medicine will burn. Try: Some kids say it feels warm, other kids say it feels tingly. Instead of: I m sorry. Try: You re being very brave. Krauss B et al. Current concepts in management of pain in children in the emergency department. Lancet 2016;387:83-92 Krauss B et al. Current concepts in management of pain in children in the emergency department. Lancet 2016;387:83-92 Instead of: Tell me when you re ready. Try: When I count to three, blow the feeling away from your body. Distraction Anxiolysis Krauss B et al. Current concepts in management of pain in children in the emergency department. Lancet 2016;387:

16 Can distraction out-perform drugs? 112 children age 4-12 undergoing elective surgery Anxiety assessment at admission and at induction Postoperative effects measured Can distraction out-perform drugs? Parent presence alone (PPIA) Parent presence + video game (VG) Parent presence + midazolam (M) Patel A et al. Distraction with a hand held videogame reduces pediatric perioperative anxiety. Pediatric Anesthesiology 2006;16: Patel A et al. Distraction with a hand held videogame reduces pediatric perioperative anxiety. Pediatric Anesthesiology 2006;16: Can distraction out-perform drugs? Active vs Passive Distraction Patel A et al. Distraction with a hand held videogame reduces pediatric perioperative anxiety. Pediatric Anesthesiology 2006;16:

17 Active vs Passive Distraction Results: self-reported pain Children 3-16 years undergoing painful procedures Randomized to active distraction (tablet) or passive distraction (cartoon) CHEOPS and self report pain scale measured at baseline, during procedure, and recovery Results: CHEOPS* Apps that work Are easy to learn Have many choices Have an auditory component Do not require long term investment *Children s Hospital Eastern Ontario Pain Scale 17

18 Strategies for App success Have several to choose from Introduce it several minutes before the procedure starts Know the basics of how your apps work Krauss B et al. Current concepts in management of pain in children in the emergency department. Lancet 2016;387:83-92 Anxiolysis Distraction 18

19 Take Home Points Thank you! Encourage a calm, relaxed atmosphere Use topical anesthetics whenever possible Buffer lidocaine for injection Distraction is key: Music, apps, or talking peterlio@gmail.com 19

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