DISCLOSURES. Learning goals 19/09/2013 PEDIATRIC ACUTE PAIN MANAGEMENT. No financial investment in the material or medications presented

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1 PEDIATRIC ACUTE PAIN MANAGEMENT Dr. Samina Ali, MDCM, FRCPC(PEM) Associate Professor Departments of Pediatrics & Emergency Medicine University of Alberta September 2013 DISCLOSURES No financial investment in the material or medications presented My research is mainly funded by the Canadian Institutes of Health Research Learning goals Understand why managing pain is essential in pediatric clinical care Describe at least 3 simple techniques for managing acute procedural pain To name at least 2 medication options for each WHO category of pain intensity 1

2 PEDIATRIC PATIENTS SELDOM NEED MEDICATION FOR THE RELIEF OF PAIN. THEY TOLERATE DISCOMFORT WELL. Swafford LI & Allan D. Pain relief in the pediatric patient. Med Clin North Am. 1968;52: Pediatric Pain Management We are not particularly good at it in any setting Doesn t matter if you are a peds or general MD We are age-ist We have not really improved over with time WHOSE MEASURE OF PAIN DO WE RELY UPON? 2

3 Pain Assessment Median FACES Median Linear Child Guardian 3 6 Professional Macioca PM et al. Eur J Emerg Med. 2003;10: Clinical scenario 1 A 4 year old boy has fallen while re-enacting a superman scene..and now has a 1.5 cm x 2mm laceration on his forehead How can you repair this with minimal pain and emotional trauma for the child? Accepted 2001 To compare effectiveness of adhesives to standard wound closure To compare effectiveness of different adhesives in different situations Acute, linear, low tension lacerations 13 trials included 3

4 Cosmesis Pain scores conclusions Acceptable alternative to standard wound care No one glue better than the other Decreased procedure time Less pain Small but statistically significant difference in dehiscence (mitigate..steristrips!) NNH = 40 4

5 Don t forget LET! Accepted 2010 ph can be between acidity=pain Physiologic ph N= 1067, 23 studies Determining the effect of ph- adjusted and non-adjusted lidocaine on pain 5

6 Clinical scenario 2 A 6 year old girl has had vomiting and diarrhea for 4 days. She is moderately dehydrated and ORT has been unsuccessful. She needs an intravenous placed, and she is frightened of the needle. She is crying and upset. What can we do to optimize the scenario for her? Accepted trials included (n=534) To compare EMLA to Amethocaine Anaesthetic efficacy Ease of needle insertion Adverse events Pain Scores 6

7 Pain reduction, different times conclusions Amethocaine is superior to EMLA for reducing overall needle insertion pain Less needle attempts Short application times Long application times Manufacturer- recommended times Child or observer pain measures Clinical scenario 3 A 2 week old infant is brought to your hospital with a fever As a part of her work-up, she needs a urinary catheterization for a sterile urine sample How can we minimize the trauma to the baby and her parents? 7

8 Accepted trials included Heel lance and venipuncture pain scores conclusions Sucrose reduces procedural pain in neonates, with minimal side effects Recommend routine use of sucrose 2 min prior to heel lance/venipuncture Not to be used in isolation (20% pain relief on composite scores) 8

9 FYI hot off the presses! Accepted trials included Evaluate the effectiveness of breastfeeding or breast milk in reducing procedural pain in neonates Type of control Procedure GA Volume of milk breastfeeding 9

10 conclusions Breastfeeding should be used to alleviate procedural pain in neonates If not available, use glucose/sucrose Don t eliminate pain, but temper it Not established for repeated painful procedures The story of Tariq & Rani Jamieson Born in Toronto, 2005 SVD, health term infant Breastfed Rani (his mom): Rx T3s for episiotomy pain Day 7: lethargic Day 11: sees pediatrician for poor feeding Tariq and Rani Day 13: died in his kitchen, as paramedics tried to revive him Post-mortem: Tariq had 7X acceptable morphine concentration Rani: phenotyped as an ultra-rapid metabolizer 10

11 Medical Literature Health Canada Warning 11

12 Why is codeine so unpredictable? Close to 12 % of the Caucasian population is unable to metabolize codeine to morphine Approximately 50% of the North American Caucasian population has at least one reduced functioning allele for CYP2D6 IF NOT CODEINE, THEN WHAT? Mild Pain: WHO 1-3/10 Ibuprofen 10mg/kg q6h, prn 12

13 SR of analgesia for MSK trauma LeMay S, Ali S, Ranger M, Gouin S, Roy C, Trottier E, Drendel A. Primary outcome: failure of assigned study medication, leading to use of rescue medication Treatment failures for ibuprofen (20.3%) lower than for acetaminophen with codeine (31.0%) Difference (10.7%) was not statistically significant (95% confidence interval 0.2% to 21.6%) Functional outcomes: significantly lower proportion of children using ibuprofen had play and eating affected by pain 13

14 Adverse Effects Clark, Plint, et al. Pediatrics Moderate Pain: WHO 4-7/10 Ibuprofen 10mg/kg +/- acetaminophen 15mg/kg q4h,prn Mid-potency dosing of opioids: Oxycodone 0.1 mg/kg (max 10mg) Oral morphine 0.2 mg/kg (max 15mg*) SO WHY USE ANY OPIOID FOR MODERATE PAIN?! 14

15 As many as 30% of children failed treatment if prescribed a single analgesic Of the children who used the rescue medication, 92% had at least a 1-face reduction in pain after using the alternative medication Severe Pain (at home):who >7/10 Higher potency opioids Oxycodone 0.2 mg/kg (+/- ibu) Oral morphine mg/kg (+/- ibu) 15

16 Intranasal/Nebulised Fentanyl PAIN IS INEVITABLE. SUFFERING IS OPTIONAL. - Dalai Lama 16