5/10/2018 MODULE 6: PAIN MANAGEMENT. SECTION I: Pain Defined. Scope of the Problem

Transcription

1 Curriculum MODULE 6: PAIN MANAGEMENT SECTION I: Pain Defined Pain is a subjective response Pain in childhood can be acute, chronic, or a combination of both Children's pain is influenced by many factors Scope of the Problem Children s pain experience 25 46% experience some level of pain <3 months duration Up to 30% experience chronic or recurrent pain severe enough to interfere with daily functioning Effect of pain on quality of life 1

2 Barriers to Pain Relief Healthcare professionals Myths related to assessment of pain Healthcare system Related to parents/children Myths Related to Pain and Pain Management in Children Risk of respiratory depression Addiction Child that is sleeping/or playing does not have pain Presence of pain indicates worsening of disease or approaching death Facts About Childhood Pain Opioid addictions are rare. Repeated exposure to painful procedures leads to increased anxiety and perception of pain. Studies have shown that children as young as 3 years old can use pain scales. Carter et al., 2011; Collins et al., 2011; Goldman et al., 2012; Hockenberry et al.,

3 Myths Related to Neonatal/Infant Pain Incapable of feeling pain Immature nervous system Incomplete myelinization No memory Analgesics unsafe Facts About Neonatal/Infant Pain Pain perception occurs early in life Neonates exhibit physiologic and behavioral cues No risk of addiction Tolerance & physical dependence can occur Impact of Pain Research asked What is it like to have a child with pain? Unendurable Sense of helplessness Sense of total commitment Unprepared/unknowledgeable Horrible/frightening No pain in heaven Dussel et al.,

4 Special Populations Injury/trauma ER PICU Pain management affected by: Emergent/critical nature of illness with primary focus on stabilization & diagnosis Child/family stress exacerbating pain & anxiety Special Populations Cancer pain Disease, treatment, & procedure related Chronic non malignant pain Sickle cell disease, diabetes, rheumatoid arthritis, HIV, cystic fibrosis, neurological degenerative diseases Special Populations Sickle cell Numerous complications of SCD result in pain Vaso occlusive crisis, priapism, dactylitis, splenic sequestration, spinal cord compression, and avascular necrosis of joints 4

5 Special Populations Musculoskeletal/rheumatic Juvenile Primary Fibromyalgia Juvenile Idiopathic Arthritis Complex Regional Pain Syndrome Special Populations Neurocognitive impairment Pain experience Pain indicators Effect of uncontrolled pain Assessment Knowing child Recognizing patterns Intersubjective process with HCP Section II: Multidimensional Assessment Self report/parent report Intensity Quality Pattern Aggravating/alleviating factors Medication history Meaning 5

6 Assessment Types of assessment Self report Behavioral Physiologic Proxy report Use of scales Reassessment of Pain Changes in pain Changes in analgesic regimen Assess consistently & at appropriate time intervals post intervention Use of diaries Neonatal/Infant Pain Assessment Tools CRIES Neonatal Postoperative Pain Measurement Score Krechel & Bildner, 1995 Premature Infant Pain Profile (PIPP) Stevens et al., 1996 Neonatal Infant Pain Scale (NIPS) Lawrence et al., 1993 Neonatal Pain Agitation and Sedation Scale (NPASS) Hummel et al.,

7 Pain Assessment Tools Pre verbal / nonverbal (examples) FLACC Pain Observation Scale Modified Objective Pain Score Non Communicating Children's Pain Checklist (NCCPC) Self Report Pain Intensity Scales FACES Pain Scale Revised (FPS R) OUCHER VAS (Visual Analog Scale) Verbal Report Scale Tools for Initial Overall Pain Assessment Initial Pain Assessment Tool Brief Pain Inventory Parent/Child Total Quality Pain Instruments Neuropathy Pain Scale Adolescent Pain Tool 7

8 Communicating Assessment Document clearly in chart Assessment Intervention Re assessment Establish pain care plans SECTION III: Pain Physiology Pain is a complex physiologic process involving cellular damage and chemical mediation resulting in an individual affective response. Types of Pain Neuropathic Pain Abnormal pain transmission May occur in the absence of tissue damage or inflammation Believed to serve no purpose; does not serve to warn against further injury Best treated with coanalgesics (i.e., anticonvulsants & tricyclic antidepressants) Nociceptive Pain Normal pain transmission Occurs in periphery with the activation of nociceptors Serves to warn & protect individuals from further injury Will typically respond to NSAIDs & opioids 8

9 Types of Pain (cont) Neuropathic Pain Centrally generated Deafferentation pain Sympathetic pain Peripherally mediated Sharp, shooting, electric Polyneuropathies Mononeuropathies Sharp, shooting, electric Nociceptive Pain Somatic Superficial cutaneous/deeper musculoskeletal structures Well localized Sharp, aching, throbbing Examples: surgical incisions, mucositis, metastatic lesions Visceral Infiltration, distension, compression/distortion of organs found in thorax, abdomen, pelvis Difficult to localize Dull, cramping Concept of Total Pain Physical Pain Pain due to disease location Other symptoms (ie, nausea) Physical decline & fatigue Spiritual pain Religious/faith, anger at God Meaning of life & illness Why me? Why my child? Psychological Pain Grief, depression Anxiety, anger Change in appearance Social Relationships with family/friends Role in the family Financial problems Tolerance effect of a medication over time, requiring dose to achieve same level of efficacy Should consider differential diagnosis Tolerance addiction Easily managed by dose or interval between dosing Should not withhold opioid 9

10 Physiological Dependence Development of withdrawal syndrome after: Abrupt discontinuation of therapy Substantial dose reduction Administration of antagonist medication (naloxone) Psychological Dependence (Addiction) Pattern of compulsive drug use characterized by continued craving for an opioid and the need to use the opioid for effects other than pain relief Three distinguishing characteristics Continued cravings with/without pain Illegal and anti social behavior in order to obtain the drug Chronic, relapsing condition APS, 2016 Pain Management Severe pain should be seen as a medical emergency Rapid assessment and treatment of pain is imperative Close collaboration with physicians/apns, pharmacists, other nurses, and family is essential to optimum use of analgesic treatments. 10

11 WHO Analgesic Stepladder Around the Clock Dosing Opioid medications should be given on scheduled basis Provide adequate PRN doses for breakthrough pain Maintain stable analgesic blood levels Designed to control baseline pain Stay Ahead of Pain Individualize to the child based on their level of pain, prior experience with opioids, and desired activity level Frequently assess pain level and adjust treatment plan as necessary In pain crisis rapid titration to comfort is imperative 11

12 Least Traumatic Route of Administration Oral is not always the least traumatic means, particularly in toddler/early childhood Flavor of medications present a challenge Verify ability to crush oral medications with pharmacy Avoid rectal No SHOTS Routes Oral/Transmucosal Long acting preps Breakthrough IR preps Transdermal Limited use in escalating pain Treat with additional analgesics until peak onset is reached with initial placement Routes (cont.) Topical Intravenous/Subcutaneous Intraspinal/epidural 12

13 Opioids in Neonatal Population Reduce clearance of majority of opioids Prolonged half life SECTION IV : Analgesics Acetaminophen/NSAIDs Acetaminophen Useful for mild pain, anti inflammatory action Works synergistically with morphine NSAIDs Can be used in mild, moderate, acute, or chronic pain alone Use in severe pain in combination with opioid + adjuvant Useful in treatment of bone pain Analgesics Management of NSAID side effects Gastric irritation, heart burn, ulceration, and bleeding Use gastroprotective for prolonged use Effect on platelet aggregation: short acting, reversible Renal effects: rare, insufficiency and nephrotoxicity can occur with prolonged high doses 13

14 Analgesics (cont) Treatment of moderate pain Tramadol Hydrocodone In combination with acetaminophen, aspirin, or ibuprofuen Analgesics (cont) Opioids Morphine is gold standard Variety of routes, formulations Large body of research Used for moderate to severe/intractable pain Fentanyl Used in anesthesia, procedural sedation Severe pain Patch has been found useful in some cancer and chronic non malignant pain Analgesics (cont) Opioids Hydromorphone More potent than morphine Good alternative if morphine or oxycodone cannot be used Methadone Used in chronic and neuropathic pain Long half life; longer time to steady state Make dose adjustments q 3 7 days to allow assessment of each dose escalation and avoid overdosing 14

15 Adjuvants for Neuropathic Pain Co analgesics: medications that are used in combination with opioids to enhance analgesia or treat specific types of pain Neuropathic pain Antidepressants: amitriptyline, nortriptyline Anticonvulsants: gabapentin, tegretol Adjuvants for Neuropathic & General Pain Anesthetics: mexilletine, lidocaine, ketamine, propofol Corticosteroids: dexamethasone Anxiolytics: lorazapam, diazapam, midazolam Barbiturates: phenobarbitol, pentobarbitol Analgesic Side Effects Constipation: prevention is KEY! Miralax, senna and ducosate sodium, casanthranol and ducosate sodium, bisacodyl, mag citrate Sedation: tolerance within a few days Precedes respiratory suppression; use monitor 15

16 Analgesic Side Effects (cont.) Urinary retention: oxybutynin Nausea/vomiting: zofran, promethazine hydroxyzine Pruritus: diphenhydramine, hydroxyzine Respiratory Suppression EXCEEDINGLY RARE Decreased depth and rate of respiration, increased sedation Use reversal drugs with caution Titration of Pain Medications Conduct thorough pain assessment Provide PRN dose of medication Reassess in 15 min if IV/SC, 30 min if PO In no relief, give another PRN dose Repeat until pain relieved Calculate dose needed for PCA/sustined prep Notify physician/aprn if requiring frequent bolus doses or change in quality of pain 16

17 Tapering Opioids Goal: avoid opioid withdrawal Recommended for patients who have required routine doses of opioids for 5 7 days Elicit help from pharmacist for wean schedule Create a calendar for family to follow Wean schedule often determined by the length of time and dose of opioids Tapering Opioids (cont.) Monitor for return of pain Monitor signs and symptoms of withdrawals Runny/stuffy nose, diarrhea, abdominal cramping, nausea/vomiting Return to dose prior to onset of symptoms Equianalgesia Changing route or medication Calculate total amount of meds in past 24 hours Make appropriate equianalgesic conversions If comfortable at current dose, continue at same equianalgesic dose. If pain is not controlled on current dose, increase equianalgesic dose by 25% to 50% 17

18 Equianalgesia (cont.) The dose of one analgesic medication that is equivalent in pain relieving potential to another analgesic medication. Equianalgesia must be considered when switching from one opioid to another, or from one route to another Failing to consider equianalgesia is a leading cause of inconsistent pain control and oversedation Equianalgesia (cont.) Based on 10mg parenteral Morphine IV PO Conversion Morphine 10mg 30mg 3 Hydromorphone 1.5mg 7.5mg 5 Methadone 10mg 20mg 2 Conversion Problem Child is currently on a Morphine PCA pump with basal 25mg IV q 24 and has received five 1mg PRN doses. Convert this to an oral equivalent: Total 24 hr dose = 30 mg (25 + 5) 30mg IV multiplied by conversion of 3 = 90mg PO Convert the Oral Morphine to Oral Dilaudid: Oral Morphine 90mg/24 hrs. 30 mg PO Morphine= 7.5 mg Hydromorphone(30/7.5 = 4) 90mg Morphine = 22.5 mg Hydromorphone 18

19 Opioid Rotation Used when titration of opioid is ineffective or causing intolerable side effects No clear guidelines for when to rotate due to ineffective pain control Cross tolerance between opioids not always complete Use equianalgesic conversion, decrease dose by 25% to 50% SECTION V: Procedural Pain Causes Placement of IV lines, lumbar punctures, bone marrow aspirations, finger/heel sticks, placement of drainage tubes, venipuncture for blood tests and SC/IM injections, catheterization Goals Minimize pain Maximize patient cooperation Minimize risk Procedural Pain Management Topical anesthetics Conscious sedation Unconscious sedation Kamat et al.,

20 Non Pharmacologic Pain Management Parental presence Visualization/guided imagery Deep breathing Massage Heat/Cold Positioning Physical therapy Meditation Play therapy Reiki Hypnosis Aromatherapy Music Hydrotherapy Consult child life, social work, rehab for assistance Non Pharmacologic Techniques for Neonates/Infants Modify environment (minimize light and sound, temperature) Minimize sleep interruptions Oral sucrose Swaddling/holding and rocking Music Infant massage Pain in Dying Children 90% of children dying of cancer experience pain or other symptoms Nearly 50% had pain relief Inadequate pain relief hastens death Wolfe et al.,

21 Pain versus Suffering Influenced by existential distress, fear of dying, and grief Affects QOL dimensions Intractable Pain Palliative chemotherapy Radiation therapy Therapeutic nerve blocks Epidural/intrathecal infusions Pain at the End of Life Practical treatments in the home Dosage of opioids Renal function Accumulation of metabolites 21

22 Palliative Sedation Communication with family Goal of sedation Treatment Comfort measures Special Considerations for Home Care Referral to home care/hospice Relationships/communication Flexibility and reliability Assess goals of child/family Role of the Nurse in Pain Management Identify obstacles Best practices Advocacy Education 22

23 Patient/Family Education Key to effective pain management Address fears/misconceptions Choose words carefully; for example: Opioid (not narcotic), Medication (not drugs) Teaching points Physiology of pain Pain assessment and use of scale How pain medications work Potential side effects and management When to call doctor/nurse Summary Pain must be assessed and managed consistently Interdisciplinary management Golden rules "If it would hurt you, it hurts them Approach the child with the same respect you would an adult Requires trust and cooperation 23