Pain management in the Pediatric Emergency Department

1. Pain management in the Pediatric Emergency Department Itai Shavit November 2001

2. Objectives • 1. Pain in children: Perception, Myths, Attitudes and Ethics • 2. Pediatric pain assessment • 3. Pediatric Procedural Sedation and Analgesia (PSA) • 4. Narcotic analgesia in acute abdomen • 5. Topical analgesia • 6. Neonatal & Sucrose analgesia • 7. AAP, September 2001 guidelines • 8. Summary

3. Pain in children: Perception, Myths, Attitudes and Ethics

4. The definition of pain • An unpleasant sensory or emotional experience associated with actual or potential tissue damage, or described in terms of such damage (International Association for the study of Pain: IASP,1979) • Does the human neonate capable of perceiving pain ????

5. The concept of pain perception • In the eighties, Premature infants who had major surgeries were treated with minimal anesthesia during and after the surgery (normal standard) • Pain and its effects in the human neonate and fetus.1987, NEJM. Landmark seminar paper. Anand and HickleyCalled into question the widely held belief that neonates do not have the Neurophysiologic apparatus required to experience pain

6. AAP & APS policy statement, 09/2001 • “The concepts of pain and suffering go well beyond that of a simple sensory experience. It has emotional, cognitive, and behavioral components as well as developmental, environmental and sociocultural aspects” (AAP and American Pain Society policy statement, September, 2001)

7. Myths • Myth 1: “Babies don’t feel pain” • Myth 2: “Babies don’t remember” • Myth 3: “My son doesn’t need pain killers” “No pain no gain”, “Pain is character building”

8. Myth 1: “Babies don’t feel pain...” Babies do experience pain!

9. By 29 wks of gestation, pain pathways and cortical + sub-cortical centers involved in the perception of pain are well developed, as are the Neurological systems for the transmission and modulation of pain sensation • Pain sensitivity in neonates may be more profound that that of older individuals; their nervous system may be less effective at blocking painful stimuli than those of adults

10. Myth 2: “They don’t remember...” Babies do remember pain!

11. Effect of neonatal circumcision on pain response during subsequent routine vaccination. 1997, Lancet. Taddio, Kats, Ilersich, Koren • Does neonatal circumcision alter pain response at 4-month or 6-month vaccination compared with the response of uncircumcised infants? • Prospective. cohort design. 87 patients. • 3 groups: uncircumcised infants, circumcised infants who had randomly pretreated with either EMLA cream or Placebo for circumcision in a previous clinical trial

12. All infants were videotaped during vaccination in a primary care clinic. Videotapes were “blindly” scored by a trained research assistant. The score measured facial action, cry duration and visual analogue scale • Results: Circumcised infants showed a stronger pain response to subsequent routine vaccination than uncircumcised infants. Among the circumcised group, preoperative treatment with EMLA attenuated the pain response to vaccination • The pain itself may not be consciously remembered but the painful experience does

13. Consequences of inadequate Analgesia during painful procedures in childen. 1998, Arch Ped Adolesc Med. Weisman, Bernstein, Schechter • How does inadequate Analgesia for painful procedures (BMA, ST) effect pain response in subsequent procedures? • Cohort study, randomized, placebo control (Placebo vs Oral Transmucosal Fentanyl), small sample • Young children (<8y) who received placebo in previous procedure had consistently higher pain scores than children who had proper analgesia

14. Myth 3: “Pain is character building…” Pain is not character building, it has a negative influence on children !

15. This statement is unfair. It legitimizes pain and takes away the child’s right for pain relief • Children younger than 8 years are not able to understand that short term pain may have long term benefit • Adolescents who had poorly managed pain procedures show increased level of anxiety in subsequent pain situations • Pain is a subjective experience and is incomparable. There is no direct relationship between “pain experience” and pain intensity or between physical pathology and pain intensity

16. Our fear of Analgesia... • Masking of symptoms and signs • Changes in the exam • Side effects and complications

17. Ethics • The Ethics of pain control in Infants and children. Walco GA, Cassidy RC, Schechter NL, NEJM, 1994;331(8):541-43 • “…The assessment and treatment of pain in children are important parts of Pediatric practice, and failure to provide adequate control of pain amounts to substandard and unethical medical practice

18. Short term effects of inadequate pain management • Significant fluctuations in HR, BP, ICP, Oxygen level, and stress hormones level • Sleep disturbances, agitation, crying Long term effects of inadequate pain management • Inadequate surgical pain management has more clinical complications, prolonged hospitalization time and higher mortality rates • Behavioral and Psychological sequaela

19. Pediatric pain assessment

20. We’ve all experienced pain • Anxiety decreases pain threshold

21. Pediatric pain assessment scales • Inability to verbalize pain appropriately under 2 years of age. At age 3-7 most children are competent to provide accurate information (using assessment tools) • Pain is a subjective experience therefore individual self report is favored (AAP recommendation) • Behavioral pain measures are more useful than physiological parameters. Physiologic parameters are unreliable

22. Pediatric pain assessment scales Pain Assessment tools • 0-2 Years: Neonatal Infant Pain Scale, Premature Infant Pain Profile, Neonatal Infant Pain Scale, DAN score • 3-7 years old: FACES pain rating scale, OUCHER Scale • 7< years old: Verbal Report Scale, Visual Analog Scale

23. Neonatal pain assessment Facial expression Eyes squeeze Brow bulge Nasolabial furrow Vocal expression

24. Circumcision

25. DAN score: Acute pain rating scale in neonates (Douleur Aigue du Nouuveau-ne, 1997) Facial expression: Calm (0), Snivels and alternates gentle eye openining and closing (1), Determine intensity of one or or more of eyes squeeze, brow bulge, nasolabial furrow: Mild, intermittent with return to calm (2), Moderate (3), Very pronounced, continuous (4) Limb movements: Calm or gentle movements (0), Determine intensity of one or more of the following signs:pedals, toes spread, legs tensed and pulled up, agitation of arms, withdrawal reaction: Mild, intermittent with return to calm (2), Moderate (3), Very pronounced, continuous (4) Vocal expression: No complaints (0), Moans briefly: for intubated child, looks anxious or uneasy (1), Intermittent crying: for intubated child, gesticulations of intermittent crying (2), Long lasting crying, continuous howl, for intubated child, gesticulations of continuous crying

26. FACES pain rating scale (3-7 years) The Wong Baker Scale

27. OUCHER scale (3-7 years) Categorical Available in versions for males and females and in multicultural forms. The child is asked to point to the picture that best shows how he or she feels

28. Verbal Report Scale (>7 years) Categorical “On a scale of 0 to 10, with 0 being ‘no pain’ and 10 being ‘the worst pain ever’, how would you rate your pain?”

29. Visual Analog Scale (>7 years) Non categorical A straight line. The left end of the line representing no pain and the right end of the line representing the worst pain. Patients are asked to mark on the line where they think their pain is

30. Visual Analog Scale (>7 years) Non categorical “The greatest pain imaginable” “No pain”

31. Pediatric procedural analgesia

32. Guidelines for Pediatric procedural sedation and analgesia • Sedation and Analgesia for procedures in children 2001,NEJM. Krauss, Green • Management of acute pain and anxiety in children undergoing procedures in the Emergency Department. 2001, Pediatric Emergency Care. Krauss • Pharmacological Management of pain and anxiety during Emergency procedures in children. 2001, Paediatric Drugs. Kennedy, Luhmann

33. Terminology • 12 different definitions for state of sedation. Most of them are based on the degree of sedation induced rather than the specific indication for sedation • Only 4 are applicable for children

34. Conscious Sedation, AAP, 1992 • A medically controlled state of depressed consciousness that: 1. Allows protective reflexes to be maintained. 2. Retains the patient ability to maintain a patient airway independently and continuously 3. Permits appropriate response by the patient to physical stimulation or verbal command, e.g., “open your eyes”.

35. Deep Sedation, AAP, 1992 • A medically controlled state of depressed consciousness or unconsciousness from which the patient is not easily aroused. It may be accompanied by a partial or complete loss of protective reflexes, and includes the inability to maintain a patent airway independently and respond purposefully to physical stimulation or verbal command.

36. General Anesthesia, AAP, 1992 • A medically controlled state of depressed consciousness accompanied by a loss of reflexes including the inability to maintain a patent airway independently and respond purposefully to physical stimulation or verbal command

37. Procedural Sedation and Analgesia (PSA), ACEP, 1998 • A Technique of administering sedatives or dissociative agents with or without analgesics to induce a state that allows the patient to tolerate unpleasant procedures while maintaining cardiorespiratory function. Procedural sedation and analgesia is intended to result in a depressed level of consciousness but one that allows the patient to maintain airway control independently and continuously. Specifically, the drugs, doses, and techniques used are not likely to produce a loss of protective airway reflexes. • Significant improvement over the traditional AAP terminology

38. Precautions • Midazolam Reduce dose when used in combination with Opioids • Ketamine Higher risk for hallucinations > 15y, may be blunted with Midazolam . Adding Midazolam to Ketamine in children younger than 15y appears to be unnecessary (Sherwin et al, Ann Em Med, 2000) • Hypersalivation can be minimized with Atropine (poor evidence) • Fentanyl Reduce dose when combined with Midazolam

39. Ultra-Short acting medications • Propofol Currently not (yet) recommended for PSA in children. High risk for apnea and loss of airway reflexes. No analgesic effect. Insufficient data (only one study in children) • Etomidate, Methohexital Insufficient data in children for safety and reliability

40. Oral/Intranasal medications for PSA • Oral Transmucosal Fentanyl (lozengens) High rate of emesis (>30%) • Intranasal Sufentanyl Insufficient data on safety and efficacy in children. 7 times more potent than Fentanyl. With Midazolam for lacerations. The nasal delivery is painless, no vomiting . Mean time to sedation 20 min, discharge time 54 min. Expensive. • Oral Ketamine Insufficient data. Optimum oral dose for safe and reliable sedation for PSA has to be determined. Long discharge time (100 min)

41. Antagonists • Naloxon Introduced in 1960, proven to be safe in children. Opioid antagonist of choice for PSA • Flumazenil Introduced in 1987, proven to be safe in children • Nalmefen New Opioid antagonist, Introduced in 1995, proven to be useful in adults. Long acting (3.5h). • Only one study in children (Nov 2001, Ann Em Med): Patients who had PSA with Fentanyl/Midazolam received Nalmefen after the procedure. Sedation reversal parameters were improved, no side effects, no cardiorespiratory changes, no resedation phenomena. Nalmefen seems to be effective in children. (small sample)

42. Narcotic analgesia in the pediatric acute abdomen

43. Narcotic analgesia in acute abdomen • The Ethical dilemma of withholding analgesia while awaiting surgical evaluation • 4 prospective randomized controlled double blind studies in adults, no studies in children • All 4 studies use Morphine sulfate or Morphine derivatives

44. Narcotic analgesia in acute abdomen • In all studies, opiates didn’t change management and were not found to be associated with increased morbidity or mortality. None of the trials was able to identify even one patient in which analgesia led to a poor outcome • In adults the use of narcotic analgesia doesn’t mask symptoms or change the physical exam findings • In children there is no data

45. Topical analgesia

46. Needlephobia • Topical anesthetics do not reduce needlephobia • Coping strategies used by parents proved to significantly reduce stress (e.g. favorite toy, books, singing songs) • Both child and parents have to be fully aware of what is going to occur and the reasons why

47. EMLA • For IV cannulation and lumbar puncture. Not recommended for IM injection or heel prick in neonates • Mixture of 2.5% lidocaine and 2.5% prilocaine in a cream base. The specific concentration gradient promote penetration of intact skin • Application under an occlusive dressing. Depth of anesthesia ranges from 3mm after 60 min (onset to pick effect), to 5 mm after 90

48. EMLA • Should be placed on skin for at list 60 min. Changing Triage protocols? • Safe. Recently been approve to for use in newborns. • Single dose does not cause Methemoglobinemia (Prilocaine side effect)

49. Tetracaine cream Ametop Gel (Smith & Nephew 1997) • 4% Tetracaine cream (Amethocaine) • Applied under occlusive dressing • Rapid onset of action (30 to 40 min) • Provide anesthesia for up to 4 hours • Should not be used in neonates (irritation, even blistering)

50. Lidocaine injection • Subcutaneously injected buffered lidocaine 1% (1/10 with Bicarbonate solution of 1meq/ml) using 30-gauge needle, reduces struggling during LPs in newborns • ± EMLA or Ametop (>1mo) prior the procedure if possible • Buffering decreases onset time for analgesia without affecting efficacy or duration • To reduce pain: Distract the patient, use buffered lidocaine, use 30 (for infants) or 27 gauge needle, warm the anesthetic to body temperature prior administration, avoid intradermal injection