1. PEDIATRIC PAIN MANAGEMENT
Stelian Serban MD
Assistant Professor of Anesthesiology
and Pain Medicine
Mount Sinai Medical Center
New York, New York

2. Patient and Family Concerns
 Physicians thought and beliefs
 Belief in child’s pain
 Pain is scary and unsettling
 Listen to parents and children
 Consult with other experts
 Children are not little adults

3. Pain Assessment in Children
 Address the various components and
match the intervention to the individual
situation
– Affective
– Behavioral
– Cognitive
– Sensory
– Physiological

4. Pain Free Me
A Multidisciplinary Team
Wipes Out Pediatric Pain

5. 90
94
80
86
90 91 92 93
84
79
77 77
88
82
93
87
84 85
96
50
60
70
80
90
100
Mar Apr May Jun Jul Aug Sep Oct Nov Dec
Did doctors or nurses tell you that they consider the treatment
of your child’s pain to be very important ?
44
35
40
48
27
64
54
58
49
40
46
53
50
44
42
54
52
42
46
20
30
40
50
60
70
Mar Apr May Jun Jul Aug Sep Oct Nov Dec
Overall, how would you rate the treatment your child received
for pain ?
%Excellent%Yes
2009
Two Year Data
2008
2008
2009

6. Find and Cure Causes
EQUIPMENT
Pain Treatment
Evaluation
“Less than Excellent”
no pediatric
medication
concentration
House staff
POLICIES
Orders for Pain
Meds
PEOPLE
Surgery
PROCEDURES
none
in ED
PCA
Pumps
delay
from
PEP
no med
bags in
Pyxis
TDS
absent in
PICU,
NICU
prn vs
standing
+/- PCA
basal rate
Telephone
Satisfaction Survey
Documentation of
Pain Scores
+/-
P4 / P5
Dialysis
ICU
I R
Anesthesia
Pain Team
Nursing
Pediatric
Pain Team
Patient
Family
cannot find
resident
Loses beeper,
unavailable 24 / 7 Lack of understanding
fear
Confusion re
acute vs. chronic
Busy, unavailable
don’t know
who to call for
a consult
Knowledge
deficit
Not empowered
PACU
Narcotics
dialyzed

7. Upward titration ?
Adjuvant Meds ?
Give before activities?
Adjust time interval ?
Pain Team
Consult
Anesthesia
Pediatric
0 1-3 4-6 7-10
Pain Free Me Algorithm
Patient Complains of Pain ..or.. Parent is Concerned
Pain Score > 0
Mild 1-3 Moderate 4-6 Severe 7-10
Acetaminophen
po / pr Ketorolac iv * Morphine ( 0.1 mg/kg)
Ibuprofen po* Codeine PO Morphine PCA
Basal &/or hi dose
Oxycodone/
acetaminophen
Hydromorphone iv
or PCA
Hydromorphone po Fentanyl PCA
Morphine iv (0.05 mg/kg) Methadone
PCA : Morphine,
Hydromorphone, Fentanyl Epidural analgesia
*Assess for bleeding risks
Consider Non-Pharmacologic Intervention
ReAssess / Consider Time to Onset of Medication Used
Non-Pharmacologic Options
? Positioning, massage,
reduce stimuli
? Art, play, music, distraction,
hypnosis therapy
? Coping strategies, diversional activities
Analgesic
Time to
Onset ( min )
Duration
( Hrs )
Acetaminophen 30 – 60 4 - 6
PO Codeine 30 – 60 4 - 8
Fentanyl ? 5 0.5 – 2
IV HYDROmorphone 15 4 - 5
PO HYDROmorphone 15 – 30 4 – 5
Ibuprofen 30 – 60 4 – 6
IV Ketorolac 15 – 30 4 – 8
IV Methadone 10 – 20
PO Methadone 30 – 60
Acute: 4 – 6
Chronic: > 8
IV Morphine 10 – 15 2 – 4
Oxycodone/
Acetaminophen
15 – 30 3 – 6
Tramadol 60 4 – 6
Pain Superheroes: BEEPER
Pediatric Pain Specialist . . . 8199
Anesthesia Pain Service
- Acute (post op) . . . 2738
- Chronic (all others) . . . 0329
Social Work specialty/ unit based
Child Life Specialist unit based
Algorithm Badge
on front: on back :

9. Oxycodone
Tramadol
Meperidine
Codeine
Methadone
Hydromorph
Fentanyl
Morphine
Opioids

10. Common Uses of Opioids in
Children
 Mechanically ventilated neonates, infants
and children
 Procedural pain
 Acute trauma or illness, including surgery
 Sickle cell anemia vasooclusive crises
 Burns
 Cancer pain
 IBD

11. Intensive Care Unit
 Fentanyl may increase ICP and increase chest
wall rigidity
 Morphine may cause some venodilatation
 Concerns over respiratory depression may limit
dosing
 Altered hepatic or renal function
 Pain may be more difficult to assess or time
may not be taken to assess pain management
Tobias et al. Ped Clin N Amer 41:1269-1292,1994
Chambliss et al. Curr Opin Pediatr 9:246-253, 1997
Jacob et al. J Pain Symptom Manage 20:59-67

12. Patient/Nurse Controlled PCA
Pros Cons
 Adequate analgesia
postoperatively
 Children less than 6
years of age?????
 No risk of
undermedication
 Patient/parent
satisfaction
 High incidence of side
effects (nausea,
pruritus)
 Risk of overdosage
(Respiratory
depression)
 Higher level of
vigilance from staff

13. Epidurals
 Administration
– Bolus
– Continuous
– Patient Controlled Epidural
Administration (PCEA)
 Greater analgesia than
other modes of pain
therapy
 Agents
– Opioids
– Local Anesthetics
– Clonidine
 Use caution in patients
that are anticoagulated
– Increase risk of
hematoma
 Analgesic Effect
– Onset
 Lipophilic > Hydrophilic
– Duration
 Lipophilic < Hydrophilic
– Area
 Lipophilic < Hydrophilic

14. Sickle Cell Pain
 Most common hemoglobinopathy
 70.000 (1:500 African-Americans, 1:36.000
Hispanics)*
 2 Mill. Sickle trait (1:12 African-Americans)*
 Vaso-occlusive crises
 Pain
– Back
– Extremities
– Chest
 Acute on chronic pain
* www.cdc.gov

15. Sickle Cell Crisis
 Morphine IV 60%
cases
 Ketorolac 25% cases
 Transition to long
acting opioids 40%
cases
Pain Med. 2008

16. 38.5%
17.6%
43.8%
38.9%
75.0%
53.8%
58.3%
50.0%
53.0%
63.0%
0%
20%
40%
60%
80%
P4 P5
July 09 Aug 09 Sept 09 Oct 09 Nov 09
Pediatric Inpatient Satisfaction Scores
Mount Sinai Kravis Childrens Hospital
% “Excellent” Rating for the Treatment of Pain

17. Mt. Sinai 2008 – 30 cases sickle
cell crises
#20 ED
Hydromorphone
Morphine
IV
#5
Morphine PCA
0-1/1.4-1.8/8mins
+/- methadone IV
+/- ketorolac IV
#15
Hydromorphone PCA
0-0.1/02-0.4/8 mins
+/- methadone IV
+/- ketorolac IV
Hosp stay
3.1+/- 0.8
days
Hosp stay
2.6+/0.7
days
Mt.Sinai Pain Service 2008

18. Our sickle cell protocol
ED hydromorphone IV
Pain Consult
PCA hydromorphone
+/- ketorolac IV 15-30mg (0.5 mg/kg) q6h

19. Inflammatory bowel syndrome
 Prevalence 0.15%
gen. population
 500 K in US
 Teenage years (12-
14)
0
5
10
15
20
25
30
Crohn
Dis.
US
popul.
millions
www.cdc.gov

20. 38.5%
17.6%
43.8%
38.9%
75.0%
53.8%
58.3%
50.0%
53.0%
63.0%
0%
20%
40%
60%
80%
P4 P5
July 09 Aug 09 Sept 09 Oct 09 Nov 09
Pediatric Inpatient Satisfaction Scores
Mount Sinai Kravis Childrens Hospital
% “Excellent” Rating for the Treatment of Pain

21. PERIOPERATIVE PAIN TREATMENT
Parenteral IV PCA – 70%
Epidural Analgesia – 30%
1. Fentanyl 2mcg/ml for < 10 yo
2. Fentanyl 5 mcg/ml > 10 yo
3. Bupivacaine 0.1%
*Fentanyl 0.5 mcg/kg/hr
*Bupivacaine 0.2-0.4 mg/kg/hr

22. Guidelines at Sinai
 1. Identify early
 2. Have a specific analgesic plan
 3. Always be present postop. (all PCA
followed by Pain Team!)
 4. Institute treatment early during
recovery
 5. Recognize side effects and treat
 6. Open communication with surgeon

23. Day 0-Catheter
Removed
Patients placed on
Percocet
N=44
Day 1 Post-Removal
Patient has VAS ≤5
on Percocet
N=30
Day 1 Post-Removal
Patient has VAS ≥5
on Percocet
N=14
Day 2 Post-Removal
Patient placed on IV
PCA because
VAS>5
N=4
Day 2 Post-Removal
Patient placed on
IV PCA because
VAS>5
N=10
Day 2 Post-Removal
Patient remains on
Percocet because
VAS≤5
N=4
Day 2 Post-Removal
Patient remains on
Percocet because
VAS≤5
N=26
Mt.Sinai Pain
Service 2008-09

24. Percent of Patients Receiving IV PCA vs. Percocet on Day 2 Post-Removal
13%
71%
87%
29%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
VAS ≤5 VAS ≥5
VAS Pain Level at Day 1 Post-Removal
NumberofPatients
IV PCA Needed Day 2 Post(VAS>5)
Percocet Continued Day 2 Post(VAS≤5)

25. Process Approach
Characterize and assess pain
High level of parent/child educ.
Implement correct guidelines
Learn from mistakes
Delineate protocols

26. THANK YOU
THANK
YOU