Pediatric Pain Management

7,486 views

Published on

Published in: Health & Medicine
0 Comments
11 Likes
Statistics
Notes
  • Be the first to comment

No Downloads
Views
Total views
7,486
On SlideShare
0
From Embeds
0
Number of Embeds
159
Actions
Shares
0
Downloads
0
Comments
0
Likes
11
Embeds 0
No embeds

No notes for slide

Pediatric Pain Management

  1. 1. PEDIATRIC PAIN MANAGEMENT Stelian Serban MD Assistant Professor of Anesthesiology and Pain Medicine Mount Sinai Medical Center New York, New York
  2. 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. 3. Pain Assessment in Children  Address the various components and match the intervention to the individual situation – Affective – Behavioral – Cognitive – Sensory – Physiological
  4. 4. Pain Free Me A Multidisciplinary Team Wipes Out Pediatric Pain
  5. 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. 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. 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 :
  8. 8. Oxycodone Tramadol Meperidine Codeine Methadone Hydromorph Fentanyl Morphine Opioids
  9. 9. 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
  10. 10. 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
  11. 11. 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
  12. 12. 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
  13. 13. 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
  14. 14. Sickle Cell Crisis  Morphine IV 60% cases  Ketorolac 25% cases  Transition to long acting opioids 40% cases Pain Med. 2008
  15. 15. 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
  16. 16. 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
  17. 17. Our sickle cell protocol ED hydromorphone IV Pain Consult PCA hydromorphone +/- ketorolac IV 15-30mg (0.5 mg/kg) q6h
  18. 18. 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
  19. 19. 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
  20. 20. 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
  21. 21. 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
  22. 22. 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
  23. 23. 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)
  24. 24. Process Approach Characterize and assess pain High level of parent/child educ. Implement correct guidelines Learn from mistakes Delineate protocols
  25. 25. THANK YOU THANK YOU

×