good ppt for undergraduate medical students

1. Pain and Sedation management PICU
Dr. Sabona Lemessa (Assistant professor in pediatrics and child health,
JUMC)
8/12/2022
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2. Outline
 Introduction
 Definition of pain
 Classification
 Causes of pain in ICU
 Effect
 Goal of sedation
 Assessment
 Management principles
 Reference
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3. Introduction
 The treatment and alleviation of pain is a basic human right that exists
regardless of age.
 Hospitalization in general, and admission to the PICU in particular
are frightening and painful experiences to children and their families
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4. Definition
 Pain is 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)
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5. Cont…
 has two important elements
pain encompasses both peripheral physiologic and central
cognitive/emotional components
may or may not be associated with real tissue damage
 may exist in the absence of demonstrable somatic pathology.
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6. Classification
 Nociceptive pain:- the result of tissue damage
typically involves bones, joints and soft tissue.
It is further subdivided into somatic & visceral.
 Neuropathic pain
arising from abnormal neural activity secondary to disease or injury
of nervous system.
It remains persistent without ongoing disease.
It involves CNS, nerve plexuses, nerve roots or PS.
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7. Causes of pain in ICU
 the primary illness, trauma or the disease process
 daily nursing procedures- turning, tracheal suctioning and wound care
 exacerbated by emotional distress and anxiety which result of
 Separation from one's parents and family
 being surrounded by unfamiliar people, sleep loss and fragmentation
 the fear of pain, loss of control or even death.
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8. Effect of pain
 While not specific or sensitive indicators of pain, responses to pain and
stress can include:-
increases in intracranial pressure, heart rate
Increase in respiratory rate, blood pressure, blood glucose
Stress hormones and decreases in oxygen saturation.
Pain can induce agitation, Stress induced secondary injury.
Agitation causing loss of artificial airway or intravenous access
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9. PICU pain assessment challenges
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10. Overlap: Pain, agitation, withdrawal, delirium
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11. Pain assessment
 A patient’s self-report is the single most reliable indicator of pain
 In neonates, infants and children aged <3 year
behavioral observational scales
rely on facial expression, motor responses and physiological indices
 Children aged 3–8 yr are generally able to use self-reporting techniques
‘faces scales’ using either photographs or drawings of faces
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12. Hierarchy of assessments for children unable to self-report
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13. Assessment tools for mechanically ventilated children
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14. Cont…
 Vital sign changes and physiologic indicators are NOT valid indicators of
pain
 However, these may be the only indicators of distress in the critically ill
child.
 Physiologic indicators-
include diaphoresis, pupil dilation and
processed electroencephalography (i.e. bispectral index).
 May be used when patients are sedated and/or muscle-relaxed
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15. Assessment of patients who are heavily sedated or muscle-relaxed
 There are no validated pain scales
 Patients unable to express pain behaviors will be scored as deeply sedated
or without pain if using behavioral scales.
 How to Assess
Search for potential sources of pain and assume pain present if
there is cause for pain
Anticipate and treat pain for procedures, Trial treatment/analgesia
Use physiologic indicators cautiously to prompt further
assessment/treatment
 but do not rely on them exclusively
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16. Sedation assessment
 COMFORT scale
5 behavioral variables (alertness, facial tension, muscle tone,
agitation and movement) and
3 physiologic variables (PR, respiration, and BP)
 State Behavioral Scale (SBS)
defines the sedation-agitation continuum to guide goal-directed
therapy
using a patient’s response to voice, gentle touch, and noxious
stimuli such as suctioning
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17. Summary of recommended sedation assessment tools for critically ill children
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18. Goal of sedation
 provide adequate comfort and safety
 optimizing patient-ventilator synchrony and
 minimizing the risk of delirium and sleep disturbances.
 both excessive and inadequate sedation should be avoided
 to provide a child with anxiolysis
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19. Management
 The most commonly used agents for long-term sedation are
benzodiazepines, opioids and a-agonists
 Parenteral drug administration through intravenous access is most
common in the critically ill ICU patient
 Enteral administration is not effective
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20. Cont…
 Requires Balancing adverse effects of pain and pain treatment
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21. Analgesics with Antipyretic Activity or Nonopioid (“Weaker”) Analgesics
 Acetaminophen (paracetamol), salicylate (aspirin), ibuprofen, naproxen and
diclofenac
 provide pain relief primarily by blocking peripheral and central prostaglandin
production
 The most commonly used nonopioid analgesic remains acetaminophen
(paracetamol).
 Unlike aspirin and the NSAIDs, acetaminophen works primarily centrally (COX
III) and
 has minimal, if any, anti-inflammatory activity
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22. Opioid Analgesics
 The opioids most commonly used In the management of pain are μ
agonists
 morphine, meperidine, methadone, codeine, oxycodone and the fentanyl
 In the PICU, fentanyl and morphine are the most commonly utilized
opioids
 Produce delayed gastric emptying, decreased intestinal peristalsis, and
urinary retention
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23. Cont…
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24. Cont…
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25. Iatrogenic withdrawal syndrome assessment in infants and children
 Prolonged administration of opioids and/or benzodiazepines may induce
drug tolerance and physiological dependency
Due to Abrupt discontinuation or (too rapid) weaning
after >=5days of continuous infusion, >=10days in intermittent
bolus
The onset of withdrawal can occur after 1 up to 48 h after tapering
off or discontinuation
An estimated 10–34 % of all PICU patients are at risk of IWS
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26. Manifestation
 Neurologic: irritability, anxiety, tremors, clonus, yawning, sneezing,
delirium, seizures, hallucinations, and mydriasis
 Gastroenteric: feeding intolerance with vomiting, diarrhea,
uncoordinated sucking
 Activation of sympathetic nervous system: tachycardia,
hypertension, tachypnea, sweating, fever, and cough
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30. Cont…
 Tolerance is defined as “decreasing clinical effects of a drug after
prolonged exposure to it”.
 Physical dependence is defined as the “physiologic and biochemical
adaptation of neurons such that
removing a drug precipitates withdrawal or
An abstinence syndrome”
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31. Cont…
 To prevent or delay tolerance:
Titrate opioids to adequate pain management; adjust to minimum
effective dose
Regularly reassess if continued use needed
Use longer acting opioids, like methadone, for persistent pain
 Consider daily interruption of sedatives
Gradually wean patients at risk
Consider a methadone weaning protocol or the addition of clonidine
or alternatives.
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32. Sleep in the PICU
 Promoting sleep can be considered a PICU pain management
Intervention
 Disruptions of sleep
Noise, Light
Analgesics/sedatives, Mechanical ventilation
Nursing care/procedures,
Post-traumatic stress (pain from trauma/burn)
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33. Cont…
 Recommendations
Decrease noise < 45 dB
Promote day/night rhythm
Daylight, Family presence
Cluster care/ minimize nighttime interruptions
 PICU patients are at risk for sleep loss/disruption, which may
contribute to delayed healing and poor pain tolerance.
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34. DELIRIUM IN THE PICU
o Characterized by an acute onset and fluctuating course with reduced
awareness
o impairments in attention and
o changes in cognition (memory deficits, language disturbances,
hallucinations)
o all in combination with a pathophysiologic cause
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35. Cont…
 Develops over hours to days
 Fluctuates in severity
 Higher rate in patients with longer PICU length of stay
 Risk factors:
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36. causes
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37. Delirium management
 Preventive measures:
o Promote daily routine, caregiver interaction during day
o Promote uninterrupted sleep
o Offer a familiar environment (e.g. favorite toys)
o Cluster care to minimize interruptions
o Conduct regular delirium screening
o Assess and manage pain
o Consistent assessment/management of pain may decrease
risk and severity of delirium
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38. Preventing adverse effects of PICU hospitalization
 Strategies to reduce pain
Identify painful events that can be eliminated or reduced
 Use developmentally appropriate pharmacological and
biobehavioral
approaches for painful procedures
 Ensure adequate analgesia if pain identified or likely
 Incorporate multi-modal analgesia
 Balance needs for analgesia and sedation
 Address sources of non-pain related distress
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39. Reference
 Sapna R. Kudchadkar, R. Blaine Easley, Kenneth M. Brady, Myron Yaster,
Pain and Sedation Management, pediatric ICU 5th edition.
 Sean Barnes, MD, MBA,* Myron Yaster, MD,† Sapna R. Kudchadkar, MD,
on Pediatric Sedation Management, Department of Anesthesiology &
Critical Care Medicine, Johns Hopkins University School of Medicine,
MAY 2016.
 Stephen D. Playfor MD, Consultant Paediatric Intensivist, Royal
Manchester Children’s, on Analgesia and sedation in critically ill children,
Volume 8 Number 3 2008.
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40.  Pain is a more terrible lord of mankind than even death itself.
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