Author: Danielle Cassidy, PharmD, BCPS
Audience: continuing education for hospice nurses
Background: describes common developmentally appropriate tools for assessing pain in children, general principles of pediatric pharmacology, common pharmacological interventions, side effects commonly associated with opioid medications & side effect management strategies.
Geriatric Special Focus, Pain Management and Analgesic Prescribing for Advanc...Michelle Peck
Michelle Peck | Geriatric Nurse Practitioner | Health Care Consultant | Professional Speaker | Nursing Faculty| Legal Nurse Consultant | Mindful Geriatrics
In collaboration with Dr. Linh Nguyen, Supportive Medicine at UTHealth Medical School, we have created this slide deck for Advanced Practice Nurses.
Our mission is to simplify the pharmacologic basics of good pain prescribing. We have not provided very much detail about schedule II controlled substances due to the current limitations on Texas Nurse Practitioner prescribing in primary care.
This lecture is designed to meet our Advanced Practice Nursing audience where they are at and provide tools, knowledge and practical tips. Areas where we detect mastery with our polling questions are briefly touched upon and more time and examples are given are to areas of audience identified needs. Prescribing pain medication for Advanced Practice Nurses is dynamic, complex and ever changing
We have also included a special focus (our passion) for pain prescribing in the geriatric population. Beer’s Criteria medications, to be used with caution or avoid completely in geriatrics are mentioned throughout this presentation.
This presentation starts with the audience writing down their biggest fear about pain prescribing. We then categorize these fears, so that throughout our lecture we can give special focus and alleviate fears with practical tips, guidelines and real life examples.
Our objectives are to discuss:
1. Benefits and side effects of common analgesics
2. The impact of patient-related factors on drug selection & dose based on knowledge of patient related changes
3. Medications to avoid, use with caution, explain why
4. Management of pain based on client care goals
We hope you Learn it-Live it-Love it!
Geriatric Population. Pain and Palliative Care for the Older (Geriatric) AdultMichelle Peck
Michelle Peck | Legal Nurse | Nurse Practitioner | Health Care | Geriatric | Consultant | Speaker | Educator | Researcher
During your journey through this slide deck of Geriatric Populations, Pain and Palliative Care for the Older (Geriatric) Adult, you will experience: the assessment of pain; pain management strategies; and learn more about Palliative Care services.
As a health care consumer it is important to recognize and be aware of the quality of life benefits of good pain and symptom control. This begins with a good assessment of the factors contributing to the pain. Pain is a multifaceted experience. There are many barriers to achieving effective pain control in the elderly (geriatric population). Health care providers need to be aware of personal biases surrounding pain for proper pain management. There are also many health care provider misconceptions regarding Palliative Care especially in the geriatric population.
To enrich your geriatric understanding, at the end of this slide deck we discuss Palliative Care: the relief you need when you are experiencing serious medical illness.
Learn it-Live it-Love it-Your path for a more informed life!
Michelle Peck | Legal Nurse | Nurse Practitioner | Health Care | Geriatric | Consultant | Speaker | Educator | Researcher
Geriatric Special Focus, Pain Management and Analgesic Prescribing for Advanc...Michelle Peck
Michelle Peck | Geriatric Nurse Practitioner | Health Care Consultant | Professional Speaker | Nursing Faculty| Legal Nurse Consultant | Mindful Geriatrics
In collaboration with Dr. Linh Nguyen, Supportive Medicine at UTHealth Medical School, we have created this slide deck for Advanced Practice Nurses.
Our mission is to simplify the pharmacologic basics of good pain prescribing. We have not provided very much detail about schedule II controlled substances due to the current limitations on Texas Nurse Practitioner prescribing in primary care.
This lecture is designed to meet our Advanced Practice Nursing audience where they are at and provide tools, knowledge and practical tips. Areas where we detect mastery with our polling questions are briefly touched upon and more time and examples are given are to areas of audience identified needs. Prescribing pain medication for Advanced Practice Nurses is dynamic, complex and ever changing
We have also included a special focus (our passion) for pain prescribing in the geriatric population. Beer’s Criteria medications, to be used with caution or avoid completely in geriatrics are mentioned throughout this presentation.
This presentation starts with the audience writing down their biggest fear about pain prescribing. We then categorize these fears, so that throughout our lecture we can give special focus and alleviate fears with practical tips, guidelines and real life examples.
Our objectives are to discuss:
1. Benefits and side effects of common analgesics
2. The impact of patient-related factors on drug selection & dose based on knowledge of patient related changes
3. Medications to avoid, use with caution, explain why
4. Management of pain based on client care goals
We hope you Learn it-Live it-Love it!
Geriatric Population. Pain and Palliative Care for the Older (Geriatric) AdultMichelle Peck
Michelle Peck | Legal Nurse | Nurse Practitioner | Health Care | Geriatric | Consultant | Speaker | Educator | Researcher
During your journey through this slide deck of Geriatric Populations, Pain and Palliative Care for the Older (Geriatric) Adult, you will experience: the assessment of pain; pain management strategies; and learn more about Palliative Care services.
As a health care consumer it is important to recognize and be aware of the quality of life benefits of good pain and symptom control. This begins with a good assessment of the factors contributing to the pain. Pain is a multifaceted experience. There are many barriers to achieving effective pain control in the elderly (geriatric population). Health care providers need to be aware of personal biases surrounding pain for proper pain management. There are also many health care provider misconceptions regarding Palliative Care especially in the geriatric population.
To enrich your geriatric understanding, at the end of this slide deck we discuss Palliative Care: the relief you need when you are experiencing serious medical illness.
Learn it-Live it-Love it-Your path for a more informed life!
Michelle Peck | Legal Nurse | Nurse Practitioner | Health Care | Geriatric | Consultant | Speaker | Educator | Researcher
Evidence-Based Practice Summary Brief exploring the effects of palliative care on pain management in children with terminal illnesses. This project was written to be presented at the Kaiser Permanente Research Symposium in conjunction with Sonoma State Nursing.
A presentation by Ulla Caverius at the 2017 meeting of the Scandinavian Society of Anaestesiology and Intensive Care Medicine.
All available content from SSAI2017: https://scanfoam.org/ssai2017/
Delivered in collaboration between scanFOAM, SSAI & SFAI.
Treatment Programs HARPS Program (Helping At-Risk Pregnant Women Succeed) - C...ErikaAGoyer
NATIONAL PERINATAL ASSOCIATION CONFERENCE 2014 - Treatment Programs HARPS Program (Helping At-Risk Pregnant Women Succeed)
- Chris Cooper, MSN, NNP-CB, APRN and Dawn Forbes, MD
BIOENGINEERED NANOROBOTICS FOR CANCER THERAPY Sivajith007
A person who is diagnosed with cancer will be offered a new alternative to chemotherapy because the traditional treatment of radiation that kills not just cancer cells but healthy human cells as well, causing hair loss, fatigue, nausea, depression, and a host of other symptoms. The application of nanorobotics can be considered as the better solution to this problems. Nanorobots are nanoelectromechanical systems designed to perform a specific task with precision at nanoscale dimensions. This technique involves the development of fully functional nanorobots capable of sensing, decision making, and actuation. From a bio inspired perspective, those in nanorobotics, including core design, propulsion and power generation, sensing, actuation, control, decision making, and system integration. The core of the nanorobots is a polysaccharide based nanoparticle, sensing and actuation ensure that it is capable of sensing and recognizing the cancer cell. These nanorobots may aid in cancer therapy, site-specific drug delivery, circulating diagnostics, advanced surgery, and tissue repair. One of the major advantages of nanorobots is it will not affect healthy cells in human body. Using strategies inspired from microorganisms, potential bioengineered nanorobots can be used for cancer therapy.
Evidence-Based Practice Summary Brief exploring the effects of palliative care on pain management in children with terminal illnesses. This project was written to be presented at the Kaiser Permanente Research Symposium in conjunction with Sonoma State Nursing.
A presentation by Ulla Caverius at the 2017 meeting of the Scandinavian Society of Anaestesiology and Intensive Care Medicine.
All available content from SSAI2017: https://scanfoam.org/ssai2017/
Delivered in collaboration between scanFOAM, SSAI & SFAI.
Treatment Programs HARPS Program (Helping At-Risk Pregnant Women Succeed) - C...ErikaAGoyer
NATIONAL PERINATAL ASSOCIATION CONFERENCE 2014 - Treatment Programs HARPS Program (Helping At-Risk Pregnant Women Succeed)
- Chris Cooper, MSN, NNP-CB, APRN and Dawn Forbes, MD
BIOENGINEERED NANOROBOTICS FOR CANCER THERAPY Sivajith007
A person who is diagnosed with cancer will be offered a new alternative to chemotherapy because the traditional treatment of radiation that kills not just cancer cells but healthy human cells as well, causing hair loss, fatigue, nausea, depression, and a host of other symptoms. The application of nanorobotics can be considered as the better solution to this problems. Nanorobots are nanoelectromechanical systems designed to perform a specific task with precision at nanoscale dimensions. This technique involves the development of fully functional nanorobots capable of sensing, decision making, and actuation. From a bio inspired perspective, those in nanorobotics, including core design, propulsion and power generation, sensing, actuation, control, decision making, and system integration. The core of the nanorobots is a polysaccharide based nanoparticle, sensing and actuation ensure that it is capable of sensing and recognizing the cancer cell. These nanorobots may aid in cancer therapy, site-specific drug delivery, circulating diagnostics, advanced surgery, and tissue repair. One of the major advantages of nanorobots is it will not affect healthy cells in human body. Using strategies inspired from microorganisms, potential bioengineered nanorobots can be used for cancer therapy.
Effective pain management in terminally ill requires
Understanding of pain control strategies
Ongoing assessment
Diagnosis of pain
Breakthrough pain relief
Fine adjustment of medications
Opioid rotation
Unresolved psychosocial or spiritual issue can be great impact to pain management
Medication non-adherence is a growing concern, as it is increasingly associated with negative health outcomes and higher cost of care. Tackling the burden of non-adherence requires a collaborative, patient-centric approach that considers individual patient needs and results in intelligent interventions that combine high-tech with high-touch.
June Lee, MD, Director of CTSI's Early Translational Research program, presents the goals and vision for the program. Learn more about June Lee at UCSF Profiles http://profiles.ucsf.edu/ProfileDetails.aspx?From=SE&Person=5208624
Translational Medicine: Patterns of Response to Antidepressant Treatment and ...Joanne Luciano
This is a talk I gave at the IEEE Schenectady Section - 17 MAY Membership Meeting.
The mission of my depression research is to help people figure out what they need to help them get out of a depressed state. That is, finding out what is best for them, not what is best for their doctor, friends, therapist, or anyone else. Depression is now a global problem. In the past 15 years it has gotten worse. Depression is complex; it has a wide range of varying symptoms and degrees of intensity. It can be challenging to determine the best course of action, whether medical treatment is necessary, or which of the many treatments (drug and non-drug) is the best match. Many people who are depressed do not get the help they need, and many people receive medications when they are not necessary. My work aims to bring together tools, technology, scientific and medical data and patient experience to help address depression, both personally and globally.
Se revisa las técnicas para evaluar el dolor, como varios sistemas de puntuación del dolor específicos por edad. Se discute el manejo farmacológico del dolor, incluyendo el uso de agentes que inhiben la formación de prostaglandinas, AINES y el acetaminofeno, así como los opioides débiles usados comúnmente, cuando la administración oral es factible, para el tratamiento del dolor leve a moderado.
Do Adolescents with Eating Disorders Ever Get Well?Dr David Herzog
Dr. David Herzog presents a slideshow regarding adolescents and their struggle with eating disorders. Do they ever get better and move past their eating disorders?
Local Advanced Lung Cancer: Artificial Intelligence, Synergetics, Complex Sys...Oleg Kshivets
Overall life span (LS) was 1671.7±1721.6 days and cumulative 5YS reached 62.4%, 10 years – 50.4%, 20 years – 44.6%. 94 LCP lived more than 5 years without cancer (LS=2958.6±1723.6 days), 22 – more than 10 years (LS=5571±1841.8 days). 67 LCP died because of LC (LS=471.9±344 days). AT significantly improved 5YS (68% vs. 53.7%) (P=0.028 by log-rank test). Cox modeling displayed that 5YS of LCP significantly depended on: N0-N12, T3-4, blood cell circuit, cell ratio factors (ratio between cancer cells-CC and blood cells subpopulations), LC cell dynamics, recalcification time, heparin tolerance, prothrombin index, protein, AT, procedure type (P=0.000-0.031). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and N0-12 (rank=1), thrombocytes/CC (rank=2), segmented neutrophils/CC (3), eosinophils/CC (4), erythrocytes/CC (5), healthy cells/CC (6), lymphocytes/CC (7), stick neutrophils/CC (8), leucocytes/CC (9), monocytes/CC (10). Correct prediction of 5YS was 100% by neural networks computing (error=0.000; area under ROC curve=1.0).
micro teaching on communication m.sc nursing.pdfAnurag Sharma
Microteaching is a unique model of practice teaching. It is a viable instrument for the. desired change in the teaching behavior or the behavior potential which, in specified types of real. classroom situations, tends to facilitate the achievement of specified types of objectives.
Here is the updated list of Top Best Ayurvedic medicine for Gas and Indigestion and those are Gas-O-Go Syp for Dyspepsia | Lavizyme Syrup for Acidity | Yumzyme Hepatoprotective Capsules etc
Basavarajeeyam is an important text for ayurvedic physician belonging to andhra pradehs. It is a popular compendium in various parts of our country as well as in andhra pradesh. The content of the text was presented in sanskrit and telugu language (Bilingual). One of the most famous book in ayurvedic pharmaceutics and therapeutics. This book contains 25 chapters called as prakaranas. Many rasaoushadis were explained, pioneer of dhatu druti, nadi pareeksha, mutra pareeksha etc. Belongs to the period of 15-16 century. New diseases like upadamsha, phiranga rogas are explained.
Adv. biopharm. APPLICATION OF PHARMACOKINETICS : TARGETED DRUG DELIVERY SYSTEMSAkankshaAshtankar
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Muktapishti is a traditional Ayurvedic preparation made from Shoditha Mukta (Purified Pearl), is believed to help regulate thyroid function and reduce symptoms of hyperthyroidism due to its cooling and balancing properties. Clinical evidence on its efficacy remains limited, necessitating further research to validate its therapeutic benefits.
ABDOMINAL TRAUMA in pediatrics part one.drhasanrajab
Abdominal trauma in pediatrics refers to injuries or damage to the abdominal organs in children. It can occur due to various causes such as falls, motor vehicle accidents, sports-related injuries, and physical abuse. Children are more vulnerable to abdominal trauma due to their unique anatomical and physiological characteristics. Signs and symptoms include abdominal pain, tenderness, distension, vomiting, and signs of shock. Diagnosis involves physical examination, imaging studies, and laboratory tests. Management depends on the severity and may involve conservative treatment or surgical intervention. Prevention is crucial in reducing the incidence of abdominal trauma in children.
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2. Learning Objectives
Describe common developmentally appropriate tools
for assessing pain in children.
List some general principles of pediatric
pharmacology.
List common pharmacological interventions for
treatment of pediatric pain.
List side effects commonly associated with opioid
medications & management strategies.
4. Background
Pediatric pain is a commonly undertreated symptom &
many children experience pain at end of life.
One study reported more than 60% of parents felt their
child received inadequate pain relief at the end of life13.
An inpatient hospital study noted that 53% of children
dying from cancer reported well controlled pain after
initiating a pediatric palliative care program2.
Estimated 50,000 infants, children, & adolescents die
each year in the United States.
~16,000 are attributable to complex chronic conditions.
~5,000 receive hospice or palliative care services.
Overall progress of pediatric palliative/hospice care has
lagged significantly behind the strides made in
hospice/palliative care services for adults with terminal
illness.
5. Background: Common Misconceptions
The American Academy of Pediatrics (AAP) & The
American Pain Society (APS) recommend pediatric
pain be recognized & treated more aggressively.
Myths/Barriers
Infants & children do not feel pain, or suffer less from it
than adults.
Misunderstanding of how to quantify a subjective
experience.
Lack of routine pain assessment.
Lack of knowledge regarding analgesic dosing strategies.
Fears of analgesic adverse effects, including respiratory
depression & addiction.
Belief that preventing pain takes too much time & effort.
6. Background: Medical Conditions
Appropriate for Pediatric Palliative Care
Conditions for which curative treatment is possible,
but may fail (e.g. advanced cancer, complex
congenital heart disease or airway anomalies).
Conditions requiring intensive long-term treatment
aimed at maintaining the quality of life (e.g. HIV,
cystic fibrosis, epidermolysis bullosa, severe GI
disorders) .
Progressive conditions where treatment is purely
palliative after diagnosis (severe metabolic
disorders, certain chromosomal abnormalities).
Conditions involving severe, nonprogressive
disability, causing extreme vulnerability to health
complications (severe cerebral palsy, extreme
prematurity).
Himelstein BP, Hilden JM, et al. Pediatric Palliative Care. N Engl J Med 2004;350:1752-1762
7. Background: Overview of Pediatric Pain
Pain can be nociceptive or neuropathic.
Nervous system is fully developed to process
nociception by 26 weeks of gestation.
Infants & young children experience a greater
neuronal response following noxious stimuli than
adults due to:
More robust inflammatory response.
Immature inhibitory pathways.
Painful experiences can lead to long-term effects
such as lowered pain tolerance for months after the
event & behavioral issues.
9. Pain Assessment
Pediatric pain scales
Observational (neonates & infants)
Allows assessment of those unable to verbalize their pain.
Simple self-report (preschool & school age children)
Uses facial expressions or small objects to describe pain
intensity.
Adult numerical pain scale, visual analog scale, verbal report
reserved for children 7 years & older.
Caregiver input should be included in overall
assessment.
Gold standard is self-report for any child able to verbalize
their pain.
Children with chronic pain rapidly adapt & may not exhibit
some of the features used in these tools.
10. Acute Pain Assessment: Neonates
Scale Scale Indicators
Degree of Crying, Required oxygen, Increased vital
CRIES signs (heart rate &/or blood pressure), Expression (e.g.
grimace), & Sleeplessness.
Premature Infant Pain Gestational age (greater than or less than 36 weeks
Profile (PIPP) gestational age), behavioral state before painful
stimulus, change in heart, change in oxygen saturation,
brow bulge, eye squeeze, nasolabial furrow.
Neonatal Infant Pain Facial expression, breathing patterns, extremity muscle
Scale (NIPS) tone , & state of arousal.
Neonatal Pain, Scores can be adjusted for gestational age.
Agitation & Sedation Crying/Irritability, Behavior state (e.g. arousal,
Scale (N-PASS) movement), facial expression, muscle tone of
extremities, & vital signs.
11. Example of CRIES Scale
Krechel, SW and Bildner, J. CRIES: a new neonatal postoperative pain measurement score– initial testing of validity and
reliability. Paediatric Anaesthesia 1995;5 53-61.
12. Acute Pain Assessment: Observational
Scales for Nonverbal Young Children
Scale Measurement
FLACC For ages 2 months to 7 years. Measures physiologic
changes of the Face (degree of grimace), Legs (degree of
restlessness/tension), Activity (degree of agitation), Cry
(degree of crying); & Consolability (amount of physical
consoling needed to comfort child).
Cognitively R-FLACC, The Non-Communicating Children’s Pain
Impaired Checklist-Revised (NCCPC-R), & The Paediatric Pain Profile
(PPP).
13. Acute Pain Assessment: Simple Self Report
Scales for Verbal Young Children
Scale Measurement
FACES Ages 3 years & up. Uses 6 faces starting with a happy face &
progressing to a crying face. Explain to the child the 1st face has
no pain, the 2nd face has a little pain, the 3rd face has a little more
pain, the 4th has more pain still, the 5th face has a lot of pain, &
the 6th face is the worst pain ever, but the child does not need to
be crying to experience the worst pain ever. Then the child is
asked which face best describes how they feel.
Oucher Ages 3 years & up. Similar to FACES, but uses a picture scale
for young children & a numeric scale for older children. Available
in different ethnic & gender versions. (www.oucher.org)
Hester’s Ages 5 years & up. Given 4 chips & told that one chip represents
Poker Chip a small amount of pain, 2 chips mean more pain, 3 chips mean
Scale even more pain, & 4 chips mean the worst pain ever. The
children are then asked to put the number of chips in the
interviewer’s hand & that best describes their pain.
14. Examples of the OUCHER Scale
Accessed February 24, 2012 at http://www.oucher.org/order.html
15. Chronic Pain Assessment
Scale Measurement
The Varni-Thompson Pediatric Pain Ages 4-16 years. Provides a
Questionnaire comprehensive assessment of the
pain experience in children with
chronic pain.
Douleur Enfant Gustav-Roussy For ages 2 to 6 years. Measures
chronic pain by incorporating several
items that deal with pain, anxiety, &
psychomotor behaviors.
17. Pharmacology: Body Compartments
Age: neonates
Trend: decreased fat, decreased muscle, &
increased water.
Clinical implications: Some water soluble drugs have
Increased drug distribution in extracellular fluids.
Increased duration of action.
Increased dosing interval.
How does body composition differ in aging adults?
Increasing fat & decreasing water.
Result- increased drug distribution & accumulation of lipid
soluble drugs.
18. Pharmacology: Plasma
Age: Neonates
Trend: Decreased concentrations of drug binding
proteins (albumin & α-1 glycoprotein)
Clinical Implications:
Higher concentrations of active (unbound) drug for highly
protein-bound medications.
Increased potential for overdose or toxicity.
How does plasma differ in aging adults?
Decreasing/unchanged albumin & increasing α-1
glycoprotein.
Result- decreased distribution of water soluble drugs.
19. Pharmacology: Hepatic
Age: neonates, infants, & children 2-6 years.
Trend:
Neonates & infants: enzymes involved in drug metabolism
mature at varying rates over 1-6 months of life.
Children 2-6 years: increased hepatic mass.
Clinical Implications:
Neonates & infants: decreased metabolic clearance; decreased
infusion rates or increased dosing intervals.
Children 2-6 years: increased metabolic clearance; increased
infusion rates or decreased dosing intervals.
How does hepatic function differ in aging adults?
Decreased liver mass, decreased liver blood flow, &
decreased/unchanged function of enzymes.
Decreased metabolism & increased duration of action.
20. Pharmacology: Renal Filtration
Age: neonates & infants.
Trend:
Decreased glomerular filtration rate.
Sufficiently mature to clear medications by 2 weeks of age &
normalizes by 8-12 months.
Clinical Implications:
Accumulation of renally excreted drugs or their active
metabolites.
Decreased infusion rates or increased dosing intervals.
How does renal function differ in aging adults?
Decreased filtration, decreased renal mass, & decreased renal
blood flow.
Decreased elimination & increased duration of action.
21. Aging & Renal Function: Example
Infants to 19 years of age:
>120 mL/min
20 to 49 years of age:
99-116 mL/min
50+ years of age:
<99 mL/min
22. Pharmacology: Respiratory
Age: neonates.
Trend: diminished ventilatory responses to
hypoxemia & hypercarbia.
Clinical Implications
Respiratory pauses or apnea lead more rapidly to
hypoxemia.
Further impairment can be seen with central nervous
system depressant drugs such as opioids &
benzodiazepines (these medications are still appropriate
for symptomatic relief & comfort when needed).
24. Pain Management: Nonpharmacologic
Therapies
World Health Organization (WHO) recommends
considering to augment pain & anxiety.
Examples include:
Improved sleep hygiene.
Cognitive behavior techniques, such as hypnosis, guided
imagery, biofeedback, & mindfulness based stress
reduction.
Child life specialists to help distract the child with games,
toys, & play therapy.
Yoga.
Massage.
Acupuncture or Accupressure
Art or music therapy.
Transcutaneous electrical nerve stimulation.
Aromatherapy
25. Pain Management: General Treatment
Principles
Dosing is based on mg/kg.
Infants younger than 6 months or less than 10 kg,
opioid doses are usually reduced by 25-30% of the
nominal starting dose.
Adolescents heavier than 50 kg can be dosed using
typical adult dosing.
As in adults, renal & liver function must also be
considered & adjusted for according to the degree of
organ dysfunction.
26. Pain Management: WHO Analgesic
Treatment Principles
By the ladder: analgesics should be started &
escalated in a stepwise approach based on the
severity of symptoms.
By the clock:
Analgesics should be given on a scheduled basis to
provide stable blood levels of the medication.
Rescue doses should be available for breakthrough pain.
By the mouth: analgesics should be given by the
simplest, most effective, & least painful route
available that allows for effective pain control.
By the child: analgesics dose/frequency should be
based on the individual child’s circumstances & their
response to therapy.
28. Pain Management: Routes of Administration
Pros & Cons
Zernikow B, Michel E, et al. Pediatric Palliative Care: Use of Opioids for the Management of Pain. Pediatr Drugs
2009;11(2):129-151.
29. Pain Management: Oral Drug
Considerations
Many children less than 6 years cannot swallow
pills/capsules.
Alternative opioid formulations
Liquid: methadone, morphine immediate release,
hydrocodone/APAP, oxycodone, codeine.
Transmucosal: fentanyl lollipop (Actiq®)
Transdermal: fentanyl patch
Crushable pills are an alternative when the drug is
not available in liquid formulation.
Masking aversive-tasting medications: stir into small
quantities (~5 mL) of chocolate/strawberry syrup,
pudding, ice cream, applesauce, or 100% fruit juice
(not recommended for less than 6 months of age) .
30. Pain Management: Nonopioid Drugs
Drug Dose <50kg (max dose) Dose ≥50kg (max dose)
Acetaminophen PO/IV: 10-15 mg/kg every 4-6 PO/IV: 650-1000 mg every 4-6
hours (90 mg/kg/day or 4g/day) hours (4g/day)
Rectal: One time 40mg/kg Rectal: 1000mg every 4-6
loading dose followed by, hours (4g/day)
20mg/kg rectally every 4-6
hours (120 mg/kg/day or
4g/day)
Ibuprofen 5-10 mg/kg PO every 6-8 hours 400-600 mg PO every 6-8
(40mg/kg or 2.4 g/day) hours (2.4 g/day)
Naproxen 5 mg/kg PO every 8-12 hours 250-375 mg every 8-12 hours
(24mg/kg or 1 g/day)× (1 g/day)
Ketrolac 0.25-0.5 mg/kg IV every 6 15-30 mg IV every 6 hours
hours (2 mg/kg or 120mg/day) x (120mg/day) x 5 days
5 days
× Higher doses can be used for children with rheumatologic disease.
Berde CB & Sethna NF. Analgesics for the Treatment of Pain in Children. N Engl J Med 2002;347(14)1094-1103.
31. Pain Management: Initial Opioid Dosing In
Opioid Naïve Children
Berde CB & Sethna NF. Analgesics for the Treatment of Pain in Children. N Engl J Med 2002;347(14)1094-1103.
32. Pain Management: Methadone
Only long acting opioid available as an oral liquid.
No published studies evaluating its use in pediatric
palliative/hospice care.
Advantages:
May still exhibit analgesia even if morphine, fentanyl, or
hydromorphone have failed.
May be beneficial for patients with neuropathic pain.
Disadvantages:
Extremely long half-life (children: 4-62 hrs, adults: 9-87 hrs)
Biphasic elimination- can result in slow accumulation &
toxicity 2-5 days after initiation or dose changes (monitor for
side effects).
33. Pain Management: WHO Recommendation
for Methadone
Use only after failing morphine & hydromorphone.
Oral route is preferred.
To prevent toxicity:
Initiation: Administer on as needed basis for the first 2-3
days. When frequency requirements are well established,
round the clock dosing can be initiated.
Maintenance: increase dose as needed every 2-5 days as
needed to achieve pain control.
Avoid in kids with rapidly changing clinical conditions or
metabolic conditions that could interfere with drug
clearance.
34. Case Study: Initial IV morphine titration
A 2 year old (weight= 12 kg) has severe pain & is
unable to hold down any oral liquids at this time.
Initial IV morphine titration:
Starting dose of morphine 0.1 mg/kg x 12 kg = 1.2 mg.
Reassess the child in 30 minutes
If still in pain & not sedated provide a repeat dose of 1.2 mg.
If still in pain, but somewhat sedated provide a repeat dose at
25-50% of the starting dose (0.3-0.6 mg).
The child is now comfortable.
Adapted from: WHO. Cancer pain relief & palliative care in children. Geneva: World Health Organization, 1998.
35. Case Study: Initial IV morphine titration
continued…
Continuous infusion of morphine:
Starting infusion rate 0.03 mg/kg/hour x 12 kg =
0.36 mg/hour.
Provide hourly rescue doses for PRN breakthrough pain
at 50-200% of the hourly infusion rate (0.18-0.72 mg).
Assess the child in one hour. Child is still comfortable.
Reassess the child in 4 hours. Child has moderate pain,
is withdrawn, & cries when not held.
36. Case Study: Initial IV morphine titration
continued…
Titration:
Administer a rescue bolus dose 0.1 mg/kg x 12 kg=
1.2mg.
If repeated breakthrough pain occurs increase the
infusion rate by 25% (0.25 x 0.36 mg/hour) + 0.36
mg/hour = 0.45 mg/hour. Continue to provide rescue
doses PRN .
Alternatively, continue rescue doses for 24 hours then
increase the infusion rate by the amount of rescue doses
administered over that 24 hour period.
For example if six rescue doses of 0.5 mg were given then
increase the infusion rate by [(0.5mg x 6 doses) ÷ 24 hours] +
0.36mg/hour = 0.48mg/hour.
38. Opioid Side Effects: Constipation
Constipation is an anticipated chronic side effect that
is uncomfortable & sometimes painful.
~50% of terminally ill children experience prolonged
constipation & should be treated preventively when
on opioid therapy.
Prophylactic treatment:
Combination therapy is generally indicated with a
stimulant laxative (senna) plus either a stool softener
(docusate) or osmotic agent (magnesium, lactulose,
polyethylene glycol).
Adding more fiber to the diet may be helpful only if liquids
are also increased.
39. Opioid Side Effects: Nausea & Vomiting
Quickly develop tolerance to the emetic effect of
opioids & usually resolves within one week of
initiation.
Potential treatments therapies:
Ondansetron (preferred), granisetron
metoclopramide, prochlorperazine (PO/PR),
chlorpromazine.
Alternatives: lorazepam, low-dose olanzapine,
droperidol, haloperidol.
Severe nausea/vomiting: consider rotating to
different opioid or initiate low-dose naloxone
infusion.
40. Opioid Side Effects: Pruritus
Common side effect (~25%).
Usually resolves after several days.
Treatment:
If the pain situation is stable attempt a opioid dose
reduction, or initiate scheduled antihistamine
(diphenhydramine, hydroxyzine) therapy, or initiate low-
dose naloxone infusion.
If pain is unstable or above measures are unsuccessful,
opioid rotation is indicated.
41. Opioid Side Effects: Somnolence
Often improves within a few days after initiation or
titration of the opioid.
Management:
If persistent or intolerable, the most effective therapy is
rotating the opioid.
Alternately may try a trial of psychostimulant (e.g.
methylphenidate).
42. Opioid Side Effects: Delirium & Myoclonus
Delirium (rare)
Commonly occurs when receiving multiple medications or
patient is critically ill.
Management: if clearly opioid related initiate a trial of
haloperidol or rotate to a different opioid.
Myoclonus
May be provoked in patients on high dose opioids (i.e.
morphine or hydromorphone).
Management:
Considered benign if occurs during sleep.
If present during waking hours or severe a benzodiazepine can
be scheduled or the opioid rotated.
43. Opioid Side Effects: Respiratory depression
True respiratory depression is rare when opioids are
dosed appropriately.
Usually seen during rapid IV opioid administration for
painful procedures or when co-administered with a
centrally active medication such as benzodiazepines.
Management (determined by treatment goals of the child
& family):
Mild to moderate: stimulating the child, holding opioid dose,
opioid dose reduction by 50%.
Severe: Respiratory support & if necessary naloxone
(should be administered with extreme caution, as sudden
opioid antagonism can lead to life-threatening withdrawal).
44. Conclusions
Common tools to assess pain in children include
observational scales (FLACC, CRIES) & simple-self
report scales (OCHER, FACES).
Neonates, infants, & young children often have
pharmacological differences such as altered renal or
hepatic function as compared to adults.
The type of pharmacological intervention is
dependent upon the level of pain observed and/or
reported by the child.
Common opioid side effects include constipation,
nausea/vomiting, pruritus, & somnolence.
45. Aging & Renal Function: Example
Infants to 19 years of age:
>120 mL/min
20 to 49 years of age:
99-116 mL/min
50+ years of age:
<99 mL/min
46. References
1) American Medical Association Pediatric Pain Management (module 6).
AMA release September 2007.
2) Moody K, Siegel L, et al. Pediatric Palliative Care. Prim Care Clin Office
Pract 2001;38:327-361.
3) Berde CB & Sethna NF. Analgesics for the Treatment of Pain in Children.
N Engl J Med 2002;347(14):1094-1103.
4) Himelstein BP, Hilden JM, et al. Pediatric Palliative Care. N Engl J Med
2004;350:1752-1762.
5) Committee on Psychosocial Aspects of Child & Family Health, American
Academy of Pediatrics; Task Force on Pain in Infants, Children, &
Adolescents, American Pain Society. The assessment & management of
acute pain in infants, children, & adolescents. Pediatrics 2001;108(3):793-
797.
6) Mathews TJ, et al. Annual summary of vital statistics: 2008. Pediatrics
2011:127(1):146-157.
7) Klick JC & Hauer J. Pediatric Palliative Care. Curr Probl Pediatr Adolesc
Health Care 2010;40:120-151.
8) Lawrence J, Alcock D, McGrath P, et al. The development of a tool to
assess neonatal pain. Neonatal Netw 1993;12(6):59–66.
47. References Continued…
9) Hummel P, Puchalski M, et al. Clinical reliability and validity of the N-PASS:
neonatal pain, agitation and sedation scale with prolonged pain. J Perinatol
2008;28:55-60.
10) Stevens B, Johnston C, et al. Premature Infant Pain Profile: Development & initial
validation. Clin J Pain 1996;12:13-22.
11) Gauvain-Piquard A, Rodary C, et al. Pain in children 2-6 years: A new observational
rating scale elaborated in a pediatric oncology unit – preliminary report. Pain
1987;31:177-188.
12) Varni JW, Thompson KL, et al. The Varni-Thompson pediatric pain questionnaire I.
Chronic musculoskeletal pain in juvenile rheumatoid arthritis. Pain 1987;28:29-38.
13) Zernikow B, Michel E, et al. Pediatric Palliative Care: Use of Opioids for the
Management of Pain. Pediatr Drugs 2009;11(2):129-151.
14) WHO. Cancer pain relief & palliative care in children. Geneva: World Health
Organization, 1998.
15) Krechel SW and Bildner J. CRIES: a new neonatal postoperative pain
measurement score– initial testing of validity and reliability. Paediatr Anaesth
1995;53-61.
16) National Kidney Foundation. Frequently asked questions about GFR
estimates. National Kidney Foundation, Inc., 2010.
48. Pain Management: Routes of Administration
Oral Transdermal Intravenous Intramuscular Rectal
Generally not
Rapid pain Generally not
Painless Painless preferred by
control recommended
children
Not indicated for
Wide variability in
Preferred by acute or Easiest to titrate
Painful therapeutic drug
children escalating pain & adjust rapidly
levels
management
Useful for
Used only when Wide variability in Can be used
intermittent bolus
pain has therapeutic drug when transient
& continuous
stabilized levels vomiting present
infusions
Appropriate for
PCA use
49. Initiating Opioid Therapy for Severe Pain
By the clock:
Initiate a strong opioid & administer the medication on a
routine schedule basis.
Order a strong opioid for breakthrough pain.
By the mouth:
Determine the appropriate route of administration that is
the least invasive & most effective.
By the child:
If taking oral opioids re-access the child at several days to
determine if the treatment is adequate.
If using IV opioids re-access the child every 30 minutes.
50. Pain Management: WHO Recommendation
for Methadone
Use only after failing morphine & hydromorphone.
Oral route is preferred.
To prevent toxicity:
Initiation: Administer on as needed basis for the first 2-3
days. When frequency requirements are well established,
round the clock dosing can be initiated.
Maintenance: increase dose as needed every 2-5 days as
needed to achieve pain control.
Avoid in kids with rapidly changing clinical conditions or
metabolic conditions that could interfere with drug
clearance.
51. Pain Management: Methadone
Only long acting opioid available as an oral liquid.
No published studies evaluating its use in pediatric
palliative/hospice care.
Advantages:
May still exhibit analgesia even if morphine, fentanyl, or
hydromorphone have failed.
May be beneficial for patients with neuropathic pain.
Disadvantages:
Extremely long half-life (children: 4-62 hrs, adults: 9-87 hrs)
Biphasic elimination- can result in slow accumulation &
toxicity 2-5 days after initiation or doses changes (monitor
for side effects).
52. Pain Management: Nonpharmacologic
Therapies
WHO recommends considering to augment pain &
anxiety.
Examples include:
Improved sleep hygiene.
Cognitive behavior techniques, such as hypnosis, guided
imagery, biofeedback, & mindfulness based stress
reduction.
Child life specialists to help distract the child with games,
toys, and play therapy.
Yoga.
Massage.
Acupuncture or Accupressure
Art or music therapy.
Transcutaneous electrical nerve stimulation.
Aromatherapy
Editor's Notes
(Reference 2, 4, 6, 13)Analgesia often is insufficient because physicians are insecure with opioid dose administration & fail to adjust the opioid dose fast enough to match changing requirements.-At present, only about 5000 children dying each year receive hospice indicating that the vast majority of children might benefit from palliativecare & hospice services.- However, 2006 when the World Health Organization, the American Academy of Pediatrics, & the Institute of Medicine called attention to the unmet needs of dying children, forward progress in pediatric palliative care has gained momentum.
(References 1,5)-In 2001 APP & APS issue a joint statement regarding the pediatric pain
(Reference 2, 4)Currently no official established criteria for determining if a child is eligible for palliative care. A general guide was published by the Royal College of Peds & Child Health in 1997 in which they outlined medical conditions appropriate for pallative care services.-Palliative care is appropriate for children with a wide range of conditions, even when cure remains a distinct goal.-AAP has supported concepts of palliative care, stating that “the components of palliative care are offered at diagnosis & continued throughout the course of illness, whether the outcome ends in cure or death.” -Palliative care should be accessible in any setting, including home, hospital, & school.
(Reference 1-3)(Raeanna’s suggestion: Make sure to define nociception vs. neuropathic for this audience-verbal definition adequate)Similar to adults pain in kids can be nociceptive or neuropathic Neuropathic pain= complex chronic pain resulting from injury to the peripheral or CNS.Nociception= refers to the ability to feel pain and usually caused by stimulation of the nocipector.Nociceptive includes visceral (spleen, liver, gallbladder, ascites, intestinal cramps) & somatic pain (mucous membranes, bone, muscle, skin).pain is a subjective experience & ideally, the assessment of pain relies heavily on self-report.
Reference 2, Pediatric pain assessment differs from adult in that it must take into consideration the developmental stage of the child. Validated assessment tools to assess physical pain based on age & cognitive ability. Behavioral scales may under represent the intensity of persistent pain, as compared with self-reports.Usually at 7 years of age, children understand the proportionality of numbers & colors and can generally use the same scales as adults (i.e., Visual Analog Scale, Numeric Rating Scale). It is important to incorporate the primary caregivers input into ur overall assessment for 2 reasons: they generally know their children best, & they may have concerns & observations that may have been subtle during clinical examination.Also similar to adults, children with chronic pain adapt to their pain & often do not exhibit changes in vital signs, or common behavioral changes associated with pain such as withdrawing from the environment or crying. -Cognitive, behavioral, emotional, & psychosocial factors (e.g., family learning, culture), & other factors (e.g., gender) play a role in a child’s pain experiences, with children & adolescents responding to noxious experiences differently at different developmental stages.
References: 2,7-10-When assessing pain at different points—as in assessing the effectiveness of a dose of medication—the same assessment method should be used for eachassessment.
Results in a total score of 0-10.
References: 2, 7, FLACC also has be used in cognitively impaired.
References: 1, 2, 7Both preschool & school-age children may attribute their pain to being punished for something they did, & it is important to address this proactively to reassure themthat this is not the cause of their pain.
References, 11, 12
References 1, 3
There are age-related differences in body composition. Body weight is based on a higher percentage of water in neonates as compared with older children & adults.
-
Most analgesics (including opioids & local anesthetics) are conjugated in the liver Neonates: P-450 subtype 2D6, which converts codeine to morphineExample: In young children sustained release morphine is often used TID vs. bid in adults.enzyme systems involved in drug conjugation (sulfation, glucuronidation, oxidation),
Renal blood flow, glomerular filtration, & tubularsecretion increase in the first weeks of life, approaching adult values by 8-12 months.Example decreased clearancemeperidine & morphine active metabolites.
References: 2, 7, 13, 14In an effort to improve pain control in children with life-threatening conditions or persistent pain, the WHO developed a simple, effective pain-management strategy based on the four principles.By the clock-when meds are given on a prn basis for moderate to severe pain, children may fear their pain may become frighten & anxious.
Nonopioid Analgesic (– Adjuvant Drug) ‘analgesic ladder’ should be used, recognizing that starting at level 2 or 3 instead of at level 1 may be appropriate.
IM-if used recommend that a numb medication like Emla be applied prior to administration.Patient-controlled analgesia (PCA) is now widely used in ped as a convenient way to prevent delays in relieving episodic pain. Activation of the button by parents (“parent-controlled analgesia”) is widely accepted in palliative Patient controlled can be used in children as young as 5 yrs old.
Fruit juice-not recommended due to osmotic properties The only long-acting oral liquid opioid available in the United States is methadone. Fentanyl patch is contraindicated in opioid navie patients. On rare occasions a nasogastric tube is necessary to assist with medication delivery, particularly if the medication is vital to the child’s care & it is viewed as the least noxious method of obtaining the medication from the point of view of the child. Some children, especially when ill with mucositis ornausea, refuse or cannot tolerate oral medication. In these instances, transdermal orintravenous routes need to be considered. In general, rectal, subcutaneous, & intramuscularroutes of administration of pain medication are avoided in children whenpossible. Often, & especially if children need intravascular access for other reasons,a percutaneous intravenous catheter or central venous catheter is placed for continuousopioid administration
Aspirin carries a risk of provoking Reye’s syndrome in infants & children. If other analgesics are available, aspirin use should be restricted to indications where anti-platelet or anti-inflammatory effect is required, rather than as a routine analgesic or antipyretic in neonates, infants, or children.
Meperidine is generally not recommended when other opioids are available because of the potential for seizures and other toxicities due to its metabolite, normeperidine.
Advantages: as per adult studiesAnalgesic effect is mediated via the opioid m-receptor and an antagonism at the NMDA receptor
Types of metabolic conditions not defined
These episodes may be alleviated by increasing the daily regular morphine dose by 25–30% if more than three daily rescue doses are needed. The breakthrough painopioid dose should be adjusted regularly to an increasing basal opioid need.
These episodes may be alleviated by increasing the daily regular morphine dose by 25–30% if more than three daily rescue doses are needed. The breakthrough painopioid dose should be adjusted regularly to an increasing basal opioid need.
References: 2,7, 13, 14All opioids cause decreased intestinal motility that lead to constipation.
Some may experience this side effect.Ondansetron preferred as well tolerated and non-sedating, most study 5hts antagonist in kids.Lorazepam- only when other treatment fail or are contraindicated (0.02-0.05 mg/kg/dose (max2 mg) every 6 hours PRN).meltoclopramide- risk of EPS is low in kids, but the exact incidence has not been defined.
True respiratory depression is characterized by sleepiness, decreased consciousness, decreased respiratory rate, & central apnea.opioid dose reduction by 50% (titrated to achieve pain control without respiratory depression.The greater the tolerance to opioids the greater the sensitivity to the administration of naloxone, thus Naloxone should be titrated in very small amounts to avoid precipitation of withdrawal.
References: 14
Three steps: initiation of the therapy, dose titration, & maintenance.The opioid dose often has to be escalated in the last week of lifealthough occasionally a dose reduction might be necessary.