kinder, gentler pain management - children's mercy … gentler pain management mary a....
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Kinder, Gentler Pain Management
Mary A. Hegenbarth, MD, FAAP, FACEP Sedation Coordinator, Section of Emergency Medicine
Medical Director, ED PAWS (Pediatric Acute Wound/Sedation) Service
Alison Monroe, CCLS Emergency Department Child Life Specialist
Objectives
Describe alternatives for non-invasive pain management in children
Pharmacologic options Intranasal drug administration—fentanyl
Topical anesthesia—J-tip lidocaine
Support positive coping Preparation, including appropriate
language
Comfort positioning
Distraction
ED Pain Management—What’s the Problem?
Inadequate pain management of children in EDs well documented
Alexander 2003—analgesia for long bone fractures and burns for different ages in ped ED
Compared 6-24 mo vs. 6-10 yr olds
Only 35% of 6-24 mo got analgesia vs. 52% of school age
Burns—only 50% of 6-24 mo got analgesia (21% narcotics) vs. 75% of school age (100% narcotics)
Alexander J, Ann Emerg Med 2003; 41:617
Why is children’s pain undertreated?
Multifactorial problem
Have good medications, but underused
Starting IV is a barrier, especially in young children
Uncooperative
Technically difficult
Needlestick pain often not addressed
Seen as minor procedure by staff, but very feared by children
Topical anesthetics typically have required long application times (30-60 min)
Intranasal fentanyl for acute pain
It’s fast (faster than starting an IV)
It’s non-invasive
It works!
Rapid absorption
Significant analgesia within 10 min
70% bioavailability
Intranasal Drug Delivery
Nasal mucosa Large surface area (180 cm2 in adult)
Rich blood supply
Higher drug levels than oral/rectal
Part of dose goes directly into brain (nose-brain pathway)
Many drugs well absorbed Fentanyl
Midazolam
Ketamine
MAD (mucosal atomizer device) allows easy, effective administration
Resource: www.intranasal.net
Opiate levels—Intranasal vs IV
www.intranasal.net
Intranasal Fentanyl—ED Studies
IN fentanyl worked as well as IV morphine in placebo controlled RCT
IN fentanyl given sooner than IV morphine (~30 min vs 60 min)
More children receive analgesia once IN fentanyl implemented
Majority have decreased pain within 10 minutes
Borland M. Ann Emerg Med 2007;49:335-340 Holdgate A. Acad Emerg Med 2010;17:214-217 Saunders et al, Acad Emerg Med 2010;17:1155
IN Fentanyl—
Dosage/Administration
IV formulation 50 mcg/mL
Dosage 1.5-2 mcg/kg, max 100 mcg (1 mL/nostril)
70% bioavailability
Head tilted back ~45°
Divide dose between nostrils
Onset 5-10 minutes
May repeat ~0.5-1 mcg/kg after 10 minutes
Prepare for IV if needed, or give PO medication
Doesn’t sting or taste bad
IN Fentanyl—
Contraindications/Complications
Contraindications Drug hypersensitivity
Nasal blockage/trauma/epistaxis (?URI)
Complications (very rare) Nausea/vomiting
Itching
Respiratory depression
Rigid chest (theoretical, not reported)
Reversal—naloxone (IM if no IV)
Monitoring—pulse ox?
Topical Anesthesia for Needle Procedures
LMX or EMLA
Require 30-60 minutes
Can be used if time allows
LMX works a little quicker
J-tip lidocaine
CO2 powered needleless injection
Works rapidly (< 5 min)
Better anesthesia than LMX/EMLA for IV placement
Spanos et al, Pediatr Emerg Care 2008;24:511 Jimenez et al, Anesth Analg 2006;102:411.
J-tip Lidocaine
1% buffered lidocaine jet injection
Topical anesthesia for needlesticks
IV/venipuncture
LP
Onset 1-3 minutes
5 min—nickel sized area
10-15 min—quarter sized area
Duration ~90 minutes
Depth of anesthesia 8 mm at 5 min
Warn child of “pop can” whoosh
You can make a difference!
Noninvasive, fast, effective pain control
Reduce needlestick pain/apprehension
Reduce trauma of ED visit
Simple, easy to incorporate
Children and families very appreciative
Staff like it too!
Supporting Positive Coping in
the Emergency Setting
Alison Monroe, CCLS
Emergency Department Child Life Specialist
Children’s Mercy Hospitals and Clinics
2401 Gillham Rd, KC, MO 64108
Preparation
•Preparation leads to a reduction in procedural distress (Chen, et al (1999) ;
Claar, et al (2002); Ellerton & Merriam (1994); Lizasoain & Polaino, et al (1995)), more cooperation from the child (Zahr, (1998); Zeilikovsky, et al (2000), and has a positive impact on future
procedures (Claar, et al (2002)
•Preparation promotes understanding of medical interventions and experiences.
•Manipulating materials fosters understanding of their use, and provides the opportunity for patients to ask questions and express and cope with fears related to the procedure or experience.
•The patient can participate in developing an individualized coping plan.
•Children may not understand adult terminology: “Child Life Suggested Words or Phrases”
Preparation Can Include:
Verbal description of procedural steps or experiences
Manipulation of appropriate medical materials
Reviewing past experiences with similar/same event to address possible misconceptions
When Providing Preparation
Be honest with the patient
Include any pharmaceutical interventions in preparation (i.e. j-tip, numbing creams, or Buzzy)
Use developmentally appropriate language Concrete descriptions
Developmentally appropriate terminology
Procedural Support
Procedure support decreases distress and anxiety (Bowen & Dammeyer (1999); Dahlquist, et al (2001); Dahlquist, et al (2002); Fanurik, et al (2000);
Kazak, et al (1998); Smart (1997); Kleiber (1999)), increases cooperation (Zelikovsky, et al (2000))improves physiological functioning (Castes, et al (1999)), and reduces need for sedation (Smart (1997)).
Procedural Support can be provided to help facilitate effective coping during any stressful event.
A coping plan should be devised prior to the event The support should be tailored to each patient’s
needs (developmental level, amount of stimulation, area of procedure)
Considerations for Procedural Support
and Distraction
The environment of the room
The developmental level of the patient
The patient’s desired coping plan
Comfort positioning
Why Position for Comfort?
Family centered care
Parents who interact with their child during a procedure are calmer and have increased satisfaction
Developmental focus
Sitting up in infancy is accompanied by sense of control
Lying children down results in a loss of control and is frightening
When developmental milestone reached, the mere act of making child lie down usually results in struggle to get up
* Cummings, E., Reid, G., Finley, G., McGrath, P. & Ritchie, J. (1996). Prevalence and source of pain in pediatric
inpatients. Pain, 68, 25-31. **Chen, E., Craske, M. & Katz, E. (2000). Children’s memories for painful cancer treatment procedures;
Implications for disress. Child Dev., 71, 933-947
Why Position for Comfort? (cont.)
Psychosocial focus IVs are the 2nd most common cause of worst
pain experienced during hospitalization * Fear, anxiety and tension heighten a child’s
response to pain Painful procedures result in negative memory
and greater pain in future procedures**
* Cummings, E., Reid, G., Finley, G., McGrath, P. & Ritchie, J. (1996). Prevalence and source of pain in pediatric inpatients. Pain, 68, 25-31.
**Chen, E., Craske, M. & Katz, E. (2000). Children’s memories for painful cancer treatment procedures; Implications for disress. Child Dev., 71, 933-947
Back to Front
Infant Cradle Infant Front to Front
Positioning for IV Start
Straddle School Age Back to Front School Age Side Sitting
Positioning for IM Injection
Front to Back School Age Straddle School Age Side Sit School Age
Let Them Be in Control •Children don’t get to make a lot of decisions when visiting
the hospital. They have to endure multiple procedures/tests,
they lose privacy, their schedule is changed, etc. Acting out is
common in children trying to regain control of their
environment.
•Offering children as many appropriate choices as possible
can help put a child at ease. Many choices can be very
simple, such as:
•How would you like to sit?
•Do you want the lights on or off?
•Which toy would you like to play with?
•Would you like to see what is happening?
•Would you like a countdown?
References
Bowen, A.M. & Dammeyer, M.M. (1999). Reducing children's immunization distress in a primary care setting. Journal of Pediatric Nursing , 14, 296-303. Castes, M., Hagel, I., Palenque, M. Canelone, P., Corao, A., & Lynch, N.R. (1999). Immunological changes associated with clinical improvement of asthmatic children subjected to psychosocial intervention. Brain, Behavior, and Immunity , 13, 1-13. Chen, E., Zeltzer, L. K., Craske, M. G., & Katz, E. R. (1999). Alteration of memory in the reduction of children's distress during repeated aversive medical procedures. Journal of Consulting and Clinical Psychology , 67, 481-490. Claar, R.L., Walker, L.S., & Barnard, J.A. (2002). Children's knowledge, anticipatory
anxiety, procedural distress, and recall of esophagogastroduodenoscopy. Journal of Pediatric Gastroenterology and Nutrition , 34, 68-72. Dahlquist, L.M. et al. (2001). Adult command structure and children's distress during the anticipatory phase of invasive cancer procedures. Children's' Health Care , 30, 151-167. Dahlquist, L.M., Busby, S.M., Slifer, K.J., Tucker, C.L., Eischen, S., Hilley L., & Sulc, W. (2002). Distraction for children of different ages who undergo repeated needle sticks. Journal of Pediatric Oncology Nursing , 19, 22-34. Ellerton, M.L. & Merriam, C. (1994). Preparing children and families psychologically for day surgery: An evaluation. Journal of Advanced Nursing , 19, 1057-1062.
References continued
Fanurik, D, Kohl, J.L., & Schmitz, M.L. (2000). Distraction techniques combined with EMLA: Effects on IV insertion pain and distress in children. Children's Heath Care 29, 87-101 Kazak, A.E., Penati, B., Brophy, P., & Himelstein, B. (1998). Pharmacologic and psychologic interventions for procedural pain. Pediatrics , 102, 59-66. Kleiber C, Harper DC. (1999) Effects of distraction on children's pain and distress during medical procedures: a meta-analysis. Nursing Research Jan-Feb;48(1):44-9. Lizasoain, O., & Polaino, A. (1995). Reduction of anxiety in pediatric patients: effect of a psychopedagogical intervention programme. Patient Education & Counseling , 25, 17-
22. Smart, G. (1997). Helping children relax during magnetic resonance imaging. MCN, The American Journal of Maternal Child Nursing , 22, 237-241 Zahr, L.K. (1998). Therapeutic play for hospitalized preschoolers in Lebanon. Pediatric
Nursing , 23, 449-454. Zelikovsky, N. Rodrigue, J.R., Gidyez, C. & Davis, M.A. (2000). Cognitive behavioral and behavioral interventions help young children cope during a voiding cystourethrogram. Journal of Pediatric Psychology , 25, 535-543.
Questions?
Contact Information:
Alison Monroe
816.234.3000 x57757
Sandy Bruner
816.234.3000 x57759
Amelia Ryan
816.234.3000 x57805