PAEDIATRIC PALLIATIVE CAREPAEDIATRIC PALLIATIVE CARE

PAIN MANAGEMENTPAIN MANAGEMENT

Lynette ThackerLynette ThackerClinical Nurse Specialist Clinical Nurse Specialist Paediatric Palliative CarePaediatric Palliative Care

0777328162107773281621Disclaimer: Whilst every effort has been made to ensure that the information in this presentation is accurate and referenced the author does not accept any responsibility for the use by any third parties.

Definition of Palliative CareDefinition of Palliative Care

Palliative care is the active, total care of the patient whosedisease is not responsive to curative treatment. Control ofpain, of other symptoms, and of social, psychological andspiritual problems is paramount. Palliative care isinterdisciplinary in its approach and encompasses the patient,the family and the community in its scope. In a sense,palliative care is to offer the most basic concept of care – thatof providing for the needs of the patient wherever he or she iscared for, either at home or in the hospital. Palliative careaffirms life and regards dying as a normal process; it neitherhastens nor postpones death. It sets out to preserve the bestpossible quality of life until death.

(European Association for Palliative Care 1998)

What is Pain What is Pain Pain is an emotion experienced in the brain, it is not like

touch, taste, sight, smell or hearing. Pain can be perceived as a warning of potential damage, but can also be present when no actual harm is being done to the body.

“Pain is what the individual tells us they are experiencing, where it is, when it occurs, what it feels like, what makes it better and when its disappeared.”

It is categorised into:• Acute pain - less than twelve weeks duration and may

serve as a warning of injury and tissue damage, this pain may not necessarily be associated with major or persistent changes in lifestyle or relationships.

• Chronic pain - of more than twelve weeks, which may be persistent or recurrent, is often associated with substantial alterations in behaviour and in relationships.

Definitions of Types of Pain Experienced in Definitions of Types of Pain Experienced in Palliative CarePalliative Care

• Allodynia - Pain due to a stimulus that does not normally provoke pain. For example, stroking the skin lightly with clothes or cotton wool will produce pain.

• Causalgia - Disruption in normal flow of sensory information along nerve to brain, creating a confusion for the brain, which is interpreted as a constant , uniquely disabling pain state which is highly resistant to normal forms of medical therapy.

• Deafferentation pain - Pain that occurs, often after trauma or surgery, presenting as neuropathic pain in an area of numbness or loss of sensation.

• Hyperalgesia - The perception of a painful stimulus as more painful than normal.

• Neuralgia - Pain in the distribution of a nerve or nerves• Neuropathic pain - Is pain initiated or caused by a primary

lesion or dysfunction in the peripheral or central nervous system. For example pain following shingles, or an amputation, or spinal cord trauma.

(The British Pain Society 2006-2007-2008)

TYPES OF PAIN

NOCICEPTIVE

• Organs – heart, liver, pancreas, gut, etc.

• Constant or crampy• Aching• Poorly localized• Referred

Somatic

•bones, joints•connective tissues•Muscles

•Aching, often constant• May be dull or sharp• Often worse with movement• Well localized

Viscera

NEUROPATHIC

Deafferentation Sympathetic Maintained Peripheral

When Do Children Experience PainWhen Do Children Experience Pain

Pains experienced by children with palliativecare conditions are a result of:• Investigations• Treatment• Disease• Disability secondary to the disease

process• Coincidental to the disease. • Both acute and chronic.

Palliative CarePalliative Care Approach To Pain ControlApproach To Pain Control

• Thorough assessment of the pain experience by skilled and knowledgeable professional.

• Assessment of pain includes history, location, intensity or severity, quality (description), duration, pattern, current treatment and response to treatment (pharmacological and non-pharmacological; interventional analgesia), physical examination.

• Discuss with child (if cognitively appropriate) and family the goals of care, hopes, expectations, anticipated course of illness.

• Refer to medical team who may wish to undertake further investigations – X-Ray, CT, MRI, etc. For treatment of reversible causes of pain.

• Ongoing reassessment and review of options, goals, expectations, etc.

How Do We Assess Pain

Choosing a pain assessment tool

Pain Scales

• Use appropriate tool for the child’s age and cognitive development

• Use the same pain scale for the child

Self-report of pain Self-report of pain The ability of children to describe and rate their own painvaries with their age, developmental stage, and health.

Wong-Baker FACES Pain Rating Scale

0 1 2 3 4 5 6 7 8 9 10No Pain Mild Moderate Severe Worst Possible

Numeric Rating Scale

Behavioural Pain ToolsBehavioural Pain ToolsPaediatric Pain ProfileThe Paediatric Pain Profile is a behaviour rating scaledeveloped to assess pain in children with severe motor andlearning disabilities. The tool is envisaged as a parent helddocument, and contains documentation of the child's pain history, baseline, and on-going pain assessments.

Consists of:• Pain history• Current pain problems• Childs behaviour on a good day• Current pain behaviour• Ongoing assessment of pain

Treating PainTreating Pain

The treatment of pain should not beabout just giving medications.

Care Planning ComponentsCare Planning Components

• Pharmacological component

• Non – pharmacological component

• Monitoring component

Non-Pharmacologic TreatmentsNon-Pharmacologic Treatments

• Exercise• Immobilisation• Transcutaneous Electrical Nerve Stimulation (TENS)• Acupunture• Relaxation and Imagery• Distraction• Psychotherapy• Hypnosis• Peer support groups• Counselling

+/- adjuvant

Non-opioid

Weak opioid

Strong opioid

Pain persist

s or i

ncreases

By the

Clock

W.H.O. ANALGESIC LADDER

+/- adjuvant

+/- adjuvant

1

2

3

Mild PainParacetamolNSAID – Ibuprofen

Moderate PainCodeineTransaxmic Acid

Severe PainMorphineDiamorphineFentanyl

Key Steps to Improving Pain ControlKey Steps to Improving Pain Control

• Step 1 – Administer medications routinely, not as required

• Step 2 – Use the least invasive route of administration first

• Step 3 – Begin with low dose – titrate up• Step 4 – Monitor and document effectiveness of

medication each shift• Step 5 – Reassess and adjust dose to optimise

pain relief while monitoring and managing side effect

Opioids

• Safe effective analgesic

• Oral route effective as injectable

• No ceiling effect

• 7 – 10% population lack CYP2D liver enzyme: codeine cannot be metabolised and therefore will not be effective

Side Effects of Opioids

• Constipation – need proactive laxative use (Movicol)

• Nausea/vomiting – consider treating with dopamine antagonists and/or prokinetics (Metoclopramide, Prochlorperazine [Stemetil], Haloperidol)

• Urinary retention (warm bath may help)

• Itch/rash – worse in children. May try antihistamines, however not great success

• Dry mouth

• Respiratory depression – uncommon when titrated in response to symptom

• Drug interactions

• Neurotoxicity (OIN): delirium, myoclonus seizures

Adjuvant AnalgesicsAdjuvant Analgesics

• first developed for non-analgesic indications

• subsequently found to have analgesic activity in specific pain scenarios

• Common uses:– pain poorly-responsive to opioids (eg. neuropathic pain), or– with intentions of lowering the total opioid dose and

thereby mitigate opioid side effects.

Adjuvants Used In Palliative CareAdjuvants Used In Palliative Care

• General / Non-specific– corticosteroids– cannabinoids (trial in adults with MS in ABMU)

• Neuropathic Pain– gabapentin– antidepressants– ketamine

• Bone Pain– bisphosphonates– (calcitonin)

Professional Barriers to Effective Opioid Professional Barriers to Effective Opioid Pain ControlPain Control

• Fear of causing addiction

• Fear of regulatory and legal barriers

• Lack of experience with opioid analgesia

• Side effects

Parent Barriers to Effective Opioid Parent Barriers to Effective Opioid Pain Control Pain Control

• Parent and family fear of addiction which is rare when given for pain less than 1%.

• Misconception about side effects

• Reluctance to report pain

• Professional parent relationship

Let us know what other topics you want on Paediatric Palliative Care

Any Questions

Thank You