Kinder, Gentler Pain Management - Children's Mercy … Gentler Pain Management Mary A. Hegenbarth, MD, FAAP, FACEP Sedation Coordinator, Section of Emergency Medicine Medical Director,

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

[email protected]

Alison Monroe, CCLS Emergency Department Child Life Specialist

[email protected]

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

[email protected]

816.234.3000 x57757

Sandy Bruner

[email protected]

816.234.3000 x57759

Amelia Ryan

[email protected]

816.234.3000 x57805