Objective Recognize methods to manage procedural pain Pain + anxiety distress 2.

© The Children's Mercy Hospital, 2015

Kimberly Hartman, MDAssistant Professor of Pediatrics

Department of Pediatric Rehabilitation MedicineChildren’s Mercy Hospital

Kansas City, MO

Procedure-related Pain

Objective

• Recognize methods to manage procedural pain

• Pain + anxiety distress

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Common Procedures

• Chemodenervation

– Botulinum toxin

– Phenol

• Intrathecal Baclofen Pump refill

• EMG

• Trigger point injections

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Why?

• Needle-based procedures induce high levels of distress:– 83% toddlers (2.5-6yo)– 51% children (7-12yo)– 28% adolescents (≥12yo)

• ED: IM injections reported in top 5 most painful and distressing procedures

• Inpatients: procedural pain reported as greater than disease-related and surgical pain

Humphrey 1992; Babl 2008; Shomaker 2015

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Acute Implications

• Increased distress:– Patient– Parent– Providers

• Inability to perform procedure accurately or completely

• Increased time spent in procedure

Walco 2008; Smith 2007; Kennedy 2008

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Memory

• Memory can shape future reactions to painful events

• Stressful experience recalled up to years later

• Adults report distress based on childhood experiences

Painful event

Remembered pain

Walco 2008; von Baeyer 2004; Noel 2002; Pate 1996

Remembered Pain

7von Baeyer 2004

•Decreased reaction over time

•Milder pain, more mature coping

Habituation

•Increased reaction over time ± reduced pain threshold

•More severe pain, younger kids, less mature coping

Sensitization

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Long-term Implications

• Increased anticipatory anxiety

• Increased pain perception

• Diminished analgesic effectiveness

• Needle phobia (10% of adult population)

• Avoidance of medical care

Walco 2008; Taddio 1997; von Baeyer 2004; Weisman 1998; Hamilton 1995; Rocha 2003

Quality >> Quantity

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Factors to Consider

• Patient temperament• Developmental age• Parental anxiety• Culture

• Prior patient experiences with procedure

• Type of procedure• Procedure duration

Bearden 2012; Kristjansdottir 2012

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Management

• Procedural• Physical• Psychological• Pharmacological

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Procedural

• Needle size

• Injection volume

• Simultaneous injections

No evidence higher Gauge is better

Patients need to be aware of sensation

Taddio 2009; Goodenough 2000; Beirne 2015; Price 2009; Hanson 2010

May have decreased pain behaviors

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Procedural

• No aspiration and rapid injection speed

• Less painful formulation injected first

• Sitting up or holding (vs. supine)

Less pain and no negative effects (for IM imms)

Similar to less painful site first?

Safety concerns? Access to site?

Taddio 2009; Goodenough 2000; Beirne 2015; Price 2009; Howard 2012

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Physical

• Stroking skin • Pressure• Cold• Vibration• Vibration + cold• Swaddling, tucking,

kangaroo care (infants)

Decreased pain with IM immunizations unknown if translates to Rehab procedures

Taddio 2009; Sahiner 2015; Howard 2012; Pillai Riddell 2012

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Vapocoolant

• Mixed results• IM: in 4-6yo, can increase pain• IV: no significant pain reduction in children• EMG (adults): more effective than EMLA

cream or no treatment

Cohen 2009; Hogan 2014; Moon 2013; MacLaren 2007; Howard 2012

Fast and cheap

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Physical

• Sucrose 24%

• Glucose 30%

• Breast-feeding

• Non-nutritive sucking

• Non-nutritive sucking (≤ 3 years)

• No benefit:

– Sweet gum

– Lollipop

– Sucrose

Infants ˂12 months Children ˃ 12 months

Harrison 2010; Kassab 2012; Harrison 2015

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Psychological: Preparation

• What will happen• How it will feel• What will be done for pain• How child can help• Demonstration

Taddio 2014; Slifer 2011

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Parent Preparation

• Calm

• Coaching to cope

• Distraction

• Anxious

• Apologizing

• Criticizing

• Reassuring

• Empathizing

Positive strategies Negative strategies

Jones 2005; Taddio 2014

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Distraction

• Distraction more beneficial than reassurance

• Parent involvement• Specialist involvement

(i.e., Child Life, Music)• No/low tech vs. high

tech• Interactive vs. passive• Child choice vs. no child

choice

McMutry 2010; Birnie 2014; Uman 2013

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Reframing Memory

• Recall of positives:

– Portions of procedure (“You held really still”)

– Positive coping strategies (“You did a great job taking deep breaths”)

• May be able to create more adaptive memories

Chen

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Pharmacological

• Topical• Enteral• Sedation• Anesthesia

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Topical

Anesthetic Dosage forms

Application time (minutes)

Lidocaine 2.5% - prilocaine 2.5%

CreamGelPatch

60-90

Liposomal lidocaine 4%

Cream 30

Lidocaine 7% - tetracaine 7%

Heat patch

20-30

• Occlusive dressing helps lido/prilo permeate

• May not need occlusive dressing with liposomal lido

• Main side effects are local

• Methemoglobinemia at high doses

Things to consider

Taddio 2014; Zempsky 2014

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Enteral

• Few studies with decreased local reaction (acetaminophen)

• No studies for acute pain during procedure• ? Benefit for soreness after procedure

Taddio 2014

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Sedation

Minimal sedation

Moderate sedation

Deep sedation

General anesthesia

Patient response

Normal Purposeful response

Cannot be easily aroused

Not arousable

Protective airway reflexes

Maintained Maintained Partial or complete loss

Partial or complete loss

Ventilation Spontaneous Spontaneous May be impaired

Impaired

CV function Maintained Maintained Usually maintained

May be impaired

Cote 2006

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ASA Physical Status ClassificationClass I A normally healthy patient

Class II A patient with mild systemic disease (eg, controlled reactive airway disease)

Class III A patient with severe systemic disease (eg, a child who is actively wheezing)

Class IV A patient with severe systemic disease that is a constant threat to life (eg, a child with status asthmaticus)

Class V A moribund patient who is not expected to survive without the operation (eg, a patient with severe cardiomyopathy requiring heart transplantation)

Cote 2006

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Midazolam

• Short-acting benzo

• Effects

– Skeletal muscle relaxation

– Amnesia

– Anxiolysis

• No analgesic properties

Enteral Intranasal IntravenousDose 0.3-0.75

mg/kg0.2-0.4 mg/kg 0.05-0.1

mg/kg repeated q3-4 minutes (total 0.5-0.7 mg/kg)

Onset 15 min 10-15 min 2-3 min

Zempsky 2014

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Nitrous Oxide

• Analgesic

• Anesthetic

• Weak sedative

• Onset: minutes

• Offset: rapid when gas discontinued

• Minimal CV or respiratory effects

Zempsky 2014; Pedersen 2013; Brochard 2009

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Other Medications

• Pentobarbital

• IV Propofol

• IV Dexmedetomidine

• Fentanyl

• Ketamine

Sedatives Analgesics

Zempsky 2014

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Anesthesia Risks

• Anesthetic-induced neuro-toxicity• Exposure < 3 years old:

– Deficits in language– Deficits in reasoning

Ing 2012; Sanders 2013

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Summary

• Untreated procedure-related pain & anxiety has short- and long-term consequences

• Treatment needs to be based on individual characteristics and developmental age

• Procedural and physical adaptations can help but may not be feasible

• Distraction helps• Topical anesthetic helps• Sedation: weigh risks &

benefits• Need more research!

Questions: [email protected]

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