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Pain Management in Infants and Children PowerPoint Presentation

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Description : Check out this medical PowerPoint presentation titled "Pain Management in Infants and Children" by Lynette Thacker, Clinical Nurse Specialist, Paediatric Palliative Care, to learn how pain management in infants and children is an important aspect of pediatric healthcare. Learn how infants and children may experience pain due to a variety of reasons such as medical procedures, injury, or illness, and how proper pain management can improve their comfort and overall well-being.

Tags : Pain Management in Infants, Pain Management in Children, pediatric healthcare

Published on : Mar 14, 2023 | Views : 1170 | Downloads : 1

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Slide 1-

Pain Management in Infants and Children Lynette Thacker Clinical Nurse Specialist Paediatric Palliative Care Disclaimer: 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.
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Operational Definition of Pain “Pain is whatever the experiencing person says it is, existing whenever he says it does.” BELIEVE THE PATIENT! Ref: McCaffery and Pasero: Pain: Clinical Manual, 1999).
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Myths About Pain in Children Infants are neurologically immature and therefore cannot conduct pain impulses. Infants do not remember pain, because of cortical immaturity. Children do not report pain while playing or sleeping so they must get over it quickly or not be experiencing it.
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The Golden Rule What is painful to an adult is painful to an infant and child unless proven otherwise.
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Types of Pain Nociceptive Somatic Well-localized Pain receptors in soft tissue, skin, skeletal muscle, bone Visceral Vague Visceral organs Neuropathic Damaged sensory nerves
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Classification of pain Many different systems e.g. based on: Duration – acute/chronic/persistent Intensity – mild/moderate/severe Location Presumed pathophysiology – visceral, somatic, sympathetic Sensitivity to opioids – sensitive/insensitive/partially insensitive Pragmatic
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Pragmatic classification of pain Neuropathic Disordered sensation Responds to anticonvulsants and antidepressants Bone Intense and focal Responds to NSAIDs and bisphosphonates Muscle spasm Responds to muscle relaxants and antispasmodics Cerebral irritation Caused by brain injury Signs of anxiety Responds to benzodiazepines
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Concept of “Total Pain Management” Four aspects must be addressed: Physical Psychological Social Spiritual Last 3 can be met only after pain and related symptoms (e.g., N/V, anxiety) are controlled.
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QUESTT Question the patient/parent/carer Use pain rating scale Evaluate behavior & physiologic signs Secure family’s involvement Take cause of pain into account Take action and assess effectiveness
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Pain Assessment What is the policy for pain assessment and documentation in your area? Methods of assessment vary according to age and cognitive level of child Patient report Numerical scale – 1 to 10 FACES – can be used at all ages FLACC used on infants
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Physiological Indications of Acute Pain Dilated pupils Increased perspiration Increased rate/ force of heart rate Increased rate/depth of respirations Increased blood pressure Decreased urine output Decreased peristalsis of GI tract Increased basal metabolic rate
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Infant Response to Pain Forcefully closed eyes Lowered brows Deepened furrow between nose and outer corner of lip. Square mouth Cupped tongue
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Toddler and Pre-school Limited in their cognitive abilities in localizing and expressing pain intensity, and understanding reasons for pain. Find out word they use to express pain Point to pain Faces is a good tool for them.
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School-age Increased ability to communicate pain in more abstract terms. They can describe pain: squeezing, stabbing or burning Respond well to direct questioning. Tools: body outline, faces scale, visual analog.
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Acute Illness Middle ear infection, pharyngitis, meningitis, abdominal pain, fractures Treatment determined by severity of pain Paracetamol Non-steroidal Opioids Locally applied medications Relaxation and distraction
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Pre-procedural Pain Key to managing procedural –related pain is anticipation Anticipated intensity and duration Child / parent receive appropriate information to minimize distress
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Operative Pain Morbidity and mortality can be reduced by good pain treatment Plans for postoperative pain should be discussed before surgery Goal is to control the pain as rapidly as possible
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Post-Operative Pain Oral administration is preferred for mild to moderate pain. IV is indicated for immediate pain relief. Persistent moderate to severe pain – continuous around the clock dosing at fixed intervals is recommended. PCA – patient-controlled analgesia – used only when patient can use pump on their own.
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Non-pharmacologic Pain Management Physical Massage Heat and cold Acupuncture Behavioral Relaxation Art and play therapy Biofeedback Cognitive Distraction Imagery and Hypnosis
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Case Study 1 Alex is a 6 year old, admitted for osteotomy as treatment for bilateral dislocated hips from quadriplegic dystonic cerebral palsy. He is non-verbal, gastrostomy fed and as epilepsy. Present analgesia consists of Buprenorphine patch 15micrograms and Oromorphine 3.5milligrams as required for pain. Using the holistic approach of physical/ psychological/social/spiritual aspects how would you manage Alex pain in the post-operative period.
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Case Study 2 Bobby is a 14 year old, admitted with a fractured radius and ulna. He is has a Lawrence Moon Biedal Barr Syndrome. He has chronic renal failure, visual impairment, mild learning disability and is verbal. Present analgesia consists of Paracetamol 500milligrams as required for pain. Bobby’s younger brother died 3 years ago from a more severe form of Lawrence Moon Biedal Barr Syndrome. Using the holistic approach of physical/ psychological/social/spiritual aspects how would you manage Bobby’s pain in the post-operative period.
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WHO analgaesic ladder
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Golden Rules Oral meds if possible NB – adjuvants at all stages Do not rotate within a step, move up Major opioids should always be regular
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Adjuvant Analgesics Adjuvant’ = not primarily analgesic but can improve pain in certain circumstances Neuropathic - anticonvulsants (carbamazepine, gabapentin), antidepressants (amitriptyline), NMDA receptor antagonists (methadone, ketamine) Bone - NSAIDs, bisphosphonates, RTx, chemo Muscle spasm - Benzodiazepines, baclofen, tizanidine, botox Cerebral irritation- Benzodiazepines, phenobarbitone Inflammatory/Oedema – Steroids Non-pharmacological - Physio, Psychology…..
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Initiating strong opioid therapy What drug? Morphine - short acting formulation (Oramorph, Sevredol) By mouth if possible What dose? 1mg/kg/day = total daily dose = 30mg 30mg ÷ 6 = 4 hourly dose = 5mg And for breakthrough pain? Give the 4 hourly dose (5mg) as required
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Titration phase Aim – to match the amount of analgesia given with the degree of pain experienced Add up all doses taken in 24 hours so if 6 doses x 5mg 30mg + 30mg = 60mg 60mg ÷ 6 = 10mg Prescribe 10mg 4hrly and 10mg prn for breakthrough pain
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Maintenance phase More convenient opioid preparations MST Total daily Oramorph requirement: 60mg Appropriate MST dose: 30mg bd Diamorphine SCI Total Oramorph requirement: 60mg Appropriate Diamorphine dose: 20mg/24hrs = 60mg/3 as Diamorphine 1/3rd stronger than Oral morphine Prescribe breakthrough analgesia
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Side Effects Nausea, vomiting and puritus are common side effects Drowsiness Respiratory Depression Constipation with prolonged use of opioids
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Monitoring What monitoring is required per hospital policy? A cardiac / respiratory monitor is used for infants less than 7 months Oximetry monitors for other patients during use of IV opioids Unstable respiratory status History of difficult airway management Neurologically impaired
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Documentation The assessment and measure of pain intensity and quality, appropriate to the patient’s age, are recorded in a way that facilitates regular re-assessment and follow-up according to criteria developed by the organization.
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Take Home Points Assess pain using an age appropriate tool. Consider starting an around the clock regimen. Continually assess pain and modify medication regimen appropriately. When to call for medical assistance: Patient has persistent or worsening pain despite appropriate analgesic regimen. When to transfer to a higher level of care: Patient develops respiratory depression with opiates Control airway and ventilation Order opioid antagonist (Naloxene)while calling for help
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Narcotics Are No More Dangerous for Children Than Adults Addiction from narcotics (opioids) used to treat pain is extremely rare in adults; no reports substantiate this fear in children; reports of respiratory depression in children are rare.