1. EAU: Equipe Analgésie à lEAU: Equipe Analgésie à l’Urgence’Urgence
Marie Joëlle Doré-Bergeron, MD FRCPC Pédiatrie
Evelyne D Trottier, MD FRCPC Urgence Pédiatrique
Marisol Sanchez, MD FRCPC Urgence Pédiatrique
Presenters disclosures:
Potential for conflict(s) of interest: Not Applicable
Société Canadienne de Pédiatrie
26 juin 2014
2. Objectives
• Use of pharmacological methods for pain control in acute and
chronic conditions
• Use of non-pharmacological methods to reduce pain and anxiety in
pediatric patients
• Reduce pain related to painful procedures
3. Pain in Pediatric
• Recommendation of leader association
‘‘Control of pain and stress for children who enter into the
emergency medical system… is a vital component of
emergency care.’’
• Multiples sources of pain and anxiety
•Pathologies (trauma, burn, abdo pain, headache, otitis…)
•Investigations (blood tests, LP, SPA…)
•Procedures (IV, immunisation, cast…)
•Hostile environment
AAP Fein Pediatrics 2012
4. Case 1: Océane, 6 years old fall from monkeys bars
• What is your analgesic plan if...
• She does not seem in pain
• She’s uncomfortable
• She is screaming
ANALGESIA
www.eleanorharbison.com
memory-of-monkey-bars/
Aurélie
5. Océane is still suffering: Why?
• No pain measurement on arrival
• Underestimation of pain
• No evaluation of pain after analgesia
• Fear of analgesia from parent-patient-doctor
• Limited knowledge on treatment strategies and consequences of
undertreatment
• Lack of time
• Lack of human resources
• Lack of $ Fein Pediatrics 2012
Dong Ped Emrg Care 2012
Cimpello Ped Emerg Care 2004
www.eleanorharbison.com
memory-of-monkey-bars/
6. Océane without pain relief...
• Anxiety related to future procedures and medical encounters
• Increased pain perception in future procedures
• Potential avoidance of medical care
www.eleanorharbison.com
memory-of-monkey-bars/
7. Océane, do YOU feel pain...
Pain assessment
• Auto evaluation:
• Verbal Numerical Scale(VNS-NRS)
• Visual Analog Scale (VAS)
• Faces Pain Scale-Revised
• Hetero evaluation: Behavioral scale
• FLACC
• EVENDOL
www.eleanorharbison.com
memory-of-monkey-bars/
www.pediadol.org
16. Simple Analgesics
• Ibuprofen
• NSAID: inhibits production of Pg (pro inflammatory)
• 10mg/kg (Max 400mg)
• Superior to
• Acetaminophen
• Codeine
• Equivalent to
• Acetaminophen /codeine
• Oxycodone
• No additional relief with codeine
• Acetaminophen
• Co-analgesia
• 15mg/kg (Max 650mg)
Lemay J Emerg Med 2013
Friday Acad Emerg Med 2009
Clark Pediatrics 2007
17. ‘‘Weak’’ Opiate
• Oral Codeine
• Analogue, requires conversion to active metabolite
Martin Exp Opin Drug Saf 2014
www.chu-sainte-justine.org/Pro/evenements.aspx?IndEvenementsPasses
Thibeault M Pharmacie CHU Ste Justine
18. ‘‘Weak’’ Opiate
• Oral Oxycodone
• Analogue, direct effect and via hepatic metabolism by CYP 2D6
• 0.1 mg/kg oral (max 15 mg)
• Onset of action: 15 minutes
• Duration of action: 2h
• Equivalent to
• Ibuprofen
• Superior to
• Codeine
Charney Ped Emerg Care 2008
Koller Ped Emerg Care 2007
Kennedy Ped drugs 2004
Martin Exp Opin Drug Saf 2014
19. ‘‘Strong’’ Opiate
• Oral/IV Morphine
• Pure agonist of mu CNS receptor
• Doses
• 0.2 mg/kg Oral (max 10-15 mg)
• 0.1 mg/kg IV (max 5mg first)
• Onset of action (30)-60 min PO, 20 min IV, duration: 4-5h
• PO: recent study indicates PO as effective as IV but higher dose may be
required in acute or non-naive patient
• IV often used as comparative
Wille Arch Ped 2005
Wong CPJ 2012
21. ‘‘Strong ’’Opiate
• INH Fentanyl
• Pure agonist mu CNS receptor
• Dose:
• 1-2mcg/kg with atomizer
• Reduced time to analgesia
• Onset of action faster than oral morphine (onset: 5 min, peak :15-20 min,
duration: 60 minutes)
• Convenient mode of administration
• Can avoid iv line
• Equivalent to iv and im morphine Mudd J Ped Health Care 2011
Holdgate Aca Emerg Med 20
Borland Emerg Med Aus 2008
Borland Ann Emerg Med 2007
Aurélie
23. Opiates observation
• Side effects:
• Nausea and vomiting
• Pruritus
• Constipation, urinary retention
• Strongly consider laxatives
• Respiratory depression
• Risk factors: Infant, renal insufficiency, after ENT surgery
• Tolerance
• Contra-indications:
• Decreased GCS
• Allergy
Marin Exp Op Drug Saf 2014
24. Case 2: Théo 4 yo, diabetic ketoacidosis
•Théo starts crying, panics and wants to run away…
www.123rf.com
25. • Explain the procedure
• What is going to happen
• What they will be allowed to do
• Be with parent
• Bring toy or teddy bear
• What will be done to help them
Preparation
26. « It won’t hurt »
« I’m so sorry »
« It’s almost finished »
Minimizing their pain or anxiety
Sympathizing
Avoid
27. During procedure
Parent’s role
• Allow parental presence
• Build their confidence
• Contact with the child (visual, physical)
• Distraction
• Their focus should be on the child
28. • Recommendation of AAP:
• Prepares and supports child and parent
• Follows the child through his journey in hospital
• Helps with distraction during procedure
AAP Pediatrics 2012
AAP Pediatrics 2000
Hall Educational Play Therapy 2010
Cisternino 2005
www.rch.org.au/comfortkid
Childlife Specialist
29. Distraction
• Parent or child life specialist
• Not the one doing the procedure
• Child empowerment
• Adapted to development
Uman Cochrane 2013
Riddell Cochrane 2012
Taddio Clin ther 2009
31. Distraction
EAU: Équipe Analgésie à l’Urgence, CHU SteJustine
www.mamural.com
EAU: Équipe Analgésie à l’Urgence, CHU SteJustine
www.mamural.com
32. Advantages for the child
• More comfort
• Reduced anxiety
• Decreased pain perception
• Parent empowerment
Advantages for health care providers
• Reduces child movements (better cooparation)
• Larger work space
• Increases satisfaction
Sparks J Ped Nurse 2007
Wente J Emerg Nurse 2012
Stephens 1999
Van Aken 1989
Proper positioning
33. • Physical contact ↓ anxiety
• Face to face with parent
• Swadling if ≤ 3 months
• Suction, breastfeeding
Positioning ≤ 6 months old
www.rch.org.au
34. Positioning ≥ 6 months old
rch.org.au/anaes/pain_management/
EAU: Équipe Analgésie à l’Urgence, CHU SteJustine
35. Topical anaesthetics
•Myth:
«Changes in underlying skin color and texture makes veins
harder to find»
•Reality:
• Decreased pain
• Higher first attempt success: 75-86% vs 50-76%
• Shorter procedure time
• Reduced perceived difficulty
• Increased satisfaction (patient, parent, nurse)
•Best if combined with non-pharmacological pain relief
Schreiber Eur J Pediatr 2013
Fein Pediatrics 2012
Kennedy Pediatrics 2008
Zempski Pediatrics 2004
36. Topical anaesthetics
Emla
Lido-Prilocaine
Ametop
Amethocaine 4%
Maxilene
Lidocaine liposomal 4%
Pain Ease
Vapocoolant spray
Delay 60min
(max 4h)
(max 1h in 0-3months)
30 min 30min
(max 2h)
Immediate
spray 10 sec or ad
skin blanching
Duration 1-2h 4h 1h 45-60 sec
Vascular loss and
cutaneous changes
Vasoconstriction Vasodilation
(erythema)
Minimal Minimal
Complications Methemoglobinemia Hypersensitivity
Methemoglobinemia
(rare)
Methemoglobinemia
(rare)
Burning sensation
Frostbite
Max twice at the
same place
Contra indications Methb, G6PD,
porphyria
Allergy
Cutaneous break
mucosa
Allergy Allergy <3 years old
Equipe d’Analgésie à l’Urgence (EAU)
www.urgencehsj.ca
37. Case 3: Alex 9 yo, routine immunization
• Alex , ex-preterm, has needle phobia
• How could we help him?
www.123rf.com
39. Vaccination in babies
• Vaccination, breastfeeding and EMLA
• They all cried… but, when measured up to 3 minutes
• Crying: median duration decreased in EB (34 s) and EW (94s)
versus placebo-Water (180s)
Eur J Pediatr (2013) 172:1527–1533
40. Case 4: Matheo 3 ans with acute otitis
• Pain despite simple analgesia
How could we help him?
www.123rf.com
42. Case 4: Lucas 1 months, bronchiolitis
• Needs capillary gas, aspiration and IV fluid
How do we help him?
www.123rf.com
43. Sucking and sucrose
• Techniques:
• Breastfeeding, pacifier, finger
• Sucrose
• Sucrose can be used for all painful procedures
• Blood test
• Cannula insertion
• Aspiration
rch.org.au/anaes/pain_management
Cochrane 2013
www.123rf.com
50. Complex regional pain syndrome (CRPS)
Signs /symptoms
• Severe pain
• Allodynia and hyperalgesia
• Autonomic signs: edema, sweating, coolness, skin discoloration
• Motor signs: dystonia, tremors
• Trophic signs: changes in nail/hair growth
51. CRPS
• Pathophysiology not completely understood
• Clinical diagnosis, based on Budapest criteria for adults
• Several diagnoses and treatments (often including
immobilization) before the CRPS diagnosis
• Severe functional impairments quite common
52. CRPS in children
• Lower limbs more often that upper limbs
• More common in girls
• In general occurs in early teens (around 13 yo)
• Much better prognosis than in the adult population
53.
54. Chronic pain syndromes in general
• More common in girls
• Sleep problems
• Mental health issues (depression, anxiety)
• School absenteeism
• Fatigue
• Familial issues (distress)
• Hypermobility
ici.radio-canada.ca
56. Chronic pain syndromes
Initial discussion about diagnosis: Crucial!
• Similar explanations no matter what is the pain problem
• In general: Minimal investigations... but follow up is essential
• Acceptance of diagnosis by the family
• Active implication of the family in the treatment
• The pain becomes the disease in itself
• Patients are often told that the pain is in their head
57. Treatment of chronic pain syndromes
• Focus of treatment:
• learning how to restore functionality on a daily basis
• Combination of:
• physical therapy
• psychology
• pharmacology
58. Medications in Chronic pain
syndromes
• Opioids rarely used in the pediatric population
• Medications acting on brain neurotransmitters and calcium
channels
• gabapentin, pregabalin
• amitriptyline, nortriptyline (TCAs)
• Few studies regarding the efficacy of these medications in
chronic pain in the pediatric population
59. Gabapentin
• Binds to voltage-gated calcium channels
• Commonly used in pediatrics for neuropathic pain
• Low incidence of drug-drug interactions
• Side-effects: somnolence, dizziness, unsteadiness
• When titrated slowly, well tolerated even in young children
• Dosage:
• start at 3-5 mg/kg at night, then BID and TID
• up to 20-30 mg/kg/day
• Max 3600 mg per day
60. TCAs (amitriptyline and
nortriptyline)
• Blockade of serotonin and noradrenaline reuptake & interaction
with sodium and calcium ion channels
• No RCTs in children for neuropathic pain but widely used
• Advantage: once daily, somnolence (if sleeping problems)
• Side-effects: dry mouth, sedation, blurred vision, urinary rentention,
constipation tachycardia, QTc prolongation
• Dosage
• Start at 10 mg q hs
• increase slowly depending on side-effects and analgesia
61. Follow up
• Physical therapy as soon as possible
• focus on restoring activities of daily living (such as walking...)
• desensitization exercises
• Psychology follow up
• Cognitive Behavioral Therapy
• relaxation techniques
• hypnosis, etc...
• Pain clinic
• Physiatrist
62. 62
Conclusion
• Objective evaluation of pain
• Pharmacological and non-pharmacological analgesia
• For procedures
• For acute painful conditions
• For chronic painful conditions
• Think about it and take the TIME!
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