Pediatric pain Management

By:Dr. Gamal Adel

Under supervision Prof Dr. Hany Elzahaby

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Pain as an unpleasant sensation that originates in traumatized tissue and warns of injury

An unpleasant sensory and emotional experience normally associated with tissue damage or described in terms of such damage

Definition of pain

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Nociceptive pain

is pain in which normal nerves transmit information to the central nervous system about trauma to tissues

Classification

Neuropathic pain

is pain in which there are structural and/or functional nervous system adaptations secondary to injury

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Cutaneous pain

Somatic pain

Neuropathic pain

Phantom limb pain

Visceral pain

Other classification..

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Pain pathway

nociceptor

Spinal cord

Higher centers

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Impulses in C fibers or A delta fibers travels to the spinal cord (Peripheral Nerve Sensitivity)

To the dorsal horn (central sensitization ) Competition by encephalin-producing

descending fibers from the brain stem interact with both pre-synaptic and post-synaptic cells to inhibit transmission “pain gate”

Incoming signals in the A beta fibers of a peripheral nerve can alter sensitivity of the post-synaptic cells to painful stimuli arriving in C and A delta fibers

Pain transmission

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Supraspinal pain modulating loops exist that can increase or decrease the amount of pain

Reticular formation, cortico-reticular signals

The dorsolateral pontine tegmentum The rostral ventral medulla The dorsal medulla The caudal medulla The lateral hypothalamus

Pain modulating loops

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Descending Pain Modulating Pathways Periaqueductal grey matter raphe nuclus locus ceruleus to dorsal horn

Spinocerebral Ascending Pathways The spinothalamic pathway The spinoreticular pathway

Areas of the brain Sensory and motor cortex areas Premotor cortex ( for planning of movement) Other parts of the parietal cortex and frontal cortex Cingulate cortex Insula Occipital cortex

Pain modulating loops (cont...)

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Let’s have a closer look!!!

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Causes of undertreated pain in children

Wrong beliefs

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Children tolerate pain better than adults

Children become accustomed to pain or painful procedures under pain recognition

Children’s behavior reflects their pain intensity.

Causes of undertreated pain in children

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Pain is less harmful than the side effects of analgesic therapy

Health care providers frequently have limited knowledge regarding state of the art pain management

Limited verbal communication in the younger children population

Other facts…

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Pain Assessment

Self ReportPhysical

ExaminationBehavioral

Observation

Pediatric Pain Assessment

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Appropriate age related tool is used to asses and document level of pain.

< 3 years old .... Behavioral observation or FACES tool or FLACC scale

3-7 years old .... FACES or visual analog scale

8-14 years old .. Visual analog scale and numeric scale or oucher scale or pocker chip scale

Tools..

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FLACC SCORE Children < 3 years and Children with Developmental disabilities

0 1 2

Face No particular

expression or smile

Occasional grimace

or

frown, withdrawn,

disinterested

Frequent to

constant

frown, clenched

jaw,

quivering chin

Legs Normal or relaxed

position

Uneasy, restless,

tense

Kicking, or legs

drawn Up

Activity Lying quietly,

normal

position, moves

easily

Squirming, tense,

shifting back and

forth

Arched, rigid, or

jerking

CryNo cry

(awake or asleep)

Moans or whimpers;

occasional

complaint

Cries steadily,

screams, sobs,

frequent complaints

Consolability Content, relaxed Assured talking or

hugging;

distractible

Difficult to console

or

Comfort

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Wong/Baker FACES Pain Rating Scale

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Numeric Scale Teenagers and Young Adults

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Other methods….

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Analgesics Strategies

Non-pharmacolo

gic Strategies

Systemic

analgesics

Regional blocks

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Non-pharmacologic strategies play an important role in pain management and can be combined with analgesics to minimize the pain experience

Non-pharmacologic approaches for the treatment of pain in children include psychological strategies, education and parental support

Non-pharmacologic Strategies

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According to type:

1-Rehabilitative: heat, cold, ultrasound, holding, mobilization or

immobilization

2-Psychological: Education, relaxation, imagery, psychotherapy,

counseling, music, swaddling and rocking

3-Complementary and Alternative: Acupuncture ,TENS and massage

Classification of methods

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Mechanism of action of complementary

methods :

Activation and stimulation of large-diameter non-noxious fibers and inhibit transmission of nociceptive information from the periphery to the brain.

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Topical anesthesia

Systemic analgesics

Pharmacological methods

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Topical local anaesthesia of the skin should be routine before all needle procedures in children

The eutectic mixture of local anesthetics (EMLA cream) is very effective when applied for 60–90 min, while tetracaine gel has a slightly more rapid onset of action (40 min) and produces vasodilatation.

Topical anesthetics

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Vapocoolant spray.

It was found that all pain measures and cry duration were similar for EMLA and the Vapocoolant. The Vapocoolant spray is much less expensive than EMLA cream and significantly faster acting

Cooling Spray (Fluori-Methane)

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Opioid Analgesics

Opioids produce analgesia by acting on both central and peripheral mu, kappa and delta Opioid receptors to inhibit the transmission and perception of nociceptive input.

Systemic analgesics

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Morphine clearance in term infants greater than 1 month old is comparable with children from 1 to 17 yr old.

In neonates aged 1–7 days, the clearance of morphine is one-third that of older infants and elimination half-life approximately 1.7 times longer.

Morphine sulphation is efficient and effective in the early neonatal period while glucuronidation maturity is some weeks later.

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Titrated loading dose of i.v. morphine 50 µg kg-1 increments, repeated up to ·4 times while I.V. or s.c. morphine infusion10–40 µg kg-1 h-

PCA with morphine

Bolus dose 20 µg kg-1

Lockout interval 5 min Background infusion 4 µg kg- h-1 (especially first 24 h)

Nurse controlled analgesia (NCA) with morphine

Bolus dose 20 µg kg-1

Lockout interval 30 min Background infusion 20 µg kg-1 h-1

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Subcutaneous cannula

subcutaneous cannula can be sited while the child is anaesthetized or under topical local anaesthetic cream and nurse-administered bolus doses can be highly effective.

A 24-gauge cannula can be inserted easily into the subcutaneous tissue of the anterior abdominal wall or the deltoid area of the upper outer arm

The pharmacokinetics and dynamics are similar to the i.v. route provided peripheral tissue perfusion is stable and adequate

Routes of administration

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Fentanyl, sufentanil, alfentanil, and remifentanil may have a role after major surgery and in intensive care practice.

Opioids with low context-sensitive half time are of extremely rapid recovery because of esterase clearance are best delivered by target controlled infusion devices.

Other opioids

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(PCA) is now widely used in children as young as 5 yr.

improve sleep pattern without increasing the adverse effects.

Children have control over their own analgesia, which has considerable psychological benefits.

Patient-controlled analgesia (PCA)

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Child less than 5 yr of age

Child with learning difficulties

Child physically unable to operate demand button

Increased intracranial pressure

Depressed conscious level

Airway obstruction

Contraindications to patient-controlled analgesia

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Respiratory depression and sedation

depressing central respiratory drive and also causing a partially obstructed upper airway as a result of oversedation

If a child is noted to be oversedated. have a consistent pulse oximetry reading of less than 94%

ventilatory frequency less than 20 bpm in an infant or less than 12 bpm in an older child.

Assessment and management of adverse effects

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  Support the airway and give high flow oxygen

Assist breathing if hypoventilation severe

Discontinue opioid administration

Give i.v. naloxone 2–4 µgkg–1

Repeat naloxone 2–4 µgkg–1 up to 10 µgkg–1

Management of opioid-induced respiratory depression

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Cause: opioid stimulation of the chemoreceptor trigger zone in the medulla of the brain

Management

reduce the dose of drug given.Antiemetics: but may cause extrapyramidal signs in children if given frequently(e.g. metoclopramide and prochlorperazine).

The 5-HT3 antagonist ondansetron does not produce sedation or extrapyramidal problems.

Transdermal hyoscine has also been used as there is often a component of motion sickness to opioid-induced nausea. Low-dose droperidol is another alternative.

changing to a different opioid decreases the incidence of nausea and vomiting

Nausea and vomiting

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The cause of pruritus induced by opioids is unclear

common when spinal opioids are used common when spinal opioids are used

Antihistamine drugs (Chlorpheniramine) but they increase the level of sedation

It may be safer to use a small dose of naloxone which does not affect the analgesic properties of the opioid

Ondansetron 0.1 mg kg–1 may be effective in reducing pruritus caused by epidural or spinal opioids

Itching

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In small babies, gentle suprapubic pressure allows bladder emptying but it may be necessary to catheterize older patient

low dose of naloxone0.5–2 µg kg–1

Laxatives, suppositories and micro-enemas may be required.

Urinary retention and gastrointestinal symptoms

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chest wall rigidity particularly with fentanyl

adductor muscle spasms may be caused by accumulation of stimulatory metabolites such as morphine-3-glucuronide specially if used in orthopedic surgeries for long periods.

Muscle spasms

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Pharmacokinetic studies of NSAIDs have revealed a higher than expected dose from adult doses

NSAIDs should be avoided in:

infants less than 6 months of age. Children with aspirin or NSAID allergy dehydration or hypovolaemia renal or hepatic failure coagulation defects significant risk of haemorrhage

Non-steroidal anti-inflammatory drugs (NSAIDs)

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Adverse effects

The most commonly reported adverse

effects are

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Bleeding, gastrointestinal, skin

Hepatic, and renal toxic effects.

Edema,bone marrow suppression,Stevens– Johnson syndrome

Adverse effects

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The COX-2 inhibitors available at present meloxicam, nimesulide, celecoxib,

COX-2 inhibitors

etoricoxib,lumaricoxib,valdecoxib

Parecoxib(rofecoxib having been withdrawn recently)

By sparing physiological tissue prostaglandin production while inhibiting inflammatory prostaglandin release, COX-2 inhibitors offered the potential of effective analgesia with fewer side effects than the NSAID

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Acetaminophen inhibits prostaglandin synthesis in the hypothalamus probably via inhibition of cycloxygenase-3

This central action produces both antipyretic and analgesic effects.

Acetaminophen also reduces hyperalgesia mediated by substance P

reduces nitric oxide generation involved in spinal hyperalgesia induced by substance P or NMDA.

Acetaminophen (paracetamol)

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Oral and rectal dosage 15-20 mg kg-1 and maintenance 15 mg kg-1 every 8-12hours according to age

Total daily doses of paracetamol should not exceeed approximately 90 mg kg–1 day–1 for up to 72 h

Peak analgesia even after i.v. administration is between 1 and 2 h.

Dosage:

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The novel i.v. formulation pro-paracetamol is cleaved by plasma esterases to produce half the mass of acetaminophen. Recently, mannitol solubilized paracetamol (PerfalganTM) has become available for i.v. use.

therapeutic plasma concentration’ of 10–20 mg ml-1

I.V. acetaminophen (PerfalganTM) (15 mg kg-1) as slow i.v. infusion over 15 min children older than 1 year.

Dosage:

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Suggested benefits include decreased intraoperative requirement for general anesthetics in acute pain management

less of a need for parenteral opioids limiting the incidence of side effects limitation of stress hormone responses Improved postoperative analgesia shortened recovery for outpatient surgery

Pediatric regional anesthesia

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In younger children, particularly infants, nerves have a thinner myelin sheath, a smaller fiber diameter, and a shorter internodal distance.

lack of hypotensive response from a sympathectomy produced by the local anesthetic increased risk of toxicity

Neonates and infants have a lower AAG concentration in serum as compared with adults; therefore, their free fraction of local anesthetics is increased accordingly

Differences of pediatrics

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The intrinsic clearance of bupivacaine is only one-third of that in adults at 1 month of age, and two-thirds at 6 months

Infants also have decreased levels of plasma pseudocholinesterase that theoretically could increase the risk of toxicity with ester

local anesthetics

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Most famous axillary and parascalene blocks Dose:-

0.3–0.5 ml/kg bupivacaine 0.25% or ropivacaine 0.2% in children younger than five–eight years.

In older children, the larger concentrations may be required, i.e., 0.3–0.5 mL/kg bupivacaine 0.5%

or ropivacaine 0.5%.

Upper Extremity Nerve Blocks

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The axillary nerve block Technique:

The needle is inserted immediately superior to the artery high in the axilla. The needle should be at a 45 degree angle pointing cephalad toward the midpoint of the clavicle and advanced until there is evidence of nerve stimulation seen distally

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Parascalene block

The needle should be inserted perpendicular to the skin at the junction of the upper two thirds and lower one third of this line near the external jugular vein. A nerve stimulator is used to determine the depth of the brachial plexus, which should be 7 to 30 mm below the skin

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Lower extremity blocks include those of the lumbar plexus (L1-L4) and sciatic (L4-S3) nerves and are generally used for orthopedic and plastic surgery procedures.

Dosing requirements for lower extremity blocks are 0.5–1 mL/kg of 0.25% bupivacaine or 0.2% ropivacaine in children younger than five to eight years.Higher range reserved for lumbar plexus anesthesia

Lower Extremity Nerve Blocks

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Femoral nerve block

The needle is inserted with a slight cephalad angle to the skin at 0.5–1 cm below the inguinal ligament and 0.5–1 cm lateral to the artery

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Two lines are drawn: 1) between the two iliac crests, and 2) parallel to the spinous processes and through the ipsilateral posterior superior iliac spine. The needle should be inserted at 90 degrees to the skin at the intersection of these lines and will traverse through the quadratus lumborum

The lumbar plexus block

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The point of needle insertion in children is at the midpoint of a line drawn between the tip of the coccyx and the greater trochanter of the femur. The needle should be perpendicular to the skin and advanced medially and upward toward the lateral border of the ischial tuberosity until a muscle twitch is seen in the foot

sciatic nerve block

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The point of needle insertion is 1 cm lateral to the line , 1 to 2 cm proximal to the popliteal crease, and lateral to the popliteal arterydirected perpendicular to the skin or with a slight cephalad angle

Popliteal block

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A 3F polyethylene catheter can be placed over a 0.018-inch wire that has been passed through a 22-gauge insulated needle or a 4F catheter can be placed over a 0.021-inch wire that has been passed through a 20-gauge insulated needle

continuous infusions of local anesthetics in children have recommended a starting rate of 0.15 ml kg-1 h-1 of bupivacaine 0.25%

Continous periperal blocks

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Blockade of these nerves is generally performed simultaneously bylocating a point 1 cm superior and 1 cm medial to the anterior superior iliac spine

Ilioinguinal/Iliohypogastric Nerve Blocks

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Subcutaneous ring block

1–5 mL of local anesthetic is required bupivacaine 0.25%–0.5%

Penile Nerve Block

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a needle or intravenous catheter (18–23 gauge) is advanced at a 45° angle cephalad until a pop is felt as the needle pierces the sacrococcygeal lig.

Maximum dose: Bupivacaine 3 mg/kg, Lidocaine 10 mg/kg

Dosage by ml? Adding morphine: 30µ/kg

Caudal Block

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Anatomical differences

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The lumbar space is usually encountered at 2.2–2.5 cm

Infusion regimens: Loading: 0.5-1 ml/seg Maintanance: 0.125%

plain 0.2–0.4 ml kg-1 h-

1 to 0.25–0.5 mgaccording to age with same max. dosages kg-1 h-1

Clonidine, an alpha-adrenoceptor agonist,in a dose of 1–2mg kg-1

ketamine, in its preservative-free form at a dose of 0.5 mg kg-1

Fentany and clonidine in the dose 1µg kg-1

Epidural block

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Side effects include:

urinary retention leg weakness tachyphylaxis epidural haematoma epidural infection risk of i.v. and subarachnoid injection Pressure sores may occur in analgesic skin

Side effects:

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26-27G needle Dosage: bupivicaine 0.5–1

mg/kg adiitminister an extra

0.1–0.2cc to compensate needle dead space

From: 0-5 kg 0.1ml/kg 5-10 kg 0.08 ml/kg > 15kg 0.06 ml/kgMorphine : 10µg/kg

Spinal block

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The multi-modal approach is considered to be the best for good pain cotrol

Examples Tosillectomy Cong.ing hernia Talipus

conclusion

Thank You