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How to Manage Acute Pain in
Neonate and Infant
Elizeus Hanindito
Dept. of Anesthesiology & Reanimation
Medical Faculty of Airlangga University dr.Soetomo General
Hospital
S U R A B A Y A
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Definition of Pain
Nyeri adalah rasa inderawi dan pengalaman emosional
yang tidak menyenangkan akibat adanya kerusakan
jaringan yang nyata atau yang berpotensi rusak atau
sesuatu yang tergambarkan seperti itu
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Proportion of NICUs Treating Pain During Invasive
Procedures *
* Pain management in NICU , Lago P. J Ped Anesthesia 2005
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60% of adult patients in the ED received
analgesia for burns & fractures compared
with 28% of pediatric patients.Selbst & Clark . Sedation & Analgesia in the ED 1990.
Pain is not recognized
Misconception of pediatric pain
Fear of respiratory depression & hypotensionFear of masking symptoms
Unfamiliarity with analgesics,doses
Inadequate training of medical professional
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CommonMisconceptions(Myths)
Myth 1 : the neural & endocrine systems of the
newborn infant are not developed to the
stage that allow for transmission of pain-
ful stimuli. That they cannot feel pain.Myth 2: newborn infants cannot remember pain
and therefore,there can be no sequelae.
Myth 3 : pain cannot be assessed in the newborninfants.
Myth 4 : newborn infants are easily comforted
without analgesics.
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CommonMisconceptions(Myths)
Myth 5 : it is unsafe to administer opioids to infants
and that infants often suffer respiratory
depression following administration of
opoids.
Limited clinical information.
Limited available research and acces.
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Neonates experience pain evenmore than older infants !
Adaptive mechanisms do not
develop until 32-36 weeks ofpostconceptional age
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Why treat pain ?
Treatment & alleviation of pain
are a basic human right !
regardless of age
Fishman SM. Recognizing Pain Management as a Human Right: A First StepAnesthesia Analgesia 2007.
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Neuroanatomy& Neurophysiology
Density of cutaneous nociceptive nerve endings~ adults.
Nociceptive tracts have completed by the end of
third trimester.Substance P and its receptors are detectable inthe fetal dorsal horn at 12 to 16 wks.
Concentration of beta-endorphin increase in
response to stress.A marked release of catecholamines, growthhormone, cortisol and glucagon occurs.
Andrews KA. The Human Developmental Neurophysiology of Pain.
Pain in Infants,Children and Adolescents 2nd Ed 2003.
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Short-term effects
Adverse short-term consequences:
Physiologic & biochemical sequelae:
hyperglycemia,protein catabolism,oxygen
consumption,gut motility,heart rate,bloodpressure.(Barker DP et al. Arch Dis Child Fetal Neonatal Ed. 1996; 75:F187)
Exposure of preterm neonates torepetitive pain and stress leads to clinicalinstability and complications(KJS Anand. Crit Care Med 1993; 21: S358)
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Long-term effects
Adverse long-term consequences:
Circumcision (without analgesia) increases
pain response to subsequent vaccination
(Taddio A et al: Lancet 1997;349: 599)
Permanent structural and functional
changes may occur in infants exposed tomultiple painful and stressful events(Porter FL et al: J Dev Behav Pediatr 1999;20:253)
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Sustained physiologic,anatomic & behavioural changes result
from repetitive or prolonged exposure to noxious stimuli.
Consequence 25 wk
PCAFull term 4-6 mo 1-2 yr 4 yr 10 yr
Hyperalgesi :
Sensitization:
Physiologic
destabilsation:
Behavioural
changes :
Personality
effects :
Yes
yes
Yes
Yes
?
Yes
Yes
Yes
Yes
?
Probably
?
?
Yes
?
?
?
?
Probably
Probably
?
?
?
Possibly
Possibly
?
?
?
?
Possibly
Anand KJ,Kenneth RG.Longterm Consequences of Pain in Neonates.
Pain in Infants Children and Adolescents 2ndEd 2003
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Pain management begins with an assessmentof the childwith pain .
Not only the explicit pain features but also the situational factors
that modulate pain-measurement of infant pain is just oneaspect ofcomprehensive pain assessment.
Pain is private & subjective, can only be accessed & measured
by indirect method.
Health care facilities now identify pain assessment as the 5th
vital signs.
Pediatric Pain Assessment
Gaffney A et al. Measuring Pain in Children: Developmental & Instrument Issues.
Pain in Infants,Children and Adolescents 2nd Ed 2003.
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Pediatric Pain Assessment
Behavioural parameters
Physiological parameters
Biochemical parameters
Self-Reporting measures
Unidimensional tool
Multidimesional tool
Anand KJS.Pain and Pain Management during Infancy.Research and Clinical Forum 1998
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Behavioural Parameters
Crying characteristics.
Facial expressions.
Simple motor responses.
Complex behavioural responses.
More specific and consistent thanphysiological measurements.
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Facial Expression of Physical
Distress
NASO-
LABIAL FOLD
deepened
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Physiological Parameters
Heart rate.
Respiratory rate.
Blood pressure.Palmar sweating.
Vagal tone.
Oxygen saturation.Transcutaneous O2/CO2.
Intracranial pressure.
Objective,Precise , but
Not specific for pain
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Biochemical Parameters
Catecholamines : Epinephrine, Norepinephrine.
Cortisol : blood, saliva, or urine.
b-EndorphinGrowth hormone, glucose, glucagon, renin,
aldosterone, and lactate have also been noted
to increase with pain.
Insulin secretion is usually suppressed.
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Newborn Pain Assessment Tools
FLACC (Face,Legs,Activity,Cry,Consolability).
PIPP (Premature Infant Pain Profile).
CRIES (Crying,oxygen Requirement,Increased vitalsigns,Expression and Sleeplessness).
NIPS (Neonatal Infant Pain Scale).
N-PASS (Neonatal Pain Agitation and SedationScale).
NFCS (Neonatal Facing Coding System).
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Childrens Hospital of Eastern Ontario Pain Scale
(CHEOPS)
Score 0 1 2
Cry
Facial
Verbal
Torso
Legs
smile
+
neutral
neutral
+
composed
shifting/tense
kick/squirm
scream
grimace
pain complaint
restraint
restraint
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Self-Report Measures
Self-report measures.
Poker Chip Tool (Hester)
Faces Scale (Bieri)Visual Analog Scale (VAS)
Oucher Scale (Beyer & Wells)
Pain Diary
Anne G,Patrick JM. Measuring Pain in Children:Developmental & Instrument Issues
Pain in Infants,Chidren and Adolescents 2ndEd 2003
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Validity & Reliability
Validity :
the ability of the pain tool to measure pain as an
isolated condition differentiated from other condition,
such as distress and agitationReliability :
the tools ability to consistently score pain each time the
tool is used (test-retest reliability) and when different
people use the tool (interrater reliability).
Easy to administer at the bedside.
appropriate for the gestational age.
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Procedural Pain in NICU
> 10/day several hundred in the course
of a prolonged admission.
Procedural intervention :
*tracheal suctioning
* heel lancing
* venepuncture
* lumbar puncture
* chest tube insertion
* tracheal intubation
* Pain management in NICU , Lago P. J Ped Anesthesia 2005
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Prevention of pain is the best approach to pain
management :
*suctioning the infant on an as needed basis
*limiting the number of painful procedure
*skilled person to perform painful procedure
*method by which we performs the procedure
(venipuncture vs heel stick)
Pharmacologic and nonpharmacologic approach.
Neonatal pain management
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Pharmacologic Intervention
Nonsteroidal antiinflammatory drugs.
Intermittent/continuous narcotic.
Patient-controlled analgesia.Peripheral nerve block.
Regional anesthetic techniques.
American Academy of Pediatric,Canadian Paediatric Society,Committee on
Drugs,Committee on Fetus and Newborn and Section on Anesthesiology
Prevention and Management of Pain and Stress in the NeonatePediatrics 2000
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Nonpharmacologic Intervention
Oral sucrose,non-nutritional sucking
Minimal handling protocols
Lowering noise levels in NICUAvoiding exposure to bright lights
Swaddling , nesting.
American Academy of Pediatric,Canadian Paediatric Society,Committee on
Drugs,Committee on Fetus and Newborn and Section on Anesthesiology
Prevention and Management of Pain and Stress in the NeonatePediatrics 2000
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Pain in pediatric trauma
Trauma Pediatric Morbidity & Mortality
(USA : 500.000 hospitalization 15.000 20.000
deaths/year).
Pain management :
* Emergency phase.
* Healing phase.
* Rehabilitation phase.
The first priority is preservation of life and
stabilization.
Rose JB. Pain Management for the Pediatric Trauma
Revista Mexicana de Anestesiologia 2004
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Ideal Analgesic in the ED
Rapid onset.
Short duration of effect.
Easily administered.Effective analgesia.
Minimal side effects.
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NSAIDs
Minimal sedation , emetic effect.
Mild-moderate pain.
Analgetic ceiling effect.Opioid sparing effect.
Contraindication:
coagulation disorder.asthma.
renal/liver disease.
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DRUG LOADING
DOSE
(mg/kg)
MAINTENANCE
DOSE
(mg/kg)
INTERVAL
(hours)
DAILY MAX
DOSE
(mg/kg)
KetoprofenIbuprofen
Naproxen
Diclofenac
Ketorolac
210
10
2
0.5
110
5
1
0.25
6-86-8
8-12
6-8
6-8
540
15
3
2
NSAID Doses in Children
Ketoprofen continuous : Loading dose 1 mg/kg in 15 minutes,infusion 3-5 mg/kg/24 h
Kokki H. Use.Abuse and Misuse of NSAIDS in Children
European Journal of Anesthesiology 2005
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Paracetamol Dosing in Children
Orally :
20 mg/kg loading dose.
15 mg/kg 4-8 hourly.
Rectally :
30-45 mg/kg loading dose.
20 mg/kg 6-8 hourly.
Maximum 90 mg/kg/day (neonate 60mg/kg/day).
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Ketorolac tromethamine
Effective for moderate postoperative pain.
Has a significant opioid-sparing effect.
Not recommended for < 1 year.
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Recommended dosage & duration of
ketorolac therapy in children
Intravenous :Initial dosage 0.5 mg/kg.
Subsequent dosage 1.0 mg/kg q6h.
I.V. infusion 0.17 mg/kg/h.
Maximum daily dosage 90 mg.
Maximum duration 2 days.
Oral :
Oral dosage 0.25 mg/kg q6h.Maximum daily dosage 1 mg/kg.
Maximum duration 7 days.
Use of intravenous ketorolac in the neonate and premature
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Use of intravenous ketorolac in the neonate and premature
babies.
Papacci P et al. pediatric Anesthesia 2004.
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Opioids
Morphine or Fentanyl most often used.
Avoid Demerol (Meperidine)
Requires frequent and thorough
assessment of adequacy of pain relief
and possible side effects
< 6 months continuous respiratory
monitoring:
* < 1 month : 9 hours
* 1-6 months : 4 hours
After the last
administraton
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Estimated Values for Vd t1/2 CL
of Morphine
Vd
(L/kg)
t1/2
(h)
CL
(ml/min/kg)
Preterm 2.8 + 2.6 9.0 + 3.4 2.2 + 0.7
Term 2.8 + 2.6 6.5 + 2.8 8.1 + 3.2
Infants &children 2.8 + 2.6 2.0 + 1.8 23.6 + 8.5
Kart T, Lona L. Recommended Use of Morphine in Neonates,Infants and Children Based on Literature
Review : Part 1 Pharmacokinetics.Pediatric Anesthesia 1997.
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Morphine Dosing
Infusion :
* 100 g/kg/hour for 2 hours.
* Followed by 10-30 g/kg/hour.Intermittent Dosing :
* 50-200 g/kg/dose i.v. slowly.
* repeat as required usually 4 hourly.Fentanyl 1-2 g/kg/hour
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Recommended Starting Setting for
PCA in Children
Recommended drug concentration is morphine
1 mg/kg in 0.9% saline 50 ml.
Bolus dose 0.02 mg/kg ; maximum 1 mg.
Lock-out time 5-10 minutes.Frequency range 5 boluses/hour.
Background infusion 4 ug/kg/h.
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Opioids Side Effects
Morphine :
Respiratory depression apnea
HypotensionUrinary retension
Fentanyl :
Bradycardia hypotensionChest-wall rigidity
Naloxone : 0.1-0.2/kg/dose (antidote)
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Check patient before administering
Rousable to voice or light touch.
Respiratory rate >20(infant) ,>30(neonate)
Heart rate is appropriate.
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Sedatives: benzodiazepines
Benzodiazepines : NOT analgesics.
sedative-hypnotic, amnesic, anxiolytic, muscle relaxant,and anti-epileptic properties.
Midazolam :
short half-life and is approved by the FDA for neonataluse. Although an effective sedative, it can causeabnormal movements and adverse hemodynamiceffects .
Dose: 0.1 mg/kg IV over 5 min q2-4h. Can also beused continuous IV (10-50 mcg/kg/h), intranasal,sublingual, oral.
Diazepam not recommended due to long half-life.
Flumazenil 0.01 mg/kg/dose (antidote)
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Precaution Needed for Use of
Sedation/Analgesia in the ED
Appropriate personnel
MonitoringEquipment
Medication
Selbst SM,Zempsky WT. Sedation & Analgesia in the ED.
Pain in Infants Children and Adolescents 2nd Ed 2003.
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Caudal epidural analgesia
Most popular central block
Easiest & safest approach
Excellent analgesia-painfree awakening
Applicable to children of all ages
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Caudal epidural catheter
Easier to place than lumbar
Easily passed cephalad
Never forcibly advance the catheter against
resistance
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Caudal Bupivacaine + Clonidine
1-2 ug/kg.
Prolonged the duration of caudal block.
Postoperative sedation + .Favorable analgesia-to-side effect profile.
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Caudal Bupivacaine + Opioids
Morphine : 20-40 ug/kg ; 75 -100 ug/kg.
Fentanyl : 0.5-1.0 ug/kg.
Postoperative sedation + .Respiratory depression,nausea/vomiting,
urinary retention.
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Peripheral Nerve Block
Penile block.
Ilioinguinal nerve block.iliohypogastric nerve block.
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Brachial Plexus Block
Interscalene approach.
Parascalene approach.
Subclavian approach.
Supraclavicular approach.
Axillary approach.
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Axillary approach
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