PAIN MANAGEMENT IN SPECIAL POPULATIONS-warangal -final Copy

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PAIN MANAGEMENT IN SPECIAL POPULATIONS:

PAIN MANAGEMENT IN SPECIAL POPULATIONS DR.S.SREENIVASARAO MD,C.C.P.P.M, ASSIST PROFESSOR, DEPT.OF ANAESTHESIA, S.V.R.R.G.G.H.&S.V.M.C, TIRUPATI

SPECIAL POPULATIONS…:

SPECIAL POPULATIONS… GERIATRICS PAEDIATRICS PEOPLE WITH DIFFERENT COMARBIDITIES MENTALLY RETARDED PEOPLE DEAF & DUMB PEOPLE INTUBATED PATIENTS RENAL FAILURE HEPATIC FAILURE CNS DISORDERS etc..

BALANCING ACT….:

BALANCING ACT…. PHYSIOLOGY MATURITY DEGENERATION COMPLICATIONS PAIN MANAGEMENT PAEDIATRICS GERIATRICS

Prevalence of pain in Elderly:

Prevalence of pain in Elderly 1 in 5 elderly have pain 18% above 65 are taking pain medications regularly One-fifth of adults 65 years and older said they had experienced pain in the past month that persisted for more than 24 hours. Almost three-fifths of adults 65 and older with pain said it had lasted for one year or more. Women report severely painful joints more often than men (10 percent versus 7 percent). CDC′s National Center for Health Statistics 2006,

Prevalence of Pain in Elderly:

Prevalence of Pain in Elderly 1 Community-dwelling older adults: 25–56% 2 Nursing home residents: 45–80% 3 Greater than 50% patients dying of a variety of illnesses, including cancer, COPD, CAD 4 31% of women & 19% of men > 75 yrs report pain in 3 or more sites AGS panel on persistent pain in older persons, JAGS 50:s205-s224, 2002. Ferrell B A: Pain evaluation and management in the nursing homes, Ann Intern Med, 123(9):681-687,1992. Minner D M et.al., Evidence based assessment and treatment of persistent pain in the community dwelling elderly receiving home health services: A pathway, Home health care management and practice 17:294-301,2005.

Challenges of pain assessment in older patients:

Challenges of pain assessment in older patients Myths that having pain is “natural” with aging Fears about addiction to pain medications Sensory and cognitive impairments Under-reporting Co-morbidities complicating the clinical picture and caregivers' beliefs and the reliability of patients' pain. Lack of congruence between patients' and caregivers' perceptions of pain Caregiver may misinterpret pain perception Atypical presentation Stein, W.M. Pain in the nursing home. Clinics in Geriatric Medicine 17, 575-94 , 2001 Stewart, K. et. al. Assessment approaches for older people receiving social care: content and coverage. International Journal of Geriatric Psychiatry 14, 147-56,1999 . Horgas , A.L. et. al. Pain in nursing home residents. Comparison of residents' self-report and nursing assistants' perceptions. Journal of Gerontological Nursing 27, 44-53, 2001 . Weiner, D., et. al. Chronic pain associated behaviours in the nursing home: resident versus caregiver perceptions. Pain 80, 577-88,1999.

Factors affecting perception of pain:

Factors affecting perception of pain Pain affects quality of life far beyond the local region of injury Feeling of loneliness is predictor of psychological distress Lack of intimate relationships, dependency, and loss increase loneliness Loneliness has been shown to lower pain threshold Loneliness is a risk factor for depression Deane G et.al., Overview of pain management in older persons. Clin Geriatr Med 24,185-201,2008.

Factors affecting the perception of pain:

Factors affecting the perception of pain Depression: lack of energy, avoidance of diversional activities, decreased engagement in treatment Anxiety: may inhibit participation in rehab efforts Sleep disturbance: pain is best predictor of sleep disturbance. Increased health care needs Isolation and reduced independence: Involvement with family and friends can provide pleasurable experience

ELDERLY-ACUTE PAIN:

ELDERLY-ACUTE PAIN Pathological conditions that are painfull in young adults,but in th elderly they produce only behavioural changes such as confusion,restlessness,aggresion,anorexia,fatigue ( Tresch 1998)

ELDERLY-ATYPICAL PRESENTATION:

ELDERLY-ATYPICAL PRESENTATION When pain is reported,it is likely to be reffered from the site of origin in an atypical manner ( Sigurdson et al 1995) For example- asymtamatic & atypical MI is uncommon in younger patients but Upto 30% of elderly survivors did not report any acute symptoms Another 30% had an atypical presentation (Mehta et al 2001 & Sigurdson et al1995)

PHYSIOLOGICAL CHANGES :

PHYSIOLOGICAL CHANGES CNS & PNS CHANGES Selective attrition of cerebral and cerebellar cortical neurons Neuron loss within certain areas of the thalamus, locus ceruleus , and basal ganglia General reduction in neuron density , with loss of 30 percent of brain mass by age 80 Decreased numbers of serotonin receptors in the cortex Reduced levels of acetylcholine and acetylcholine receptors in several regions of the brain Decreased levels of dopamine in the neostriatum and substantia nigra and reduced numbers of dopamine receptors in the neostriatum

PowerPoint Presentation:

R eduction in the complexity of neuronal connections , A decrease in the synthesis of neurotransmitters , A n increase in the enzymes responsible for their postsynaptic degradation Immobility leads to atrophy of the musculoskeletal system Muscles innervated by fewer axons, leading to possible denervation atrophy Conduction velocity is slightly affected by aging (slower) Reduction in number of fibers in spinal cord tracts

Studies of physiological changes on age:

Studies of physiological changes on age C & A δ Fibre function decreases with age ( Parkhouse & Le quesne & Chakour et al 1996) Decreased neuroplasticity with age has been reported throughout the CNS ( Crutcher 2002) Compared to younger volunteers elderly people show altered temporal summation to repeated noxious thermal stimulation , which may reflect impaired C fibre activity or NMDA receptor activation (Edwards & fillingim 2001)

PowerPoint Presentation:

Ageing associated with impairements in descending endogenous pain inhibition networks (Edwards et all 2003& washington et all) Adaptation to painfull stimuli is reduced in the elderly with age related dysfunction of both opiodergic & hormonal systems In response to painfull thermal stimuli both young & older adults show activation of midline & central cortical regions but older adults also show activation in more frontal& lateral sides implying wider recruitment of neurons & slower cognitive processing in the elderly (Gibson et all1994)

PHARMACOKINETICS & DYNAMICS :

PHARMACOKINETICS & DYNAMICS Pharmacological Concern Change with Normal Aging Common Disease Effects Gastrointestinal absorption or function Slowing of gastrointestinal transit time may prolong effects of continuous release enteral drugs. Opioid -related bowel dysmotility may be enhanced in older patients. Disorders that alter gastric pH may reduce absorption of some drugs. _ Surgically altered anatomy may reduce absorption of some drugs. Transdermal absorption Under most circumstances, there are few changes in absorption based on age but may relate more to different patch technology used Temperature and other specific patch technology characteristics may affect absorption

PowerPoint Presentation:

Pharmacological Concern Change with Normal Aging Common Disease Effects Distribution Increased fat to lean body weight ratio may increase volume of distribution for fatsoluble drugs. Aging and obesity may result in longer effective drug half-life Liver metabolism Oxidation is variable and may decrease resulting in prolonged drug half-life. _ Conjugation usually preserved. _ First-pass effect usually unchanged. _ Genetic enzyme polymorphisms may affect some cytochrome enzymes Cirrhosis, hepatitis, tumors may disrupt oxidation but not usually conjugation

PowerPoint Presentation:

Pharmacological Concern Change with Normal Aging Common Disease Effects Renal excretion Glomerular filtration rate decreases with advancing age in many patients, which results in decreased excretion Chronic kidney disease may predispose further to renal toxicity Active metabolites Reduced renal clearance will prolong effects of metabolites Renal disease. _ Increase in half-life Anticholinergic side effects Increased confusion, constipation, incontinence, movement disorders. Enhanced by neurological disease processes

PAIN MANAGEMENT:

PAIN MANAGEMENT EVALUATION ASSESSMENT TREATMENT

EVALUATION :

EVALUATION HISTORY EXAMINATION PHYSICAL PSYCHOLOGICAL STATUS INVESTIGATION

Pain Management– Assessment Steps Chronic Pain History:

Pain Management– Assessment Steps Chronic Pain History  “PQRST” Provocative/palliative factors (e.g., position, activity, etc.) Quality (e.g., aching, throbbing, stabbing, burning) Region (e.g., focal, multifocal, generalized, deep, superficial) Severity (e.g., average, least, worst, and current) Temporal features (e.g., onset, duration, course, daily pattern)  Medical History Existing comorbidities Current medications Source: Valley, MA. Pain measurement. In: Raj PP. Pain Medicine. St. Louis MO. Mosby, Inc. 1996:36-46.

ASSESSMENT :

ASSESSMENT Assessment Tools Visual Analogue Scales Facial Pain Scales Numeric Rating Scales Verbal Rating Scales Multidimensional tools McGill PQ Pain map May be more of a global view, effect on function Multiple others – at least 12 different behavioral based tools for patients with dementia

PowerPoint Presentation:

THE McGILL Pain Questionnaire is sufficiently sensitive for the assessment of age and time related changes in postoperative pain Gagliese & Kartz 2003

PAIN MAP:

PAIN MAP VAS—7/10 7-3-2012 BURNING LOCALISED

Pain Thermometer:

Pain Thermometer No pain Slight pain Mild pain Severe pain Moderate pain Extreme pain Pain as bad as it could be (Herr and Mobily , 1993)

Pain Assessment in Dementia:

Pain Assessment in Dementia Patients’ self report are still reliable Reports from caregivers/family members are also reliable if they are familiar with patient. Behaviors exhibited may indicate pain Facial pain scale Do not use pain scales and ask to recall information from past.

Pain assessment in advanced dementia:

Pain assessment in advanced dementia The Pain Assessment in Advanced Dementia (PAINAD) scale Assess breathing independent of vocalization Negative vocalization Facial expression Body language Consolability Each behavior is scored 0 to 2,higher the score more severe the pain.

Pain assessment in nonverbal patients:

Pain assessment in nonverbal patients Checklist of Nonverbal Pain Indicators (CNPI): Nonverbal vocal complaints (sighs, gasps, moans, groans, cries) Facial grimacing Bracing (clutching or holding onto furniture, equipment) Rubbing (massaging affected area) Restlessness Verbal vocal complaints such as “ouch” or “stop” Feldt K S., Pain Manag Nurs 1(1):13-21,2000.

Barriers to Effective Pain Management:

Barriers to Effective Pain Management Study of 805 chronic pain sufferers, >50% changed physicians due to lack of physician’s: Willingness to treat the pain aggressively, Failure to take the pain seriously, Lack of knowledge about pain management Chronic pain in America: roadblocks to relief. Survey conducted for the American Pain Society, The America Academy of Pain Medicine, and Janssen Pharmaceutica. Hanson, NY: Roper Starch Worldwide, 2000.

Health care system barriers:

Health care system barriers Lack of a neighborhood pharmacy Lack of transportation to the physician or pharmacy, an absence of high doses of opioids at the pharmacy Lack of a home caregiver to assist with administering drugs pose major obstacles to pain treatment

Patient related barriers to effective pain management:

Patient related barriers to effective pain management Communication: Patients with communication problems with physician had worse pain control. Psychological: Anxiety, distress, depression, anger, and dementia, all of which can complicate assessment by masking symptoms. Attitudinal issues: Fear of addiction, tolerance, and side effects, belief that pain was inevitable.

Total care:

Total care emotional spiritual physical social ‘‘Pain management continues to be the most difficult problem facing medicine today.’’ Jason R. Bauer and Charles E. Ray, Jr. WHY ………….?

Treatment:

Treatment Age-Related Physiologic Changes Decreased renal function Decreased volume of distribution because of decreased lean body weight Decreased liver mass and hepatic blood flow Decreased activity of some drug-metabolizing enzymes Decreased serum protein concentrations Decreased pulmonary function

TREATMENT:

TREATMENT PHARMACOLOGICAL NONINVASIVE INVASIVE NONPHARMACOLOGICAL

Modified WHO Analgesic Ladder:

Pain Step 1 ± Nonopioid ± Adjuvant Pain persisting or increasing Step 2 Opioid for mild to moderate pain ± Nonopioid ± Adjuvant Pain persisting or increasing Pain persisting or increasing Step 3 Opioid for moderate to severe pain ± Nonopioid ± Adjuvant Invasive treatments Opioid Delivery Quality of Life Modified WHO Analgesic Ladder Proposed 4 th Step The WHO Ladder Deer, et al., 1999

ACETOMINOPHEN:

ACETOMINOPHEN Central antinociceptive effect & potential mechanisms for this include inhibition of a CNS COX-2 Inhibition of a central cyclooxygenase ‘COX-3’ that is selectively susceptible to paracetamol , Modulation of inhibitory descending serotinergic pathways Prevent PG production at the cellular transcriptional level, independent of cyclooxygenase activity Extremely good safety profile at therapeutic doses Coadministration of paracetamol and alcohol is known to produce the hepatotoxic metabolite N -acetyl-p- benzoquinoneimine Causes none of the side-effects associated with opioids or indeed the gastrointestinal and platelet complications observed with NSAIDs

PowerPoint Presentation:

AMERICAM GERIATRIC SOCIETY 2009 GUIDE LINES Acetaminophen is the first drug of choice to treat acute pain about hepatic toxicity with acetaminophen has been raised, it appears that the transient elevations of alanine aminotransferase that have been observed in long-term patients do not translate into liver failure or hepatic dysfunction when maximum recommended doses are avoided. AGS-2009

Treatment:

Treatment Nonselective NSAIDs Inhibit prostaglandin synthesis Appropriate for short term use All have ceiling effect Risk of gastrointestinal bleed, renal impairment, platelet dysfunction Selective COX-2 inhibitors (celecoxib is only one currently available in U.S.) Reduced gastrointestinal side-effects and platelet inhibition

Treatment with Opioids:

Treatment with Opioids Stimulates mu opioid receptor. Used for moderate to severe pain. Used for both nociceptive and neuropathic pain. Opioid drugs have no ceiling to their analgesic effects and have been shown to relieve all types of pain. Elderly people, compared to younger people, may be more sensitive to the analgesic properties. Advanced age is associated with a prolonged half-life and prolonged pharmacokinetics of opioid drugs

Opioids:

Opioids Morphine Hepatic metabolism and renally excreted; not dialyzable. Oral bioavailability 30-40%, M6G is active metabolite with analgesic activity, M3G is another metabolite causes neurotoxicity, Morphine is available in oral (liquid and pill), topical, sublingual, parenteral, intrathecal, epidural and rectal routes. High doses can lead to myoclonus and hyperalgesia.

Opioids:

Opioids Fentanyl Patch 100 times more potent than morphine Absorption altered by temperature, Depot of drug in excess adipose tissue Tramadol Synthetic mu (opioid) agonist and inhibition of serotonin and norepinephrine reuptake 1/5 th as potent as morphine Lowers threshold for seizure and multiple drug-grug interactions.

TAPENTADOL:

TAPENTADOL Centrally acting analgesic with a unique dual mode of action as an agonist at the μ- opioid receptor & as a norepinephrine reuptake inhibitor 18-fold affinity for the μ opioid receptor in as compared to morphine Improved GI tolerability when compared to opioids Dose adjustment is not needed in the presence of renal impairment No Hepatoxicity Potency between Tramadol and Morphine Contraindicated in severe bronchial asthma, paralytic ileus , and patients on MAOI

COMPLICATIONS-OPIOIDS:

COMPLICATIONS-OPIOIDS Initial Nausea and vomiting Drowsiness Unsteadiness Continuing: Constipation Nausea and vomiting Inactivity drowsiness Dry mouth Occasional: Urinary retention Myoclonus Itching

Non-opioid medications for pain:

Non-opioid medications for pain Tricyclic antidepressants ( amytriptyline, desipramine) for neuropathic pain, depression, sleep disturbance. Not used often due to side-effects. Duloxetine (Cymbalta ) is newer antidepressant FDA approved for neuropathic pain. Anticonvulsants ( gabapentin, pregabalin, carbamazepine) for neuropathic pain. Carbamazepine can be used for trigeminal neuralgia, may cause pancytopenia. Muscle relaxants : for muscle spasm, monitor for sedation Local anesthetics (lidocaine patch, topical voltaren gel, capsaicin). Capsaicin depletes substance P, may take weeks to reach full effect, adverse effects include burning and erythema. Lidocain patch FDA approved for post herpetic neuralgia. Placebos: unethical

Non-opioid treatment:

Non-opioid treatment Massage reduces pain, including release of muscle tension, improved circulation, increased joint mobility, and decreased anxiety TENS unit: Can be considered for diabetic neuropathy but not for chronic low back pain

Non-drug treatment:

Non-drug treatment Education: basic knowledge about pain (diagnosis, treatment, complications, and prognosis), other available treatment options, and information about over-the-counter medications and self-help strategies. Exercise: tailored for individual patient needs and lifestyle; moderate-intensity exercise, 30 min or more 3-4 times a week and continued indefinitely. Physical modalities (heat, cold, and massage) Cold for acute injuries in first 48 hours, to decrease bleeding or hematoma formation, edema, and chronic back pain. Heat works well for relief of muscle aches and abdominal cramping.

Non-drug treatment:

Non-drug treatment Physical or occupational therapy; should be conducted by a trained therapist Chiropractic: Effective for acute back pain. Potential spinal cord or nerve root impingement should be ruled out before any spinal manipulation Acupuncture: Performed by qualified acupuncturist. Effects may be short lived and require repetitive treatments

Non-drug treatments:

Non-drug treatments Relaxation: repetitive focus on sound, sensation, muscle tension, inattention towards intrusive thoughts. Requires individual acceptance and substantial training. Meditation: Guided or self-directed technique for calming the mind, allows thoughts, emotions and sensations to travel through conscious awareness without judgment. Progressive muscle relaxation: Individual tensing and relaxing of certain muscle groups. Hypnosis: effective analgesic, state of inner absorption and focused attention. Reduces pain by distraction, altered pain perception, increased pain threshold. Norelli L J et.al., : Behavioral approaches to pain management in the elderly, 24(2), Clinics in Geriatric Medicine, 2008.

Non-drug treatment:

Non-drug treatment Cognitive-behavioral therapy: Pain is influenced by cognition, affect and behavior. Conducted by a trained therapist, focuses on changing individual cognitive activity to modify associated behavior, thoughts, and emotions. 10-12 weekly individual or group sessions Participants have to be cognitively intact Operant behavior therapy: Use of negative and positive consequences to modify the behaviors. Mind-body conditioning practices: Yoga, tai chi, qigong. Norelli L J, et.al.,: Behavioral approaches to pain management in the elderly, 24(2), Clinics in Geriatric Medicine, 2008.

10 recommendations for pain management in elderly:

10 recommendations for pain management in elderly Always ask about pain Reinforce that pain is not a normal part of ageing Expect atypical presentations Use validated pain assessment instruments,appropriate to patients cognitve level Assess psychological distress,quality of life,& functional impairment Combine pharmacological & nonpharmacological interventions if possible Monitor vigilantly for adverse effects Involve family caregivers Repeat assessments regularly Modify treatment plan to maximize function & pain relief

PowerPoint Presentation:

MORE GAP BETWEEN SENIOR CITIZENS & US FILL IT WITH LOVE & AFFECTION

PAIN MANAGEMENT IN PAEDIATRICS:

PAIN MANAGEMENT IN PAEDIATRICS

Barriers:

Barriers Myth that children and especially infants do not feel pain the same as adults No untoward consequences to not treating pain Lack of assessment skills Lack of pain treatment knowledge Notion that addressing pain takes too much time Fears of adverse effects of analgesia – respiratory depression, addiction Personal values and beliefs; i.e. pain builds character AAP 2001 Task Force on Pain in Infants, Children and Adolescents

PIC DRAWN BY 10YRS BOY WITH HEADACHE….:

PIC DRAWN BY 10YRS BOY WITH HEADACHE….

Background:

Background Historically children and infants received less post-operative analgesia than adults Well documented that children are often undertreated for pain Specifically in neonates: Recent studies show that neonates can experience pain by 26 weeks of gestation Mature afferent pain transmission Untreated pain in neonates lead to increased distress and altered pain response in the future

Consequences of Pain:

Consequences of Pain Endocrine : stress hormone, metabolic rate, heart rate & water retention Immune : Impaired immune functions Pulmonary : flow and volume retained secretions and atelectasis Cardiovascula r: cardiac rate systemic vascular resistance peripheral vascular resistance coronary vascular resistance  blood pressure and myocardial oxygen consumption Gastrointestinal : Delayed return of gastric and bowel function Musculoskeletal: Decreased muscle function, fatigue and immobility

5 General Principles of Pain Management:

5 General Principles of Pain Management Anticipate & prevent pain Adequately assess pain Use multi-modal approach Involve parents Use non-noxious routes Pediatrics in Review 2003; 24 (10)

1: Anticipate & Prevent Pain:

1: Anticipate & Prevent Pain Prepare patient and parent on what to expect Guide them on ways to minimize pain and anxiety Utilize quiet environment Treat pain prophylactically when anticipated E.g. Following surgery or local anesthetic for lumbar puncture Takes more medication to treat pain than to prevent its occurrence

2: Pain Assessment:

2: Pain Assessment Obtain a detailed assessment of pain HPI, description of pain, experience with pain medications, use of non-pharmacologic techniques, parent experience with pain Quality, location, duration, intensity, radiation, relieving & exacerbating factors, & associated symptoms Use age appropriate tool Scales for neonate, infant, children ages 3-8, >8 years, and children with cognitive impairments Directly ask child when possible Pain can be multi-dimensional and therefore, tools can be limited

Assessment in Neonates & Infants:

Assessment in Neonates & Infants Challenging Combines physiologic and behavioral parameters Many scales available NIPS (Neonatal Infant Pain Scale) FLACC scale (Face, Legs, Activity, Cry Consolability)

Neonatal Infant Pain Scale (NIPS):

Neonatal Infant Pain Scale (NIPS)

PowerPoint Presentation:

Peds pain scales... F FACE LEGS ACTIVITY L A CRY No particular expression or smile 0 Occasional grimace or frown, withdrawn, disinterested 1 Frequent to constant quivering chin, clenched jaw 2 Normal position or relaxed 0 Uneasy, restless, tense 1 Kicking or legs drawn up 2 Lying quietly, normal position, moves easily 0 Squirming, shifting back and forth, tense 1 Arched, rigid or jerking 2 No cry, (awake or asleep) 0 Moans or whimpers; occasional complaint 1 Crying steadily, screams or sobs. Difficult to console. 2 C Content, relaxed 0 Reassured by occasional touching, hugging or being talked to. 1 Difficult to console or comfort 2 CONSOLE C

Children between 3-8 years :

Children between 3-8 years Usually have a word for pain Can articulate more detail about the presence and location of pain; less able to comment on quality or intensity Examples: Color scales Faces scales

Children older than 8 years:

Children older than 8 years Use the standard visual analog scale Same used in adults

Children with Cognitive Impairment:

Children with Cognitive Impairment Often unable to describe pain Altered nervous system and experience pain differently Use behavioral observation scales e.g. FLACC Can apply to intubated patients

Non-pharmacological:

Non-pharmacological

PowerPoint Presentation:

World Health Organization (WHO) Principles of Pediatric Acute Pain Management By the clock With the child By the appropriate route WHO Ladder of Pain Management

PowerPoint Presentation:

By the Clock Regular scheduling ensures a steady blood level Reduces the peaks and troughs of PRN dosing PRN = as little as possible???

PowerPoint Presentation:

With the Child Analgesic treatment should be individualized according to: The child’s pain Response to treatment Frequent reassessment Modification of plan as required

PowerPoint Presentation:

Correct Route Oral Nebulized Buccal Transdermal Sublingual Intranasal IM IV / SC Rectal

PowerPoint Presentation:

World Health Organization (WHO) Principles of Pediatric Acute Pain Management

Sucrose for Infants:

Sucrose for Infants Sucrose 24% oral solution Can be used for procedures such as heel stick, venipuncture, catheterization, etc. Effective analgesic in preterm and term infants Not effective beyond 3 months old Dip pacifier in sucrose solution or give 0.2 mL to buccal area May repeat but be cautious with many doses to younger infants

4: Patient & Parental Involvement:

4: Patient & Parental Involvement Parent Excellent sources of information on child Learn techniques to help coach through pain Reduces anxiety Patient Age & developmentally appropriate Gives them control in their pain experience Learn techniques to help with pain control Reduces anxiety

5: Non-noxious Routes:

5: Non-noxious Routes Administer analgesia through most painless route Avoid IM injections Oral and Intravenous routes are preferred Oral route for mild to moderate pain Intravenous route for immediate pain relief and severe pain

Pharmacology of Pain Management:

Pharmacology of Pain Management

Principles of Pharmacology:

Principles of Pharmacology Consider patient’s age, associated medical problems, type of pain, & previous experience with pain Choose type of analgesia Choose route to control pain as rapidly and effectively as possible Titrate further doses based on initial response Anticipate side effects Recognize synergistic effects

PowerPoint Presentation:

NEJM 2002; 347 (14).

Non-opioid Analgesics:

Non-opioid Analgesics Mild to moderate pain No side effects of respiratory depression Highly effective when combined with opioids Acetaminophen NSAIDs COX-2 inhibitors Aspirin No longer used in pediatrics

Acetaminophen:

Acetaminophen Antipyretic Mild analgesic Administer PO or PR Pediatric Oral dose 10-15 mg/kg/dose every 4 hr Infant dose is 10-15 mg/kg/dose every 6-8 hr Adult dose 650 mg-1000 mg/dose Onset 30 minutes

Acetaminophen:

Acetaminophen Per rectum dose 40 mg/kg once followed by 20 mg/kg/dose every 6 hours Uptake is delayed and variable Peak absorption is 60-120 minutes Unreliable to cut suppositories Maximum daily dosing Infants: 60-75 mg/kg/day <60 kg: 100 mg/kg/day >60 kg: 4 grams/day

Side Effects of Acetaminophen:

Side Effects of Acetaminophen Generally a good safety profile Do not use in hepatic failure Causes hepatic failure in overdose Infant drops are MORE concentrated than the children’s suspension Infant’s Acetaminophen 80 mg/0.8 mL Children’s Acetaminophen 160 mg/5 mL

NSAIDs:

NSAIDs Antipyretic Analgesic for mild to moderate pain Anti-inflammatory COX inhibitor  Prostaglandin inhibitor Platelet aggregation inhibitor

NSAIDs: Ibuprofen:

NSAIDs: Ibuprofen Dose 10 mg/kg/dose every 6 hours Adult dose 400-600 mg/dose every 6 hours Onset 30-45 minutes Maximum daily dosing <60 kg: 40 mg/kg >60 kg: 2400 mg May use higher doses in rheumatologic disease

NSAIDs: Ketorolac:

NSAIDs: Ketorolac Intravenous NSAID (also available P.O.) Dose 0.5 mg/kg/dose every 6 hours Onset 10 minutes Maximum I.V. dose 30 mg every 6 hours Monitor renal function Do not use more than 5 days Significant increase in side effects after 5 days

Side Effects of NSAIDs:

Side Effects of NSAIDs Gastritis Prolonged use increases risk of GI bleed Still rare in pediatric patients compared to adults NSAID use contraindicated in ulcer disease Nephropathy (ATN) Bleeding from platelet anti-aggregation Increased risk versus benefit post-tonsillectomy NSAID use contraindicated in active bleeding Delayed bone healing?

COX-2 inhibitors:

COX-2 inhibitors Selectively inhibits Cyclooxygenase-2 which reduces risk of gastric irritation and bleeding Same risk for nephropathy as non-selective COX inhibitors Shown to have increased cardiovascular events in adults More studies needed in pediatric patients COX-2 inhibitors used in rheumatologic diseases

Opioids Analgesics:

Opioids Analgesics Moderate to severe pain Various routes of administration Different pharmacokinetics for different age groups Infants younger than 3 months have increased risk of hypoventilation and respiratory depression Low risk of addiction among children

Side Effects of Opioids:

Side Effects of Opioids All opioids have side effects that should be anticipated & managed Respiratory depression Nausea, vomiting Constipation Pruritis Urinary retention

Opioids:

Opioids Codeine Oxycodone Morphine Fentanyl Hydromorphone Methadone

Morphine:

Morphine Available orally, sublingually, subcutaneously, intravenous, rectally, intrathecally Moderate to severe pain Hepatic conversion with renally excreted metabolites Use in caution with renal failure Duration of I.V. analgesia 2-4 hours Oral form comes in an immediate and sustained release Dose dependent on formulation I.V. Dose 0.05-0.2 mg/kg/dose every 2-4 hours Onset 5-10 minutes Side effect of significant histamine release

Fentanyl:

Fentanyl Available intravenous, buccal tab, lozenge and transdermal patch Use buccal tabs, lozenges and patch only in opioid tolerant patients Severe pain Rapid onset, brief duration of action With continuous infusion, longer duration of action I.V. Dose 1 mcg/kg/dose every 30-60 minutes Side effect of rapid administration may produce glottic and chest wall rigidity Careful observation, CRM and immediate availability of airway equipment and skills

Monitor Patients receiving Opioids:

Monitor Patients receiving Opioids Close observation of all patients receiving opioids Routine vital signs Sedation scales when indicated Particular close attention to patients: History of OSA Craniofacial anomalies Infants who are younger than 6 months or older infants with history of apnea or prematurity Opioid-naïve patients with continuous infusions

Local Anesthetics:

Local Anesthetics For needle procedures, suturing, lumbar puncture, etc. Topical or infiltration Acts by blocking nerve conduction at Na-channels If administered in excessive doses, can cause systemic effects CNS effects of perioral numbness, dizziness, muscular twitching, seizures & cardiac toxicity Aspirate back before injecting to avoid direct injection into blood vessels Calculate maximum mg/kg dose to avoid overdose Buffering lidocaine can help with pain of infiltration 9 mL lidocaine mixed with 1 mL sodium bicarbonate

Types of Pain:

Types of Pain Procedural pain Post-operative pain Sickle cell pain Neuropathic pain Cancer pain Pain in palliative care

Procedural Pain:

Procedural Pain Consider the type of procedure, expected duration of pain, the patient and parents involved, and child’s pain history Educate the parents and patients on what to expect Utilize non-pharmacologic methods and local anesthesia Calm environment Consider anxiolytic Be skilled in airway management

Post-operative Pain:

Post-operative Pain Anticipate pain depending on type of surgery Utilize different classes of analgesics Control pain as soon as possible to allow for steady serum levels Use continuous/around-the-clock dosing at fixed times for moderate to severe pain Address side effects of opioid medications

Sickle Cell Pain:

Sickle Cell Pain Typically vaso-occlusive crisis Complete careful history and physical to rule out other causes of pain VOC may involve 2-3 sites and maybe migratory Assess pain (generally relies on self-report) Pay attention to degree of pain relief and any adverse reactions Change medications and doses depending on clinical response of patient Utilize non-pharmacologic management Involve patient in plan

Vaso-occlusive Crisis:

Vaso-occlusive Crisis Acetaminophen and NSAIDS typically first line for mild to moderate pain Maybe combined with opioid for moderate pain Opioids to treat moderate to severe pain PCA if appropriate Rapid triage, physical assessment, and analgesia Start with appropriate dose of medication and re-evaluate If need more opioid, give 25-50% more of initial dose Once relief achieved, around-the-clock medication with breakthrough medications available Adjunct management with I.V. fluids Monitor patients closely for respiratory depression Hypoventilation may precipitate acute chest syndrome

Key Points:

Key Points Treat pain Adhere to general principles of pain management Anticipate & prevent pain Adequately assess pain Use multi-modal approach Involve parents & patients Use non-noxious routes Understand the pharmacology of non- opioid and opioid analgesics Approach and treat different types of pain accordingly

THANK YOU ….:

THANK YOU ….

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