CAP-Pain

pediatrics.uchicago.edu

CAP-Pain

CAP-Pain CAP Pain

Melanie Brown, MD

May 7, 2012


Pain

Assessment

Management

Outline


What is Pain?

Pain: unpleasant sensory and emotional

experience associated with actual or

potential tissue damage

– ALWAYS subjective

– Historically undertreated in infants and

children


Three Hierachical Levels of Pain

Sensory Sensory-Discriminative Discriminative Component

– location, location, intensity, intensity, quality quality

Motivation Motivation-Affective Affective Component

– depression, depression, anxiety anxiety

Cognitive Cognitive-Evaluation Evaluation Component

– thoughts thoughts concerning concerning the the cause cause and and

significance significance of of the the pain

pain


Three Categories of Pain

Acute: generally indicates tissue damage

serving as a protective mechanism

Recurrent Acute: pain episodes < 3 months but

with pain-free pain free windows between episodes

Chronic: less indicative of tissue damage; not a

protective response


Three Pain Mechanisms

Nociceptive

Neuropathic

Psychogenic and Idiopathic


Evolution of Pain Theories

Rene Descartes

“Cogito Cogito ergo sum” sum


Types of Peripheral Nerve Fibers

Sensory

– A beta

Pain

– A delta

– C


Nervous system at

birth displays

remarkable

hypersensitivity to

pain/noxious stimuli

compared to adult

Quite possible to

induce long term

behavioral and CNS

effects from early

Early Pain Effects


Pain Assessment in Children


Pain Scales-Unidimensional

Scales Unidimensional

Numeric rating scale

Visual Analog Scale

Faces pain scale


Pain Scales-Multidimensional

Scales Multidimensional

McGill Pain Questionnaire (MQP)

Brief Pain Inventory

Pain Type Specific tools

– Ex. Neuropathic Pain Scale

Treatment Outcomes of Pain Survey


Why Treat Pain?


Anticipate and

Prevent

General Principles

Adequate Assessment

Multimodal Approach


Who Pain Relief Ladder


Pharmacologic management of pain


Non-opiates

Non opiates

Mainstay of mild to moderate pain

management

– Generally safe, effective


Cathy Freeman 2000 Olympics. Photograph: Reuters


Generally Mu receptor

agonists

Mandated for severe

pain or critically ill

child

Possibility of

dependence after 5-7 5 7

days

ALL opioids lead to

resp depression when

given in equipotent

doses

Opiates


Morphine is considered to have potency of

1

Methadone is equivalent

Fentanyl is 100x more potent

Dilaudid is roughly 5-10x 5 10x more potent

Oxycodone 0.2mg/kg orrally is roughly

equianalgesic to 0.1mg/kg of IV morphine

Codeine is a much better cough

suppressant than analgesic


Side Effects

Respiratory Depression

Constipation

Sedation

Nausea

Itching


Analgesia algorithm


Nonpharmacologic Pain

Management

Distraction

Hypnosis

Sound Therapy

Massage

Transcutaneous Electrical Nerve

Stimulation (TEMS)


Local Adjuncts

Topical Analgesics

– EMLA, Freezy Spray

– Buzzy

Injectable

– Lidocaine


Street Drugs


The Real Street Drugs

Drug Diversion


Prescription Drug Safety


Prescription Drug Safety


Cases


Monday afternoon on the gen peds

floor

18 m/o with significant empyema POD#2

from VATS with decortication. decortication.

CT

continues to drain purulent fluid. Despite

Morphine 0.1 mg/kg/dose toddler is still

miserable.


Tuesday morning

15 y/o boy transferred from PINT with

splenic lac and multiple fractures POD#1

s/p ORIF of comminuted femur frx. frx.

Ortho

service has written for morphine 0.1

mg/kg q 2-4 2 4 hours. Pain is controlled but

pt complains severe pruritis and nausea.


Wednesday afternoon

16 y/o presents to ER with a femur

fracture sustained during football practice.

He is in agony. He ate lunch 2 hours ago.

What can you do for him?


Thursday during Grand Rounds

You get a 911 page from the pediatrics

floor. 12 y/o with ESRD on HD admitted

with pyomyositis s/p I & D has new onset

GTC seizure activity. Electrolytes are all

normal on morning labs. He has been

receiving meperidine for pain for 48 hours.

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