Management Of Pain

MANAGEMENT OF PAIN Mohamed Khashaba,MD Professor of Pediatrics/Neonatology Head NICU

Objectives • to provide the knowledge necessary to effectively assess and manage postoperative, procedural, and disease-related pain in hospitalized Neonate.

Why to relieve Pain ? • Humanitarian considerations. • Scientific principles.

• Definition and sources of pain • Effects of pain on the neonate • Neonatal pain assessment • Management of neonatal pain • Non pharmacological and • Pharmacologic pain relief

• Definition and sources of pain • Effects of pain on the neonate • Neonatal pain assessment • Management of neonatal pain • Non pharmacological and • Pharmacologic pain relief

Definition of Pain • “an unpleasant sensory and emotional • experience associated with actual or potential • tissue damage, or described in terms of such damage.” • The International Association for the Study of Pain (2004)

sources of pain • • • • •

Three main categories: 1.nociceptor 2.non nociceptor 3.psychogenic pain.  

Nociceptor pain • tissue damage produces a stimulus that sends an electrical impulse across a pain receptor (nociceptor) by way of a nerve fiber to CNS. • Nociceptor pain • 1.Visceral pain from the stimulation of nociceptorsin abdominal cavity and thorax, • 2. Somatic pain which is divided into deep somatic and cutaneous pain. • Some tissues such as the lungs and the brain have no nociceptors and some

Non nociceptor (neuropathic) Pain Caused by direct injury to the structures of the nervous system.

Psychogenic pain There is no or little physical evidence of organic disease.

Modulation of pain • Once the brain perceives the pain, the body releases neuromodulators, such as endogenous opioids (endorphins and enkephalins), serotonin, norepinephrine, and GABA. • They hinder the transmission of pain and produce an analgesic effect (modulation).

Hormonal responses • Preterm neonates have hormonal stress responses such as noradrenaline, cortisol, b-endorphin, and corticotrophin. following invasive interventions. • These hormonal responses can be prevented by analgesia.

Q of myelination • Incomplete myelination merely implies a slower conduction velocity in the nerves or central nerve tracts of neonates, which is offset completely by the shorter interneuron and neuromuscular distances travelled by the impulse

Sources of Pain • Infants born at 25–42 weeks gestation experience an average of 14 painful procedures per day during the first 2 weeks of life. (Gibbins et al., 2006; Stevens et al.,2007).

• The most frequent procedures are nasal, endotracheal, and nasopharyngeal suctioning followed by heelstick, intravenous and nasogastric tube insertions.

• The inability to communicate verbally does not negate the possibility that an individual is experiencing pain and is in need of pain-relieving treatment. • Newborns display physiologic and behavioral cues to signal tissue damage.

Failed Attempts • failure rate for placement of CVC, peripheral arterial catheters, and IV cannulaeare 45.6%, 37.5%, and 30.9% (Simons el 2003)

• most of the procedures performed • in this study were rated by physicians and nurses to be painful (>4 on a 10-point scale).

• Definition and sources of pain • Effects of pain on the neonate • Neonatal pain assessment • Management of neonatal pain • Non pharmacological and • Pharmacologic pain relief

Effect of Pain • 1. Effect on neonatal outcome. • 2. Effect on neurodevelopmental outcome.

Effect of Pain • Increased demands on the cardio respiratory system and metabolism. • Marked changes in cerebral blood flow and oxygen delivery and elevation in intracranial pressure, theoretically increasing the risk of IVH.

Adverse neurodevelopmental outcomes • Decreased sensitivity to common childhood pain. • A higher incidence of somatic complaints.

Parents’ perceptions of their infant’s pain • One of the most stressful experiences reported by parents of infants in (NICU) is seeing their infant experience pain. • Memories of the infant’s pain and the mothers’ inability to protect the infant from pain may continue to be a source of stress.

• Definition and sources of pain • Effects of pain on the neonate • Neonatal pain assessment • Management of neonatal pain • Non pharmacological and • Pharmacologic pain relief

Physiologic Measures of Pain 1. Heart rate : the most reliable . 2. Other frequently used measures: a.oxygen saturation, b.blood pressure, c. breathing patterns. brief, acute noxious stimuli Heart rate and blood pressure generally increase Oxygen saturation decreases. • Respiratory rate typically becomes more rapid, shallow, or irregular . • • • • • • •

Difficulty in Interpretetion • They may be influenced by non noxious stimuli, particularly in the ill or preterm neonate. • If they are observed simultaneously with other behavioral and contextual indicators, they may add significant information

• Physiologic responses are important in • pharmacologically paralyzed • or who are neurologically impaired

• Physiologic measures reflect the body’s • nonspecific response to stress. • should be used along with behavioral measures.

Behavior response to pain • Facial activity (i.e., brow bulge, eye squeeze, nasolabial furrow, and open mouth) is the most specific indicator of acute procedural pain.

Cry • Types of cries differ along a continuum • of intensity according to graded levels of noxious stimuli that correspond to adults’ • Its absence should not be equated with absence of pain.

• Healthy, full-term newborns make swiping motions toward a lanced foot with the unaffected leg, as if trying to push away the noxious stimulus. Franck(1986)

• Preterm infants may uniquely respond to • acute pain by increased flexion and extension

Very premature babies Inadequate muscle strength, posture, tone, and movement compared to term infants • Physiologic changes and behavior cues are non reliable indicators.

• Awake or alert infants demonstrate a more robust reaction to painful stimuli than sleeping infant. • Persistence of pain deactivates sympathetic responses.

Contexual factors altering pain expression • • • • • •

Severity of illness, Technician expertise, Gender, Environmental stress, Procedural modifiers, and Initial threshold and sensitization after repeated stimulation;

Premature Infant Pain Profile PIPP assigning points • 3 behavioural (facial action: brow bulge, eye squeeze and nasolabial furrow), • 2 physiological (heart rate and oxygen saturation) • 2 contextual (gestational age, behavioural state) • PIPP scores range from 0 to 21, with each of the 7 indicators scoring a possible 0 to 3 points, depending on the amount of

PIPP Score • The higher the score is, the more pain that is experienced by the neonate. • scores < 6 represent minimal pain, • PIPP scores > 12 represent moderate to severe pain.

Fullterm Babies • • • •

Behaviour pain score Assesses : Motor activity Cry consolability Sleep.

• Definition and sources of pain • Effects of pain on the neonate • Neonatal pain assessment • Management of neonatal pain • Non pharmacological and • Pharmacologic pain relief

Pain Producing interventions

A. Diagnostic • • • • • • • •

Arterial puncture Bronchoscopy Endoscopy Heel lancing Lumbar puncture ROP examination Suprapubic bladder tap Venipuncture

B. Therapeutic • • • • • • • •

Bladder catheterization Central line insertion/removal Chest tube insertion/removal Chest physiotherapy Dressing change Gavage tube insertion Intramuscular injection Peripheral venous catheterization

• • • • • • •

Mechanical ventilation Postural drainage Removal of adhesive tape Suture removal Tracheal intubation/extubation Tracheal suctioning Ventricular tap

nonpharmacologic approaches • Behavioral and Environmental strategies

• Reduce the number of painful procedures performed on infants . • Using noninvasive monitoring techniques • Critically evaluating the need for all practices, such as the number and grouping diagnostic procedures,

Windup phenomenon • Painful procedures should not be performed at the same time as other, nonemergency routine care . • Evidence suggests that after exposure to a painful stimulus, a preterm infant’s pain sensitivity is accentuated by an increased excitability of nociceptive neurons in the dorsal horn of the spinal cord • Grunau,Oberlander,&Whitfield, 2005).

• This sensory hypersensitivity, may exist for prolonged periods after a painful

• Swaddling during and after a heel stick reduces the physiological and behavioral pain indicators in preterm neonates

facilitated tucking • Hand-swaddling technique • (i.e., holding the infant’s extremities flexed and contained close to the trunk), during a painful procedure may significantly reduce pain responses in preterm infants • (Cignacco et al., 2007)

• Excessive and unpredictable sound levels and • bright or continuous lighting levels in the NICU • have been associated with increased physiologic and behavioral stress responses in preterm infants • Uchiboi, 1986).

(Shiroiwa, Kamiya,&

Nonnutritive sucklig (NNS) • most widely studied nonpharmacological approach to pain management. • mechanisms of action • thought to be related to the activation of nonopioid pathways as the infant sucks on the • pacifier. • Pain-relieving effects of NNS cease after • the pacifier is removed from the mouth

Sucrose

Safety and efficacy • IN preterm and term infants . • A systematic review of 21 randomized • controlled trials found that sucrose decreased • crying time, heart rate, facial action, and composite pain scores during heel lance and venipuncture •

(Stevens, Yamada, &

Dose and method of sucrose adminstration • 0.05 - 2 ml of a 24% solution . Approximately 2 minutes before the painful stimulus. • Effect lasting 5-10 minutes • (Stevens et al., 1999).

• optimally administered to the tip of the tongue where sweet receptors lie.

Babies less than 27 ws • There is less evidence for the safety and • efficacy of sucrose for infants less than 27 • weeks gestation.

Breast Milk • If available, breast feeding or breast milk should be used to alleviate procedural pain in neonates undergoing a single painful procedure. • glucose or sucrose had similar effectiveness • as breastfeeding for reducing pain. • The effectiveness of breast milk for repeated painful procedures is not

Pharmacologic pain relief

• Pharmacological agents such as non steroidal anti-inflammatory drugs (NSAIDs) and paracetamol interfere with the metabolic pathways involved in the production of prostaglandin, ultimately interfering with the transmission of pain signals even at this peripheral level.

• Paracetamol is safe and effective if given in the correct dose, and frequently enough

Sedatives • They blunt behavioral responses to noxious stimuli without providing pain relief. Therefore, sedatives should not be used unless pain has been ruled out.

Take care of the dose Immaturity of the baby’s nervous system and metabolic pathways. Different way in which the drugs are distributed, Reduced ability of the baby to excrete the drug though the kidneys. A correct dosage by mass for a baby of 6 months old would be quite wrong for a premature neonate.

Heel stick Pain 1. Oral 24% Sucrose 0.5 -1.5 ml. 2. Topical lidocaine (0.5-1% ). 3. Automated devices. squeezing for blood collection is the most painful part of the procedure. • acetaminophen, and warming the heel are ineffective for heel lancing; • • • •

Other minor procedures • • • •

Venipuncture. Arterial puncture. IV placement. Immunization.

• Sucrose 24%

Umbilical Catheter Insertion   • Consider the use of a pacifier with sucrose. • Use swaddling, containment, or facilitated tucking. • Avoid the placement of sutures or hemostat clamps on the skin around the umbilicus.

Spinal Tap • 1. Lidocaine0.1-0.2 ml 1% subcutaneously (optional). • 2. Topical lidocaine (ELMA). • And Morphia or fentanyl ( in ventilated neonate ) .

EMLA 5% cream • Eutectic Mixture of Local Analgesic. • Smaller application dose for preterms and LBW. • Needs 40-60 min. for maximum effect. • 0.5-1.0 gm for 1-2 hours, then remove excess. • Local edema, methemoglobinemia

Lidocaine SQ • 1ml/kg of 0.5% solution. • 0.5 ml/kg of 1% solution.

opiates morphine and fentanyl is most often used in the hospital setting, while codeine is effective for use at home

Analgesics (Opiates ) • Morphine • 0.05-0.15 mg/kg IV or SQ.*

• Fentanyl • 0.5-2 ug/kg IV** • Routine continuous infusion is not recommended. • * 1/2 this dose in non ventilated. • ** 1/3 this dose in non ventilated.

Fentanyl • IV infusion over > 10 minutes. • Dose repeated every 2-4 hours. • Maximum conc. Is 10ug/ml.

Morphine • IV Given over > 5 min. • Can be given IM or SQ. • Conc. 0.01-0.02 mg/kg/hr. infusion.

Indications of Opiates • • • • • •

Elective intubation and ventilation. During ventilation. Chest tube insertion and removal. Umbilical catheterization. CVC placement. Pre and post operative.

Analgesics ( Acetaminophen) • 10-15 mg/kg oral/PR /6 Hrs. • Max. daily dose is 40mg/kg.

Sedatives • • • • • • • •

Midazolam* Only in full terms. 0.05-0.1 mg/kg IV or nasal. Chloral Hydrate* 20-30 mg/kg PO Phenobarbital** PO,IV * short acting ** Long acting

Summary • • There is good scientific evidence that babies feel as much pain as adults do

• treating established pain, and ensuring adequate analgesia before painful procedures, improves the outcome of injuries and procedures

• Untreated pain in the newborn may have harmful effects which last into childhood and possibly longer.

• Ordinary loving physical care and comforting has been scientifically shown to be effective, and remains the mainstay of managing infants in pain.

• We should learn to use analgesics appropriately. Infant should not be given analgesics without a diagnosis of their pain