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• Be able to debunk myths of pediatric pain• Understand the neuro-biologic pathways • Know different modalities that will help a • Evaluate a parent’s desire to help• Understand the long and short term • Audience response system• Sometimes there is a right answer• Sometimes it is just an opinion poll• Teamwork• Play, learn and have fun• Get ready to play! – Whatever the person experiencing it says it is. – Something that you just have to put up with experience associated with actual or potential tissue damage or described in terms of such damage.
experience associated with actual or potential tissue damage or described in terms of such damage.” (APS, 1992) • Whatever the person experiencing it says – Infants do not feel or remember pain– Crying represents fear instead of pain– Pain builds character– It is better to hold the child down and get the procedure over with while the parent is out of the room • Lack of knowledge and education of healthcare • Informal survey • Group of experts queried through the • send a message to [email protected] with
the following in the first line of the body of the message: SUB PEDIATRIC-PAIN your-first-name your-last-name • For more information: http://pediatric- • Immunization pain management guidelines (Taddio et al, Pediatrics, • 2012 WHO Guidelines on the pharmacologic treatment of persisting pain in children with medical il nesses • Nitrous oxide/oxygen delivered by RN in medical settings• Increased understanding of the neurobiology of pain• FDA approval and availability of IV acetaminophen• Pediatric Pain List Serve• Methadone to manage chronic and complex pain• Popularization of ultrasound technology for regional • Founding of the Pediatric Research Network for Pain• Topical anesthetics prior to painful procedures• Comfort measures (position of comfort, parental presence during painful procedures with role) • Numerical rating scale evidence for use in children • What is the most important advancement? – Immunization pain control– 2012 WHO Guidelines – RN administered Nitrous oxide/oxygen– Neurobiology of pain– IV acetaminophen– Pediatric Pain List Serve– Methadone– Ultrasound for regional nerve blocks– Founding of the Pediatric Research Network for Pain– Topical anesthetics– Comfort measures– Numerical rating scale • Neurobiology• Topical anesthesia• Nitrous• Parental Involvement • Who is likely to feel the most intense pain? – A teenager after bowel resection surgery for – A newborn getting a heal stick for labs– A 5 year old who has never had any painful – Subtypes respond to different stimuli • Nociceptors are stimulated when tissue is damaged or – Prostoglandins– Bradykinin– Serotonin– Substance P– Histamine– Postassium • This results in an action potential that heads to the spinal column via afferent nerve fibers and then up to the brain • Myelinated• Sharp, prickly well localized pain• Non-opioids • Unmyelinated• Dull, aching or burning and poorly localized pain • Opioids • Enters into the spinal tract through the dorsal horn – Special substances are needed to transmit the signal from the – This is where opioid receptors lie– Signal continues up the spinothalamic tract • Pain becomes a conscious experience• Autonomic responses• Interpretation• Emotional response • Cognitive behavioral strategies – Brain can accommodate a limited number of • Descending pathway• Neurotransmitters can be blocked when endogenous or exogenous opioids lock onto the opioid receptors – Endogenous opioids bind in dorsal horn– Serotonin– Norepinephrine– GABA– Substance-P • Despite increased awareness of the long term effects of neonatal stress and uncontrolled pain neonates in NICU’s continue to be exposed to many painful minor procedures daily (AAP/CPS, 2006) – 2 week period– 42,413 painful first attempt procedures • 98.6 procedures per patient• 7 procedures per patient per day Threshold for responding to cutaneous stimulation is lowest in youngest neonates (McLaughlin,1990; Fitzgerald,1988; Teng & Abbot,1998)– Nociceptive nerve endings in cutaneous and mucous – Complete myelination of pain pathways to brainstem and – Thalamus to cortex by 37 weeks.
– Complete myelination of nerve pathways not required for – Inhibitory pathways do not develop until after birth with responses to this pathway delayed until the second week of Pain sensitivity in neonates may be more profound that that of older individuals. (Anand,1985,1998) • What happens when we don’t control pain – They get over it because they have no ability – It alters neuro-biological development. – They build up pain tolerance.
– There are no long term effects.
– Increased sensitivity of nociceptor– Chemicals from inflammatory response sensitize receptors in the area of – Fire with less stimulus with more frequent impulses– Surrounding fibers may be recruited to be sensitized– Nociceptor may begin to fire without stimulation – Wind up: Increasing responsiveness by the dorsal horn neurons to C fiber – Long-term potentiation: Cel ular memory leads to lower thresholds and thus over-excitation during future painful episodes – Facilitation: Reduced input threshold and increased intensity of response – If pain fibers are not utilized some will be pruned out – uncircumcised infants– circumcised with EMLA– circumcised with Placebo Al infants were videotaped during vaccination in a primary care clinic. Videotapes were scored without knowledge of circumcision status. The score measured facial action, cry duration and recorded in a visual analogue scale.
– Circumcised infants showed a stronger pain response to subsequent routine vaccination than – Among the circumcised group, preoperative treatment with EMLA attenuated the pain – Injury and tissue damage sustained in infancy can cause sustained changes in CNS function, which persist after the wound has healed and influences behavioral responses to painful • Prospective Study• Compared 3 groups – Extremely low GA (ELGA) ≤ 28 wks– Very Low GA (VLGA) 29-32 wks– Control Group: Term infants without NICU stay • ELGA & VLGA had history of being exposed to painful procedures • Given novel visual stimulus at 8 mos of age• Saliva cortisol levels tested• Results • Which of the following procedures could – Bladder catheter placement– LP– NG tube placement– IV insertion– All of the above– A and D only – Place small amount on cotton ball wait 5 • Insert tip into urethra and inject small amount• Repeat 2-3 times every 3 minutes• Dredge catheter through lidocaine gel – Video significantly more than NS (Nott & Hughes, J of Anesth, 1995) significantly less than NS (Wolfe et al, Ann Emerg Med, 2000) • 1% buffered lidocaine jet injector (J-Tip®) – 2 to 3 minutes
RaisingArizonaKids:Help kids cope with painful
• 2.5% lidocaine with 2.5% prilocaine (EMLA®) – No difference between eutectic mixture and – Jet-injector with 1% buffered lidocaine provided significantly less pain than jet-injector with saline – Nitrous oxide/oxygen sedation is used only in – Nitrous oxide/oxygen can only be given by an anesthesiologist in a hospital setting.
– Even if nitrous oxide/oxygen sedation is used you still need to use topical anesthetics.
– Every child should be offered nitrous • Common in dental offices• Increasing use in the hospital • Kids awake and can cooperate• Appropriate for minimally • Nitrous Oxide was discovered in 1773 by Joseph Priestly• It was first used in surgery in 1795 by Humphrey Davy yet he is not credited with the discovery of anesthesia • Discovery by Horace Wel s for its use as an anesthetic in • Dr. John Riggs extracted a wisdom tooth on Dr. Wells the day after Dr. Wells observed a demonstration of nitrous oxide • Popular in pediatric dentistry• Studies show it is safe and effective sedation for pediatrics (Griffin, 1981; Stewart, 1983) • Drawback of demand valve for pediatrics• Reemergence of popularity with Entox (50/50)• Advances in delivery systems and scavenger • Luhmann, et al (1999) showed safe and cost effective in the ED • Early 2000’s multiple articles detailed use for: – IV starts– Bone marrow biopsy– LP’s– Dressing changes– Otologic exams– VCUG’s– Cyst excisions– Laceration repair– Drain removal • Children’s Hospitals and Clinics of MN – Began their program for children receiving – Went to their board of nursing to define scope– Over seen by sedation team physicians– Have done over 10,000 cases – Now include many other minor procedures – Comfortable and relaxed– Acknowledges reduced fear & anxiety– Aware of surroundings– Responds to directions and conversation– Protective cough and gag intact– Eyes become less active and glazed looking – Books, stories of own life events, video • Which of the following statements is true regarding parental involvement during a child’s – Al parents should be involved.
– It is too difficult on the parent for them to be – The procedure takes longer because staff have – Parental presence increases the child’s anxiety.
– Parents have varying desires of how they want to be • Parent involvement in children’s pain care: views of parent and nurse (Simons, Franck & Roberson, J Adv Nsg, 2001) – Interviews of parents and nurses– Perceptions of parental involvement – When nurses and parental responses were compared to the question about whether the parent had been involved in the child’s pain assessment and management less than half were in agreement – Involvement was passive in nature (understood care)– Parents were surprised when they were involved and expressed frustration at not being involved enough.
– Most parents wanted more done for their child’s pain or more information about the pain treatment.
– Nurses may accept a higher degree of pain than the parents– All this led to frustration and difficulty in communication– Only 2 nurses of the 20 commented that parental involvement might be • Family-centered preparation for surgery improves perioperative outcomes in children (Kain et al. Anes, 2007)Std of care (SoC) = no premedication and no parental • Parental presence = SoC plus parental presence during • ADVANCE = SoC plus Anxiety reduction, Distracion, video modeling and education, Adding parents, No excessive reassurance, Coaching and Exposure/shaping – Were less anxious in holding area (as were – Less anxious during induction– More compliant during induction except when – Experienced less emergence delirium– Required less analgesia in recovery room • The role of parental presence in the context of children’s medical procedures: a systematic review (Piira, et al, Child: Care, Health and Development, 2005) – Eliminates separation anxiety– Minimizes use of pre-medications– Increases child’s cooperation– Enhances parental satisfaction in feeling they are – Parental sense of duty to be present– Parental satisfaction with care • Technical complications/ease of procedure • Nurse satisfaction with parental presence – Studies show high level of nurse satisfaction odor on full-term newborns (Rattaz C et al. J Dev Behav Pediatr 2005) • Cotton bal with water• Cotton ball with vanilla• Cotton bal with mother’s • Which of the following are consequences – Decreased participation in rehabilitation– Decreased immune response– Poor relationship with care givers– Restructuring of the pain pathways– A,B and D only– All of the above • Poor participation in rehabilitation activities • Poor interaction with caregivers• Higher anxiety with non-painful procedures – Peripheral neurons need less stimulation to fire pain – Spinal cord needs less incoming signals to send pain • Poor utilization of medical services in the future • What is the most important component of – Adequate pain medications prescribed– Closely involving the parents in the patient’s – The mind/body connection– Getting the child and family to understand that • • Infants do not feel or remember pain• Crying represents fear instead of pain• Pain builds character• It is better to hold the child down and get the procedure over with while the parent is out of the room • Understanding the pain pathways can help you determine the best intervention to manage pain • Lidocaine is not just for IV’s anymore.
• Assess the parent’s desire to participate and then give them specific information on how to be • Uncontrolled pain has both short and long term • The brain is an important factor in how pain is through your knowledge of the consequences of under treated pain • Teach others• Support parents• Create a team to help you provide the most comfortable environment for patients and their families.


A Randomized, Placebo-Controlled Trial of Citalopram for the Prevention of Major Depression During Treatment for Head and Neck Cancer William M. Lydiatt, MD; David Denman, MD; Dennis P. McNeilly, PsyD;Susan E. Puumula, MS; William J. Burke, MD Objective: To determine whether prophylactic treat- Results: The numbers of subjects who met predefined ment with the antidepressant citalopram h

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