مدیریت درد مزمن در کودکان

1. مدیریت درد مزمن در کودکان

2. Cognitive-behavioral Education Relaxation Imagery Psychotherapy Hypnosis Biofeedback Music, art, play Prayer, meditation Physical Approach Massage Acupuncture Heat or Cold TENS Therapeutic exercise Multi-modal Approach

3. 4: Patient & Parental Involvement • Parent • Excellent sources of information on child • Learn techniques • Reduces anxiety • Patient • Age & developmentally appropriate • Gives them control in their pain experience • Learn techniques to help with pain control • Reduces anxiety

4. Non-noxious Routes • Administration: painless route • Avoid IM injections • Oral and Intravenous routes are preferred

5. Pharmacology of Pain Management

6. Principles of Pharmacology • 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 sideeffects • Recognize synergistic effects

7. 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

8. Acetaminophen • Antipyretic • Mild analgesic • Administer PO or PR • Pediatric Oral dose 10-15 mg/kg/dose every 4 hr • Onset 30 minutes

9. 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

10. Side Effects of Acetaminophen • Generally a good safety profile • Do not use in hepatic failure • Causes hepatic failure in overdose

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

12. 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

13. 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 • side effects

14. Side Effects of NSAIDs • Gastritis • 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

15. COX-2 inhibitors • Selectively inhibits Cyclooxygenase-2 • ↓ Gastric irritation and bleeding • Same risk for nephropathy as non-selective COX inhibitors • Shown to have increased cardiovascular events in adults • COX-2 inhibitors • Rheumatologic diseases • Cancer • GI

16. 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

17. Side Effects of Opioids • Respiratory depression • Nausea, vomiting • Constipation • Pruritus • Urinary retention

18. Opioids • Codeine • Oxycodone • Morphine • Fentanyl • Hydromorphone • Methadone

19. Codeine • Oral analgesic (also anti-tussive) • Weak opioid • Used often in conjunction with acetaminophen to increase analgesic effect • Metabolized in the liver and demethylated to morphine • Some patients ineffectively convert codeine to morphine so no analgesia is achieved • Dose 0.5-1 mg/kg every 4-6 hours

20. Morphine • Available PO, SL, SC, IV, REC, IT • Moderate to severe pain • Hepatic conversion with renally excreted metabolites • caution (renal failure) • Duration of I.V. analgesia 2-4 hours • Oral form (immediate and sustained release) • I.V. Dose 0.05-0.2 mg/kg/dose every 2-4 hours • Side effect: histamine release

21. Patient Controlled Analgesia (PCA) • Programmable pump • Patient can choose when to deliver • patient will fall asleep when over sedated and is unlikely to administer too much drug • Teaching

22. When to use PCA • Useful • sickle cell vaso-occlusive episodes • postoperative pain • cancer pain • palliative care • Take patient’s age, maturity, and medical condition into the decision

23. How to set up a PCA • Loading dose • Basal infusion rate • Patient demand dose • Lockout interval (5-10 min) • Maximum hourly limit • Sedation and vital sign assessment is mandatory

24. Naloxone • Opioid antagonist • 1 ampule = 0.4 mg/mL • Use when unresponsive to physical stimulation, shallow respirations (<8 breaths/min), pinpoint pupils • Stop Opioid • Mix Naloxone 1 ampule with NS 9 mL = 40 mcg/mL • For <40 kgs: Naloxone ¼ ampule with NS 9 mL = 10 mcg/mL • Administer slowly and observe response • 1-2 mcg/kg/min • Discontinue naloxone as soon as patient responds • Duration 30-45 minutes • Monitor the patient; repeat doses may be needed

25. Anti depressants Suicide ideation

26. TCADs مصرف دردهای نوروپاتیک درد فانکشنال شکمی میگرن خواب آوری عوارض آنتی کلینرژیک هدایت قلبی سندروم قطع

27. SSRIs افسردگی و اضطراب همزمان عوارض کمتر گوارشی سردرد و بی قراری بی خوابی اختلال عملکرد جنسی ↑ تعریق فلوکسیتین عارضه سروتونرژیک میوکلونوس هایپررفلکسی بی ثباتی اوتونوم ریژیدیتی دلریوم سندروم قطع (پاروکسیتین)

28. SSNRIs Duloxetine (کاهش وزن) Venlafaxine Neuropathic pain Fibromyalgia pain

29. Anti epileptics Carbamazepine Oxcarbazepine Valporate Topiramate Gabapentin, Pregabalin Mood Disorders, Neuropathic Pain, Zoster, Fibrmyalgia, Chronic Headache, CRPS.

30. benzodiazepines رفع اسپاسم و درد در بیمارستان رفع اضطراب و بهبود خواب محدودیت: ایجاد وابستگی در مصرف مدید رفتار کنترل نشده و شبه سایکوز دپرشن تنفسی آتاکسی افزایش ترشحات برونشیال PTSD در پیوند عضو قطع طی دو هفته

31. Antipsychotics Typical Anipsychotis Atypical Anipsychotis Olanzapine Quetiapine Clozapine Aripiprazole

32. عوارض آنتی سایکوتیک هاتیپیکال ↓آستانه تشنج آگرانولوسیتوز وزن ↑ ECG اختلال هدایت قلبی دیس کینزی تاخیری هیپوتنشن اورتواستاتیک اختلال عملکرد کبدی دیس تونی حنجره

33. عوارض آنتی سایکوتیک هاآتیپیک ↓ دیسکسینزی و دیستونی

34. سندروم نورولپتیک بدخیم بی ثباتی اوتووم ریژیدیتی عضلانی هیپرترمی کاتاتونی تغییر سطح هوشیاری

35. Local Anesthetics • For needle procedures, suturing, lumbar puncture, etc. • Topical or infiltration

36. Anesthesia • Regional • Blocks afferent pathways to CNS • Good for post-operative pain relief • Epidural and caudal anesthesia • Peripheral nerve blocks • General