1. Pain Management and Sedation Nightfloat Curriculum 2010-2011 LPCH Pediatric Residency Program

2. Teaching Goals Be comfortable initiating pain medications Learn to assess pain and modify treatment strategies Know how to choose appropriate sedation strategies based on patient age and procedure

3. Pain Management Pediatricians often under-treat children’s pain When initiating pain medications, a standing regimen is preferable – PRN = Patient Not Receiving – Avoid combination products (i.e. Vicodin) at first Constantly re-assess your pain plan – Is it working? – Any side effects?

4. Assessing Pain Infants – FLACC Verbal Children – Scale of 1-10 (may use faces and/or numbers)

5. FLACC 012 FACENo particular expression or smile Occasional grimace or frown, withdrawn, disinterested Frequent to constant quivering chin, clenched jaw LEGSNormal position or relaxed Uneasy, restless, tense Kicking or legs drawn up ACTIVITYLying quietly, normal position, moves easily Squirming, shifting back and forth, tense Arched, rigid, or jerking CRYNo cryMoans or whimpers, occasional complaint Crying steadily, screams or sobs CONSOLABILITYContent, relaxedReassured by touching, hugging, voice, distraction Difficult to console of comfort

6. Pain Medications Acetaminophen – PO: 10-15 mg/kg every 4-6 hours – PR: Loading dose 35-50 mg/kg; Maintenance dose 20 mg/kg every 6 hours – NO MORE THAN 5 DOSES in 24 hours Ibuprofen – PO: 5-10 mg/kg every 6-8 hours – MAX 40 mg/kg/day – Contraindicated in active GI bleeding, hypersensitivity to NSAIDs – Caution in severe asthmatics

7. Pain Medications OPIATE – If one doesn’t work, try another AVOID Codeine – 1/3 of patients gain no analgesia Morphine – PO: 0.2-0.5 mg/kg every 4-6 hours – IV: 0.05-0.2 mg/kg every 2-4 hours – PCA: 0.015 mg/kg/hr basal with 0.015 mg/kg PCA dose q10 min lockout

8. Pain Medications Oxycodone – PO: 0.1-0.2 mg/kg every 3-4 hours Fentanyl – IV: 0.5-4 mcg/kg every 1-2 hours Hydromorphone – PO: 0.03-0.08 mg/kg every 3-4 hours – IV: 0.015 mg/kg every 3-6 hours

9. Moderate Sedation Patient Assessment – ASA Class – Airway – Allergies Informed Consent – Risks and benefits

10. Moderate Sedation Sedation certified nurse Monitoring Suction and bag-mask readily available Reversal agents ordered and drawn up

11. Moderate Sedation Midazolam – PO: 0.5 mg/kg per dose, may repeat with 0.25 mg/kg; max 20 mg – IV: 0.05-0.1 mg/kg per dose, may repeat up to total of 0.2 mg/kg – Intranasal: 0.2-0.3 mg/kg per dose administered in 1 ml syringe over 15 seconds Lorazepam – IV, PO: 0.05 mg/kg/dose every 4-8 hours; max 2 mg per dose

12. Moderate Sedation Chloral Hydrate – PO: 50 mg/kg as single dose, may repeat with 25 mg/kg after 20 minutes; max 100 mg/kg in 24 hours – Preferred in younger children and with painless procedures Pentobarbital – PO, IM, IV: 4 mg/kg, may repeat with 2 mg/kg; max is 100 mg – May cause HYPERalgesia – avoid in painful procedures

13. Reversal Agents Flumenazil – IV: 0.01 mg/kg/dose given over 15 seconds, may repeat every minute; max TOTAL dose is 0.05 mg/kg or 1 mg Naloxone – IV, IM, ET, SubQ: 0.001 mg/kg/dose, MINIMUM dose is 0.01 mg, may repeat every 1-2 minutes

14. Case 1 15 month infant needs an urgent lumbar puncture. What agents would you use for sedation and analgesia? What if she needed to get an MRI?

15. Case 2 A 4 year old has recently returned from having an abcess drained and has a painful JP drain in place. How would you treat his pain?