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- Family-Controlled Analgesia
- One family member (usually a parent) or other caregiver designated as child’s primary pain manager with responsibility for pressing PCA button
- Guidelines for selecting a primary pain manager for family controlled analgesia:
- Spends a significant amount of time with the patient
- Is willing to assume responsibility of being primary pain manager
- Is willing to accept and respect patient’s reports of pain (if able to provide) as best indicator of how much pain the patient is experiencing; knows how to use and interpret a pain rating scale
- Understands the purpose and goals of patient’s pain management plan
- Understands concept of maintaining a steady analgesic blood level
- Recognizes signs of pain and side effects and adverse reactions to opioid
- Nurse-Activated Analgesia
- Child’s primary nurse designated as primary pain manager and is only person who presses PCA button during that nurse’s shift
- Guidelines for selecting primary pain manager for family-controlled analgesia also applicable to nurse-activated analgesia
- May be used in addition to basal rate to treat breakthrough pain with bolus doses; patient assessed every 30 minutes for need for bolus dose
- May be used without a basal rate as a means of maintaining analgesia with around-the-clock bolus doses
- Intramuscular
- Note: Not recommended for pain control; not current standard of care
- Painful administration (hated by children)
- Tissue and nerve damage caused by some drugs
- Wide fluctuation in absorption of drug from muscle
- Faster absorption from deltoid than from gluteal sites
- Shorter duration and more expensive than oral drugs
- Time-consuming for staff and unnecessary delay for child
- Note: Not recommended for pain control; not current standard of care
- Intranasal
- Available commercially as butorphanol (Stadol NS); approved for those older than 18 years of age
- Should not be used in patient receiving morphine-like drugs because butorphanol is partial antagonist that will reduce analgesia and may cause withdrawal
- Intradermal
- Used primarily for skin anesthesia (e.g., before lumbar puncture, bone marrow aspiration, arterial puncture, skin biopsy)
- Local anesthetics (e.g., lidocaine) cause stinging, burning sensation
- Duration of stinging dependent on type of “caine” used
- To avoid stinging sensation associated with lidocaine:
- Buffer the solution by adding 1 part sodium bicarbonate (1 mEq/mL) to 9 to 10 parts 1% or 2% lidocaine with or without epinephrine
- Normal saline with preservative, benzyl alcohol, anesthetizes venipuncture site
- Same dose used as for buffered lidocaine
- Topical or Transdermal
- EMLA (eutectic mixture of local anesthetics [lidocaine and prilocaine]) cream and anesthetic disk or LMX4 (4% liposomal lidocaine cream)
- Eliminates or reduces pain from most procedures involving skin puncture
- Must be placed on intact skin over puncture site and covered by occlusive dressing or applied as anesthetic disc for 1 hour or more before procedure
- Lidocaine-tetracaine (Synera, S-Caine)
- Apply for 20 to 30 minutes
- Do not apply to broken skin
- LAT (lidocaine-adrenaline-tetracaine), tetracaine-phenylephrine (tetraphen)
- Provides skin anesthesia about 15 minutes after application on nonintact skin
- Gel (preferable) or liquid placed on wounds for suturing
- Adrenaline not for use on end arterioles (fingers, toes, tip of nose, penis, earlobes) because of vasoconstriction
- Transdermal fentanyl (Duragesic)
- Available as patch for continuous pain control
- Safety and efficacy not established in children younger than 12 years of age
- Not appropriate for initial relief of acute pain because of long interval to peak effect (12 to 24 hours); for rapid onset of pain relief, give an immediate-release opioid
- Orders for “rescue doses” of an immediate-release opioid recommended for breakthrough pain, a flare of severe pain that breaks through the medication being administered at regular intervals for persistent pain
- Has duration of up to 72 hours for prolonged pain relief
- If respiratory depression occurs, possible need for several doses of naloxone
- Vapo-coolant
- Use of prescription spray coolant, such as Fluori-Methane or ethyl chloride (Pain-Ease); applied to the skin for 10 to 15 seconds immediately before the needle puncture; anesthesia lasts about 15 seconds
- Some children dislike cold; may be more comfortable to spray coolant on a cotton ball and then apply this to the skin
- Application of ice to the skin for 30 seconds found to be ineffective
- EMLA (eutectic mixture of local anesthetics [lidocaine and prilocaine]) cream and anesthetic disk or LMX4 (4% liposomal lidocaine cream)
- Rectal
- Alternative to oral or parenteral routes
- Variable absorption rate
- Generally disliked by children
- Many drugs able to be compounded into rectal suppositories
- Regional Nerve Block
- Use of long-acting local anesthetic (bupivacaine or ropivacaine) injected into nerves to block pain at site
- Provides prolonged analgesia postoperatively, such as after inguinal herniorrhaphy
- May be used to provide local anesthesia for surgery, such as dorsal penile nerve block for circumcision or for reduction of fractures
- Inhalation
- Use of anesthetics, such as nitrous oxide, to produce partial or complete analgesia for painful procedures
- Side effects (e.g., headache) possible from occupational exposure to high levels of nitrous oxide
- Family-Controlled Analgesia
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