Pediatrics : Family-Controlled Analgesia

        • 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
        • 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
        • 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

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