Pediatric Pain Management and Medication Error Prevention

Transcription

1 Pediatric Pain Management and Medication Error Prevention Tara L. Smith, Pharm. D. Clinical Pharmacy Manager Sacred Heart Hospital, Pensacola, FL May 19, 2010

2 Disclosures There are no disclosures for this speaker

3 Objectives Define pain Discuss assessment of pediatric pain Review current treatment options Identify methods to prevent errors with pain medications

4 Pain Pain (pān) [L. poena, dolor; Gr. algos, odynē] a more or less localized sensation of discomfort, distress, or agony, resulting from the stimulation of specialized nerve endings. It serves as a protective mechanism insofar as it induces the sufferer to remove or withdraw from the source. accessed May 2010

5 Pain can be Acute Procedural Post-operative Traumatic Chronic Sickle Cell Migraine Cancer

6 Types of Pain Nociceptive Somatic tissue or joint injury, dull or aching Viceral deep internal pain, pressure or cramping Neuropathic pain occurring after an injury heals, involves peripheral nerves or CNS Psychogenic pain related to psychological distress

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8 Developmental Pain Perception Neonates & Infants Can t verbally explain their pain or tell you where it hurts Have physiologic and neurobiologic differences Neural transmission in peripheral nerves is slower Dorsal horn neurons have wider receptive fields and lower excitatory thresholds Brislin RP, Rose JB. Anes Clin N Am 23 (2005)

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10 Toddlers & Children Can usually verbalize where it hurts, however Do not have vocabulary to describe the pain Cannot pinpoint the exact site of pain

11 Adolescents Can better explain pain Where it hurts What it feels like How long it lasts How intense the pain feels Must differentiate drug seeking from true pain

12 Pain Assessment Few formal studies for pediatric pain treatment The Joint Commission has put more emphasis put on pain as the 5 th vital sign More evidence pointing to long term effects of painful experiences in childhood

13 Pain Assessment Multiple pain rating scales Wong-Baker Faces FLACC (Faces, Legs, Activity, Cry, Consolability) N-PASS (Neonatal Pain, Agitation, & Sedation Scale) CHIPPS (Children s and Infants Postoperative Pain Scale)

14 Wong-Baker & Number Scale Hockenberry, MJ, Wilson, D: Wong s Nursing Care of Infants and Children, ed. 8, St. Louis, 2007, Mosby. Reprinted with permission. Copyright Mosby.

15 FLACC Scale

16 Sedation Assessment Ramsay Scale GCS modified by Cook & Palma Vancouver Sedative Recovery Scale (VSRS) COMFORT Scale Sedation Agitation Scale (SAS) Motor Activity Assessment Scale (MAAS)

17 Developmental Pharmacology of Pain Treatment Drug Distribution Vd - Higher water to total body ratio in neonates and infants = potential for longer duration of action of water-soluble drugs Neonates have higher percentage of cardiac output going to brain = higher drug concentrations in brain Smaller fat and muscle stores = higher plasma concentration due to less drug uptake Brislin RP, Rose JB. Anes Clin N Am 23 (2005)

18 Developmental Pharmacology of Pain Treatment Hepatic metabolism CYP450 responsible for metabolism of many analgesics (NSAIDs and opioids) At birth hepatic enzymes are immature resulting in reduced clearance of drugs Drug clearance in 2-6 year olds is higher than adults due to hepatic mass relative to body mass Brislin RP, Rose JB. Anes Clin N Am 23 (2005)

19 Developmental Pharmacology of Pain Treatment Renal excretion Depends on renal blood flow, glomerular filtration rate and tubular secretory function Renal function reaches adult levels by 1 year of age Greco C, Berde C. Pediatr Clin N Am 52 (2005)

20 Developmental Pharmacology of Pain Treatment Protein binding reduced in neonates Lower plasma albumin and glycoprotein Highly protein bound drugs (opioids, anesthetics) have higher unbound concentration Greco C, Berde C. Pediatr Clin N Am 52 (2005)

21 Treatment - NSAIDS Acetaminophen Ibuprofen Aspirin Ketorolac Oral and IV formulation

22 Treatment Opioids Morphine Standard opioid that other opioids are measured against

23 Treatment Opioid Derivatives Hydromorphone Methadone Fentanyl Meperidine Codeine Oxycodone Hydrocodone Tramadol

24 Treatment Atypical Opioids Ketamine Phencyclidine derivative Dissociative anesthesia

25 Treatment - Miscellaneous Nalbuphine Kappa agonist and mu antagonist Clonidine Alpha 2 adrenergic agonist Dexmedetomidine Alpha 2 receptor agonist

26 Pain Management Strategies - Oral Various options for dosing Liquid Tablet Chewable tablet Extended-release

27 Pain Management Strategies - IV Intermittent Bolus dosing peaks and valleys with pain control Can be combined in-patient with oral meds to cover breakthrough pain Can cover breakthrough pain with PCA

28 Pain Management Strategies - IV Continuous In-patient use only with close monitoring Routine sedation assessments

29 Pain Management Strategies - PCA, PCEA Best used in children that can understand when to push the button (usually children greater than 7 years old) Must be cautious that parents or nurses are not managing the drug administration

30 Pain Management Strategies - Intranasal Fentanyl Useful in short procedures with quick recovery from sedation Butorphanol Dispensed as nasal spray Ketorolac tromethamine (Sprix ) New product not yet approved in pediatrics Less side effects than IV or oral products

31 Pain Management Strategies - Transdermal Lidocaine/prilocaine cream Buffered lidocaine Jet propulsion Fentanyl patches Cannot be cut Patch can be blocked so only the portion touching the skin is being absorbed

32 Pain Management Strategies - Non-pharmacologic Cognitive behavior therapies Distraction Guided imagery Relaxation Child Life Specialists

33 Monitoring and Managing Side Effects Nausea Pruritis Sedation Constipation

34 Out-Patient Med Error Prevention Acetaminophen 32mg/ml liquid 100mg/ml infant drops Ibuprofen 20mg/ml liquid 40mg/ml infants drops

35 Dosing Devices Different dropper sizes Pediacare Fever Drops come with a 1.25ml (¼ tsp) dropper Motrin and Advil Infant's Drops come with a 1.875ml syringe for dosing The administered dose is the same, but dosing tools are different

36 Combination Products Be careful with dose calculations Acetaminophen with Codeine Acetaminophen with Hydrocodone Dose is based on most potent drug

37 Caregiver Understanding Milligrams vs. milliliters Teaspoon vs. milliliters Confirm dose measurement with caregiver at point of dispensing EVERY refill

38 In-patient Medication Error Prevention Multiple concentrations of injectable meds Morphine 2mg/ml 4mg/ml 5mg/ml 10mg/ml 15mg/ml Multiple concentrations of oral meds Morphine Liquid 2mg/ml Liquid concentrate 20mg/ml Immediate-release tablet Extended-release tablet

39 Verbal Orders

40 Standard Drip Concentrations Continuous IV infusions Standard concentrations and volumes Appropriate rates for patient size (neonate vs. teen) Programmable smart pumps PCA Bolus doses and hourly limits Basal rates PCEA Often combination products

41 Pain Protocols ISMP Guidelines for Standard Order Sets Post-operative order sets Procedural order sets CT, MRI Central line placement Disease state specific orders Migraine Sickle Cell Oncology

42 ISMP Confused Drug Names Morphine Hydromorphone Clonidine Klonopin Codeine Lodine Toradol Foradil Fentanyl Sufentanil Hydrocodone Oxycodone Ketorolac Ketalar Methadone Metadate Methylphenidate Naloxone Lanoxin Narcan Norcuron Celebrex Cerebyx

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