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CancerOne of the goals of pain management during pediatric procedures is to make the child comfortable so that the child (and parents) will not dread the subsequent procedures. Thus, success is not a matter of merely restraining the child sufficiently to allow the procedure to be performed. Consider measures to control pain and anxiety an integral part of patient management. It is imperative that aggressive pain management be part of the initial diagnostic evaluation, since this may help prevent future difficulties with these and other procedures.
A. General principles In general, avoid unnecessary tests.
Consolidate blood work so that all necessary studies are obtained at the same time; use central lines when possible.
Persons performing a procedure should have a documented level of skill, and there must be appropriate supervision of less-experienced operators.
B. Environment
Major procedures (e.g., bone marrow aspiration, lumbar puncture) should never be performed in the patient’s bed.
The environment of the treatment room should be relatively calm.
Encourage a parent (or parent substitute) to attend the procedure and to participate actively in assisting the child. Do not demand that the parent restrain the child in any way. Instead, the parent should provide comfort or lead the child in any of a variety of distracting behavioral interventions.
C. Behavior management
Use age-appropriate behavior management techniques. For infants, this may include stroking, swaddling, or use of a pacifier. Older children may be managed with distraction, story telling, bubble blowing, or hypnosis.
A full review of these techniques is beyond the scope of this chapter but may be found in McGrath (1990).
D. Sedation
Follow the standards for administering, monitoring, and documenting conscious sedation as developed by the American Academy of Pediatrics or the American Society of Anesthesiology (see Bibliography). Patients should have nothing by mouth (NPO) for clear liquids at least 2 hours before the procedure and NPO for solid foods at least 4-6 hours before the procedure. There must be a time-based record that documents vital signs and the level of sedation at appropriate intervals. Monitor all patients for pulse oximetry, blood pressure, heart rate, response to verbal command, and adequacy of pulmonary ventilation. Electrocardiogram (ECG) monitoring may be indicated for patients with significant cardiovascular disease.
E. Pharmacologic intervention
Warning: Before administering a sedative or opioid agent, ensure the immediate availability of oxygen, naloxone, flumazenil, and resuscitative equipment for the maintenance of a patent airway and support of ventilation. Pulse, respiration, blood pressure, and pulse oximeter measurements should be monitored by a person specifically assigned to this task.
1. Age 0-6 months
a. Apply local anesthesia with EMLA cream by occlusive
dressing at least 1 hour before performing the procedure. Infiltration of the deeper tissues with 196 lidocaine is helpful. Buffering of lidocaine with NaHC03 (9 parts lidocaine: 1 part NaHC03 USP) may alleviate some of the burning discomfort associated with the lidocaine injection. For procedures performed without EMLA cream, use buffered 1 % lidocaine for the skin as
well as deeper structures. The dose of lidocaine should not exceed 5 mg/kg (0.5 mL/kg).
b. Consider using a 22-gauge lumbar puncture needle for both bone marrow aspiration and lumbar puncture.
c. The use of opioids and sedatives for conscious sedation with this age group may be difficult. If analgesia is deemed necessary, consider small doses of a single medication. Consider completing the procedure under general anesthesia or deep sedation by an anesthesiologist.
2. Age >6 months
a. Apply local anesthesia with EMLA patch by occlusive dressing at least 1 hour before the procedure. This may be supplemented by infiltrating 196 lidocaine intrader-mally and subcutaneously (to the level of the periosteum for bone marrow procedures); the dose of lidocaine should not exceed 5 mg/kg (0.5 mL/kg).
b. With patients who do not have an established intravenous (IV) route and for whom an IV line would not otherwise be indicated, try the oral route first. With patients who already have an IV line in place, use intravenous sedation.
c. Use a combination of a sedative (for anxiety) and an opioid (for analgesia) Sedatives alone are inadequate.
i. Sedative
Give midazolam (Versed) IV solution: 0.2-0.4 mg/kg PO 20-30 minutes before the procedure or 0.05 mg/kg IV 3-4 minutes before the procedure. When deemed appropriate, midazolam can also be administered rectally at a dose of 0.2-0.5 mg/kg 5-10 minutes before the procedure. If intravenous access is available, half the original dose may be repeated if the child is not adequately sedated when the procedure begins. When using midazolam (or other benzodiazepines), flumazenil (Romazicon), a benzodiazepine reversing agent, should be available; the dose of flumazenil is 0.01 mg/kg (maximum dose 0.2 mg) by slow IV push. and
ii. Opioid
Give fentanyl 0.001 mg/kg (1 pg/kg) IV over 1-2 minutes, 3-5 minutes before the procedure. Half the original dose can be repeated if the child is not adequately sedated when the procedure begins. or
Give morphine sulfate 0.15-0.2 mg/kg PO 20-30 minutes before the procedure or 0.05 mg/kg IV over 1-2 minutes, 10 minutes before the procedure begins.
d. Consider transmucosal fentanyl citrate (Fentanyl
Oralet).
This transmucosal opioid delivery system has been shown to be useful as a single agent for painful procedures in children with cancer. The dose is 5-15 pg/kg with the unit dose chosen closest to that to be administered (100, 200, 300, and 400 pg sizes). The unit dose is sucked (must not be chewed) in the buccal pouch 15-20 minutes before the procedure is to be performed.
Do not administer with anxiolytics or other opioids. In general, this is not useful in toddlers, who may not be able to cooperate by sucking the lozenge, e. If efforts to produce conscious sedation are inadequate or if multiple painful procedures (e.g., bilateral bone marrow aspirations and biopsies) are to be performed, consider general anesthesia. Some clinicians advocate agents such as ketamine, propofol, and nitrous oxide as appropriate for use for conscious sedation in children undergoing painful procedures. All of these agents may best be used by anesthesiologists with specialized training in their administration and in appropriate support of the airway.
i. Ketamine is a dissociative general anesthetic agent that has many well-known side effects that are potentially difficult to manage. These include hypersalivation, increased cerebral blood flow, disturbing hallucinations, and prolonged recovery periods.
ii. Propofol is an intravenous diisopropylphenol general anesthetic agent that can easily result in loss of all protective reflexes, markedly decreases systemic vascular resistance, and can cause severe myocardial depression.
iii. Nitrous oxide is a clear, odorless inhaled anesthetic agent that is analgesic as well as amnestic. It can be administered in oxygen and has been used for painful procedures as well as in emergency rooms. It can induce general anesthesia with loss of protective reflexes. In addition, it must be used with a dedicated scavenging system to prevent environmental
contamination.
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