Palliative Care: Pain and symptom management

PALLIATIVE CARE: PAIN AND SYMPTOM MANAGEMENT CAROL MAY RN, MSN, MBA, CHPPN SUPPORTIVE CARE PROGRAM CHILDRENS HOSPITAL OF PITTSBURGH OF UPMC PAIN DEFINED Pain is a subjective response

Pain in childhood can be acute or chronic Children's pain is influenced by many factors POPULATIONS AT RISK Chronic conditions Trauma/Injury Neonates/Infants Neurological Impairment Non-English speaking

Cultural, gender stereotyping Hx substance abuse BARRIERS TO PAIN RELIEF Healthcare professionals Healthcare system Related to parents/children

MYTHS Respiratory depression Addiction Running out of pain meds Presence of pain indicates worsening of disease and approaching death FACTS ABOUT CHILDHOOD PAIN

Opioid addictions are rare Repeated exposure leads to increased anxiety and perception of pain Studies have shown that children as young as 3 years old can use pain scales Carter et al., 2004; Goldman et al., 2006; Hockenberry & Wilson, 2006; Schecter, 2003

MYTHS RELATED TO NEONATAL/INFANT PAIN Incapable of feeling pain Immature nervous system Incomplete myelinization No memory Objective assessment impossible Neonates cannot communicate pain Analgesics unsafe

FACTS ABOUT NEONATAL/INFANT PAIN Pain perception occurs early in life Neonates exhibit physiologic and behavioral cues IMPACT OF PAIN Research asked What is it like to have a child with pain? Unendurable

Helplessness Sense of total commitment Feels pain physically Unprepared/unknowledgeable Horrible/frightening No pain in heaven Wish for death Ferrell et al., 1994a & 1994b

SPECIAL POPULATIONS Neurocognitive Impairment Pain Experience Pain Indicators Effect of Uncontrolled Pain Assessment Knowing Child Recognizing Patterns Intersubjective process with HCP

TYPES OF PAIN Nociceptive Pain (normal processing of pain) Somatic Bone, joints, connective tissue Achy, throbbing Well localized

Visceral Organs, soft tissue Aching, cramping Localized, diffuse Neuropathic Pain (abnormal processing of pain) Centrally mediated

Deafferentation pain Sympathetic pain Peripherally mediated Polyneuropathies Mononeuropathies Sharp, shooting, electric Usually requires adjuvant medications

TOLERANCE effect of a medication over time, requiring dose to achieve same level of efficacy Should consider differential diagnosis Tolerance addiction Easily managed by dose or interval between dosing Should not withhold opioid PHYSIOLOGICAL DEPENDENCE

Development of withdrawal syndrome after: Abrupt discontinuation of therapy Substantial dose reduction Administration of antagonist medication (naloxone) PSYCHOLOGICAL DEPENDENCE (ADDICTION) Pattern of compulsive drug use characterized by continued craving for an opioid and the need to use the opioid for effects other than pain relief

Three distinguishing characteristics Continued cravings with/without pain Illegal and anti-social behavior in order to obtain the drug Chronic, relapsing condition APS, 2003 ANALGESICS

Acetaminophen/NSAIDs Acetaminophen Little is known about mechanism of analgesia centrally mediated

Useful for mild pain, little antiinflammatory action NSAIDs Cyclooxygenase inhibition leads to interference with production of PGs (Cox-2) Decreased PGs also responsible for gastric SEs (Cox-1) Cox-2 inhibitors do not inhibit Cox-1, thereby

limiting gastric SEs Can be used in mild, moderate, acute or chronic, pain alone Use in severe pain in combination with opioid + adjuvant Dosing PRN or ATC depending on source of pain

ANALGESICS Management of NSAID Side Effects Primary SE is gastric irritation, heart burn Serious SE is ulceration and bleeding Use gastroprotective for prolonged use Effect on platelet aggregation short acting, reversible Renal effects rare, insufficiency and nephrotoxicity can occur with prolonged high doses

ANALGESICS Combination Analgesics (weak opioids) Codeine Use in mild pain only, limited use in severe pain Maximum recommended dose (60mg) produces analgesia equal to 600mg aspirin Combination product with acetaminophen Hydrocodone Only available in combination with acetaminophen, aspirin, or

ibuprophen Not appropriate for moderate to severe pain ANALGESICS Opioids Morphine as gold standard Variety of routes, formulations Large body of research Used for moderate to severe/intractable pain

Fentanyl Used in anesthesia, procedural sedation Acute moderate to severe pain Patch has found use in some cancer and chronic non-malignant pain ANALGESICS Opioids Hydromorphone

More potent than morphine Available in high-potency formulations Methadone Gaining favor as analgesic in chronic pain Long half-life therefore longer time to steady state Not useful in breakthrough pain ADJUVANTS Co-analgesics - medications that are used in combination with opioids to

enhance analgesia or treat specific types of pain Antidepressants - amitriptyline, nortriptyline Anticonvulsants gabapentin, tegretol Anesthetics - lidocaine, ketamine, propofol Corticosteroids dexamethasone Anxiolytics - lorazapam, diazapam, midazolam Barbiturates - phenobarbitol, pentobarbitol

ANALGESIC SIDE EFFECTS Constipation Tolerance DOES NOT occur Miralax, senna and ducosate sodium, ducosate sodium, bisacodyl, mag citrate, lactulose Sedation Tolerance w/in a few days Dextroamphetamine, methylphenidate, caffeine ANALGESIC SIDE EFFECTS (CONT.)

Urinary retention oxybutynin Nausea/Vomiting zofran, Ativan, benadryl Pruritus - diphenhydramine, hydroxyzine, narcan NON-PHARMACOLOGICAL PAIN MANAGEMENT

Visualization/Guided Imagery Deep breathing/Relaxation Massage

Heat Positioning Physical Therapy Hydrotherapy Consult Child Life, Social Work, Rehab Med for assistance WHY ARE WE SEEING MORE SYMPOTMS Children are living longer with complex chronic medical conditions.

Multiple acute and chronic health crises create significant challenges for the child and family. HOW CAN WE AS A TEAM HELP THE FAMILY Family shapes types of interventions Illness experience QOL and sources of suffering as defined by the family Goals of care Curative/restorative

Life prolongation Comfort SYMPTOMS AND SUFFERING Determine priority symptoms for the child Symptoms create suffering and distress Interdisciplinary care Are we all talking together

NEUROLOGICAL Autonomic Dysregulation storming Dystonias Restlessness/Agitation Seizure

DYSTONIA/SPASTICITY Definitions Populations Complications Management RESTLESSNESS/AGITATION Definition

Causes Assessment TREATMENT Provide routine, comfort and support Decrease stimulation Pharmacologic Non-pharmacologic Relaxation

Massage SEIZURES Overview Causes Presentation Treatment DYSPNEA

Distressing shortness of breath Breathlessness Associated diseases TREATMENT OF DYSPNEA Non-pharmacologic Oxygen Energy conservation

Fans, elevation Counseling Other TERMINAL RESPIRATIONS Characteristics Causes Assessment Treatment

ISSUES RELATED TO FLUIDS/ NUTRITION Personal/ethical dilemmas No different then withholding artificial ventilation Parental support CAUSES OF CONSTIPATION Disease related (e.g. obstruction, hypercalcemia, neurolgic, inactivity)

Treatment related (e.g. opioids, other meds) CAUSES OF NAUSEA AND VOMITING Gastrointestinal causes Metabolic Causes CNS causes PHARMACOLOGIC TREATMENT OF NAUSEA

AND VOMITING Anticholinergics Antihistamines Steroids Prokinetic agents Other NON-DRUG TREATMENT OF NAUSEA AND VOMITING

Distraction Dietary Small/slow feeding Invasive therapies FATIGUE Subjective, multidimensional experience of exhaustion Commonly associated with many diseases Impacts all dimensions of quality of life

CAUSES OF ANXIETY Medications and substances Uncertainty TREATMENT OF ANXIETY Medications

Empathetic listening Assurance and support Maximize symptom management Relaxation/imagery WHAT SYMPTOMS? What have you seen that you have questioned the treatment of??

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