Key Concepts
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Patients of all ages experience pain, including infants, neonates, and premature babies.
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Oligoanalgesia, the inadequate treatment of pain, has many short-term and long-term consequences: worse patient outcomes, increase in patient’s pain threshold, and development of chronic pain.
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Pain management may include a combination of techniques: analgesics, topical anesthetics, local anesthetic injections, oral sucrose in infants, and nonpharmacologic interventions.
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Nonpharmacologic interventions to decrease pain or anxiety include parental presence; physical measures, such as heat or cold therapy and splinting for musculoskeletal injuries; and behavioral or cognitive measures, such as distraction and play therapy.
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Topical anesthetics are recommended to decrease the pain of minor procedures, such as venipuncture or IV cannulation.
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Techniques for decreasing the pain of intradermal injections include topical agent prior to the intradermal injection; slowly injecting warmed, buffered local anesthetic solution from within the wound with the smallest gauge needle possible; and limiting the number of needle punctures.
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When using large amounts of local anesthetics in small children or infants, calculate the drug dose to avoid toxicity; a 1% solution = 1 g/100 mL or 10 mg/mL.
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Procedural sedation and analgesia (PSA) requires pre-sedation evaluation; sufficient monitoring (during and after the procedure) by qualified individuals capable of dealing with any adverse events that may occur; age-appropriate equipment (including airway equipment) and medications (including reversal agents and advance life support drugs); and discharge criteria for when the patient is fully awake, returns to baseline with normal vital signs, and is able to be discharged in the care of a responsible adult.
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Overall, preprocedural fasting is not necessary for most emergency patients, because large studies show no clinically significant differences with airway complications, emesis, or other adverse effects between groups of patients stratified by their preprocedural fasting status.
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Choice of sedative and analgesic for PSA depends on many variables including patient factors and the procedure to be done. Slow titration of medications can achieve the desired level of sedation and analgesia while minimizing risk of adverse events.
Sedation
Foundations
Sedation is a controlled reduction of environmental awareness. Sedation is a continuum that begins with minimal, moving to moderate, then deep sedation, and may proceed to general anesthesia.
Definitions ,
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Anxiolysis is a state of decreased apprehension concerning a particular situation in which the patient’s level of awareness does not change.
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Analgesia refers to the relief of pain without the intentional alteration of mental status, such as occurs in sedation. An altered mental state may be a secondary effect of the medications administered for this purpose.
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Minimal sedation (e.g., anxiolysis) is a drug-induced state during which patients respond normally to verbal commands. Although cognitive functions and coordination may be impaired, ventilatory and cardiovascular functions are unaffected.
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Moderate sedation/analgesia (formerly called “conscious sedation”) refers to a drug-induced depression of consciousness during which patients respond purposefully to verbal commands, either alone or accompanied by light tactile stimulation. Reflex withdrawal from the painful stimulus is NOT considered a purposeful response. No interventions are required to maintain a patent airway, and spontaneous ventilation is adequate. Cardiovascular function is usually maintained.
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Dissociative sedation is a trancelike cataleptic state induced by the dissociative agent ketamine and characterized by profound analgesia and amnesia, while protective airway reflexes, spontaneous respirations, and cardiopulmonary stability are maintained.
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Deep sedation/analgesia describes a drug-induced depression of consciousness during which patients cannot be easily aroused but respond purposefully after repeated or painful stimulation. The ability to independently maintain ventilatory function may be impaired. Patients may require assistance in maintaining a patent airway, and spontaneous ventilation may be inadequate. Cardiovascular function is usually maintained.
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General anesthesia is a drug-induced loss of consciousness during which patients are not arousable, even with painful stimulation. The ability to independently maintain ventilatory function is usually impaired. Patients require assistance in maintaining a patent airway, and positive-pressure ventilation may be required because of depressed spontaneous ventilation or drug-induced depression of neuromuscular function. Cardiovascular function may be impaired.
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Procedural sedation and analgesia (PSA) are techniques of administering a sedative or dissociative agent, usually along with an analgesic, to induce a state that allows the patient to tolerate painful or unpleasant procedures while maintaining adequate spontaneous cardiorespiratory function. It is intended to result in a depressed level of consciousness that allows the patient to maintain oxygenation and airway control independently and continuously.
The goal of PSA is to alleviate the anxiety, pain, and suffering associated with medical procedures. PSA is an essential part of emergency medicine practice and part of the core curriculum for emergency medicine training programs. Providers should be prepared to appropriately manage the airway and in rare instances intubate if sedation becomes deeper than expected.
Specific Issues
Preparation
The patient’s American Society of Anesthesiology (ASA) physical status classification should be calculated prior to procedure ( Table 157.1 ) and airway assessed, for example, using the Mallampati score (see Chapter 1 ) to identify potential difficulties. Children with special needs, anatomic airway abnormalities, moderate to severe tonsillar hypertrophy, and current or recent upper respiratory illness present increased risk and require additional consideration. , ASA classes I and II are considered appropriate candidates for minimal, moderate, or deep sedation. Staff are encouraged to consult with appropriate subspecialists (e.g., pediatric anesthesiologist) if there is a question of sedation adverse events because of an underlying medical/surgical condition (e.g. Pierre Robin syndrome). Those aged less than 3 months or with weight less than 5 kg are at increased risk for sedation adverse events.
TABLE 157.1
American Society of Anesthesiologists Physical Status Classification
| Class | Description | Examples | Sedation Risk |
|---|---|---|---|
| I | Normal and healthy patient | No past medical history | Minimal |
| II | Mild systemic disease without functional limitations | Mild asthma, controlled diabetes | Low |
| III | Severe systemic disease with functional limitations | Pneumonia, poorly controlled diabetes mellitus, hypertension or seizure disorder | Intermediate |
| IV | Severe systemic disease that is a constant threat to life | Advanced cardiac disease, renal failure, sepsis | High |
| V | Moribund patient who may not survive without procedure | Septic shock, severe trauma | Extremely high |
| VI | A declared brain-dead patient whose organs are being removed for donor purposes | ||
There should be at least one provider, in addition to the provider performing the procedure, who is responsible to monitor appropriate physiologic parameters and assist in any needed supportive or resuscitation measures. Pulse oximetry and capnography readings should be continuously monitored; depth of sedation, heart rate, blood pressure, and respiratory rate should be recorded at regular intervals. Although there are scales for assessing the depth of sedation in pediatric patients, continuous monitoring is more important than any specific measurement on a sedation scale. Although there is no evidence of benefit in young healthy individuals, cardiac monitoring has been shown useful in those with a cardiac history and older patients. Thus, we recommend continuous cardiac rhythm monitoring, especially for high-risk patients (e.g., preexisting cardiovascular disease or a history of dysrhythmias) or high-risk procedures (e.g., cardioversion).
Providers administering pediatric procedural sedation should have training and skills in airway management and be ready to rescue the patient from a deeper level than intended for the procedure, since it is common for children to pass easily into a deeper level of sedation. In addition to monitoring equipment and oxygen, age-appropriate suction, bag-valve-mask, and intubating equipment should be available and readied prior to administering medications. The SOAP-ME mnemonic provides an equipment checklist for sedation :
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S ize-appropriate suction catheters (connected, checked, and with suction turned on)
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O xygen supply (connected to bag and turned on)
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A irway: Size-appropriate airway equipment (appropriate size mask and intubation supplies)
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P harmacy: Advanced life support medications and antagonists
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M onitors: Size-appropriate oximeter, end-tidal carbon dioxide monitor, and blood pressure cuff
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E quipment or drugs for a particular case
Children over age 4 can benefit from simple information about what to expect for their procedure. Explaining the steps, as well as what they might see or feel, being shown the medical supplies (e.g., irrigation solution), and offering realistic options for their procedure help them feel in control. Similarly, parents should be prepared for where to sit and how they can assist with positioning or distraction. A child’s ability to control behavior and cooperate for a procedure depends on chronologic age and cognitive/emotional development.
Preprocedural Fasting
The ASA has guidelines for preoperative fasting in healthy patients of all ages undergoing elective procedures. In patients undergoing PSA in the emergency department (ED), the evidence indicates that preprocedural fasting does not decrease the risk of emesis or aspiration, as noted in the American College of Emergency Physicians (ACEP) clinical policy. , Recent studies in pediatric patients do not find any evidence of association between vomiting and shortened fasting time, and no patients were found to have aspiration. Therefore, adherence to the ASA preoperative fasting guidelines for procedures is not necessary in ED patients undergoing PSA.
Supplemental Oxygen and Capnography During Procedural Sedation and Analgesia
Use of supplemental oxygenation has been shown to decrease the incidence of desaturation in pediatric patients from 17% to 10%, although it may delay the recognition of hypoventilation or apnea. Oxygen desaturation and delay in assisted ventilation events can be significantly reduced with the use capnography. Close capnography monitoring can detect hypoventilation early, prior to a drop in pulse oximetry, irrespective of use of supplemental oxygen. ACEP and AAP clinical policy recommend capnography be routinely used to monitor ventilation in children undergoing PSA.
Specific Medications
Table 157.2 details specific PSA sedative agents commonly used in infants and children. Patient age, preexisting conditions, and anticipated level of pain or anxiety should guide choice of sedative. Providers should administer drugs by slow intravenous (IV) titration to decrease the risk of adverse events, including hypotension and respiratory depression. For intranasal medications or nitrous oxide use, employing a Child Life specialist or the parents to assist with distraction, music, or other cognitive behavioral modalities may be advantageous.
TABLE 157.2
Commonly Used Sedatives for Procedural Sedation in Children and Infants
| Sedative | Route | Dose | Usual Dose | Maximum Dose | Onset | Duration | Side Effects | Advantages/Comments |
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| Dexmedetomidine | IN | 2–4 mcg/kg/dose | 3 mcg/kg/dose | 200 mcg (100 mcg/nare) | 30 min | 60–90 min | Decreased HR and BP | Contraindication with heart block, severe renal or hepatic impairment or use of beta blockers |
| Etomidate | IV | 0.1–0.3 mg/kg | 0.2 mg/kg PSA | 0.4 mg/kg | <1 min | 3–10 min | Pain on injection, myoclonic movements, adrenal insufficiency (prolonged use) | Minimal CV/respiratory depression |
| Ketamine | IV | 1–2 mg/kg initial (repeat 0.5–1 mg/kg for longer procedures) | 1.5 mg/kg initial PSA | 1 min | 15 min |
Sympathomimetic effects (↑︎HR, ↑︎BP)
Nausea, vomiting Emergence reaction Laryngospasm (rare) |
Warn parents of nystagmus as an expected effect. Has analgesic effect CV/respiratory stability bronchodilator (use in asthmatics)
Battlefield use/disasters |
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| Ketamine | IM | 4 mg/kg |
4 mg/kg
2 mg/kg if <2 years old |
5 min | 30 min |
(Same as above)
Higher risk of nausea |
(Same as above) | |
| Ketamine | IN | 3–9 mg/kg | 10 min | 60 min | (Same as above) | (Same as above) | ||
| Midazolam | IV |
0.05–0.1 mg/kg (6 months to 5 years old or adult)
0.025–0.05 mg/kg (≥6 years old) Give slowly 1–2 mg over ≥ 2 min and titrate to effect |
If giving with fentanyl, may dose at 0.02 mg/kg | 0.6 mg or 6 mg if ≤5 years old and 10 mg if >6 years old | 5 min | 30 min | Paradoxical agitation, vomiting, coughing, hiccups, dizziness, respiratory depression, apnea so use lower dose if given with opioids or respiratory depressants |
Protective in seizure patients
↓︎ ICP, CBF, ↓︎ LV filling pressure may benefit cardiac patients Mild CV effects unless hypovolemicReversed by antagonist flumazenil |
| Midazolam | IN | 0.2–0.5 mg/kg | 0.2 mg/kg | 10 mg | <10 min | (Same as above) | (Same as above) | |
| Pentobarbital f | IV | 1–6 mg/kg | 1–2 mg/kg initial, repeat 3–5 min to desired effect or max dose | 100 mg/dose | 1–2 min | 15–60 min |
CV/respiratory depression, paradoxical agitation, extravasation can cause tissue necrosis
Contraindication: Porphyria |
↓︎ IOP, ↓︎ ICP, used to treat status epilepticus
Use in head injury/neurology patients Can use if malignant hyperthermia |
| Propofol | IV | 0.5–1.5 mg/kg (repeat 0.5 mg/kg every 3–5 min for longer procedures) | Variable, may be 1 mg/kg | None | <1 min | 5–15 min (mean 8 min) |
CV/respiratory depression
Use with caution if shock/low BP/impaired cardiac function Caution if allergy to eggs, soybean oil, EDTA g |
Rapid onset/recovery
No dose change if renal or liver disease Can use if malignant hyperthermia |
| Nitrous oxide | Inhalation | Dose is 30%–70% mixture | Commercially available in 50%:50% mixture | 70% | 1–2 min | 15–20 min | Contraindications: Trapped air (bowel obstruction, pneumothorax, emphysema, air emboli) | Need a scavenger system and proper ventilation, potential for abuse, chronic exposure may have adverse effects |
fPentobarbital can be given PO or PR or IM, but onset and duration are longer with more variable effect, so IV is preferred.
g Although the manufacturer’s labeling lists egg allergy as a contraindication, available studies (mostly retrospective) and an American Academy of Allergy, Asthma, and Immunology statement have suggested that propofol may be used safely in soy- or egg-allergic patients (AAAAI [Lieberman 2015]; AAAAI 2019; Asserhoj 2016; Dziedzic 2016; Murphy 2011). In patients with more severe soy or egg allergy, some experts recommend the use of an alternative anesthetic or a small trial dose of propofol prior to full dose administration (Sicherer 2020).
BP, Blood pressure; CBF, cerebral blood flow; CV, cardiovascular; EDTA, ethylenediaminetetraacetic acid; HR, heart rate; ICP, intracerebral pressure; IM, intramuscular; IN, intranasal; IOP, intraocular pressure; IV, intravenous; LV, left ventricular; PO, per oz. (by mouth); PR, per rectum; PSA, procedural sedation and analgesia; RSI, rapid sequence intubation.
Propofol
Propofol has several advantages for PSA; it has a rapid onset in 30-60 seconds, is short acting, and has antiemetic properties. Its side effects include hypotension and respiratory depression. However, studies have shown safe administration in the ED for sedation by physicians who are skilled in airway management and resuscitation of patients that may enter deeper sedation or respiratory distress. Although the dosing of propofol varies from 0.5 to 2 mg/kg, an initial dose of 0.5 to 1.0 mg/kg should be administered and titrated to effect with additional doses, usually in increments of 0.5 mg/kg.
Ketamine
Ketamine, a dissociative anesthetic, has sedative, amnestic, and analgesic properties. Ketamine maintains cardiovascular and respiratory stability, has minimal respiratory depression, and maintains protective airway reflexes in patients with spontaneous respirations. Ketamine’s sympathomimetic effects include increased blood pressure, heart rate, cardiac output, and bronchodilation, making it the preferred sedative in patients with asthma.
Apnea is rare with ketamine (0.8% incidence), but has been associated with very high doses, rapid administration, and co-administration with narcotics or other respiratory depressants. Ketamine increases salivary secretions, which may increase the incidence of laryngospasm, especially in oral procedures; however laryngospasm can typically be resolved with simple airway maneuvers. Laryngospasm is usually transient and responds to repositioning of the head, supplemental oxygen administration, gentle suctioning if secretions are the irritant, and positive pressure ventilation with a bag-valve mask. Although rarely needed, the use of a paralytic at lower doses than required for intubation (e.g., succinylcholine given at 10% of a paralytic dose) has been shown to break laryngospasm when the above measures fail. Rapid sequence intubation is rarely needed, but a last resort option to treat laryngospasm.
Ketamine may be given intravenously, intramuscularly, per os (by mouth; PO), or intranasal (IN). For IV administration in pediatric patients, initial doses range from 1.0 to 2.0 mg/kg, with further bolus doses of 0.5 to 1 mg/kg titrated to desired effect. Intramuscular (IM) dosing is an option when IV access is unobtainable; dosing ranges from 4 to 5 mg/kg. The disadvantages of IM ketamine include a higher rate of vomiting, longer recovery time, and lack of IV access in the event of complications requiring IV medication administration (e.g., paralytics). IN ketamine can be used in dosing ranges from 3-9 mg/kg/dose with onset of action between 5 and 10 minutes. As with all intranasal medications, the optimal intranasal dose per nare is 0.5 to 1 mL.
Use of Ketamine in Patients With Head Injury
Multiple studies have dispelled the myth that ketamine increases intracranial pressure (ICP). Ketamine may even have beneficial effects on the brain, including protection against seizures, cerebral ischemia, and secondary brain injury related to hypotension.
Ketamine Recovery Agitation: Use of Benzodiazepines
Emergence reaction or recovery agitation refers to agitation (which may include floating sensation, vivid pleasant dreams, nightmares, hallucinations or delirium) that can occur after waking up or emerging from ketamine. Pediatric studies have not demonstrated benefit in routine use of benzodiazepines to prevent recovery agitation, likely due to their own adverse effects; although rare, they can cause paradoxical agitation. A large pediatric study showed no significant difference in the report of agitation in patients receiving ketamine and benzodiazepine versus ketamine alone. As no pediatric studies to date have shown benefit, we do not recommend that midazolam be routinely given as an adjunct to ketamine in children. However, when recovery agitation occurs, children can be treated with midazolam (0.03 mg/kg; up to a maximum of 5 mg for ages 6 months to 5 years old, or a maximum cumulative dose of 10 mg for children greater than 5 years old).
Emergence reactions occur more frequently in patients greater than 16 years of age, females, shorter operative procedures, large doses, and individuals with psychiatric disorders. Providers should consider an alternate agent or ketamine plus midazolam for older teens and children with psychiatric illness; schizophrenia is an absolute contraindication. Children typically emerge from the sedated state in the format that they achieve sedation; all children, but teenagers especially, may benefit from the use of positive visualization, music, massage, or other distraction techniques in preparation for sedation.
Use of Anticholinergics With Ketamine
Ketamine stimulates tracheobronchial and salivary secretions. However, studies have shown that the co-administration of anticholinergic medications is associated with an increase in the odds of adverse events. Providers may consider anticholinergics for children undergoing an airway examination (e.g., fiberoptic laryngoscopy) to improve visibility, or in patients with clinically significant hypersalivation or an impaired ability to mobilize secretions, but it should not routinely be used.
Glycopyrrolate is the preferred anticholinergic over atropine; it is a more potent anti-sialagogue and has fewer tachy-dysrhythmias. Unlike atropine, glycopyrrolate does not cross the blood brain barrier, so has no central nervous system (CNS) side effects. CNS side effects of atropine range from drowsiness to coma and include headache, nervousness, insomnia, excitement, dizziness, disorientation, hallucinations, and ataxia. Headache is the only CNS side effect listed for glycopyrrolate.
Use of Antiemetics with Ketamine
Vomiting with ketamine sedation in children is common. Vomiting usually develops during recovery, when patients are alert and can clear their airways. Slow IV administration over several minutes may mitigate this response. Risk is higher among adolescents and patients receiving high doses or IM administration. Although ondansetron is associated with a small decrease in the incidence of vomiting associated with ketamine sedation in children, ondansetron is also associated with other adverse effects, including QT prolongation and serotonin syndrome. We recommend reserving treatment with ondansetron for patients who develop nausea or vomiting during recovery from ketamine.
Ketofol: Ketamine Plus Propofol
The combination of ketamine with propofol has the potential to provide benefits of both sedatives. The combination allows for lower doses of each medication, which may theoretically minimize adverse effects of either sedative alone. The incidence of hypotension from propofol alone has been shown to be lessened when combined with ketamine. , However, studies have not shown significant differences in rates of respiratory depression between co-administration versus either sedative alone.
Ketamine and propofol (ketofol) can be dosed at 0.5 mg/kg to 0.75 mg/kg for each drug via separate syringes. For short procedures, re-dosing is usually not needed. For longer procedures, if the sedation is wearing off, propofol is usually re-dosed (due to its shorter half-life) at 0.1 to 0.5 mg/kg IV.
Dexmedetomidine
Dexmedetomidine is an effective sedative, anxiolytic and analgesic that does not cause respiratory depression. 13 A loading dose poses the risk of bradycardia and hypotension due to α 2 -agonist effects on the sympathetic ganglia. Lack of amnesia can be a concern in certain situations, however, this can be managed with the addition of low dose benzodiazepines. Use of dexmedetomidine in addition to propofol has been shown to decrease cardiovascular, respiratory, and agitation-related adverse effects. Dexmedetomidine can be used intranasally at 2 to 3 mcg/kg/dose (max 100 mcg/nare). An additional 1 mcg/kg/dose may be administered in 30 minutes (max cumulative dose 4 mcg/kg). Contraindications include heart block, severe renal or hepatic impairment, or use of a beta blocker.
Nitrous Oxide
The use of inhaled nitrous oxide in the pediatric emergency setting has been well established for mildly painful or distressing procedures. Although the exact mechanism of action is not known, sedation is likely achieved due to a noncompetitive inhibition of the NMDA-receptor and analgesia via central opioid and opioid-like receptors. Concentrations between 50% and 70% are commonly used, with best effect to side effect ratios seen with inhalation times less than 30 minutes. The combination of inhaled nitrous oxide and IN fentanyl obviates painful and time-consuming IV access insertions and delivers a short recovery time. Another study in a pediatric emergency department found fewer adverse reactions and lower length of stay in patients treated with inhaled nitrous oxide and IN fentanyl, as compared to ketamine and midazolam, with no difference in efficacy between groups.
Post-Sedation Monitoring
Once the procedure is complete and the painful stimuli are removed, patients are at risk of hypoventilation or hypoxia. Monitoring should continue until the patient has met predetermined discharge criteria, which should include normal vital signs and baseline mental and physical status. Once fully awake, patients should be discharged to the care of a responsible adult. Patients should receive predeveloped age-appropriate PSA discharge instructions.
Outcomes
Adequately treating anxiety and pain results in greater procedural success rates; improved patient and caregiver satisfaction; decreased likelihood of the patient developing chronic pain; and improved patient outcomes. Patients at increased risk of adverse events during PSA include the following: the very young or very old; those with comorbidities (e.g., cardiopulmonary diseases) or craniofacial abnormalities (e.g., Down syndrome and Pierre Robin syndrome); the morbidly obese; and those with a higher ASA physical status classification (see Table 157.1 ).
Pain Management
Foundations
Pain is defined as an unpleasant visceral or somatic experience or sensation associated with actual, potential, or perceived tissue damage. Pain receptors, termed nociceptors, are the free nerve endings of a sensory neuron that convert mechanical, thermal, or chemical stimuli into electrical activity, and initiates an impulse that travels along the neuron and then on to the dorsal horn of the spinal cord ( Fig. 157.1 ). Input from various peripheral nerves and additional sensory stimuli are processed, undergoing integration and modulation in the dorsal horn of the spinal cord, and then transmitted up the spinal cord to the CNS ( Fig. 157.2 ).
Nociceptors.
CNS, Central nervous system.
Figure illustration by Department of Medical Art and Photography—Cleveland Clinic and Mr. Dave Schumick with permission.
Pain Pathway.
Figure illustration by Department of Medical Art and Photography—Cleveland Clinic and Mr. Dave Schumick with permission.
There are two types of pain: nociceptive or neuropathic. Nociceptive pain occurs when tissue injury or inflammation stimulates intact pain receptors. Nociceptive pain can be further divided into visceral pain (i.e., of internal organs) and somatic pain (i.e., of the skin, soft tissue, and musculoskeletal structures). Neuropathic pain occurs when there is abnormal functioning or stimulation of damaged sensory nerves. Children with severe developmental impairment may have central neuropathic pain or pain secondary to visceral hyperalgesia.
Neuropathic pain is typically burning, searing, tingling, shooting, or electric in quality. Nociceptive somatic pain is generally described as sharp and well localized. However, pain in deeper structures (e.g., bones, joints, or tendons) can cause achy, diffuse, or radiating pain. Nociceptive visceral pain is typically poorly localized, deep, and aching. Chronic pain is a maladaptive response in which the pain persists after the original injury or illness has resolved.
Specific Issues
Pain Assessment
Patient self-report is the most accurate measure of pain severity. Pain assessments can be used to guide pain management. Pain scales should be age-specific; subjective or self-reporting scales can start being used at 3 years of age, depending on developmental level. Children younger than 3 years old do not have the cognitive or verbal skills needed to communicate levels of pain and, thus, require behavioral or psychological pain scales. Behavioral pain scales rely on the observation of specific child or infant behaviors. Some of the parameters used in behavioral pain scales include facial expressions, consolability, interaction level, limb responses, trunk motor responses, and verbal responses. Behavioral and physiologic pain scales combine behavioral observations and physiologic parameters (e.g., vital signs) to obtain a score.
The numeric rating scale (NRS) and the visual analogue scale (VAS) are commonly used self-report scales that have been found to have reliability and validity. With the VAS, patients are asked to place a mark on a 10-cm line with descriptors along the line. With the NRS, patients are asked to rate their pain severity on a scale from 0 to 10 or 0 to 100, with 0 being no pain and 10 or 100 the worst pain possible. Horizontal lines are preferred rather than vertical lines because scores are more normally distributed. Patients with poor hand-eye coordination, visual acuity or hand dexterity have difficulty completing the VAS.
As noted, the use of pain scales is based on age. Adolescents and adults can rate their pain using an NRS or VAS. Older children (8 to 11 years old) can also use an NRS or VAS. Younger children (3 to 8 years old) can quantify their pain using a faces pain scale, most commonly, the Faces Pain Scale–Revised (FPS-R) . The Premature Infant Pain Scale (PIPP) is used to assess pain in premature infants. The Crying, Requires oxygen, Increased vital signs, Expressions, and Sleeplessness (CRIES) scale is for infants. The Faces, Legs, Activity, Cry, Consolability (FLACC) pain scale can be used for infants and toddlers. The Children’s Hospital of Eastern Ontario Pain Scale (CHEOPS) and the Observational Scale of Behavioral Distress (OSBD) may be used for toddlers and young children.
Nonverbal children with neurological impairment, irrespective of age, cannot self-report their pain. The child’s caregiver generally knows his or her typical behavior patterns, both at baseline and in response to stimuli or needs. Behaviors that may indicate pain include facial expressions (e.g., grimacing), vocalizations (crying or moaning), inconsolability, increased movement, increased tone or posture (e.g., stiffening or arching), and uncharacteristic or atypical behaviors (e.g., withdrawal, lack of expression, or even laughing). The revised FLACC (r-FLACC) scale is one pain scale designed for use in children with cognitive impairment.
We recommend that all patients have a pain assessment and that the FLACC scale be used in infants to age 3 years of age and those with developmental delay and nonverbal of any age, the FPS-R scale be used in children 3 to 8 years of age, and the NRS used in children 8 years of age or older.
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