Evidence in Procedural Pain

Dr Theogene Twagirumugabe

Anesthesiologist & Intensivist

Disclosure

• No conflict of interest

Outline

1 Introduction

2 Importance of procedural pain

3 Procedural pain management:

Pharmacological

Non-pharmacological

4 Conclusion

Introduction

• Health care–associated short-lived acute pain experienced along non-surgical procedures:

Diagnostic

Therapeutic

Palliative care

• Procedure causes:actual or potential tissue damage PAIN

• All categories: age, gender, race, socioeconomic status..

Introduction

Types of procedures1. Simple:

Dressing

Venipunctures

Blood sample drawing

NG intubation

2. Invasive:Lumbar puncture

Fracture reduction

Biopsies

Introduction:Adverse effects of untreated pain

• Adverse effects of pain on the nervous systems of newborns and young children: a review of the literature:– Painful stressors may lead to :

– sleep disturbances,

– Decreased appetite

– inability to self-regulate.

– Long-term effects of pain -->increased pain perception, chronic pain syndromes, and somatic complaints.

– Energy stealing and growth retardation

Mitchell A et al. J Neurosci Nurs 2002Vinall et al. Paediatr Res 2014

Importance of procedural pain:In neonate children

Medical and nursing staff perception• Most painful procedures at AED in children aged 12-18

months:– Suprapubic aspiration – Intramuscular injection– Lumbar puncture

• Most distressful:– NGT insertion– IV insertion– Lumbar puncture

Babl FE et al. Ped Anesth 2008

Importance of procedural pain:EUROPAIN study: Procedural Pain in ICU

Pountillo KA et al. AJCCRM2014

Importance of procedural pain:Factors

Pountillo KA et al. AJCCRM2014

Procedural pain management

Consider:

– Before: past experience, support plan, communication of the plan, preparation

When patient is prepared for the pain, adaptive responses ->attenuation the degree of fear and anxiety

– During: pharmacological and nonpharmacological interventions

– After

Procedural pain management: The Gap in Paed

Common:• Procedural sedation with e.g. Ketamine for fracture redaction• Local anesthetics for lacerations repair

Not common:• pain management for:

– Venipuncture– Blood draw for lab– Urinary catheterization– Nasogastric– Lumbar puncture : no pain management in 71% for 1 yearMacLean S et al. Paed Emerg Care 2007

Ferrante P et al. BMC Pediatrics 2013

Procedural pain management: Sedation

Bourger A et al. SAJAA 2019

Procedural pain management:Nonpharmacological

Neonates (during simple medical or nursing procedures)

– Skin-to-skin contact (Kangaroo care) by the mother of the father

– +/- dextrose

Have shown:Decreased heart rate variation

Decreased duration of crying

Decreased pain scores Johnston C et al. Cochrane DSR 2017

Procedural pain management:Nonpharmacological

• Sucrose (?? Glucose, dextrose) reduces pain scores during venipuncture when administered before procedure

Taddio A et al CMAJ 2008

Procedural pain management:Nonpharmacological

Sucrose vs sterile water on pain: RCT (heel lance in newborn infants)

– Significantly lower pain scores

– Significantly less infants with facial expression

BUT

– Comparable nociceptive brain activity

– Comparable spinal nociceptive withdrawal reflex

Slater R et al. Lancet 2010

Hypnosis Kendrick C et al. Int J Clin Exp Hypn 2017

Procedural pain management:Pharmacological

Hui-Chen F et al. J Trop Paed 2013

EMLA and venipuncture in neonates

Procedural pain management:Pharmacological

Brian V et al. Paediatrics 2011

EMLA+Sucrose for venipuncture

Procedural pain management:Pharmacological

Lander JA et Al. Cochr DSR2014

Amethocaine vs EMLA

Conclusion

• Procedural pain is real in all categories of patients

• Pain poorly assessed and managed

• Different predictors to be looked at

• Pharmacological and nonpharmacological interventions are useful

• Combinations

MURAKOZE