مدیریت درد مزمن در کودکان

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مديريت درد مزمن در كودكان 

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Multi-modal Approach * Cognitive- * Physical Approach behavioral - Massage - Education - Acupuncture ‏اور رت‎ - Heat or Cold ‏7و۳‎ - TENS Sat) solani] Ng - Therapeutic - Hypnosis exercise - Biofeedback - Music, art, play - Prayer, meditation 

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4: Patient & Parental Involvement ¢ Parent - Excellent sources of information on child - Learn techniques - ‏۸ات د5عع1ال86‎ * Patient - Age & developmentally appropriate - Gives them control in their pain experience - Learn techniques to help with pain control - Reduces anxiety 

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Non-noxious Routes * Administration: painless route - Avoid IM injections - Oral and Intravenous routes are preferred 

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Pharmacology of Pain Management 

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Principles of Pharmacology Age, associated medical problems, type of pain, & previous experience with pain Choose type of analgesia Choose route to control pain as rapidly and Effectively as possible Titrate further doses based on initial ‏ع05مو5ع]‎ Anticipate side effects Recognize synergistic effects 

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Non-opioid Analgesics Mild to moderate pain No side effects of respiratory depression Highly effective when combined with opioids Acetaminophen NSAIDs COX-2 inhibitors Aspirin - No longer used in pediatrics 

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Acetaminophen ° Antipyretic * Mild analgesic * Administer PO or PR ٠ Pediatric Oral dose 10-15 mg/kg/dose every 4 hr * Onset 30 minutes 

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Acetaminophen ٠ Per rectum dose 40 mg/kg once followed by 20 mg/kg/dose every 6 hours - Uptake is delayed and variable - Peak absorption is 60-120 minutes - Unreliable to cut suppositories * Maximum daily dosing - Infants: 60-75 mg/kg/day - <60 kg: 100 mg/kg/day - >60 kg: 4 grams/day 

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Side Effects of Acetaminophen * Generally a good safety profile - Do not use in hepatic failure * Causes hepatic failure in overdose 

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NSAIDs ° Antipyretic * Analgesic for mild to moderate pain * Anti-inflammatory - COX inhibitor > Prostaglandin inhibitor * Platelet aggregation inhibitor 

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NSAIDs: Ibuprofen * Dose 10 mg/kg/dose every 6 hours - Adult dose 400-600 mg/dose every 6 ‏ا‎ ‎* Onset 30-45 minutes * Maximum daily dosing - <60 kg: 40 mg/kg - >60 kg: 2400 mg * May use higher doses in rheumatologic disease 

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NSAIDs: Ketorolac ¢ Intravenous NSAID (also available P.O.) * Dose 0.5 mg/kg/dose every 6 hours * Onset 10 minutes * Maximum I.V. dose 30 mg every 6 hours * Monitor renal function * Do not use more than 5 days - side effects 

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Side Effects of NSAIDs * Gastritis - ‏اه‎ 0 - Still rare in pediatric patients compared to adults - NSAID use contraindicated in ulcer disease * Nephropathy (ATN) * Bleeding from platelet anti-aggregation - Increased risk versus benefit post-tonsillectomy - NSAID use contraindicated in active bleeding * Delayed bone healing 

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COX-2 inhibitors * Selectively inhibits Cyclooxygenase-2 ٠ 1 Gastric irritation and bleeding * Same risk for nephropathy as non- selective COX inhibitors * Shown to have increased cardiovascular events in adults * COX-2 inhibitors - Rheumatologic diseases - Cancer = Gi 

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Opioids Analgesics * Moderate to severe pain * Various routes of administration * Different pharmacokinetics for different age groups - Infants younger than 3 months have increased risk of hypoventilation and respiratory depression * Low risk of addiction among children 

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Side Effects of Opioids - Respiratory depression - Nausea, vomiting - Constipation can a AULA AOI) - Urinary retention 

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[010۵ * Codeine * Oxycodone ¢ Morphine ° Fentanyl * Hydromorphone * Methadone 

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Codeine * Oral analgesic (also anti-tussive) ¢ Weak opioid - Used often in conjunction with acetaminophen to increase analgesic effect * Metabolized in the liver and demethylated to morphine - Some patients ineffectively convert codeine to morphine so no analgesia is achieved * Dose 0.5-1 mg/kg every 4-6 hours 

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Morphine Available PO, SL, SC, IV, REC, IT Moderate to severe pain Hepatic conversion with renally excreted metabolites ‎(ele)‏ تا ‎Duration of |.V. analgesia 2-4 hours ‎- Oral form (immediate and sustained release) LV. Dose 0.05-0.2 mg/kg/dose every 2-4 hours ‎Side effect: histamine release 

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Patient Controlled Analgesia (PCA) * Programmable pump * Patient can choose when to deliver * patient will fall asleep when over sedated and is unlikely to administer too much drug * Teaching 

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When to use PCA لحا ل ‎sickle cell vaso-occlusive episodes‏ - ‎postoperative pain‏ - ‎cancer pain‏ - ‎bee Yelle Merl‏ ‎٠ Take patient’s age, maturity, and medical‏ ‎condition into the decision‏ 

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How to set up a PCA Loading dose فلع ات اننال :| Patient demand do: Lockout interval (5-10 min) Maximum hourly limit Sedation and vital sign assessment is mandatory 

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Naloxone Opioid antagonist 1 ampule = 0.4 mg/mL Use when unresponsive to physical stimulation, shallow respirations (<8 breaths/min), pinpoint تاازه ۱ Stop Opioid Mix Naloxone 1 ampule with NS 9 mL = 40 mcg/mL - For <40 kgs: Naloxone ¥% ampule with NS 9 mL = 10 mcg/mL Administer slowly and observe response - 1-2 mcg/kg/min Discontinue naloxone as soon as patient responds Duration 30-45 minutes - Monitor the patient; repeat doses may be needed 

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Anti depressants Suicide ideation 

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TCADs مصرف ۶ دردهای نوروپاتیک Gy Seay © ‏میگرن‎ ۶ خواب آوری عوارض آنتی کلینرژیک كك 

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SSRIs Oley et re) pt -PH ERAS pene)| عوارض کمتر ‎٠‏ كوارشى سردرد و بى قرارى بى خوابى اختلال عملكرد ا ا ‏عارضه سروتونرزيك ‏* ميوكلونوس هايبررفلكسى بى ثباتى اوتونوم ‎DE Do]‏ ل ‏سندروم قطع (ياروكسيتين) 

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SSNRIs ۱9۱۱۵۳۹ ene) Venlafaxine Neuropathic pain Fibromyalgia pain 

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Anti epileptics Carbamazepine Oxcarbazepine Valporate Topiramate Gabapentin, Pregabalin Mood Disorders, Neuropathic Pain, Zoster, Fibrmyalgia, Chronic Headache, CRPS. 

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benzodiazepines رفع اسپاسم و درد در بیمارستان رفع اضطراب و بهبود خواب : محدودیت ار ۲ رفتار کنترل نشده و شبه سایکوز دپرشن تنفسی ‎Reece]‏ ‏افزایش ترشحات برونشیال ب عضو قطع طی دو هفته 

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Antipsychotics Typical Anipsychotis Atypical Anipsychotis Olanzapine Quetiapine Clozapine Aripiprazole 

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عوارض آنتى سايكوتيك ها 0 reves alll 7 9 530960055 دیس کینزی تاخیری ‎ear Caen)‏ اختلال عملکرد کبدی ديس تونى حنجره 

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1۰ ديسكسينزى و ديستونى لا 

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سندروم نوروليتيك بدخيم بی ثباتی اوتووم 2 كاتاتونى تغيير سطح هوشيارى 

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Local Anesthetics * For needle procedures, suturing, lumbar puncture, etc. * Topical or infiltration 

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Anesthesia * Regional - Blocks afferent pathways to CNS - Good for post-operative pain relief - Epidural and caudal anesthesia - Peripheral nerve blocks * General