مدیریت درد مزمن در کودکان

مدیریت درد مزمن در کودکان

اسلاید 1: مدیریت درد مزمن در کودکان

اسلاید 2: Multi-modal ApproachCognitive-behavioralEducationRelaxationImageryPsychotherapyHypnosisBiofeedbackMusic, art, playPrayer, meditation Physical ApproachMassageAcupunctureHeat or ColdTENSTherapeutic exercise

اسلاید 3: 4: Patient & Parental InvolvementParentExcellent sources of information on childLearn techniquesReduces anxietyPatientAge & developmentally appropriateGives them control in their pain experienceLearn techniques to help with pain controlReduces anxiety

اسلاید 4: Non-noxious RoutesAdministration: painless routeAvoid IM injectionsOral and Intravenous routes are preferred

اسلاید 5: Pharmacology of Pain Management

اسلاید 6: Principles of PharmacologyAge, associated medical problems, type of pain, & previous experience with painChoose type of analgesiaChoose route to control pain as rapidly and Effectively as possibleTitrate further doses based on initial responseAnticipate side effects Recognize synergistic effects

اسلاید 7: Non-opioid AnalgesicsMild to moderate painNo side effects of respiratory depressionHighly effective when combined with opioidsAcetaminophenNSAIDsCOX-2 inhibitorsAspirinNo longer used in pediatrics

اسلاید 8: AcetaminophenAntipyretic Mild analgesicAdminister PO or PRPediatric Oral dose 10-15 mg/kg/dose every 4 hrOnset 30 minutes

اسلاید 9: AcetaminophenPer rectum dose 40 mg/kg once followed by 20 mg/kg/dose every 6 hoursUptake is delayed and variablePeak absorption is 60-120 minutes Unreliable to cut suppositoriesMaximum daily dosingInfants: 60-75 mg/kg/day<60 kg: 100 mg/kg/day>60 kg: 4 grams/day

اسلاید 10: Side Effects of AcetaminophenGenerally a good safety profileDo not use in hepatic failureCauses hepatic failure in overdose

اسلاید 11: NSAIDsAntipyretic Analgesic for mild to moderate painAnti-inflammatoryCOX inhibitor  Prostaglandin inhibitorPlatelet aggregation inhibitor

اسلاید 12: NSAIDs: IbuprofenDose 10 mg/kg/dose every 6 hoursAdult dose 400-600 mg/dose every 6 hoursOnset 30-45 minutesMaximum daily dosing <60 kg: 40 mg/kg>60 kg: 2400 mgMay use higher doses in rheumatologic disease

اسلاید 13: NSAIDs: KetorolacIntravenous NSAID (also available P.O.)Dose 0.5 mg/kg/dose every 6 hoursOnset 10 minutesMaximum I.V. dose 30 mg every 6 hoursMonitor renal functionDo not use more than 5 daysside effects

اسلاید 14: Side Effects of NSAIDsGastritisGI bleedStill rare in pediatric patients compared to adultsNSAID use contraindicated in ulcer diseaseNephropathy (ATN)Bleeding from platelet anti-aggregationIncreased risk versus benefit post-tonsillectomyNSAID use contraindicated in active bleedingDelayed bone healing

اسلاید 15: COX-2 inhibitorsSelectively inhibits Cyclooxygenase-2↓ Gastric irritation and bleedingSame risk for nephropathy as non-selective COX inhibitorsShown to have increased cardiovascular events in adultsCOX-2 inhibitorsRheumatologic diseasesCancerGI

اسلاید 16: Opioids AnalgesicsModerate to severe painVarious routes of administrationDifferent pharmacokinetics for different age groupsInfants younger than 3 months have increased risk of hypoventilation and respiratory depressionLow risk of addiction among children

اسلاید 17: Side Effects of OpioidsRespiratory depressionNausea, vomitingConstipationPruritusUrinary retention

اسلاید 18: OpioidsCodeineOxycodoneMorphineFentanylHydromorphoneMethadone

اسلاید 19: CodeineOral analgesic (also anti-tussive)Weak opioidUsed often in conjunction with acetaminophen to increase analgesic effectMetabolized in the liver and demethylated to morphineSome patients ineffectively convert codeine to morphine so no analgesia is achievedDose 0.5-1 mg/kg every 4-6 hours

اسلاید 20: MorphineAvailable PO, SL, SC, IV, REC, ITModerate to severe painHepatic conversion with renally excreted metabolitescaution (renal failure)Duration of I.V. analgesia 2-4 hoursOral form (immediate and sustained release)I.V. Dose 0.05-0.2 mg/kg/dose every 2-4 hoursSide effect: histamine release

اسلاید 21: Patient Controlled Analgesia (PCA)Programmable pump Patient can choose when to deliverpatient will fall asleep when over sedated and is unlikely to administer too much drugTeaching

اسلاید 22: When to use PCAUsefulsickle cell vaso-occlusive episodespostoperative paincancer painpalliative careTake patient’s age, maturity, and medical condition into the decision

اسلاید 23: How to set up a PCALoading dose Basal infusion rate Patient demand dose Lockout interval (5-10 min) Maximum hourly limitSedation and vital sign assessment is mandatory

اسلاید 24: NaloxoneOpioid antagonist1 ampule = 0.4 mg/mLUse when unresponsive to physical stimulation, shallow respirations (<8 breaths/min), pinpoint pupilsStop OpioidMix Naloxone 1 ampule with NS 9 mL = 40 mcg/mLFor <40 kgs: Naloxone ¼ ampule with NS 9 mL = 10 mcg/mL Administer slowly and observe response1-2 mcg/kg/minDiscontinue naloxone as soon as patient respondsDuration 30-45 minutesMonitor the patient; repeat doses may be needed

اسلاید 25: Anti depressantsSuicide ideation

اسلاید 26: TCADsمصرفدردهای نوروپاتیکدرد فانکشنال شکمیمیگرنخواب آوریعوارض آنتی کلینرژیکهدایت قلبیسندروم قطع

اسلاید 27: SSRIsافسردگی و اضطراب همزمانعوارض کمترگوارشی سردرد و بی قراری بی خوابی اختلال عملکرد جنسی ↑ تعریقفلوکسیتینعارضه سروتونرژیکمیوکلونوس هایپررفلکسی بی ثباتی اوتونوم ریژیدیتی دلریومسندروم قطع (پاروکسیتین)

اسلاید 28: SSNRIsDuloxetine (کاهش وزن)VenlafaxineNeuropathic painFibromyalgia pain

اسلاید 29: Anti epilepticsCarbamazepineOxcarbazepineValporateTopiramateGabapentin, PregabalinMood Disorders, Neuropathic Pain, Zoster, Fibrmyalgia, Chronic Headache, CRPS.

اسلاید 30: benzodiazepinesرفع اسپاسم و درد در بیمارستانرفع اضطراب و بهبود خوابمحدودیت:ایجاد وابستگی در مصرف مدیدرفتار کنترل نشده و شبه سایکوزدپرشن تنفسیآتاکسیافزایش ترشحات برونشیالPTSD در پیوند عضوقطع طی دو هفته

اسلاید 31: AntipsychoticsTypical AnipsychotisAtypical AnipsychotisOlanzapineQuetiapineClozapineAripiprazole

اسلاید 32: عوارض آنتی سایکوتیک ها تیپیکال↓ آستانه تشنجآگرانولوسیتوزوزن ↑ECG اختلال هدایت قلبیدیس کینزی تاخیریهیپوتنشن اورتواستاتیکاختلال عملکرد کبدیدیس تونی حنجره

اسلاید 33: عوارض آنتی سایکوتیک ها آتیپیک ↓ دیسکسینزی و دیستونی

اسلاید 34: سندروم نورولپتیک بدخیم بی ثباتی اوتوومریژیدیتی عضلانیهیپرترمیکاتاتونیتغییر سطح هوشیاری

اسلاید 35: Local AnestheticsFor needle procedures, suturing, lumbar puncture, etc.Topical or infiltration

اسلاید 36: AnesthesiaRegionalBlocks afferent pathways to CNSGood for post-operative pain relief Epidural and caudal anesthesiaPeripheral nerve blocksGeneral