Chapter 3: Analgesia and Sedation

ANALGESIA

General Principles

Analgesia is the diminution or elimination of pain in the conscious patient.

• Even neonates demonstrate behavioral and hormonal changes in response to painful procedures.

• Children do not have to understand the meaning of pain to communicate pain or to experience it.

• Preemptive analgesia may decrease postinjury opioid requirements

ASSESSMENT OF PAIN

Observational-Behavioral Measures

• Useful in infants and toddlers (who do have physiologic and behavioral responses to pain, such as increased heart rate, blood pressure, respiratory rate, crying, flushing, facial expressions, and body movements)

• Example: FLACC (Face, Leg, Activity, Cry, Consolability) Behavioral Pain Scale (Merkel SI, et al. The FLACC: a behavioral scale for scoring postoperative pain in young children. Pediatr Nurs 1997;23:293–297.)

Self-Report

• The OUCHER scale combines numeric and faces scales, making it appropriate for young children (available at https://oucherpainscalecuu.wordpress.com).

• Wong–Baker FACES scale: The child is asked to point to the face that best represents his/her own pain (available at http://www.wongbakerfaces.org).

• Verbal numeric pain rating: Useful in developmentally normal children 6–7 years of age (or older). Pain is rated from 0 to 10 (0 is no pain and 10 is the worst pain imaginable).

NONPHARMACOLOGIC METHODS OF ANALGESIA

• Distraction, music, play

• Acupuncture, massage, and hypnosis are other methods of analgesia; these usually require trained practitioners.

LOCAL ANESTHESIA

EMLA

• 2.5% lidocaine/2.5% prilocaine

• Apply to intact skin; complete anesthesia in 60–90 minutes

• Use for blood drawing/IV placement, bone marrow aspiration, lumbar puncture in nonemergent settings

• May use LMX, which is topical lidocaine only; it has a faster onset, with anesthesia in 30 minutes.

• Contraindications: Methemoglobinemia (avoid EMLA) in children less than 1 month of age

LET

• Used for dermal lacerations; may apply to open wound

• Contraindicated in areas supplied by end arteries (digits, pinna, nose, penis).

Viscous Lidocaine

• For older children who can expectorate

• Combine with diphenhydramine and aluminum hydroxide, magnesium hydroxide (e.g., Maalox) in equal parts (1:1:1) to create “magic mouthwash” (can exclude lidocaine if mouth sores create a concern for systemic absorption)

• Usual dose: 15 mL of undiluted mixture to “swish and spit” (not swallow); maximum dose is 4.5 mg/kg of body weight or 300 mg of lidocaine component (up to every 3 hours). Smaller amounts work well.

Lidocaine Jelly

• Used for nasogastric tube placement and urethral catheterizations

Injectable Local Anesthetic

• Buffer with 1 mL (1 meq/mL) sodium bicarbonate (NaHCO₃) per 9 mL lidocaine or 0.1 mL NaHCO₃ per 10 mL bupivacaine to reduce pain associated with injection.

• Enhance efficacy and duration by using in combination ...