Regarding PSA in children, which ONE of the following principles is TRUE?
Answer: B: The ASA physical class system remains the standard for assessing a child before the procedure. This risk grading system is also recommended by the paediatrics and child health division of The Royal Australasian College of Physicians in their guideline statement on the management of procedure-related pain in children and adolescents. Classes 1–2 are generally considered to be at low risk during PSA. A higher risk class is not an absolute contraindication for ED PSA, especially when performed for emergency procedures. However, emergency clinicians should strongly consider a referral for general anaesthesia or deferring the procedure.
The ASA physical classes are:
Children should be adequately prepared for any procedure in the ED. This entails some forethought on the part of the administrators of the ED, as a developmentally appropriate plan should be in place to deal with infants, school-aged and adolescent children. Non-pharmacological techniques in preparing the parents include coaching parents to act in a positive fashion (not a physical restrainer) during the procedure, and to address their own anxiety before participating in the procedure, as well as involving them as part of the team rather than as a passive bystander. Preparing children by allowing them to see the procedure room, explaining the procedure and practising on a doll with the equipment to be used are all good measures to alleviate stress and anxiety.
Guidelines by various anaesthetic bodies such as the American Society of Anaesthesiologists recommend that children should not consume solids for 4–8 hours or clear liquids for 2–3 hours prior to undergoing sedation for an elective procedure. Several large studies of children undergoing procedural sedation and analgesia outside of the operating theatre had no episodes of clinically evident aspiration. Therefore, although vomiting with aspiration is of great concern during procedural sedation and analgesia, the risk is low and the benefit of delaying the procedure to allow gastric emptying seems minimal. Delaying the procedure to meet fasting guidelines may actually compromise the patient’s condition in some instances. Similarly, gastric emptying strategies for sedation procedures is not well studied in children.
Reference:
Pain scales and tools are used in the assessment of pain in children.
Which ONE of the following is TRUE?
Answer: B: It is unclear whether assessing for pain before a procedure will cue the child to expect pain and therefore alter the normal pain response during a procedure. What is evident, however, from the literature is that under-predicting pain in children has adverse consequences on any subsequent need for procedures, and this effect may be lifelong into adulthood. For this reason, it is better to over-predict than under-predict. Furthermore, the initial assessment of a child’s pain score and his/her ability to understand and cope with a procedure is only a starting point. Re-evaluation of the progress through a given choice of procedural analgesia or sedation may need to be altered depending on the evolving pain assessment.
Measuring pain intensity is only one part of pain assessment. There are different objective and subjective methods of measuring pain: physiological monitoring of bodily processes, rating scales and observation measures (for both the child and parent/ staff). The FLACC scale is commonly used for children with cognitive impairment but it has not been validated for procedures.
Self-report tools vary depending on developmental age. Commonly used self-report tools include:
The Pieces of Hurt, also know as the Poker Chip Tool, were developed to allow children to rate their pain by using chips that are described as ‘pieces of hurt’ (one white chip representing no pain, and four red ones representing pain). The more chips the child uses, the greater their hurt.
Faces scales show a series of faces that are graded in increasing intensity from no pain to the worst pain possible. One scientifically validated and commonly used scale is Faces Pain Scale – Revised. Others include the Wong and Baker Faces scale and the Oucher scale.
Visual analogue scales require the patient to make a mark somewhere along a 100 mm line to indicate the amount of pain that they experience, with ‘no pain’ at one end of the scale and ‘the worst pain’ at the other.
Numerical scales (e.g. 0–10) use numbers to represent increasing degrees of pain. Children must understand number concepts and have sufficient abstract thinking ability to use this type of scale.
Which ONE of the following non-pharmacological techniques will most likely interfere with the child’s coping ability during a painful procedure in the ED?
Answer: C: The evidence is conflicted as to whether it is beneficial to have parents in attendance during painful procedures. What is important is how they behave in a given situation. Adult behaviours likely to interfere with a child’s coping include:
Play therapists are a mainstay of non-pharmacological strategies to decrease anxiety in the peri-procedural phase in paediatric oncology and EDs.
References:
Regarding the use of anaesthetic agents in reducing pain during skin puncture in children, which ONE of the following is INCORRECT?
Answer: A: Venepuncture is the preferred method of blood sampling when a significant volume of blood is required. It has been shown to be less painful in neonates and less likely to require resampling. Capillary sampling is often used when the volume of blood required is small. EMLA® cream, other topical anaesthetic agents and paracetamol do not relieve the pain of capillary sampling. Administration of 15–50% sucrose is effective in neonates and may be effective up to 2 months of age. Systematic reviews of the literature suggest doses in the order of 0.5– 1.0 mL of 24% sucrose in 0.25 mL aliquots, commencing 2 minutes before the procedure. Multiple published reviews dating back to the late 1990s have clearly showed the efficacy and potency of sucrose in alleviating pain in neonates – the challenge has been converting this body of evidence into practice. Current evidence suggests that the use of EMLA® with sucrose does not result in any further analgesic efficacy than sucrose alone in neonates undergoing skin puncture.
A Cochrane review in 2006 concluded that amethocaine (Ametop®, AnGel®) is better than EMLA® for reducing pain from intravenous cannulation. A newer topical agent, LMX4® (lignocaine 4%) promises to provide more potent analgesia and longer lasting action, without requiring refrigeration. No randomised studies are available as yet to compare its use to the older formulations in children, although one published study in adults did indicate it is effective in reducing pain from cannulation. It is the author’s opinion that the best topical agent for use in children is AnGel® cream, especially for cannulation, while EMLA® is useful in settings where some vasoconstriction is desirable, for example, LP in infants and children (or adults!). LMX4® looks like a promising product for intravenous cannulation analgesia and is probably equivalent to AnGel® cream in this regard, with formal studies pending.
Regarding management of procedure-related pain in children, which ONE of the following is INCORRECT?
Answer: D: General considerations in laceration repair in children include:
The mixture of lignocaine, adrenaline and tetracaine (ALA® or LET®) should be used in preference to cocaine-containing topical anaesthetics (such as TAC® and AC Gel®) because of equivalent efficacy and better safety profile. Laceraine® (4% lignocaine hydrochloride, 0.5% amethocaine hydrochloride, 0.1% adrenaline1.8 mg/mL) is the topical agent of choice, although specific studies are still pending.
Inhaled nitrous oxide is effective in providing analgesia and anxiolysis to facilitate suturing in children. Midazolam does not have analgesic properties. For more complicated lacerations, intravenous ketamine and midazolam can provide excellent conditions for laceration repair providing a high degree of motion control. Oral or intranasal midazolam may be used to facilitate laceration repair in children but the reported efficacy is significantly lower than the above-stated techniques.
The combination of ketamine and midazolam provides more effective analgesia than the fentanyl and midazolam combination for fracture manipulation, and has fewer respiratory side effects. The combination of propofol/fentanyl offers a similar level of analgesia to ketamine and midazolam but a much higher incidence of airway complications and is therefore not recommended for children at this time.
Regarding skin puncture in children, vapocoolant is more effective in relieving pain during immunisation than EMLA®. Its role in the ED during acute procedures is currently being explored and holds promise.
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