Pain management |
Jo Eland |
|
Associate Professor of Nursing, Iowa City |
Abstract of a paper presented at the General Assembly of the ICCCPO, July 11, 1995, Washington, D.C.
Cancer pain falls into three categories:
1) diagnostic procedures,
2) treatment-related pain, such as from surgery or drugs (e.g. vincristine) that cause pain,
3) disease-related pain.
In addition children with cancer can also have the usual assortment of cuts and bruises, ear infections and minor injuries not associated with their cancer.
Pain needs to be assessed. Use numbers, with 0 representing no pain, and 5 representing the worst pain, or units of measure, as in "How big is the fire?" or "How many rupees?". How does the child act - are they acting "normally", for them? What things do they enjoy? Can they enjoy their normal (within the confines of their treatments) activities? Can they enjoy their friends, grandparents, brothers and sisters?
You may want to keep a record of pain so that you can more clearly understand it and report it to those taking care of your child. The things that would need to be included in such a record include:
Hurt/pain record
| date | time | amount of hurt/ pain | amount of pain medicine you took | how much medicine you took | other things you did | amount of main one hour later |
| July 11 | 8.00 am | 5 | MSContin | 1 pill | Went back to bed | 3-2 hours later |
PROCEDURAL PAIN - PHARMACOLOGICAL AGENTS
Local anesthetics
| Lidocaine | Must be injected with a tiny needle. Sodium bicarbonate (1 meq./ml) at a ration of 9 parts lidicaine to 1 part bicarb greatly reduces the stinging. |
| EMLA | This is a cream that makes the skin numb if left on for one hour. In dark-skinned individuals it may need longer. |
Sedatives and Hypnotics
Note: Sedatives do not provide pain relief.
| Chloral hydrate | The drug of choice for painless procedures such as x-rays. |
| Pentobarbital | Use for sedation for those who do not respond well to chloral hydrate, or are older or developmentally delayed. |
| Benzodiazepines | Often used with opioid to provide relief during procedures such as bone marrows. |
| Diazepam | Can be used orally and lasts a long time. |
| Midazolam | Can be given orally, or sprayed in the nose or in the vein. Many times children do not remember procedures when this drug is used. |
Opioids
Note: All drugs have risks. When benzodiazepines and drugs like morphine or fentanyl are used together, the risk for slowing down breathing are increased, so procedures have to be done where emergency equipment is located!
| Morphine pain reliever | Intravenous 10-20 minutes before the procedure, or orally one hour prior to the procedure. |
| Fentanyl | Intravenous 5-10 minutes prior to the procedure. |
DISEASE RELATED-PAIN
When pain is a problem, give the medicine by mouth if possible, around the clock (not missing doses), by the WHO ladder, and constantly measure the change in pain.
The WHO Ladder (World Health Organization)
Step 1: Begin with acetaminophen (paracetamol). Aspirin and drugs such as ibuprofen may interfere with blood clotting.
Some use choline magnesium trisaliculate.
Step 2: If pain continues: add codeine or oxycodone to the acetaminophen.
Step 3: If pain continues: use acetaminophen to morphine, hydromorphone, methadone.
References
Omoigui Sota. The Pain Drugs Handbook. St. LCV Mosby-Year Books, 1994
Schechter, Neil, et al., eds. Pain in Infants, Children and Adolescents- article by Anderson, Zeltzer and Fanurik. Baltimore, MD: Williams and Wilkens, 1993
U.S. Agency for Health and Care and Policy Research (AHCPR), Management of Cancer Pain guidelines (Call: 1 800 358 9295)
Resources
A World Wide Web site on the Internet that addresses some pediatric cancer pain is at:
http://coninfo.nursing.uiowa.edu
The World Health Organization will have a new book available in Fall 1995, Cancer Pain Relief and Palliative Care in Children (Fax: + 41 22 791 2300)