PHM Session: The Agony and the Ecstasy: Pain Assessment and Management in the Clinical Setting
Presenter: David Casavant, MD, Boston Children’s Hospital, Boston, Mass.
Dr. David Casavant presented his approach to pediatric pain evaluation, physiology, and treatment considerations. He began by discussing some of the pain evaluation tools that are most often used, including some less commonly reported signs such as the patient’s posture, ability to attend to activities outside of their pain, and the cross-leg sign.
Next, he led the audience through a comparison of the different types of pain, which he delineated as acute (consisting of nociceptive and inflammatory) and chronic (consisting of neuropathic and central sensitization). Dr. Casavant gave examples of possible treatment options for the two major categories of pain, including the appropriate uses of both pharmacologic and non-pharmacologic modalities.
The following portion of the discussion was focused on patient-controlled analgesia (PCA), with a focus on the history of use, mechanics of administration, and pharmacology. Dr. Casavant walked through an explanation of how optimal medication dosing is determined, introducing the concepts of ED50, TD50, and a drug’s therapeutic index. He highlighted the importance of using the combination of a continuous infusion and small frequent doses of medication to maintain analgesia while limiting side effects. To illustrate this point, attendees worked through PCA troubleshooting cases.
The final segments of the presentation consisted of a discussion regarding the dangers of using oxygen for comfort in the case of hypoventilation and an approach to the use of reversal agents. The audience was reminded to monitor the end-tidal CO2 during procedural sedation and to use medications such as naloxone or flumazenil sparingly when in an inpatient setting. It’s Dr. Casavant’s stance that the problem is often hypoventilation rather than overmedication. He notes that the short half-life of reversal agents and their ability to precipitate a pain crisis should limit their use.
- “Pain treatment is a contact sport,” highlighting that you should always assess the patient when treating pain.
- Beware of oxygen for comfort, as it will not solve the problem of hypoventilation.
- Remember to consider the therapeutic index of a drug to maintain patients above the minimal effective dose but below the toxic dose.
- Practitioners should understand the mechanisms underlying acute and chronic pain, applying treatment modalities that are effective for the types of pain that are being experienced.
- PCA is effective because it matches the treatment of pain to its occurrence.
- Use reversal agents sparingly, as the problem is often hypoventilation rather than over-medication.
Dr. Wedoff is a second-year pediatric hospital medicine fellow at the Medical University of South Carolina, Charleston, S.C. He has research interests in pediatric firearm violence prevention and opioid utilization.