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Pain - procedural pain management in PCCS

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Caution

This protocol only applies provided the criteria outlined in the Starship Sedation Policy are adhered to (this includes documentation, monitoring and fasting times). All doses as prescribed must be administered under strict medical supervision.

The doses suggested below are intended to cover most painful procedures undertaken in PCCS, however if a child has special needs or other co-morbidities to consider it may be appropriate to discuss the child's specific needs with the paediatric pain service.

Preparation for painful/noxious events

It is essential that the child and family are adequately prepared and that every effort is made to minimize their anxiety before, during and after the procedure. Examples of how this can be achieved include:

  • For older children, perform procedures in the treatment room so that their bed space  remains a "safe" place for them (the exception being IOA patients if their level of  surveillance requires them to remain in their own space).
  • Make sure the room and equipment is set up before you take the child in to minimize  the time the child spends in the procedure room.
  • Use play therapists and/or parents to prepare the child and to provide comfort and  distraction for the child for every procedure as appropriate, even if they are given  sedation. The ADHB Child Pain Management guideline outlines non-pharmacological  interventions, including distraction that can be used during noxious procedures.
  • Be honest with the child and family and explain how the procedure will "feel" from the  child's perspective, what the steps are, how long it will take and which parts will be  painful.
  • It is important that the nurses undertaking the procedure, project an atmosphere of  calm control; children and parents will pick up on any anxiety or lack of confidence.
  • One RN should be allocated to manage just the sedation and/or to coach the child  and family during the procedure.

Pacing wire removal

Pacing wire removal is briefly uncomfortable but not painful, adults describe a pulling sensation, and therefore procedural analgesia/sedation is not usually required. Distraction is usually adequate for most children.

If the child is VERY anxious or combative consider using analgesia and/or sedation as described in the painful procedures section below.

Consider sucrose for neonates. See the Newborn Clinical Guideline for more details.

CVL or other line removal

Line removal is not painful and therefore procedural analgesia/sedation is not required. Distraction is usually adequate for most children.

If the child is VERY anxious or combative consider using analgesia and/or sedation as described in the painful procedures section below.

Consider sucrose for neonates. See the  Newborn Clinical Guideline for more details.

IV line insertion

The Starship Pain Service has a specific guideline for IV insertion and it suggests using topical analgesia as a minimum (except for neonates) as this is well supported by the evidence - see Appendix 1 of the ADHB Procedural Pain Management Guideline for children).

Painful Procedures (e.g Chest drains and painful dressings)

Dosages for painful procedures need to provide adequate analgesia and sedation to carry out the procedure BUT being mindful that once the source of pain is removed (for instance once a chest drain is removed) that the child does not become over-sedated. Thus it is prudent to start with a lower dose and give supplemental doses if necessary.

Neonates (under 1 month)

Generally neonates are given morphine only for painful procedures.

Drug Dosage Preparation Onset Duration
Morphine  hydrochloride (oral) Dose 0.15 - 0.3mg/kg (or  150-300mcg/kg) Suggest  starting at dose of  0.15mg/kg (or  150mcg/kg)*# Morphine Elixir 1mg/ml 30-40 minutes 60-90
minutes
OR
Morphine sulphate (IV)
0.02mg/kg (or 20mcg/kg)  reassess at 5 minute  intervals to a max of  0.1mg/kg (or100mcg/kg)  **# Prepare and  administer solution as described in the Paediatric IV Protocol Morphine guideline 10-20
minutes
60-90
minutes

*If patient is already prescribed oral morphine for analgesia at the above doses, either undertake the procedure 30 minutes after a regular dose or administer a PRN dose 30 minutes prior to the procedure. Alternatively, consider a  once only dose at these doses - ensuring that this is reflected on the medication chart to prevent duplication of doses.

** If patient is already prescribed an IV morphine infusion for analgesia (NCA), administer prescribed bolus doses (to achieve the above dose of 0.02mg/kg (or 20mcg/kg)), bearing in mind the usual lockout is 15 minutes (e.g. if 20mcg/kg equates to two NCA doses, give one bolus dose 30 minutes prior to procedure and one dose 15 minute prior - then you can give a third dose once the procedure has started - if needed).

#Neonates have an incomplete blood brain barrier and thus more of an administered dose of morphine is transported to the brain. This may result in increased sedative effects and thus the lowest dose range should be used. For premature neonates the dose may need to be reduced further see Newborn Services Oral Morphine Guideline. Consider prescribing naloxone (0.1 - 0.2 mg/kg/dose IV, or IM) to reverse respiratory depression.

Infant 1 - 3 months of age

Generally infants aged 1-3 months of age are given morphine only for painful procedures.

Drug Dosage Preparation Onset Duration
Morphine hydrochloride (oral) Dose 0.15 - 0.3mg/kg (or  150-300mcg/kg) Suggest
starting at dose of  0.2mg/kg (or  200mcg/kg)*
Morphine Elixir 1mg/ml 30-40 minutes 60-90
minutes
OR
Morphine sulphate (IV)
0.02mg/kg (or 20mcg/kg)  reassess at 5 minute  intervals to a max of  0.1mg/kg (or 100mcg/kg)  ** Prepare and  administer solution as described in the Paediatric IV Protocol Morphine guideline 10-20
minutes
60-90
minutes

*If patient is already prescribed oral morphine for analgesia at the above doses, either undertake the procedure 30 minutes after a regular dose or administer a PRN dose 30 minutes prior to the procedure. Alternatively, consider a once only dose at these doses - ensuring that this is reflected on the medication chart to prevent duplication of doses.

** If patient is already prescribed an IV morphine infusion for analgesia (NCA), administer prescribed bolus doses (to achieve the above dose of 0.02mg/kg (or 20mcg/kg)), bearing in mind the usual lockout is 15 minutes (e.g. if 20mcg/kg equates to two NCA doses, give one bolus dose 30 minutes prior to procedure and one dose 15 minute prior - then you can give a third dose once the procedure has started - if needed).

A child older than 3 months but younger than 5 years

Would usually be given Morphine plus Midazolam

Morphine plus Midazolam

Drug Dosage Preparation Onset Duration
Morphine hydrochloride (oral) <15kg Dose 0.2 -  0.3mg/kg (or 200-  300mcg/kg)*
15-30kg 5-10mg*
More than 30kg 10-20mg*
Morphine Elixir 1mg/ml

Sevredol Tablets: 10mg, 20mg
30-40 minutes 60-90
minutes
OR
Morphine sulphate (IV)
<50kg  0.04mg/kg (or 40mcg/kg)  at 5 minute intervals to a  max of 0.2mg/kg (or  200mcg/kg) ** Prepare and  administer solution as described in the Paediatric IV Protocol Morphine guideline    
>50kg  2mg at 5 minute intervals
until they are ready to a  max of 10mg **
Prepare and  administer solution as described in the Paediatric IV Protocol Morphine guideline    


*If patient is already prescribed oral morphine for analgesia at the above doses, either undertake the procedure 30 minutes after a regular dose or administer a PRN dose 30 minutes prior to the procedure. Alternatively, consider a once only dose at these doses - ensuring that this is reflected on the medication chart to prevent duplication of doses.

** If patient is already prescribed an IV morphine infusion for analgesia (NCA), administer prescribed bolus doses (to achieve the above dose of 0.02mg/kg (or 20mcg/kg)), bearing in mind the usual lockout is 15 minutes (e.g. if 20mcg/kg equates to two NCA doses, give one bolus dose 30 minutes prior to procedure and one dose 15 minute prior - then you can give a third dose once the procedure has started - if needed).

PLUS

Drug Dosage Preparation Onset Duration
Midazolam (oral) 0.5mg/kg (max  15mg) Midazolam Elixir 2mg/ml***

Midzolam 7.5mg tablet
30-40 minutes 60-90 minutes
OR
Midazolam (intranasal) if oral refused
0.2mg/kg  (max 10mg) 15mg/3ml  Hypnovel Injection  (DO NOT USE 5mg/5ml  strength) IV solution  administered using Muscosal  Atomisation device (MAD  300)**** 10  minutes 60-90  minutes


***Midazolam liquid is a Section 29 medication
**** N.B. solution is acidic and this route should be used as a last resort

A child older than 5 years

Older children may be given:

  • Option 1: Morphine plus Midazolam or
  • Option 2: Morphine plus Entonox (self administered)

Or if the child is likely to have multiple procedures and/or is very anxious:

  • Option 3: Ketamine PO plus Midazolam

Option 1:  Morphine plus Midazolam

Drug Dosage Preparation Onset Duration
Morphine hydrochloride (oral) <15kg Dose 0.2 -  0.3mg/kg (or 200-  300mcg/kg)*
15-30kg 5-10mg*
More than 30kg 10-20mg*
Morphine Elixir 1mg/ml

Sevredol Tablets: 10mg, 20mg
30-40 minutes 60-90
minutes
OR
Morphine sulphate (IV)
<50kg  0.04mg/kg (or 40mcg/kg) at 5 minute intervals to a  max of 0.2mg/kg (or  200mcg/kg) ** Prepare and  administer solution as described in the Paediatric IV Protocol Morphine guideline    
>50kg  2mg at 5 minute intervals
until they are ready to a  max of 10mg **
Prepare and  administer solution as described in the Paediatric IV Protocol Morphine guideline    

* If patient is already prescribed oral morphine for analgesia at the above doses, either undertake the procedure 30 minutes after a regular dose or administer a PRN dose 30 minutes prior to the procedure. Alternatively, consider a once only dose at these doses - ensuring that this is reflected on the medication chart to prevent duplication of doses.

** If patient is already prescribed an IV morphine infusion for analgesia (NCA), administer prescribed bolus doses (to achieve the above dose of 0.02mg/kg (or 20mcg/kg)), bearing in mind the usual lockout is 15 minutes (e.g. if 20mcg/kg equates to two NCA doses, give one bolus dose 30 minutes prior to procedure and one dose 15 minute prior - then you can give a third dose once the procedure has started - if needed).

PLUS

Drug Dosage Preparation Onset Duration
Midazolam (oral) 0.5mg/kg (max  15mg) Midazolam Elixir 2mg/ml***

Midzolam 7.5mg tablet
30-40 minutes 60-90 minutes
OR
Midazolam (intranasal) if oral refused
0.2mg/kg  (max 10mg) 15mg/3ml  Hypnovel Injection  (DO NOT USE 5mg/5ml  strength) IV solution  administered using Muscosal  Atomisation device (MAD  300)**** NB Solution is acidic 10 minutes 60-90 minutes


***Midazolam liquid is a Section 29 medication

Option 2: Morphine plus Entonox (self administered)

Drug Dosage Preparation Onset Duration
Morphine hydrochloride (oral) <15kg Dose 0.2 -  0.3mg/kg (or 200-  300mcg/kg)*
15-30kg 5-10mg*
More than 30kg 10-20mg*
Morphine Elixir 1mg/ml

Sevredol Tablets: 10mg, 20mg
30-40 minutes 60-90
minutes
OR
Morphine sulphate (IV)
<50kg  0.04mg/kg (or 40mcg/kg)
at 5 minute intervals to a  max of 0.2mg/kg (or  200mcg/kg) **
Prepare and  administer solution as described in the Paediatric IV Protocol Morphine guideline    
>50kg  2mg at 5 minute intervals
until they are ready to a  max of 10mg **
Prepare and  administer solution as described in the Paediatric IV Protocol Morphine guideline    


* If patient is already prescribed oral morphine for analgesia at the above doses, either undertake the procedure 30 minutes after a regular dose or administer a PRN dose 30 minutes prior to the procedure. Alternatively, consider a once only dose at these doses - ensuring that this is reflected on the medication chart to prevent duplication of doses.

** If patient is already prescribed an IV morphine infusion for analgesia (NCA), administer prescribed bolus doses (to achieve the above dose of 0.02mg/kg (or 20mcg/kg)), bearing in mind the usual lockout is 15 minutes (e.g. if 20mcg/kg equates to two NCA doses, give one bolus dose 30 minutes prior to procedure and one dose 15 minute prior - then you can give a third dose once the procedure has started - if needed).

PLUS

Entonox

Entonox may be considered if the criteria below are met:

  • The child is able to self administer
  • Initial use of Entonox for any cardiac patient should occur between the hours of 0830-1700
  • Initial use of Entonox should be approved by primary cardiologist.
  • Extreme caution should occur with the following 2 patient groups:
    • Children with complex cardiac disease and other co morbidities (e.g. significant heart  failure or significant respiratory disease)
    • Children known to have pulmonary hypertension +/- medication for pulmonary  hypertension (e.g. Sildenafil / Bosentan)

See ADHB Child Health procedural pain guideline for full administration guidelines for Entonox 

Option 3: Ketamine PO plus Midazolam

Drug Dosage Preparation Onset Duration
Ketamine (oral) 3-10mg/kg  Usually start with  5mg/kg and titrate to  effect for subsequent
procedures (maximum  dose 200mg)
Ketamine Biomed) IV  solution given orally  100mg in 10ml 30-40 minutes 60-90 minutes

PLUS

Drug Dosage Preparation Onset Duration
Midazolam (oral) 0.5mg/kg (max  15mg) Midazolam Elixir 2mg/ml***

Midzolam 7.5mg tablet
30-40 minutes 60-90 minutes
OR
Midazolam (intranasal) if oral refused
0.2mg/kg  (max 10mg) 15mg/3ml  Hypnovel Injection  (DO NOT USE 5mg/5ml  strength) IV solution  administered using Muscosal  Atomisation device (MAD  300)****
NB Solution is acidic
10 minutes 60-90 minutes


***Midazolam liquid is a Section 29 medication

Care should be taken when using the above option if the child is already prescribed other drugs that may have a sedative effect such as opiate analgesia.

References / Sources

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Document Control

  • Date last published: 08 August 2016
  • Document type: Clinical Guideline
  • Services responsible: Paediatric Cardiology
  • Author(s): Andrew Liley
  • Owner: Andrew Liley
  • Editor: Marion Hamer
  • Review frequency: 2 years