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Child Health Guideline Identifier

Pain - procedural pain management

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Non-pharmacological management

The goals of psychological interventions, when used with or without pharmacological interventions are:

  • To decrease pain, anxiety and distress, before, during and after a procedure
  • To promote active coping

If available, a play specialist can be utilised for assistance with non-pharmacological management by helping with preparation and distraction.

Preparation

Preparation of a child/young person for a painful or uncomfortable procedure involves helping them understand what will happen, how they will feel and how long the procedure and feeling will last. This can be done using play or education.

The health professional carrying out the preparation needs to have the correct information about the procedure to be undertaken and communicate this to the child/young person in a developmentally appropriate way.

A child/young person's existing knowledge and understanding of a procedure must be determined before preparation begins. The information given to the child/young person must be factually correct, honest and delivered at a level they can understand.

The child/young person's role should be explained, which should include setting boundaries and outlining acceptable behaviour. Parents should also be prepared and their role in the procedure discussed.

Preparation techniques include:

  • Role play
  • Calico dolls
  • Role modelling
  • Books and photographs
  • Hospital box
  • Discussion
  • Videos
  • Leaflets
  • Body outlines

It is important to remember that every child or young person is an individual - what works for one may not work for another.

Distraction

Distraction involves helping a child/young person focus attention away from pain or discomfort. Attention can either be focused internally (fantasy or guided imagery), or externally.

Distraction techniques are more effective if they employ all the senses. Whichever technique is chosen, there needs to be interaction between the child/young person and the person doing the distraction.

Often parents can perform the distraction, giving them an opportunity to actively help their child/young person through a procedure.

Distraction Techniques:

  • Interactive books (sound books, pop up books)
  • Story telling
  • Blowing bubbles
  • Singing
  • Counting
  • Puppets
  • Musical toys
  • Guided imagery
  • Breathing exercises
  • Games (I spy, board games, etc)

Buzzy Bee®

Buzzy® is an alternative pain relieving method and distraction technique that can be used for intravenous cannulation, injections or phlebotomy. The device works through utilisation of cold and vibration, confusing pain pathways.

Buzzy Bee 1               Buzzy Bee 2

The handheld device is placed proximal with the larger round end (Buzzy®s bottom) towards the cannulation or injection site. The cold wings used in conjunction with Buzzy® must be frozen solid and placed under Buzzy® in contact with the skin.

Buzzy® should be used in partnership with topical anaesthetics mentioned below where able.

Topical anaesthetics for cannulation

The below table outlines the agents that can be used to help reduce the pain and discomfort associated with a blood test or intravenous cannulation.

Table 1. Topical Anaesthetics, Ethyl Chloride Spray and Sucrose - Cannulation, Venepuncture or Micro-collect

  Emla™ Cream 5% Ametop™ Gel Ethyl chloride spray Sucrose 66.7%
Age  >37 weeks (corrected age)
(use with caution in <3 months - do not exceed recommended dose or application time as Methaemoglobinaemia may occur)
> 1 month > 3 months > 31 weeks post conceptual age
Max 18 months
Suitable for micro-collect  No  No No Yes
Minimum application time  1 hour
(>3 months - 90 mins for optimal anaesthesia)
30 mins for venepuncture
45 mins for cannulation
<1 minute 2 minutes prior to procedure 
Removal time  1-4 hours
(<3 months - do not exceed 1 hour)   
Must be removed 45 mins post application N/A N/A
Duration of anaesthesia/  analgesia  2-4 hours post removal  4-6 hours post removal    Transient  5- 8 minutes
No minimal interval between doses
Prescription required  Yes-Standing order Yes-Standing order    No   Yes
Prescribing advice   Age Max dose (g) Max skin
area (cm2)
One tube of Ametop® gel contains 1.5 grams.

This will anaesthetise an area of 6cm x 5cm.

One tube should be enough for 2 sites.
  No     Babies 0 - 1 months
0.2- 0.5ml
(max 4 doses in 24hrs)

Infants 1 - 18 months
0.5 - 1 ml
(max 4 doses in 24hrs)     
>37 weeks (corrected)
- 3 months
 1
(max 1 application
per day)
 10
Avoid use with other medications
that may cause Methaemoglobinaemia
 3 - 11 months  2  20
 1 - 5 years 10   100
 6 - 11 years 20   200

Entonox (nitrous oxide 50% and oxygen 50%)

Entonox is a self-administered, inhaled agent that provides quick and effective analgesia for procedures of short duration. It is a homogenous gas containing 50% nitrous oxide (N2O) and 50% oxygen (O2) compressed into a cylinder. Nitrous oxide is a sweet smelling colourless gas. It is a weak anesthetic agent but a potent analgesic.

Entonox is self-administered using a demand regulator, which safeguards the user from overdose of nitrous oxide. When the child/young person becomes drowsy, the mask or mouthpiece drops away from the face and the flow of gas ceases. This allows the child/young person to control the dose and prevents the onset of deeper stages of anaesthesia and the loss of the protective laryngeal reflexes.

The advantage of Entonox is that it provides analgesia whilst retaining verbal contact with the child/young person. Some children/young people may become drowsy and/or disinhibited, however it allows a greater degree of co-operation throughout the procedure.

At Starship Hospital, Entonox cylinders and equipment are located on:

  • General Surgical ward (24B)
  • Orthopaedic ward (24A)
  • Oncology ward (27B)
  • Cardiac ward (23B)
  • Orthopaedic Outpatient Department
  • Children's Emergency Department
  • Radiotherapy Department
  • Day Stay

The Emergency Department equipment is not for general use.

Indications

  • Changing dressings
  • Removing drains
  • Removing sutures
  • Redressing burns
  • Invasive procedures, e.g. Catheterisation, sigmoidoscopy
  • Initial management of some traumatic injuries
  • Applying traction
  • Insertion, cleaning and removal of skeletal pins
  • Application of plaster of paris
  • Physiotherapy
  • Suturing wounds

This list represents only a cross section of established uses.

Child/young person suitablity

Children/young people over 5 years should be able to self-administer Entonox effectively, depending on their cognitive and physical ability.

Contraindications

Entonox should not be used:

  • Where there is a decrease in the level of consciousness, e.g.
    • Head Injuries
    • Intoxication
    • Diabetic coma or other metabolic disease
  • Where there is air trapped within the body and where expansion might be dangerous
    • Pneumothorax
    • Air embolism
    • Decompression sickness
    • Following a recent underwater dive
    • Gross abdominal distension
    • Following myringoplasty
    • Recent eye surgery with the use of intraocular gas
  • When a child/young person is not able to understand and co-operate
  • During the first trimester of pregnancy
  • When a child/young person is immunosuppressed

Cautions

Entonox should be used in caution in the following:

  • Children/young people with severe pulmonary hypertension and/or severe myocardial impairment. In these circumstances an airway skilled physician should be immediately available. (see Starship Clinical Guideline - Sedation).
  • Frequent repeated administration. Frequent repeated administration, more than once every 4 days may lead to interference in bone marrow function. If frequent use is needed, a full blood count should be checked. This is correctable with Vitamin B12/ Folic acid.
  • Immunosuppressed children/young people - administered only after consultation with a physician as nitrous oxide affects white blood cell production and function.

Side effects

  • Potential for loss of consciousness.
  • Expansion of air-filled spaces. It is therefore dangerous in any condition where air is trapped within the body and further expansion may occur.
  • Minor side effects such as euphoria, disorientation, sedation, generalised tingling, dizziness, tiredness or nausea and vomiting may occur but are rapidly reversible.

Occupational hazards

Nursing or Medical Staff Pregnancy:

  • First trimester - should not administer nitrous oxide because there is a small risk of miscarriage associated with exposure. (This includes staff who think they may be pregnant)
  • Second and third trimesters - may supervise the self-administration of Entonox on an occasional basis

Administration

  • Quick acting due to the insoluble nature of nitrous oxide
  • Equally rapid offset when administration ceases
  • It can be used alone or in combination with:
    • Opiates
    • Oral analgesia
    • Oral sedation (eg. Midazolam)
  • Use in caution when in combination with opiates or oral sedation as there is an increased risk of decreased level of consciousness and respiratory complications.

Fasting

It is recommended that children/young people have not had any food or drink for two hours prior to the administration of Entonox due to an increased risk of vomiting and aspiration. A minimum fast time of 1 hour may be considered in situations where a longer fast time is not possible.

Observations

Child/Young Person should be monitored using a pulse oximeter when opiates or oral sedatives are used in combination with Entonox. See Starship Clinical Guideline - Sedation.

Documentation

  • Entonox should be prescribed on the oxygen therapy and medical gases section of the Medication Record Chart.
  • If opiates or oral sedatives are used in combination with Entonox a Sedation Record Chart - CR8762 should be completed.
  • Details around the procedure and the use of Entonox should be documented in the patients' clinical notes.

Self-administration management steps

A Registered nurse, who has had their Entonox Competency signed off, can supervise the self-administration of Entonox.

The procedure must be performed by a second nurse.

Follow the steps below to supervise the Self Administration of Entonox.

  1. Assess the need for the use of Entonox for a short procedure.
    If the degree of pain is high, Entonox may be augmented by the use of opiates but additional monitoring (pulse oximetry) will be required.
    Remember to administer any additional analgesia in adequate time before the procedure commences
  2. Ensure Entonox and any additional analgesia are prescribed
  3. Check whether there are any precautions to be considered prior to administration, i.e. exclude contraindications
  4. Ensure child/young person is fasted for a minimum of 1 hour. If the procedure is planned, a 2 hour fast from food is preferable.
  5. Gather and prepare the equipment. Check delivery system. Fit a new filter
  6. Explain how the equipment works and how the gas will make them feel. Offer the child/young person the option of a face mask or mouthpiece
  7. A member of staff should be observing the child/young person self-administering Entonox while the procedure is being carried out by a second member of staff
  8. Do not allow the painful procedure to start until the child/young person is receiving the full effects of the Entonox and is able to co-operate
  9. Continually assess the child/young person during the procedure. Ask if they are comfortable with the Entonox equipment and if they are feeling any pain.
    Check for drowsiness. If the child/young person drops the hand piece, remember the effects of Entonox wear off quite quickly. If further pain relief is required, ensure the child/young person continues to use the equipment
  10. When the procedure is completed:
    Dispose of the filter
    Close the cylinder valve and exhaust the residual pressure in the system by depressing the test button or purge diaphragm
  11. Ensure that the facemask or mouthpiece is disposed of (single patient use only). If the patient is having a repeat procedure the mask or mouthpiece can be cleaned and kept for their use at a later date.
  12. Monitor thechild/young person until the effects of Entonox have completely worn off, i.e. dizziness or disorientation
  13. Document the procedure and the use of Entonox in the designated notes.
  14. If a child/young person requires Entonox more than once every four days then medical staff should be informed and full blood counts monitored

References

  1. BOC. (2011) Entonox medical gas data sheet: Essential Safety Information. Retrieved from http://www.boc-healthcare.co.nz/internet.lh.lh.nzl/en/images/HCD067B_Entonox%20Data%20Sheet_V4_ARIS434_131351.pdf?v=2.0
  2. Bruce E (2000). 'Self-administered nitrous oxide (Entonox) for the management of procedural pain'. Paediatric Nursing. Vol 12, No7, pp15 - 19
  3. Canbulat Şahiner, N., İnal, S., & Sevim Akbay, A. (2015). The effect of combined stimulation of external cold and vibration during immunization on pain and anxiety levels in children. Journal of Perianesthesia Nursing: Official Journal of the American Society of PeriAnesthesia Nurses, 30(3), 228-235.
  4. New Zealand Medicines and Medical Devices Safety Authority (2017) Emla Data Sheet. Retrieved from http://www.medsafe.govt.nz/profs/datasheet/e/Emlacream.pdf

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Document Control

  • Date last published: 26 October 2017
  • Document type: Clinical Guideline
  • Services responsible: Paediatric Pain Service
  • Owner: Paediatric Pain Service
  • Editor: Greg Williams
  • Review frequency: 2 years

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