ORIGINAL ARTICLE
Managing Painful Procedures in Children With Cancer Marilyn J. Hockenberry, PhD, RN-CS, PNP, FAAN,* Kathy McCarthy, BSN, RN,* Olga Taylor, MPH,* Meredith Scarberry, MS,* Quinn Franklin, MS, CCLS,w Chrystal U. Louis, MD, MPH,* and Laura Torres, MDz
Summary: Children with cancer experience repeated invasive and painful medical procedures. Pain and distress does not decrease with repeated procedures and may worsen if pain is not adequately managed. In 1990, the first recommendations on the management of pain and anxiety associated with procedures for children with cancer were published. Guiding principles described in the recommendations continue to hold true today: maximize comfort and minimize pain, use nonpharmacologic and pharmacologic interventions, prepare the child and family, consider the developmental age of the child, support family and child involvement, assure provider competency in performing procedures and sedation, and use appropriate monitoring to assure safety. This article reviews these key components for managing painful procedures in children and reviews the latest pharmacological and nonpharmacological interventions most effective in minimizing pain and discomfort. Key Words: procedures in children with cancer, procedure sedation, managing bone marrow aspirations with sedation, managing lumbar punctures with sedation
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here is evidence to support that pain and distress does not decrease with repeated procedures and may worsen if pain is not adequately managed.1,2 In 1990, the first recommendations on the management of pain and anxiety associated with procedures for children with cancer were published by the American Academy of Pediatrics.1 Guiding principles described in the recommendations continue to hold true today: Maximize comfort and minimize pain. The ideal goal for procedure pain management is to make the experience as comfortable as possible for the child and parents. Use nonpharmacologic and pharmacologic interventions. Nonpharmacologic interventions like cognitive-behavioral interventions (CBI) should be taught to every child who is developmentally able to use these strategies to decrease anxiety and distress. Pharmacologic therapies are safe and effective when carefully administered and monitored by appropriately trained personnel. Prepare the child and family. The key to managing procedure-related pain and distress is preparation and education. Parents and children should receive appropriate information regarding what to expect before, durReceived for publication April 9, 2010; accepted July 9, 2010. From the *Pediatric Hematology Oncology, Baylor College of Medicine, Texas Children’s Cancer Center; wEvidence-Based Outcomes Center; and zAnesthesiology, Texas Children’s Hospital, Houston, TX.. Reprints: Marilyn J. Hockenberry, PhD, RN-CS, PNP, FAAN, Texas Children’s Hospital, 6621 Fannin St, Houston TX 77030 (e-mail:
[email protected]). Copyright r 2011 by Lippincott Williams & Wilkins
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ing, and after the procedure. Stress reducing techniques can be taught for use before, during, and after procedures. Consider the developmental age of the child. The child’s cognitive development provides the foundation for establishing standards of care for children undergoing painful procedures. Support family and child involvement. Families should be involved in choices offered for pharmacologic and nonpharmacologic therapies. Assure provider competency in performing procedures and sedation. Procedures must be performed by persons with technical expertise or by providers directly supervised by experts. Use appropriate monitoring to assure safety. Sedation and anesthesia should be administered in a monitored setting with immediately available resuscitative drugs and equipment.3
Key components to managing painful procedures in children with cancer include effective parent teaching and education, appropriate preparation for the procedure for both parent and child, and optimal analgesia and sedation. This article provides a review of child and family preparation for painful procedures and a review of the latest pharmacological and nonpharmacological interventions most effective in minimizing pain and discomfort.
CHILD AND FAMILY PREPARATION FOR PROCEDURES Children and their families should be prepared before the procedure and well supported during and after painful procedures.4,5 By first establishing rapport with the child and family, the clinician is able to assess the family’s knowledge of the procedure, expectations, and preferred learning style.5 This assessment should include discussion of the child’s developmental level, coping strategies, and previous experiences with procedures that can greatly impact his/her anxiety level.2,4 Table 1 provides a developmental overview of important aspects to consider when preparing children of all ages and their families for painful procedures. Inclusion of child life programs in pediatric settings has become widely accepted and advocated by the American Academy of Pediatrics.6 With expertise in child development, child life specialists (CLS) promote effective coping and adjustment during potentially stressful situations through play, psychological preparation, education, and support. CLS prepare children psychologically for medical procedures and events to increase their sense of mastery, reduce anxiety, and plan and rehearse coping strategies. Psychological preparation is patient focused and is defined as a “process of communicating accurate and developmentally appropriate information, identifying potential stressors, as well as planning and practicing coping strategies.”6
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TABLE 1. Preparation for Procedures and Development
Infant Involve parent in procedure if desired. If parent is unable to be with infant, place familiar object with infant (eg, stuffed toy). Have usual caregivers perform or assist with procedure. Make advances slowly and in a nonthreatening manner. Limit number of strangers entering room during procedure. During procedure use sensory soothing measures (eg, stroking skin, talking softly, giving pacifier). Cuddle and hug infant after stressful procedure; encourage parent to comfort infant. Perform painful procedures in a separate room, not in crib (or bed).
Toddler/Preschooler
School Age
Adolescent
Use same approaches as for infant, plus the following. Explain procedure in relation to what child will see, hear, taste, smell, and feel. Use play; demonstrate on doll but avoid child’s favorite doll. Emphasize those aspects of procedure that require cooperation (eg, lying still). Tell child it is okay to cry, yell, or use other means to express discomfort verbally. Expect treatments to be resisted; child may try to run away. Use firm, direct approach. Ignore temper tantrums. Use a few simple terms familiar to child. Give child one direction at a time (eg, “lie down,” then “hold my hand”). Prepare child shortly or immediately before procedure. Keep teaching sessions short (about 5-10 min). Tell child when procedure is completed. Allow choices whenever possible but realize that child may still be resistant and negative. Allow child to participate in care and to help whenever possible.
Explain procedures using correct medical terminology. Explain procedure using simple diagrams and photographs. Discuss why procedure is necessary; concepts of illness and bodily functions are often vague. Explain function and operation of equipment in concrete terms. Allow child to manipulate equipment; use doll or another person as model to practice using equipment Allow time before and after procedure for questions and discussion. Plan for longer teaching sessions (about 20 min). Prepare up to 1 day in advance of procedure to allow for processing of information. Include child in decision making when possible (eg, time of day to perform procedure, preferred site). Encourage active participation.
Discuss why procedure is necessary or beneficial. Explain long-term consequences of procedures; include information about body systems working together. Encourage questioning regarding fears, options, and alternatives. Provide privacy; describe how the body will be covered and what will be exposed. Discuss how procedure may affect appearance (eg, scar) and what can be done to minimize it. Emphasize any physical benefits of procedure. Involve adolescent in decision making and planning. Impose as few restrictions as possible. Explore what coping strategies have worked in the past; they may need suggestions of various techniques. Accept regression to more childish methods of coping.
Whether taught by a CLS or nurse, educational preparation for the procedure emphasizes sensory aspects of the procedure: what the child will feel, see, hear, smell, and touch and what the child can do during the procedure (eg, lie still, count out loud, squeeze a hand, hug a doll). Allow for ample discussion during educational preparation to prevent information overload and confusion and ensure satisfactory feedback. Allow the child to practice procedures and be comfortable with the sequence of events that will require cooperation (eg, deep breathing). Teaching dolls are frequently used to help children understand where on the body the procedure will be performed. Allowing the child choices when possible and empowering the child by giving them specific roles or jobs during the procedure decreases fear and anxiety. Emphasize that the procedure will end quickly and stress any pleasurable events afterward (eg, going home, seeing parents). Provide a positive ending, praising efforts at cooperation and coping. Like the child, parents also experience high levels of stress during procedures, and their anxiety does not decrease during treatment. However, parent anxiety levels can be minimized when the child is adequately prepared.7–9 Several studies report a positive impact on parental distress and satisfaction and no difference in technical complications when parents remain with children.8,10,11
CBI CBI are techniques intended to alter the procedure experience by changing the child’s thoughts through
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attention diversion, images, and self-determination.1,2,7,11–19 Examples of common CBI strategies used with children with cancer include distraction through music or other pleasant diversions, story telling, deep breathing, relaxation, guided imagery, massage, and yoga. CBI techniques are known to decrease anxiety and discomfort during painful procedures 1,2,12–19 and a variety of techniques are available to facilitate the child and family’s coping during the procedure (Table 2). Distraction involves concentrating on an event or object other than the pain. Distraction is a powerful coping strategy during painful procedures.20 Infants and toddlers are easily distracted because of their short attention span. Distraction is accomplished by focusing the child’s attention on something other than the procedure. Singing favorite songs, listening to music with a headset, counting aloud, or blowing on a magic wand are effective techniques. Older children can be distracted with activities such as video games, television, and music. Guided imagery works well with school-aged children and adolescents who can visualize an enjoyable experience or pleasant memory. The child describes the event in detail as he or she visualizes it. The child describes details of the event, including as many senses as possible (eg, “feel the cool breezes,” “see the beautiful colors,” “hear the pleasant music”). The child concentrates only on the pleasurable event during the painful time by enhancing the image, often by reading a script or playing a tape. The effectiveness of this method is enhanced by the use of a coach. The coach may be a parent or other adult who discusses the event with the child and keeps the r
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Managing Painful Procedures in Children With Cancer
TABLE 2. Cognitive-Behavioral Interventions and Development
Age Range
Techniques
Infants (0-12 mo) Toddlers (12-36 mo) Preschoolers (3-5 y) School agers (6-12 y) Adolescents (13-18 y)
Parent’s voice (eg, talking, singing on tape), touching (eg, holding and rocking), pacifier, music, swaddling, massage Same as infants in addition to: pinwheels, storytelling, peek-a-boo, busy box Pinwheels, party blowers, feathers, pop-up books storytelling, comfort item, music, singing, manipulatives Electronic toys (eg, Nintendo DS, PSP, IPOD), pop-up books, I Spy books, participation in procedure, imagery, storytelling, breathing techniques, muscle relaxation Music, comedy tapes, imagery massage, muscle relaxation, TV, video, other electronics
image alive during the procedure. Muscle relaxation is another CBI that is useful in children and adolescents. The child is asked to take a deep breath and “go limp as a rag doll” while exhaling slowly; then ask child to yawn. Begin progressive relaxation by starting with the toes, and systematically instructing the child to let each body part “go limp” or “feel heavy”; if child has difficulty relaxing, instruct child to tense or tighten each body part and then relax it. The child can keep eyes open, as children may respond better if eyes are open rather than closed during relaxation. As parent participation plays a major role in reducing a child’s anxiety associated with procedures,4,5 when possible, parents should have the option to remain with their child during the procedure and be involved in the CBI techniques used.
SEDATION FOR PROCEDURES There are 3 main categories of sedation used for painful procedures: minimal sedation, moderate sedation, and deep sedation/general anesthesia. CBI should be used in combination with sedation/analgesic agents. Table 3 provides a brief description of each sedation category.
Minimal Sedation Children receiving minimal sedation are able to respond to verbal commands; airway, spontaneous ventilation,
TABLE 3. Categories of Sedation21 Minimal sedation (anxiolysis) Patient responds to verbal commands Cognitive function may be impaired Respiratory and cardiovascular systems unaffected Moderate sedation (previously conscious sedation) Patient responds to verbal commands but may not respond to light tactile stimulation Cognitive function is impaired Respiratory function adequate; cardiovascular unaffected Deep sedation Patient cannot be easily aroused except with repeated or painful stimuli Ability to maintain airway may be impaired Spontaneous ventilation may be impaired; cardiovascular function is maintained General anesthesia Loss of consciousness, patient cannot be aroused with painful stimuli Airway cannot be maintained adequately and ventilation is impaired Cardiovascular function may be impaired
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and cardiovascular function are unaffected.3 This type of sedation is achieved by administering agents to treat symptoms of anxiety (Table 4). The benefits of anxiolytic therapy should be carefully considered as there are side effects including paradoxical effects resulting in agitation. It remains important to work with each child, using CBI during their procedure so they develop coping skills over time. Once the child’s anxiety lessens, nonpharmacologic interventions may become sufficient and anxiolytics may no longer be needed.
Moderate Sedation Moderate sedation is a drug-induced depression of consciousness during which the patient responds purposefully to verbal command, either alone or accompanied by light tactile stimulation.3 Usually no interventions are necessary to maintain a patent airway. Spontaneous ventilation is adequate and cardiovascular function is maintained. Numerous studies report midazolam, fentanyl, and ketamine as safe and effective agents for moderate sedation for painful procedures in children with cancer (Table 5).22–29 Two agents are often combined to provide both sedation and analgesia. Ketamine, fentanyl, and midazolam can be administered by a nonanesthesiologist outside of the operating room when proper monitoring and trained personnel are available.7,24–27,29–32 It is essential to continue using CBI with these children to develop coping skills over time, even when moderate sedation is used. Midazolam is a benzodiazepine with no analgesic properties of its own. Fentanyl is an opioid analgesic, and ketamine is a dissociative anesthetic/analgesic. These drugs
TABLE 4. Anxiolytic Agents*
Agent
Dose
Diazepam
Children: Oral: 0.12-0.8 mg/kg/d in divided doses every 6-8 h IV: 0.04-0.3 mg/kg/dose every 2-4 h; a maximum of 0.6 mg/kg, OR 10 mg within 8 h Adults: Oral: 2-10 mg given 2-4 times/d IV: 2-10 mg, may repeat in 3-4 h if needed Neonates, infants, and children: Oral, IV: 0.05 mg/kg/dose every 4-8 h; Max: 2 mg/dose Lorazepam Adults: Oral: 1-10 mg/d in 2-3 divided doses; usual dose: 2-6 mg/d in divided doses *Dosages from Lexicomp online. IV indicates intravenous; Max, maximum dose; OR, operating room.
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TABLE 5. Sedation Agents*
Agent
Moderate Sedation
Deep Sedation
Onset/Duration
Fentanyl
50 kg IV: 0.5-1 mg/kg/ dose or 25-50 mg/ dose, may repeat full dose in 5 min if needed, MAX cumulative dose: 100 mg >6 mo-2 mg/kg/dose or >MAX cumulative dose 100 mg
Onset: IV: 4-5 min Duration: 20-60 min
Respiratory depression, apnea; muscle rigidity and chest wall spasm occur after rapid IV administration; hypotension, bradycardia, seizures, delirium
Provides rapid onset of action with a short duration of action; minimal hemodynamic changes
NA
Onset: IV: 1-2 min Duration: 2-6 h
Respiratory depression, bitter taste, amnesia, blurred vision, headache, hiccoughs, nausea, vomiting, coughing, sedation; cardiac arrest, and hypotension have occurred after premedication with a narcotic Hypertonicity, nystagmus, diplopia; contraindicated in patients in which a rapid rise in blood pressure would be detrimental and in patients with increased ICP
Provides no analgesia; effective anxiolytic, sedative, amnesic; fewer cardiac complications
Midazolam
Ketamine
Children and adults IV: 0.5-1 mg/kg/ dose over 2-3 min; may repeat as needed up to MAX cumulative dose of 100 mg or 2 mg/kg in a 30 min time period
Children and adults IV: >1 mg/kg/ dose, or cumulative dose of 100 mg or 2 mg/kg in a 30 min time period
Onset: IV: 1-2 min Duration: 10-15 min
Propofol
NA
Children and adults IV bolus: 1 mg/kg/ dose IV infusion: 50-200 mg/kg/min; MAX: 200 mg/kg/ min
Onset: IV: 50 kg should be dosed in 20-50 mg increments
*Dosages from Lexicomp online. IV indicates intravenous; ICP, increased intracranial pressure; MAX, maximum dose; NA, nonavailable.
are administered in combination to provide both sedation and analgesia. However, combining midazolam and ketamine in some childhood cancer patients is associated with hypoxia, hypertension, tachypnea, vomiting, and hallucinations.25,28,29 Combining midazolam and fentanyl may cause decreased heart rate and blood pressure, oxygen desaturation, and emesis.24 Administering ondansetron with the analgesia agents reduces vomiting or retching after the procedure.30 The risk for ketamine complications is dose and age dependent. In a 2009 meta-analysis on emergency department procedural sedation, ketamine caused increased airway or respiratory adverse events, emesis, and recovery agitation when administered in an unusually high intravenous dose (initial dose Z2.5 mg/kg or total dose Z5.0 mg/kg).22,23 Ketamine was associated with adverse airway and respiratory events in children younger than 2 years and those 13 years and older, as well as increased emesis in younger
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adolescents. Older children have less distress with procedures than younger children when moderate sedation is used.7,33 Distress is further reduced by adding nonpharmacologic interventions to the sedation drug regimen.7,32,34–37 Nitrous oxide (N2O) is an anesthetic gas that provides moderate sedation and is most commonly used for painful dental procedures in children.38,39 In a small number of studies, N2O was effective in reducing pain and anxiety in children undergoing various painful nondental procedures [eg, venous cannulation, lumbar puncture (LP), bone marrow aspiration (BMA), and dressing change].40–42 In these studies, concentrations of N2O varied (ranging from 0% to 70% N2O in oxygen) and were administered by certified nurses or physicians in a controlled setting such as a clinic, procedure room, or operating room. Patients who received N2O before procedures had lower levels of distress, lower pain scores, were more relaxed, and many had no recollection of the procedure.40–42 r
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A small percentage of patients (ranging from 5% to 15%) experienced minor side effects from N2O; the most common included nausea, vomiting, excitement, dysphoria, and oxygen desaturation.40,41 More serious complications such as inhibition of the methionine pathway, hematological, neurological, and/or myocardial injury were associated with prolonged N2O use (>6 h) and higher concentrations (>70% N2O in oxygen).43 Serious side effects are not found in the review of studies using N2O for procedures that involve short-term sedation. Adequate room ventilation and effective scavenging systems are required when using N2O to reduce exposure to ambient gas.39,44,45 In addition, the N2O system must be capable of administering 100% oxygen (never
