Clinical Guidelines (Hospital)

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Procedural Pain Management

Introduction

The Royal Children's Hospital's (RCH) philosophy and practice aims at a child-centred rather than a procedure focussed management of procedural pain and distress.

The objective of this guideline is to outline appropriate pharmacological and non-pharmacological techniques in paediatric procedural pain management.

Procedural pain management will be discussed in three phases: before, during and after the procedure. Preparation for the procedure is a crucial phase. Staff must collaborate with families so that information is shared, coping skills maximised and the child and family actively participate in the process (Mutual participation model). In this way, the management of a child for a procedure is tailored to that child's needs. The same procedure performed on two different children may require very different procedural pain management. The child's developmental stage is one of the important factors which will influence the management plan. The preparation phase must begin before the child enters the procedural area.

It is the responsibility of all RCH staff involved in the care of children, whether performing a test, ordering it or as the support person, to support and implement such practices into their work areas.

Furthermore, staff should read this guideline in conjunction with the Hospital Policy on Procedural Pain Management.

Definition of Terms

Family centred care model: A health care model that places the patient and family at the centre of care given. This model of care emphasizes collaboration, empowerment and education.

Pain: Pain is a subjective experience as described in the formal definition: "An unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage" (www.iasp-pain.org). Note: The inability to communicate verbally does not negate the possibility that an individual is experiencing pain and is in need of appropriate pain-relieving treatment.

Procedure: Any medical intervention that may be potentially painful, or cause distress or anxiety.

Procedural sedation: Administration of sedatives or dissociative agents with or without analgesia to induce a state that allows the patient to tolerate unpleasant procedures while maintaining cardio respiratory function ¹

Analgesic: A drug or non-pharmacological technique that relieves pain.

A Mutual Participation Model: Staff should consult and collaborate with families ensuring information is shared, coping skills are maximised and the children and families actively participate.

Non-pharmacological procedural pain management: is the management of procedural pain and distress without medications. This includes behavioural and psychological techniques not only to manage and reduce pain but also to control anxiety and distress. Methods of non-pharmacological procedural pain management include appropriate preparation for the procedure, involvement of a support person for the child, appropriate surrounds and physical positioning of the child as well as specific psychological techniques such as distraction, deep breathing and relaxation.

1. Before the procedure - Preparation

All procedures must be planned and timed so that the child and family, staff and equipment are appropriately prepared prior to the procedure commencing.

1.1 Key questions for all procedures²

is the procedure really necessary?
how urgent is the procedure?
what is the expected intensity and duration of pain or discomfort for this child?

1.2 Patient's factors that influence choice of technique

age of the child
developmental, cognitive and emotional stage
cultural influences
medication and medical history
previous experience with procedures and pain management
assess pain, distress and anxiety level of child and family (through observation, communication and listening to the family).

1.3 Preparation of adults at the procedure

Make sure parents understand what the procedure involves. Avoid medical jargon, give an outline of what is going to happen and in which order.

Obtain consent from the parents (written consent is required for those procedures performed with sedation - Procedural Sedation Guidelines).

Train adults in the use of coping strategies and when to use these behaviours. Adult behaviours likely to enhance a child coping before and during a procedure include distraction techniques.

N.B. Parent's making reassuring comments to the child has shown to increase the child's anxiety and distress.

1.4 Preparation of the child/adolescent for the procedure

Provide age and developmentally appropriate information about the procedure.

Consider specific coping strategies for the child. Distraction refocuses attention away from a negative focus onto something more positive.

Distraction techniques include*:

Choosing a CD to play music
Allowing the child to watch a favourite DVD
Counting objects in the room or to look at posters on the wall or roof.
Non-medical conversation (e.g. chat about favourite hobbies)
Playing with developmentally appropriate toys
Reading interactive story books
Visual imagery (e.g. asking the child to imagine a place where they would like to be and then asking the child to tell you about this place)

*Some of the techniques, such as visual imagery may require the child and parent to be given the opportunity to practice as part of their preparation.

Physical and environmental comfort strategies:

Swaddling for infants (for 0-6 months)
Position for comfort (e.g. children on parent's lap or parent to maintain some type of physical contact with parent)
Comfort your child with gentle touch/massage. Offer to hold your child's hand

1.5 Pharmacological techniques (including sedation)

Appropriate analgesia should be planned and administered. Consider analgesia, local anaesthetic, sucrose and/or sedation.

Any child having sedation should have a risk assessment and be appropriately fasted (refer to Procedural Sedation Guidelines or MR56S).

1.6 Environment

All procedures must be conducted in the appropriate environment. This should be in a designated area away from the patient's bed and other patients.

1.7 Equipment

Equipment for distraction should be available e.g. toys, interactive books. They should be age specific to the child.

Prepare and set up the procedural equipment before the child enters the procedure room.

1.8 The Procedualist and staffing

Staff performing the procedure (i.e. the proceduralist) must have appropriate technical skillexpertise, or be closely supervised by someone who does.

For children likely to need a high level of technical skill for the procedure, early involvement of staff with appropriate procedurale expertise should occur or the procedure should be deferred.

For patients receiving sedation, there must be appropriate staff levels to monitor the patient (refer to Procedural Sedation Guidelines).

1.9 Timing

Optimise waiting time: too little time may increase distress but too much time may increase anticipatory anxiety.
Timing of local anaesthetic application and preparation of the child and their family should be considered.

2. During the procedure

Give the child some feeling of control (as developmentally appropriate) e.g. choice of hand for IV, sitting up or lying down.

Prompt the child (and adult) to use the coping method that was planned.

Monitor the effectiveness of pain management techniques during a procedure and change methods as required.

Consider changing pain control measures or aborting the procedure if the child is not coping well (Please note, additional information will added to this guideline regarding this)

3. After the procedure

Encourage the parent to remain with their child

Assess the need for analgesia.

Depending on the procedure, the child may need the opportunity to debrief. For example, staff and parents should focus on the helpful things their child did during the procedure. Staff may also like to suggest what techniques they think went well and suggestions for any further procedures that may be planned.

Documentation

All procedures should be documented legibly as per Hospital Documentation: Medical Records policy
Include details of:

When and where the procedure took place
Who participated
Which non-pharmacological and pharmacological techniques were used
How successful these interventions were at minimizing pain and distress
Recommendations for future procedures/procedural pain management.

The provision of adequate procedural pain management should include adequate verbal and/or written information and preparation to allow optimal procedural pain management.

Special Considerations

Particular attention should be paid to managing procedural pain and distress in patients from vulnerable populations such as neonates and cognitively impaired children.
Children identified as having difficulties coping with procedures or those at high risk (such as children with chronic or serious illness having regular or repeated procedures) should be referred to play therapy department or the mental health practitioners for assessment and management.

Other medications

There are specific guidelines regarding the following:

Clinical incident reporting

Clinical incident reporting via RCH incident reporting system refer to Risk Management Policy

References

1. The American College of Emergency Physicians. Clinical policy for procedural sedation and analgesia in the emergency department. Annals of Emergency Medicine 1998; 31(5): 663-77

2. The Royal Australasian College of Physicians, Paediatric and Child Health division Guideline Statement: Management of Procedure -related Pain in Children and Adolescents

Evidence Table

Procedural Pain Management Evidence Table