Which interventions are necessary?

Childern‘s pain & withdrawal:
Which interventions are
necessary?
Jennifer Stocker, Pflegefachfrau
Schwerpunktstation Kardiologie
Universitätskinderspital Zürich
Physical Dependence – Withdrawal Syndrome
– Introduction
– Problems seen in Clinical Practice
– Information sought in the Literature
– Withdrawal Symptoms
– Assessment Instruments
– Treatment Strategies
– Procedures from the Treatment Protocol
– Results
– Negative/Positive Aspects
Childern‘s pain & withdrawal: Which interventions are necessary? / Jennifer Stocker / Zürich
11.06.2015
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Background
– 0.6% of all births Congenital Heart Disease of moderate to great
complexity
– Increasing number of operations on neonates and young
children for heart defects
– Longer periods of Analgosedation due to:
– Postoperative Instability
– Pulmonary Hypertension
– Pain
Oechslin, 2006; Pohl-Schickinger et al., 2008
Childern‘s pain & withdrawal: Which interventions are necessary? / Jennifer Stocker / Zürich
11.06.2015
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Which medications are most frequently used?
– Morphine
– Fentanyl
– Midazolam
– Chloralhydrate
Arbeitsgemeinschaft der Wissenschaftlichen
Medizinischen Fachgesellschaften, 2009;
Jenkins et al., 2006
Childern‘s pain & withdrawal: Which interventions are necessary? / Jennifer Stocker / Zürich
11.06.2015
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Tolerance
– Developement of tolerance due to longer periods of treatment
– Decrease in Effectiveness
– Factors conducive to developing tolerance
– Duration of pain therapy
– Pre-term Infants
– Male babies
– Short-acting Opioids
Childern‘s pain & withdrawal: Which interventions are necessary? / Jennifer Stocker / Zürich
11.06.2015
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Physical Dependence – Withdrawal Syndrome
– Drug tolerance
– Seen after stopping or reducing the dose of a medication that
has been administered over a longer period of time
Tobias, 2000
Childern‘s pain & withdrawal: Which interventions are necessary? / Jennifer Stocker / Zürich
11.06.2015
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Problems Seen in Clinical Practice
– Difficulties to Identify Withdrawal
– Similar to other problems that can appear following cardiac
surgery
– Lack of a reliable assessment instrument
Childern‘s pain & withdrawal: Which interventions are necessary? / Jennifer Stocker / Zürich
11.06.2015
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Information sought in the Literature
– Which are the most common withdrawal symptoms?
– Are there assessment instruments to identify withdrawal
syndromes in neonates?
– What measures can protect from or treat withdrawal symptoms?
Childern‘s pain & withdrawal: Which interventions are necessary? / Jennifer Stocker / Zürich
11.06.2015
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Withdrawal Symptoms
Häufigkeiten
Frequency
CNS-Overstimulation
ZNS-Überstimulation
34 %
55 %
11 %
Gastrointestinal
Gastrointestinale
Symptoms
Symptome
autonome
AutonomicDysfunktion
Dysfunction
Ista et al., 2009; Anandet al., 2009
Childern‘s pain & withdrawal: Which interventions are necessary? / Jennifer Stocker / Zürich
11.06.2015
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Assessment Instrument: SOS Scale
Sophia
Observation
Withdrawal
Symptoms
Scale
Ista et al., 2009
Childern‘s pain & withdrawal: Which interventions are necessary? / Jennifer Stocker / Zürich
11.06.2015
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Treatment Strategies
– Avoid symptoms of withdrawal
– Gradual dose reduction
– Early conversion from continuous opiod infusions to intermittent
intravenous opiods, or enteral administration
– Treatment of a Withdrawal Syndrome
– Stress reduction
– Care by primary nursing and involving parents
– Use of Clonidine
Anand et al., 2009; Arenas-López et al., 2004
Childern‘s pain & withdrawal: Which interventions are necessary? / Jennifer Stocker / Zürich
11.06.2015
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„Protocol to Prevent Withdrawal Symptoms“
– 20% reduction of medication dose daily
– Use of the „SOS- Sophia Observation Withdrawal Symptom Scale“
– 4-6 hours following dose reduction
– When Withdrawal Syndrome is suspected
– To monitor successful dose reduction or cessation
Childern‘s pain & withdrawal: Which interventions are necessary? / Jennifer Stocker / Zürich
11.06.2015
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Childern‘s pain & withdrawal: Which interventions are necessary? / Jennifer Stocker / Zürich
11.06.2015
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Results
– 51 Patients were observed
– 1.56 years old
– 7 days to wean
– 12 patients developed a
Withdrawal Syndrome
– Most frequent Withdrawal
Symptoms
– Sweating
– Agitation
– Anxiety
– Insomnia
Childern‘s pain & withdrawal: Which interventions are necessary? / Jennifer Stocker / Zürich
11.06.2015
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Negative/Positive Aspects
– Assessment remains challenging
– Complex Protocol
– Can not always be consistently followed, must be indiviually
adapted
– Assessments are acknowledged and accepted
– Patients at risk are assessed and quickly treated
Childern‘s pain & withdrawal: Which interventions are necessary? / Jennifer Stocker / Zürich
11.06.2015
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… Take-home Messages
– Vigilant Observations
– Evaluate within the treatment teams
– Standardized Treatment Protocol
– Knowledge generated for improved care of future patients
Childern‘s pain & withdrawal: Which interventions are necessary? / Jennifer Stocker / Zürich
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References
– Arbeitsgemeinschaft der Wissenschaftlichen Medizinischen
Fachgesellschaften, AWMF (2009). Analgesie, Sedierung
&Delirmanagement in der Intensivmedizin [On-Line].
– Arenas-López, S., Riphagen, S., Tibby, S., Durward, A., Tomlin, St.,
Davies, G. & Murdoch, I. (2004). Use of oral clonidine for sedation in
ventilated paediatric intensive care patients. Intensive Care Medicine,
30, 1625- 1629.
– Borth-Bruhns, T. & Eichler, A. (2004). Pädiatrische Kardiologie.
Berlin: Springer.
– Ista, E., van Dijk, M., de Hoog, M., Tibboel, D. &Duivenvoorden, H.
(2009). Construction of the Sophia Observation withdrawal
Symptoms-scale (SOS) for critically ill children. Intensive Care
Medicine, 35, 1075-1081.
– Jenkins, I., Playfor, St., Bevan, C., Davies, G. & Wolf, A. (2007).
Current United Kingdom sedation practice in pediatric intensive care.
PediatricAnesthesia, 17, 675-683.
Childern‘s pain & withdrawal: Which interventions are necessary? / Jennifer Stocker / Zürich
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– Ista, E., van Dijk, M., Gamel, C., Tibboel, D. & de Hoog, M. (2007).
Withdrawal symptoms in children after long-term administration of
sedatives and/or analgesics: a literature review. “Assessment
remains troublesome”. Intensive Care Medicine, 33, 1396-1406.
– Lorenz, H.-P. (2008). Postoperative Intensivtherapie. In G.
Schumacher, J. Hess & K. Bühlmeyer (Hrsg.), Klinische
Kinderkardiologie- Diagnostik und Therapie der angeborenen
Herzfehler(S. 528- 536). Heidelberg: Springer.
– Oechslin, E. (2006). Angeborene Herzfehler: lebenslange,
spezialisierte Betreuung für eine chronische Erkrankung.
Kardiovaskuläre Medizin, 9, 373-375.
– Pohl-Schickinger, A., Lemmer, J., Hübler, M., Alexi-Meskishvili, V.,
Redlin, M., Berger, F. & Stiller, B. (2008). Intravenous clonidine
infusion in infants after cardiovascular surgery. Pediatric Anesthesia,
18, 217-222.
– Tobias, J. (2000). Tolerance, withdrawal, and physical dependency
after long-term sedation and analgesia of children in the pediatric
intensive care unit. Critical Care Medicine, 28, 2122- 2132.
–
Childern‘s pain & withdrawal: Which interventions are necessary? / Jennifer Stocker / Zürich
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Many thanks for your attention
Childern‘s pain & withdrawal: Which interventions are necessary? / Jennifer Stocker / Zürich
11.06.2015
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