Implementation of a protocol for pharmacological treatment of pain in hospitalized children

Binotto, Natália Shinkai; Gabani, Flávia Lopes; Linck Júnior, Arnildo; Rossato, Lisabelle Mariano; Rossetto, Edilaine Giovanini; Tacla, Mauren Teresa Grubisich Mendes

doi:10.5935/2595-0118.20210024

Natália Shinkai Binotto Correspondence to: Departamento de Enfermagem da Universidade Estadual de Londrina Centro de Ciências da Saúde Av. Robert Kock, 60 - Vila Operária 86039-440 Londrina, PR, Brasil. E-mail: natalia_binotto@hotmail.com nataliasbinotto@gmail.com

State University of Londrina, Nursing Department, Londrina, PR, Brazil.

http://orcid.org/0000-0002-2405-1828

Flávia Lopes Gabani

State University of Londrina, Nursing Department, Londrina, PR, Brazil.

http://orcid.org/0000-0002-9442-4896

Arnildo Linck Júnior

State University of Londrina, Pediatrics and Pediatric Surgery Department, Londrina, PR, Brazil.

http://orcid.org/0000-0002-6813-019X

Lisabelle Mariano Rossato

University of São Paulo, Nursing Department, São Paulo, SP, Brazil.

http://orcid.org/0000-0003-3375-8101

Edilaine Giovanini Rossetto

State University of Londrina, Nursing Department, Londrina, PR, Brazil.

http://orcid.org/0000-0002-0996-5154

Mauren Teresa Grubisich Mendes Tacla

State University of Londrina, Nursing Department, Londrina, PR, Brazil.

http://orcid.org/0000-0001-8928-3366

Correspondence to: Departamento de Enfermagem da Universidade Estadual de Londrina Centro de Ciências da Saúde Av. Robert Kock, 60 - Vila Operária 86039-440 Londrina, PR, Brasil. E-mail: natalia_binotto@hotmail.com nataliasbinotto@gmail.com

AUTHOR’S CONTRIBUTIONS

Natalia Shinkai Binotto

Data Collection, Conceptualization, Resource Management, Research, Methodology, Writing - Preparation of the original, Writing - Review & Editing, Supervision, Visualization

Flávia Lopes Gabani

Research, Writing - Preparation of the original, Writing - Review & Editing, Supervision

Arnildo Linck-Júnior

Project Management, Research, Writing - Preparation of the original, Writing - Review & Editing, Supervision

Lisabelle Mariano Rossato

Conceptualization, Methodology, Writing - Preparation of the original, Writing - Review & Editing

Edilaine Giovanini Rossetto

Conceptualization, Methodology, Writing - Preparation of the original, Writing - Review & Editing

Mauren Teresa Grubisich Mendes Tacla

Data Collection, Conceptualization, Project Management, Research, Methodology, Writing - Preparation of the original, Writing - Review & Editing, Supervision, Visualization

Figures (1)
Tables (4)

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Figure 1.
The #criançasemdor logo

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Table 1
Pharmacologic pain treatment for hospitalized children: analgesics and sedatives ²³23 American Academy of Pediatrics. [Internet]. Available from: www.aap.org
www.aap.org...

24 Agência Nacional de Vigilância Sanitária. Bulário eletrônico. 2018. Disponível em: http://portal.anvisa.gov.br/bulario-eletronico1,
http://portal.anvisa.gov.br/bulario-elet... ^-²⁵25 World Health Organization. WHO Guidelines on the pharmacological treatment of persisting pain in children with medical illnesses. 2012. Available from: https://www.ncbi.nlm.nih.gov/books/NBK138354/pdf/Bookshelf_NBK138354.pdf
https://www.ncbi.nlm.nih.gov/books/NBK13...

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Table 2
Interval and indication of analgesics and sedatives for the pharmacologic treatment of pain in hospitalized children²³23 American Academy of Pediatrics. [Internet]. Available from: www.aap.org
www.aap.org...

24 Agência Nacional de Vigilância Sanitária. Bulário eletrônico. 2018. Disponível em: http://portal.anvisa.gov.br/bulario-eletronico1,
http://portal.anvisa.gov.br/bulario-elet... ^-²⁵25 World Health Organization. WHO Guidelines on the pharmacological treatment of persisting pain in children with medical illnesses. 2012. Available from: https://www.ncbi.nlm.nih.gov/books/NBK138354/pdf/Bookshelf_NBK138354.pdf
https://www.ncbi.nlm.nih.gov/books/NBK13...

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Table 3
Interval and indication of antagonists for the pharmacologic treatment of pain in hospitalized children²³23 American Academy of Pediatrics. [Internet]. Available from: www.aap.org
www.aap.org...

24 Agência Nacional de Vigilância Sanitária. Bulário eletrônico. 2018. Disponível em: http://portal.anvisa.gov.br/bulario-eletronico1,
http://portal.anvisa.gov.br/bulario-elet... -²⁵25 World Health Organization. WHO Guidelines on the pharmacological treatment of persisting pain in children with medical illnesses. 2012. Available from: https://www.ncbi.nlm.nih.gov/books/NBK138354/pdf/Bookshelf_NBK138354.pdf
https://www.ncbi.nlm.nih.gov/books/NBK13...

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Table 4
Standard operational procedure

Drugs	Dose	Presentation	Safe concentration for direct intravenous (IV) administration
Paracetamol	Oral route (OR): 10 to 15 mg/kg. Maximum dose: 650 mg/day	100 mg/mL 200 mg/Ml	-
Dipyrone	IV or OR: 10 to 15mg/kg	IV: 500 mg/mL Drops: 500 mg/mL Solution: 50 mg/mL	Dilute 1mL of dipyrone in 9mL of 0.9% saline solution to a concentration of 50 mg/mL
Ibuprofen	OR: 5 to 10 mg/kg Maximum dose: 600 mg/day	50 mg/mL 100 mg/mL	-
Ketoprofen	OR: 0.5 mg/kg 1 drop/kg Maximum dose: 300 mg/day	Solution: 1 mg/mL Drops: 20 mg/mL	-
Fentanyl^* * Analgesic with low sedative action. Administer with medical presence.	IV: 1 to 3µg/kg	50 µg/mL	Dilute 1mL of fentanyl with 9mL of 0.9% saline solution to a concentration of 5µg/mL^† † Slow infusion.
Morphine (analgesic without sedative action)	IV: 0.05 to 0.2 mg/kg	1 mg/mL 10 mg/mL	Dilute 1mL of morphine (1 mg/mL) with 9mL of 0.9% saline solution to a concentration of 0.1 mg/mL^† † Slow infusion.
Ketamine (analgesic and sedative)	IV: 0.5 to 2 mg/kg Intramuscular (IM): 1 to 4 mg/kg	50 mg/mL	Dilute 1mL of ketamine with 9mL of 0.9% saline solution to a concentration of 5 mg/mL^† † Slow infusion.
Midazolam (sedative)	IV: 0.1 to 0.3 mg/kg OR: single dose 0.25 to 0.5 mg/kg Maximum dose: 20 mg	IV: 5 mg/mL OR: 2 mg/mL	Dilute 1mL of midazolam with 9mL of 0.9% saline solution to a concentration of 0.5 mg/mL^† † Slow infusion.
Etomidate (sedative)	IV: 0.2 to 0.4 mg/kg	2 mg/mL	Non diluted administration (pure)

Drugs	Minimum interval between doses		Indication
Drugs	Procedures	After procedures for maintenance in prescription	Indication
Paracetamol	4 hours	4 to 6 hours	Mild pain Adjunct in the association with opioids
Paracetamol	Risk of hepatotoxicity in newborns and infants. In case of poisoning, use N-acetylcysteine.
Dipyrone	4 hours	4 to 6 hours	Mild pain OR: from 3 months on IV: from 1 year on
Ibuprofen	6 hours	6 to 8 hours	Mild pain From 6 months on
Ketoprofen	6 hours	6 to 8 hours	Mild pain From 1 year on
Fentanyl	20 minutes^* * Associate with ketamine in minimal dose in procedures.	2 hours	Moderate do severe pain Post-surgery Phlebotomy Central venous puncture Chest drain insertion and removal
	1^st choice in asthmatic crisis, post biliary tract surgery, hemodynamic instability, history of chronic constipation. Avoid when there are signs of hypovolemia, hypotension, or bradycardia. In the case of chest rigidity, use naloxone 0.01mg/kg.
Morphine	Avoid for procedures. Fentanyl or ketamine are preferable.	2 hours	Moderate to intense pain Postoperative Maintenance of chest drain
	Do not use in case of hypotension, asthmatic crisis and postoperative biliary tract surgery
Ketamine	In case of single dosage: 20 minutes In case of maximum dosage: 40 minutes	2 hours	Moderate to intense pain Phlebotomy Central venous puncture Chest drain insertion and removal
	Do not use in younger than 3 months of age
Midazolam	20 minutes	2 hours	OR: children older than 6 months. Can be associated with Ketamine for procedures.
	Do not use in arterial hypotension
Etomidate	5 to 10 minutes	1 hour
	Do not use in sepsis because of the risk of adrenal insufficiency.

Drugs	Dose and presentation	Safe concentration for direct IV administration	Minimum interval between doses in procedures
Sugamadex (antagonist of non-depolarizing neuromuscular blockers)	2 mg/kg 100 mg/mL	10 mg/mL	Administer at most 2 doses each 2 to 4 minutes
Naloxone (opioid antagonist)	0.01 to 0.02 mg/kg 0.4 mg/mL	Non diluted and fast administration	5 to 10 minutes
Flumazenil (benzodiazepines antagonist)	0.01 to 0.03 mg/kg 0.5 mg/5mL	Non diluted and fast administration	5 to 10 minutes
Acetylcysteine N-acetylcysteine (paracetamol antagonist)	OR: 20 mg/mL (older than 2 years) IV: 100 mg/mL
	OR: initial dosage of 140 mg/kg followed by doses of 70 mg/kg each 4 hours for 3 days IV: loading dose: 150 mg/kg in 3mL/kg of 5% glucose solution for 60 min; 2^nd dose: 50 mg/kg in 7mL/kg of 5% glucose solution for 4 hours; 3^rd dose: 100 mg/kg in 14mL/kg of 5% glucose solution for 16 hours. Dilution in 5% glucose solution.

Systematization of pain management in hospitalized children
Concept The systematization of pain management in hospitalized children encompasses the phases of identification, assessment, and treatment.
Purpose Avoid undertreatment of underestimated pain resulting from subjective assessments; reduce stress and trauma providing a rapid recovery and early hospital discharge of the child. Moreover, the promotion of adequate pain management in pediatrics will ensure the legal right of the hospitalized child and adolescent to not feel pain when there are means to avoid it, as stated in Resolution nº 41, of October 13, 1995, from the Conselho Nacional dos Direitos da Criança e do Adolescente (National Council for the Rights of Children and Adolescents).
Responsible for execution Professionals responsible for the direct care of hospitalized children: • Nursing team (assistants, technicians, nurses) • Medical team (Pediatrics, Pediatric Surgery, Neurosurgery, Orthopedics and other specialties) • Physiotherapy team
Indication • To identify, assess the intensity and treat pain in children aged between zero and 12 years old hospitalized in the Pediatric Unit (PU).

[1] Correspondence to: Departamento de Enfermagem da Universidade Estadual de Londrina Centro de Ciências da Saúde Av. Robert Kock, 60 - Vila Operária 86039-440 Londrina, PR, Brasil. E-mail: natalia_binotto@hotmail.com nataliasbinotto@gmail.com

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Implementation of a protocol for pharmacological treatment of pain in hospitalized children

ABSTRACT

BACKGROUND AND OBJECTIVES:

METHODS:

RESULTS:

CONCLUSION: