6.2 Pharmacologic Strategies for Procedural Pain

The needs of the individual and the type of procedure to be performed shape the pharmacologic approach to managing procedure-related pain. Because children have special needs, the practitioners expertise and experience with children are key to successful therapy. For all patients, an opioid or a local anesthetic is needed to reduce the pain. Anxiolytics (i.e., medications for the relief of anxiety) and sedatives are used specifically to reduce anxiety before and during the procedure, but if used alone (i.e., without an analgesic), they may blunt the behavioral response without relieving the pain. Patients who have built up a tolerance to opioids or benzodiazepines may need much higher initial doses than those given in Table 21.

Cardiovascular, hemodynamic, necrologic, or pulmonary instability are not absolute contraindications to systemic analgesia, but careful titration and monitoring should be provided. No agent should be used unless the clinician understands the proper technique of administration, the proper dosage, contraindications, side effects, and treatment of overdose. The use of systemic analgesics and sedatives should be approached differently in infants younger than 6 months of age (see Chapter 7).

The mixture of meperidine, promethazine, and chloropromazine is not recommended even though commonly given intramuscularly for painful procedures in children. The efficacy of this mixture is controversial; disadvantages include the need for painful intramuscular injection and the prolonged sedation associated with its use (Nahata, Clotz, and Krogg, 1985).

Nitrous oxide, ketamine, thiopental, propofol, and methohexital can also be used as part of the pharmacologic strategy if trained personnel and appropriate monitoring procedures are available (Zeltzer, Jay, and Fisher, 1989). Administered by a mask or tent, nitrous oxide is a potent, short-acting inhalant analgesic that has been used for procedural pain and in the treatment of refractory pain in the terminally ill. A significant drawback is the high degree of room air contamination, making occupational exposure a serious concern. Thus, although nitrous oxide may be valuable, its use should be limited to situations in which appropriate environmental adaptations, trained personnel, and monitoring procedures are in place (Miser, Ayesh, Broda, et al., 1988). General anesthesia is appropriate in certain situations (Zeltzer, Altman, Cohen, et al., 1990) such as when a young child must undergo a painful procedure.

Related Chunks

General comments and cautions regarding the use of opioid analgesics

Drugs and routes of administration not recommended for treatment of cancer pain

PROCEDURE-RELATED PAIN IN ADULTS AND CHILDREN

Managing Procedure-Related Pain

Pharmacologic agents for management of procedural pain

Sedation for Procedural Pain

Analgesics for Neonates and Young Infants

Epidural Analgesia

Index