| Contents | Previous | Next |
Patients with cancer undergo painful procedures for diagnosis, therapy, and supportive care, including lumbar puncture, bone marrow aspiration, and biopsy. Although venipunctures, insertion of intravenous catheters, and intramuscular injections are less invasive, less painful procedures, their frequency and repetition become a major source of distress and apprehension. For aggressive treatment protocols, multiple invasive procedures may be performed weekly or daily.
Children with cancer consider painful procedures to be the most difficult part of having cancer, and frequent repetition of procedures does not desensitize them to the distress (Fowler-Kerry, 1990; Weekes and Savedra, 1988). No published studies have focused on the reactions of adults to frequent and cumulative procedures, but some adults may be able to cope because of their greater cognitive ability and life experience in dealing with adversity and stress. Nevertheless, what is painful for a child or adolescent is also likely to be painful for an adult, especially when already stressed by the diagnosis of a potentially fatal illness. For all cancer patients, then, intervention for suffering should include concern for and management of the pain and distress associated with procedures.
Much of the data available on the management of procedure-related pain comes from studies on children with cancer and addresses nonpharmacologic management. For these guidelines, relevant data on cognitive-behavioral management in children were extrapolated to adults when there were no studies with adult patients.
Painless procedures (such as CT scanning, MRI positioning for radiotherapy, and ultrasonic examination) that require patients to lie still, often on a cold, hard surface, may be frightening and indirectly provoke pain and distress. For patients older than 5 years, preparatory education about the sensations and surroundings the patient will experience (Johnson, Rice, Fuller, et al., 1978) and the use of hypnosis, distraction, imagery (Katz, Kellerman, and Ellenberg, 1987; Zeitzer, Altman, Cohen, et al., 1990), and relaxation (Pfaff, Smith, and Gowan, 1989) may decrease distress and facilitate coping with the procedure. Sedatives, including oral chloral hydrate, pentobarbital, and midazolam (Sievers, Yee, Foley, et al., 1991), may be appropriate for painless procedures that require patient cooperation in remaining still, particularly for children under 6 years of age and for cognitively impaired patients. Because pharmacologic sedation may result in the loss of protective reflexes, patients must be closely monitored (American Academy of Pediatrics Committee on Drugs, 1992). Intrinsically painful procedures may exacerbate ongoing cancer-related pain, and supplemental analgesia may be required (Table 20).
Plans for managing pain associated with painful procedures should address several questions:
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 practitioner's 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.
| Table 20. General principles of management for painful procedures | |
| General considerations | |
| Treat anticipated procedure-related pain prophylactically. | |
| Patients benefit from predictability as to time. frequency, and "clustering" of procedures, with an identified block of time when no procedures are to be performed, barring emergencies. | |
| Be attentive to the environment and to privacy. For children, a room other than the child's room should be used whenever possible. Environmental factors, such as cold or crowded rooms or "beepers" on machines, can escalate distress (Fowler-Kerry, 1990; Hester, 1989). | |
| Before beginning the procedure, manage preexisting pain as well as possible. | |
| Tailor treatment options to the patient's and the family's needs and preferences, to the procedure, and to the context. | |
| Integrate pharmacologic and nonpharmacologic options in a complementary style. | |
| After the procedure, review with the patient and family their experiences and perceptions about the effectiveness of pain management strategies. | |
| Psychological preparation of the patient | |
| Provide adequate preparation of the patient and family. For children, discuss with the child and parents what can be expected and how the child might respond. | |
| Procedural considerations | |
| For procedures that will be repeated, maximize treatment for the pain and anxiety of the first procedure to minimize anxiety before subsequent procedures. | |
| Ensure the competency of the person performing the procedure and the timeliness of the procedure (Zettzer, Altman, Cohen, et al., 1990). | |
| Minimize delays to prevent escalation of pain and anxiety (Fowler-Kerry, 1990). | |
| Provide monitoring and resuscitative equipment if drugs are used for sedation. Facilities, equipment, and trained personnel to manage emergencies (e.g., vomiting, inadequate ventilation, and anaphylaxis) should be immediately available (American Academy of Pediatrics Committee on Drugs, 1992; | |
| American Nurses Association, 1992). | |
| Nonpharmacologic interventions | |
| For children, allow parents to be with the child during the procedure, if parents choose to remain. The presence of a parent is a source of great comfort for the child (Bauchner, Waring, and Vinci, 1991). The parent's knowledge of the child can be valuable. Parents should be taught what to do, where to be, and what to say to help their child through the procedure. Parents should not be asked to restrain the child during the procedure. | |
| For adults, the presence of a supportive friend or relative may be helpful (Puntillo, 1990). Elicit the patient's preferences in this regard. | |
| Infants can benefit from sensory motor interventions (e.g., using a pacifier. touching, and patting) (Campos. 1989; NAACOG Committee on Practice. 1991). Potentially effective cognitive-behavioral strategies for older childreninclude distraction techniques such as music (Ryan, 1989), coping skills (Siegel and Peterson, 1981), hypnosis (Kuttner, 1988; OIness, 1981; Zeitzer and LeBaron, 1982), play therapy (Ellerton, Caty, and Ritchie, 1985), and thought stopping (Ross, 1984). Physical agents include TENS therapy (Eland, 1989) and counterirritants such as ice (Zeitzer, Attman, Cohen, et al., 1990). Cognitive-behavioral interventions that have been effective in reducing procedural pain or analgesic use in adults include imagery (Horan, Laying, and Pursell, 1976) and hypnosis (Reeves, Redd, Storm, et al., 1983), and sensory and procedural information (Reading, 1982). Many of these methods, including the provision of preparatory information, hypnosis, thought stopping, and counter-irritation, may also be useful for adults. For all ages, choice should be based on the patient's preference, personality, and coping style. | |
| Pharmacologic interventions | |
| If possible, administer pharmacologic agents by a painless route (e.g., oral, transdermal, or intravenous). If parenteral agents are necessary and the patient does not have intravenous access, a single injection may be preferable to multiple attempts at insertion of an intravenous catheter. | |
Cardiovascular, hemodynamic, neurologic, 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).
| Table 21. Pharmacologic agents for management of procedural pain | |
| Local anesthetics | |
| These agents may be administered by local infiltration or topical application. For topical use, an eutectic mixture of local anesthetics (EMLA) is efficacious in use with procedures and is now available in the United States (Kapelushnik, Koren, Solh, et al., 1990). When EMLA is used as a local anesthetic, it should be applied 60 to 90 minutes before the procedure. | |
| Opioids | |
| These drugs can be given via the intravenous or oral route. The intravenous route has the advantage of rapid effect and ease of titration. Intravenous opioids can be given in increments (e.g., 0.03 to 0.05 mg per kg of morphine every 5 minutes for children and other patients who weigh less than 50 kg, or 2 to 4 mg of morphine every 5 minutes for adults and children who weigh more than 50 kg) and titrated to analgesic effect (Schechter, Weisman, Rosenblum, et al., 1990). Oral opioids can be used when close and rapid titration to effect is not required. | |
| Other opioids may be used instead of morphine. Meperidine is suitable for bhef, titrated dosing but not for prolonged use. Intravenous fentanyl may be used in small doses (25-p.g increments, or 0.5 p-g/kg for patients who weigh 50 kg or less). If given slowly in increments, the risk of chest wall rigidity is extremely small, but if it occurs, it should be managed immediately by the administration of a rapid-onset muscle relaxant and supporting ventilation. Transdermal fentanyf is not recommended for this indication because it requires on average 14 hours to reach peak application after administration (Varvel, Shafer, Hwang, et al., 1989). | |
| Benzodiazepines | |
| These agents can be given orally, intravenously, or transmucosally and provide anxiolysis, skeletal muscle relaxation, and in higher doses, amnesia. After opioids, intravenous benzodiazepines are given in increments and titrated to sedative effect (Sievers, Yee, Foley, et al., 1991; Zettzer, Altman, Cohen, et al., 1990). Unlike diazepam, midazolam does not cause pain and local sclerosis when given intravenously (Zettzer, Altman, Cohen, et al., 1990). For adults, midazolam is traditionally titrated in increments of about 0.5 mg. Benzodiazepines provide sedation, not analgesia, and hence, they often are used with opioids for painful procedures. If the combination of opioid plus benzodiazepine is used, the risk of respiratory depression is increased significantly, and careful titration and monitoring are required, particularly in the elderly. | |
| Barbiturates | |
| These drugs provide excellent sedation. They have no analgesic effects and are used with analgesics for painful procedures. Some patients may have paradoxical reactions, and for most patients, the sedation persists for many hours after the procedure is completed (Zeitzer. Jay, and Fisher, 1989). As with benzodiazepines, close observation for respiratory depression is essential, particularly when the intravenous route is used or if an opioid is co-administered. | |
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.
Skilled supervision is necessary whenever systemic pharmacologic agents are used for conscious sedation (i.e., the patient maintains a response to verbal and physical stimuli). At any site where painful procedures may be performed, patient-size-appropriate resusdtative equipment and resuscitative drugs should be immediately available to treat promptly any untoward effects. When conscious sedation is used, at least one health care professional who is well trained in airway management and advanced life support should be available. Patients should not eat or drink before procedures that use conscious sedation.
During such procedures, a health care professional not involved in performing the procedure or restraining the patient should monitor the patient. Monitoring includes frequent assessment of heart rate, respiratory rate and effort, blood pressure, and level of consciousness. Continuous pulse oximetry to measure arterial oxygen saturation is strongly encouraged because visual observation of cyanosis is not sensitive to level of oxygen saturation. Guidelines from the American Academy of Pediatrics (1992) emphasize the importance of vigilant monitoring during conscious sedation:
The caveat that loss of consciousness should be unlikely is a particularly important aspect of the definition of conscious sedation, and the drugs and techniques used should carry a margin of safety wide enough to render unintended loss of consciousness highly unlikely. Since the patient who receives conscious sedation may progress into a state of deep sedation and obtundation, the practitioner should be prepared to increase the level of vigilance corresponding to that necessary for deep sedation, (p. 1112)
After the procedure, monitoring should continue until the patient is fully awake and has resumed the fomat level of function. Discharged patient should be accompanied by an adult for a time at least as long as two half-lives of the agents used (e.g. at least 6 hours for morphine). These patients should be advised not to drive an automobile or operate dangerous machinery until it is likely that all medication effects are resolved (usually 24 to 48 hours). Documentation of the monitoring during the procedure, observation before discharge, and discharge instructions should be part of the patient's permanent record.
In contrast to conscious sedation, deep sedation (i.e., when the patient is not responsive to verbal or physical stimuli) is equivalent to general anesthesia and should be performed only under controlled circumstances by a professional trained in its use and skilled in airway management and advanced life support. Reference to specific published guidelines is recommended (e.g., in particular, American Academy of Pediatrics, 1985,1992; American Nurses Association, 1991).
Despite careful titration of sedative doses, individual responses are variable, and patients may occasionally have respiratory compromise or loss of airway reflexes. Because respiratory depression is strongly related to the degree of sedation, stimulation of the patient, and administration of small doses of naloxone (e.g., 0.04-mg doses for patients weighing 40 kg or more, or 0.5 to 2 u.g/kg for patients weighing less than 40 kg), may be adequate to reverse mild degrees of hypoventilation (Schechter, Weisman, Rosenblum, et al., 1990). Assisted ventilation by bag and mask or (ultimately) by endotracheal intubation and repetitive naloxone dosing may be required to reverse severe degrees of respiratory depression. If such depression does occur, the patient should be observed until well after the naloxone effect has worn off (usually after 1 hour).
For lumbar punctures, local anesthetics are used, although efficacy in infants is controversial. Young children and some older children and adults benefit from a benzodiazepine. Supplementation with opioids is helpful for some patients, especially when difficulty in performing the procedure is anticipated. Patients over 5 years of age, who can effectively use cognitive and behavioral coping skills, may prefer not to use sedatives or opioids (Zeitzer, Altman, Cohen, et al., 1990).
Management for bone marrow aspirations and biopsies includes the use, along with local anesthesia, of either general anesthesia or conscious sedation with benzodiazepines and opioids. Adequate time is necessary for the local anesthetic agent to have full effect.
In children, nonpharmacologic methods with demonstrated ellicacy for lumbat punctures and bone narrow aspirations and biopeare include hypnosis (Zetzer and LeBaron, 1982);thought stopping (Ross, 1984); and multidimensional psychological intervention that includes a breathing exercise, reinforcement, imagery, behavioral rehearsal, and filmed modeling (Jay, Elliott, Ozolins, et al., 1985). These strategies alone, however, often do not reduce pain sufficiently.
In addressing procedure-related pain, clinicians should consider the nature of the procedure (invasive or noninvasive), the degree of pain expected, and the needs of the patient in the development of a plan that emphasizes prevention of pain before the procedure. Further, especially in children, followup should include an assessment of pain secondary to the inflammatory process and provision of treatment (e.g., applications of cold or heat unless contraindicated or use of mild analgesics or NSAID).