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Resident
Orientation Manual (Feb. 2000)
Produced by Galveston Shriners Burn Hospital and
The University of Texas
Medical Branch Blocker Burn Unit.
Contributors: Sally Abston MD, Patricia Blakeney
PhD, Manubhai Desai MD,
Patricia Edgar RN, CIC,John P Heggers PhD, David N Herndon MD,
Marsha Hildreth RD, Janet A
Marvin RN, MSN,
Ray J Nichols Jr. MD
PAIN MANAGEMENT PROTOCOL
Pain Control Recommendations (Revised 01/04/01)
Tenet #1 - If the patient says
he/she has pain - he/she has pain.
Tenet #2 - Analgesics are most
effective when given on a regular basis (not as needed or required).
Tenet #3 - Intra-muscular
injections are not usually appropriate because the child fears the injection
as much as the pain (when IM injections are given, EMLA cream should be
used). Tenet #4 -
Bowel management begins with the narcotic pain management.
Tenet #5 - Pain management protocol
should be initiated beginning with the following suggested doses.
These are starting doses to be modified as the situation dictates in
consultation with faculty.
Exceptions: This protocol includes the following exceptions in
which each dose of pain medication should be individualized for each
situation. The following patients will be handled by the senior
resident in consultation with faculty --
 First 24-48 hours post-burn
wherein blood flow is reduced to all organs if patient is in shock.
Respiratory difficulty - any
cause, if not intubated.
Septic shock patient.
Malnutrition, unless approved by
faculty.
Background Pain:
1) Begin with Acetaminophen:
Acetaminophen dose = 15 mg/kg/dose PO q4h
Draw acetaminophen blood levels starting one day after scheduled
acetaminophen is begun. Draw level one hour after dose is given, then
weekly thereafter on Mondays.
Therapeutic Level = 10-30 ug/ml
Toxic Level = >50 ug/ml
2) If the
pain is not controlled, give morphine in addition to acetaminophen:
IV Morphine dose = 0.03 mg/kg/dose IV q4h
PO Morphine dose = 0.1 to 0.3 mg/kg/dose PO q4h
3) If
morphine is given in children less than 3 years of age, these rules must be
followed:
a. Do not give if asleep.
b. Do not give for sleep - give only for pain.
c. Do not give during initial resuscitation (i.e., first 24 hours
post-injury).
d. Do not give if patient is in shock or is septic.
e. Give only if the patient is being monitored for ECG, respiration,
pulse and oxygen saturation.
f. Do not give if the respiratory rate is less than 20 or the oxygen
saturation is less than 95%.
g. If the patient is still in pain, call faculty. Do not
increase the morphine dose without faculty approval.
4)
Levorphanol (Levo-Dromoran):
Use only in patients that are over 16 years of age and
> 50 kg in weight. Call psychiatrist-on-call prior to ordering
this medication.
Levorphanol dose = 2 mg PO q6-24h prn pain.
5) Taper
narcotics over 3 days.
6) Ibuprofen (when anti-inflammatory action is also
indicated)
Ibuprofen dose = 10 mg/kg PO q4h.
Do not prescribe for others without approval from the
psychiatrist-on-call.
Bowel Regimen:
1) Start with the
following anytime narcotics are administered -
|
Prune Juice |
< 5 years |
2 oz. |
| |
> 5 years |
4 oz. |
| |
> 10 years |
6 oz. |
| Docusate Sodium |
< 3 years |
25 mg/day |
| (Colace©) |
3-6 years |
50 mg/day |
| |
6-12 years |
100 mg/day |
2) Then, add one of the
following if the patient becomes constipated:
a. Mineral Oil
-- 1-3 oz./day
b. Mini-enema (Colace© - glycerine) if no bowel
movement by noon
c. SBH enema if no bowel movement by 15:00 hours
Benzodiazepines for Baseline
Anxiety:
1) Before using anxiolytics:
 Address pain management
Address Acute Stress Disorder (ASD)
problems
2) Lorazepam
IV or PO Lorazepam dose:
0.03 mg/kg/dose q4h
Lorazepam taper for patients on
Lorazepam for > 15 days:
Reduce dose by 50% every 2nd day and then reduce frequency.
May be tapered post-discharge, if necessary.
3) Diazepam
Useful for rehabilitation
therapy because it relaxes skeletal muscle.
Longer half-life than Lorazepam
or Midazolam. No taper necessary.
IV or PO Diazepam dose:
0.1 mg/kg/dose q8-12h
Procedural Pain Relief and Anxiety Management:
1) For all age groups.
2) To be added in addition to background pain management.
3) The Child Life Therapy Department may be consulted before the
procedure for teaching and development of coping skills.
4) Procedural pain medication should be scheduled 30 minutes to 1
hour pre-procedure rather than prn.
5) An anxiolytic with amnesic properties should be given in
conjunction with the pain medication (Lorazepam or Midazolam are more potent
amnesics than diazepam).
6) Procedural Pain Medication for Dressing Changes: Increase
these doses if pain is not well-controlled and over-sedation is not seen.
a. Acetaminophen 15 mg/kg/dose may be used if patient does not
require opiate therapy.
b. Morphine dose for procedural pain is typically twice the dose for
background pain --
PO Morphine dose: 0.3 - 0.6 mg/kg/dose (if >15kg)
IV Morphine dose: 0.05 - 0.1 mg/kg/dose (if >15kg)
c. Fentanyl Oralet dose: 10 mcg/kg/dose rounded to
nearest hundred.
(Fentanyl Oralets available in 100mcg, 200mcg, 300mcg and 400mcg.)
7) Procedural Anxiolytics for
Dressing Changes:
a. IV or PO Lorazepam dose: 0.05 mg/kg/dose.
8) Pain Medication for Pre-Rehab
Therapy: On request of the therapist 30 minutes before exercise --
a. Morphine
PO Morphine dose: 0.1 - 0.3 mg/kg/dose
IV Morphine dose: 0.03 mg/kg/dose
b. Hydrocodone/Acetaminophen Combinations
Hydrocodone dose: 0.2 mg/kg/dose
→
Lortab Elixir: Each 5ml contains 2.5mg
Hydrocodone and 167mg
Acetaminophen
Lortab Elixir dose:
0.4 ml/kg/dose
→ Vicodin Tablet: Each tablet contains 5mg
Hydrocodone and 500mg
Acetaminophen
Vicodin dose: 1
tablet/25 kg
9)
Pain Management for Acute Patients During Post-Operative Period:
a. Patient Controlled Analgesia (PCA): Recommended for
children >5 years old undergoing reconstructive surgery and considered for
acute patients. Quality of analgesia should be assessed frequently by
the nursing staff. Inadequate pain control should be reported to the
primary physician as soon as discovered. PCA is discontinued when pain
can be controlled adequately by oral medication.
→ Morphine PCA -
PCA dose: 0.01 -
0.015 mg/kg
Lockout: 6 - 10
minutes
4 hour limit: 0.24
- 0.3 mg/kg
→ Meperidine PCA -
PCA dose: 0.15 -
0.2 mg/kg
Lockout: 6 - 10
minutes
4 hour limit: 2.5
mg/kg
b. Morphine Continuous Infusion via PCA pump:
Infusion dose:
0.015 mg/kg/hour and/or
Self/administered
bolus: 0.05 mg/kg
c. Nurse or Physician administered bolus:
Morphine IV 0.02
- 0.03 mg/kg/dose q2h
(hold if level of
responsiveness < 3)
10)
Pain Management for Reconstruction Patients During Post-Operative Period:
a. Hydrocodone/Acetaminophen Combinations: Do not give
concomitantly with Tylenol© --
→ Hydrocodone dose: 0.2 mg/kg/dose PO q4h prn
pain
→ Lortab Elixir: Each 5ml contains 2.5mg
Hydrocodone and 167mg
Acetaminophen
Lortab Elixir dose:
0.4 ml/kg/dose
→ Vicodin Tablet: Each tablet contains 5mg
Hydrocodone and 500mg
Acetaminophen
Vicodin dose: 1
tablet/25 kg
b. Morphine: If pain is not controlled with hydrocodone/acetaminophen
combination or patient is not on morphine PCA --
IV Morphine
dose: 0.05 mg/kg/dose IV q4h prn pain
PO Morphine dose:
0.3 mg/kg/dose PO q4h prn pain
11)
Opiate and Benzodiazepine Reversal Agents: Flumazenil and Naloxone
(NarcanTM) at bedside - Physician is called
whenever flumazenil or naloxone are administered.
Doses as follows --
→ Flumazenil for Reversal of Benzodiazepines:
< 40 kg:
0.01 mg/kg (max. 0.2 mg)
then after 45 seconds, 0.005 - 0.01 mg/kg (max. 0.2 mg)
then every 60 seconds to 1 mg max. dose.
> 40 kg:
0.2 mg over 15 seconds.
May repeat 0.2 mg dose over 45 seconds,
then every 60 seconds to 1 mg max. dose.
→ Naloxone (NarcanTM)
for Reversal of Opiates:
(Dilute 0.4 mg/ml ampule
in 10 ml of NS = 0.04 mg/ml)
< 20 kg:
Give 1 ml = 0.04 mg. May repeat every 1 minute x 3 doses
> 20 kg:
Give 2 ml = 0.08 mg. May repeat every 1 minute x 3 doses
DEEP
SEDATION and ANALGESIA for MAJOR INVASIVE PROCEDURES
Ketamine: Titrate to effect according to pain stimulus and
respiratory function. Repeated doses of ketamine may increase
tolerance to effect.
a.
Children
IV Ketamine dose: 1 -2
mg/kg/dose.
May repeat dose every 20 minutes if
child vocalizes pain.
IM Ketamine dose: 3 - 7
mg/kg/dose.
Give only when there is no peripheral
IV access.
PO Ketamine dose: 6 - 10
mg/kg/dose.
b.
Adults
For patients that are > 16
years of age and > 50 kg in weight, order benzodiazepines in
conjunction with ketamine to counteract higher incidence of hallucinations
and nightmares in adults receiving ketamine.
IV Ketamine dose: 1 - 2
mg/kg/dose, titrate to effect
IM Ketamine dose: 3 - 8
mg/kg
Next - Post-Operative
Management of Nausea in Reconstruction Patients
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