Analgesia and Fever Control in Common Pe

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Information about Analgesia and Fever Control in Common Pe

Published on January 12, 2009

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Analgesia and Fever Control in Common Pediatric Disease : Analgesia and Fever Control in Common Pediatric Disease Dion Neame M.B., B.Ch., B.Sc., F.R.C.P.c, F.A.A.P. Assistant Clinical Professor McMaster Children’s Hospital Chief of Pediatrics, Joseph Brant Memorial Hospital Objectives : Objectives Acetaminophen, Codeine, and Ibuprofen. Ibuprofen association with Reye syndrome? Ibuprofen is an Anti-inflammatory. Ibuprofen, Acetaminophen and Codeine in the Pediatric practice. Review of systems approach to numerous uses of analgesia in the pediatric patient. Conclusions Acetaminophen, the drug : Acetaminophen, the drug Acetaminophen, the drug : Acetaminophen, the drug Mechanism of action Inhibits the synthesis of prostaglandins in the central nervous system and peripherally blocks pain impulse generation. Acetaminophen produces antipyresis from inhibition of the hypothalamic heat regulating centre. Dosage; 15 mg/kg every 4 to 6 hours P.O. Codeine, the drug : Codeine, the drug Codeine, the drug : Codeine, the drug Codeine is an alkaloid obtained from opium, or prepared from morphine by methylation. Codeine is a centrally active analgesic Side effect profile is similar to morphine; respiratory depression, depression of cough, activation of vomiting, and constipation. Dosage; 0.5 mg/kg every 4 to 6 hours P.O. Ibuprofen, the drug : Ibuprofen, the drug Ibuprofen, the drug : Ibuprofen, the drug Nonsteroidal Anti-inflammatory Drug (NSAID) Mechanism of Action; competitive inhibitor reversibly binding to the arachidonic acid binding site of the cyclooxygenase enzyme. Dosage; 3 months to 23 months 5 mg/kg every 6 to 8 hrs P.O. > 23 months 10 mg/kg every 6 to 8 hrs P.O. Ibuprofen, the drug : Ibuprofen, the drug Prevents the conversion of arachidonic acid to PGH2 Ibuprofen versus Acetaminophen : Ibuprofen versus Acetaminophen Multiple studies comparing both drugs for efficacy and safety have found both drugs equal for fever and mild to moderate pain. Acetaminophen is embraced by Pediatric societies due to duration of usage versus efficacy and safety data. Fear of an association with Ibuprofen and Reye syndrome has limited support. Ibuprofen versus Reye syndrome : Ibuprofen versus Reye syndrome There is only a theoretical risk of a link between ibuprofen and Reye syndrome. Children’s Analgesic Medicine Project and Boston Fever Study; In approximately 75,000 cases, no cases of Reye syndrome were documented. Summary of Core Differences in the Mechanisms of Actions : Summary of Core Differences in the Mechanisms of Actions Ibuprofen Acetaminophen Codeine Analgesic Analgesic Analgesic Antipyretic Antipyretic Anti-inflammatory What is Inflammation again? : What is Inflammation again? Inflammation is a normal response of the body to protect tissues from infection, injury or disease. The hallmarks are, pain, redness, swelling, heat, and loss of function. Inflammatory Mechanism : Inflammatory Mechanism Acetaminophen, Ibuprofen, Both?? : Acetaminophen, Ibuprofen, Both?? Archives Pediatric Adolescent Medicine Feb 2006 Patients using alternating acetaminophen and ibuprofen q 4 hourly. Significantly lower mean temperatures and lower scores on the pain checklist, compared to those receiving either agent alone. Quick summary : Quick summary Ibuprofen is as good as acetaminophen for fever and mild to moderate pain. Codeine is the best analgesic, but no effect on fever. Ibuprofen has not been found to be associated with Reye syndrome in recent studies. Ibuprofen is a NSAID, which aids in inflammatory symptom relief which acetaminophen and codeine do not provide. Acetaminophen + Ibuprofen gives better control. Analgesia in the Pediatric Practice : Analgesia in the Pediatric Practice Practical Points in Common Pediatric Disease Analgesia in the Pediatric Practice : Analgesia in the Pediatric Practice Ibuprofen, Acetaminophen, and Codeine have multiple uses in the pediatric age group, far beyond fever and mild to moderate analgesia. If you follow a systems review of pediatric disease, there are over twenty indications for their use above and beyond fever and analgesia. Also common day to day pediatric procedures are aided by Ibuprofen, Acetaminophen, Codeine and combinations of these medications. Ear, Nose, and Throat : Ear, Nose, and Throat Serous otitis media Acute otitis media Otitis externa Sinusitis Acute pharyngitis Serous Otitis Media : Serous Otitis Media Blockage of the Eustachian tube leads to bacteria free fluid build up in middle ear. Ibuprofen or acetaminophen can aid the parents to treat the pain. If pain breaks through medication dosing, the parent should seek medical attention to reassess for acute otitis media. Acute Otitis Media : Acute Otitis Media Second most common reason for a child to visit the doctor. Pain is due to the inflammatory response within the middle ear. Antibiotics will kill the bacteria, but will do nothing in the first 48 hours to relieve the pain. Ibuprofen should be used to reduce the inflammatory response ie. pain. Otitis Externa : Otitis Externa Commonly known as swimmers ear Caused by bacterial overgrowth in water trapped in the external auditory canal. Otitis externa can be extremely painful. In the first 48 hours, antibiotics ear drops combined with ibuprofen can limit pain and aid in the administration of drops Acute Purulent Sinusitis : Acute Purulent Sinusitis Acute sinusitis is relatively rare in children If an upper respiratory tract infection persists for more than 10 days, with fever > 39, facial pain, periorbital edema, post nasal drip, halitosis and cough, try; Antibiotics and ibuprofen or acetaminophen will reduce symptoms. Acute Pharyngitis : Acute Pharyngitis Acute pharyngitis is generally caused by viruses. Group A beta-hemolytic streptococcus common. Strep. throat is associated with fever, headache, and sore throat. Antibiotics, chloraseptic spray, ibuprofen alleviate symptoms. Central Nervous System : Central Nervous System Fever Headache Febrile seizures Fever : Fever Fever occurs when the hypothalamic thermoregulatory set point has been increased Uncomplicated fever is a relatively harmless event, and promotes beneficial components of the immune response. Treatment is based on the child’s discomfort. Headaches : Headaches Most headaches are benign and require symptom relief only. For tension, stress, or migraines headaches ibuprofen is an appropriate treatment. If headaches persist, or the headaches are associated with neurological signs, further investigations are needed. Febrile seizures : Febrile seizures Intuition would suggest that to prevent a febrile seizure occurrence or reoccurrence the fever should be well controlled by anti pyuretics. Studies have not shown 100% success, yet it is still standard practice to fever control consistently throughout the febrile period. Gastrointestinal system : Gastrointestinal system Hand foot and mouth disease Herpes gingivostomatitis Teething Hand Foot and Mouth Disease : Hand Foot and Mouth Disease HFMD is caused by Coxsackie Group A virus. Clinically 4 to 5 days of a flu-like illness is followed by painless rash/vesicles over the palms and soles. Painful mouth lesion may lead to anorexia and dehydration. Ibuprofen and/or codeine decreases pain and inflammation in the throat allowing the child to rehydrate. Herpes Gingivostomatitis : Herpes Gingivostomatitis 90 % of primary herpes infection are sub clinical. The clinical infection is dramatic in the primary stage, presenting with multiple discrete superficial ulcers throughout the oral cavity. Pain ranges from mild to severe, with anorexia and dehydration complicating. Rxn: Zovirax, viscous lidocaine, Ibuprofen and/or codeine. Teething : Teething The emersion of teeth occurs between 2 months and 3 years. Symptoms are local and systemic. Local; mouth pain, drooling, perioral irritation. Systemic; fever, irritability, anorexia, diarrhea, diaper rash. Rxn; Teething rings, Acetaminophen/Ibuprofen Musculoskeletal System : Musculoskeletal System Joint Trauma Muscular injury Growing pains Rheumatologic conditions Joint Trauma : Joint Trauma Repeated trauma to the joint will result in inflammation of the synovial membrane and joint capsule. The inflamed synovial membrane and leucocytes, release free radicals, cytokines, and prostaglandins, which may damage the articular cartilage. Rxn; rest, ice, ibuprofen, consult your doctor Muscular Injury : Muscular Injury Hockey Basketball Soccer Football Tennis Gymnastics Volleyball Cycling Shoveling snow Growing Pains : Growing Pains Normal occurrence in 25% of children. Two age groups, early childhood 3 to 5 yrs, late childhood 8 to 12 yrs. Etiology unclear Pain symptoms in the late afternoon, evening, or night waking the child. Frequency of 1 per week or less. Rxn; massage, stretching, heat, Ibuprofen, support. Rheumatologic conditions : Rheumatologic conditions These conditions must always be diagnosed, followed, and reviewed by a physician. Ibuprofen is an element of the treatment, yet the complexity of the disease requires multiple therapies. JRA, SLE, AS, HSP, Kawasaki disease, Dermatomyositis, etc. Dermatology : Dermatology Atopic dermatitis is common in children. Genetic predisposition, associated with asthma and allergies. Rxn; avoid irritants, moisturize skin, topical steroids, immunomodulators, antibiotics, antihistamines, analgesics, Ibuprofen Gynecology : Gynecology Primary Dysmenorrhea Usually starts 1 to 2 yrs. after menarche, at 12 to13 yrs. of age. Prostaglandins produce muscular contractions which cut off blood supply and oxygen causing pain. Antiprostaglandins; Ibuprofen taken as the bleeding or cramping starts diminishes symptoms. Vaccinations : Vaccinations Ibuprofen is effective pre and post vaccination. Analgesic given 30 minutes pre vaccination will reduce injection pain and vaccine solvent administration pain. Analgesic can be topical and/or oral. Topical lidocaine is now available. Ibuprofen is the oral choice. Vaccinations : Vaccinations Common post vaccine side effects. Systemic; fever, irritability, joint or muscle pain, and headache. Local; swelling, induration, tenderness, redness or erythema at site of injection. These adverse events will be attenuated by Ibuprofen. Mild to Moderate Pain : Mild to Moderate Pain Post operative pain; myringotomy tubes, tonsillectomy, adenoidectomy, cryotherapy wart removal, sutures, fractures, dental procedures, laser therapy, silver nitrate procedures. Observe Precautions : Observe Precautions Use caution in judicious use of ibuprofen: Patients with renal disease Patients with dehydration Patients with chicken poxs Pre and post operatively Potentially with asthma Conclusion : Conclusion Ibuprofen = Acetaminophen in fever and mild to moderate pain. Ibuprofen has not been related to Reye syndrome in recent literature. Ibuprofen > Acetaminophen for common pediatric disease with an inflammatory component. Ibuprofen and Acetaminophen can be used effectively in an alternate dosing schedule. Codeine is by far your best oral analgesic.

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