Introduction of Assessment Scales and Analgesic Protocols in Pediatric Hematology-Oncology CHUC Algeria

Dr.Farah Abada*

*Correspondence to: Dr.Farah Abada, Intern at the pain center hospital trousseau aphp paris. Assistant pediatrician Polyclinic Massinissa El khroub Constantine Algeria, Assistant clinical head in pediatrics Ibn Badis University Hospital Center Constantine Algeria.

 

Copyright

© 2023: Dr.Farah Abada. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Received: 8 September 2023

Published: 30 September 2023

Context

The pediatric hematology-oncology department of CHU CONSTANTINE ALGERIE

The service primarily welcomes patients aged from a few weeks to 15 years old, presenting with malignant hematological or oncological pathology. Depending on its possibilities, it also welcomes children with other pathologies. The patients received mainly reside in Constantine but also come from all the cities in the east of the country.

 

The needs of the service regarding pain management:

      -In my department there is no systematic pain assessment

      -no analgesic protocols

      -untrained personnel (lack of knowledge of ladders and tools)

      -the problem of pain is not a priority for the healthcare team

      -painkillers not available (out of stock)

- inventory in relation to the problem identified:

 

A study of 30 files:

Assessment: number of children assessed by a scale: 0

Age 1 to 15 years

Type of analgesics used: paracetamol, injectable morphine in PSE,

In which pathology: acute myeloid leukemia

For what reason: mucositis

Reassessment after the analgesic: no, if he can eat we stop the injectable morphine in PSE

 

Objective

Introduce pain assessment scales with analgesic protocols during pain care in a pediatric hemato-oncology department.

 

Methodology              

The bias: Increasing knowledge and convincing individually

-Set up a working group to carry out the necessary protocols, especially during care;

-Implementation of a systematic pain assessment:

From 0 EVENDOL to 7 years EVA to 10 years IN more than 10 years

Evendol Treatment threshold 4/15

EVA AND EN Treatment threshold 3/10

-Distribution of EVENDOL and EVA scales

-EVENDOL workshop for all staff

-Implementation of several training courses

-Measuring the impact of training

-Revaluation

 

  Steps :

-Inform my superiors

-Bibliographic search :

www.Pediadol.org

www.dolomio.org

Pain management for children with cancer in Africa. Pediatric archives volume 20, issue 3, March 2013, page 257-264

-as a tool I used the EVENDOL Training (CDROM)

-Solicit colleagues (ask for help)

-Convince nurses of the use of an evaluation scale??

-Start investigation

-Learning: 10 training courses in total in Visio: Conduct training for nursing staff

 

Emphasize pain assessment using tools

Main self-assessment scales

Face scale

Visual analog scale

Numerical scale

Heteroassessment scales

 

I mainly talked about the evaluation of pain using the Evendol scale. I used an EVENENDOL training DVD for the assessment of the child's pain: educational and interactive, with many practical situations to view and rate collected from the pain center at the Trousseau hospital with the EVENDOL strips

 

I started with the presentation of the scale:

 Description of the scale

EVENDOL: Pain assessment scale

From 0 to 7 years old

Validated from birth to 7 years to measure the child's pain in emergencies (medical or traumatic or surgical emergencies), also in medical pediatrics, postoperatively (SSPI and surgical department), for SAMU-SMUR transport; in 2014, currently being validated for full-term newborns, and currently being validated for pain care.

 

Has the advantage of recording acute pain (cries, agitation) as well as established pain (immobility) and prolonged pain with psychomotor atonia.

The two times (rest and mobilization) and the administration of analgesics are recorded on the scale.

1. At quiet rest (R): observe the child before any treatment or examination, in the

Best possible conditions of comfort and confidence, for example remotely,

With his parents, when he plays...

2. During examination or mobilization (M): this is the clinical examination or mobilization

Or palpation of the painful area by the nurse or doctor.

3. Reassess regularly, particularly after analgesics, at the time of peak action:

After 30 to 45 minutes if oral or rectal, 5 to 10 minutes if IV. Specify the situation,

Rest (R) or mobilization (M).

Score – Treatment Threshold

• Score: 0 to 15.

• Treatment threshold: from 4.

   Rating demonstration

   Basics of a good evaluation

  

I also talked about situations requiring painkillers mainly:

Mucositis in hemato-oncology

Treatment proposed in 1st intention: IV morphine, Analgesia according to the service protocol.

Mouthwashes with local anesthetics (according to department protocol

Viscous lidocaine in local application: do not exceed 2 mg/kg/application

cation/2 h (Afssaps Recommendations 2009 – Professional agreement).

Appeal processing

If the pain persists despite morphine + paracetamol + local care, low dose ketamine is possible

 

I also spoke on Pain in Hemato-Oncology:

Treatment proposed as first intention

Frequent indications for opioids.

Oral morphine if possible.

Frequent contraindication of NSAIDs.

Frequent association with neuropathic pain.

Appeal processing

Use of other opioids (rotation of opioids even off-label: transcutaneous and transmucosal fentanyl, oxycodone, hydromorphone).

 

I also spoke about the pain caused by treatment:

Inform and prepare the child for care, prevention, climate of trust, role of parents, avoid restraint

At the end of the training I spoke about non-pharmacological analgesic methods: distraction, hypno analgesia, and pharmacological methods: Local anesthesia with xylocaine, EMLA cream and patch, level 2 or 3 analgesics, anxiolytics

• Measurement of the impact of training:
• Distribution of essential child pain pocket guide
• Implementation of a systematic pain assessment
• Include EVENDOL in the care file
• Revaluation
• Creation of protocols with the team

 

 

The difficulties:

-To change the mentalities

-Everyone considered it an extra job, especially the nurses, until now I haven't been able to convince them to attend the training!!

The staff who attended were mainly doctors, no nurses wanted to participate

-at the beginning the head doctor thought that the use of evaluation scales is not so important especially since the necessary drugs are very lacking

(I suggested that she use injectable morphine orally, she told me I'm afraid especially that at the service level they are not used to working with oral morphine)

-Too much paperwork to get injectable morphine out

-Lack of molecules, no oral morphine, no nalbuphine, no PCA, sometimes there are stock shortages…

-The head doctor of the pharmacology department suggested that we give injectable morphine directly orally with the presence of an anesthetist and that there is no point in making it into a syrup!!!

-Lack of will and a lot of work load

-Difficult to take stock of the situation given that there was no evaluation at all

-Application of the proposed protocols is not always done

-No availability for training, the first two training courses had only 2 doctors

 

Results and Discussion

It’s difficult to find people involved but I’m not giving up! Since January I have been able to do 10 online training courses on pain assessment, A total of 23 doctors attended, including pediatricians, pediatric oncology residents and anesthesiologists.

Duration of each training 2.5 hours, During these EVENDOL (CDROM) workshops: all pediatricians were motivated for change they were convinced of the usefulness of the assessment and management of pain setting up a systematic pain assessment with a validated tool (EVENDOL, EN)

Include EVENDOL in the care file (place to note): I insisted on the traceability of the evaluation, the tool used the treatment and the re-evaluation on the care sheet for the moment not always applied by everyone by forgetfulness or outdated??

Then I was able to have 2 meetings with the hospital pain team: we talked about the non-existence of treatment and assessment of pain in children, about the drugs available and how to convince the galenic service to manufacture oral morphine

They were motivated to start setting up a mobile unit (doctor and psychologist), pair consultations with a psychologist for children, starting first with training. Furthermore, I was also able to contact the hospital's central pharmacy and see with the pharmacist the painkiller medications available:

Oxycodone hydrochloride at 10 and 20 m

SKENAN LP (morphine sulfate) at 10 and 30 mg

 Injectable morphine at 10 mg/ml

And we also have fentanyl in patch then a pharmacist specializing in galenics gave us a protocol for manufacturing vials of morphine drops from injectable morphine, according to him it is feasible, Moreover, my boss was in Paris for a day and there was a presentation of the plaster association. She took with her several copies of the essential pocket guide with EVENDOL evaluation scales and she distributed them to the doctors in the department.

 

 In the end we decided to use protocols during pain care mainly myelogram, intrathecal and pl.

The application of protocols is not yet always carried out,

-re-evaluation: in discussion group: those who attended the training used EVENDOL for pain assessment but no traceability??

I also ordered EVA rulers, facial scales from the Apicil foundation and I sent them with EVENDOL scales to Algeria for my department and another pediatric oncology department in Algiers Parnet Hospital

 

Projects:

We count

-Include EVENDOL in the care file (place to note)

-Regularly systematically evaluate all professionals:

        At the arrival,

        Once per team,

       Or if pain peaks before and after treatment 30 min to 1 hour

       Before during after painful examination

       Provide a specific place to note the assessment in the care file

-Record the analgesic treatment with regard to the evaluation

-Specify the tool used opposite the score

-being able to use oral morphine manufactured in galenics

-apply protocols

 

Conclusion and perspectives

I passed on knowledge doctors are aware and agree nurses are more reluctant. Pain management should be an obligation and not a luxury.

 

Conclusion

In recent years, the prevention and relief of pain, whatever its origin, has become a priority for all medical teams, particularly for children with cancer. With its profound socio-cultural changes, Algeria is no exception. All teams at our hospital are aware of the situation and hope for major improvement in pain management in the near future through increased resources and training.