Caring for the Critically Ill Patient with Cerebral Palsy

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1 Caring for the Critically Ill Patient with Cerebral Palsy Hannah Sauer, PharmD PGY1 Pediatric Pharmacy Resident Mayo Clinic Children s Center 2015 MFMER slide-1

2 Objectives Describe challenges in acute medical management of patients with cerebral palsy (CP) List special considerations for drug therapy in patients with CP Identify the optimal approach to pain and sedation in patients with CP 2015 MFMER slide-2

3 Objectives Describe challenges in acute medical management of patients with cerebral palsy (CP) List special considerations for drug therapy in patients with CP Identify the optimal approach to pain and sedation in patients with CP 2015 MFMER slide-3

4 Cerebral Palsy (CP) Occurs in 205 per 1000 live births Permanent disorder of the development of movement and posture resulting in activity limitation Caused by non-progressive disturbances that occurred in the developing fetal or infant brain Novak, I. J Child Neurol, 2914; 29(8): MFMER slide-4

5 Morbidity and Mortality Most have normal life expectancy 5-10% mortality during childhood Comorbid epilepsy and intellectual disability predictive of premature death Deterioration of function occurs due musculoskeletal impairments Medical interventions do not improve overall gross motor function Taft, LT. Pediatrics in Review, 1995; 16(11): Novak, I. J Child Neurol, 2914; 29(8): MFMER slide-5

6 Classification by Severity I - Indepdently ambulates II - Indepdently ambulates with limitations III - Ambulates with walking aids IV - Independently mobilizes with powered mobility V - Dependent for all mobility 2015 MFMER slide-6

7 Most patients with CP will walk I - Indepdently ambulates II - Indepdently ambulates with limitations III - Ambulates with walking aids IV - Independently mobilizes with powered mobility V - Dependent for all mobility 2015 MFMER slide-7

8 CP Subtypes Spastic Dyskinetic Ataxic 2015 MFMER slide-8

9 Comorbidities Neurologic/Psychiatric Intellectual disability (50%) Behavior disorder (25%) Non-verbal (25%) Epilepsy (25%) Bladder incontinence (25%) Sleep disorder (20%) Musculoskeletal Chronic pain (75%) Hip displacement (33%) Sensory Blindness (10%) Deafness (4%) Other Chronic lung disease (33%) Gastroesophageal reflux Hyper-salivation 2015 MFMER slide-9

10 Chronic Critical Illness Complex disease state with multiple comorbidities Common reasons for ICU admission Orthopedic surgeries Acute infections (pneumonia) Refractory epilepsy Novak, I. J Child Neurol, 2914; 29(8): MFMER slide-10

11 Challenges in Cerebral Palsy Low rates of confidence Consult overload Communication barriers Emotional burden Provider Factors Patient Factors Medication Factors Disease Factors Polypharmacy Medication sensitivity? Pediatric features Limited literature 2015 MFMER slide-11

12 Objectives Describe challenges in acute medical management of patients with cerebral palsy (CP) List special considerations for drug therapy in patients with CP Identify the optimal approach to pain and sedation in patients with CP 2015 MFMER slide-12

13 Common Medications Anti-epileptics Anti-spasticity Anti-spasmodics Analgesics Antacids Laxatives Anti-sialogogues Prophylactic antibiotics Bisphosphonates Assess for drug interactions. Novak, I. J Child Neurol, 2014; 29(8): MFMER slide-13

14 Drug Sensitivity May be more sensitive to dose changes Comorbid intellectual disability associated with idiosyncratic reactions Increased risk for medication withdrawal? Nolan, J, et al. Anaesthsia, 2000; 55(32-41) MFMER slide-14

15 Intrathecal Baclofen Withdrawal If pump must be removed oral baclofen should be started 2-3 days beforehand Monitor for withdrawal Tachycardia, labile pressures, hypothermia Delirium, hallucinations, seizures Muscle rigidity, paresthesis Symptom-directed treatment Ross, JC, et al. Neurocrit Care, 2011; 14: MFMER slide-15

16 Paralytic Agents Up-regulation of ACh receptors in CP patients (30%) Increased risk of hyperkalemia following succinylcholine? Increased sensitivity to non-depolarizing agents? Prosser, DP and Sharma, N. Anaesthsia, 2010; 10(3): MFMER slide-16

17 Paralytic Agents Up-regulation of ACh receptors in CP patients (30%) Increased risk of hyperkalemia following succinylcholine? Increased sensitivity to non-depolarizing agents? Clinically Succinycholine is not contraindicated Non-depolarizing agents are less potent and have shorter duration Prosser, DP and Sharma, N. Anaesthsia, 2010; 10(3): MFMER slide-17

18 Dosing Considerations Increased body surface area to body weight ratio ( giant neonates ) Low body weight relative to non-cp individuals Poor nutritional status Altered absorption Dehydration and hypovolemia common Consider appropriate assessments of renal function Taft, LT. Pediatrics in Review, 1995; 16(11): Novak, I. J Child Neurol, 2914; 29(8): MFMER slide-18

19 ASSESSMENT QUESTION 1 Which of the following represents a true statement about critically ill adult patients with CP? a) Serum creatinine is a reliable indicator of renal function b) Succinylcholine is an appropriate paralytic agent for rapid sequence intubation c) Intrathecal baclofen can be safely held for 48 hours d) Pediatric weight-based dosing should be avoided in anyone over 18 years 2015 MFMER slide-19

20 General Principles of Medication Management Use appropriate weight-based dosing, even in adult patients Keep medication withdrawal on differential Consider unpredicted responses to medications Re-start home medications as soon as possible 2015 MFMER slide-20

21 Objectives Describe challenges in acute medical management of patients with cerebral palsy (CP) List special considerations for drug therapy in patients with CP Identify the optimal approach to pain and sedation in patients with CP 2015 MFMER slide-21

22 Audience Poll: True or False Individuals with cerebral palsy are desensitized to pain and therefore have increased pain tolerance. A. True B. False 2015 MFMER slide-22

23 Pain in CP Increased sensitivity to pain stimuli due to altered excitability in the somatosensory cortex Heterogeneous pain experiences both interand intra-personally Typical and atypical physical manifestations Significant emotional and spiritual burden Riquelme I, et al. Pain Med, 2011; 12(4): Warlow and Hain. Children 2018; 5(13) MFMER slide-23

24 Baseline Pain Burden 75% of patients experience pain at least weekly 50% have episodes of pain that last >9 hours Muscle fatigue, immobility Hypertonia Constipation Musculoskeletal Pain Gastrointestinal dysmotility Warlow and Hain. Children 2018; 5(13) MFMER slide-24

25 Post-Operative Pain Management Post-operative analgesia should be continuous rather than on demand regimens Options: Continuous intravenous opioids Intermittent intravenous and oral opioids Epidural opioids Epidural opioids + local anesthetic 2015 MFMER slide-25

26 Epidural v. Systemic Analgesia Protocols Moore, et al. Study design Retrospective comparison of post-operative analgesia protocols Population Pediatric patients with cerebral palsy undergoing selective dorsal rhizotomy Efficacy Outcomes Difference in age-appropriate pain scale score Frequency of severe pain episode (pain 5) Safety Outcomes Treated nausea or pruritis Hypoxia, supplemental O2 requirements Moore, et al. Pediatric Anesthesia, 2013; 23( ) MFMER slide-26

27 Systemic Protocol Epidural Protocol Continuous infusion fentanyl 1 mcg/kg/h x12 hours followed by 0.5 mcg/kg/h until noon POD2 Diazepam 0.1 mg/kg q4h scheduled x6 doses, then q6h x4 doses Gabapentin added D2 for kids 10 years Ropivicaine 0.2%/ hydromorphone 2.5 mcg/ml Rate of 0.2 ml/kg/h until 6 am POD3 Ketorolac 0.5 mg/kg q6h (total of 8 doses) Methocarbamol 15 mg/kg q8h prn for breakthrough spasm Moore, et al. Pediatric Anesthesia, 2013; 23( ) MFMER slide-27

28 Study Protocols Gabapentin if age-appropriate Midazolam POD1 POD2 POD3 Ropivacaine/hydromorphone epidural Ketorolac Methocarbamol as needed Systemic Protocol Epidural Protocol 2015 MFMER slide-28

29 Patient Characteristics Epidural (n=31) Systemic (n=41) Age (years) 6.06 (±3.78) 6.63 (±4.02) Weight (kg) (±9.53) 24.9 (±14.12) Male 64.5% 61% Diplegia 93.5% 92.6% Moore, et al. Pediatric Anesthesia, 2013; 23( ) MFMER slide-29

30 Post-Operative Pain Scores Epidural Systemic Moore, et al. Pediatric Anesthesia, 2013; 23( ). *p< MFMER slide-30

31 Results Epidural (n=31) Systemic (n=41) OR p-value Episodes of severe pain (POD 0-1) Episodes of severe pain (POD 0-1) Respiratory depression 9.6% 68.3% 20.1 < episodes 74 episodes NR NR 6.5% 41% 10.3 <0.001 Moore, et al. Pediatric Anesthesia, 2013; 23( ). POD=post-op day 2015 MFMER slide-31

32 Epidural v. Systemic Analgesia Protocols Study Conclusions Multimodal approach to pain control is ideal Epidural may be preferred route of analgesia in postoperative setting Study Limitations Study design Cause of improved pain control? Other medications not reported Pain assessment tools Moore, et al. Pediatric Anesthesia, 2013; 23( ) MFMER slide-32

33 Validated Pain Assessment Tools Pediatric Pain Profile (PPP) Twenty item behavioral scale (4 points each) Designed for nonverbal children with severe neurological impairment (SNI) Highly sensitive and specific Face Legs Activity Cry Consolability (FLACC) Five item behavior scale (3 points each) Quick assessment Only validated in postoperative settings for SNI Non-Communication Children s Pain Checklist Revised Thirty item behavior scale (4 points each) Two hours of observation required Highly sensitive and specific Weak correlation to parent scores Warlow and Hain. Children 2018; 5(13) MFMER slide-33

34 ASSESSMENT QUESTION 2: Which of the following may be a sign of pain in a non-verbal patient with cerebral palsy? a) Flushing and/or pallor b) Tachycardia c) Sudden stillness d) Self-harm e) All of the above 2015 MFMER slide-34

35 Procedural Sedation in CP Preferred agents Historically propofol, benzodiazepines No sedative agents contraindicated Consider co-morbidities Seizures Respiratory status Optimal doses and general approaches remain controversial 2015 MFMER slide-35

36 Sedation in Patients with CP Disability associated with risk for respiratory depression and delayed awakening Review of intravenous sedation in patients with disabilities revealed cerebral palsy: Independently associated with SpO2 <90% (OR 1.642, p=0.018) Not independently associated with delayed awakening Yoshikawa, et al. Anesth Prog, 2013; MFMER slide-36

37 General Anesthesia in CP Patients with cerebral palsy require lower doses of propofol for anesthesia induction Target bispectral index (BIS ) mg/kg versus 3.6 mg/kg (p=0.03) Decreased minimum alveolar concentration (MAC) of halothane Levels 20% lower compared to healthy controls (p<0.05) Delayed emergence? Saricaoglu F, et al. Pediatric Anesthesia, 2005; 15: Frei, FJ, et al. Anaesthesia, 1997; 52(11): MFMER slide-37

38 Optimal Propofol Dose for MRI Kim, et al. Study Population Intervention Efficacy Outcomes Cerebral palsy Age 6 months to 5 years Scheduled for brain MRI under sedation Propofol started at 2 mg/kg and modified for sequential patients If unsuccessful, dose increased by 0.5 mg/kg for next child If successful, decreased by 0.5 mg/kg for next child Successful sedation (UMSS* score 3 after 1 minute) ED50 and ED95 determined by modified up-and-down method Kim EJ, et al. Korean J Anesthesiol, 2011; 61(3): *University of Michigan Sedation Scale 2015 MFMER slide-38

39 Patient Characteristics N=20 Age 28.7 months ± 17.8 Weight 10.3 kg ± 4.6 Male 80% MRI scanning time 26.3 minutes Co-morbid behavior disturbances 16 On anti-epileptic medications 4 Kim EJ, et al. Korean J Anesthesiol, 2011; 61(3): MFMER slide-39

40 Results Successful completion of all MRI scans Ten received 2 mg/kg (50% success) Five received 1.5 mg/kg (0% success) Five received 2.5 mg/kg (80% success) Desaturation in 5 patients with successful sedation Proposed therapeutic index: ED50 = 2.07 mg/kg (CI ) ED95 = 2.69 mg/kg (CI )* Mean total dose 3.2 mg/kg ± 0.9 mg/kg Kim EJ, et al. Korean J Anesthesiol, 2011; 61(3): *Up-down method used 2015 MFMER slide-40

41 Study Summary and Conclusions Typical starting procedural sedation 1-2 mg/kg CP alone may not be a compelling indication to give lower doses of procedural sedation Lingering questions What subgroups of patients are worth exploring? Is desaturation in 25% of patients significant? What is the appropriate starting dose of propofol for procedural sedation? Kim EJ, et al. Korean J Anesthesiol, 2011; 61(3): MFMER slide-41

42 The Bottom Line for Pain and Sedation Assess and treat anxiety related to disease and hospitalization Multimodal approaches to pain are ideal (don t forget about baseline pain factors) Continuous pain control > on demand pain control Use appropriate pain assessment tools and rely on caregiver assessments Start with low end of sedative dose ranges and titrate slowly 2015 MFMER slide-42

43 ASSESSMENT QUESTION 3: A 24 yom (30 kg) with cerebral palsy s/p orthopedic surgery is being admitted to your ICU. Which of the following standard post-operative orders is your priority for re-assessment prior to his arrival to the unit? a) Morphine PCA 2 mg load, followed by (level 1) 1 mg IV every 10 minutes 20 mg LO q4h b) Ketorolac 15 mg IV q6h x 4 doses c) Cefazolin 1 g q8h x2 doses d) Senna 17.2 mg PO QHS 2015 MFMER slide-43

44 Summary A lack of published experience in managing CP patients in ICU settings makes it a challenging population Patients with CP should be assessed for appropriate weight-based dosing, drug interactions and medication withdrawal CP does not permit a one size fits all approach to optimal pain and sedation 2015 MFMER slide-44

45 Questions & Discussion 2015 MFMER slide-45

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