Acute pain management in the paediatric patient FPM spring meeting Torquay 2017

Transcription

1 Acute pain management in the paediatric patient FPM spring meeting Torquay 2017 A/Prof Greta Palmer Anaesthetist and Pain Specialist Royal Children s and Royal Melbourne Hospitals Murdoch Childrens Research Institute University of Melbourne

2 Overview The APMSE paediatric chapter Interesting points/evidence as summarised and since [No disclosures]

3 Children form 27% of the world s population Of the registered trials: 12-17% are paediatric Of that, those in under 5 years is small With a handful only in neonates

4 The Paediatric chapter in the book 4 th Ed. more than doubled in size with smaller font: 105 pages and ~920 references Key messages: 10 U, 22 S and 40 N Tick box: 17 N?split to own book

5 Neurobiology/Later consequences Rodent and human data Strengthen the understanding that early pain alters pain thresholds in later life and response can be modified by analgesia (S)

6 Pain assessment tools Many available for children including Those with intellectual disability And 40 + in neonates Take home message: Stop creating and use the tools we have vs proxies of functional activity or analgesic rescue

7 Tonsils and bleeding risk debate Dexamethasone Recent SRs have o lap of the RCTs (Q) associated with increase reoperation rate in children 8 RCTs But does not increase overall risk of bleeding Weighed against its benefits in terms of pain, PONV and early return to soft diet

8 nsnsaid & post tonsil bleeds 3 SR several RCT o lap: n~1, 000 & 1,350 & Cochrane 1,100 no increased risk of surgical or non-surgical intervention for bleeding post-tonsil in children Cochrane: Need larger trial n=2400 With newer surgical technique/s

9 Codeine and adverse events Convenient liquid and OTC combination preparation Black listed by FDA 2012, EMA 2013 and TGA Several paed deaths in neonates of br. feeding mothers and toddlers and obese children post T and A (65 total events in 45y &1.9x10 6 doses) TGA > Feb 2018 prescription only

10 Will Tramadol have the same fate? Studied in neonates & older children: efficacious Schnabel Cochrane paed RCTs n=1,170 low risk of adverse events incl resp. depr. CYP2D6 metabolism to M1 30% of effect via mu agonism

11 FDA new CIn against Tramadol 2017 In under 18y in T & A and 12y and under & now precaution in breastfeeding mothers Concentrated drop formulation with potential confusion: 10 drops = 25mg =0.25mL OD resulting in respiratory depression in 5yo and death in 2 yo Rest of world s response

12 3 rd line analgesic? If codeine and tramadol contraindicated?what to give if fail simple analgesia given strictly Other full agonist opioids? May not be subject to metabolism issues But OIVI risk with OSA/SDB.Level IV key message?half dose

13 Standards of care in paed centres Large scale audit data now published (Level IV) n= 2,000-13,500 infusions/ NCA n= 5,000 PCA 0.13% incidence of OIVI 1 in 10,000 of serious harm

14 Regional in paediatrics Same change in practice as is occurring in adults Decreased epidural use and increase in wound catheters and continuous peripheral nerve block infusions

15 Regional Level IV Old 1996 French audit n~25,000 Now rptd French & large scale US ongoing prospective audit data = Paediatric Regional Analgesia Network (PRAN) n 31-54, 000+ Affirming low complication rates and safety including insertion under GA Better informing the consent process CPNB n~1,500 and 2,000

16 Caudals LA alone Level IV RCTs additives to extend duration The adjunct section summarises some studies that should not have passed ethics review 2x high dose neostigmine, tramadol..with no IV comparator

17 Paediatric black holes Multiday dosing paracetamol/nsaid IV route When to dose reduce paracetamol TPN admin give protection? Which children should be started on a proton pump inhibitor? PICU, burns

18 Zero to low level evidence for adjuncts Post-op Ketamine infusion Standard of care in over 2 y failing opioid Rx 4 x RCTs n=212 Rescue Rx with lignocaine infusion: Nil paed data based on adult lap data - neuropathic pain or resistant pain eg ischaemic limbs, burns

19 Alpha-2 agonists Level I evidence for single dose 1 small RCT and Level III-2 for 24h to inform practice; none for multiday Rx NR Clonidine anxiolysis, supplement analgesia (by systemic route), behavioural modification, opioid withdrawal Dose extrapolated from caudal SS data and emergence agitation trials

20 No evidence for antineuropathics in children Amitriptyline no data - prolific use PGB 0 GBP Level II n= 59 JS 3 5 day 5mg/kg tds reduced PACU and POD 1 and 2 opioid

21 Stepdown Recommendations another black hole A big part of APS work; No evidence Targin is used off licence with no paed data?tapentadol IR?IV SL TD Bup?smaller dosette/patch

22 Further black holes Multidosing; multiagent Developmental Pharmacokinetics Synergism; Optimal dose combination Targeted analgesic recommendations informed by PK-PD data according to Age Procedure

23 Procedural intervention - evidence Non-nutritive sucking (dummy) 4 RCT n=264 and sweet solutions Cochrane 44 RCT n~4000 eg Sucrose 33% 0.5mL Topical LA: Amethocaine (AnGel) cream (poor penetration into ED practice)

24 Cool sense device (-2 degrees apply for 10 seconds) Buzzy device uses cold and vibration (apply proximal and dilates veins)

25 Non-pharm recommendation Kangaroo care Cochrane 19 RCTs n= 1,600 ~skin to skin cuddle

26 Thank you to my co-editors Jane Trinca and Richard Halliwell David Scott and Stephan Schug

27 & the paediatric contributors Paed FPM and paed anaes, paediatric emerg from NSW, Vic, WA, NZ: Jonathan De Lima, Sue Hale Jordan Wood, Sarah Johnston John Collins Jane Thomas, Elsa Taylor, Brian Anderson David Sommerfield, George Chalkiadis, Liz Cotterell, Meredith Borland, Franz Babl Greta Palmer