New Modalities for Treating. Perioperative Pediatric Pain OPIOID-ASSOCIATED SIDE EFFECTS

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1 New Modalities for Treating Perioperative Pediatric Pain R. Scott Dingeman, MD, FAAP Associate Clinical Professor, UCSF Department of Anesthesia & Perioperative Care Co-Director, Integrated Pediatric Pain & Palliative Care Team, UCSF Benioff Children s Hospital New Modalities for Treating Perioperative Pediatric Pain I. Emerging non-pharmacologic therapeutic interventions II. Regional anesthesia in children III. New uses for intravenous analgesics OPIOID-ASSOCIATED SIDE EFFECTS 12 y/o girl with h/o UC on oxycodone & gabapentin ATC at home presents for SIL Colectomy Sedation Respiratory depression Nausea and vomiting Constipation Pruritis Tolerance Hyperalgesia Shianne 1

2 Emerging non-pharmacologic therapeutic interventions Pediatric hypnosis: hypno-anesthesia Acceptance & commitment therapy (ACT) and Medical acupuncture Pediatric Hypnosis: Hypno-anesthesia The Magic Glove: an example of hypno-anesthesia What is it? An altered state of consciousness Involves narrowing of attention and suspension of critical judgments Characterized by concrete and primary process thinking Post-hypnotic suggestions possible Benefits: Decreases anxiety in preparation for anesthesia & surgery Adjunct for pain management, PONV, and behavioral problems perioperatively Method of inducing a sense of comfort and trust during recovery Shortens hospital stays Portable and cost-effective To know what is happening, but not be bothered An example of hynpo-anesthesia: The Magic Glove 13. Kuttner L. Pediatric hypnosis: pre-, peri-, and post-anesthesia. Paediatric Anaesthesia 2012;22: Kuttner L. Pediatric hypnosis: pre-, peri-, and post-anesthesia. Paediatric Anaesthesia 2012;22:

3 Cognitive-Behavioral Therapy & Distraction If distraction doesn t work, then what s next? A common CBT technique is distraction Directing attention away from noxious stimulus towards an alternative Used by parents and health-care professionals Alleviate both acute and chronic pain in children 14. Grewal S, Petter M, Feinstein AB. The use of distraction, acceptance, and mindfulness-based techniques in the treatment of pediatric pain. Pediatric Pain Letter 2012;14(1)1-9 Acceptance & commitment therapy and Acceptance & commitment therapy and Mindfulness Paying attention in a particular way on purpose in the present moment and non-judgmentally Acceptance Willingness to let things be as they are as soon as we become aware of them. Experiencing pain without reaction, disapproval or attempts to reduce or avoid it. 14. Grewal S, Petter M, Feinstein AB. The use of distraction, acceptance, and mindfulness-based techniques in the treatment of pediatric pain. Pediatric Pain Letter 2012;14(1)1-9 3

4 Acceptance & commitment therapy and Change the way the children think about pain. Strive to live a meaningful life by pursuing activities in line with one s values whether or not one has pain Emphasizes exposure to experiences previously avoided Pain reduction is not the primary goal but a byproduct - Acupuncture points are along or connected by 20 meridians - Meridians are paths which life energy known as qi flow - >600 points 14. Grewal S, Petter M, Feinstein AB. The use of distraction, acceptance, and mindfulness-based techniques in the treatment of pediatric pain. Pediatric Pain Letter 2012;14(1)1-9 Medical acupuncture Regional Anesthetics Treatment for PONV, pain, and certain illnesses preor post-operatively Can it be done intra-operatively under GA? Reduced postoperative pain Reduced agitation Upon arrival in PACU and 30 minutes later 12. Lin YC, Tassone RF, Jahn S, et.al. Acupuncture management of pain and emergence agitation in children after bulateral myringotomy and tympanostomy tube insertion. Paediatric Anaesthesia 2009;19(11): Suresh S, Birmingham PK, Kozlowski RJ. Pediatric Pain Management. Anesthesiology Clinics of North America 2012;30:

5 Bilateral Tranverse Abdominis Plane Blocks New regional medications: - Ropivicaine 0.2% <0.3ml/kg - Clonidine 2mcg/kg Extended-release local anesthetics 5 Liposomes Lipospheres Polyglycolic acid microspheres Hydrogels Neosaxitoxin (neostx) 11 Site 1 sodium-channel toxin Mount Sinai Department of Anesthesia 5. Wu CL, Raja SN. Treatment of acute postoperative pain. The Lancet 2011:377; Rodriguex-Navarro AJ, Berde CB, Wiedmaier G. Comparison of neosaxitotoxin versus bupivacaine via port infiltration for postoperative analgesia following laparoscopic cholecystectomy: a randomized, double-blind trail. Regional Anesthesia & Pain Medicine 2011;36(2): ALPHA-2 AGONISTS WHAT ABOUT KETAMINE? Dexmedetomidine Reduce opioid consumption 5 Improve centrally mediated analgesia 5 Reduce emergence agitation at 0.3mcg/kg Clonidine Reduce emergence agitation at 2mcg/kg 6 Enhance & prolong regional anesthetics 1,7 Adjuvant for weaning opioids and benzodiazepines Intravenous, transdermal, or oral administration 1. Berde C, Greco C. Pain Management in Children. In: Gregory GA, Andropoulos DB, editors. Gregory s Pediatric Anesthesia. Boston: Blackwell Publishing; p Wu CL, Raja SN. Treatment of acute postoperative pain. The Lancet 2011;377: Malviya S. Clonidine for the prevention of emergence agitation in young children: efficacy and recovery profile. Pediatric Anesthesia 2006;16: Cucchiaro G, Ganesh A. The effects of clonidine on postoperative analgesia after peripheral nerve blockade in children. Anesthesia & Analgesia 2007;104(3):

6 Ketamine: The other side of ketamine: Phenylpiperidine (PCP or angel dust ) derivative Dissociative anesthetic Historical usage: Cardiovascular stability with increased SVR and CO maintaining blood pressure (even in cases of hypovolemia) Spontaneous breathing and laryngeal reflexes preserved Side effects including psychodysphoric symptoms, sialorrhea, & nystagmus limit its use 2. Lois F, De Kock M. Something new about ketamine for pediatric anesthesia. Current Opinion in Anesthesiology 2008;21: Decreases emergence agitation in children Single dose of 0.25mg/kg IV 3 Treats hyperalgesia 2, 4 May reduce proinflammatory effects 2 2. Lois F, De Kock M. Something new about ketamine for pediatric anesthesia. Current Opinion in Anesthesiology. 2008;21: Abu-Shahwan, Chowdary K. Ketamine is effective in decreasing the incidence of emergence agitation in children undergoing dental repair under sevoflurane general anesthesia. Paediatric Anaesthesia 2007;17: De Dock M, Lavand homme P, Waterloos H. Balanced analgesia in the perioperative period: is there a place for ketamine? Pain 2001;92: WHY METHADONE? What are the benefits of methadone? Long-acting opioid with high bio-availability Racemic mixture l-isomer u opioid agonist Analgesia d-isomer non-competitive NMDA antagonist in brain, spinal cord, and peripheral nerves Analgesia Reduction in hyperalgesia Partial reversal of tolerance to u opioids Start at 0.1mg/kg IV or PO every 12 hours & titrate slowly every 24 hours 1. Berde C, Greco C. Pain Management in Children. In: Gregory GA, AndropoulosDB, editors. Gregory s Pediatric Anesthesia. Boston: Blackwell Publishing; p

7 Summary References: Don t always rely on opioids to treat perioperative pain in children Consider regional techniques Think outside the box, and consider alternative therapies Hypno-anesthesia & the Magic Glove Acupuncture, ACT & mindfulness Consider adding adjuvants that provide analgesia without opioid-associated side effects Dexmedetomidine Clonidine Ketamine Add methadone to help treat your patients with a h/o opioid use & tolerance or suspected hyperalgesia. 1. Berde C, Greco C. Pain Management in Children. In: Gregory GA, Andropoulos DB, editors. Gregory s Pediatric Anesthesia. Boston: Blackwell Publishing; p Lois F, De KockM. Something new about ketamine for pediatric anesthesia. Current Opinion in Anesthesiology 2008;21: Abu-Shahwan, Chowdary K. Ketamine is effective in decreasing the incidence of emergence agitation in children undergoing dental repair under sevoflurane general anesthesia. Paediatric Anaesthesia 2007;17: De Dock M, Lavand homme P, Waterloos H. Balanced analgesia in the perioperative period: is there a place for ketamine? Pain 2001;92: Wu CL, Raja SN. Treatment of acute postoperative pain. The Lancet 2011;377: Malviya S. Clonidine for the prevention of emergence agitation in young children: efficacy and recovery profile. Pediatric Anesthesia 2006;16: Cucchiaro G, Ganesh A. The effects of clonidine on postoperative analgesia after peripheral nerve blockade in children. Anesthesia & Analgesia 2007;104(3): Ing C, DiMaggio C, Whitehouse A, Hegarty MK, et. Al. Long-term differences in language and cognitive function after childhood exposure to anesthesia. Pediatrics 2012;130(2): Sprung J, Flick RP, Katusic SK, et al. Attention-deficit/hyperactivity disorder after early exposure to procedures requiring general anesthesia. Mayo Clinic Proceedings 2012;87(2): Suresh S, Birmingham PK, Kozlowski RJ. Pediatric Pain Management. Anesthesiology Clinics of North America 2012;30: Rodriguex-Navarro AJ, Berde CB, Wiedmaier G. Comparison of neosaxitotoxin versus bupivacaine via port infiltration for postoperative analgesia following laparoscopic cholecystectomy: a randomized, double-blind trail. Regional Anesthesia & Pain Medicine 2011;36(2): Lin YC, Tassone RF, Jahn S, et.al. Acupuncture management of pain and emergence agitation in children after bilateral myringotomy and tympanostomy tube insertion. Paediatric Anaesthesia 2009;19(11): Kuttner L. Pediatric hypnosis: pre-, peri-, and post-anesthesia. Paediatric Anaesthesia 2012;22: Grewal S, Petter M, Feinstein AB. The use of distraction, acceptance, and mindfulness-based techniques in the treatment of pediatric pain. Pediatric Pain Letter 2012;14(1)1-9 7

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