Perioperative Management of the Pediatric Chronic Pain Patient -What Anesthesiologists Need to Know- Tracy Harrison M.D.
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1 Perioperative Management of the Pediatric Chronic Pain Patient -What Anesthesiologists Need to Know- Tracy Harrison M.D. 07 March 2014
2 Conflicts of Interest None to disclose
3 Cases 14yo healthy anxious female with chronic generalized pain and deconditioning on metoprolol, pyridostigmine; for wisdom tooth extraction 15 yo male with pectus excavatum for Nuss procedure 12yo female with relapsed ALL with headache for a lumbar puncture
4 Objectives Characterize the impact of chronic pain in the perioperative period Discuss strategies for acute pain management in the context of chronic pain Describe the strategy of chronic pain rehabilitation
5 *Impact of Chronic Pain* Chronic pain is common Pertinent Issues Medical diagnoses Medications Psychosocial factors Acute surgical pain and chronic pain Chronic pain patient coming for surgery Poorly controlled acute pain that develops into chronic pain
6 Epidemiology Pediatric chronic pain in school sample % of children (Simons 2012, Huguet 2008) May underestimate prevalence Functional disability Varying disability >30% 3-10% greatly disabled (Hechler 2010) HRQOL lower for children with chronic noncancer pain Medical utilization Mean annual cost per adolescent 8000 ($16000) Twenty-fold increase in healthcare consultations
7 Medical Diagnoses of Chronic Pain Patients Headache, abdominal pain, generalized pain, CRPS Spinal cord/peripheral nerve stimulators Sickle cell, cancer, IBD, etc. Deconditioning and POTS Dizziness, spells, tachycardia, nausea Nutritional challenges G-tubes, port-a-cath
8 Medications Opioids Metoprolol/propranolol Buprenorphine Fludrocortisone Benzodiazepines Midodrine Muscle relaxants Pyridostigmine Clonidine IVIG Diphenhydramine Methylphenidate Scopolamine Dextroamphetamine Ondansetron Amitriptyline/nortriptyline Gabapentin/pregabalin
9 Medications Opioids/buprenorphine Benzos/muscle relaxants/diphenhydramine Scopolamine Ondansetron/amitriptyline/nortriptyline Gabapentin/pregabalin
10 Medications Metoprolol/propranolol Fludrocortisone Midodrine Pyridostigmine IVIG Methylphenidate/dextroamphetamine
11 Psychosocial Issues School attendance Delay in functional milestones Enmeshed parents Anxiety/panic/PTSD Mood disturbances
12 *Strategies of Acute Pain Management in the Context of Chronic Pain* Three categories of patients Chronic non-cancer pain Extensive surgery Cancer
13 Pre-anesthetic Management Consider oral premedication Midazolam, acetaminophen Gabapentin for extensive procedures? Allow patient to make age-appropriate choices Mask induction vs. peripheral IV Parental presence in OR? Be aware of effects of medications Ketamine on anxiety/nightmares Synergistic medication effects
14 Prevention of Post-operative Pain Regional techniques Intraoperative ketamine? Scheduled adjunctive medications Acetaminophen NSAIDS (ketorolac, ibuprofen) Neurontin Lidoderm patches Non-pharmacologic strategies Distraction, diaphagmatic breathing Communicate these plans to patients
15 Management of Acute on Chronic Pain Ask about patient s baseline pain level Ask about functional limitations at home prior to surgery Communicate expectations Some pain is normal Activity level IV vs PO pain medications Provide opportunity to ask questions
16 Opioid Management Restart home pain medications as appropriate Opioids, adjunctive medications Oxycodone 10mg q 6 hours, i.e. Provide appropriate pain medications specific for surgical procedure Fentanyl PCA, i.e. Caution with multiple sedating drugs benzodiazepines, diphenhydramine, etc.
17 *Theory of Chronic Pain Rehabilitation* Ensure appropriate and thorough medical evaluation Encourage school attendance and engagement in life from the beginning Children first, patient second Empowerment/self-esteem Introduce non-pharmacologic and biobehavioral pain management strategies as early as possible
18 Take Home Points Ask about patient s concerns Restart home medications Communicate appropriate expectations Multimodal treatment for pain Team involvement
19 References Farrell C Perioperative management of patients taking treatment for chronic pain. BMJ.344:e4148 doi: /bmj.e4148. Fortier MA Acute to chronic postoperative pain in children: preliminary findings. Journal Pediatr Surgery.46: Hays S Pain, Pain, Go Away! Older drugs, newer options for pediatric perioperative pain management. Refresher Course Pediatric Anesthesiology. Hechler T Commentary: A worldwide call for multimodal inpatient treatment for children and adolescents suffering from chronic pain and painrelated disability. Journal Pediatric Psychology.35(2): Huguet H The severity of chronic pediatric pain: an epidemiological study. The Journal of Pain.9(3): Simons Vetter TR A clinical profile of a cohort of patients referred to an anesthesiology-based pediatric chronic pain medicine program. Anes analg.106(3):
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