PARTICULAR ASPECTS OF SEDATION AND ANALGESIA IN CHILDREN WITH PLEUROPNEUMONIA

Transcription

1 Journal of Experimental Medical & Surgical Research Cercetãri Experimentale & Medico-Chirurgicale Year XVII Nr.2/2010 Pag JOURNAL Experimental Medical of Surgical R E S E A R C H PARTICULAR ASPECTS OF SEDATION AND ANALGESIA IN CHILDREN WITH PLEUROPNEUMONIA A. Crãciun 1, I. Simedrea 1, P. Þepeneu 1, D. Chiru 1, R. Giurescu 1, O. Sârbu 2, I. Mariº 1, C. Dãescu 1, T. Marcovici 1 SUMMARY: Introduction. Pneumonia is one of the most frequent infections in children and one of the main causes that lead to hospitalization. There are many instances when sedation may be beneficial in the pediatric intense care unit (PICU). Sedation for pleural catheter insertion facilitates the procedure in the uncooperative patient. Case Report.We present 4 pediatric cases, on different age, with pleuropneumonia, on different etiology, which required the insertion of a pleural catheter. In all 4 cases a pleural catheter was inserted for continuous suction of air and fluids from the pleura, using a set for pleura- and thorax drainage: Pleuracan A (B-Braun). For mild, short-acting sedation, we used in children drugs such as Midazolam ( mg/kg), Fentanyl (2-4 mcg/kg) and Propofol (2-4 mg/kg). In adult, local anesthesia with lidocaine is preferred. No complications in the time of procedure or after were noticed. Post-procedural analgesia was achieved using intravenous Acetaminophen (Perfalgan) 15 mg/kg q six hours for 24 hours. After that no analgesia was needed. The extraction of chest tube was performed by light sedation with Midazolam 0.1 mg/kg. Conclusions. Moderate sedation of pediatric patients should not be undertaken unless the facility is appropriately equipped and staff has adequate experience with this procedure. The safest approach to procedural sedation is to titrate medications in a stepwise fashion to a desired level of sedation, starting with the lowest effective dose. The highest risk of complications especially respiratory depression and apnea occurs at the beginning of sedation (when medications have just been administered) and during the immediate post procedure period (when painful stimuli are removed). Key Words: analgesia, pleuropneumonia, chest tube, children. ASPECTE PARTICULARE ALE SEDÃRII ºI ANALGEZIEI ÎN PLEUROPNEUMONIILE COPILULUI Received for publication: Revised: Rezumat: Introducere Pneumonia este una dintre cele mai frecvente infecþii ale copilului ºi una dintre principalele cauze care duc la spitalizare. Existã numeroase situaþii când sedarea poate fi beneficã în secþia de terapie intensivã pediatricã. Sedarea pentru introducerea drenajului pleural faciliteazã procedura la pacientul necooperant. Material clinic Prezentãm cazurile a 4 copii, de vârste diferite, cu pleuropneumonie de etiologie diferitã, care au necesitat introducerea unui drenaj pleural. La toate cele 4 cazuri s-a introdus un tub de dren pleural pentru aspirarea continuã a aerului ºi lichidului, folosind setul Pleuracan A (B-Braun). Pentru sedarea de scurtã duratã, utilizãm la copil Midazolam ( mg/kg), Fentanyl (2-4 mcg/kg) ºi Propofol (2-4 mg/kg). La adult se preferã anestezia localã cu Lidocainã. Nu a survenit nicio complicaþie în timpul procedurii sau ulterior. Analgezia post-proceduralã s-a efectuat cu Acetaminofen (Perfalgan) intravenous 15 mg/kg la ºase ore timp de 24 ore. Dupã 24 ore, analgezia nu a mai fost necesarã. La extragerea tubului de dren s-a utilizat sedare uºoarã cu Midazolam 0.1 mg/kg. Concluzii Sedarea moderatã la copii ºi adolescenþi nu ar trebui sã fie întreprinsã decât în cazul în care unitatea este echipatã corespunzãtor ºi personalul are experienþã adecvatã pentru aceastã procedurã. Cea mai sigurã abordare a sedãrii proceduale este de a se titra medicamente în mod treptat la un nivel dorit de sedare, începând cu cea mai micã dozã eficace. Cel mai mare risc de apariþie al complicaþiilor, în special depresie respiratorie ºi apnee, este la începutul sedãrii (atunci când medicamente tocmai au fost administrate), precum ºi în perioada imediat postprocedurã (atunci când stimulii dureroºi sunt îndepãrtaþi) University of Medicine and Pharmacy Victor Babeº Timiºoara 2. - Children s Hospital Louis Þurcanu Timiºoara Correspondence to:dr. A. Craciun, Children s Hospital Louis Þurcanu Timiºoara, Str. Dr. Iosif Nemoianu nr

2 INTRODUCTION Pneumonia is one of the most frequent infections in children and one of the main causes that lead to hospitalization. More than 95% of the episodes of pneumonia in the world occur in developing countries. It is estimated that 150 million cases occur annually in children who are <5 years old(1). Pneumonia can be caused by over 100 organisms 2. The relationship between specific clinical features and etiological organism is insufficiently strong to allow a clinical diagnosis of the causative organism (3,4). In adults, Streptococcus pneumoniae is the most commonly isolated organism in community-acquire pneumonia. The next most common pathogens in patients admitted to intensive care unit (ICU) are: Legionella species, Haemophilus influenzae, Enterobacteriaceae species, Staphylococcus aureus and Pseudomonas species(5). In children, Staphylococcal pneumonia most commonly occurs in infants, young children, and patients who are debilitated. Patients with a pleural effusion provide the opportunity to diagnose, at least presumptively, the underlying process responsible for pleural fluid accumulation. Pleural effusions are most commonly caused by primary lung disease 6. Pleural disease is an unusual cause for admission to the pediatric intensive care unit (PICU). Exceptions are a large hemothorax for monitoring bleeding rate and hemodynamic status and an unstable secondary spontaneous pneumothorax or large unilateral or bilateral pleural effusions that have caused acute respiratory failure. There are many instances when sedation may be beneficial in the PICU such as the placement of central lines, centesis tubes, intubation and several investigations. Sedation facilitates the procedure in the uncooperative patient and allows long or uncomfortable procedures to be performed. MATERIAL AND METHOD - CASES PRESENTATION Case 1 B.P., 16 years old female, without significant antecedents, was transferred from Resita Country Hospital with the diagnosis of Left pleuropneumonia, for establish the etiology. The girl presented fever ( C), nonproductive cough and left thoracic pain affirmatively for 7 days. On physical examination, the patient is thin and mildly ill-appearing. Her temperature is 37.0 C, her pulse has a regular rhythm, with a rate of 90 beats per minute (bpm), and blood pressure is 115/70 mm Hg. The 142 patient s respirations are regular and unlabored at 18 breaths/min. The examination of the head and neck is normal. Auscultation of the lung reveals the absence of vesicular murmur in the lower two thirds of the left hemithorax and no respiratory effort is noted. On percussion of the thorax, we find dullness in the left lower two thirds. Oxygen saturation level (SpO 2 ) while breathing air room is 99%. The S1 and S2 heart sounds are normal, and no murmurs are detected. The examination of the abdomen is normal and the neurological examination is also normal. The patient s laboratory studies show a hemoglobin (HB) of 10.1 g/dl, red blood cell count (RBC) of 3.65 x 10 6 /µl, white blood cell count (WBC) of 7.2 x 10 3 / µl, with 68.7% neutrophils and 18.5% lymphocites, erythrocyte sedimentation rate (ESR) of 91 mm/hr, positive qualitative C-reactive protein (CRP) determination and fibrinogen levels of 5.72 g/l. We found a normal arterial blood gas (ABG) values. Chest X-ray (see Figure 1) shows opacification in the lower two thirds of the left hemithorax. Fig. 1: Chest X-ray on admission case 1 (B.P., 16 years old female) was an exudate, the color was pale, yellow, positive Rivalta test, LDH of 356 U/l, glucose of 89 mg/dl, on cytologic examination more than 80% lymphocytes, direct smear microscopy positive for Mycobacterium tuberculosis. Case 2 P.P., 6 month old boy, transferred from Arad County Hospital to Pediatric Surgery with the diagnosis of Right pleuropneumonia and Acute cardio-respiratory failure, and then transferred to PICU in I st Pediatric Clinic (after 2 days) with the diagnosis of Right pleuropneumonia and Right pneumothorax with subcutaneous emphysema. The onset was 3 days ago with an obstructive syndrome (expiratory dyspnea, dry

3 nonproductive cough). On physical examination, the infant is with general condition marked influenced, with septic fever type ( C), pale skin and perioral cyanosis. The patient s heart rate is 130 bpm, blood pressure is 80/50 mmhg, respirations labored at 50 breaths/min. Subcutaneous emphysema is present on right part of the body (cervical, hemithorax, abdominal and scrotal). The patient has chest drain tube in 2 nd intercostal right space. Auscultation of the lung reveals the absence of vesicular murmur on right hemithorax, crepitations on left hemithorax. On percussion of the thorax, we find tympanism in the right upper one third, and dullness in the right lower two thirds. SpO 2 while breathing air room is 96%. The other examinations were normal. The patient s laboratory studies show a HB of 8.9 g/dl, RBC of 3.5 x 10 6 /µl, WBC of 28.5 x 10 3 / µl, with 66.8% neutrophils and 17.8% lymphocites, ESR of 95 mm/hr, positive CRP determination and fibrinogen levels of 5.12 g/l. Respiratory acidosis was present on ABG. Chest X-ray (see Figure 2) shows the tip of pleural catheter on the level of 4 th intercostal space and large subcutaneous emphysema. In evolution, after 5 days of hospitalisation, the patient require secondary pleural catheter fitting in 5 th intercostal right space, orientated down for pleural effusion (see Figure 3). was an exudate, a purulent fluid with positive Rivalta test, Gram positive cocci on direct smear microscopy and positive culture for Staphylococcus aureus. Case 3 S.A., 5 years old male, admitted with the diagnosis of Left pleuropneumonia. The onset was 7 days ago with fever, nonproductive cough, dysphagia and rhinorrhea. On physical examination, the child is ill-appearing, with fever ( C). The patient s heart rate is 90 bpm, blood pressure is 110/65 mmhg, respirations unlabored at 20 breaths/min. The examination of the head and neck is normal. Auscultation of the lung reveals Fig. 2: Chest X-ray on admission case 2 (P.P., 6 month old boy) Fig. 4: Chest X-ray on admission case 3 (S.A., 5 years old male) Fig. 3: Chest X-ray in evolution case 2 (P.P., 6 month old boy) the absence of vesicular murmur in the lower two thirds of the left hemithorax, crepitations on upper one third of the left hemithorax, and all right hemithorax. No respiratory effort is noted. On percussion of the thorax, we find dullness in the left lower two thirds. SpO 2 while breathing air room is 98%. The S1 and S2 heart sounds are normal, and no murmurs are detected. The other examinations were normal. The patient s laboratory studies show a HB of 10.6 g/dl, RBC of 4.42 x 10 6 /µl, white WBC of x 10 3 / µl, with 87.5% neutrophils and 6.2% lymphocites, ESR of 120 mm/hr, CRP of mg/dl and fibrinogen levels of 4.24 g/l. ABG values were normal. Chest X-ray (see Figure 4) shows opacification in the lower two thirds of the left hemithorax. was an exudate, a purulent fluid with positive Rivalta 143

4 Fig. 5: Chest X-ray in evolution case 3 (S.A., 5 years old male) test, LDH of 2467 U/l, glucose of 0.54 mg/dl, protein of 56.8 g/l, on cytologic examination more than 80% neutrophils, Gram positive diplococci on direct smear microscopy and positive culture for Streptococcus pneumoniae. Case 4 M.A., 4 month old boy, was transferred from Arad County Hospital with the diagnosis of Right spontaneous pneumothorax (partially drained with a needle) after acute bronchiolitis. On physical examination, the infant is with general condition marked influenced, with septic fever type ( C), extremely agitated, perioral and peripheral cyanosis. The baby has tachycardia (heart rate of 160 bpm), blood pressure is 80/55 mmhg, and respirations labored at 80 breaths/min. Subcutaneous emphysema are present on right part of the thorax. The right hemithorax is without respiratory Fig. 6: Chest X-ray on admission case 4 (M.A., 4 month old boy) movements. Auscultation of the lung reveals the absence of vesicular murmur on right hemithorax, crepitations on left hemithorax. On percussion of the thorax, we find tympanism on right hemithorax. SpO 2 while breathing air room is 88%. The patient s laboratory studies show a HB of 8.4 g/dl, RBC of 3.72 x 10 6 /µl, WBC of x 10 3 / µl, with 75% neutrophils and 8.4% lymphocites, ESR of 82 mm/hr, CRP of mg/l and fibrinogen levels of 5.06 g/l. Metabolic acidosis was present on ABG. Chest X-ray (see Figure 6) certified the presence of right pneumothorax. was an exudate, a purulent fluid with positive Rivalta Fig. 7: Chest X-ray in evolution case 4 (M.A., 4 month old boy) Fig. 8: Set for pleura- and thorax drainage: Pleuracan A 144

5 test, glucose of 20 mg/dl, protein of 41.9 g/l, on cytologic examination more than 80% neutrophils, Gram positive cocci on direct smear microscopy and positive culture for Staphylococcus aureus. In all 4 cases we made supplementary blood test such as LDH levels and serum albumin levels, transaminase serum levels, serum creatinine levels and blood urea nitrogen, which were normal. RESULTS In all 4 cases a pleural catheter was inserted for continuous suction of air and fluids from the pleura, not with thoracotomy, but using a set for pleura- and thorax drainage: Pleuracan A (B-Braun) (see Figure 8). We explained the procedure to the child in an age-appropriate manner in the first case (16 years old), and to the family in the other 3 cases. A peripheral intravenous catheter is started for parenteral sedation or in the event that a complication arises, for intravenous therapy. Monitoring includes continuous pulse oximetry and heart rate. Supplemental mask oxygen was necessary for patients with respiratory distress (in case 2 and case 4). Many procedures performed on children, included the placement of a pleural catheter, involve pain and anxiety, and because of that in children we use mild, short-acting sedation with combine drugs such as Midazolam ( mg/kg), Fentanyl (2-4 mcg/kg) and Propofol (2-4 mg/kg). In adult, local anesthesia with lidocaine is preferred. Because of the short duration of the procedure (approximate minute), each child received minimal doses for sedation (Midazolam 0.1 mg/kg, Fentanyl 2 mcg/kg and Propofol 2 mg/kg), without needed to supplement the doses. The procedure was performed with the child in a sitting position in case 1 and case 3 (adolescent and child) and in the lateral decubitus position with the chest slightly elevated in case 2 and case 4 (infants). The pleural fluid levels were ultrasonography verified. The area was widely prepared in a sterile manner with an antiseptic (Betadine). The puncture site was in 4 th 5 th intercostal space in all 4 cases, on posterior axillary line and penetrating with the needle catheter over the superior margin of the rib. After penetrating the pleura, the catheter is inserted through the needle and oriented down for draining the fluids in case of pleural effusion (case 1 and case 3), and oriented up for draining air in case of pneumothorax (case 2 and case 4). No complications in the time of procedure or after were noticed. On catheter we made pleural lavage with saline solution and Betadine (3 ml in 500 ml saline solution) to prevent the formation of pleural adhesions. After chest tube insertion, post-procedural analgesia was achieved using intravenous acetaminophen (Perfalgan) 15 mg/kg q six hours for 24 hours. After that no analgesia was needed. Treatment was supplemented with antibiotics (for tuberculosis Rifampicin and Isoniaside, for Staphylococcus aureus - Cephalosporins/Linezolid and Gentamicin; for Streptococcus pneumoniae - Penicillin G/Cephalosporins). The next day after pleural catheter was inserted, we made chest X-ray for catheter position inspection (see Figure 3, Figure 5 and Figure 7). The intercostal drainage was maintained for 3 days in case 1, 7 days in case 2 and case 3, and 9 days in case 4. Extraction was performed by light sedation with Midazolam 0.1 mg/kg. DISCUSSIONS In pneumonia, the differential diagnosis is wide and treatment should be started before the etiological agent is known. The differential diagnosis and the likely causative organisms can be narrowed by using epidemiological clues, the most important of which are whether the pneumonia is community-acquired or health care-associated and whether the patient is immunocompromised. The flora and antibiotic resistance patterns vary from country to country, hospital to hospital and even ICU to ICU within a hospital 7 and this must be taken into account. Also, early administration of appropriate antibiotics is important(3,8). It is no longer a matter of debate that all children, including neonates, experience pain 9. However, several myths and misunderstandings about pain relating to children persist and must be dispelled. Following are some of the more common of these(10). Myth no. 1: Compared to adults, infants experience less pain because their nervous system is immature. Neuroanatomical studies have shown that by 29 weeks of gestation the neurological pathways for the transmission and modulation of painful sensations and the cortical and subcortical centers involved in the perception of pain are well developed(11). Myth no. 2: Infants and young children have no memory of painful experiences. Recent studies suggest that early experiences of pain, such as those associated with circumcision, may produce permanent structural 145

6 and functional reorganization of developing nociceptive neural pathways that can endure in memory. This can cause disturbances of feeding and sleeping and can affect future experiences of pain(12). Myth no. 3: Children need less pain medication than adults. Physicians often have an exaggerated fear of complications when using pain medication for pediatric patients, resulting in the use of less potent regimens or underdosing of medication. Oligoanalgesia is particularly prevalent in younger children, who are significantly less likely to receive analgesics, particularly opioid analgesics 13. Of note, children receiving care at a community ED are at greater risk for oligoanalgesia than those receiving care at an academic pediatric emergency center(14). Myth no. 4: Infants and children are more sensitive to the respiratory depressant effects of narcotics. The potential for these complications is not disputed, yet there are no data to support the belief that children are more susceptible than adults to the risk of narcotic-induced respiratory depression. In fact, because of their increased metabolic rate, children often tolerate proportionally larger and more frequent doses of analgesics than adults. With an understanding of drug pharmacology, proper use of monitoring equipment and the availability of reversal agents, clinicians can safely administer opioid analgesics to children in the PICU 10. Myth no. 5: Children are at increased risk for addiction. Despite fears to the contrary, there are no known physiologic or psychological characteristics of children that make them more vulnerable to addiction than adults(15,16). Myth no. 6: Narcotic use may mask symptoms of intra-abdominal pathology. Morphine provides significant pain reduction to children with acute abdominal pain without adversely affecting the examination 17. The use of analgesics makes children more comfortable and facilitates both abdominal examination and diagnostic testing (e.g., ultrasound). CONCLUSIONS Moderate sedation of pediatric patients should not be undertaken unless the facility is appropriately equipped and staff have adequate experience with this procedure. Extra caution is required when sedating children with underlying illness, especially those with neurologic disease. Children may cry or move while under sedation, and therefore personnel should be prepared to apply physical restraint if necessary. The safest approach to procedural sedation is to titrate medications in a stepwise fashion to a desired level of sedation, starting with the lowest effective dose. More medication can always be given, but excessive medication already administered cannot be withdrawn. If deep sedation or anesthesia is necessary, the procedure should likely be performed in the operating room. Any procedure should be stopped if it becomes clear that a different setting would be more appropriate or safer for the patient. Physician supervision of procedural sedation should not end simply because the procedure is finished. This is in fact one of the most dangerous times for the patient. The highest risk of complications especially respiratory depression and apnea occurs at the beginning of sedation (when medications have just been administered) and during the immediate postprocedure period (when painful stimuli are removed). REFERENCES 1. Rudan I, Tomaskovic L, Boschi-Pinto C, et al. Global estimate of the incidence of clinical pneumonia among children under five years of age. Bull World Health Organ 2004; 82 (12): Mandell LA, Marrie TJ, Grossman RF et al. Canadian guidelines for the initial management of community-acquired pneumonia: an evidence-based update by the Canadian Infectious Diseases Society and the Canadian Thoracic Society. Clin Infect Dis 2001; 31: American Thoracic Society. Guidelines for the management of adults with community-acquired pneumonia. Am J Respir Crit Care Med 2001; 163: Fang GD, Fine M, Orloff J et al. New and emerging etiologies for community-acquired pneumonia with implications for therapy. A prospective multicenter study of 359 cases. Medicine (Baltimore) 1990; 69: File TM, Jr. Community-acquired pneumonia. Lancet 2003; 362: Sahn SA: The pleura. Am Rev Respir Dis 138:184, Namias N, Samiian L, Nino D et al. Incidence and susceptibility of pathogenic bacteria vary between intensive care units within a single hospital: implications for empiric antibiotic strategies. J Trauma 2001; 49: Dupont H, Mentec H, Sollet JP et al. Impact of appropriateness of initial antibiotic therapy on the outcome of ventilator-associated pneumonia. Intens Care Med 2001; 27:

7 REFERENCES (CONTINUED) 9. Yaster M, Deshpande JK. Medical progress: management of pediatric pain with opioid analgesics. J Pediatr. 1988; 113: Walco GA, Cassidy RC, Schechter NL. Pain, hurt, and harm: the ethics of pain control in infants and children. N Engl J Med. 1994; 331: Anand KJS, Hickey PR. Pain and its effects in the human neonate and fetus. N Engl J Med. 1987; 317: Fitzgerald M, Anand KJS. Developmental neuroanatomy and neurophysiology of pain. In: Schechter NL, Berde CB, Yaster M, eds. Pain in Infants, Children, and Adolescents. Baltimore: Williams & Wilkins; 1993: Selbst SM, Clark M. Analgesic use in the emergency department. Ann Emerg Med. 1990; 19: Rupp T, Delaney KA. Inadequate analgesia in emergency medicine. Ann Emerg Med. 2004; 43: Schechter NL, Allan DA. Physicians attitudes toward pain in children. J Dev Behav Pediatr. 1986; 7: McCaffery M, Ferrell BR. Opioid analgesics: nurses knowledge of doses and psychological dependence. J Nurs Staff Dev. 1992; 8: Kim MK, Strait RT, Sato T. A randomized clinical trial of analgesia in children with acute abdominal pain. Acad Emerg Med. 2002; 9: