Perioperative pain management in the paediatric population: what about outcome?? Kris vermeylen

Perioperative pain management in the paediatric population: what about outcome?? Kris vermeylen

Perioperative pain management Introduction Physiology Therapeutic possibilities Conclusion THM

Introduction

Evidence regarding the efficacy of analgesics available to guide postoperative treatment in paediatric patients is limited few evidence-based reports are available to guide the use of opioid medications in children

the majority of pain medications available on the market today are unlabeled for use in pediatric patients lack of adequate research

Pain in children : unrecognized poorly treated under-prescribed under-dosed for opioid and non-opioid analgesics unwarranted concerns of respiratory depression and/or poor understanding of the need for pain medications in children

A child is not an adult

Paediatric physiology Circulation Ventilation Central nervous system Metabolism Temp regulation

Paediatric physiology Circulation Ventilation Central nervous system Metabolism Temp regulation

Central nervous system Incomplete myelinisation BBB is incomplete: increased sensitivity for stimuli Parasympathic system >> Sympathic system : increased vagal tonus: bradycardia!! Higher sensitivity for pain: pain at young age can give lower pain thresholds (at that age) and therefore higher pain responses when adult

Central nervous system Immature neuromuscular transmission Amount of Acetylcholine is limited Train of 4 : often only 3 answers Foetal form of nicotine receptors (replaced in the first weeks after birth to mature ones)

Liver: immature Metabolism Lower plasma-lipid fraction: lipid binding decreased: higher med free fraction Kidney function immature: lower excretion rate

Good pain management is crucial

Different sources of pain Acute pain Trauma Postoperative Other Chronic pain Postoperative Other

What do we do? Therapeutic possibilities

Acute pain management

protocols for the recognition and treatment of pain for children during their perioperative stay Standardizing pain measurements require the use of appropriate pain scales. There are many pain scales available, all of which have advantages and disadvantages. It is not so important which of these pain scales is used, but that they are used on a consistent basis.

Pain Scores

Pain scores in children What do we look for? Physiological changes: acute pain! HR and RR changes BP changes Pupil dilatation Nausea Transpiration Behaviour changes

Pain scores in children

Pain scores in children Name of Type Description Age Group Scale Numeric (0-10 Scale) Self-Report Verbal 0-10 scale; 0 = no pain, 10 = worst pain you could ever imagine Children who understand the concept of numbers, rank, and order. Approximately > 8 yrs Bieri Faces Self-Report 6 faces that range from no pain to the worst pain you can imagine. See Appendix 1 Younger children who have difficulty with numeric scale. Cognitive age 3-7 FLACC CRIES, NIPS, PIPP Behavioral Observer Behavioral Observer 5 categories: face, legs, activity cry and consolability. Range of total score is 0-10. Score 7 is severe pain. See Appendix 1 Rates a set of standard criteria and gives a score. years. Non-verbal children > 1 year of age Non-verbal infant < 1 year of age.

Pain scores in children Bieri Faces Pain Scale-Revised 0 2 4 6 8 10

Pain scores in children FLACC Pain Assessment Tool Categories Score 0 Score 1 Score 2 Face Legs No particular expression or smile Normal position or relaxed Occasional grimace or frown, withdrawn, disinterested Uneasy, restless, tense Frequent to constant frown, clenched jaw, quivering chin Kicking, or legs drawn up Activity Cry Consolability Lying quietly, normal position, moves easily No cry (awake or asleep) Content, relaxed Squirming, shifting back and forth, tense Moans or whimpers, occasional complaint Reassured by occasional touching, hugging, or being talked to, distractible Arched, rigid, or jerking Crying steadily, screams or sobs, frequent complaints Difficult to console or comfort

Pain scores in children: cheops

Medication

Pain ladder

PCA dosing recommendations Table 2: PCA dosing recommendations Morphine Fentanyl Hydromorphone Solution 1 mg/ml Solution 10 0.1mg/ml or Initial dose 15-20 mcg/kg (max 1.5mg) mcg/ml 0.25mcg/kg 1mg/ml 3-4mcg/kg (max 0.3mg) Lockout time 8-10 minutes 8-10 minutes 8-10 minutes Basal infusion Maximum starting dose 0-20mcg/kg- /hr 100mcg/kg/- hr 0-1mcg/kg/hr 0-4mcg/kg/hr 1-2mcg/kg/hr 20mcg/kg/hr

Problems with systemic analgesics Many drugs are still used off label Little characterized efficacy and safety profile in children Little scientific background Studies are considered unethical Problems with informed consent Validated endpoints to measure efficacy

Is it possible to treat pain without opioids?

Alternatives Combinations of non-opioid analgesics in multimodal approach NSAIDs in combi with acetaminophen Tramadol in combi with acetaminophen Bethamethasone, clonidine, Regional anaesthesia Lam DK, Corry GN, Tsui BC. Evidence for the use of ultrasound imaging in pediatric regional anesthesia: a systematic review. Reg Anesth Pain Med 2016; 41:229 241. Guay J, Suresh S, Kopp S. The use of ultrasound guidance for perioperative & neuraxial and peripheral nerve blocks in children: a Cochrane review. Anesth Analg 2017; 124:948 958.

Regional anaesthesia

Regional anaesthesia and paediatrics : does it match? Lam DK, Corry GN, Tsui BC. Evidence for the use of ultrasound imaging in anaesthesia: a systematic review. Reg Anaesth Pain Med 2016; 41:229 241. paediatric regional Guay J, Suresh S, Kopp S. The use of ultrasound guidance for perioperative & neuraxial and peripheral nerve blocks in children: a Cochrane review. Anesth Analg 2017; 124:948 958.

Long history of RA and kids Dr. August Bier performed in 1898 the first RA blocks in modern Anaesthesia intraspinal injections of cocaine -> 5 of his first 10 patients were children

Literature Long history of paediatric regional anaesthesia Evidence in literature: lots of advantages Reduced stress response Better postoperative analgesia Less opioid related side-effects Early extubation therefore, a local technique should be used for all operations unless contraindicated S Roberts, Review article, Utrasonographic guidance in pediatric regional anesthesia, Pediatric Anesthesia 2006, 16, 1112-1124

Regional anaesthesia techniques providing an excellent intra- and post-operative analgesia have become an extremely important part of paediatric anaesthesia Markakis D.A. Regional anesthesia in pediatrics. Anesthesiol Clin North America, 2000;18:355-81 Dalens B. in Regional anesthetic Techniques in Pediatric anesthesia. B. Bissonnette and B. Dalens, Eds. 2002, McGraw Hill: 528-75.

Regional anaesthesia: mechanism

Regional anaesthesia: Awake or asleep? 90% of the RA techniques are under GA supported by the pediatric anaesthesiologists world wide Krane E.J., The safety of epidurals placed during general anesthesia [editorial]. Reg Anesth Pain Med, 1998. 23(5): p. 433-38. Taenzer A et al. Asleep vs Awake: Does it matter?reg Anesth Pain Med 2014;39:279-283..

Common paediatric RA techniques Penile block Caudal block Ilioingiunal block Femoral block. all adult blocks can be performed on children

Neuraxial anaesthesia

Epidural dosing cont. infusion Agents Concentration Infusion Bupivacaine 0.1-0.--125% 0.15-0.4 cc/kg/hr Bupivacaine / Fentanyl 0.1-0.--125% / 2-4 ug/cc 0.15-0.4 cc/kg/hr Fentanyl 2-5 ug/cc 0.3-0.75 ug/kg/hr Morphine (PF) 50-100 ug/cc 2-10 ug/kg/hr Hydromorphone 10 ug/cc 1-3 ug/kg/hr 1) The maximum infusion rates should not exceed 0.5 mg/kg /hr of bupivacaine in

Epidural dosing PCEA Bupivacaine plus fentanyl Solution 0.75mg/ml bupivicaine + 5 mcg/ml fentanyl Initial dose 0. 1ml/ kg/ dose Lockout time 20-30 minutes Basal infusion 0.2ml/kg/hr (max 9.9ml/hr) Maximum dose 0.4ml/kg/hr

Peripheral nerve blocks

Role of US

Peripheral vs neuraxial extremely low incidence of complications after peripheral nerve blocks!! In favor in comparison with neuraxial blocks due to good visualisation of the nerves and the surrounding structures Giaufre E et al. Anesth Analg 1996; 83:904-12. Berde C et al. Anesth Analg 1996; 83:897-900. Llewellyn N et al. Paediatric Anaesth 2007;17:520-533. Taenzer A et al. Reg Anesth Pain Med 2014;39:279-283.

dose reduction Van Geffen et al. Ultrasound-guided bilateral continuous sciatic nerve bloks with stimulating catheters for postoperative pain relief after bilateral lower limb amputations. Anesthesia 2006;61:1204-7.

Peripheral vs neuraxial: or the combination!! Acta Anaesthesiol Belg. 2011;62(3):151-5. Ultrasound as guidance for a combined bilateral supraclavicular and caudal block, in order to reduce the total anaesthetic dose in a two year old child after a pneumococcal sepsis. Vermeylen K, Berghmans J, Van de Velde M, De Leeuw T, Himpe D.

Supraclavicular plexus in 2 year old

USG Caudal block dose reduction transverse axis view on the lower lumbar level (view on the intervertebra level L4L3) : ultrasound confirmation of the caudal block, LA=local anaesthetic, CSF=cerebrospinal-fluid, dura is pushed to anterior as result of the local anaesthetic

Continuous fascia iliaca compartment block in children: a prospective evaluation of plasma bupivacaine concentrations, pain scores, and side effects. Anesth Analg. 2001 May;92(5):1159-63. Paut O, Sallabery M, Schreiber-Deturmeny E, Rémond C, Bruguerolle B, Camboulives J. Abstract We sought to determine the plasma concentrations of bupivacaine and its main metabolite after continuous fascia iliaca compartment (FIC) block in children. Twenty children (9.9 +/- 4 yr, 38 +/- 19 kg) received a continuous FIC block for either postoperative analgesia (n = 16) or femoral shaft fracture (n = 4). A bolus dose of 0.25% bupivacaine (1.56 +/- 0.3 mg/kg) with epinephrine was followed by a continuous administration of 0.1% bupivacaine (0.135 +/- 0.03 mg. kg(-)(1). h(-)(1)) for 48 h. Plasma bupivacaine levels were determined at 24 h and 48 h by using gas liquid chromatography. Heart rate, arterial blood pressure, respiratory rate, side effects, and pain scores were recorded at 4-h intervals during 48 h. No significant differences were found between mean plasma bupivacaine levels at 24 h (0.71 +/- 0.4 microg/ml) and at 48 h (0.84 +/- 0.4 microg/ml) (P = 0.33). FIC block provided adequate analgesia in most cases. No severe adverse effects were noted. We conclude that the bupivacaine plasma concentrations during continuous FIC block in children are within the safety margins. FIC block is well tolerated, and provides satisfactory pain relief in most cases. IMPLICATIONS: In this study, we have shown that, in children, continuous fascia iliaca compartment block, a technique providing neural blockade of the thigh and the anterior part of the knee, was associated with safe plasma bupivacaine concentrations, was well tolerated, and provided satisfactory pain scores in most cases.

Chronic paediatric pain

Can we predict patients at risk?? Post surgical pain = pain > 3 months postop Prevalence up to 20% after 12 months of surgery Determined by severity of acute postoperative pain in the first 24 hours after surgery (VAS>3) Related to dermatome Can be after an asymptomatic period Treede RD, Rief W, Barke A, et al. A classification of chronic pain for ICD-11. Pain ; 156:1003 7. Lavand homme P. Why me? The problem of chronic pain after surgery. Br J && Pain 2017; 11:162 165. Outstanding review on chronic postsurgical pain (CPSP). Rabbitts JA, Fisher E, Rosenbloom BN, Palermo TM, et al. Prevalence and & predictors of chronic postsurgical pain in children: a systematic review and meta-analysis. J Pain 2017; 18:605 614. Undated Meta-analysis on the predictors of CPSP in children and adolescents. Batoz H, Semjen F, Bordes-Demolis M, et al. Chronic postsurgical pain in children: prevalence and risk factors. A prospective observational study. Br J Anaesth 2016; 117:489 496.

Chronic Pain Management The multidisciplinary approach is standard of care for treating chronic pain in children. All children evaluated for chronic pain should be seen by all primary members of the team on their initial visit. Multidisciplinary pain team include: pain physician, pediatric psychologist psychitatrist, OT/PT, APN s, social worker.

Chronic Pain Management Pediatric pain physicians cross many specialties but most commonly they are anesthesiologists, rheumatologists, or neurologists without formal training in pediatric pain. Although, multiple approaches exist in caring for these patients the most successful programs base their approach on combined intensive rehabilitation and intensive psychotherapy relying minimally on invasive procedures and pharmacotherapy.

Conclusions

Future research Clinical trials are needed to evaluate the safety and efficacy of analgesics across all pediatric age spans to avoid inappropriate extrapolation of adult data to children.

Conclusions Treatment options have evolved in recent years Using combinations of nonopioid analgesics and multimodal approach may limit need for opioids Combinations of multimodal regimens and regional anaesthesia

Conclusions US guided RA!!