Effective Postoperative Pain Management for Children Nancy L. Glass, MD, MBA, FAAP nglass@bcm.edu @DrNancyGlass1
None Disclosures
Learning Objectives At the end of this presentation, participants will be able to: Formulate a plan for multi-modal perioperative analgesia in surgical patients of various ages Identify risk factors for adverse events from a given plan Manage side effects appropriately
A Simpler Goal Everyone in the audience leaves with at least ONE NEW and USEFUL TOOL for managing pain in pediatric patients
Audience Poll How many of you anesthetize children on a regular basis? A. YES B. NO
Audience Poll Where do you care for kids MOST OFTEN? A. Surgicenter B. Academic pediatric hospital C. Community pediatric hospital D. General hospital E. I avoid the little buggers like the plague.
Patient #1 3 yo with spastic quadriplegia, developmental delay, dysphagia, and seizures is undergoing an open revision of her fundoplication. Her lungs are clear now; she frequently requires Bipap when ill or congested.
Pt #1: Your Pain Plan A. Intermittent IV opiates B. Parent-controlled PCA C. Epidural analgesia D. Other regional technique E. Other analgesic plan
Pt #1: the procedure, 3 hrs Easy induction/intubation Good access, including A/L Minimal blood loss Pressures well-maintained, warm Decision to extubate
Audience Poll: Assessing Pain A. Use vital signs to guide therapy B. Use a behavioral scale C. Ask the mother D. Assume she is comfortable if she isn t crying
Physiologic Signs of Pain Hypertension, tachycardia, tachypnea--not reliable, not specific for pain Physiologic signs fade over time Not a good way to tell if your patient is in pain
Behavioral Scale A slightly different form is available for impaired children Think of this as an Apgar score for Pain except that high scores are BAD!
Faces Scales May be useful beginning between 3 and 6 yrs of age.but 50% of 6 yo were unable to use a Faces scale Neutral anchor Faces Pain Scale-Revised Pain score of 2/10 shows beginning distress Anchor NOT neutral Pain score of 3 (6/10) is the earliest sign of distress in this scale Wong-Baker Faces Pain Rating Scale Von Baeyer CL, Pain Res Manag, 2009
Oucher Pain Scales Color photographs, both genders, many ethnic groups. Need for color copying, multiple versions limit the usefulness of the Oucher scales. Vertical scales ARE PREFERABLE, with respect to children s cognitive development.
Pain Plan Multimodal Scheduled IV acetaminophen while NPO Scheduled Ketorolac if no contraindications Sched Aceta 12-6-12-6, Ketorolac 3-9-3-9 Intermittent IV opiates available Q 2h prn Parent-controlled PCA Avoid background infusion Parent education Monitoring for resp depression
PCA by Proxy (Surrogate) Younger children, developmentally delayed Alterations in PCA orders slightly longer intervals, interval dose based on safe hourly doses of agent In a study comparing regular PCA with PCA by proxy (PCA-P): PCA and PCA-P showed similar prevalence of adverse events: 22 % vs. 24% PCA-P pts were more likely to need rescue or escalation of care to ICU setting Risk factors: orthopedic surgery, cognitive impairment, respiratory co-morbidity, use of basal infusion, concomitant use of diazepam Voepel-Lewis et al, Anesth Analg, 2008
Patient #2 14 yo healthy boy undergoing the Nuss procedure for pectus excavatum. Mild asthma, albuterol inhaler prn. Anxious.
Pt #2: Your Plan A. Intermittent IV opiates B. Patient-Controlled Analgesia C. Epidural analgesia D. Other regional technique E. Other analgesic plan
Poll: If epidural, awake or asleep? A. Awake for thoracic epidural, no exceptions B. Depends on the kid, would prefer awake/sedated thoracic epidural C. Anesthetized only, no chance for unexpected pt movement D. I would never place a thoracic epidural in a child/adolescent
My plan Thoracic epidural analgesia Awake vs asleep Meds? PCEA? Ropivacaine 0.1% + Fentanyl 2 mcg/ml @ 0.3 ml/kg/hr Or Ropi + Hydromorphone 10 mcg/ml @ 0.15 ml/kg/hr
Adjuncts / Other choices Gabapentin preop/postop? Ketorolac? LA alone in epidural? PCA opiate for prn pain? Transitioning to oral meds: when? / how? Take-home meds? Expectations / teaching for pain at home?
Controversy with Nuss Pts Several devastating outcomes at one center Was it the epidural? Was it the forces on the chest wall/spinal cord? Challenge of transitioning from great epidural analgesia to oral meds, may prolong discharge
Epidural Analgesia Caudal or lumbar Thoracic direct, or threaded from caudal space Local anesthetic + opiate Time- & labor-intensive Walking: expected with thoracic epid, +/- with lumbar Voiding without foley: usually with thoracic, not with lumbar
Epidural Analgesia in Kids Asleep vs. awake: KIDS ARE DIFFERENT Know how deep to go! Thoracic: document catheter tip location Local anesthetic + opiate Ropivacaine or bupivacaine + fentanyl or hydromorphone Consider clonidine Time- & labor-intensive
Patient #3 6 yo patient with hepatoblastoma for excision of tumor She has received chemotherapy, counts have returned to baseline; coagulation studies are normal. You and surgeon agree on plan to extubate at end of procedure.
Audience Poll: Your Plan A. Intermittent IV opiates B. Patient-Controlled Analgesia C. Epidural analgesia D. Other regional technique E. Other analgesic plan
Pt #3: the procedure, 8 hrs Easy induction/intubation Good access, including A/L Considerable blood loss, ~1 blood volume Pressures well-maintained, warm Decision to leave intubated overnight Does the decision to ventilate overnight change your plan?
Advantages PCA Easily titrated to need Little-no effect on BP May help with painsedation for ETT, discomfort of NGT Advantages EPID Less opiate Faster/easier extubation? Reduce risk of DVT?
No one right answer! It depends! Use adjuncts aggressively: acetaminophen, gabapentin (if neuropathic component suspected) Depends on your systems, ability to see the patient frequently Goal: early extubation / mobilization
Common PCA Doses Loading Dose Continuous Infusion Interval Dose Lockout Interval 4 hour Max Morphine.05-0.1 mg/kg 0.01-0.015 mg/kg 0.015-0.025 mg/kg 6-12 min 0.15-0.35 mg/kg Hydromorphone 5-15 mcg/kg 3-5 mcg/kg/hr 3-5 mcg/kg 6-15 min 50-60 mcg/kg Fentanyl 1 mcg/kg 0.1 mcg/kg/hr 0.15-0.3 mcg/kg 6-8 min 3-5 mcg/kg If background infusion used, the hourly rate of the infusion should always be less than the interval dose
PCA Challenges Analgesia Not comfortable when PCA started Interval dose too low, infusion too high Poor sleep quality Side effects consider naloxone infusion Itching Nausea/vomiting 0.25 mcg/kg/hour Oversedation, respiratory depression Maxwell LG, et al, Anesth Analg 2005; 100(4): 953-8.
A. Patient not comfortable to start with, interval doses only briefly lead to analgesia B. Barely comfortable to start with, level falls, takes many pushes to get comfortable again The sweet spot, starting comfortably, staying there! C. Comfortable when PCA starts, but infusion is too high, so patient becomes increasingly somnolent with respiratory depression
Opiate-sparing Effects Why do we care about this? Less nausea and vomiting Earlier return of bowel function Less constipation Less sedation
Compared 25 children with opiate ADEs and 98 procedure-matched children without ADEs: respiratory depression, oversedation Rescue: naloxone or rapid response team call Looked at intraop, PACU, interval opiate dosing on postop units, sedation scores, O2 sat, O2 use Voelpel-Lewis T et al, Pediatric Anesthesia 2013;23:162-169
Risk Factors for Opiate Adverse Drug Effects & Need for Rescue ASA status was an independent risk factor Early and consistent use of NONOPIATE adjuncts REDUCED RISK of opiate ADEs Need for supplemental oxygen at PACU discharge was predictive of later ADE and need for rescue
Weaning Opioids When the surgical condition is improving, pt tolerating PO Weaning PCA Start an oral agent Wean continuous infusion first, then lengthen interval between bolus doses Weaning oral meds at home tips for success Continue non-opioids/adjuncts Eliminate night-time dose last, don t forget bowel regimen
Brachial plexus Nerve Block Analgesia Single shot or plexus catheter placement Branches of lumbar plexus femoral & sciatic Head and neck blocks Supraorbital nerve block for VP Shunt placement Sciatic block Suresh and Voronov, Ped Anes, 2012
Nerve Block Analgesia Transverse Abdominis Plane Block TAP Intercostals T7-T12 Ilioinguinal, iliohypogastric n Lat branches of L1-3 rami Appendectomy Abdominal wall surgery Ostomy creation/closure Kidney transplant Suresh S, Chan VW, Paediatr Anaesth. 19(4):296-9, 2009 McDonnell J, et al. Anesth Analg 104(1): 193-7, 2007
Multi-modal Analgesia for Surgical Outpatients Scheduled ibuprofen or other NSAID, PLUS Acetaminophen-containing opiate hydrocodone preferred (Vicodin or Lortab ) OR Scheduled ibuprofen, PLUS Tramadol
Multi-modal Analgesia for Surgical In-patients 1) Scheduled NSAID: Ibuprofen or Ketorolac, PLUS 2) Scheduled Acetaminophen (IV or PO), PLUS 3a) Morphine or hydromorphone IV every 2 hours PRN OR 3b) Morphine or hydromorphone PCA, OR 3c) Regional anesthetic technique
Summary The ideal pain plan for both inpatients and outpatients includes a multi-modal approach, designed to maximize comfort and minimize side effects and toxicity
To cure sometimes, to relieve often, to comfort always 15 th century French folk saying, inscribed on the statue of Dr. Edward Trudeau in upstate New York