What's New in Post-Operative Pain in Children by uhj16850


									   What’s New in
Post-Operative Pain in
      Lori Palozzi, RN, MScN, ACNP
    CNS-NP Anesthesia Pain Service
   SickKids Hospital, Toronto, Canada


No potential conflict of interest
                   Learning Objectives

1.Highlight relevant practice guidelines for post-operative pain in

2.Review the literature on post-operative pain assessment
  measures in children and adolescents

3.Discuss the latest evidence on the pharmacological
  management of pain
 Is post-operative pain in children a problem?

 Undertreatment of post-op pain in children for 30 years (Eland &
Anderson, 1977; Mather & Mackie, 1983; Beyer, 1983, Burokas 1985, Johnston,
et al 1992)

 Increased attention to organizational pain management in the
90’s and implementation of institutional guidelines early 2000

 Research-practice gap still exists for many reasons

 More research needed on effective knowledge translation
            SickKids Inpatient Pain Audit
            (2004) Summary of findings

Pain assessment
      infrequently documented (18%)
Pain during admission
      77% of inpatients
          64% moderate-severe in previous 24h
Analgesic therapy
      44% did not receive any analgesia
      Commonly intermittent and single agent
          70% mod-severe pain did not receive regular analgesia
      87% receiving analgesia found it helpful
Practice Guidelines & Policy Statements

Acute Pain Management Scientific Evidence 2nd edition ANZCA 2005

 Practice Guidelines for Acute Pain Management in the Perioperative
Setting Anesthesiology 2004, 100: 1573-81

Policy Statements from the American Academy of Pediatrics:

       Assessment and management of Acute Pain in Infants, Children
and Adolescents Pediatrics (2001) 108: 793-797

        Prevention and management of pain and stress in the Neonate
Pediatrics (2006) 118: 2231-2241
Guiding Principles
Prevention and Treatment
      Multimodal approach
      Anticipate pain and provide analgesia continuously
      PRN boluses for breakthrough pain
      Titrate dose and wean to prevent withdrawal

Assessment and Reassessment
     Cornerstone of effective pain management
     Frequent intervals and documented
     Validated and reliable measures

   AAP 2001, ANZCA 2005
   Postoperative Pain Assessment :
  Recommendations for Clinical Trials

                                 Observational (Behavioural)
      Stinson, J, et al (2006)
                                    Von Bayer, C & Spagrud, L (2007)

Pieces of Hurt (Hester, 1979)    FLACC (Merkel, et al 2002)
          3-4 years                     4-18 years
                                     Hospital setting

 Faces Pain Scale- Revised       Parent’s Post-operative Pain
     (Hicks et al, 2001)                Measure (PPPM)
        4-12 years                   (Chambers et al 1996)
                                          2-12 years
                                        Home setting
       100 mm VAS
     8 years and older
Treating Pain: The 3 P’s

        •WHO ladder
        •Systemic and regional
        •Adjuvant rx rx

 Effective for mild pain and useful adjunct to severe pain

 Opioid sparing after tonsillectomy using 40mg/kg oral
 acetaminophen (Anderson et al 1996)

 Rectal administration: kinetics less predictable and
 bioavailability less than oral (Anderson, et al 1996)
 Rectal loading doses 30-40mg/kg required (Birmingham, 1997)

 Propacetamol: IV formulation prodrug of acetaminophen
 Effective for mild to moderate pain
 Opioid sparing and improves quality of analgesia        (Morton & O’Brien 1999)

 Age issues
    <6 months not well established
    Reports of renal impairment in neonates (Devavaram, 2007)

    NSAIDs did not significantly alter number of perioperative bleeding events
    requiring surgical intervention
    Reduction in nausea and vomiting when NSAIDS used
   (Cardwell et al, 2005)
NSAIDS cont’d

Spinal Fusion (Rueben 2004)
    Large doses given over several weeks associated with
    delayed bone healing in animals
    Human studies using high doses of ketolorac
    (>2mg/kg/day) over 3 months had higher non-union rates
    (x5) vs. no ketolorac
    Appropriate dose controversial
Summary: Non-Opioids                  (ANZCA 2005)
 Acetaminophen and NSAIDS are effective for moderately severe pain
and decrease opioid requirements after major surgery (level II)

 Safe dosing of acetaminophen requires consideration of age and
weight of child and duration of therapy (expert opinion)

 Aspirin should be avoided in children, but serious adverse events after
NSAIDS are rare in children over 6 months (expert opinion)
 Developmental Differences in PK and PD
 Adjust dose to weight and individual situation, monitor
 Codeine may be ineffective due to low activity of CYP2D6
 Efficacy of codeine for post-op pain
      -Improved analgesia with acetaminophen (Tobias et al,
     1995, Pappas et al 2003) ; no difference following
     myringotomy (Ragg & Davidson, 1997) or tonsillectomy pain
     (Moir et al 2001)
 Safety and efficacy of IV morphine infusion well established
(Beasley & Tibballs 1987, Esmail et al 1999)

 Intermittent IM injections less effective than infusions, and
disliked by children (Bray 1983, McNichol, 1993)
Patient Controlled Analgesia
 Established in children < 5 yr

 Selection Criteria: age and
 understanding, ability to use
 PCA, trained staff, educated
 families, monitoring

 Use of background infusion
 more common in children

 PCA by Proxy
        “Authorized Agent Controlled Analgesia”

      “The ASPMN does not support the use of “PCA by Proxy”
     In which unauthorized person activates the pump, thereby
        increasing the risk for potential harm to the patient.

 The ASPMN further delineates that support for AACA* is contingent
     upon a health care agency having in place clear guidelines
     outlining the conditions under which safe practice may be
      implemented, including monitoring procedures that will
                   insure the safe use of therapy.”

         * Nurse controlled or Caregiver controlled analgesia

Wurhman, et al (2007) Pain Management Nursing, 8: 4-11
Other opioids
      Studies limited by small samples and difficulty determining comparative
      analgesic doses (ANZCA 2005)
      Oral tamadol 2mg/kg more effective than 1 mg/kg for post-op pain
      following cessation of PCA (Finkel et al 2002)

      CR oxycodone for pediatric spinal fusion (Czarnecki et al 2004), retrospective
       Mean pain scores decrease from 4.2 to 3.7/10
       Mean ratio of conversion form morphine to oxycodone 1:1
       Used for total of 13.3 days, which included average wean time
       of 6 days
Summary: Opioids              (ANZCA, 2005)
  Effective PCA prescription in children incorporates a bolus adequate to
control movement-related pain, may include a low dose background
infusion to improve efficacy and sleep (Level II)

  Intermittent IM injections are distressing for children and are less
effective for pain control than IV infusions (Level III-I)

  IV opioids can be used safely and effectively in children of all ages
(expert opinion)

 Initial dose of opioid should be based on age and weight of the child,
and then titrated to response (expert opinion)
 10 month with Rt lung agenisis,
thoractomy for tissue expander

 Morphine infusion 40 mcg.kg.hr,
IV ketolotac, and acetaminophen

 Weaned from 40 to 10 mcg/kg/hr
over 3 days in CCU, transferred to
floor constant obs.
RN and mom noticed profuse
diaphoresis, irritability, tachycardia

 Referral to APS for opioid

Increased infusion to 30 mcg/kg/hr
x 24 hours then decreased by 5
mcg/kg/hr (approx 15%) Q 24-36
hours as tolerated.
         Regional Techniques: Overview

Prospective study on safety of pediatric regional anesthesia in
France: 24,409 regional blocks, overall complication rate 0.9 per
1000, all related to central caudal blocks (Giaufre et al 1996)

Increased reporting of the use of electrostimulation and ultrasound
to identify the epidural space (Tsui, 2006), to assist with catheter tip
placement and catheter advancement

Newer local anesthetic agents ropivacaine and levobupivacaine may
provide a better safety profile than bupivacaine (Dalens, 2006;
Bosenberg et al 2005)

Clonidine can enhance the quality and duration of caudal analgesia
(Eck & Kinder Ross , 2002)
Continuous Peripheral Nerve Block
 Indications:   intense post-op pain; painful PT; CRPS

 Ropivacaine best choice for CPNB in children (Dadure & Capdevila 2005)

 PCRA for lower limb surgery, prospective, 4-17y, N= 27
      0.2% ropivacaine (0.02ml.kg.hr) + 0.1ml/kg bolus Q 30 min
      mean VAS 1.09 (SD 1.15), mean CHEOPS 4.75 (SD 1.1) motor block (2) ,
      (Duflo et al 2004)

 CEB versus CPNB in foot surgery, RCT, 1-12 yr, N=52
      Excellent postop analgesia; adverse events higher in CEB (p<0.05) (N & V,
        urinary retention and premature d/c of catheter in younger children) ;
        Parental satisfaction: CEB 86% , CPNP 100%
      (Dadure et al 2006)
PCEA vs Continuous Epidural Infusion
PCEA with infusion of ropivacaine 0.2% vs. continuous infusion (Antok
     et al 2003)
  N =48 children 7-12 years of age, RCT
  lower extremity orthopedic surgery;
     PCEA group used less LA (p<0.001);
     no differences in side effects, supplemental analgesia, or pain

PCEA in children (Birmingham et al 2003)
  Prospective N= 128, 5-12 yr
  Able to use PCEA, 90% satisfactory pain relief
  3.8% changed to PCA for unsatisfactory pain relief
Summary: Regional Anesthesia                              (ANZCA, 2005)
Clonidine prolongs analgesia when added to caudal local anesthetics blocks
        (Level I)

Clonidine improves analgesia when added to epidural local anesthetic infusions
        (Level II)

Epidural infusions of local anesthetic provide similar levels of analgesia as
       systemic opioids (Level II)

Epidural opioids alone are less effective than local anesthetic or combinations of
       local anesthetic and opioid (Level II)

Caudal blocks provide effective analgesia for lower abdominal, perineal and lower
       limb surgery; a low incidence of serious complications (expert opinion)

Continuous epidural infusions provide effective postoperative analgesia in
       children of all ages and are safe if appropriate dose and equipment are
       used by experiences practitioners, with adequate monitoring and
       management of complications (expert opinion)
 Systematic review of ketamine as adjunct to opioid
4 studies N= 232; Evidence mixed, different pain scales used;
Side effects not increased when ketamine given as a single
bolus; IV infusion associated with increased CNS side effects in
one study (Subramaniam et al 2004)

 Single dose and neuraxial administration is effective but more
research needed in children (Lin, 2005)

  Case report: Low dose ketamine infusion + IV PCA in spinal
fusion showed excellent analgesia and early participation in
rehab but no opioid-sparing effect (Tsui et al 2007)
  Little known about gabapentin and post-op pain in children,
although used widely in adults pre-operatively (Ho et al, 2006)

 Potential to reduce opioid requirements, minimize side effects,
      prevent or reduce neuropathic pain?

 More research needed with children in different post-operative
      pain contexts
Special Issues
Children with Cognitive Impairment
 At risk for poor post-operative management (Koh et al, 2004,
 Malviya et al, 2001)
 Assessment difficult due to limitations in communication
     Non-communicative Children’s Pain Checklist- Post-op
     version (Breau, et al 2002)
 Neuropathic pain described in a case series of children having
 multilevel orthopedic surgery (Lauer & White 2005)
      Allodynia, hyperalgesia, burning, shooting or stabbing pain, started 4-9
      days after surgery
Persistent Postsurgical Pain
 Incidence 10-50% in adults (Kehlet et al 2006)
 Common procedures:
    groin hernia repair, breast and thoracic surgery, leg amputation,
    coronary artery bypass surgery
 1-3 % of APS patients develop ANP (Hayes et al, 2002)
    56%incidence of persistent pain at 1 yr
 Post-operative pain in children remains a challenge
 Regular assessment is the cornerstone of effective
 Many pharmacological approaches are safe and effective,
using systemic and regional techniques although more
research is needed in areas
 Children with cognitive impairment are at risk
 Persistent pain after surgery may be an under recognized

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