Peri-operative pain
                                                                                                  You ...
Pain management                                   Individualize the care
   Multidisciplinary team approach:
        •   M...
Can Surgeons be trained to run PCA?                                  The safety and efficacy of parent-/nurse-
           ...
Non-opioid Analgesics                                                       Non-opioid iv analgesics
  Codeine:           ...
Epidural Analgesia                                                       Regional Anaesthesia
         Caveats/side effect...
Life-threatening Arrhythmias                                                          Intralipid for LA Toxicity
      Int...
Caudal Catheter Tunneling                                                                            PCEA in Children
    ...
Epidural Fentanyl                                                                Epidural Morphine
                       ...
S(+)-Ketamine                                                Caudal Neostigmine
 Its role in caudal analgesia?            ...
On Q -- L.A. for surgeons           Nerve blocks or SubQ?
                                    Two studies, 13 years apart:...
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Per-operative Pain Managment in Children

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Transcript of "Per-operative Pain Managment in Children"

  1. 1. Peri-operative pain You think I don't management feel pain? Well, this isn't my "happy in children to see you" face!!!! Jerrold Lerman BASc, MD, FRCPC, FANZCA Clinical Professor of Anesthesiology Women’s & Children’s Hospital of Buffalo, SUNY, Strong Memorial Hospital, University of Rochester, New York Pain management Albert Schweitzer wrote: “We all must die. But that I can save him from days of torture, that is what I feel as my great and ever new privilege. Pain is a more terrible lord of mankind than even death itself.” On the edge of the Primeval Forest, New York, Macmillan, 1931, p 62 Pain Framework Pain management Parents’ management of children’s pain following ‘minor’ surgery “Even when parents recognise that their children are in pain, most give inadequate doses of medication to control the pain.” Finley GA, et al Pain 64:83, 1996 1
  2. 2. Pain management Individualize the care Multidisciplinary team approach: • MD (anesthesiology, surgery) • RN (pain team, PACU, ICU, ward) • Pharmacist • Resident-trainees • Pediatrician • ….and the parents/caregiver Pain Management Pain management Preoperative strategies: When: • Preop assessment: • All perioperative pain • Patient history, medications, preferences • For what duration postop? • Pre-existing diseases/disorders • Hours ⇒ days? • Parents/caregiver knows the child best • Where? • Pain threshold? MMC have sensory level • Ward • Modalities available… • PICU • Education • NICU • Surgical requirements PCA Dosing Regimen PCA Dosing Regimen PCA dosing: Optimal regimen: • For morphine: • Background infusion permits 50% of the • PCA bolus: 10-30 µg/kg bolus dose compared with no bckgrd, • Continuous rate: 10-40 µg/kg same end-points Yildiz K, et al • Lockout interval: 6-10 minutes Ped Anesth 2003:13;427 • 4 hour limit: 0.25-0.40 mg/kg • Alternatives include dilaudid (hydromorphone) • For weaning… (and demerol) • First ensure tolerating po fluids • d/c the background infusion • Determine total daily morphine consumption as oral analgesic dose 2
  3. 3. Can Surgeons be trained to run PCA? The safety and efficacy of parent-/nurse- controlled analgesia in patients less than six years of age Monitto CL, et al Anesth Analg 91:573, 2000 • Retrospective 1 year review of 212 children, 240 PNCA uses • 2.3 ± 1.7 yr • Median 4 days used • > 80% had OPS ≤ 3/10 PNCA Outcomes Non-opioid Analgesics Parent/nurse controlled analgesia (PNCA): Analgesics: • Complications • Acetaminophen • 8% incidence of pruritus • Codeine, Tramadol • 15% vomiting on POD 1 • NSAIDs: • 1.7% PNCA-related apnea or desaturation • Ketorolac, Ibuprofen, Diclofenac • Improved with naloxone • COX-2: no longer used • ASA: no longer used Monitto CL, et al Anesth Analg 2000:91;573 Non-opioid iv analgesics Non-opioid Analgesics Propacetamol: Codeine: • 30 mg/kg Pro (15 mg/kg para) q6h iv • Liquid: acetam + codeine 120/12 mg - 5 ml • Clearance is reduced in 27 wk PCA, • Tablets: matures to 84% by 1 year • Tylenol #2: Acetam 325 mg + 15 mg codeine • Effective analgesic blood levels of 10 • Tylenol #3: Acetam 325 mg + 30 mg codeine mg/L para achieved in 2-15 year olds • Tylenol #4: Acetam 325 mg + 60 mg codeine • Effective analgesic for mild/mod. pain • Oxycodone: 0.1-0.15 mg/kg q4-6h Anderson BJ, et al Ped Anesth 2005:15;282 3
  4. 4. Non-opioid Analgesics Non-opioid iv analgesics Codeine: Ketorolac: • Common and safe • Dosing: 0.5-1 mg/kg q6h • Effective analgesic by metabolism to • Advantages: morphine in vivo • Equivalent analgesia • Polymorphisms in > 10% of children! • Opioid sparing, ⇓ PONV, bladder spasm • Deficient in CYP 450 2D6 for conversion • ⇓ respiratory depression • Wild polymorphism: ultra-rapid metabolizer • Ciszkowski, et al. NEJM 2009:361;827. • Disadvantages; • Side effects: respiratory depression, • Risk of bleeding?, bone-healing, constipation in CP children bronchospasm, acute renal insufficiency Who volunteers for a regional block? Non-opioid iv analgesics Tramadol: • Synthetic codeine analogue, uncontrolled • Mechanism of action is µ-receptor and inhibition of neurotransmitter reuptake • Dosing: 1-2 mg/kg iv • Advantages: lack of sedation, min. respiratory depression • Disadvantage: PONV…5HT3 mediated (partic. after oral dose) (5HT3 anti-emetics reduce analgesic efficacy…at spinal receptors?) Are Cont. Epidurals Dead? Are Cont Epidurals Dead? The facts: Problems with epidurals: • 17-23% of epidurals terminated prematurely • Catheter tip has to be in epidural space • 67% incidence of side Fx/complications • Catheter tip needs to be near surgery • 6% had back pain post (in 1 study) • Block may be unilateral or patchy • Open tip or multi-orificed • Is there evidence that continuous epidurals • Change LA/add adjuvants if poorly functioning provide BETTER outcomes than other forms of analgesia? • Side effects: • PONV, motor blockade, pruritus, urinary retention, poor success • Is there evidence of superior alternatives? rate, add clonidine but creates problems, epidural hematoma/abscess, respiratory distress, air embolism, PDPH, nerve trauma Chalkiadis G, Chalkiadis G, Paed Anaesth 2003:13;91 Paed Anaesth 13:91, 2003 4
  5. 5. Epidural Analgesia Regional Anaesthesia Caveats/side effects: Complication rate in 24,000 blocks: • Avoid neuroaxial blocks with ⇑ ICP? • caudal 0.7/1000 • Infection, headache • sacral caudal 6.8/1000 • Toxic responses: • lumbar epidural 3.7/1000 • L.A. lower seizure thresholds by 50% • thoracic epidural 0/1000 • Repeat pain evaluations • spinal 2/1000 • Pressure sores • Compartment syndrome • peripheral blocks 0/1000 Giaufre, et al. Anesth Analg 83:904, 1996 Regional Anaesthesia Caudal Blocks Incidence of critical events is low, but the complications may be devastating: • anaesthetic overdose • respiratory depression • neuropraxia • paralysis • infection • cardiac arrest and death • Dermal puncture with 18 ga needle • Passive backflow • Use BD angiocath® (stiff catheter) • ECG is OBSERVED • Advance catheter 2 mm • Whole volume is a test dose Ambulatory Surgery Single Shot Caudal Block What volume should we use? Caudal/epidural blocks: • 54 children, 1-6 years, inguinal hernia • optimal concentration for single-shot is: • 0.175% bupivacaine with epi BUPIVACAINE 0.175%, 1.0 ml/kg (max. 20 ml) • 0.25% bupi x 7 ml plus NaCl x 3 ml = 10 ml (or 20 ml) • Bupi volume: 0.7, 1.0 and 1.3 ml/kg • maximum analgesia, minimal motor block, no • NO difference in time to first analgesia, urinary retention ambulation or discharge Gunter et al, Anesthesiology 75:57, 1991 Schrock CR, et al Paed Anaesth 2003:13;403 5
  6. 6. Life-threatening Arrhythmias Intralipid for LA Toxicity Intravascular and intraosseous injections Peaked T waves ± ST segment elevation Intralipid 1 ml/kg, repeat x 3 www.lipidrescue.org Badgwell JM, et al May 7, 2007 Epidural Catheters Continuous Epidurals Successful placement of tip for remote To prevent excessive bupivacaine surgery: concentrations in neuroaxial infusions: • Preferrable to use a stiff/larger catheter • same loading dose as ambulatory • 17 or 19 ga rather than 22 ga • begin caudal/epidural infusions immediately • Use caudal rather than epidural route after the loading dose at: • Place catheter at level block required • neonates: 0.2 -0.25 mg/kg/h 0.2 ml/kg/h of 0.1-0.125% bupivacaine • Tsui technique • infants: 0.2-0.4 mg/kg/h 0.3 ml/kg/h of 0.1-0.125% • Epidurogram • children: 0.4-0.5 mg/kg/h bupivacaine • Use morphine instead of more soluble agents Berde C. Anesth Analg 1996:83;897 Epidural Bupivacaine in Neonates Caudal Catheters Colonization Rate 30 (10/34) Bupivacaine 0.2 mg/kg/h 20 (%) (36/343) 10 (3/32) 0 Untunneled Tunneled Lumbar Larsson BA, et al Caudal Bubeck J, et al Epidural Anesth Analg 99:689;2004 Anesth Analg 1997:84;501 6
  7. 7. Caudal Catheter Tunneling PCEA in Children Two studies: • 128 children, ≥ 5 years: ortho, pectus, renal, laparotomy, thoracotomy, etc • Bupi 0.1% with Fentanyl 5 µg/ml, • Continuous < 0.2 ml/kg/h • Demand 1-3 ml • Lockout 15-30 min • Max: < 0.4 mg/kg/h Bubeck, J, et al Birmingham et al Anesth Analg 2004:99;689 Anesth Analg 2003:96;686 PCEA in Children Stereoisomers PCEA vs CEA: Racemic mixture: • 48 children, 7-12 years, postop pain, lumbar epidural • equal concentrations of each stereoisomer • Ropi 0.2% @ 10 ml • PCEA: Chiral Compound: • Ropi 0.2% @ 2 ml boluses • “handedness” non-superimposable, mirror images • Lockout 10 min • Infusion 1.6 ml/h Stereoisomers: • Max 13.6 ml/h • same compounds but different 3-D configuration • CEA: • Ropi 0.2% @ 0.4 mg/kg/h • eutomer is the more potent isomer, • distomer less potent; • Results: PCEA 0.2 ± 0.08 mg/kg/h • eudismic ratio is the ratio of their potencies (P < 0.001) CEA 0.4 ± 0.08 mg/kg/h Antok, et al Anesth Analg 2003:97;1608 Relative Cardiac Severity Relative Cardiac Severity 15 Caudal Solution Additives Table 1 Drugs added to local anaesthetic solutions in paediatric caudal anaesthesia, frequency of usage and doses used 95% confidence Drug added to local Frequency of use by intervals for 10 anaesthetic 210 respondents (%) percentage Dose range (mode) Epinephrine 24 (11) 7.5, 16.5 1: 200,000 -1 -1 Fentanyl 44 (21) 15.7, 27.1 0.5–4.0 µg ml (2.0 µg ml ) -1 -1 Diamorphine 27 (13) 8.7, 18.2 20–50 µg ml (20 µg ml ) -1 -1 Clonidine 55 (26) 20.4, 32.7 0.5–2.5 µg ml (2.0 µg ml ) -1 -1 Ketamine 67 (32) 25.7, 38.7 0.25–1.00 mg ml (0.50 mg ml ) Bicarbonate 7 (3) 1.4, 6.8 Not specified -1 -1 5 Morphine 4 (2) 0.5, 4.8 50–100 µg ml (50 µg ml ) -1 Midazolam 1 (0.5) 0, 2.6 0.5 µg ml Br. J. Anaesth. 2002; 89:707-710 Journal Content Copyright © 1991-Present, ASA, IARS, BJA, CAS. All Rights Reserved. Reproduction of said Sanders JC material, without prior permission from the Proprietor holding the copyright to the material, is illegal. BJA 2002:89;707 0 Bupivacaine Ropivacaine Lidocaine Reiz & Nath Reiz & Nath Acta Anaesth Scand 33:93-8, 1989 Acta Anaesth Scand 1989:33;93-8 7
  8. 8. Epidural Fentanyl Epidural Morphine Pharmacology: Is there a role in children? • single epidural doses of 33 - 100 µg/kg last 10-13 h • Limited evidence in children (and 3-5 µg/kg/h titrated to effect…analgesia, sedation) • At Fentanyl 1 µg/ml alone at 0.3 ml/kg/h confers • incidence of PONV, pruritus ranges from 20-40% > 90% analgesia • urinary retention has not been evaluated • Strong evidence of side effects, particularly with • 9% of 136 children with duramorph required escalating doses naloxone: • Pruritus • Urinary retention • 10 of the 11 children were < 1 yr • 6 of 10 had also received parenteral opioids Lerman, et al • Postoperative monitoring!!!!!!! Anesthesiology 2003:99;1166 Nonopioid Additives Clonidine for Caudal Analgesia Systematic Review: • RCTs, < 18 years, up to 2002 • 17 of 107 studies were accepted • 12 clonidine, 4 ketamine, 2 both, 2 midazolam and 1 adrenaline • Clonidine (n = 12) • Dose range: 1-5 µg/kg • Dose-dependent increase in duration of analgesia • Dose-dependent increase in degree of sedation • No respiratory depression Ansermino M, et al Ansermino M, et al Paed Anaesth 2003:13;561 Paed Anaesth 2003:13;561 Clonidine Non-opioid Additives Systematic Review: Economics: • Ketamine (n=5): • Roxane Pharmaceuticals -- Duraclon • 0.25-0.5 mg/kg increased duration of analgesia • Avg increase in analgesia: 7h • Single dose, no preservatives • No increase in sedation or emesis • 100 µg/ml x 10 ml -- $23.62 • 1 mg/kg ketamine, sole agent, behavioral changes • At 1 µg/kg, the cost of clonidine is 2.36 CENTS/kg! • Midazolam (n=2): • Entire ampoule use…avg $1.00/kg • 50 µg/kg adjunct to bupivacaine • Increased duration of analgesia 3.5h • NOT indicated for acute pain…only chronic • No sedation evident • Toxicology shows no evidence of neurotoxicity • Adrenaline (n=1): • Effect depends on site of surgery and age of child • Useful to detect intravascular injection Ansermino M, et al Paed Anaesth 2003:13;561 8
  9. 9. S(+)-Ketamine Caudal Neostigmine Its role in caudal analgesia? POV • Preservative free 25% • Twice the analgesic potency of the racemate • Fewer psychomotor disturbances • Less salivation • More rapid recovery • 30 children, 0.125% bupi ± 0.5 mg/kg S-ketamine 10% 30% Weber F, Wulf H, Abdulatif et al Paed Anaesth 2003:13;244 Anesth & Analg 2002:95;1215 Nonopioid Additives Regional Anaesthesia Cautionary notes: In children: • Ketamine, midazolam and clonidine are NOT licensed for acute epidural pain management • Safe techniques • Clonidine is marketed for epidural • Levo enantiomers preferrable (preservative-free) use…chronic pain • Levobupivacaine, ropivacaine • Clonidine shows no evidence of neurotoxicity • Adjunct agents: • Inadvertent intrathecal injection of ketamine or • Epinephrine midazolam may lead to neurologic event • Clonidine • ?Fentanyl • Lidocaine 5% was safe -- then 5 cases of cauda • Morphine equina syndrome (Acta Scand Anaesth 1999) • ??Ketamine, neostigmine, midazolam Nerve Blocks Pain management Monitoring epidurals on the ward: • 53 peds institutions responded • 50% were < 200 beds, 50% > 200 beds • 92% routinely use continuous monitors • 37.5% use oximetry only • 30% use oximetry and apnea • 7.5% use apnea only • 7.5% use NO MONITORS Brislin RP, Rose JB. Brenn et al. Anesth Cl N Am 2005:23;789 Anesthesiology 1995:83:432 9
  10. 10. On Q -- L.A. for surgeons Nerve blocks or SubQ? Two studies, 13 years apart: • Casey WF, et al. Anesthesiology 1990:72;637. A comparison of bupivacaine instillation versus II/IH nerve block for postoperative analgesia following inguinal herniorrhaphy in children. • Machotta A, et al. Paed Anaesth 2003:13;397. Qualities: Comparison between instillation of bupivacaine • Easy, safe and portable versus caudal analgesia for postoperative analgesia • Analgesia for DAYS! following inguinal herniotomy in children. • Direct local effect • Few side effects: systemic? • Dose limited No Difference! Okay Doc, now give me your best pain control or I’ll let my parents loose on you! 10

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