Persistent postsurgical pain in children
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A presentation by Ulla Caverius at the 2017 meeting of the Scandinavian Society of Anaestesiology and Intensive Care Medicine. All available content from SSAI2017: https://scanfoam.org/ssai2017/ Delivered in collaboration between scanFOAM, SSAI & SFAI.
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Persistent postsurgical pain in children
- 1. Persitent Postoperative Pain in children ULLA CAVERIUS, MD
- 2. I have no conflict of interest to declare!
- 3. Persistent Pain “They thought I was a Surrealist, but I wasn't. I never painted dreams. I painted my own reality.” - Frida Kahlo
- 4. Persistent pain and QOL worry pain friends activity sleep school family thoughts fear depression anxiety
- 5. Is PPP in children common? • Adults: 10 – 50 % after common surgery. Severe PPP in 2 – 10 % Kehlet et al. Lancet. 2006 • Children: 22 % after major surgery. Severe PPP in 13 % (NRS >7) Pagé et al. J Pain Res. 2013
- 6. Riskfaktors for PPP in adults • Moderate/severe postperative pain • Nerve injury • Duration of operation • Persistent pain preop • Repeated surgery • Moderate/severe acute postop pain • Female • Psychological distress eg. catastrophizing, preop anxiety • Social/environmental • … Kehlet et al, Lancet 2006 Macrae, BJA 2008 Tawik et al, J Anaesth 2017 Economic burden Major health issue
- 7. Risk- and maintenance factors of PPP in children Pagé G, Stinson J, Campbell F, Isaak L, Katz J Pagé G, Stinson J, Campbell F, Isaak L, Katz J. J Pain Res. 2013 • Pain and pain unpleasantness 2 w’s postop predict transition from acute to persistent postoperative pain. • Anxiety sensitivity predicts maintenance of moderate to severe PPP • Parental catastrophizing at the time for surgery risk factor for PPP
- 8. Acute pain can transform into persistent pain Biopsychosocial model: Katz & Seltzer, Expert Rev Neurother. 2009 Gatchel et al, Am Psych 2014 Vlayen & Linton, Pain. 2000 PAIN
- 9. Pre-disposing factors Trigger Buffer Motor/catalyzing factors Maintaining factors Why do some develop persistent pain? Linton, Att förstå patienter med smärta. 2013
- 10. Pre-disposing factors Trigger Buffer Motor/catalyzing factors Maintaining factors • Anxiety • Severe APP • Parental catastrophizing • Sensitization Acute Persistent Postoperative Pain. • Surgery• Expectations • Anxiety • Fear • Catastrophizing • Persistent pain • Repeated operations • Avoidance • Emotional, psychological, social factors • Sleep problem • Parents’ distress • The child’s coping skills • The parent’s coping skills • Acceptance
- 11. Prevention of PPP in children ??? • Increase awareness of PPP. Educate medical professionals? • Indication for surgery? • Identify patients at risk preop? Prepare and support • Set realistic expectations and decrease worry and anxiety. Preop information and support to child and parents? • Adequate perioperative pain relief in hospital + at home? • Guidelines and good routines for pain management? • Follow up on risk patients?
- 12. Conclusion • Persistent pain often have impact on QOL and function. • Persistent postoperative pain (PPP) is common. • PPP is complex. • Parents coping behavior have great influnce on the child’s coping. • Prevention possible?
- 13. Regards from team BUSE
- 14. Persistent Postoprative Pain - PPP High impact on QOL and physical, social and psychological function is common in patients suffering from persistent pain.
- 15. Persistent Postoperative Pain – a complex problem • A common problem. • Look at persistent postoperative pain from a bio-psycho-social view. • Psychological factors are shown to influence the risk of and the maintenance of persistent pain in children. • Parents coping behaviors are important for the child’s coping. • High pain scores postop is a riskfactor • Multimodal approach to persistent postoperative pain. • Prevent.
- 16. Prevent PPP? • Educate medical staff about persistent postoperative pain? • Identify patients/family at risk? • Decrease the risk of worry, fear, anxiety, catastrophizing through infomation? • Prevent severe postoperative pain. Adequate pain relief and routines? • Follow up on patients at risk?
- 17. Pre-disposing factors Trigger Buffer Motor/catalyzing factors Maintaining factors • Worry and fear • High APOP and pain- unpleasentness • Parental catastrophizing Can we predict and prevent PPP in children? • Surgery• Expectations • Anxiety • Fear • Catastrofizing • Illness beliefs • Avoidance behavior • Emotional distress • Psychological distress • The child’s coping skills • The parents’ coping skills • The professionals support • Acceptance •Identify anxiety, worry and fear – child and parents •Inform and prepare •Identify ongoing preoperative pain (sensitization?) •Surgery necessary? •Preemtive analgesia?Blocs? •Prevent hyperalgesia – ketamin, gabapentin, clonidine? •Educate professional and the public about PPP •Adequate pain relief in- hospital and at home •Routines and guidelines •Help the child to good coping •Help the parents to coach and support the child •Multidimensional approach – psychological, physical and pharmacological •LiAPOP/PPP is not equal to failed surgery •Follow-up on patients at risk: •Still in pain? •Impact on QOL and physical, psychological and social well-being? School abscense? •Parents worrying •Need for referal to pain clinic?
- 18. Suggested Definition of PPP PPP in adults: • Develops after or increases in intensity after surgery. • The pain should be of at least 3 – 6 months’ duration and significantly affect the HR- QOL. • The pain is either a continuation of acute post-surgery pain or develops after an asymptomatic period. • The pain is either localized to the surgical field, projected to the innervation territory of a nerve situated in the surgical field or referred to a dermatome (after surgery in deep somatic or visceral tissues). • Other auses of pain should be excluded, e.g. infection or continuing malignancy in cancer surgery. PPP in children: ???
- 19. Picture: Pediatric Pain Service, Lund
Editor's Notes
- Look at these colourful self-portraits of Frida Kahlo. Frida was in a bus accident during her teens and was badly hurt in both her pelvis and back, and suffered all her life from excruciating pain and numerus operations. She died in 1954 after days of severe pain and fever, officially from pulmonary embolism, but is believed to have taken her own life with an overdose of opioids 47 y’s old. A drastic way to handle persiting pain, which is often complex and hard for the patient and the professionals to handle.
- Well, the patients I meet in my daily practice don’t usually show up this colourful and dramatic picture. Rather a grey, with suffering not only from the pain – but the consequences of years of pain and avoidance behavior., which put them and their parents into a negative spiral of anxiety, sleep disturbances, depression, school abscence, isolation, lack of visions for the future etc. etc. They live in a context usually not only affecting them but the whole family and absolutely the the parents. It’s known from research that parents are (and I think all parents in here know) very much affected by their child’s suffering from longlasting conditions and hospitalisation. They/we often feel guilty, grief with our children, and studies report anxiety, fear, lack of control and distress in us parents when our children suffer longstanding or recurrent or persistent or chronic pain (whatever you choose to call it). PPP is just one of the kinds. (1. Meshkani ZS, Bavarian B. Parents’ fear and distress during child inpatient care. Acta Med Iran. 2005;43(5):355–358. 2. Kain ZN, Mayes LC, O’Connor TZ, Cicchetti DV. Preoperative anxiety in children. Predictors and outcomes. Arch Pediatr Adolesc Med. 1996;150(12):1238–1245. 3. LaMontagne LL, Hepworth JT, Salisbury MH. Anxiety and postoperative pain in children who undergo major orthopaedic surgery. Appl Nurs Res. 2001;14(3):119–124.) Wouldn’t we like to prevent this situation if possible??? At least that’s what I and my team would like, even if it would make us useless. But to be honest – I liked my earlier career as a paed. anaesthetist and intensivist much too and could happily continue with that. Actually – may be it was there I had the biggest possibilities to help out with the prevention of persistent pain, with the endless numbers of patients undergoing minor and major surgical procedures?Where I met loads of worried parents who did their best from the given circumstances. I too made the best I could from my circumstances and knowledge, but I’m not sure I always handled the situation the way I preach. Especially not informing them ahead of surgery that pain is NOT equal to failed surgery, but a normal consequence of tissue damage which we (the staff) will do our best to handle. The pain will gradually disappear, but it might take some time and is normal. This will probably help set the stage for realistic expectations for both the child and the parents. (Ref: Macrae, BJA 2008)
- PPP common in children– yes or no? Have you seen any kids with persistent postoperative pain? Or maybe you don’t see them after they leave the operating theater ever again? 10 – 50 % amputation, mastectomy, hernias, thoracic surgery etc. (10 – 50 % in retrospective studies)
- Macrae: CPSP: 10 years on. Adults: Major public health issue! Large number of patients (394 000 – 1,5 milj in USA for op most known for PPP) Important economic consequences direct and indirect Sign effect on QOL Often neuropathic (at least partly) – hard to treat. PREVENT!!! R.F.: Surgery. Question indication for surgery – eg. cosmetic. Nerve injury and type of surgery Severe APOP. Prevent and treat properly Long operations Already sensitized. Eg. FM Gender reviews of adult CPSP have identi ed different categories of risk factors, including patient-related (eg, previous or concurrent pain experience, acute postsurgical pain [APSP] intensity, younger age, female sex, analgesic consumption during the rst week after surgery11–13), social/environmental (eg, social support8), and psychological (eg, anxiety, pain catastrophizing, surgery-related fears, psychological vulner- abilities, emotional numbing).11,12,14–16 Repeated operations Psychological factors – risk or maintaining factors? Pagé: Children: Pain and Parents’ coping influencethe child’s experience and coping. Parents catastrophizing increase the risk for PPP – the longer time from operation the higher risk. As in adults – moderate/severe pain/painunplaesantness a risk factor for PPP. (No obvious correlation to nerve injury of surgery) Anxiety sensitivity in the child negative interpretation of pain related to sensation relates to fear of pain and avoidance behavior -> maintenance of chronic pain. Parental catastrophizing at the time surgery increase the risk for PPP at 6 and 12 m’s post surgery.
- We need to look at persistent pain from a biopsychosocial view. Physiological changes, like sensitization, is triggered not only by the duration of pain and intensity, but fueld by psychological, social and physical factors like avoidence behavior from fear and anxiety. We use this picture when we explain chronic pain for children. It all interferes in biopsychosocial soup. Katz Seltzer: The transition is complex and poorly understood developmental process involving biological, psychological and environmental factors. A biopsychosocial model. Johan W.S. Vlaeyen, Steven J. Linton: Fear-avoidance and its consequences in chronic musculoskeletal pain: a state of the art. Pain 85 (2000) 317-332. Review article Fig. 2. The ‘fear’-avoidance model. If pain, possibly caused by an injury, is interpreted as threatening (pain catastrophizing), pain-related fear evolves. This leads to avoidance behaviors, and hypervigilance to bodily sensations followed by disability, disuse and depression. The latter will maintain the pain experiences thereby fueling the vicious circle of increasing fear and avoidance. In non-catastrophizing patients, no pain-related fear and rapid confrontation with daily activities is likely to occur, leading to fast recovery. Pain catastrophizing is assumed to be also influenced by negative affectivity and threatening illness information. Pain-catastrophizing fuels the transformation to chronic or persistent pain.
- Steven Linton made a beautiful model to explain the transformation from acute to persistent pain.
- My team at the Pain Rehabilitation at SUS – paediatric pain clinic for persitent pain (BUSE). Work with children 0 – 18 and their families/parents. Work with the consequences of PP – and rehabilitation to valued life and increased QOL and function.
- The speaker’s own interpretation of litterature Linton, Macrae and Medical Product Agency´s recommendations: - Macreae, BJA 2008 - Medical Products Agency (Läkemedelsverket), Recommendations for pharmacological treatment of chronic pain. PPP in children and youths.2017
- Earlier definition left open for many interpretations and a variety of different study designs and inclusion criterias, which made it hard to compare results and numbers. Wether or not you demand affect on QOL and function will also influnce the results and numbers. In children: There are few well powered studies and only a few, I’ve found one, longitudinal, prospective study. There is not any definition agreed on but > 2 or > 3 – 6 m’s duration are usually used. Impact on QOL not always looked at.
- We need to look at persistent pain from a biopsychosocial view. Physiological changes, like sensitization, is triggered not only by the duration of pain and intensity, but fueld by psychological, social and physical factors like avoidence behavior from fear and anxiety. We use this picture when we explain chronic pain for children. It all interferes in biopsychosocial soup. Katz Seltzer: The transition is complex and poorly understood developmental process involving biological, psychological and environmental factors. A biopsychosocial model. Johan W.S. Vlaeyen, Steven J. Linton: Fear-avoidance and its consequences in chronic musculoskeletal pain: a state of the art. Pain 85 (2000) 317-332. Review article Fig. 2. The ‘fear’-avoidance model. If pain, possibly caused by an injury, is interpreted as threatening (pain catastrophizing), pain-related fear evolves. This leads to avoidance behaviors, and hypervigilance to bodily sensations followed by disability, disuse and depression. The latter will maintain the pain experiences thereby fueling the vicious circle of increasing fear and avoidance. In non-catastrophizing patients, no pain-related fear and rapid confrontation with daily activities is likely to occur, leading to fast recovery. Pain catastrophizing is assumed to be also influenced by negative affectivity and threatening illness information. Pain-catastrophizing fuels the transformation to chronic or persistent pain.