postoperative pain management in pediatrics bfs speaker slides/postoperative pain...9/29/2016 1...
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POSTOPERATIVE PAIN MANAGEMENT IN PEDIATRICS
PRESENTED BY: JENIFER LICHTENFELS, M.D.
OBJECTIVES PHARMACISTS
Identify risk factors for narcotic induced respiratory depression in children with OSA
State the current recommendations for perioperative pain management in children with OSA
Compare benefits and side effects of narcotics and NSAIDS in general surgery and orthopedic surgery in children
Acknowledge the importance of and adopt a position of “Narcotic Stewardship”
TECHNICIANS Recognize two serious complications of adeno-tonsillectomy (AT) in children
Explain why the FDA issued a black box warning regarding the use of codeine in children after AT
Acknowledge the importance of “Narcotic Stewardship”
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GENERAL PRINCIPLES OF PAIN PREVENTION AND INTERVENTION
POSTOP ENT MANAGEMENT
POSTOP GENERAL SURG MANAGEMENT
POSTOP ORTHOPEDIC MANAGEMENT
THE WORSENING U.S. OPIOID EPIDEMIC
NARCOTIC STEWARDSHIP
RISK FACTORS ASSOCIATED WITH INCREASED POSTOPERATIVE PAIN
●PREOPERATIVE ANXIETY●AGE
●OBESITY●ETHNICITY AND RACE
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PHARMACOLOGICAL PSYCHOLOGICAL
PHYSICAL
THE 3 P’S OF PAIN PREVENTION AND INTERVENTION
PAIN ASSESSMENT AND MANAGEMENT OF A CHILD
PAIN ASSESSMENT—WHEN?ON ADMISSION AND ONCE A SHIFT
BEFORE/DURING/AFTER PAINFUL PROCEDURES OR SURGICAL INTERVENTIONSPAIN ASSESSMENT—HOW?
USE DEVELOPMENTALLY APPROPRIATE TESTPIPP FLACC PAIN WORD SCALE FACES NRS NCCPCNEONATES 2 M0-7YO 3-7YRS 5-12YRS >7YRS NONCOMMUNICATIVE
3-18YRS
IS PAINPRESENT?
MANAGEMENT AND INTERVENTIONSPHARMACOLOGICAL PHYSICAL PSYCHOLOGICAL• GIVE ANALGESICS REGULARLY HEAT &/OR COLD EXPLANATION TO CHILD AND PARENT• USE LEAST INVASIVE ROUTE MASSAGE DISTRACTION• FOLLOW WHO STEP TREATMENT PRESSURE RELAXATION
AMBULATE CHILD LIFE OR BEHAVIORAL HEALTH
REASSESS
YES
NO
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PHARMACOLOGICAL
ENTADENOTONSILLECTOMY
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OBSTRUCTIVE SLEEP APNEA
Adenotonsillectomy (AT) most common surgical treatment for obstructive sleep apnea (OSA) in childhood
OSA during childhood has a prevalence of 1-5%
First line medical treatment includes nasal steroids, leukotriene inhibitors, oral or topical decongestants
Many of these children end up with surgical intervention for persistently disturbed sleep, excessive daytime sleepiness, daytime neurobehavioral and mood disorders
530,000 AT’s for OSA in children annually
POSTOP COMPLICATIONS OF ADENOTONSILLECTOMY
MAJORRESPIRATORY COMPROMISE
HEMORRHAGE
MINORPAIN
NAUSEAVOMITING
DEHYDRATION
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RISK OF RESPIRATORY COMPROMISEOR HEMORRHAGE
AT FOR OSA AT EXTUBATION, 43.3% WITH O2
DESATURATION
IN PACU, 63.3% REQUIRED O2
5-FOLD INCREASED RISK OF RESPIRATORY COMPLICATIONS
AT FOR RECURRENT TONSILLITIS
AT EXTUBATION, 6.6% WITH O2 DESATURATION
IN PACU, 10% REQUIRED O2
2.5-FOLD INCREASED RISK OF HEMORRHAGE
CODEINE METABOLISM
In most individuals ~10% of an administered codeine dose is metabolized to the bioactive analgesic, morphine
The metabolism is controlled by the CYP2D6 enzyme pathway, The gene encoding CYP2D6 is highly polymorphic and shows a
gene-dose effect Poor metabolizers—Metabolize<10% codeine to morphine, 5-10%
patients Extensive metabolizers (EM)—Normal metabolism, 77-92% patients Ultra-rapid metabolizers (UM)---Multiple gene copies resulting in >>10%
conversion of codeine to morphine more quickly, and the risk of morphine overdose, 1-2% patients
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THE CODEINE CONUNDRUM
Commonly acetaminophen-codeine was used for post-op AT pain control
2009, case report of a toddler death post-AT who was found at postmortem to be an ultra-rapid metabolizer (UM) of codeine
May 2012, 3 additional deaths; 2-UM and 1-EM metabolizer FDA issued warning in August, 2012 warning of the rare but life
threatening respiratory compromise in OSA children following T+/-A treated with codeine or other analgesics that utilize CYP2D6
January 2013, FDA update reports 13 additional children with fatal or near fatal respiratory compromise with appropriate dosages of codeine; 8/13 were tonsillectomy patients
PRACTICE SHIFT FOLLOWING THE 2012 BLACK BOX WARNING
Increased use of morphine and oxycodone postoperatively
Reluctance to use NSAID’s because of concerns of an increased risk of bleeding
Intraoperative administration of acetaminophen and dexamethasone to pre-emptively treat pain and nausea
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MCMASTER UNIVERSITY, THE HOSPITAL FOR SICK CHILDREN, 2012-2014 STUDY COMPARED
IBUPROFEN AND MORPHINE POST-AT
Faces pain scale on post-op Days 1 & 5
Objective Pain Scale scores on post-op Days 1 & 5
# of days until back to normal diet
# of children with post-tonsillectomy bleeding events
Adverse drug reactions Sedation Constipation Nausea/Vomiting Dizziness/Confusion
Refusing fluids/Anorexia Agitation Night terrors Fever Diarrhea
MCMASTER UNIVERSITY, THE HOSPITAL FOR SICK CHILDREN, 2012-2014 STUDY
N=91 IBUPROFEN MORPHINE
Δ Lowest O2 saturation 3.96 (12.65) 2.38 (12.30) .64
Mean O2 saturation (% nadir)
Preoperative 97.41 (1.02) 97.20 (1.22)
Postoperative 96.55 (2.07) 95.00 (2.18)
Δ Mean O2 saturation 0.79 (2.33) 2.13 (1.42) .33
Total number of desaturation events/h
Preoperative 4.52 (7.87) 3.64 (3.71)
Postoperative 3.04 (3.27) 14.26 (11.85)
Δ Total desaturation events/h −1.79 (7.57)
+ 11.17 (15.02) <.01
Number of children improved 65% (17/26) 13% (4/30) <.01
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SECONDARY OUTCOMES
FACES PAIN SCALE DAY 1 & 5 0.29
OBJECTIVE PAIN SCALE DAY 1 & 5 0.95
# DAYS BACK TO PRE-OP DIET 0.89
# POST-OP BLEEDING EVENTS 0.67
# ADVERSE DRUG REACTIONS 0.16-0.51
P VALUE
CURRENT RECOMMENDATIONS FOR ANALGESIA FOR AT
INTRA-OPERATIVE 40MG/KG ACETAMINOPHEN RECTALLY OR 15MG/KG IV
DEXAMETHASONE 0.1-0.5MG/KG IV
ONDANSETRON 0.1MG/KG IV
SHORT ACTING OPIOID, FENTANYL 1MCG/KG IV
POST-OPERATIVE IBUPROFEN 10MG/KG Q6HR INITIALLY ROUTINE, THEN PRN
ACETAMINOPHEN 15MG/KG Q4HR PRN
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GENERAL SURGERY
CONSIDERATIONS
UNDERLYING SURGICAL PATHOLOGY RUPTURED APPENDIX WITH OPEN LAPAROTOMY VS. “LAP-APPY”
TAKE INTO ACCOUNT OTHER RISK FACTORS ANXIOUS, OBESE ADOLESCENT AFRICAN-AMERICAN FEMALE
DEVELOPMENTALLY DELAYED WITH POOR COMMUNICATION PARENTAL HELP IN REPORTING USUAL SIGNS AND EXPRESSION OF
PAIN
PREVIOUS HISTORY OF SURGERY WHAT WORKED WELL AND WHAT DID NOT
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ORTHOPEDIC PAIN
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MUSCULOSKELETAL TRAUMA
2007 STUDY FROM OTTOWA, CANADA RANDOMIZED CHILDREN AGED 6-17 Y.O. TO INITIAL ANALGESIA
WITH IBUPROFEN (10MG/KG), ACETAMINOPHEN (15MG/KG) OR CODEINE (1MG/KG)
PAIN SCALES (VAS) AT PRESENTATION, 30, 60, 90, 120 MIN. NO SIGNIFICANT PAIN IMPROVEMENT OR DIFFERENCE BETWEEN GROUPS AT 30 MIN.
AT 60 MIN ONLY THE IBUPROFEN GROUP HAD SIGNIFCANTLY, P <.001, BETTER PAIN CONTROL AND ACHIEVED ADEQUATE ANALGESIA, P <.001, COMPARED TO ACETAMINOPHEN OR CODEINE.
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UPPER AND LOWER EXTREMITY SURGERY
2015 GUIDELINES FROM THE AMERICAN PAIN SOCIETY, THE AMERICAN SOCIETY OF REGIONAL ANESTHESIA AND PAIN MEDICINE AND THE AMERICAN SOCIETY OF ANESTHESIOLOGISTS’ COMMITTEE ON REGIONAL ANETHESIA, EXECUTIVE COMMITTEE AND ADMINISTRATIVE COUNCIL
STRONGLY RECOMMEND CONSIDERATION OF SITE-SPECIFIC PERIPHERAL REGIONAL ANESTHESIA AS PART OF MUTIMODAL ANALGESIA PLAN
NSAID USE AS PART OF MUTIMODAL ORTHOPEDIC PAIN MANAGEMENT
SOME RELUCTANCE BECAUSE OF ANIMAL MODEL STUDIES SHOWING DELAYED BONE FUSION
OBSERVATIONAL EVIDENCE IN ADULTS, NO RCT, OF HIGH DOSE NSAIDS AND NONUNION IN SPINAL FUSION SURGERY
PEDIATRIC LITERATURE, RETROSPECTIVE REVIEWS, NO ASSOCIATION OF NSAIDS AND NONUNION IN SPINAL SURGERIES
CLEARLY NEEDED PROSPECTIVE RCT
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OUR NARCOTIC EPIDEMIC
WHAT IS THE COMMON DENOMINATOR?
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In 2014, the five states with the highest rates of death due to drug overdose were West Virginia, New Mexico, New Hampshire, Kentucky and Ohio.
ALTERNATIVESOPTIONS FOR TREATING PAIN DUE TO BACK PAIN, MIGRAINES, SURGICAL PAIN
NSAIDS +/- ACETAMINOPHENPHYSICAL THERAPYACUPUNCTURECHIROPRACTIC CARECOGNITIVE BEHAVIOR THERAPY
IMPEDIMENTSINSURANCE NON-COVERAGE, HIGH CO-PAY FOR ALTERNATIVE TREATMENTSRELATIVE LOW COST OF NARCOTIC RXPATIENT DEMANDS FOR RX
STRATEGIESOPIOID RX’S LOW DOSES AND FOR LIMITED PERIOD OF TIMECLOSE ATTENTION TO STATE MONITORING PROGRAMSSTEER ABUSING/ADDICTED PATIENTS TO TREATMENT PROGRAMS
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TURN THE TIDE
SURGEON GENERAL’S, DR. VIVEK MURTHY, CAMPAIGN FIGHTING THE OPIOID EPEDEMIC
SAFE AND EFFECTIVE MANAGEMENT OF PAIN
http://turnthetiderx.org/
REFERENCES Raiz A, Malik HS, Fazal N, Saeed M, Naeem S,. Anaethetic risks in children with
obstructive sleep apnea syndrome undergoing adenotonsillectomy. J Coll Physicians Surg Pak. 2009:19(2):73-76.
Nixon Gm, Kermack As, Mcgregor Cd, et al. Sleep and breathing on the first night after adenotonsillectomy for obstructive sleep apnea. Pediatr Pulmonol. 2005; 39(4): 332-338.
Graziela De Luca Canto, Camila Pachêco-Pereira, Secil Aydinoz, Rakesh Bhattacharjee, Hui-Leng Tan, Leila Kheirandish-Gozal, Carlos Flores-Mir,David Gozal. Adenotonsillectomy Complications: A Meta-analysis.Pediatrics, Oct 2015, 136 (4) 702-718
Lewis SR1, Nicholson A, Cardwell ME, Siviter G, Smith AF. Nonsteroidal anti-inflammatory drugs and perioperative bleeding in paediatric tonsillectomy. Cochrane Database SystRev. 2013 Jul 18;(7):CD003591. doi: 10.1002/14651858.CD003591.pub3.
Lauren E. Kelly, Doron D. Sommer, Jayant Ramakrishna, Stephanie Hoffbauer, Sadaf Arbab-tafti, Diane Reid, Jonathan Maclean, Gideon Koren. Morphine or Ibuprofen for Post-Tonsillectomy Analgesia: A Randomized Trial, Published Online (date) January 26, 2015doi: 10.1542/peds.2014-1906.
Eric Clark, Amy C. Plint, Rhonda Correll, Isabelle Gaboury, Brett Passi. A Randomized, Controlled Trial of Acetaminophen, Ibuprofen, and Codeine for Acute Pain Relief in Children With Musculoskeletal Trauma, Pediatrics, Mar 2007, 119 (3) 460-467.
Practice guidelines for acute pain management in the perioperative setting; An updated report by the America Society of Anesthesiologists Task Force on Acute Pain Management. Anesthesiology 2012; 116: 218-73.
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REFERENCESManagement of Postoperative Pain: Guideline From The American Pain Society, The American Society Of Regional Anesthesia And Pain Medicine And The American Society Of Anesthesiologists’ Committee On Regional Anethesia, Executive Committee And Administrative Council. The Journal of Pain 2016; 17(2): 131-157.
Garetz, Susan, Adenotonsillectomy for obstructive sleep apnea. 2015, Up To Date.
FDA Drug Safety Communication: Codeine use in certain children after tonsillectomy and/or adenoidectomy may lead to rare, but life-threatening adverse events or death. 08/15/2012FDA Drug Safety Communication: Safety review update of codeine use in children; new Boxed Warning and Contraindication on use after tonsillectomy and/or adenoidectomy. 02/20/2013.Fiona Campbell. Improving postoperative pain outcomes for children. International Forum on Pediatric Pain, ?2014.Increases in Drug and Opioid Overdose Deaths—United States, 2000-2014. MMWR, 01/01/2016: 64(50): 1378-82.Doctors will Play a Critical Role in the Opioid Epidemic. NYT, Editorial Board; 08/30/2016.