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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.