9/29/2016 OBJECTIVES PHARMACISTS Identify risk factors for - - PDF document

9/29/2016 1 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

• rthopedic 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”  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

PHARMACOLOGICAL PSYCHOLOGICAL PHYSICAL T HE 3 P’S O F PA IN PREVENT IO N A ND INT ERVENT IO N PAIN ASSESSMENT AND MANAGEMENT OF A CHILD

PAIN ASSESSMENT—W HEN? ON ADMISSION AND ONCE A SHIFT BEFORE/DURING/AFTER PAINFUL PROCEDURES OR SURGICAL INTERVENTIONS PAIN ASSESSMENT—HO W ? USE DEVELOPMENTALLY APPROPRIATE TEST PIPP FLACC PAIN WORD SCALE FACES NRS NCCPC

NEONATES 2 M0-7YO 3-7YRS 5-12YRS >7YRS NONCOMMUNICATIVE 3-18YRS IS PAIN PRESENT?

MANAGEMENT AND INT

ERVENT IO NS

PHARMACOLOGICAL 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

9/29/2016 2

PHARMACOLOGICAL

ENT ADENOTONSILLECTOMY

OBSTRUCTIVE SLEEP APNEA

 Adenotonsillectomy (AT) most common surgical treatment for

• bstructive 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

MAJOR

RESPIRATORY COMPROMISE HEMORRHAGE

MINOR

PAIN NAUSEA VOMITING DEHYDRATION

RISK OF RESPIRATORY COMPROMISE OR 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

9/29/2016 3

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

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

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

9/29/2016 4 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

ORTHOPEDIC PAIN

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 O NL

Y THE IBUPROFEN GROUP HAD SIGNIFCANTLY, P

<.001, BETTER PAIN CONTROL AND ACHIEVED ADEQUATE ANALGESIA, P <.001, COMPARED TO ACETAMINOPHEN OR CODEINE.

9/29/2016 5

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

OUR NARCOTIC EPIDEMIC

WHAT IS THE COMMON DENOMINATOR?

In 2014, the five states with the highest rates of death due to drug

• verdose were West Virginia, New Mexico, New Hampshire,

Kentucky and Ohio. ALTERNATIVES OPTIONS FOR TREATING PAIN DUE TO BACK PAIN, MIGRAINES, SURGICAL PAIN NSAIDS +/- ACETAMINOPHEN PHYSICAL THERAPY ACUPUNCTURE CHIROPRACTIC CARE COGNITIVE BEHAVIOR THERAPY IMPEDIMENTS INSURANCE NON-COVERAGE, HIGH CO- PAY FOR ALTERNATIVE TREATMENTS RELATIVE LOW COST OF NARCOTIC RX PATIENT DEMANDS FOR RX STRATEGIES OPIOID RX’S LOW DOSES AND FOR LIMITED PERIOD OF TIME CLOSE ATTENTION TO STATE MONITORING PROGRAMS STEER ABUSING/ADDICTED PATIENTS TO TREATMENT PROGRAMS

9/29/2016 6

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

• bstructive 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 Syst

• Rev. 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, 2015 doi: 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.

REFERENCES

Management 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

• f 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. 08/15/2012 FDA 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.