SPA Annual Meeting Reviews
Session III: PEDx Error Traps in Acute Pediatric Pain Management
Reviewed by Ashlee Holman, MD
Assistant Professor of Anesthesiology
University of Michigan
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Dr. Holman |
Error Traps in Acute Pediatric Pain Management
Amy Beethe, MD
Amy Beethe, MD (Children’s Hospital, University of Nebraska Medical Center, Assistant Professor) began her talk with the objectives:
- Discuss risk of post-operative renal failure and bleeding with Non-Steroidal Anti-Inflammatory Drugs (NSAID) use,
- Explain available non-pharmacologic modalities to improve pain scores, and
- Discuss appropriate opiate conversion and home prescribing regimens.
Error #1: NSAIDs Are Too Risky
Dr. Beethe stressed that NSAIDs are extremely effective with similar analgesic efficacy to morphine and meperidine.
She referenced an article by Misurac et al1 which states that NSAID use accounts for 2.7% of acute kidney injury via mechanisms related to kidney hypoperfusion and blockage of afferent arteriole vasodilation secondary to NSAID-induced COX enzyme blockade. Dr. Beethe recommended careful titration and thoughtful use of NSAIDs in medically complex patients, those with reduced nephron number, in hypovolemic states, and in neonates. Careful titration may include decreasing initial dose as well as decreasing frequency while following creatinine levels.
One article from Forrest et al2 described the use of ketorolac for post-operative pain control in children and stated that inhibition of COX enzymes may theoretically lead to increased risk of bleeding via alteration of platelet function and prolongation of bleeding times (although bleeding times generally remain within normal limits). Neurosurgical literature such as the article by Richardson et al3 demonstrated no increased risk of bleeding, no difference in blood transfusion, and better pain control with ketorolac administration. In this population, use of ketorolac is recommended. One study showed a 5-fold increased risk of hemorrhage in adult (but not pediatric) tonsillectomy with use of ketorolac, and due to the large confidence interval reported in a recent Cochrane Review4, the American Academy of Otolaryngology-Head and Neck Surgery recommends against the use of ketorolac in tonsillectomy. In circumcision, one study by Gao et al5 showed that ketorolac was associated with increased risk of post-operative bleeding.
Error #2: Poor Use of Non-pharmacologic Therapy
Dr. Beethe recommended minimizing the amount of painful experiences and decreasing anxiety by pre-planning procedures (e.g. venipuncture, blood draws, wound checks, heel/finger sticks, dressing changes, adhesive removal, bladder catheterization, intramuscular/subcutaneous injections) with services and nursing staff. Specific non-pharmacologic tricks to use include sleep, oral glucose, breast/bottle-feeding, swaddling, skin-to-skin, topical/local anesthetics, acetaminophen, and appropriate use of deep sedation/anesthesia for more-invasive procedures (e.g. wound treatments, incision/drainage, tracheal intubation, lumbar puncture, chest tube insertion, central line placement).
Error #3: Appropriate Opiate Conversion with Appropriate Home Prescriptions
Dr. Beethe recommended parental and patient reassurance, frequent pain assessments, and nursing education regarding medication regimen plan and rationale. Residents and trainees should be educated on appropriate dosing, scheduling, and amount of home prescriptions. Electronic medical record warnings may be useful to remind prescribers to limit amount of pain medication prescriptions. Dr. Beethe encouraged the audience to learn state laws and regulations regarding prescriptions for pain medications.
References:
- Misurac JM, Knoderer CA, Leiser JD, et al. Nonsteroidal anti-inflammatory drugs are an important cause of acute kidney injury in children. J Pediatr. 2013 Jun;162(6):1153-9.
- Forrest JB, Heitlinger EL, Revell S. Ketorolac for postoperative pain management in children. Drug Saf 1997 May;16(5):309-29.
- Richardson MD, Palmeri NO, Williams SA, et al. Routine perioperative ketorolac administration is not associated with hemorrhage in pediatric neurosurgery patients. J Neurosurg Pediatr. 2016 Jan;17(1):107-15.
- Lewis SR, Nicholson A, Cardwell ME, et al. Nonsteroidal anti-inflammatory drugs and perioperative bleeding in paediatric tonsillectomy. Cochrane Database Syst Rev. 2013 Jul;2013(7):CD003591.
- Gao B, Remondini T, Dhaliwal N, et al. Incidence of bleeding in children undergoing circumcision with ketorolac administration. Can Urol Assoc J. 2018 Jan;12(1):E6-E9.
