Conference Coverage

Make the most of nonopioids: Managing acute pain in children


 

EXPERT ANALYSIS AT THE AAP NATIONAL CONFERENCE

ORLANDO – Effective management of acute pain in children is important not only for improving comfort, but also for improving outcomes, according to Dr. Joseph D. Tobias.

"The important thing to realize is that there are many benefits (of pain management). Although we walk a fine line between adverse effects and benefits, many times with adequate analgesia we put patients in a better place, Dr. Tobias, chief of anesthesiology and pain medicine at Nationwide Children’s Hospital in Columbus, Ohio, said at the annual meeting of the American Academy of Pediatrics.

That’s because with inadequate analgesia there are a host of humoral factors, including increased endogenous catecholamines, that have adverse physiologic effects on oxygen consumption, CO2 production, and on the immune system, he explained.

Multiple studies have demonstrated that aggressive pain management has beneficial immune effects, he added, noting that patients with adequate pain management are less likely to experience infections and that neonates and infants without adequate pain management may experience chronic pain and pain syndromes later in life because of the neuroplasticity of the infant brain.

He recommends the classic "stepwise ladder" approach to pain management in pediatric patients with acute pain following surgery, trauma, or acute illness, for example. Step 1 involves administration of nonopioids and adjuvants.

"But even as we move to step 2 and add opioids, it’s very important to keep the nonopioids and adjuvants going. I don’t think anybody should ever be in the hospital on [patient-controlled analgesia] getting opioids and not getting nonsteroidal [drugs], acetaminophen, and other adjuvants, because what you’re going to do is decrease your opioid requirements, and as you do that, you then decrease opioid-related side effects," he said.

Keep in mind that the maximum dose of oral or rectal acetaminophen has been decreased from 4 to 3 grams, he said, noting that reports of significant toxicity with acetaminophen have been increasing, so it is important to limit the dose.

The same holds true for the new intravenous preparation of acetaminophen, given reports of 10-fold overdose (10 mg/mL concentration).

"We need to be cognizant of that," he said.

A number of salicylates and NSAIDs are also available for use in children. Ibuprofen is among the most commonly used, and also is now available in an intravenous formulation.

Ketorolac is another good treatment option, but intravenous acetaminophen is preferable in children under age 1 year, because of concerns regarding decreased renal perfusion, he said.

Other emerging options that are making their way from the adult to the pediatric pain-management arena are ketamine, gabapentin and pregabalin, dexamethasone, and dexmedetomidine, all of which appear to have some potential benefits for improving pain management and reducing the need for opioids.

Watch for interactions and adverse effects

Be sure to assess for potential drug interactions in children on several medications and to protect against the adverse gastrointestinal tract effects of nonsteroidal drugs, Dr. Tobias advised.

"If you’re using nonsteroidals, especially postoperatively in patients, it’s always a good idea to combine them with a proton pump inhibitor, or an H2 antagonist," he said, noting that that these can generally be discontinued once the patient is tolerating a regular diet.

Effects on renal function are also an important concern, particularly in those with preexisting renal dysfunction, concomitant use of other nephrotoxic agents, hypovolemia, hypoperfusion, and prolonged administration.

Bleeding is another concern, particularly in those receiving ketorolac, which shouldn’t be used in children undergoing tonsillectomy or in other cases involving increased bleeding risk, he said.

As for opioids, morphine and hydromorphone are the most commonly used in children, accounting for about 99% of usage.

Morphine is more often associated with pruritus in older children and adolescents, so hydromorphone may be a better option to start with in these patients.

"As far as dosing guidelines, I think it’s very important to adjust the dose based on the patient’s status and follow pain scores. I think everybody in the hospital needs to have their pain score checked. It doesn’t matter which (pain scale) you use," Dr. Tobias said.

Also, a steady-state serum concentration should be maintained with avoidance of peaks and troughs, and patients on opioids should be monitored for adverse effects, he said, noting that patient-controlled analgesia (PCA) devices are useful – after a loading dose – to maintain those concentrations. PCA devices can be used by children as young as 5 or 6 years of age; nurse-controlled analgesia is best for those who are younger or have cognitive impairment.

A lower basal infusion rate (4-5 mcg/kg per hour) allows for better sleep while reducing side effects, he said.

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