Error traps in acute pain management in children.
pain, acute
pain, opioids
pain, regional
Journal
Paediatric anaesthesia
ISSN: 1460-9592
Titre abrégé: Paediatr Anaesth
Pays: France
ID NLM: 9206575
Informations de publication
Date de publication:
09 2022
09 2022
Historique:
revised:
14
06
2022
received:
24
01
2022
accepted:
19
06
2022
pubmed:
26
6
2022
medline:
9
8
2022
entrez:
25
6
2022
Statut:
ppublish
Résumé
Providing effective acute pain management to hospitalized children can help improve outcomes, decrease length of stay, and increase patient and parental satisfaction. Error traps (circumstances that lead to erroneous actions or undesirable consequences) can result in inadequately controlled pain, unnecessary side effects, and adverse events. This article highlights five error traps encountered when managing acute pain in children. They include failure to appropriately assess pain, optimally utilize regional anesthesia, select suitable systemic analgesics, identify and treat medication-related side effects, and consider patient characteristics when choosing medication or dosing route. These issues are easily addressed when the clinician is cognizant of ways to anticipate, identify, and mitigate or avoid these errors.
Substances chimiques
Analgesics
0
Analgesics, Opioid
0
Types de publication
Journal Article
Review
Langues
eng
Sous-ensembles de citation
IM
Pagination
982-992Informations de copyright
© 2022 John Wiley & Sons Ltd.
Références
Peiro JL, Crombleholme TM. Error traps in fetal surgery. Semin Pediatr Surg. 2019;28(3):143-150.
Masaracchia MM, Sunder RA, Polaner DM. Error traps in pediatric regional anesthesia. Paediatr Anaesth. 2021;31(11):1161-1169.
Sohn L, Peyton J, von Ungern-Sternberg BS, Jagannathan N. Error traps in pediatric difficult airway management. Paediatr Anaesth. 2021;31(12):1271-1275.
Stiegler MP, Neelankavil JP, Canales C, Dhillon A. Cognitive errors detected in anaesthesiology: a literature review and pilot study. Br J Anaesth. 2012;108(2):229-235.
von Baeyer CL, Spagrud LJ, McCormick JC, et al. Three new datasets supporting use of the numerical rating scale (NRS-11) for children's self-reports of pain intensity. Pain. 2009;143(3):223-227.
Shields BJ, Palermo TM, Powers JD, Grewe SD, Smith GA. Predictors of a child's ability to use a visual analogue scale. Child Care Health Dev. 2003;29(4):281-290.
Bieri D, Reeve RA, Champion DG, Addicoat L, Ziegler JB. The faces pain scale for the self-assessment of the severity of pain experienced by children: development, initial validation, and preliminary investigation for ratio scale properties. Pain. 1990;41(2):139-150.
Wong DL, Baker CM. Pain in children: comparison of assessment scales. Okla Nurse. 1988;33(1):8.
Lawrence J, Alcock D, McGrath P, Kay J, MacMurray S, Dulberg C. The development of a tool to assess neonatal pain. Neonatal Netw. 1993;12(6):59-66.
Ambuel B, Hamlett KW, Marx CM, Blumer JL. Assessing distress in pediatric intensive care environments: the COMFORT scale. J Pediatr Psychol. 1992;17(1):95-109.
Hadjistavropoulos HD, Craig KD, Grunau RV, et al. Judging pain in newborns: facial and cry determinants. J Pediatr Psychol. 1994;19(4):485-491.
Voepel-Lewis T, Merkel S, Tait AR, Trzcinka A, Malviya S. The reliability and validity of the face, legs, activity, cry, consolability observational tool as a measure of pain in children with cognitive impairment. Anesth Analg. 2002;95(5):1224-1229.
Khin Hla T, Hegarty M, Russell P, Drake-Brockman TF, Ramgolam A, von Ungern-Sternberg BS. Perception of pediatric pain: a comparison of postoperative pain assessments between child, parent, nurse, and independent observer. Paediatr Anaesth. 2014;24(11):1127-1131.
Rajasagaram U, Taylor DM, Braitberg G, et al. Paediatric pain assessment: differences between triage nurse, child and parent. J Paediatr Child Health. 2009;45(4):199-203.
Blount RL, Loiselle KA. Behavioural assessment of pediatric pain. Pain Res Manag. 2009;14(1):47-52.
Zeltzer LK, Bush JP, Chen E, et al. A psychobiologic approach to pediatric pain: part 1. History, physiology, and assessment strategies. Curr Probl Pediatr. 1997;27(6):225-253.
Gaba M, Vazquez H, Homel P, et al. Language barriers and timely analgesia for long bone fractures in a pediatric emergency department. West J Emerg Med. 2021;22(2):225-231.
Sharma SK. Failed nerve blocks: prevention and management. J Anaesth Crit Care Case Rep. 2018;4(3):3-6.
Abrahams MS, Aziz MF, Fu RF, Horn JL. Ultrasound guidance compared with electrical neurostimulation for peripheral nerve block: a systemic review and meta-analysis of randomized controlled trials. Br JAnaesth. 2009;102(3):408-417.
Wadhwa A, Kandadai SK, Tongpresert S, Obal D, Gebhard RE Ultrasound guidance for deep peripheral nerve blocks: a brief review. Anesthesiol Res Pract 2011;2011:262070, 1, 6.
Hébert-Blouin MN, Tubbs RS, Carmichael SW, et al. Hilton's law revisited. Clin Anat. 2014;27(4):548-555.
Boezaart AP, Wright TW. Rational use and pitfalls of regional anesthesia for orthopedic surgery. Tech Orthop. 2017;32(4):209-216.
Lirk P, Messner H, Deibl M, et al. Accuracy in estimating the correct intervertebral space level during lumbar, thoracic and cervical epidural anaesthesia. Acta Anaesthesiol Scand. 2004;48(3):347-349.
Beilin Y, Arnold I, Telfeyan C, Bernstein HH, Hossain S. Quality of analgesia when air versus saline is used for identification of the epidural space in the parturient. Reg Anesth Pain Med. 2000;25(6):596-599.
Michael S, Richmond MN, Birks RJ. A comparison between open-end (single hole) and closed-end (three lateral holes) epidural catheters. Complications and quality of sensory blockade. Anaesthesia. 1989;44(7):578-580.
Suresh S, Ecoffey C, Bosenberg A, et al. The European Society of Regional Anaesthesia and Pain Therapy/American Society of Regional Anesthesia and Pain Medicine recommendations on local anesthetics and adjuvants dosage in pediatric regional anesthesia. Reg Anesth Pain Med. 2018;43(2):211-216.
Tsui BCH, Boretsky K, Berde C. Maximum recommended dosage of ropivacaine and bupivacaine for pediatric regional anesthesia. Reg Anesth Pain Med. 2018;43(8):895-896.
Berde CB. Convulsions associated with pediatric regional anesthesia. Anesth Analg. 1992;75(2):164-166.
Hernandez MA, Boretsky K. Chloroprocaine: local anesthetic systemic toxicity in a 9-month infant with paravertebral catheter. Paediatr Anaesth. 2016;26(6):665-666.
Ivani G, Suresh S, Ecoffey C, et al. The European Society of Regional Anaesthesia and Pain Therapy and the American Society of Regional Anesthesia and Pain Medicine joint committee practice advisory on controversial topics in pediatric regional anesthesia. Reg Anesth Pain Med. 2015;40:526-532.
Mossetti V, Ivani G. Controversial issues in pediatric regional anesthesia. Paediatric Anesth. 2012;22:109-114.
Pöpping DM, Elia N, Marret E, et al. Clonidine as an adjuvant to local anesthetics for peripheral nerve and plexus blocks: a meta-analysis of randomized trials. Anesthesiology. 2009;111(2):406-415.
Michelet D, Andreu-Gallien J, Bensalah T, et al. A meta-analysis of the use of nonsteroidal antiinflammatory drugs for pediatric postoperative pain. Anesth Analg. 2012;114(2):393-406.
Voepel-Lewis T, Wagner D, Burke C, et al. Early adjuvant use of nonopioids associated with reduced odds of serious postoperative opioid adverse events and need for rescue in children. Paediatr Anaesth. 2013;23(2):162-169.
Gornitzky AL, Flynn JM, Muhly WT, Sankar WN. A rapid recovery pathway for adolescent idiopathic scoliosis that improves pain control and reduces time to inpatient recovery after posterior spinal fusion. Spine Deform. 2016;4(4):288-295.
Kost-Byerly S, Jackson EV, Yaster M, Kozlowski LJ, Mathews RI, Gearhart JP. Perioperative anesthetic and analgesic management of newborn bladder exstrophy repair. J Pediatr Urol. 2008;4(4):280-285.
Shao B, Tariq AA, Goldstein HE, et al. Opioid-sparing multimodal analgesia after selective dorsal rhizotomy. Hosp Pediatr. 2020;10(1):84-89.
Trzcinski S, Rosenberg RE, Vasquez Montes D, et al. Use of gabapentin in posterior spinal fusion is associated with decreased postoperative pain and opioid use in children and adolescents. Clin Spine Surg. 2019;32(5):210-214.
Verret M, Lauzier F, Zarychanski R, et al. Perioperative use of gabapentinoids for the management of postoperative acute pain: a systematic review and meta-analysis. Anesthesiology. 2020;133(2):265-279.
Cavalcante AN, Sprung J, Schroeder DR, Weingarten TN. Multimodal analgesic therapy with gabapentin and its association with postoperative respiratory depression. Anesth Analg. 2017;125(1):141-146.
https://www.fda.gov/drugs/drug-safety-and-availability/fda-warns-about-serious-breathing-problems-seizure-and-nerve-pain-medicines-gabapentin-neurontin. Accessed June 5, 2022.
Bertolizio G, Otis A, Tam K, Aswar S, Garbin M, Ingelmo P. Multimodal analgesic plan for children undergoing chimeric 14.18 immunotherapy. J Pediatr Hematol Oncol. 2021;43(2):e169-e172.
Dahmani S, Michelet D, Abback PS, et al. Ketamine for perioperative pain management in children: a meta-analysis of published studies. Paediatr Anaesth. 2011;21(6):636-652.
Masaracchia MM, Sites BD, Lee J, Thomas JJ, Fernandez PG. Subanesthetic ketamine infusions for the management of pediatric pain in non-critical care settings: an observational analysis. Acta Anaesthesiol Scand. 2019;63(9):1225-1230.
Chalkiadis G, Goobie S, Walker S. Are opioids pediatric anesthesiologists' sword of Damocles? With great power comes great responsibility and risk. Paediatr Anaesth. 2019;29(6):544-546.
Burgart AM, Char D. The opioid crisis should lead pediatric anesthesiologists to a broader vision of opioid stewardship. Paediatr Anaesth. 2019;29(11):1078-1080.
DiGiusto M, Bhalla T, Martin D, Foerschler D, Jones MJ, Tobias JD. Patient-controlled analgesia in the pediatric population: morphine versus hydromorphone. J Pain Res. 2014;7:471-475.
Sadhasivam S, Aruldhas BW, Packiasabapathy S, et al. A novel perioperative multidose methadone-based multimodal analgesic strategy in children achieved safe and low analgesic blood methadone levels enabling opioid-sparing sustained analgesia with minimal adverse effects. Anesth Analg. 2021;133(2):327-337.
Machado FC, Vieira JE, de Orange FA, Ashmawi HA. Intraoperative methadone reduces pain and opioid consumption in acute postoperative pain: a systematic review and meta-analysis. Anesth Analg. 2019;129(6):1723-1732.
Ye J, Myung K, Packiasabapathy S, et al. Methadone-based multimodal analgesia provides the best-in-class acute surgical pain control and functional outcomes with lower opioid use following major posterior fusion surgery in adolescents with idiopathic scoliosis. Pediatr Qual Saf. 2020;5(4):e336.
Inturrisi CE, Craig DS, Lipman AG. Opioid analgesics. In: Ballantyne JC, Fishman SM, Rathmell JP, eds. Bonica's management of pain. 5th ed. Wolters Kluwer; 2018:4120.
Andrews CM, Krantz MJ, Wedam EF, Marcuson MJ, Capacchione JF, Haigney MC. Methadone-induced mortality in the treatment of chronic pain: role of QT prolongation. Cardiol J. 2009;16(3):210-217.
Gasche Y, Daali Y, Fathi M, et al. Codeine intoxication associated with ultrarapid CYP2D6 metabolism. N Engl J Med. 2004;351(27):2827-2831.
Kelly LE, Rieder M, van den Anker J, et al. More codeine fatalities after tonsillectomy in north American children. Pediatrics. 2012;129(5):e1343-e1347.
US Food and Drug Administration (2017). FDA drug safety communication: FDA restricts use of prescription codeine pain and cough medicines and tramadol pain medicines in children; recommends against use in breastfeeding women. Available at: https://www.fda.gov/downloads/Drugs/DrugSafety/UCM553814.pdf. Accessed June 5, 2022.
Murtagh FE, Chai MO, Donohoe P, et al. The use of opioid analgesia in end-stage renal disease patients managed without dialysis: recommendations for practice. J Pain Palliat Care Pharmacother. 2007;21(2):5-16.
Bartlett SE, Cramond T, Smith MT. The excitatory effects of morphine-3-glucuronide are attenuated by LY274614, a competitive NMDA receptor antagonist, and by midazolam, an agonist at the benzodiazepine site on the GABAA receptor complex. Life Sci. 1994;54(10):687-694.
Walker BJ, Polaner DM, Berde CB. Acute pain. In: Coté CJ, Lerman J, Anderson B, eds. A Practice of Anesthesia for Infants and Children. 6th ed. Elsevier; 2019:1023-1062.
Verscheijden LFM, Litjens CHC, Koenderink JB, et al. Physiologically based pharmacokinetic/pharmacodynamic model for the prediction of morphine brain disposition and analgesia in adults and children. PLoS Comput Biol. 2021;17(3):e1008786.
Brown KA, Laferrière A, Lakheeram I, Moss IR. Recurrent hypoxemia in children is associated with increased analgesic sensitivity to opiates. Anesthesiology. 2006;105(4):665-669.
Coté CJ, Posner KL, Domino KB. Death or neurologic injury after tonsillectomy in children with a focus on obstructive sleep apnea: Houston, we have a problem! Anesth Analg. 2014;118(6):1276-1283.
Chapman CR, Davis J, Donaldson GW, Naylor J, Winchester D. Postoperative pain trajectories in chronic pain patients undergoing surgery: the effects of chronic opioid pharmacotherapy on acute pain. J Pain. 2011;12(12):1240-1246.
Grancaric N, Lee W, Scanlon M. Postoperative analgesia in the chronic pain patient. Otolaryngol Clin North Am. 2020;53(5):843-852.
Schubart JR, Schaefer E, Janicki P, et al. Resistance to local anesthesia in people with the Ehlers-Danlos syndromes presenting for dental surgery. J Dent Anesth Pain Med. 2019;19(5):261-270.
Vecchione T, Waisel D, Boretsky K. Peripheral nerve blocks in children and adolescents with Ehlers-Danlos syndrome hypermobility type. Reg Anesth Pain Med. 2021;46(2):184-185.
Balestracci A, Ezquer M, Elmo ME, et al. Ibuprofen-associated acute kidney injury in dehydrated children with acute gastroenteritis. Pediatr Nephrol. 2015;30(10):1873-1878.
Mody K, Kaur S, Mauer EA, et al. Benzodiazepines and development of delirium in critically ill children: estimating the causal effect. Crit Care Med. 2018;46(9):1486-1491.
Keegan MT, Brown DR, Rabinstein AA. Serotonin syndrome from the interaction of cyclobenzaprine with other serotoninergic drugs. Anesth Analg. 2006;103(6):1466-1468.
Tramèr MR, Walder B. Efficacy and adverse effects of prophylactic antiemetics during patient-controlled analgesia therapy: a quantitative systematic review. Anesth Analg. 1999;88(6):1354-1361.
Maxwell LG, Kaufmann SC, Bitzer S, et al. The effects of a small-dose naloxone infusion on opioid-induced side effects and analgesia in children and adolescents treated with intravenous patient-controlled analgesia: a double-blind, prospective, randomized, controlled study. Anesth Analg. 2005;100(4):953-958.
Mallick-Searle T, Fillman M. The pathophysiology, incidence, impact, and treatment of opioid-induced nausea and vomiting. J Am Assoc Nurse Pract. 2017;29(11):704-710.
Engelman E, Salengros JC, Barvais L. How much does pharmacologic prophylaxis reduce postoperative vomiting in children? Calculation of prophylaxis effectiveness and expected incidence of vomiting under treatment using Bayesian meta-analysis. Anesthesiology. 2008;109(6):1023-1035.
Gan TJ, Belani KG, Bergese S, et al. Fourth consensus guidelines for the management of postoperative nausea and vomiting. Anesth Analg. 2020;131(2):411-448.
Kovac AL. Postoperative nausea and vomiting in pediatric patients. Paediatr Drugs. 2021;23(1):11-37.
Yuan CS, Foss JF, Osinski J, Toledano A, Roizen MF, Moss J. The safety and efficacy of oral methylnaltrexone in preventing morphine-induced delay in oral-cecal transit time. Clin Pharmacol Ther. 1997;61(4):467-475.
Jannuzzi RG. Nalbuphine for treatment of opioid-induced pruritus: a systematic review of literature. Clin J Pain. 2016;32(1):87-93.
Jitpakdee T, Mandee S. Strategies for preventing side effects of systemic opioid in postoperative pediatric patients. Paediatr Anaesth. 2014;24(6):561-568.
Cashman JN, Dolin SJ. Respiratory and haemodynamic effects of acute postoperative pain management: evidence from published data. Brit J Anaesth. 2004;93(2):212-223.
Weingarten TN, Herasevich V, McGlinch MC, et al. Predictors of delayed postoperative respiratory depression assessed from naloxone administration. Anesth Analg. 2015;121(2):422-429.
Nagappa M, Weingarten TN, Montandon G, Sprung J, Chung F. Opioids, respiratory depression, and sleep-disordered breathing. Best Pract Res Clin Anaesthesiol. 2017;31(4):469-485.
Miller KM, Kim AY, Yaster M, et al. Long-term tolerability of capnography and respiratory inductance plethysmography for respiratory monitoring in pediatric patients treated with patient-controlled analgesia. Paediatr Anaesth. 2015;25(10):1054-1059.
Society for Pediatric Anesthesia. Pedi crisis critical events checklists. 2020. https://pedsanesthesia.org/wp-content/uploads/2020/11/SPAPediCrisisChecklistsNov2020.pdf. Accessed January 5, 2022.