Society for Pediatric Pain Medicine
Better Care for Children in Pain

Correct answer: (C) Improves local vasodilation and oxygen delivery


Pharmacotherapy for Sickle Cell Disease vaso-occlusive crisis targets peripheral and central nociceptive and inflammatory-mediated pathways. The 2020 American Society of Hematology (ASH) guidelines for the management of acute and chronic pain in Sickle Cell Disease (SCD) provided updated recommendations for multimodal treatment modalities with the introduction of regional anesthesia to this pathway. Regional anesthesia blunts autonomic nociception and the inflammatory response for surgical stimulants, while promoting local vasodilation to improve tissue oxygenation. These characteristics are beneficial for SCD patients with vaso-occlusive crisis (VOC). Two pediatric prospective observational reports demonstrated decreased opioid consumption, improved oxygenation and activity rehabilitation following the thoracic epidural analgesia for severe sickle cell mediated acute chest syndrome. However, there is no literature replicating this with peripheral nerve blockade and SCD-VOC. The up-regulation of interleukins (ILs), cytokines and endothelial adhesion molecules details the pathophysiology of the microvascular occlusion characteristic of VOC. Furthermore, there are no regional anesthesia studies investigating the up-regulation or down-regulation of inflammatory markers specific to SCD-VOC. Albeit, several surgical case reports have demonstrated the reduction in the inflammatory response following regional anesthesia; suggesting this effect may be seen in patients with SCD-VOC after receiving regional anesthesia as well. Further investigation into the pathophysiology of regional anesthesia for SCD-VOC is prudent.


References:


1. Tighe PJ, Elliott CE, Lucas SD, et al. Noninvasive tissue oxygen saturation determined by near-infrared spectroscopy following peripheral nerve block. Acta Anaesthesiol Scand 2011:55(10):1239-1246.


2. Weber G, Liao S, Burns MA. Sciatic (Popliteal Fossa) Catheter for Pediatric Pain Management of Sickle Cell Crisis: A Case Report. A A Case Rep 2017:9(10):297-299.


3. Wyatt KE, Pranav H, Henry T, et al. Pericapsular nerve group blockade for sickle cell disease vaso-occlusive crisis. J Clin Anesth 2020:66:109932.


4. Yaster M, Tobin JR, Billett C, et al. Epidural analgesia in the management of severe vaso-occlusive sickle cell crisis. Pediatrics 1994:93(2):310-315.


5. New T, Venable C, Fraser L, et al. Management of refractory pain in hospitalized adolescents with sickle cell disease: changing from intravenous opioids to continuous infusion epidural analgesia. Journal of pediatric hematology/oncology 2014:36(6):e398-402.


6. Brandow AM, Carroll CP, Creary S, et al. American Society of Hematology 2020 guidelines for sickle cell disease: management of acute and chronic pain. Blood Adv 2020:4(12):2656-2701.


7. Wyatt KE, Liu CJ. Regional Anesthesia for Sickle Cell Disease Vaso-occlusive Crisis. SPPM Newsletter Fall 2020.

Correct Answer is C. A case series of 8 patients showed significant reduction in pain scores after receiving propofol in patients who failed a combination of triptans, opioids, NSAIDs, or steroids


RATIONALE:


Migraine headaches can cause severe, disabling pain, leading many patients to present to the Emergency Room (ER) in search of pain relief. Migraines are common in children with prevalence of 5% by age 10 and this increases further during adolescence. The use of propofol for refractory migraines is currently being investigated. A retrospective study on children with migraines showed propofol to be an effective abortive treatment. (1). In another study, even though propofol was not superior to standard therapy, it resulted in fewer rebound headaches and shorter length of stay. (2) A RCT in adults concluded that propofol can be used for management of acute migraines with decreased rates of recurrence in the propofol group compared to the Sumatriptan group. (3) A case series of 8 patients showed significant reduction in pain scores after receiving propofol in patients who failed a combination of triptans, opioids, NSAIDs, or steroids. (4) Propofol works by increasing GABA-mediated inhibitory tone in the CNS. Propofol decreases the rate of dissociation of the GABA from the receptor, thereby increasing the duration of the GABA-activated opening of the chloride channel with resulting hyperpolarization of cell membranes.


Migraines result from a combination of lifestyle, environmental, and genetic factors. The risk of suffering from migraines is about 50% higher among those who have a first degree relative with migraines. Certain disorders that affect children have been associated with migraines and may represent manifestations of migraine genes in their early years. Ability to diagnose and treat migraines in a timely manner may decrease disability, minimizing days away from school and the negative impact on social life. Preventive treatment includes lifestyle modifications, cognitive behavior therapy and medications. The Pediatric Migraine Disability Assessment (PedMIDAS) is a useful tool in assessing the degree of disability and the response to treatment.


REFERENCES:


1. Gelfand A., Pediatric and adolescent headache. Continuum (MINNEAP MINN), 2018; 24(4): 1108-1136


2. Sheridan D.C., Spiro D. M., Nguyen T., Koch T.K., Mackler G.D., Low dose Propofol for the abortive treatment of pediatric migraine in the emergency department. Pediatric Emergency Care, 2012; 28(12): 1293-1296


3. Sheridan D.C., Hansen M.L., Lin A.L., Fu R., Meckler G.D., Low dose Propofol for pediatric migraine: A prospective, randomized controlled Trial. Journal of Emergency Medicine. 2018; 54(5):600-606


4. Moshtaghion H., Heiranizadeh N., Rahimdel A., Esmaeili A., Hashemian H., Hekmatimoghaddam S., The efficacy of Propofol vs. subcutaneous Sumatriptan for treatment of acute migraine headaches in the emergency department: A double-blinded clinical trial. Pain practice, 15(8), 701-705.