Society for Pediatric Pain Medicine
Better Care for Children in Pain

{“questions”:{“uarqe”:{“id”:”uarqe”,”mediaType”:”image”,”answerType”:”text”,”imageCredit”:””,”image”:””,”imageId”:””,”video”:””,”imagePlaceholder”:””,”imagePlaceholderId”:””,”title”:”Author: Terri Voepel-Lewis, PhD, RN \r\n\r\nPrescription opioid misuse is defined as using a prescribed drug without a physician\u2019s order (i.e., taking someone else\u2019s prescription) or taking a prescribed drug in a higher dose, more frequently, or as otherwise not intended. Despite decreases in prescription opioid misuse over the past decade, 5% to 15% of U.S. teens have recently admitted to misusing a prescribed opioid. Which of the following factors have been associated with increased risk for prescription opioid misuse?\t”,”desc”:””,”hint”:””,”answers”:{“c1d3r”:{“id”:”c1d3r”,”image”:””,”imageId”:””,”title”:”A. Having been prescribed an opioid in the past”},”heghj”:{“id”:”heghj”,”image”:””,”imageId”:””,”title”:”B. Current or past substance use (including smoking, alcohol use)”},”p40ar”:{“id”:”p40ar”,”image”:””,”imageId”:””,”title”:”C. Having a diagnosis of ADHD”},”hk936″:{“id”:”hk936″,”image”:””,”imageId”:””,”title”:”D. Having a parent who misused a prescribed opioid”},”ph3g3″:{“id”:”ph3g3″,”image”:””,”imageId”:””,”title”:”E. All of the above increase the risk for opioid misuse”,”isCorrect”:”1″}}}},”results”:{“r8eug”:{“id”:”r8eug”,”title”:””,”image”:””,”imageId”:””,”min”:”0″,”max”:”1″,”desc”:””,”redirect_url”:”https:\/\/pedspainmedicine.org\/wp-content\/uploads\/2022\/11\/SPPM-QOM-November-2022.pdf”}}}

{“questions”:{“9rm2p”:{“id”:”9rm2p”,”mediaType”:”image”,”answerType”:”text”,”imageCredit”:””,”image”:””,”imageId”:””,”video”:””,”imagePlaceholder”:””,”imagePlaceholderId”:””,”title”:”Authors: Rita Agarwal, MD, FAAP, FASA and Julie Good, MD, FAAP: Stanford University School of Medicine – Stanford, CA \r\n\r\n18 y.o man with incurable, recurrent metastatic Ewing Sarcoma presents acutely with severe abdominal pain. His abdomen is distended, and a mini laparotomy reveals diffuse intraabdominal metastasis and inoperable multi-location bowel obstruction. At a post-operative care discussion, he and his family express a primary goal of better pain control, and the patient further states he wants to be more alert. The patient is currently on Hydromorphone PCA 500 mCg per hour basal rate, 300 mCg demand dose with 8-minute lockout, Celebrex 200 mg po bid, gabapentin 1200 mg po tid and acetaminophen 650 mg po every 6 hours. The worst pain is in his bilateral lower abdominal and pelvic area which he rates as 8\/10. He is DNAR\/DNI and is unable to move much due to pain. He can\u2019t sit up in bed, nor can he comfortably lie on his side. His INR is 1.4. \r\nThe patient, family and oncologists are requesting a regional technique to help manage his pain. \r\nAll of the following interventions should be considered EXCEPT:\r\n”,”desc”:””,”hint”:””,”answers”:{“6kv6m”:{“id”:”6kv6m”,”image”:””,”imageId”:””,”title”:”A. An epidural under deep sedation \/general anesthesia “},”x4npe”:{“id”:”x4npe”,”image”:””,”imageId”:””,”title”:”B. Adjust or rotate opioids and adjuvant medications “},”pgt16”:{“id”:”pgt16″,”image”:””,”imageId”:””,”title”:”C. Intrathecal morphine catheter”},”0cl8q”:{“id”:”0cl8q”,”image”:””,”imageId”:””,”title”:”D. Refuse a regional technique because of increased INR and aspiration risk “,”isCorrect”:”1″}}}},”results”:{“7t0ws”:{“id”:”7t0ws”,”title”:””,”image”:””,”imageId”:””,”min”:”0″,”max”:”1″,”desc”:””,”redirect_url”:”https:\/\/pedspainmedicine.org\/wp-content\/uploads\/2022\/10\/SPPM-QOM-10-11-2022.pdf”}}}

{“questions”:{“12dre”:{“id”:”12dre”,”mediaType”:”image”,”answerType”:”text”,”imageCredit”:””,”image”:””,”imageId”:””,”video”:””,”imagePlaceholder”:””,”imagePlaceholderId”:””,”title”:”What pain medication is most likely to cause hemolytic anemia in normal therapeutic doses in patients with severe G6PD deficiency?”,”desc”:””,”hint”:””,”answers”:{“7xrg0”:{“id”:”7xrg0″,”image”:””,”imageId”:””,”title”:”A. Acetaminophen”},”7cful”:{“id”:”7cful”,”image”:””,”imageId”:””,”title”:”B. Ibuprofen”},”byu5t”:{“id”:”byu5t”,”image”:””,”imageId”:””,”title”:”C. Acetylsalicylic Acid (Aspirin)”,”isCorrect”:”1″},”679yx”:{“id”:”679yx”,”image”:””,”imageId”:””,”title”:”D. Oxycodone”}}}},”results”:{“n1l96”:{“id”:”n1l96″,”title”:””,”image”:””,”imageId”:””,”min”:”0″,”max”:”1″,”desc”:””,”redirect_url”:”https:\/\/pedspainmedicine.org\/wp-content\/uploads\/2022\/09\/SPPM-QOM-Posted-9-13-2022.pdf”}}}

{“questions”:{“jt83o”:{“id”:”jt83o”,”mediaType”:”image”,”answerType”:”text”,”imageCredit”:””,”image”:””,”imageId”:””,”video”:””,”imagePlaceholder”:””,”imagePlaceholderId”:””,”title”:” \r\n\r\nA 3-month-old infant is undergoing pelvic surgery and will be a candidate for regional anesthesia. What important protein is deficient in newborns and infants (as compared to older children and adults) that can contribute to toxicity if amide local anesthetics are used? \r\n”,”desc”:””,”hint”:””,”answers”:{“jqkwn”:{“id”:”jqkwn”,”image”:””,”imageId”:””,”title”:”A. Haptoglobin”},”5d0vv”:{“id”:”5d0vv”,”image”:””,”imageId”:””,”title”:”B. Alpha-1 antiglobulin”,”isCorrect”:”1″},”y2dw4″:{“id”:”y2dw4″,”image”:””,”imageId”:””,”title”:”C. Fibronectin”},”vewnc”:{“id”:”vewnc”,”image”:””,”imageId”:””,”title”:”D. Alpha-fetoprotein”}}}},”results”:{“jr6dp”:{“id”:”jr6dp”,”title”:””,”image”:””,”imageId”:””,”min”:”0″,”max”:”1″,”desc”:”Correct Answer: B. Alpha-1 antiglobulin \r\n\r\nHypoproteinemia reduces patients\u2019 capacity for protein-binding of local anesthetics and other medications. Local anesthetics primarily bind to albumin<\/em> (high capacity for binding with low affinity) and \u03b11-acid glycoprotein<\/em> (low capacity for binding with high affinity). Various local anesthetics exhibit protein binding to different extents, which influences duration of action. For example, lidocaine is approximately 65% protein-bound, whereas ropivacaine is about 95% bound to protein in healthy patients. Since the free fraction (not protein-bound) of the drug contributes to clinical effect as well as toxicity, factors that reduce protein binding have a greater effect on highly protein-bound local anesthetics. Furthermore, metabolism of amide local anesthetics by hepatic cytochrome P450 enzymes are reduced in our youngest patients due to limited hepatic function (and therefore protein production) in the first months of life. To a lesser degree, immature renal development also contributes to poor amide metabolism. Collectively, these physiologic and pharmacologic properties make the risk of toxicity from amide local anesthetics significantly higher in the neonate and infant populations. This makes ester local anesthetic agents the preferred choice for neonates and young infants receiving local anesthetics. \r\n \r\nReferences: \r\n1. Neal JM, Barrington MJ, Fettiplace MR et al. The third american society of regional anesthesia and pain medicine practice advisory on local anesthetic systemic toxicity: Executive summary 2017. Reg Anesth Pain Med<\/em> 2018;43:113-123.\r\n2. Suresh S, Ecoffey C, Bosenberg A, Lonnqvist PA, de Oliveira GS Jr, de Leon Casasola O, de Andr\u00e9s J, Ivani G. 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 Feb;43(2):211-216. \r\n3. Veneziano G, Tobias JD. Chloroprocaine for epidural anesthesia in infants and children. Paediatr Anaesth. 2017 Jun;27(6):581-590. doi: 10.1111\/pan.13134. Epub 2017 Mar 21. “,”redirect_url”:””}}}

{“questions”:{“bdpx0”:{“id”:”bdpx0″,”mediaType”:”image”,”answerType”:”text”,”imageCredit”:””,”image”:””,”imageId”:””,”video”:””,”imagePlaceholder”:””,”imagePlaceholderId”:””,”title”:” \r\n\r\nA 6-month-old male, otherwise healthy, presented to an ambulatory surgical center for a revision circumcision. The child underwent an uneventful inhalation induction, placement of a peripheral intravenous catheter and a secured endotracheal tube. The surgeon prepped, draped and performed a surgical time out, after which there was placement of a penile block with 0.5% bupivacaine without difficulty. Within seconds of the local anesthetic injection, the patient became hypotensive and bradycardic. PALS protocol was initiated and it was quickly determined that local anesthetic systemic toxicity (LAST) was the likely diagnosis. What is the next step in treatment?”,”desc”:””,”hint”:””,”answers”:{“bq8mf”:{“id”:”bq8mf”,”image”:””,”imageId”:””,”title”:”A. Epinephrine 10 mcg\/kg IV”},”mhb96″:{“id”:”mhb96″,”image”:””,”imageId”:””,”title”:”B. Call for surgical cardiopulmonary bypass initiation “},”lpi5z”:{“id”:”lpi5z”,”image”:””,”imageId”:””,”title”:”C. Increase FiO2 to 100% and stop volatile anesthetic”,”isCorrect”:”1″},”4dkvc”:{“id”:”4dkvc”,”image”:””,”imageId”:””,”title”:”D. Midazolam 0.05-0.1 mg\/kg IV “}}}},”results”:{“yqm5t”:{“id”:”yqm5t”,”title”:””,”image”:””,”imageId”:””,”min”:”0″,”max”:”1″,”desc”:”The correct answer is – C : Increase FiO2 to 100% and stop volatile anesthetic \r\n\r\nIn this LAST scenario, recognition of the problem occurred quickly and PALS was initiated. The patient already has a secured airway. While many of the above answers would all be happening simultaneously, the next step should be to remove the volatile anesthetic which will contribute to the hypotension which is caused by the intravascular injection of local anesthesia. Before lipid infusion was used, there was only supportive therapy until the local anesthestic could be metabolized. \r\nThe definitive treatment of LAST is Intralipid which creates a lipid \u201csink\u201d or gradient to draw bupivacaine out of the tissue into lipid micelles so that the cardiac and neurological pharmacodynamic effects are minimized. The initial treatment is 1.5 ml\/kg bolus over one minute followed by the initiation of an infusion of lipid at 0.25 mL\/kg\/min. If after 5 min, there is no change in the patient status, then another bolus of 1.5 mL\/kg may be given and the infusion should be increased to 0.5 mL\/kg\/min. The lipid infusion should last for 10 min after return of hemodynamic stability. PediCrisis notes that the maximum intralipid volume is 10 mL\/kg over the first 30 minutes. \r\nEpinephrine is a very important component of standard PALS protocols. However, in LAST, epinephrine decrease lipid resuscitation and should be used in small bolus doses. \r\n\r\n\r\nReferences: \r\n1. \tJones Oguh, S; Kraemer, F. Pediatric Local Anesthetic Systemic Toxicity. SPPM News. Spring 2022. \r\n2.\t Pedi Crisis application on iOS (Apple Inc., Cupertino, CA) \r\n3.\t Weinberg, G., Rupnik, B., Aggarwal, N., Fettiplace, M., & Gitman, M. (2020, February). APSF Newsletter<\/em>. Retrieved June 30, 2022, from https:\/\/www.apsf.org\/article\/local-anesthetic-systemic-toxicity-last-revisited-a-paradigm-in-evolution\/. \r\n\r\n”,”redirect_url”:””}}}