Society for Pediatric Pain Medicine
Better Care for Children in Pain

{“questions”:{“wbw0k”:{“id”:”wbw0k”,”mediaType”:”image”,”answerType”:”text”,”imageCredit”:””,”image”:””,”imageId”:””,”video”:””,”imagePlaceholder”:””,”imagePlaceholderId”:””,”title”:”\r\n\r\n\r\n\r\nFor January’s Question of the Month, Dr. Rita Agarwal teamed up with a parent of and advocate for children with hereditary pancreatitis and chronic or recurrent pain, Beth Larson-Steckler https:\/\/www.childhoodpancreatitis.org\/ \r\nThis question is based on composite patient experience and is not meant as a critique of healthcare professionals in pediatric pain management, but a reflection of lived experience of patients and their families. Many families with children with chronic pain live in areas with limited access to health care and attempting to get appropriate care for their children can be challenging. These families often rely on their PCP and have minimal access to specialists. \r\n\r\nQuestion: My 13-year-old daughter has acute and chronic pain related to hereditary pancreatitis that was well controlled on a stable dose of opioids. Her pediatrician switched her medications to gabapentin because he was concerned about the risk of opioids. Since she started taking gabapentin, she is short with us, crabby and depressed. She is crying all the time and her pain is worse. I am very concerned, I\u2018d like to have her switched back but her doctor keeps saying it\u2019s better than opioids. What should I do first?\r\n”,”desc”:””,”hint”:””,”answers”:{“iflp0”:{“id”:”iflp0″,”image”:””,”imageId”:””,”title”:”A.\tKeep going, eventually her symptoms will improve”},”24x6e”:{“id”:”24x6e”,”image”:””,”imageId”:””,”title”:”B.\tAsk your physician for a referral to a pediatric chronic pain program to explore multidisciplinary based approach to management. “,”isCorrect”:”1″},”e7u93″:{“id”:”e7u93″,”image”:””,”imageId”:””,”title”:”Continue trialing other chronic pain medications, something will eventually work “},”xqlhx”:{“id”:”xqlhx”,”image”:””,”imageId”:””,”title”:”D.\tDemand you child get put back on opioids “}}}},”results”:{“qv10k”:{“id”:”qv10k”,”title”:””,”image”:””,”imageId”:””,”min”:”0″,”max”:”1″,”desc”:”CORRECT ANSWER: B. Ask your physician for a referral to a pediatric chronic pain program to explore multidisciplinary based approach to management. \r\nGabapentin is a medication that is commonly used for the treatment of chronic and acute pain. It\u2019s exact mechanism of action in relieving pain is not known, although gabapentin and pregabalin are hypothesized to work via modulation of voltage-gated calcium channels^{1<\/sup>. It may be effective in some patients and is often used for neuropathic pain but may take up to 4 weeks for effect. It has some side effects, including mood dysregulation, sedation, and irritability that require close monitoring when initially prescribed. 2,3<\/sup>. If a child is not getting relief from gabapentin or having side effects that are difficult to manage, parents should be encouraged to talk to their physician about changing medications or adjusting the dose. There are other medications that may work better with less side effects. However, many parents navigating these changes often worry that they or their child will get labeled as difficult, doctor shopping, or drug seeking. This is particularly true for families that live in rural areas or locations with limited access to specialist healthcare. In a survey by the US Pain Foundation less than 50% of patients are cared for by a pain specialist and almost 40% of families have tried unsuccessfully to see a pain specialist.4<\/sup>\r\n\r\nThe use of long-term opioids in patients with chronic pain is controversial.5,6,7,8<\/sup> Previously patients including children with chronic non-cancer pain were sometimes prescribed opioids and were getting relief from stable doses of opioids. However, with the increasing evidence regarding the lack of long-term efficacy, and potential harm from opioid use and with the 2016 CDC Guideline regarding prescribing opioids for chronic pain many practitioners are choosing to, or being forced by institutional policies to summarily stop prescribing opioids, in some cases without adequate appropriate alternative multimodal therapy. Families should first discuss these options with their health professional. Multimodal and multidisciplinary techniques to pain management in children have been shown to be the most effective approach. \r\n\r\nIf a patient\u2019s pain is chronic and complex in nature, the family should ask for a referral to a multidisciplinary pediatric chronic pain program. Since many programs are offering telehealth visits this may be more possible or practical now for families with children living in remote areas. Most specialists in pediatric pain will manage patients with a multidisciplinary approach that includes pain psychology, physical therapy, occupational therapy, and may include psychiatry, and\/or interventional procedures such as trials of nerve blocks. While in-person visits are still ideal, a lot of care including PT\/OT\/complementary therapy, biofeedback, mindfulness, relaxation therapy and hypnosis can be offered in a virtual setting. \r\n\r\nPediatric Chronic pain specialists and clinics can be found here https:\/\/pedspainmedicine.org\/patients-and-families-useful-links\/ or http:\/\/childpain.org\/wp-content\/uploads\/2020\/03\/PedPainClinicList_2020-v2.pdf\r\n\r\n\r\n\r\n\r\nReferences: \r\n1.\tMathew, E., Kim, E. & Goldschneider, K. R. Pharmacological Treatment of Chronic Non-Cancer Pain in Pediatric Patients. Pediatric Drugs 16, 457\u2013471 (2014). \r\n2.\tLi G, Li P. (2020, Summer) The use of membrane stabilizers in acute and chronic pain. SPPM Newsletter. Retrieved from https:\/\/pedspainmedicine.org\/wp- content\/uploads\/newsletters\/2020\/summer\/nonopioid\/Membrane%20Stabilizers%20.html \r\n3.\tTrends in Gabapentin and Pregabalin Prescribing in a Tertiary Pediatric Medical Center. Donado C, Nedeljkovic K, Wangnamthip S, Solodiuk JC, Bourgeois FT, Berde CB.Hosp Pediatr. 2021 Aug;11(8):909-914. doi: 10.1542\/hpeds.2020-003582. Epub 2021 Jul 13.PMID: 34257145 \r\n4.\tUS Pain Foundation. 2021 Pediatric Pain Survey, US Pain Foundation, 2021, https:\/\/uspainfoundation.org\/wp-content\/uploads\/2021\/06\/2021-Pediatric-Pain-Survey-SMALL.pdf. \r\n5.\tDowell D, Haegerich TM, Chou R. CDC guideline for prescribing opioids for chronic pain\u2014United States, 2016 JAMA. doi:10.1001\/jama.2016.1464. \r\n6.\tThe Potential Impact on Children of the CDC Guideline for Prescribing Opioids for Chronic Pain: Above All, Do No Harm. Schechter NL, et al. JAMA Pediatr. 2016. PMID: 26977702 \r\n7.\tEuropean* clinical practice recommendations on opioids for chronic noncancer pain – Part 1: Role of opioids in the management of chronic noncancer pain. H\u00e4user W, Morlion B, Vowles KE, Bannister K, Buchser E, Casale R, Chenot JF, Chumbley G, Drewes AM, Dom G, Jutila L, O’Brien T, Pogatzki-Zahn E, Rakusa M, Suarez-Serrano C, T\u00f6lle T, Kr\u010devski \u0160kvar\u010d N. Eur J Pain. 2021 May;25(5):949-968. doi: 10.1002\/ejp.1736. Epub 2021 Mar 2.PMID: 33655607 \r\n8.\tGuidelines on the management of chronic pain in children. Geneva: World Health Organization; 2020. Licence: CC BY-NC-SA 3.0 IGO.\r\n\r\n”,”redirect_url”:””}}}}

{“questions”:{“5xo73”:{“id”:”5xo73″,”mediaType”:”image”,”answerType”:”text”,”imageCredit”:””,”image”:””,”imageId”:””,”video”:””,”imagePlaceholder”:””,”imagePlaceholderId”:””,”title”:”\r\n\r\n\r\nLI-4 is an acupuncture point that has been shown to decrease anxiety in children and adults. Which of the following statements is true regarding acupuncture at LI-4?\r\n\r\n”,”desc”:””,”hint”:””,”answers”:{“hqvcb”:{“id”:”hqvcb”,”image”:””,”imageId”:””,”title”:”A.\tIt is located at the highest point of the thenar muscle, between the first and second metacarpal.”},”enier”:{“id”:”enier”,”image”:””,”imageId”:””,”title”:”B.\tAcupressure at this point can be taught to parents and pediatric patients.”},”mic6d”:{“id”:”mic6d”,”image”:””,”imageId”:””,”title”:”C.\tIt is a commonly used acupuncture point in the treatment of headache and generalized pain.”},”drvpi”:{“id”:”drvpi”,”image”:””,”imageId”:””,”title”:”D.\tIt is particularly useful in the treatment of ailments of the head and face.”},”to25r”:{“id”:”to25r”,”image”:””,”imageId”:””,”title”:”E.\tAll of the above statements are true.”,”isCorrect”:”1″}}}},”results”:{“162oc”:{“id”:”162oc”,”title”:””,”image”:”https:\/\/pedspainmedicine.org\/wp-content\/uploads\/2021\/12\/Acupuncture.jpg”,”imageId”:”2150″,”min”:”0″,”max”:”1″,”desc”:”Picture from A Manual of ACUPUNCTURE by Peter Deadman and Mazin Al-Khafaji, with Kevin Baker. The Journal of Chinese Medicine, 2nd edition, 2007. Digital format \r\n\r\nCorrect Answer: E. All of the above statements are true.\r\n\r\nLI-4 is a very commonly used acupuncture point used in the treatment of pain and anxiety. It is located on the dorsum of the hand, at the most prominent point of the thenar muscle, on the radial side of the midpoint of the second metacarpal. Because it is an easy point to locate, acupressure at this point can be easily performed and taught to patients, parents, or other medical providers. There are many studies demonstrating its effectiveness in the treatment of anxiety and headache when used in combination with other points^{2,3,4,5<\/sup>. In medical acupuncture, it is known to be particularly useful in the treatment of a variety of head and face disorders1<\/sup> including toothache6,7<\/sup>, jaw pain\/spasms8,9<\/sup>, rhinitis, nasal congestion, changes in taste10, and ear pain\/tinnitus. It can also be used to relieve dysmenorrhea 1,11,12<\/sup>. ———————————————————————————————-\r\n\r\nReferences: \r\n1 A Manual of ACUPUNCTURE by Peter Deadman and Mazin Al-Khafaji, with Kevin Baker. The Journal of Chinese Medicine, 2nd edition, 2007. Digital format\r\n\r\n2 Amini Rarani S, Rajai N, Sharififar S. Effects of acupressure at the P6 and LI4 points on the anxiety level of soldiers in the Iranian military. BMJ Mil Health. 2021 Jun;167(3):177-181. doi: 10.1136\/jramc-2019-001332. Epub 2020 Feb 2. PMID: 32015185. \r\n3 Coeytaux RR, Befus D. Role of Acupuncture in the Treatment or Prevention of Migraine, Tension-Type Headache, or Chronic Headache Disorders. Headache. 2016 Jul;56(7):1238-40. doi: 10.1111\/head.12857. Epub 2016 Jul 13. PMID: 27411557. \r\n4 Doll E, Threlkeld B, Graff D, Clemons R, Mittel O, Sowell MK, McDonald M. Acupuncture in Adult and Pediatric Headache: A Narrative Review. Neuropediatrics. 2019 Dec;50(6):346-352. doi: 10.1055\/s-0039-1695785. Epub 2019 Aug 29. PMID: 31466110. \r\n5 Linde K, Allais G, Brinkhaus B, Fei Y, Mehring M, Shin BC, Vickers A, White AR. Acupuncture for the prevention of tension-type headache. Cochrane Database Syst Rev. 2016 Apr 19;4:CD007587. doi: 10.1002\/14651858.CD007587.pub2. PMID: 27092807; PMCID: PMC4955729. \r\n6 Grillo CM, Wada RS, da Luz Ros\u00e1rio de Sousa M. Acupuncture in the management of acute dental pain. J Acupunct Meridian Stud. 2014 Apr;7(2):65-70. doi: 10.1016\/j.jams.2013.03.005. Epub 2013 Apr 11. PMID: 24745864. \r\n7 Devanand Gupta, Deepak Ranjan Dalai, Swapnadeep, Parul Mehta, B Niranjanaprasad Indra, Saurabh Rastogi, Ankita Jain, Mudita Chaturvedi, Saumya Sharma, Sanjeev Singh, Shruti Gill, Nisha Singh, Rajendra Kumar Gupta. Acupuncture (\u91dd\u7078 Zh\u0113n Ji\u01d4) \u2013 An Emerging Adjunct in Routine Oral Care. Journal of Traditional and Complementary Medicine. 2014;4(4). 218-223. ISSN 2225-4110. doi.org\/10.4103\/2225-4110.139113. \r\n8 Shen YF, Younger J, Goddard G, Mackey S. Randomized clinical trial of acupuncture for myofascial pain of the jaw muscles. J Orofac Pain. 2009 Fall;23(4):353-9. PMID: 19888488; PMCID: PMC2894813. \r\n9 Lu DP, Lu GP, Lu PM. Clinical effectiveness of acupuncture for mandibular subluxation and dislocation. Acupunct Electrother Res. 2010;35(3-4):187-92. doi: 10.3727\/036012910803860896. PMID: 21319604. \r\n10 Djaali W, Simadibrata CL, Nareswari I. Acupuncture Therapy in Post-Radiation Head-and-Neck Cancer with Dysgeusia. Med Acupunct. 2020 Jun 1;32(3):157-162. doi: 10.1089\/acu.2020.1410. Epub 2020 Jun 16. PMID: 32595823; PMCID: PMC7310235 \r\n11 Huang T, Yang L, Jia S, Mu X, Wu M, Ye H, Liu W, Cheng X. Capillary blood flow in patients with dysmenorrhea treated with acupuncture. J Tradit Chin Med. 2013 Dec;33(6):757-60. doi: 10.1016\/s0254-6272(14)60008-x. PMID: 24660607. \r\n12 Bazarganipour F, Taghavi SA, Allan H, Beheshti F, Khalili A, Miri F, Rezaei M, Mojgori M, Imaninasab F, Irani F, Salari S. The effect of applying pressure to the LIV3 and LI4 on the symptoms of premenstrual syndrome: A randomized clinical trial. Complement Ther Med. 2017 Apr;31:65-70. doi: 10.1016\/j.ctim.2017.02.003. Epub 2017 Feb 21. PMID: 28434473.\r\n”,”redirect_url”:””}}}}

{“questions”:{“950rt”:{“id”:”950rt”,”mediaType”:”image”,”answerType”:”text”,”imageCredit”:””,”image”:””,”imageId”:””,”video”:””,”imagePlaceholder”:””,”imagePlaceholderId”:””,”title”:”\r\n\r\nVirtual reality-based guided relaxation (VR-GR) used as a non-pharmacological intervention in children and adolescents with acute postoperative pain has been shown in a pilot study to be associated with a decrease in which of the following parameters:”,”desc”:””,”hint”:””,”answers”:{“byvbl”:{“id”:”byvbl”,”image”:””,”imageId”:””,”title”:”A. Opioid use”},”jj71d”:{“id”:”jj71d”,”image”:””,”imageId”:””,”title”:”B. Pain unpleasantness”,”isCorrect”:”1″},”xr2c5″:{“id”:”xr2c5″,”image”:””,”imageId”:””,”title”:”C. Breathing rate”},”can7c”:{“id”:”can7c”,”image”:””,”imageId”:””,”title”:”D. Family satisfaction”}}}},”results”:{“rzmpk”:{“id”:”rzmpk”,”title”:””,”image”:””,”imageId”:””,”min”:”0″,”max”:”1″,”desc”:”Correct Answer: B. Pain unpleasantness \r\n\r\nVirtual reality (VR), a multimodal system that transports users into a fully immersive virtual world, has been explored as a complementary pain management strategy for many years. Until now, the primary use of VR in both pediatric and adult care has been distraction-based therapy during acutely painful procedures.^{1\u20135<\/sup> However, given the risks associated with opioid exposure in children, including after surgery,6<\/sup> VR is now being explored as a method of helping to decrease postoperative pain and anxiety after surgery.7\u20139<\/sup> \r\n\r\nA pilot study done at Cincinnati Children\u2019s Hospital Medical Center explored the use of a single, guided relaxation-based VR session (VR-GR) in children and adolescents following surgery.8,10<\/sup> Over a 9-month period, a total of 51 children and adolescents followed by the Acute Pain Service participated in a single, 10-minute session using the \u201cMindful Aurora\u201d application (Invincikids, Palo Alto, CA). Baseline measurements of pain intensity, pain unpleasantness, and anxiety were taken for each patient and compared to these same values immediately following the experience as well as 15 and 30 minutes following session completion. The VR-GR session was associated with transient reductions in pain intensity, pain unpleasantness, and anxiety. Patient and family satisfaction with the experience was high. Future study is being done to assess the efficacy of VR in decreasing pain, anxiety, opioid, and benzodiazepine consumption via a randomized controlled trial allowing for further exploration of this alternative, non-pharmacological intervention. \r\n\r\nReferences: \r\n1. \tMalloy KM, Milling LS. The effectiveness of virtual reality distraction for pain reduction: A systematic review. Clin Psychol Rev<\/em>. 2010;30(8):1011-1018. doi:10.1016\/j.cpr.2010.07.001 \r\n2. \tIndovina P, Barone D, Gallo L, Chirico A, De Pietro G, Giordano A. Virtual Reality as a Distraction Intervention to Relieve Pain and Distress During Medical Procedures: A Comprehensive Literature Review. Clin J Pain<\/em>. 2018;34(9):858-877. doi:10.1097\/AJP.0000000000000599 \r\n3. \tMallari B, Spaeth EK, Goh H, Boyd BS. Virtual reality as an analgesic for acute and chronic pain in adults: a systematic review and meta-analysis. J Pain Res<\/em>. 2019;Volume 12:2053-2085. doi:10.2147\/JPR.S200498 \r\n4. \tGarrett B, Taverner T, Masinde W, Gromala D, Shaw C, Negraeff M. A Rapid Evidence Assessment of Immersive Virtual Reality as an Adjunct Therapy in Acute Pain Management in Clinical Practice. Clin J Pain<\/em>. 2014;30(12):1089-1098. doi:10.1097\/AJP.0000000000000064 \r\n5. \tLi A, Monta\u00f1o Z, Chen VJ, Gold JI. Virtual reality and pain management: current trends and future directions. Pain Manag<\/em>. 2011;1(2):147-157. doi:10.2217\/pmt.10.15 \r\n6. \tHarbaugh CM, Lee JS, Hu HM, et al. Persistent Opioid Use Among Pediatric Patients After Surgery. Pediatrics<\/em>. 2018;141(1):e20172439. doi:10.1542\/peds.2017-2439 \r\n7. \tOlbrecht VA, Williams SE, O\u2019Conor KT, et al. Guided relaxation-based virtual reality versus distraction-based virtual reality or passive control for postoperative pain management in children and adolescents undergoing Nuss repair of pectus excavatum: protocol for a prospective, randomised, controlled trial (FOREVR Peds trial). BMJ Open<\/em>. 2020;10(12):e040295. doi:10.1136\/bmjopen-2020-040295 \r\n8. \tOlbrecht VA, O\u2019Conor KT, Williams SE, et al. Guided Relaxation-Based Virtual Reality for Acute Postoperative Pain and Anxiety: A Pilot Study in a Pediatric Population. J Med Internet Res<\/em>. Published online May 4, 2021. doi:10.2196\/26328 \r\n9. \tOlbrecht VA, O\u2019Conor KT, Williams SE, et al. Transient Reductions in Postoperative Pain and Anxiety using Virtual Reality in Children. Pain Med Malden Mass<\/em>. Published online June 27, 2021:pnab209. doi:10.1093\/pm\/pnab209 \r\n10. \tO\u2019Conor KT, Olbrecht VA. Using Guided-Relaxation Based Virtual Reality to Manage Post-Surgical Pain and Anxiety in Children. Society for Pediatric Pain Medicine Newsletter<\/em>. https:\/\/pedspainmedicine.org\/wp-content\/uploads\/newsletters\/2021\/summer\/VR\/guided%20relax.html. Published Summer 2021. Accessed September 20, 2021. \r\n\r\n\r\n”,”redirect_url”:””}}}}

{“questions”:{“u446w”:{“id”:”u446w”,”mediaType”:”image”,”answerType”:”text”,”imageCredit”:””,”image”:””,”imageId”:””,”video”:””,”imagePlaceholder”:””,”imagePlaceholderId”:””,”title”:”\r\n\r\nThere is a strong evidence base for the association between sleep and pain. Researchers have grappled with the direction of causality\u2014can sleep disturbance increase pain? Prospective studies have found evidence for sleep disturbance preceding pain exacerbations in individuals with chronic pain. Studies suggest that as little as _____ of sleep disturbance can result in increased pain. “,”desc”:””,”hint”:””,”answers”:{“2priv”:{“id”:”2priv”,”image”:””,”imageId”:””,”title”:”A. One night”,”isCorrect”:”1″},”rg0a9″:{“id”:”rg0a9″,”image”:””,”imageId”:””,”title”:”B. Two nights”},”t2bxq”:{“id”:”t2bxq”,”image”:””,”imageId”:””,”title”:”C. One week”},”76u4x”:{“id”:”76u4x”,”image”:””,”imageId”:””,”title”:”D. Two weeks”}}}},”results”:{“p7gmp”:{“id”:”p7gmp”,”title”:””,”image”:””,”imageId”:””,”min”:”0″,”max”:”1″,”desc”:”Correct Answer: A. One night \r\nSleep is a highly complex process that is essential for recuperation, memory, emotional modulation, performance and learning.1 Disturbances in sleep have been shown to impact all areas of functioning as well as acute and chronic pain in children.2 The directionality between sleep and pain, where poor sleep results in increased pain or increased pain results in poor sleep, have been highly debated. In adult populations, more recent evidence has showed a stronger effect of poor sleep resulting in worsening pain as opposed to the bidirectional relationship that was previously thought.1 A single night of sleep deprivation in patients with arthritis resulted in increased self-reported pain.3 Further, experimental studies in healthy volunteers showed that two nights of poor sleep resulted in spontaneous bodily pain after partial sleep deprivation.3 \r\nThe pediatric literature is less clear. In the acute pain setting, evidence seems to indicate that poor sleep was associated with greater next day pain.4 In youth with sickle cell disease, pain and sleep seemed to be bidirectional.5 Comorbidities and socioeconomic factors also affect sleep in children.6,7 Although further studies are needed to establish the sleep-pain relationship, poor sleep in children with pain should be addressed and improved. \r\n\r\n\r\nReferences: \r\n 1. Babiloni AH, De Koninck BP, Beetz G, De Beaumont L, Martel MO, Lavigne GJ. Sleep and pain: recent insights, mechanisms, and future directions in the investigation of this relationship. Journal of Neural Transmission. 2020;127:647-660. \r\n 2. Valrie CR, Bromberg MG, Palermo T, Schanberg LE. A Systematic Review of Sleep in Pediatric Pain Populations. J Dev Behav Pediatr. 2013;34(2):120-8. \r\n 3. Finan, PH, Goodin BR, Smith MT. The association of sleep and pain: an update and a path forward. J Pain. 2013;14(12): 1539-1552. \r\n 4. Rabbitts JA, Zhou C, Narayanan A, Palermo TM. Longitudinal and Temporal Associations Between Daily Pain and Sleep Patterns After major Pediatric Surgery. J Pain. 2017;18(6):656-663. \r\n 5. Fisher K, Laikin AM, Howard Sharp KM, Criddle CA, Palermo TM, Karlson CW. Temporal relationship between daily pain and actigraphy sleep patterns in pediatric sickle cell disease. J Behav Med. 2018;41(3):416-422. \r\n 6. Allen JM, Graef DM, Ehrentraut JH, Tynes BL, Crabtree VM. Sleep and Pain in Pediatric Illness: A Conceptual Review. CNS Neurosci Ther. 2016;22(11):880-893. \r\n 7. Evans S, Taub R, Tsao JCI, Meldrum M, Zeltzer LK. Sociodemographic factors in a pediatric chronic pain clinic: The roles of age, sex and minority status in pain and health characteristics. J Pain Manag. 2010;3(3):273-281. \r\n\r\n\r\n”,”redirect_url”:””}}}

{“questions”:{“1owm5”:{“id”:”1owm5″,”mediaType”:”image”,”answerType”:”text”,”imageCredit”:””,”image”:””,”imageId”:””,”video”:””,”imagePlaceholder”:””,”imagePlaceholderId”:””,”title”:”\r\n\r\n\r\nThe American Society of Hematology non-opioid pharmacologic guidelines for Sickle Cell Disease acute pain management now recommends the use of regional anesthesia for select adult and pediatric patients with focal vaso-occlusive crisis. Regional anesthesia with peripheral nerve blockade is beneficial for this population as it:”,”desc”:””,”hint”:””,”answers”:{“bmmf0”:{“id”:”bmmf0″,”image”:””,”imageId”:””,”title”:”(A)\t Stimulates the upregulation of IL-1, IL-6 and TNF”},”5wojm”:{“id”:”5wojm”,”image”:””,”imageId”:””,”title”:”(B)\t Stimulates the upregulation of p-selectin, vascular cellular adhesion molecules (VCAM) and intercellular adhesion molecules (ICAM)\r\n”},”s3sks”:{“id”:”s3sks”,”image”:””,”imageId”:””,”title”:”(C)\t Improves local vasodilation and oxygen delivery”,”isCorrect”:”1″},”ucao6″:{“id”:”ucao6″,”image”:””,”imageId”:””,”title”:”(D)\t Reduces the duration of vaso-occlusive crises”}}}},”results”:{“oy3yl”:{“id”:”oy3yl”,”title”:””,”image”:””,”imageId”:””,”min”:”0″,”max”:”1″,”desc”:”Correct answer: (C)\t Improves local vasodilation and oxygen delivery\r\n\r\nPharmacotherapy 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. \r\n\r\nReferences:\r\n\r\n1.\tTighe 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. \r\n2.\tWeber 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. \r\n3.\tWyatt KE, Pranav H, Henry T, et al. Pericapsular nerve group blockade for sickle cell disease vaso-occlusive crisis. J Clin Anesth 2020:66:109932. \r\n4.\tYaster 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. \r\n5.\tNew 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. \r\n6.\tBrandow 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. \r\n7.\tWyatt KE, Liu CJ. Regional Anesthesia for Sickle Cell Disease Vaso-occlusive Crisis. SPPM Newsletter Fall 2020. \r\n”,”redirect_url”:””},”71ovm”:{“id”:”71ovm”,”title”:””,”image”:””,”imageId”:””,”min”:”0″,”max”:”1″,”desc”:””,”redirect_url”:””}}}