Society for Pediatric Pain Medicine
Better Care for Children in Pain

{“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”:””}}}

{“questions”:{“bijfd”:{“id”:”bijfd”,”mediaType”:”image”,”answerType”:”text”,”imageCredit”:””,”image”:””,”imageId”:””,”video”:””,”imagePlaceholder”:””,”imagePlaceholderId”:””,”title”:” \r\n\r\nA 15-year-boy presents for an urgent revision of a previous ankle dislocation after falling off his skateboard. His past history is significant for ADHD, and anxiety and ankle surgery 6 months ago. He started using marijuana when he was 13, and misused his opioid prescription after his previous surgery. He is very concerned about postoperative pain management and states that he had significant pain after his last surgery. On his way back to the OR he admits to using opioids or \u201cwhatever he can get his hands on\u201d daily since that surgery, and that he seems to need higher and higher doses. He reports having tried to stop without success and is worried about withdrawal. \r\n\r\nWhich of the following terms best describes his probable current diagnosis?\r\n”,”desc”:””,”hint”:””,”answers”:{“9pxb6”:{“id”:”9pxb6″,”image”:””,”imageId”:””,”title”:”A. Drug addict”},”1075s”:{“id”:”1075s”,”image”:””,”imageId”:””,”title”:”B. Substance abuser”},”0l3tw”:{“id”:”0l3tw”,”image”:””,”imageId”:””,”title”:”C. Prescription opioid abuser”},”mfhvh”:{“id”:”mfhvh”,”image”:””,”imageId”:””,”title”:”D. Person with substance use disorder “,”isCorrect”:”1″}}}},”results”:{“ulqx4”:{“id”:”ulqx4″,”title”:””,”image”:””,”imageId”:””,”min”:”0″,”max”:”1″,”desc”:”Correct Answer: D. Person with substance use disorder \r\n\r\nThe patient\u2019s symptoms fit with a possible<\/em> diagnosis of substance use disorder. A mental health professional such a psychiatrist would need to formally make the diagnosis and get further history to confirm that the patient meets the criticeria for substance use disorder. The term addict, drug addict or even drug abuser assumes moralistic and judgmental connotation. There is blame, shame and stereotyping, even though increased medical and scientific evidence reveals that addiction is a chronic disease with remission, recurrence and relapse. The public already holds highly stigmatizing views regarding people with SUD; these attitudes as well as those help by the patients themselves can prevent individuals from seeking help, in particular adolescents and young adults ^{4<\/sup>. The DSM V specifically uses the terminology substance (or specific drug such as opioid) use disorder in contrast to previous editions of the DSM. \r\n\r\nThe DSM V criteria for substance use disorder is as follows1,2,3<\/sup> : \r\n1.\tTaking the substance in larger amounts or for longer than you’re meant to. \r\n2.\tWanting to cut down or stop using the substance but not managing to. \r\n3.\tSpending a lot of time getting, using, or recovering from use of the substance. \r\n4.\tCravings and urges to use the substance. \r\n5.\tNot managing to do what you should at work, home, or school because of substance use. \r\n6.\tContinuing to use, even when it causes problems in relationships. \r\n7.\tGiving up important social, occupational, or recreational activities because of substance use. \r\n8.\tUsing substances again and again, even when it puts you in danger. \r\n9.\tContinuing to use, even when you know you have a physical or psychological problem that could have been caused or made worse by the substance. \r\n10.\tNeeding more of the substance to get the effect you want (tolerance). \r\n11.\tDevelopment of withdrawal symptoms, which can be relieved by taking more of the substance. \r\n\r\nWe will and do see patients\u2019 with SUD in the operating room, acute pain and chronic pain environments, and avoiding the use of problematic language can make a real difference in patients\u2019 experience and improve compassionate care. The American Academy of Pediatric recently published a paper on the use of the recommended terminology in the care of children, adolescents, young adults and their families 5<\/sup>. There is an incredibly helpful table that makes it easy to appreciate which terms are preferred and why those terms should be used. https:\/\/doi.org\/10.1542\/peds.2022-057529 \r\n\r\n\r\nReferences: \r\n1.\tMcLellan AT. Substance misuse and substance use disorders: Why do they matter in healthcare?. Trans Am Clin Climatol Assoc. 2017;128:112-130. \r\n2.\thttps:\/\/www.verywellmind.com\/dsm-5-criteria-for-substance-use-disorders-21926 \r\n3.\tAmerican Psychiatric Association Diagnostic and Statistical Manual of Mental Disorders 5th ed. Arlington, VA 2013 \r\n4.\tHadland S et.al. Stigma Associated with Opioid Use Disorder in young Adults: A Case Series. Addict Sci Clin Pract 2018, 13: 15 https:\/\/www.ncbi.nlm.nih.gov\/pmc\/articles\/PMC5937046\/ \r\n5.\tAlinsky RH et.al. Recommended Terminology for Substance Use Disorders in the Care of Children, Adolescents, Young Adults and Families. Pediatrics.2022: 149 (6) https:\/\/publications.aap.org\/pediatrics\/article\/149\/6\/e2022057529\/188090\/Recommended-Terminology-for-Substance-Use?autologincheck=redirected \r\n\r\n\r\n”,”redirect_url”:””}}}}