Society for Pediatric Pain Medicine
Better Care for Children in Pain

{“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”:””}}}

{“questions”:{“0ipbc”:{“id”:”0ipbc”,”mediaType”:”image”,”answerType”:”text”,”imageCredit”:””,”image”:””,”imageId”:””,”video”:””,”imagePlaceholder”:””,”imagePlaceholderId”:””,”title”:”July’s Question Submitted By:\r\n\r\nJamie Kitzman, MD \r\nPediatric Anesthesiologist\r\nAssistant Professor \r\nDepartment of Anesthesiology \r\nChildren’s Healthcare of Atlanta\r\n\r\nYintang is an acupuncture point that has been shown to decrease preoperative anxiety in children and adults. Which of the following statements is true about Yintang?”,”desc”:””,”hint”:””,”answers”:{“cswp6”:{“id”:”cswp6″,”image”:””,”imageId”:””,”title”:”a. \tIt is located at the glabella, at the midpoint between the eyebrows.”},”uswxl”:{“id”:”uswxl”,”image”:””,”imageId”:””,”title”:”b. \tAcupressure at this point can be taught to parents and pediatric patients.”},”a842l”:{“id”:”a842l”,”image”:””,”imageId”:””,”title”:”c. \tIt is a commonly used acupuncture point in the treatment of anxiety and pain.”},”ku377″:{“id”:”ku377″,”image”:””,”imageId”:””,”title”:”d. \tIt can be used in the treatment of insomnia and headache.”},”gzt3y”:{“id”:”gzt3y”,”image”:””,”imageId”:””,”title”:”e. \tAll of the above statements are true.”,”isCorrect”:”1″}}}},”results”:{“y3kwq”:{“id”:”y3kwq”,”title”:””,”image”:””,”imageId”:””,”min”:”0″,”max”:”1″,”desc”:”CORRECT ANSWER: E. \tAll of the above statements are true.\r\n\r\nRATIONALE: \r\nYintang is a very commonly used acupuncture point used in the treatment of pain and anxiety. It is an easy point to locate making it a very teachable point for others to use. Medical providers can learn how to apply acupressure to this point and, in turn, teach their patients and\/or parents of patients how to use this point. It is located at the glabella, or midpoint between the eyebrows. To perform acupressure, sit\/lay down in a comfortable position. Then, apply firm, deep pressure for 5 seconds in a circular motion and release. Allow the muscles in your face to relax. Repeat as needed. There are many studies demonstrating its effectiveness in the treatment of preprocedural anxiety. It is also commonly used in the treatment of pain, headache, agitation, nasal\/sinus ailments, and insomnia. \r\n\r\n\r\n\r\n \r\nPicture from https:\/\/jinshinjyutsuheleneiliste.wordpress.com\/tag\/yin-tang\/ \r\n \r\n\r\nREFERENCES \r\n1.\tKwon CY, Lee B. Acupuncture or Acupressure on Yintang (EX-HN 3) for Anxiety: A Preliminary Review. Med Acupunct. 2018 Apr 1;30(2):73-79. doi: 10.1089\/acu.2017.1268. PMID: 29682147; PMCID: PMC5908420. \r\n2.\tWiles MD, Mamdani J, Pullman M, Andrzejowski JC. A randomised controlled trial examining the effect of acupuncture at the EX-HN3 (Yintang) point on pre-operative anxiety levels in neurosurgical patients. Anaesthesia. 2017 Mar;72(3):335-342. doi: 10.1111\/anae.13785. Epub 2017 Jan 16. PMID: 28092106. \r\n3.\tWang SM, Escalera S, Lin EC, Maranets I, Kain ZN. Extra-1 acupressure for children undergoing anesthesia. Anesth Analg. 2008 Sep;107(3):811-6. doi: 10.1213\/ane.0b013e3181804441. PMID: 18713889.\r\n \r\n”,”redirect_url”:””}}}

{“questions”:{“zf4ni”:{“id”:”zf4ni”,”mediaType”:”image”,”answerType”:”text”,”imageCredit”:””,”image”:””,”imageId”:””,”video”:””,”imagePlaceholder”:””,”imagePlaceholderId”:””,”title”:”June’s Question Submitted By:\r\n \r\nThomas Spain, MD, MPH \r\nAssociate Professor UT Southwestern \r\nChildren’s Medical Center Dallas \r\n\r\n\r\nCase History: \r\nYou are called to the ED to evaluate a 16-year-old male with a severe headache. The patient has a history of testicular germ cell tumor diagnosed two years ago and is s\/p surgical resection and chemotherapy. Today he complains of a 10\/10 pulsating pain in the right temporal region. As you enter the patient\u2019s room, you notice that all the lights are off. The patient\u2019s mom quickly greets you at the door, whispering as she introduces herself, she provides you with some further history. You note that the patient is resting in bed with a cold rag over his eyes with a nearby emesis basin filled with vomitus. Mom reports that the patient started experiencing similar headache episodes 6 months ago. He had an ER visit three weeks ago where he was treated with Benadryl, Compazine, and Toradol with limited benefit. He was then admitted for three days for treatment with DHE that was effective, but his headache returned after 48 hours. Mom is asking if something different can be used to help her child. \r\n\r\nBased on the current literature, which of the following is true?\r\n”,”desc”:””,”hint”:””,”answers”:{“7fzfb”:{“id”:”7fzfb”,”image”:””,”imageId”:””,”title”:”A.\tPropofol has more rebound headaches and a longer length of stay than standard therapy. “},”e9y6d”:{“id”:”e9y6d”,”image”:””,”imageId”:””,”title”:”B.\tA RCT in adults concluded that propofol can be used for management of acute migraines with similar rates of recurrence in the propofol group compared to the Sumatriptan group. “},”s2jcb”:{“id”:”s2jcb”,”image”:””,”imageId”:””,”title”:”C.\tA 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.”,”isCorrect”:”1″},”slaec”:{“id”:”slaec”,”image”:””,”imageId”:””,”title”:”D.\tPropofol works by blocking the Na+ channels in the CNS and therefore limits the transmission of pain.”}}}},”results”:{“71bem”:{“id”:”71bem”,”title”:””,”image”:””,”imageId”:””,”min”:”0″,”max”:”1″,”desc”:”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 \r\nRATIONALE: \r\nMigraine 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. \r\nMigraines 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. \r\n\r\n\r\nREFERENCES: \r\n1.\tGelfand A., Pediatric and adolescent headache. Continuum (MINNEAP MINN), 2018; 24(4): 1108-1136 \r\n2.\tSheridan 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 \r\n3.\tSheridan 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 \r\n4.\tMoshtaghion 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.\r\n\r\n\r\n”,”redirect_url”:””}}}

{“questions”:{“ua2ox”:{“id”:”ua2ox”,”mediaType”:”image”,”answerType”:”text”,”imageCredit”:””,”image”:””,”imageId”:””,”video”:””,”imagePlaceholder”:””,”imagePlaceholderId”:””,”title”:”\r\nMembrane stabilizers are commonly used to treat both acute and chronic pain in children and adolescents. Which of the following is the MOST likely mechanism of gabapentin?”,”desc”:””,”hint”:””,”answers”:{“orgb6”:{“id”:”orgb6″,”image”:””,”imageId”:””,”title”:”A. Selective inhibition of GABA_{B<\/sub> receptors containing the GABAB1a<\/sub> and GABAB2<\/sub> subunits”},”pwhg6″:{“id”:”pwhg6″,”image”:””,”imageId”:””,”title”:”B. Selective inhibition on voltage-gated calcium channels containing the \u03b12\u03b4-1 subunit”,”isCorrect”:”1″},”gq3nj”:{“id”:”gq3nj”,”image”:””,”imageId”:””,”title”:”C. Selective inhibition on voltage-gated sodium channels containing the \u03b12\u03b4-1 subunit”},”5nxh8″:{“id”:”5nxh8″,”image”:””,”imageId”:””,”title”:”D. Selective inhibition on voltage-gated potassium channels containing the \u03b12\u03b4-1 subunit”}}}},”results”:{“azuqm”:{“id”:”azuqm”,”title”:””,”image”:”https:\/\/pedspainmedicine.org\/wp-content\/uploads\/2021\/08\/SPPM-QOM-August-2021.jpg”,”imageId”:”1791″,”min”:”0″,”max”:”1″,”desc”:”Correct Answer: B. Selective inhibition on voltage-gated calcium channels containing the \u03b12\u03b4-1 subunit \r\n\r\nAlthough early proposed mechanisms of gabapentin were interaction by activation of the GABAB<\/sub> receptors containing the GABAB1a<\/sub> and GABAB2<\/sub> subunits, thereby enhancing NMDA current or inhibiting AMPA-receptor-mediated transmission to the spinal cord, more recent studies have instead favored selective inhibition at the \u03b12\u03b4-1 subunit of spinal N-type Ca (2+) channels.\r\n\r\nReferences: \r\n1.\tChen J, Li L, Chen SR, et al. The \u03b12\u03b4-1-NMDA Receptor Complex Is Critically Involved in Neuropathic Pain Development and Gabapentin Therapeutic Actions. Cell Rep<\/em>. 2018;22(9):2307-2321. doi:10.1016\/j.celrep.2018.02.021 \r\n\r\n2.\tCheng JK, Chiou LC. Mechanisms of the antinociceptive action of gabapentin. J Pharmacol Sci. 2006;100(5):471-86. doi: 10.1254\/jphs.cr0050020. Epub 2006 Feb 11. PMID: 16474201. \r\n\r\n3.\tLi G, Li P. (2020, Summer) The use of membrane stabilizers in acute and chronic pain. SPPM Newsletter<\/em>. Retrieved from https:\/\/pedspainmedicine.org\/wp-\r\ncontent\/uploads\/newsletters\/2020\/summer\/nonopioid\/Membrane%20Stabilizers%20.html \r\n\r\n4.\tSills GJ, Rogawski MA. Mechanisms of action of currently used antiseizure drugs. Neuropharmacology. 2020 May 15;168:107966. doi: 10.1016\/j.neuropharm.2020.107966. Epub 2020 Jan 14. PMID: 32120063. \r\n”,”redirect_url”:””}}}}