Error traps in acute pediatric pain management. Part 2
Myron Yaster MD and Lynne Maxwell MD
Today’s Pediatric Anesthesia Article of the Day is part 2 of error traps in acute pediatric pain management. As discussed in part 1, error traps are “Cognitive errors involving faulty-thought processes and subconscious biases, and are important contributors to missed diagnoses and patient injury.”1
Today’s PAAD focuses on the final 3 of the 5 error traps (figure) discussed in the article. Myron Yaster MD
Original article
Tricia M Vecchione, Rita Agarwal, Constance L Monitto. Error traps in acute pain management in children. Paediatr Anaesth. 2022 Sep;32(9):982-992. PMID: 35751474
Failure to choose appropriate systemic analgesics
“Commission bias1, a tendency toward action over inaction, can motivate clinicians to routinely prescribe opioids as first-line therapy to treat all types and levels of pain”.2 Less potent analgesics, particularly, weak analgesics with anti-pyretic effects (e.g., acetaminophen and ibuprofen) may be all that’s needed for mild to moderate pain and, are always useful as components of multi-modal analgesia, when treating severe pain. The authors also describe the use of gabapentenoids and NMDA blockade and provide an excellent table on dosing suggestions.
Another error is premature closure,1 in which a preliminary conclusion regarding the source of a patient's pain is chosen without consideration of alternate etiologies, can similarly lead to inappropriate or ineffective analgesic choices. For example, muscle spasms may be a primary source of pain after some types of surgery, and muscle relaxants may provide the most effective pain relief.”2 Not discussed by the authors in this context is the increased risk of respiratory depression when benzodiazepines are co-administered with opioids. Indeed, in several recent PAADs I’ve (MY) urged the provision of a prescription for intranasal naloxone when opioids and benzodiazepines are co-prescribed for patients on discharge from the hospital.
Vecchione et al.2 also discuss the use of IV patient-controlled analgesia (PCA) in this section of the article. What they didn’t discuss is the use of surrogate IVPCA or better said, patient- or parent-controlled analgesia and the use of continuous background opioid infusions while using PCA. Although very common at Hopkins and Stanford where the authors work, many institutions do not allow these therapies or only offer them in a very limited way. The failure to use these therapies, we believe fall under the cognitive errors of confirmation bias, that is, seeking or acknowledging only information that confirms the desired or suspected diagnosis or omission bias, the hesitation to start a therapy for fear of being wrong or causing harm, which tends towards inaction.
Failure to consider patient characteristics when dosing analgesics
“Patients may have underlying physiologic conditions that necessitate modification of dosing. Genetic factors, extremes of age, and disease states can alter drug metabolism, binding, and elimination, predisposing some patients to serious adverse effects”.2
As most of you know, I (MY) believe that opioids are an essential part of pain management because 3,000 years of experience has proven that they work. Thus, we agree with Veccione et al that avoiding opioids at all costs is unacceptable. On the other hand, “focusing solely on managing the patient's pain while failing to consider their underlying physiologic condition (anchoring bias) can potentially result in inappropriately high opioid dosing and unintended adverse consequences”.2 Anchoring bias is focusing on one issue at the expense of understanding the whole situation.1 Thus, patients with renal disease, or with abnormal CYP2D6 or the newborn will require lower than usually prescribed morphine, codeine, and tramadol doses because they cannot metabolize and excrete these drugs normally.
Sometimes our analgesic therapies don’t work as well as we would hope, or patients need more drugs than the classic tables suggest (just think patients with chronic pain). These patients are often labeled “difficult” and engender negative feelings amongst those taking care of them. This is visceral bias, “counter-transference; our negative or positive feelings about a patient influencing our decisions.”1
Failure to identify and treat medication-related side effects
There is no free lunch, all medicines have side effects, and many of the analgesics we use have lots. Even the most “benign” acetaminophen and ibuprofen can cause liver and kidney damage respectively. Opioids are in a class of their own though, frequently causing nausea, vomiting, constipation, pruritus, sedation, and respiratory depression. For most, the best defense is a good offense. Proactively using antidotes like 5-hydroxytryptamine agents for nausea and vomiting, Miralax or other bulk producing laxative as soon as the patient is eating or drinking to prevent opioid-induced bowel dysfunction, antihistamines or low dose naloxone to prevent pruritus, and monitoring for and having naloxone available for opioid-induced respiratory depression are discussed in detail.
Finally, Vecchione et al. concentrated on in-hospital issues. Hopefully a future article can discuss the error traps involved in outpatient pain therapy. How much drug to dispense, how to dispose, how to monitor, co-administration of sedative hypnotics, intranasal naloxone and how to follow patients who received peripheral nerve catheters are just a few of the issues that could be discussed.
References
1. Stiegler MP, Neelankavil JP, Canales C, Dhillon A: Cognitive errors detected in anaesthesiology: a literature review and pilot study. Br J Anaesth 2012; 108: 229-35
2. Vecchione TM, Agarwal R, Monitto CL: Error traps in acute pain management in children. Paediatr Anaesth 2022; 32: 982-992
