From Myron Yaster MD
Do you use medical apps on your phone? I hope you have SPA’s PediCrisis v 2 on your cell phone as well as Dr. Francis Veyckemans’ “Anesthetic Management of Syndromes and Rare Diseases in Pediatrics”(http://tinyurl.com/PED-RARE). And if you don’t have these apps. please download them now from the SPA website! We are looking for other apps that you, our readers, find useful. Pease send me (myasterster@gmail.com) the app’s name, the link, and your consumer report.
From Christopher B. Massa MD PhD
Thank you for publishing our submission on Dec 11, 2024 entitled: POCUS and Aeration heterogeneity in neonates and how it may vary with different respiratory disorders. I received significant help from my colleague at CHOP Anthony Alexander and had intended him to be a coauthor ont the publication. I apologize for this omission. Is it possible for you to update the post on the website and send a follow up message stating his contribution?
From Dr. Mark Schreiner
The recent PAAD on GLP-1 inhibitors states that "This brings us to an interesting clinical question in pediatric anesthesia: do these medications meaningfully increase the risk of pulmonary aspiration? The short answer is that, yes, they likely do.” I strongly disagree. Where is the evidence that larger gastric fluid volumes increase the risk of aspiration? 95% of healthy children have gastric fluid volumes up to 1.25 mL/kg and some have GFV as much as 4.5 mL/kg. But do those with larger GFV have an increased risk for aspiration of gastric fluid?
As a surrogate for risk of aspiration, GFV utterly fails. As I wrote in 1997 editorial "Because GFVs >0.4 mL/kg are common and aspiration pneumonia is not, it is possible to conclude that other pathways or mechanisms that are not captured by the measurement of GFV are important. Logically, interventions that focus only on reducing GFV or altering gastric pH will not necessarily influence the incidence or severity of aspiration pneumonia unless they also affect the other causative risk factors and mechanisms. A dose-response gradient for GFV and risk of pulmonary aspiration has not been established, and, as a surrogate end point, it has failed to prove its relevancy to outcomes that matter to patients.”(1)
Let’s focus on actual risk factors that lead to aspiration pneumonia and stop this focus on an utterly unproven surrogate.
1. Schreiner MS. Gastric fluid volume: is it really a risk factor for pulmonary aspiration? Anesth Analg. 1998 Oct;87(4):754-6. PMID: 9768764.
From Andreas H. Taenzer, MD, MS, Professor of Anesthesiology and Critical Care Medicine & Pediatrics, The George Washington University School of Medicine and Health Sciences
We do use intraoperative Ketorolac based on Albert Oh’s institutional prospective cohort study that showed no change in bleeding, referenced below. Noteworthy that most plastic surgeons utilize a “palate block” as an epinephrine delivery method for better hemostasis for the repair that is conditio sine qua non.
Hence in our current RCT we are using SZMB plus palatine blocks with no intraoperative opioids (under IRB review). Opioid free, iv acetaminophen, iv ketorolac, iv dexmedetomidine at >=1 mcg/kg are part of the protocol.
Reference
Stein JR, Mantilla-Rivas E, Aivaz M, Rana MS, Mamidi IS, Ichiuji BA, Manrique M, Rogers GF, Finkel JC, Oh AK. Safety and Efficacy of Single-Dose Ketorolac for Postoperative Pain Management After Primary Palatoplasty: A Prospective Cohort Study With Historical Controls. Cleft Palate Craniofac J. 2022 Apr;59(4):505-512. doi: 10.1177/10556656211012864. Epub 2021 May 4. PMID: 33942669.
From Brendan Morgan, MD, FRCPC, Pediatric Anesthesiologist, Department of Anesthesiology and Pain Medicine, The Hospital for Sick Children, Toronto, Canada.
I applaud the PAAD team and the authors of these articles for highlighting the role of the anesthesiologist in caring for young patients with substance-use disorders. I wholeheartedly agree with the recommendations made by Kitzman et al1 and Martin et al2. At The Hospital for Sick Children, our Transitional Pain Service3 has been using the CRAFFT version 2.0 screening tool4 (which includes questions about edibles and vaping) during intake appointments and have identified several high-risk patients who were referred on for further treatment. This tool has both clinician-administered and self-administered options and has been translated into more than 30 languages. We are interested in expanding the use of standardized screening to our pre-operative clinic and other areas. Some of the biggest challenges are how to screen patients privately (remotely by video/call and in clinic) and how to keep the results confidential, especially if a caregiver is a proxy on the EMR or has access to medical records. Marking clinic notes as sensitive in the EMR is one solution (depending on the EMR), but it may not be practical or reasonable for all pre-op assessments. I would love to hear from readers about strategies that they have employed in their hospitals.
For those looking to introduce institutional policies, we found that collaborating with the Adolescent Medicine service is extremely helpful. It affords expertise and long-term follow-up that set youth up for success. Regarding pain and substance use disorders, I would also like to underline two points:
1. Vaping is very common; a recent survey of Canadian teens reported rates of vaping as high as 21.8% among 12th graders.5 Vape liquid contains as much as 20mg/ml of nicotine with some cartridges containing 15-20ml. Since one absorbs about 1-2mg of nicotine from smoking a cigarette, some of our patients are inhaling the equivalent of a pack or more of cigarettes a day through vaping. Acute nicotine withdrawal can increase pain intensity,6 so the use of nicotine replacement therapy may help manage post-op pain for some patients.
2. Regarding opioid use disorder, I find it useful to reassure the patient, the caregivers, and other healthcare workers that the appropriate use of opioids for postoperative pain (in addition to multimodal analgesia and harm reduction techniques -- e.g. close follow up with a taper -- outlined by Kitzman et al1) may be associated with a lower rate of relapse and morbidity than avoiding perioperative opioids in patients with an opioid use disorder. Undertreated pain is commonly cited by patients as a reason to leave against medical advice and is correlated with worse health outcomes, including relapse.7
Armed with our understanding of pharmacology (e.g. patients with opioid use disorders often require larger doses of opioids for a longer duration) and knowledge of the risks and benefits of treatment options for adolescents with substance-use disorders, anesthesiologists can be strong advocates for the optimal inpatient management of these very high-risk populations.
References
Kitzman JM, Mesheriakova VV, Borucki AN, Agarwal R. Substance Use Disorders in Adolescents and Young Adults: History and Perioperative Considerations From the Society for Pediatric Pain Medicine. Anesth Analg. 2023 Jul 14. doi: 10.1213/ANE.0000000000006623. Epub ahead of print. PMID: 37450650. 139(6):1244-1255, December 2024.
Martin, T, Steele, E. (2024). Substance-Use Disorders in Young Patients—Much More Than Preop Questions and Potential for Drug Interactions. Anesthesia & Analgesia, 139 (6), 1240-1243. doi: 10.1213/ANE.0000000000007232.
Isaac L, Rosenbloom BN, Tyrrell J, Ruskin DA, Birnie KA. Development and expansion of a pediatric transitional pain service to prevent complex chronic pain. Front Pain Res (Lausanne). 2023 Nov 2;4:1173675. doi: 10.3389/fpain.2023.1173675. PMID: 38028427; PMCID: PMC10651731.
Knight, JR (2016). The CRAFFT Questionnaire (version 2.0). Boston, MA: Center for Adolescent Substance Abuse Research. https://crafft.org/get-the-crafft/
Boak, A, Hamilton, HA (2024). Drug use among Ontario students, 1977–2023: Findings from the Ontario Student Drug Use and Health Survey (OSDUHS). Toronto, ON: Centre for Addiction and Mental Health. https://www.camh.ca/-/media/research-files/osduhs-drug-use-report_2023.pdf
Ditre JW, Zale EL, LaRowe LR, Kosiba JD, De Vita MJ. Nicotine deprivation increases pain intensity, neurogenic inflammation, and mechanical hyperalgesia among daily tobacco smokers. J Abnorm Psychol. 2018;127(6):578-589. doi:10.1037/abn0000353