SPPM Global Virtual Conference: A Continuum of Acute and Chronic Pain, Part 2

Rita Agarwal MD, FAAP, FASA and Galxy Li MD

THIS! This is what all virtual conferences should aspire to be: a forum of international experts from multiple countries discussing research and clinical perspectives in pediatric acute pain, chronic pain, anesthesia, and sustainability. Today, we continue our review of SPPM Global that was held on 5 Nov 2022 by the Society for Pediatric Pain Medicine.

Pain impacts everyone at some point in their lives and is the most common reason one seeks medical care for themselves or their loved ones. Yet, it can often be problematic to successfully treat, without confounding side effects. Connecting together all those who are interested in understanding, treating and improving pain outcomes can ultimately help reduce the pain burden children suffer.  Conference Chair Galaxy Li MD of Nemours Children’s Health, Jacksonville, FL; SPPM Education Committee Chair Yuan Chi Lin MD of Boston Children’s Hospital; Program Shadow Jamie Kitzman MD of Children’s Healthcare of Atlanta; and the Society for Pediatric Pain Medicine launched SPPM Global on 5 Nov 2022, a fantastic meeting that was recorded, and is now available for on-demand viewing for registrants. Each of the speakers delivered profound lectures applicable to pediatric anesthesiologists.

The second half of SPPM Global’s inaugural virtual conference opened with moderators Anita Davis PhD of Nemours Health Jacksonville and Ken Goldschneider MD of Cincinnati Children’s Hospital warming up the virtual crowd.  Session 2 commenced with Geoff Frawley MD, Associate Professor from the Royal Children’s Hospital, Melbourne, Australia, discussing “Awake Regional Anaesthesia in the Infant: Lessons from the GAS study.” Dr. Frawley eloquently reviewed the history of neurodevelopmental concerns regarding the use of anesthetics and sedatives in the developing brain in the face of increasing use of awake regional anesthetics for infants. He explained that while the evidence in animals may be compelling, the evidence in humans is much more challenging to interpret.  Dr Frawley remarked that the GAS study was an international, multi-institutional prospective randomized controlled trial comparing sevoflurane to awake regional anesthesia that concluded that ”slightly less than 1hr of general anesthesia in early infancy did not alter neurodevelopmental outcomes at age 5 compared to awake regional anesthesia.”  He noted that since the GAS study there had been multiple clinical studies that have shown while IQ and school performance may not be affected by a single anesthetic, behavioral and emotional domains may be.

Carolyn Berryman PhD, MscMed, a post-doctoral research fellow from the University of South Australia, Adelaide then presented an intriguing discourse on “The Credibility, Accuracy, and Comprehensiveness of Websites educating Consumers about Complex Regional Pain Syndrome (CRPS) in Australia.” Her team examined trusted sources available on-line in Australia and evaluated them for clarity, accuracy and importance of the recommendations on these sites. She found that only 43% gave clear and accurate recommendations (based on the 96 Gold Standard recommendations). Her group then partnered with CRPS patients and other health care professionals to develop educational tools based on the importance of the information and recommendations. Dr Berryman summarized that healthcare professionals’ top 5 recommendations were: explaining the importance of pacing and setting realistic goals, providing basic signs and symptoms, explaining that CRPS is a lifelong disease and that pain main affect mood, and describing how pain works and how it affects the brain. Interestingly, her study found that  CRPS patients ranked slightly different information as most important. This included: explaining that CRPS us not in the head but is real, the importance of advocating for themselves, the importance of maintaining mobility, , the importance of self-care, and how symptoms may change with weather and stress.. As our understanding of CRPS has continued to evolve, Dr Berryman served as an ambassador connecting the perspectives of our patients experiencing it to those of us and our colleagues who aim to effectively diagnose and treat this conundrum.

Ross Drake MBChB, Lead Consultant from Starship Children’s Health in Auckland, New Zealand, delineated often unclear borders with his lecture “A Continuum of Acute and Chronic Pain- The intersection of Palliative Care and Pain Medicine.” Using patient vignettes, he demonstrated the impact of pain on patients with cancer and other severe progressive diseases. He shared the case of a 9 year old who had been hospitalized for 61 consecutive days after a new diagnosis of M7 acute myeloid leukemia. This patient had endured multiple (>65) blood draws, 2 lumbar punctures, urine catheters and cultures 12 times, 2 chest/abdominal X-rays, 2 echocardiograms, 2 bone scans with MRI, a bone marrow aspiration, one tissue biopsy, 2 central line placements and 2 PICC line placements. Dr. Drake discussed the importance of both nonpharmacologic approaches and medication management for children with prolonged hospitalizations and recurrent invasive interventions. He stressed the importance of developing an assessment framework to focus not on the disease, but the impact of the disease on the patient. Dr Drake reviewed the dosing and rationale behind opioid rotation for patient on a prolonged course of opioids, demystifying concepts that can commonly challenge pain providers.

In the spirit of the green virtual conference compared to the traditional in-person conferences, the final SPPM Global lecturer delivered his address on one of the most important topics facing our planet: environmental health and sustainability.  Forbes McGain PhD, Associate Professor of Anesthesia and Intensive Care at Western Health, Melbourne, is one of the leading names in and pioneers of sustainability science. His lecture “The Environmental Footprint of What We Do and How we can Join The Race to Zero” provided a comprehensive synopsis of how our daily healthcare routines impact our environment. He empowered all by asserting that most healthcare providers can make relatively more substantial effects on our environment at work than simply recycling home products or using renewable sources of energy to heat personal homes or power personal cars. Dr McGain explained that the carbon footprint of using 1 MAC of desflurane or nitrous oxide for an hour is equivalent to 48 hours of sevoflurane at 1 MAC which is equivalent to burning 30 liters of gasoline. For an average new car in the US at 27 miles per gallon, that equates to over 215 miles covered.  He outlined that switching to reusable equipment can be both a cost savings and decrease the carbon footprint of anesthesia, but its benefit is maximized in areas utilizing renewable sources of energy. With that in mind, Dr McGain pointed out that cost and green gas house gas emissions vary based on geographical location and the predominant sources of energy in that region (coal-based in Australia and China vs wind, nuclear, solar in many parts of Europe). The keynote speaker reviewed his recent study examining the differences in carbon footprint among pure regional anesthesia, general anesthesia, and combined general/regional anesthesia for knee surgery. Predictable trends, such as the decreased use of inhaled agents in the pure regional and combined anesthetic arm vs the pure general anesthesia arm, were discussed but notable details, such as more O2 consumption in the pure regional anesthesia arm and increased electricity use for cleaning reusables such as the nerve block trays and gowns used for performing regional anesthesia, were surprising. Dr’s McGain’s message resonated with all at SPPM Global: Improving sustainability is everyone’s responsibility.

Overall, this was a brilliant way to spend 4 ½ environmentally-conscious hours with internationally-known pediatric pain specialists at the comfort of my own home without the usual headaches of travelling or cvd19/flu/RSV/MPX risks. Here’s to more such offerings and a continued focus on international collaboration.