- Email: [email protected]
(832)
Abstracts
S59
D17 - Perioperative Pain: Opioids
D18 - Perioperative Pain: Other
(832) The effectiveness of a scheduled oral analgesic dosing regimen for the management of postoperative pain in preschool children following tonsillectomy
(834) Topical sterile lidocaine patch to reduce postoperative pain and decrease need for oral analgesics after inguinal herniorrhaphy
K Sutters, C Miaskowski, S Paul, M Savedra, S Waite, D Holdridge-Zeuner, K Mahoney, B Lanier; Central California Ear, Nose, Throat Medical Group, Fresno, CA The purpose of this study, in a sample of preschool children (ages 3 to 5 years; N⫽47), was to describe the state of pain management in young children at home following outpatient tonsillectomy and to evaluate the feasibility of scheduled analgesic dosing. Parents were instructed to give their child acetaminophen with hydrocodone (167mg/5ml) every 4 hours around-the-clock for the first 3 days following surgery, and to record each dose on a medication record. Parental assessments of their child’s pain intensity with/without swallowing were recorded at discharge, then twice a day, for the first three days at home, using the FLACC behavioral pain scale. Facial expression, leg movement, activity, cry and consolability were each scored 0-2, for a total FLACC score of 0-10. Parental assessment of their child’s pain relief was recorded at discharge, then twice a day, for the first three days at home, using a 0-10 scale (0⫽no pain relief, 10⫽complete pain relief). Repeated measures ANOVA demonstrated no significant changes over time in pain intensity scores with/without swallowing. Mean pain intensity scores were less than 2 for each time, indicating mild discomfort. There was a significant increase in pain relief scores over time (p⬍0.0001). However, the only significant difference was between parental ratings of minimal pain relief at discharge compared to moderate pain relief scores at all other times. There was a significant decrease in total daily analgesic dose over time (p⫽0.033), and a significant increase in the number of missed doses over time (p⫽0.017). Over 90% of parents missed at least one scheduled dose each day for the first 3 days after surgery. Study results suggest that parental adherence to a scheduled analgesic dosing regimen decreases over time, and that acetaminophen with hydrocodone was effective in relieving preschool children’s pain following tonsillectomy. Supported by a grant from NINR-NR04826.
E Lockhart; EpiCept Corp, Englewood Cliffs, NJ We designed a sterile lidocaine patch for application to a closed wound to reduce pain and systemic analgesic use after inguinal herniorrhaphy. We conducted a double-blind placebo(P)controlled parallel, dose-response study comparing the daily application of a 3.5% lidocaine patch to a 10% lidocaine patch for 48 hours after surgery. 221 subjects who underwent unilateral herniorrhaphy using a tension-free mesh were randomized to one of three patches. Anesthesia was general or spinal and no local anesthetic was injected at closure to determine the time of onset of the lidocaine in the patch. Rescue medication was oral methimazole, a short-acting analgesic. Pain intensity (PI) was assessed at time points for up to 48 hours. The AUC for PI from 2-48 hours was P 109, 3.5% 102, and 10% 89,(p⫽0.05). The AUC for PI from 2-24 hours was P 63, 3.5% 60, and 10% 52 (p ⫽ 0.045) and from 24-48 hours was P 47, 3.5% 42, and 10% 34 (p ⫽ 0.03). The pain reduction for 10% vs. P from 2 to 48 hours was 19%, from 2-24 hrs was 18% and from 24-48 hours was 27%. The number of rescue analgesic doses over the 48 hours was P 101, 3.5% 81, 10% 65 (p ⫽ 0.01), a reduction of 36%(10% patch vs. placebo). The lesser magnitude of AUC in the first 24 hours indicates the onset of the lidocaine patch is 2 to 3 hours. The safety of a 10% lidocaine patch was demonstrated by a single wound infection and no effect on wound healing. A 10% sterile lidocaine patch applied daily over the wound was shown to be safe and effective in reducing post operative pain after inguinal herniorrhaphy. Most importantly, a decrease in the use of oral rescue analgesic after surgery, thereby reducing post-operative side effects.
(833) Broken heart syndrome following acute withdrawal of opioid therapy in the perioperative setting
D19 - Preemptive Analgesia
A Locketz, J Rivera, K Fritz, M Kinney; Mayo Clinic College of Medicine, Rochester, MN This study took place in a tertiary care health center. The patient was a 61 yo woman with history of depression, hypertension, and chronic opioid dependence. She presented to the emergency department one day after being dismissed following a total knee replacement with acute onset dyspnea and mild chest pain. She had previously taken Oxycodone sustained release 60 mg twice daily plus breakthrough for a history of multiple non-cancer pain complaints. Physical exam at admission revealed a heart rate of 146, blood pressure 170/106, oxygen saturation 94%. She had acute respiratory distress, appeared pale, and was diaphoretic. Electrocardiogram showed precordial ST elevation. Cardiac angiography demonstrated an ejection fraction of 26% and was consistent with stress-induced cardiomyopathy with features of atypical (non-apical) ballooning syndrome. As she declined intubation, her initial treatment consisted of BiPap, aspirin, metoprolol, heparin, nitroglycerin drip, enalaprilat, furosemide, and morphine. Our results showed that the case is consistent with acute stress-induced cardiomyopathy in the setting of opioid withdrawal. After acute treatment and restarting her preoperative opioid dose she recovered and was dismissed home. Stress- induced cardiomyopathy is also known as broken heart syndrome, Tako-Tsubo syndrome, regional systolic dysfunction, and transient LV apical ballooning. Diagnostic criteria is characterized by regional wall motion abnormalities beyond the distribution of a single vessel, hyperkinesis in the basal left ventricular segment and ballooning of the apex, no obstructive CAD or acute plaque rupture, new ST elevation and T-wave inversion on electrocardiogram, and absence of recent significant head trauma or bleeding. It is usually reversible over time. We conclude that treating patients receiving chronic opioid therapy requires recognition of the importance of avoiding withdrawal to avoid serious complications and unnecessary hospitalizations. To our knowledge this is the first reported case of Tako-Tsubo syndrome reported in association with acute opioid withdrawal in an adult.
(835) The analgesic properties of oral sucrose: Efficacy and duration during routine immunizations at 2 and 4 months of age L Hatfield, M Gusic, A Dyer, R Polomano; University of Pennsylvania, Philadelphia, PA The purpose of this study was to evaluate the efficacy and duration of oral sucrose as a pre-procedural intervention for acute pain during routine immunizations at 2- and 4-months of age. A prospective, randomized, clinical trial of eighty-two healthy, term infants receiving their routine 2- or 4-month immunizations at an academic medical center’s ambulatory pediatric clinic was sampled. Infants were randomly stratified into a 2- or 4-month study group then randomized to receive 24% oral sucrose (0.6ml/kg) or a sterile water control solution, (0.6ml/kg). The intervention was administered 2 minutes before the combined DTaP, IPV, and Hep B vaccine. The University of Wisconsin Children’s Hospital pain scale measured infant behavioral pain response for the treatment and control group at baseline, and 2, 5, 7, and 9 minutes following solution administration. A 2 by 2 repeated measure ANOVA examined the effects of treatment conditions and age on pain assessment scores. The treatment group (sucrose, n⫽38) and control group (sterile water, n⫽44) displayed increasing behavioral pain responses from baseline at 2, 5, and 7 minutes. Compared to the control group, the treatment group had significantly lower behavioral pain response at 2 minutes (p⬍0.0001); 5 minutes (p⬍0.0001); 7 minutes (p⬍0.0078) and 9 minutes (p⬍0.0001). Between 7 and 9 minutes, the treatment group’s behavioral pain response decreased significantly more than the control group’s (p⬍0.003). Behavioral pain response exceeded a moderate amount at 2 minutes in the control groups compared to 5 minutes in the treatment groups. Sucrose is an effective pre-procedure intervention for painful injections at 2 and 4 months of age. Immunizations constitute a necessary, frequent preventive health measure in pediatric clinics. The development of a practical clinical intervention for pain management during immunizations offers an alternative approach to promote comfort and alleviate pain and distress in healthy newborns. Support: ANF Grant #2003051.
S59
D17 - Perioperative Pain: Opioids
D18 - Perioperative Pain: Other
(832) The effectiveness of a scheduled oral analgesic dosing regimen for the management of postoperative pain in preschool children following tonsillectomy
(834) Topical sterile lidocaine patch to reduce postoperative pain and decrease need for oral analgesics after inguinal herniorrhaphy
K Sutters, C Miaskowski, S Paul, M Savedra, S Waite, D Holdridge-Zeuner, K Mahoney, B Lanier; Central California Ear, Nose, Throat Medical Group, Fresno, CA The purpose of this study, in a sample of preschool children (ages 3 to 5 years; N⫽47), was to describe the state of pain management in young children at home following outpatient tonsillectomy and to evaluate the feasibility of scheduled analgesic dosing. Parents were instructed to give their child acetaminophen with hydrocodone (167mg/5ml) every 4 hours around-the-clock for the first 3 days following surgery, and to record each dose on a medication record. Parental assessments of their child’s pain intensity with/without swallowing were recorded at discharge, then twice a day, for the first three days at home, using the FLACC behavioral pain scale. Facial expression, leg movement, activity, cry and consolability were each scored 0-2, for a total FLACC score of 0-10. Parental assessment of their child’s pain relief was recorded at discharge, then twice a day, for the first three days at home, using a 0-10 scale (0⫽no pain relief, 10⫽complete pain relief). Repeated measures ANOVA demonstrated no significant changes over time in pain intensity scores with/without swallowing. Mean pain intensity scores were less than 2 for each time, indicating mild discomfort. There was a significant increase in pain relief scores over time (p⬍0.0001). However, the only significant difference was between parental ratings of minimal pain relief at discharge compared to moderate pain relief scores at all other times. There was a significant decrease in total daily analgesic dose over time (p⫽0.033), and a significant increase in the number of missed doses over time (p⫽0.017). Over 90% of parents missed at least one scheduled dose each day for the first 3 days after surgery. Study results suggest that parental adherence to a scheduled analgesic dosing regimen decreases over time, and that acetaminophen with hydrocodone was effective in relieving preschool children’s pain following tonsillectomy. Supported by a grant from NINR-NR04826.
E Lockhart; EpiCept Corp, Englewood Cliffs, NJ We designed a sterile lidocaine patch for application to a closed wound to reduce pain and systemic analgesic use after inguinal herniorrhaphy. We conducted a double-blind placebo(P)controlled parallel, dose-response study comparing the daily application of a 3.5% lidocaine patch to a 10% lidocaine patch for 48 hours after surgery. 221 subjects who underwent unilateral herniorrhaphy using a tension-free mesh were randomized to one of three patches. Anesthesia was general or spinal and no local anesthetic was injected at closure to determine the time of onset of the lidocaine in the patch. Rescue medication was oral methimazole, a short-acting analgesic. Pain intensity (PI) was assessed at time points for up to 48 hours. The AUC for PI from 2-48 hours was P 109, 3.5% 102, and 10% 89,(p⫽0.05). The AUC for PI from 2-24 hours was P 63, 3.5% 60, and 10% 52 (p ⫽ 0.045) and from 24-48 hours was P 47, 3.5% 42, and 10% 34 (p ⫽ 0.03). The pain reduction for 10% vs. P from 2 to 48 hours was 19%, from 2-24 hrs was 18% and from 24-48 hours was 27%. The number of rescue analgesic doses over the 48 hours was P 101, 3.5% 81, 10% 65 (p ⫽ 0.01), a reduction of 36%(10% patch vs. placebo). The lesser magnitude of AUC in the first 24 hours indicates the onset of the lidocaine patch is 2 to 3 hours. The safety of a 10% lidocaine patch was demonstrated by a single wound infection and no effect on wound healing. A 10% sterile lidocaine patch applied daily over the wound was shown to be safe and effective in reducing post operative pain after inguinal herniorrhaphy. Most importantly, a decrease in the use of oral rescue analgesic after surgery, thereby reducing post-operative side effects.
(833) Broken heart syndrome following acute withdrawal of opioid therapy in the perioperative setting
D19 - Preemptive Analgesia
A Locketz, J Rivera, K Fritz, M Kinney; Mayo Clinic College of Medicine, Rochester, MN This study took place in a tertiary care health center. The patient was a 61 yo woman with history of depression, hypertension, and chronic opioid dependence. She presented to the emergency department one day after being dismissed following a total knee replacement with acute onset dyspnea and mild chest pain. She had previously taken Oxycodone sustained release 60 mg twice daily plus breakthrough for a history of multiple non-cancer pain complaints. Physical exam at admission revealed a heart rate of 146, blood pressure 170/106, oxygen saturation 94%. She had acute respiratory distress, appeared pale, and was diaphoretic. Electrocardiogram showed precordial ST elevation. Cardiac angiography demonstrated an ejection fraction of 26% and was consistent with stress-induced cardiomyopathy with features of atypical (non-apical) ballooning syndrome. As she declined intubation, her initial treatment consisted of BiPap, aspirin, metoprolol, heparin, nitroglycerin drip, enalaprilat, furosemide, and morphine. Our results showed that the case is consistent with acute stress-induced cardiomyopathy in the setting of opioid withdrawal. After acute treatment and restarting her preoperative opioid dose she recovered and was dismissed home. Stress- induced cardiomyopathy is also known as broken heart syndrome, Tako-Tsubo syndrome, regional systolic dysfunction, and transient LV apical ballooning. Diagnostic criteria is characterized by regional wall motion abnormalities beyond the distribution of a single vessel, hyperkinesis in the basal left ventricular segment and ballooning of the apex, no obstructive CAD or acute plaque rupture, new ST elevation and T-wave inversion on electrocardiogram, and absence of recent significant head trauma or bleeding. It is usually reversible over time. We conclude that treating patients receiving chronic opioid therapy requires recognition of the importance of avoiding withdrawal to avoid serious complications and unnecessary hospitalizations. To our knowledge this is the first reported case of Tako-Tsubo syndrome reported in association with acute opioid withdrawal in an adult.
(835) The analgesic properties of oral sucrose: Efficacy and duration during routine immunizations at 2 and 4 months of age L Hatfield, M Gusic, A Dyer, R Polomano; University of Pennsylvania, Philadelphia, PA The purpose of this study was to evaluate the efficacy and duration of oral sucrose as a pre-procedural intervention for acute pain during routine immunizations at 2- and 4-months of age. A prospective, randomized, clinical trial of eighty-two healthy, term infants receiving their routine 2- or 4-month immunizations at an academic medical center’s ambulatory pediatric clinic was sampled. Infants were randomly stratified into a 2- or 4-month study group then randomized to receive 24% oral sucrose (0.6ml/kg) or a sterile water control solution, (0.6ml/kg). The intervention was administered 2 minutes before the combined DTaP, IPV, and Hep B vaccine. The University of Wisconsin Children’s Hospital pain scale measured infant behavioral pain response for the treatment and control group at baseline, and 2, 5, 7, and 9 minutes following solution administration. A 2 by 2 repeated measure ANOVA examined the effects of treatment conditions and age on pain assessment scores. The treatment group (sucrose, n⫽38) and control group (sterile water, n⫽44) displayed increasing behavioral pain responses from baseline at 2, 5, and 7 minutes. Compared to the control group, the treatment group had significantly lower behavioral pain response at 2 minutes (p⬍0.0001); 5 minutes (p⬍0.0001); 7 minutes (p⬍0.0078) and 9 minutes (p⬍0.0001). Between 7 and 9 minutes, the treatment group’s behavioral pain response decreased significantly more than the control group’s (p⬍0.003). Behavioral pain response exceeded a moderate amount at 2 minutes in the control groups compared to 5 minutes in the treatment groups. Sucrose is an effective pre-procedure intervention for painful injections at 2 and 4 months of age. Immunizations constitute a necessary, frequent preventive health measure in pediatric clinics. The development of a practical clinical intervention for pain management during immunizations offers an alternative approach to promote comfort and alleviate pain and distress in healthy newborns. Support: ANF Grant #2003051.