Anesthetic considerations for the pediatric oncology patient--part 1: a review of antitumor therapy

Guideline for Children With Cancer Receiving General Anesthesia for Procedures and Imaging

Children with cancer and those undergoing hematopoietic stem cell transplantation frequently require anesthesia for imaging as well as diagnostic and therapeutic procedures from diagnosis through follow-up. Due to their underlying disease and side effects of chemotherapy and radiation, they are at risk for complications during this time, yet no published guideline exists for preanesthesia preparation. A comprehensive literature review served as the basis for discussions among our multidisciplinary panel of oncologists, anesthesiologists, nurse practitioners, clinical pharmacists, pediatric psychologists, surgeons and child life specialists at the Children's Hospital of Philadelphia. Due to limited literature available, this panel created an expert consensus guideline addressing anesthesia preparation for this population.

Pediatric Anesthesia Considerations for Interventional Radiology

Anesthesiologists are increasingly called on to care for pediatric patients undergoing diagnostic imaging and invasive procedures in interventional radiology. These procedures are typically classified as either nonvascular or vascular, and can range from short diagnostic imaging studies or biopsies to significantly longer and more invasive intravascular procedures. Anesthesia providers must consider each child's ability to cooperate reliably during the procedure, their age, and any cognitive impairment to define the best anesthetic plan. Several unique pediatric patient populations with specific procedural implications and anesthetic considerations who will benefit from additional periprocedural planning are discussed.

Anesthesia for the child with cancer

Children with cancer undergo a host of surgeries and procedures that require anesthesia during the various phases of the disease. A safe anesthetic plan includes consideration of the direct effects of tumor, toxic effects of chemotherapy and radiation therapy, the specifics of the surgical procedure, drug-drug interactions with chemotherapy agents, pain syndromes, and psychological status of the child. This article provides a comprehensive overview of the anesthetic management of the child with cancer, focuses on a systems-based approach to the impact from both tumor and its treatment in children, and presents a discussion of the relevant anesthetic considerations.

Anesthetic management of children undergoing hematologic-oncologic procedures outside the operating room

PURPOSE OF REVIEW

There is an increasing demand on anesthetic services to provide care for children undergoing hematologic-oncologic procedures outside the operation room; in particular, to mitigate the pain and unpleasant side-effects of these treatments. This review provides an update of the latest findings on this topic.

RECENT FINDINGS

An Italian survey of the management of procedural pain in children undergoing hematologic-oncologic interventions indicates that international guidelines are still not completely realized. It is essential to weigh safety concerns against patient comfort when deciding where the procedure will take place and who will perform it. An approach that addresses individual patient as well as institutional issues is optimum. Nonpharmacologic interventions combined with standard pharmacological ones are essential to reduce fear and distress in the children and their relatives. Psychological interactions as well as the child's development have to be considered. Special training for providers and an interdisciplinary approach are likely to be effective in improving treatment modalities and quality.

SUMMARY

Treatment of children undergoing hematologic-oncologic procedures outside the operation room is challenging. Expertise and high standards are essential to assure patient safety.

Perioperative management of the child on long-term opioids

The strategies used to manage children exposed to long-term opioids are extrapolated from adult literature. Opioid consumption during the perioperative period is more than three times that observed in patients not taking chronic opioids. A sparing use of opioids in the perioperative period results in both poor pain management and withdrawal phenomena. The child's pre-existing opioid requirement should be maintained, and acute pain associated with operative procedures should be managed with additional analgesia. This usually comprises short-acting opioids, regional or local anesthesia, and adjuvant therapies. Long-acting opioids, transdermal opioid patches, and implantable pumps can be used to maintain the regular opioid requirement. Intravenous infusion, nurse controlled analgesia, patient-controlled analgesia, or oral formulations are invaluable for supplemental requirements postoperatively. Effective management requires more than simply increasing opioid dose during this time. Collaboration of the child, family, and all teams involved is necessary. While chronic pain or palliative care teams and other staff experienced with the care of children suffering chronic pain may have helpful input, many pediatric hospitals do not have chronic pain teams, and many patients receiving long-term opioids are not palliative. Acute pain services are appropriate to deal with those on long-term opioids in the perioperative setting and do so successfully in many centers. Staff caring for such children in the perioperative period should be aware of the challenges these children face and be educated before surgery about strategies for postoperative management and discharge planning.

Pain management in 100 episodes of severe mucositis in children

OBJECTIVE

We aimed to review the pain management in 100 episodes of severe mucositis in children and determine the incidence of associated side effects.

BACKGROUND

Mucositis is a painful, debilitating condition affecting the alimentary mucosa and occurs following many anticancer treatments. Severe pain associated with mucositis may necessitate reductions, delays or termination of anticancer therapy and so intravenous morphine, preferably by patient-controlled analgesia (PCA) is the treatment of choice.

METHODS

Retrospective review of consecutive episodes of mucositis in children requiring intravenous opioid analgesia over a 3-year period (May 2006-April 2009).

RESULTS

In 24/92 (26%) of cases, morphine PCA provided insufficient pain relief and children required adjuvant ketamine therapy. These children had rapidly increasing morphine requirements approaching 1000 mcg/kg/day by day 2 (more than double compared with children on morphine alone), were more likely to be female, and tended to be older (median [IQR] age 12 [6-12] years vs 7 [3-14] years). The addition of ketamine to the morphine PCA appears to be associated with reduced morphine consumption, improved pain scores, causing minimal side effects and no hallucinations.

CONCLUSIONS

Children with severe mucositis who have escalating morphine requirements may benefit from the addition of ketamine to their morphine PCA.