Anesthetic considerations for the pediatric oncology patient--part 3: pain, cognitive dysfunction, and preoperative evaluation

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.

Perioperative management in children with chronic pain

Children with chronic pain often undergo surgery and effective perioperative management of their pain can be challenging. Identification of the pediatric chronic pain patient preoperatively and development of a perioperative pain plan may help ensure a safer and more comfortable perioperative course. Successful management usually requires multiple different classes of analgesics, regional anesthesia, and adjunctive nonpharmacological therapies. Neuropathic and oncological pain can be especially difficult to treat and usually requires an individualized approach.

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.

The new challenging pediatric patient

The 'new' challenging pediatric patients are those who could be called 'the survivors' and neonates undergoing birth under materno-fetal circulation. Their anesthetic management is complex because their initial pathology was previously lethal: the physiologic, pharmacologic, and or technical aspect of their management is presently unknown or hypothetical. Some examples are described. Communication with the pediatrician in charge of the child is the key to safe and effective anesthetic care of these cases.

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.