Pain in Intellectually Disabled Children: Towards Evidence-Based Pharmacotherapy?

This critical opinion article deals with the challenges of finding the most effective pharmacotherapeutic options for the management of pain in intellectually disabled children and provides recommendations for clinical practice and research. Intellectual disability can be caused by a wide variety of underlying diseases and may be associated with congenital anomalies such as cardiac defects, small-bowel obstructions or limb abnormalities as well as with comorbidities such as scoliosis, gastro-esophageal reflux disease, spasticity, and epilepsy. These conditions themselves or any necessary surgical interventions are sources of pain. Epilepsy often requires chronic pharmacological treatment with antiepileptic drugs. These antiepileptic drugs can potentially cause drug-drug interactions with analgesic drugs. It is unfortunate that children with intellectual disabilities often cannot communicate pain to caregivers. Although these children are at high risk of experiencing pain, researchers nevertheless often have to exclude them from trials on pain management because of ethical considerations. We therefore make a plea for prescribers, researchers, patient organizations, pharmaceutical companies, and policy makers to study evidence-based, safe and effective pharmacotherapy in these children through properly designed studies. In the meantime, parents and clinicians must resort to validated pain assessment tools such as the revised FLACC scale.

Effect of intravenous paracetamol on postoperative morphine requirements in neonates and infants undergoing major noncardiac surgery: a randomized controlled trial

IMPORTANCE

Continuous morphine infusion as standard postoperative analgesic therapy in young infants is associated with unwanted adverse effects such as respiratory depression.

OBJECTIVE

To determine whether intravenous paracetamol (acetaminophen) would significantly (>30%) reduce morphine requirements in neonates and infants after major surgery.

DESIGN, SETTING, AND PATIENTS

Single-center, randomized, double-blind study conducted in a level 3 pediatric intensive care unit in Rotterdam, The Netherlands. Patients were 71 neonates or infants younger than 1 year undergoing major thoracic (noncardiac) or abdominal surgery between March 2008 and July 2010, with follow-up of 48 hours.

INTERVENTIONS

All patients received a loading dose of morphine 30 minutes before the end of surgery, followed by continuous morphine or intermittent intravenous paracetamol up to 48 hours postsurgery. Infants in both study groups received morphine (boluses and/or continuous infusion) as rescue medication on the guidance of the validated pain assessment instruments.

MAIN OUTCOME MEASURES

Primary outcome was cumulative morphine dose (study and rescue dose). Secondary outcomes were pain scores and morphine-related adverse effects.

RESULTS

The cumulative median morphine dose in the first 48 hours postoperatively was 121 (interquartile range, 99-264) μg/kg in the paracetamol group (n = 33) and 357 (interquartile range, 220-605) μg/kg in the morphine group (n = 38), P < .001, with a between-group difference that was 66% (95% CI, 34%-109%) lower in the paracetamol group. Pain scores and adverse effects were not significantly different between groups.

CONCLUSION AND RELEVANCE

Among infants undergoing major surgery, postoperative use of intermittent intravenous paracetamol compared with continuous morphine resulted in a lower cumulative morphine dose over 48 hours.

TRIAL REGISTRATION

trialregister.nl Identifier: NTR1438.

Pain management in intellectually disabled children: a survey of perceptions and current practices among Dutch anesthesiologists

BACKGROUND

  Intellectually disabled children are more likely to undergo surgical interventions and almost all have comorbidities that need to be managed. Compared with controls, intellectually disabled children tend to receive less intraoperative analgesia and fewer of them are assessed for postoperative pain.

AIM

  To evaluate perceptions and practices of anesthesiologists in the Netherlands concerning pain management in intellectually disabled children.

METHODS/MATERIALS

  We surveyed members of the Section on Pediatric Anesthesiology of the Netherlands Society of Anesthesiology in 2005 and 2009, using a self-designed questionnaire.

RESULTS

  The response rate was 47% in both years. In 2005, 32% of the anesthesiologists rated intellectually disabled children as 'more sensitive to pain' than nonintellectually disabled children--vs 25% in 2009. But no more than 7% in 2005 vs 6% in 2009 agreed with the statement 'children with intellectually disabled children need more analgesia'. Most anesthesiologists gave similar doses of intraoperative opioids for intellectually disabled and nonintellectually disabled children, 92% in 2005 vs 89% in 2009. In 2005, only 3% applied a pain assessment tool validated for intellectually disabled children, vs 4% in 2009.

CONCLUSIONS

Anesthesiologists in the Netherlands take a different approach when caring for intellectually disabled children and they were not aware of pain observation scales for these children. However, the majority think that intellectually disabled children are not more sensitive to pain or require more analgesia. These opinions did not change over the 4-year period. One way to proceed is to implement validated pain assessment tools and to invest in education.

Lower bispectral index values in children who are intellectually disabled

BACKGROUND

Very few data are available on the use of bispectral index (BIS) monitoring in children who are intellectually disabled. Epileptiform electroencephalogram activity, underlying cerebral pathology, or anticonvulsant/spasmolytic therapy might influence BIS monitoring. Our aim in this exploratory study was to first compare BIS values at 4 different stages of anesthesia between intellectually disabled children and controls. Our second aim was to investigate the discriminative properties of BIS between consciousness and unconsciousness for intellectually disabled children and for controls.

METHODS

Eighteen intellectually disabled children and 35 control children, aged 2-13 yr, were included. BIS values, landmark events, and standard monitoring values of vital functions were recorded throughout the whole procedure. The performance of BIS in distinguishing between a conscious and unconscious state was assessed from receiver operating characteristic curves.

RESULTS

Median (interquartile range) BIS values for the intellectually disabled group were significantly lower than those for controls in the awake state (72 [48-77] vs 97 [84-98], P < 0.001), during stable intraoperative anesthesia (34 [21-45] vs 43 [33-52], P = 0.02), and during return of consciousness (59 [36-68] vs 73 [64-78], P = 0.009). The discriminative properties of the BIS monitor for the state of consciousness were comparable between the 2 groups according to the receiver operating characteristic curves. Nevertheless, the optimal cutoff BIS value for discrimination between conscious and unconscious state was 28 points lower for the intellectually disabled group.

CONCLUSIONS

We advise anesthesiologists to be alert to possible lower BIS values in intellectually disabled children. There is a risk that they will inadvertently misinterpret the state of consciousness in intellectually disabled children. New multicenter studies must find the optimal manner of evaluating (un)consciousness in intellectually disabled patients with documented and confirmed specific etiologies of their intellectual disability.

A comparison in adolescents of composite auditory evoked potential index and bispectral index during propofol-remifentanil anesthesia for scoliosis surgery with intraoperative wake-up test

BACKGROUND

The electroencephalogram-derived Bispectral Index (BIS), and the composite A-line ARX index (cAAI), derived from the electroencephalogram and auditory evoked potentials, have been promoted as anesthesia depth monitors. Using an intraoperative wake-up test, we compared the performance of both indices in distinguishing different hypnotic states, as evaluated by the University of Michigan Sedation Scale, in children and adolescents during propofol-remifentanil anesthesia for scoliosis surgery. Postoperative explicit recall was also evaluated.

METHODS

Twenty patients (aged 10-20 yr) were enrolled. Prediction probabilities were calculated for induction, wake-up test, and emergence. BIS and cAAI were compared at the start of the wake-up test, at purposeful movement to command, and after the patient was reanesthetized. During the wake-up test, patients were instructed to remember a color, and were then interviewed for explicit recall.

RESULTS

Prediction probabilities of BIS and cAAI for induction were 0.82 and 0.63 (P < 0.001), for the wake-up test, 0.78 and 0.79 (P < 0.001), and 0.74 and 0.78 for emergence (P < 0.001). During the wake-up test, a significant increase in mean BIS and cAAI (P < 0.05) was demonstrated at purposeful movement, followed by a significant decline after reintroduction of anesthesia.

CONCLUSIONS

During induction, BIS performed better than cAAI. Although cAAI was statistically a better discriminator for the level of consciousness during the wake-up test and emergence, these differences do not appear to be clinically meaningful. Both indices increased during the wake-up test, indicating a higher level of consciousness. No explicit recall was demonstrated.