Opioid use in palliative care of children and young people with cancer
Child; Female; Humans; Male; Great Britain; Adult; Analgesics; Questionnaires; Prospective Studies; Research Design; Longitudinal Studies; Therapeutic Equivalency; Prescriptions; adolescent; Preschool; infant; Administration; Oral; Pain/drug therapy/etiology; Palliative Care/methods; Infusions; Injections; Intravenous; Neoplasms/complications; Subcutaneous; Drug/statistics & numerical data; Opioid/administration & dosage/therapeutic use; Fentanyl/therapeutic use; Heroin/therapeutic use; Morphine/therapeutic use; Rectal
OBJECTIVE: Identify opioids prescribed, preferred routes, and doses among children with incurable cancer. STUDY DESIGN: Prospective survey with monthly questionnaires regarding patients 0 to 19 years old from oncology centers. Data were collected by professionals on each patient for 6 months or until death, and analyzed from patients who died. Impact of tumor was analyzed with Kruskal-Wallis and Mann-Whitney tests. Major opioid dosages are expressed as oral morphine equivalents. RESULTS: Of 185 children recruited, 164 (88 boys, 76 girls) died. Mean palliative care duration was 67 days. One hundred forty-seven (89.6%) received major opioids. Morphine, diamorphine, and fentanyl were prescribed in 75%, 57.9%, and 11.6%, respectively. Seventy-three (44.5%) received >1 major opioid. Median monthly maximum doses prescribed rose from 2.1 mg/kg/24 h (study entry) to 4.4 mg/kg/24 h (death) (P < .001); overall variable (0.09-1500 mg/kg/24 h, median 3.7 mg/kg/24 h). Opioids were given by the oral (117/164, 71.3%), intravenous (68/164, 41.5%), subcutaneous (40, 28%), rectal (20, 12.2%), and transdermal (18, 11%) routes. There was a shift to intravenous use as death approached. Numbers within each tumor group were too small to show significance. Children with solid tumors outside the central nervous system were likely to receive more opioids, be given multiple different opioids, and receive opioids in the last month. CONCLUSIONS: The study shows the United Kingdom practice of opioid use and provides comparator data for practice in children's palliative medicine.
2008
Hewitt M; Goldman A; Collins GS; Childs M; Hain R
The Journal Of Pediatrics
2008
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Journal Article
<a href="http://doi.org/10.1016/j.jpeds.2007.07.005" target="_blank" rel="noreferrer">10.1016/j.jpeds.2007.07.005</a>
Effective parenteral clodronate treatment of a child with severe juvenile idiopathic osteoporosis
Child; Humans; Male; Age Factors; Infusions; Clodronate; Recurrence; Antimetabolites/administration & dosage/therapeutic use; Bone Density/drug effects; Clodronic Acid/administration & dosage/therapeutic use; Osteoporosis/drug therapy; Parenteral; Puberty
We report on an 8 years and 3 months old boy with severe idiopathic juvenile osteoporosis (IJO). Clinical features included multiple fractures, especially of the vertebrae, and neurological symptoms. Biological studies showed non-parathyroid hormone-mediated excessive bone resorption and massive urinary calcium loss. Although IJO is usually a self-limiting condition after puberty, the severity of our patient's manifestations required therapeutic intervention. Clodronate (dichloromethylene-bisphosphonate) was administered parenterally every 3 months for a period of 2 years. Dramatic clinical and biochemical improvement was noted within 2 weeks. All parameters of bone resorption normalised and no new fractures occurred. After 6 months of treatment, radiological improvement with healing of fractures and rebuilding of the vertebral plates was documented. Bone mineral density increased to normal within 1 year and growth velocity was accelerated. After 2 years, treatment was stopped at the age of 10 years and 3 months. One year later, back pain and increasing pain in the knee region recurred. A tibial fracture was evident and, again, bone mineral density was far below normal. Bisphosphonate medication was reinstituted leading to rapid improvement. No side-effects were observed. CONCLUSION: Parenteral clodronate therapy is effective in managing severe idiopathic juvenile osteoporosis.
2005
Melchior R; Zabel B; Spranger J; Schumacher R
European Journal Of Pediatrics
2005
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Journal Article
<a href="http://doi.org/10.1007/s00431-004-1541-7" target="_blank" rel="noreferrer">10.1007/s00431-004-1541-7</a>
Long-term use of peripherally inserted central venous catheters for cancer chemotherapy in children
Child; Female; Humans; Male; Adult; Follow-Up Studies; Risk Factors; Incidence; adolescent; Preschool; Non-U.S. Gov't; Research Support; PedPal Lit; infant; retrospective studies; Infusions; Intravenous; Neoplasms/drug therapy; Catheterization; Antineoplastic Agents/administration & dosage; Central Venous/adverse effects; Hematologic Tests
BACKGROUND: Peripherally inserted central venous catheters (PICCs) have been increasingly used in pediatric patients. However, little is known about the incidence and risk of complications when using this device in children with cancer. The purposes of this study are to assess the feasibility of PICCs and to determine the risk factors for PICC-related complications in pediatric patients with various types of malignancies. PATIENTS AND METHODS: We attempted to place PICCs in 53 patients with a median age of 5 years ranging from 2 months to 20 years. PICCs were used to administer fluid, parenteral nutrition, anticancer agents, antibiotics, and blood products and also for the through-line blood sampling. The duration of catheterization and the incidence of PICC-related complications requiring removal were retrospectively evaluated in association with the diagnosis, sex, age and body weight of the patients, size, insertion site and tip location of the catheters, type of treatment, and duration of leukopenia. RESULTS: PICCs were successfully placed in 109 of 112 attempts (97.3%) in 53 patients, and they were followed for a total of 11,797 catheter days (median placement, 87 days; range, 3 to 512 days). Fifty five PICCs (50.5%) were removed as a result of PICC-related complications with a rate of 4.66 per 1,000 catheter days. The most common reasons for catheter removal were occlusion (n=18), breakage/leakage (15), and infection (10). More than 70% of such complications occurred more than 30 days after placement. The catheter tip location in the superior vena cava or the right atrium might decrease the risk of complications. Other parameters did not influence the incidence of complications. CONCLUSIONS: PICCs were found to provide a reliable access for prolonged intravenous administration and blood sampling in children intensively treated for hematologic and solid malignancies, thus leading to a reduction of physical pain and psychological stress in such patients. However, the long-term placement of PICCs may also be related to an increased risk of complications.
2006
Matsuzaki A; Suminoe A; Koga Y; Hatano M; Hattori S; Hara T
Support Care Cancer
2006
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Journal Article
The decision to use topical anesthetic for intravenous insertion in the pediatric emergency department
Child; Female; Humans; Male; Pennsylvania; Clinical Competence; Sensitivity and Specificity; Clinical Protocols; Anesthetics; Preschool; PedPal Lit; Comparative Study; Administration; Infusions; Hospital; Nursing Assessment/methods; Topical; Emergency Service; Pain/drug therapy/etiology; Emergency Nursing/methods/standards; Intravenous/adverse effects/nursing; Local/administration & dosage; Pediatric Nursing/methods; Triage/standards
OBJECTIVES: Topical anesthetic creams to reduce the pain of intravenous (IV) placement may be more effectively used in the emergency setting if they are applied by nurses in the triage area of the emergency department or soon after the patient is placed into a room. This strategy requires accurate prediction of which patients will require IV placement. The objective of this study was to compare triage nurse judgment regarding IV placement in pediatric patients with a triage prediction rule using chief complaint, referral status, and high-risk medical history. A secondary objective was to evaluate whether the presence of the anesthetic cream placed in triage influenced the subsequent decision to place an IV and thus invalidate the prediction strategy. METHODS: Triage nurses were randomly assigned to a prediction score group (PRD), classifying patients as "IV likely" if the prediction score was > or =2, or an "own judgment" (RN JDGMT) group, classifying any patient that he or she considered to have a > or =50% risk of receiving an IV. The rate of actual IV placement in the emergency department treatment rooms was compared between the triage prediction strategies. To assess the influence of the presence of lidocaine 2.5% and prilocaine 2.5% (EMLA cream) on the judgment to place an IV, only 75% of the "IV likely" patients had EMLA applied in triage; the IV placement rate was compared between "IV likely" patients who did or did not have EMLA applied. RESULTS: The authors enrolled 3,790 of 5,025 (75.4%) of eligible patients. The RN JDGMT group predicted 165 of 250 (66%; 95% confidence interval = 59% to 72%) of IVs placed, compared with 127 of 305 (41%; 95% CI = 36% to 47%) in the PRD group (p < 0.0001). Positive predictive values were 59% and 53% for the RN JDGMNT and PRD groups, respectively. There was no difference in IV placement rates in the "IV likely" patients who did and did not have EMLA applied. CONCLUSIONS: Triage nurse judgment to predict eventual IV placement had greater sensitivity and similar predictive value compared with a prediction model based on medical history and chief complaint. The triage placement of topical anesthetic in pediatric patients did not change the eventual rate of IV placement.
2006
Fein JA; Gorelick MH
Academic Emergency Medicine
2006
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Journal Article
Short-term safety assessment in the use of intravenous zoledronic acid in children
Child; Female; Humans; Male; Follow-Up Studies; Time Factors; adolescent; Preschool; retrospective studies; Infusions; Intravenous; Fever/chemically induced; Nausea/chemically induced; Clodronate; Calcium/blood; Bone Resorption/metabolism/prevention & control; Creatinine/blood; Diphosphonates/administration & dosage/adverse effects; Imidazoles/administration & dosage/adverse effects; Pain/chemically induced; Phosphorus/blood; Urea/blood; Vomiting/chemically induced
The clinical side effects of the potent new bisphosphonate zoledronic acid in children are unknown. In this study of 34 children with various bone disorders, the frequency of postinfusion flu-like illness, hypocalcemia, and hypophosphatemia was 85%, 74%, and 82%, respectively. No renal side effects were detected after up to 3 consecutive infusions.
2004
Hogler W; Yap F; Little D; Ambler G; McQuade M; Cowell CT
The Journal Of Pediatrics
2004
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Journal Article
<a href="http://doi.org/10.1016/j.jpeds.2004.06.066" target="_blank" rel="noreferrer">10.1016/j.jpeds.2004.06.066</a>
Patient-controlled analgesia with intravenous L-methadone in a child with cancer pain refractory to high-dose morphine
Child; Humans; Male; Pain; Analgesics; Analgesia; Treatment Failure; Infusions; Intravenous; Neoplasms/complications; Opioid/administration & dosage/therapeutic use; Patient-Controlled; Morphine/administration & dosage/therapeutic use; Intractable/drug therapy/etiology; Methadone/administration & dosage/therapeutic use
2002
Sabatowski R; Kasper SM; Radbruch L
Journal Of Pain And Symptom Management
2002
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Journal Article
<a href="http://doi.org/10.1016/s0885-3924(01)00389-x" target="_blank" rel="noreferrer">10.1016/s0885-3924(01)00389-x</a>
Intravenous ketamine infusion as an adjuvant to morphine in a 2-year-old with severe cancer pain from metastatic neuroblastoma
Female; Humans; Palliative Care; Pain; Analgesics; Fatal Outcome; quality of life; Preschool; Non-U.S. Gov't; Research Support; Administration; Oral; Infusions; Intravenous; Intractable/drug therapy/etiology; Combination; Codeine/administration & Drug Therapy; Dyspnea/chemically induced; Hallucinations/chemically induced; Ketamine/administration & Methadone/administration & dosage/adverse effects/therapeutic use; Morphine/administration & Neuroblastoma/physiopathology; Non-Narcotic/administration & dosage/therapeutic use; Opioid/administration & Child
A 2.8-year-old female patient (11.6 kg) was admitted to the hospital for uncontrolled pain and swelling in the left leg relating to a metastatic neuroblastoma. Initially, her pain was managed with oral morphine 2 mg (approx. 0.2 mg/kg) every 4 hours. Because she was quite somnolent but still in significant pain, analgesia was then changed to methadone 1 mg orally every 6 hours (approximately 0.1 mg/kg/dose) and was eventually increased over 36 hours to 2 mg every 6 hours (approximately 0.2 mg/kg/dose). She received oral methadone 0.6 mg (approximately 0.05 mg/kg) every 4 hours as needed for breakthrough pain. She continued to have severe pain and experienced side effects, including respiratory depression, sedation, visual hallucinations, and vomiting. An intravenous ketamine infusion was started at 100 microg/kg/hour. Regular opioid administration was ceased, but she was given intravenous morphine 0.5 to 0.75 mg for breakthrough pain. She required only zero to three doses of breakthrough morphine per day, initially. After starting the ketamine infusion, her pain control improved and her symptoms of opioid toxicity abated. She was more alert and able to partake in limited activities. As a result of pain from progressive disease, the ketamine infusion was increased to 200 microg/kg/hour after 6 days with positive results. Her condition continued to deteriorate. An intravenous morphine infusion was initiated 2 weeks after starting the ketamine infusion and was eventually increased to 50 microg/kg/hour. One week later, she died with reasonable pain control. This case illustrates the use of ketamine as an effective analgesic in an adjuvant setting in a pediatric patient with advanced poorly controlled cancer pain. Ketamine not only eased the child's suffering while preserving life but also improved her quality of life by maintaining the child's ability to communicate and engage in activities.
2004
Tsui BC; Davies D; Desai S; Malherbe S
Journal Of Pediatric Hematology/oncology
2004
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Journal Article
<a href="http://doi.org/10.1097/01.mph.0000140656.96085.2c" target="_blank" rel="noreferrer">10.1097/01.mph.0000140656.96085.2c</a>
The efficacy and side effects of continuous infusion intravenous morphine (CIVM) for pain and symptoms due to advanced cancer
Female; Humans; Male; United States; Pain; Adult; Analgesics; Aged; Middle Aged; 80 and over; retrospective studies; Palliative Care/methods; Infusions; Intravenous; Opioid/administration & dosage/adverse effects; Intractable/drug therapy/etiology; Morphine/administration & Neoplasms/complications
Morphine is the strong opioid of choice in the management of moderate-to-severe chronic cancer pain. The preferred route of administration is oral, in individually titrated doses, regularly scheduled around the clock We conducted a retrospective study of continuous intravenous morphine (CIVM) in a palliative medicine program in 107 consecutive patients. The results suggest CIVM is an effective, safe, and versatile method of morphine administration when used with a defined protocol. Efficacy was similar to that obtained by others with intravenous morphine sulfate and also for oral morphine. Safety was suggested by the low incidence of dose-limiting side effects, most of which responded to dose reduction. Particularly noteworthy was the flexibility of CIVM with dose reduction in 20 percent.
2002
Glare P; Walsh D; Groh E; Nelson KA
The American Journal Of Hospice & Palliative Care
2002
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Journal Article
<a href="http://doi.org/10.1177/104990910201900512" target="_blank" rel="noreferrer">10.1177/104990910201900512</a>
Use of patient-controlled analgesia for management of acute pain
Humans; Acute Disease; Pain/drug therapy; Analgesics/administration & dosage/adverse effects; Infusion Pumps; Infusions; Injections; Intravenous; Self Administration/adverse effects/instrumentation
Patient-controlled analgesia (PCA) provides improved titration of analgesic drugs, thereby minimizing individual pharmacokinetic and pharmacodynamic differences. Patient-controlled analgesia decreases patient anxiety resulting from delays in receiving pain-relieving medication and from the slow onset of analgesic action when these drugs are administered either intramuscularly or in the extradural space. With PCA therapy, patients are reportedly able to maintain a near optimal state of analgesia with minimal sedation and few side effects. The potential for overdose can be minimized if small bolus doses are used with a mandatory lockout interval between successive doses. Finally, studies of the cost-effectiveness of PCA therapy are important if this therapeutic approach is to achieve more widespread acceptance.
1988
White PF
Jama
1988
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Journal Article
<a href="http://doi.org/10.1001/jama.259.2.243" target="_blank" rel="noreferrer">10.1001/jama.259.2.243</a>
Continuous intravenous infusion of morphine sulfate for control of severe pain in children with terminal malignancy
Child; Palliative Care; Pain; Terminal Care; Pain; Morphine; Palliative treatment; Infusions; Injections; Intravenous; Parenteral; Intractable
1980
Miser AW; Miser JS; Clark BS
Journal Of Pediatrics
1980
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Journal Article
<a href="http://doi.org/10.1016/s0022-3476(80)80585-3" target="_blank" rel="noreferrer">10.1016/s0022-3476(80)80585-3</a>
Plasma morphine levels produced by continuous infusion in children
Child; Humans; Pain; Time Factors; adolescent; Preschool; infant; Infusions; Parenteral; Postoperative/drug therapy; Morphine/administration & dosage/blood/therapeutic use
Blood samples were taken from six children aged between 10 months and 15 years, at intervals over a period of 40 hours while they were receiving continuous morphine infusions. The plasma morphine values obtained showed similar and consistent levels 15-30 minutes after starting the infusions.
1986
Bray RJ; Beeton C; Hinton W; Seviour JA
Anaesthesia
1986
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Journal Article
<a href="http://doi.org/10.1111/j.1365-2044.1986.tb12847.x" target="_blank" rel="noreferrer">10.1111/j.1365-2044.1986.tb12847.x</a>
Continuous subcutaneous infusion of morphine in children with cancer
Child; Adult; Preschool; infant; Infusions; Human; Palliative Care; Parenteral; Adolescence; Morphine/administration & dosage/adverse effects; Neoplasms/drug therapy
Seventeen children with severe pain due to malignant neoplasm were successfully treated with a subcutaneous infusion of morphine sulfate using a syringe pump. Pain relief was adequate in every case without major side effects. The median dosage required was 0.06 mg/kg/hr (range, 0.025 to 1.79 mg/kg/hr). Three patients received the subcutaneous infusion at home. No patient required an intravenous line for pain control.
1983
Miser AW; Davis DM; Hughes CS; Mulne AF; Miser JS
American Journal Of Diseases Of Children
1983
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Journal Article
Comparison of continuous subcutaneous and intravenous hydromorphone infusions for management of cancer pain
Female; Humans; Male; Aged; Middle Aged; Severity of Illness Index; Time Factors; Double-Blind Method; Non-U.S. Gov't; Research Support; Comparative Study; Evaluation Studies; Palliative Care/methods; Infusion Pumps; Infusions; Intravenous; Hydromorphone/administration & dosage/adverse effects/blood/therapeutic use; Implantable; Neoplasms/blood/physiopathology; Pain/blood/drug therapy/etiology; Parenteral/methods
To compare the safety and efficacy of subcutaneous and intravenous infusion of opioid analgesics, a randomised, double-blind, crossover trial was carried out in inpatients. 15 patients with severe cancer pain received two 48 h infusions of hydromorphone--one subcutaneously and one intravenously in randomly allocated order. The study was made double-blind by the use of two infusion pumps throughout; during the active subcutaneous infusion the intravenous pump delivered saline and vice versa. Serial measurements of pain intensity, pain relief, mood, and sedation by means of visual analogue scales showed no clinically or statistically significant difference between the two infusion routes. Side-effects were slight, and the mean number of morphine injections for breakthrough pain did not differ significantly between the routes (4.8 [SD 4.5] for intravenous vs 5.3 [5.6] for subcutaneous). Plasma hydromorphone concentrations measured at 24 h and 48 h of infusion showed stable steady-state pharmacokinetics; the mean bioavailability from subcutaneous infusion was 78% of that with intravenous infusion. Because of the simplicity, technical advantages, and cost-effectiveness of continuous subcutaneous opioid infusion into the chest wall or trunk, intravenous opioid infusion for the management of severe cancer pain should be abandoned.
1991
Moulin DE; Kreeft JH; Murray-Parsons N; Bouquillon AI
Lancet
1991
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Journal Article
<a href="http://doi.org/10.1016/0140-6736(91)93401-t" target="_blank" rel="noreferrer">10.1016/0140-6736(91)93401-t</a>
A double-blind, crossover trial of intravenous clodronate in metastatic bone pain
Female; Humans; Male; Pain Measurement; Adult; Aged; Middle Aged; Double-Blind Method; 80 and over; Infusions; Intravenous; Clodronate; Clodronic Acid/administration & dosage/therapeutic use; Bone Neoplasms/physiopathology/secondary; Pain/diagnosis/drug therapy/etiology
After a baseline symptom and laboratory assessment, 24 patients with metastatic bone disease and pain were randomized to receive either a 4-hr intravenous infusion of 2-dichloromethylene bisphosphonate (Cl2MDP), 600 mg in 500 mL of normal saline, or a 4-hr placebo infusion, 500 mL of normal saline. The administration was double blind. After 1 wk, the assessment was repeated and the patients were crossed over to the alternate treatment. After 1 more wk, a final assessment and blinded choice by the patient and investigator took place. Of the 21 evaluable patients, 12 (57%) chose the Cl2MDP and 4 (19%) chose the placebo; 5 (24%) patients did not have a specific preference (p = NS). The investigator chose the Cl2MDP in 14 (67%) cases, placebo in 6 (29%) cases and was unable to discern a difference in 1 (5%) case (p less than 0.05). The patients and investigator made similar selections in 16 (76%) instances. On the visual analogue scale assessments, a significant decrease in pain scores was observed following the Cl2MDP infusion (p less than 0.01) and an increase in activity scores was also demonstrated (p less than 0.01). No significant difference in the daily oral morphine equivalent analgesic requirement was demonstrated for either arm. No difference in clinical and laboratory parameters of toxicity was evident between the placebo and Cl2MDP arms of the trial. Our preliminary findings suggest that Cl2MDP is safe, and has analgesic properties that may prove to be useful in the management of metastatic bone pain.
1992
Ernst DS; MacDonald RN; Paterson AH; Jensen J; Brasher P; Bruera E
Journal Of Pain And Symptom Management
1992
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Journal Article
<a href="http://doi.org/10.1016/0885-3924(92)90101-m" target="_blank" rel="noreferrer">10.1016/0885-3924(92)90101-m</a>
Control of severe pain in children with terminal malignancy
Child; Female; Male; Preschool; Non-U.S. Gov't; infant; retrospective studies; Pain/drug therapy; Infusions; Human; Parenteral; Support; Adolescence; Terminal Care; Neoplasms/physiopathology; Palliative Care/methods; Analgesia/methods; Morphine/administration & dosage/therapeutic use
OBJECTIVE: To identify the characteristics of the subset of children with malignancy in whom massive opioid infusions are needed during the terminal phase. DESIGN: Retrospective review of the records of the 199 patients who died of malignancy after treatment at Children's Hospital, Boston, from March 1989 to July 1993, identifying characteristics of patients who required massive opioid infusions (operationally defined as infusion of > 3 mg/kg per hour of morphine dose equivalent) during the terminal phase. RESULTS: Twelve patients (6%) required massive opioid infusions, and eight of these patients required extraordinary measures (epidural or subarachnoid infusion and/or sedation) to achieve adequate analgesia. The duration of epidural or subarachnoid infusions in three patients ranged from 3 to 9 days, and minimal complications occurred. The duration of sedation ranged from 1 to 15 days. Maximal intravenous opioid dosing ranged from 3.8 to 518 mg/kg per hour of morphine equivalent. The maximal infusion rate (exceeding all previous published reports) occurred in an infant with an isolated metastasis in the periaqueductal gray matter, a brain-stem site linked to mediating analgesia and defense reactions. The need for massive opioid dosing in 11 of 12 patients was associated with tumor spread to the spinal nerve roots, nerve plexus, large peripheral nerve, or spinal cord compression. CONCLUSIONS: Standard dosing of opioids adequately treats most cancer pain in children; however, a significant group requires more extensive management. These problems occur more commonly among patients with solid tumors metastatic to spine and major nerves.
1995
Collins J J; Grier HE; Kinney HC; Berde CB
Journal Of Pediatrics
1995
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Journal Article
<a href="http://doi.org/10.1016/s0022-3476(95)70370-5" target="_blank" rel="noreferrer">10.1016/s0022-3476(95)70370-5</a>
Pediatric acute pain management
Child; infant; Analgesics; Time Factors; Acute Disease; Nebulizers and Vaporizers; Anesthetics; Preschool; infant; Chronic disease; Newborn; Infusions; Intravenous; Human; Local/therapeutic use; Nerve Block/methods; Non-Narcotic/administration & dosage/therapeutic use; Opioid/administration & dosage/blood/therapeutic use; Pain/drug therapy/physiopathology
The past decade has brought about an explosion of knowledge about the physiology of nociception and many new techniques for pain relief, new analgesic drugs, and new applications of old analgesic drugs. These techniques include methods of opioid administration by transdermal and transmucosal absorption and the use of neuraxial analgesia for the management of pain in children. Interest in the use of regional anesthesia in children has been rekindled, and analgesic properties and pre-emptive analgesic properties of many agents not typically considered analgesics, such as clonidine and ketamine, have been recognized. Perhaps the greatest advance has been the paradigm shift in the recognition that pain not only exists in infants and children but also is a significant cause of morbidity and even mortality. Given the unprecedented interest in pain management in adults and children, physicians can now look forward to the development of new methods of drug delivery and of receptor-specific drugs that divorce analgesia from the untoward side effects of existing analgesics. Improvement in the quality of life of hospitalized children also will occur.
2000
Golianu B; Krane EJ; Galloway KS; Yaster M
Pediatric Clinics Of North America
2000
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Journal Article
<a href="http://doi.org/10.1016/s0031-3955(05)70226-1" target="_blank" rel="noreferrer">10.1016/s0031-3955(05)70226-1</a>
Patient-controlled analgesia
Humans; Pain; Adult; Analgesics; Patient Selection; Analgesia; Infusions; Injections; Intravenous; Dose-Response Relationship; Drug; Opioid/adverse effects/therapeutic use; Safety; Patient-Controlled/instrumentation; Postoperative/prevention & control; Respiration/drug effects
In appropriately selected patients, PCA safely provides analgesia superior to that obtained with traditional IM prn opioid administration; however, to date, no compelling evidence shows that PCA is associated with a reduction in morbidity or a more rapid recovery. PCA is deceptively easy to prescribe; however, to use it effectively and safely requires experience, frequent patient assessment, and a skilled and knowledgeable nursing staff.
1999
Etches RC
The Surgical Clinics Of North America
1999
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Journal Article
<a href="http://doi.org/10.1016/s0039-6109(05)70384-4" target="_blank" rel="noreferrer">10.1016/s0039-6109(05)70384-4</a>
Subcutaneous clodronate
Humans; Male; Analgesics; Aged; Middle Aged; Infusions; Parenteral; Hypercalcemia/drug therapy; Clodronic Acid/administration & dosage; Non-Narcotic/administration & dosage
1996
Walker P; Watanabe S; Lawlor P; Bruera E
Lancet
1996
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Journal Article
<a href="http://doi.org/10.1016/s0140-6736(05)64524-2" target="_blank" rel="noreferrer">10.1016/s0140-6736(05)64524-2</a>
Efficacy and complications of morphine infusions in postoperative paediatric patients
Child; Female; Humans; Male; Pain; Analgesics; Follow-Up Studies; Confidence Intervals; Incidence; Acute Disease; adolescent; Preschool; infant; retrospective studies; Infusions; Intravenous; Opioid/administration & dosage/adverse effects/therapeutic use; Morphine/administration & dosage/adverse effects/therapeutic use; Postoperative/prevention & control; Respiration/drug effects; Akathisia; Analgesia/nursing; Anesthesia Recovery Period; Anoxemia/chemically induced; Arousal/drug effects; Drug-Induced/etiology; Postoperative Nausea and Vomiting/chemically induced; Pruritus/chemically induced; Urinary Retention/chemically induced
The aim of the study was to evaluate the efficacy and the incidence of clinically significant adverse drug reactions (ADRs) in paediatric patients receiving continuous intravenous morphine infusions for acute postoperative pain. Definitions were established for ADRs and data were collected in an immediately retrospective fashion for a maximum of 72 h in 110 patients >/=5 three months of age (0.3-16.7 years) receiving morphine infusions and admitted to a general ward over a three month convenience sampling period. Inadequate analgesia occurred in 65.5% of patients during the first 24 h of therapy and occurred most frequently in patients with infusion rates of 20 microg.kg-1.h-1 or less. Nausea/vomiting was the most commonly experienced ADR (42.5%). The incidence of respiratory depression was 0% (95% CI=0-3.3%). Other ADRs included: urinary retention (13.5%), pruritus (12.7%), dysphoria (7.3%), hypoxaemia (4.5%), discontinuation of morphine for treatment of an ADR (3.6%), and difficulty in arousal (0.9%). The most common ADRs associated with morphine infusions were inadequate analgesia (in the first 24 h) and nausea/vomiting. There were no cases of respiratory depression. Methods of avoiding initial inadequate analgesia and treating nausea and vomiting associated with morphine infusions are needed.
1999
Esmail Z; Montgomery C; Courtrn C; Hamilton D; Kestle J
Paediatric Anaesthesia
1999
Article information provided for research and reference use only. PedPalASCNET does not hold any rights over the resource listed here. All rights are retained by the journal listed under publisher and/or the creator(s).
Journal Article
<a href="http://doi.org/10.1046/j.1460-9592.1999.00384.x" target="_blank" rel="noreferrer">10.1046/j.1460-9592.1999.00384.x</a>
Osteoporosis pseudoglioma syndrome: treatment of spinal osteoporosis with intravenous bisphosphonates
Child; Female; Humans; Male; Analgesics; Growth; Non-U.S. Gov't; Research Support; Syndrome; Infusions; Intravenous; Clodronate; Pain/prevention & control; Clodronic Acid/administration & dosage; Non-Narcotic/administration & dosage; Diphosphonates/administration & dosage; Fractures; Bone Density/physiology; Bone/complications/physiopathology; Osteoporosis/complications/drug therapy/physiopathology; Spine/physiopathology; Vision Disorders/complications
OBJECTIVES: To determine whether intravenous bisphosphonate treatment is helpful for children with osteoporosis pseudoglioma syndrome who have severe osteoporosis. METHODS: Three children (ages 9 to 11 years) with osteoporosis pseudoglioma syndrome who had multiple vertebral collapse were treated over a 2-year period with intermittent intravenous bisphosphonate infusions (pamidronate in 2, clodronate in 1). The responses to therapy were assessed with clinical and radiographic evaluation and bone densitometry of the spine. RESULTS: All 3 subjects reported early reductions in bone pain and improved mobility. Radiographs showed dense new bone in the vertebral end plates and remodeling of the vertebral bodies. Areal bone mineral density at the lumbar spine (age-appropriate SD score) improved from a mean of -4.5 before treatment to -2.8 after 2 years (P <.05). No new fractures occurred, and side effects were minimal. Growth and pubertal development proceeded normally. CONCLUSIONS: Intravenous bisphosphonate therapy appears safe and beneficial in patients with this condition and may prevent progressive vertebral deformity.
2000
Zacharin M; Cundy T
The Journal Of Pediatrics
2000
Article information provided for research and reference use only. PedPalASCNET does not hold any rights over the resource listed here. All rights are retained by the journal listed under publisher and/or the creator(s).
Journal Article
<a href="http://doi.org/10.1067/mpd.2000.107838" target="_blank" rel="noreferrer">10.1067/mpd.2000.107838</a>
Patient-controlled analgesia with low dose background infusions after lower abdominal surgery in children
Child; Female; Humans; Male; Pain; Analgesia; Drug Administration Schedule; Non-U.S. Gov't; Research Support; Comparative Study; Infusions; Intravenous; Nausea/chemically induced; Morphine/administration & dosage/adverse effects; Postoperative Period; Sleep/drug effects; Vomiting/chemically induced; Postoperative/drug therapy; Appendectomy; Patient-Controlled/adverse effects/methods
Forty-five children (aged 6-12 yr) undergoing appendicectomy received one of three analgesic regimens using patient-controlled analgesia (PCA) with morphine: no background infusion (BO); background infusion 4 micrograms kg-1 h-1 (B4); background infusion 10 micrograms kg-1 h-1 (B10). Total consumption of morphine was greater in group B10 compared with groups B0 (P < 0.01) and B4 (P < 0.05). There was no significant difference in morphine consumption in groups B0 and B4. All three groups self-administered similar amounts of morphine and there were no significant differences in pain scores or incidence of excessive sedation. Group B4 suffered less hypoxaemia compared with groups B0 (P < 0.01) and B10 (P < 0.001). Group B10 suffered more nausea and vomiting than groups B0 (P < 0.001) and B4 (P < 0.001), but there was no significant difference in the incidence of nausea and vomiting between groups B0 and B4. Groups B4 and B10 spent more time at night asleep than group B0 (P < 0.05). There were no significant differences between the groups in the amount of time spent asleep during the day. Inclusion of a background infusion of morphine 4 micrograms kg-1 h-1 in a PCA regimen for children did not increase the incidence of side effects and was associated with less hypoxaemia and a better sleep pattern than no background infusion.
1993
Doyle E; Harper I; Morton NS
British Journal Of Anaesthesia
1993
Article information provided for research and reference use only. PedPalASCNET does not hold any rights over the resource listed here. All rights are retained by the journal listed under publisher and/or the creator(s).
Journal Article
<a href="http://doi.org/10.1093/bja/71.6.818" target="_blank" rel="noreferrer">10.1093/bja/71.6.818</a>
Pharmacokinetics of continuous infusions of fentanyl in critically ill children
adolescent; Child; Humans; infant; Male; Critical Illness; Prospective Studies; Fentanyl; Half-Life; Preschool; Newborn; Infusions; Intravenous; Metabolic Clearance Rate
OBJECTIVE: To determine the pharmacokinetics of fentanyl when used as a long-term continuous infusion for sedation/analgesia in mechanically ventilated critically ill infants and children. DESIGN: Prospective, case series. SETTING: A university hospital pediatric intensive care unit (ICU). PATIENTS: Nineteen mechanically ventilated infants and children (0.05 to 14 yrs of age) who received continuous infusions of fentanyl for > 24 hrs. INTERVENTIONS: None. MEASUREMENTS: Plasma concentrations of fentanyl were measured 1 hr after a loading dose and at various intervals during and after the infusions were discontinued. Noncompartmental pharmacokinetic variables, total body clearance, volume of distribution at steady state, and terminal elimination half-life were calculated. Clinical sedation scores, ventilatory settings, pupillary size and reactivity, and patient demographics were recorded. RESULTS: After the use of fentanyl by long-term infusion, the volume of distribution at steady state was increased 15.2 L/kg (range 5.1 to 30.5) and the terminal elimination half-life was prolonged 21.1 hrs (range 11.2 to 36.0) compared with previous studies. Clearance was rapid and consistent with other studies. There was a large interpatient variability in clearance that was age dependent. Clearance did not appear to increase over time. CONCLUSIONS: Total body clearance of fentanyl is highly variable and it should be dosed to effect. Patients seen in a pediatric ICU may require a ten-fold variability in fentanyl infusion rates to achieve similar levels of sedation.
1993-07
Katz R; Kelly HW
Critical Care Medicine
1993
Article information provided for research and reference use only. PedPalASCNET does not hold any rights over the resource listed here. All rights are retained by the journal listed under publisher and/or the creator(s).
Journal Article
<a href="http://doi.org/10.1097/00003246-199307000-00012" target="_blank" rel="noreferrer">10.1097/00003246-199307000-00012</a>
Using high-dose morphine to relieve cancer pain
Humans; Male; Adult; Infusions; Intravenous; Neoplasms/physiopathology; Morphine/administration & dosage/adverse effects; Oncologic Nursing/methods; Pain/drug therapy/nursing
For cancer patients, the question of how much morphine is too much may be irrelevant-they need as much as it takes to relieve their pain. Discover the principles of administering high doses of morphine, including which routes to use, how to convert doses from one route to another, and which adverse reactions to expect.
1993
Fulton JS; Johnson GB
Nursing
1993
Article information provided for research and reference use only. PedPalASCNET does not hold any rights over the resource listed here. All rights are retained by the journal listed under publisher and/or the creator(s).
Journal Article
<a href="http://doi.org/10.1097/00152193-199302000-00011" target="_blank" rel="noreferrer">10.1097/00152193-199302000-00011</a>
Ketamine-fentanyl-midazolam infusion for the control of symptoms in terminal life care
Female; Humans; Male; Pain Measurement; Aged; Middle Aged; Treatment Outcome; Drug Therapy; 80 and over; Biomarkers of Pain; retrospective studies; Infusions; Intravenous; Neoplasms/complications; Receptors; Pain/diagnosis/drug therapy/etiology; Terminal Care/methods; Combination; N-Methyl-D-Aspartate/antagonists & inhibitors; Analgesics/pharmacology/therapeutic use; Cognition Disorders/drug therapy/etiology; Fentanyl/pharmacology/therapeutic use; Hypnotics and Sedatives/pharmacology/therapeutic use; Ketamine/pharmacology/therapeutic use; Midazolam/pharmacology/therapeutic use; Psychomotor Agitation/drug therapy/etiology
In this report, we describe nine terminally ill patients with metastatic cancer who were treated with an intravenous infusion consisting of ketamine (2 mg/ml)/fentanyl (5 micrograms/ml)/midazolam (0.1 mg/ml) (K/F/M) to control pain after traditional analgesic therapies were unsuccessful. In addition to pain, all patients exhibited some symptoms of cognitive compromise and agitation. After initiation of the K/F/M infusion, all patients exhibited some degree of qualitative improvement in these symptoms as well as in overall pain control. We feel that these observations warrant reporting of the efficacy of this infusion for the treatment of uncontrolled pain and agitation in terminally ill patients when the traditional methods of pain control are inadequate.
2000
Berger JM; Ryan A; Vadivelu N; Merriam P; Rever L; Harrison P
The American Journal Of Hospice & Palliative Care
2000
Article information provided for research and reference use only. PedPalASCNET does not hold any rights over the resource listed here. All rights are retained by the journal listed under publisher and/or the creator(s).
Journal Article
<a href="http://doi.org/10.1177/104990910001700213" target="_blank" rel="noreferrer">10.1177/104990910001700213</a>
Intravenous morphine for emergency treatment of cancer pain
Female; Male; Palliative Care; Adult; Analgesics; Aged; 80 and over; retrospective studies; Infusions; Intravenous; Human; Developing Countries; Adolescence; Middle Age; Neoplasms/complications; Morphine/administration & dosage/adverse effects; Emergency Treatment; India; Opioid/administration & dosage/adverse effects; Pain/drug therapy/prevention & control
Despite the wide use of the World Health Organization (WHO) analgesic ladder for the relief of cancer pain, it is not uncommon to find patients presenting with severe pain to palliative care centres. This is more so in the developing world, where facilities for pain relief are few and the health care system is not well organized. It has been the practice in a pain and palliative care clinic in south India to give repeated boluses of 1.5 mg of morphine intravenously every 10 min to patients presenting with severe pain. An audit of the procedure was undertaken by a retrospective study of 793 case notes. Seventy-nine per cent of patients had total relief of their pain with intravenous morphine. Three per cent of patients experienced side-effects during the procedure. These included nausea and vomiting, itching, giddiness, restlessness, dyspnoea, chest pain, disorientation and a feeling of uneasiness. Thirty-two per cent of patients had drowsiness, which was one of the end-points of the procedure. It is concluded that intravenous morphine in repeated boluses of 1.5 mg every 10 min is a safe and effective method of managing cancer pain emergencies in a clinical setting in a developing country.
2000
Kumar KS; Rajagopal MR; Naseema AM
Palliative Medicine
2000
Article information provided for research and reference use only. PedPalASCNET does not hold any rights over the resource listed here. All rights are retained by the journal listed under publisher and/or the creator(s).
Journal Article
<a href="http://doi.org/10.1191/026921600670697351" target="_blank" rel="noreferrer">10.1191/026921600670697351</a>
Pharmacokinetic optimisation of opioid treatment in acute pain therapy
Humans; Pain; Analgesics; Drug Interactions; Analgesia; Drug Administration Schedule; Administration; Oral; Pain/drug therapy; Infusions; Injections; Intravenous; Dose-Response Relationship; Drug; Subcutaneous; Intramuscular; Patient-Controlled; Postoperative/drug therapy; Substance-Related Disorders; Opioid/pharmacokinetics/pharmacology/therapeutic use; Central Nervous System/drug effects/metabolism
Traditionally, opioids have been administered as fixed doses at fixed dose intervals. This approach has been largely ineffective. Patient-controlled analgesia (PCA) and upgraded traditional approaches incorporating flexibility in dose size and dose interval, and titration for an effect in individual patients with the monitoring of pain and sedation scores, can greatly improve the efficacy of opioid administration. Optimising opioid use, therefore, entails optimising the titration process. Opioids have similar pharmacodynamic properties but have widely different kinetic properties. The most important of these is the delay between the blood concentrations of an opioid and its analgesic or other effects, which probably relate to the delay required for blood and brain and spinal cord (CNS) equilibrium. The half-lives of these delays range from approximately 34 minutes for morphine to 1 minute for alfentanil. The titration is influenced by the time needed after an initial dose before it is safe to administer a second dose and the duration of the effects of a single dose, which varies widely between opioids, doses and routes of administration. To compare opioids and routes of administration, we examined the relative CNS concentration profiles of opioids - the CNS concentration expressed as a percentage of its maximum value. The relative onset was the defined as the time the relative CNS concentration first rose to 80% of maximum, while the relative duration was defined as the length of time the concentration was above 80%. For an intravenous bolus dose, the relative onset varies from approximately 1 for alfentanil to 6 minutes for morphine, while their relative durations are approximately 2 and 96 minutes, respectively. Although all of the common opioids, perhaps with the exception of alfentanil, have kinetic and dynamic properties suitable for use in PCA with intravenous bolus doses, the long relative duration of morphine makes it particularly suited to an upgraded traditional approach using staff administered intramuscular or subcutaneous doses. There is a clear kinetic preference for regimens with a rapid onset and short duration (e.g. intravenous PCA) for coping with incident pain. It is shown that, in general, titration is improved by the more frequent administration of smaller doses, but it is important to use additional doses to initially 'load' a patient. The titration of opioids should always be accompanied by the monitoring of pain and sedation scores and ventilation.
1997
Upton RN; Semple TJ; Macintyre PE
Clinical Pharmacokinetics
1997
Article information provided for research and reference use only. PedPalASCNET does not hold any rights over the resource listed here. All rights are retained by the journal listed under publisher and/or the creator(s).
Journal Article
<a href="http://doi.org/10.2165/00003088-199733030-00005" target="_blank" rel="noreferrer">10.2165/00003088-199733030-00005</a>