Dexmedetomidine and Propofol Use for Palliative Sedation Therapy (PST) in Pediatric Oncology: A Ten-Year Review (GP750)

Cuviello, Andrea; Pasli, Melisa; Anghelescu, Doralina L.; Johnson, Liza‐Marie; Baker, Justin N.

doi:10.1016/j.jpainsymman.2022.04.141

Cited by 4 publications

(7 citation statements)

References 0 publications

Supporting

Mentioning

Contrasting

Unclassified

Order By: Relevance

“…In rare cases, suffering persists despite all interventions, and PST is an effective tool for refractory suffering at the EOL ( 40 – 44 ). PST practices are variable in pediatric oncology, and medication choices for implementation of PST are evolving ( 40 , 68 , 69 ). Propofol and dexmedetomidine are utilized more commonly for this intervention ( 68 – 71 ).…”

Section: Discussionmentioning

confidence: 99%

Compassionate de-escalation of life-sustaining treatments in pediatric oncology: An opportunity for palliative care and intensive care collaboration

Cuviello

Pasli²,

Hurley³

et al. 2022

Front. Oncol.

Self Cite

View full text Add to dashboard Cite

ContextApproximately 40%-60% of deaths in the pediatric intensive care unit (PICU) are in the context of de-escalation of life-sustaining treatments (LSTs), including compassionate extubation, withdrawal of vasopressors, or other LSTs. Suffering at the end of life (EOL) is often undertreated and underrecognized. Pain and poor quality of life are common concerns amongst parents and providers at a child’s EOL. Integration of palliative care (PC) may decrease suffering and improve symptom management in many clinical situations; however, few studies have described medical management and symptom burden in children with cancer in the pediatric intensive care unit (PICU) undergoing de-escalation of LSTs.MethodsA retrospective chart review was completed for deceased pediatric oncology patients who experienced compassionate extubation and/or withdrawal of vasopressor support at EOL in the PICU. Demographics, EOL characteristics, and medication use for symptom management were abstracted. Descriptive analyses were applied.ResultsCharts of 43 patients treated over a 10-year period were reviewed. Most patients (69.8%) were white males who had undergone hematopoietic stem cell transplantation and experienced compassionate extubation (67.4%) and/or withdrawal of vasopressor support (44.2%). The majority (88.3%) had a physician order for scope of treatment (POST – DNaR) in place an average of 13.9 days before death. PC was consulted for all but one patient; however, in 18.6% of cases, consultations occurred on the day of death. During EOL, many patients received medications to treat or prevent respiratory distress, pain, and agitation/anxiety. Sedative medications were utilized, specifically propofol (14%), dexmedetomidine (12%), or both (44%), often with opioids and benzodiazepines.ConclusionsPediatric oncology patients undergoing de-escalation of LSTs experience symptoms of pain, anxiety, and respiratory distress during EOL. Dexmedetomidine and propofol may help prevent and/or relieve suffering during compassionate de-escalation of LSTs. Further efforts to optimize institutional policies, education, and collaborations between pediatric intensivists and PC teams are needed.

show abstract

Section: Discussionmentioning

confidence: 99%

Compassionate de-escalation of life-sustaining treatments in pediatric oncology: An opportunity for palliative care and intensive care collaboration

Cuviello

Pasli²,

Hurley³

et al. 2022

Front. Oncol.

Self Cite

View full text Add to dashboard Cite

show abstract

“…Through agonism of presynaptic alpha-2 adrenergic receptors, dexmedetomidine can lead to a reduction in the pain signaling pathway and has been shown to be both safe and effective in pediatrics [ 23 ]. More recently, a retrospective analysis showed a potential increasing role for dexmedetomidine at the EOL for symptom relief [ 27 ]. Once again, this case emphasizes the benefits of interdisciplinary team collaboration, specifically pain and palliative care services, to optimize symptom management for dying children.…”

Section: Case-based Application Of Pst Algorithmmentioning

confidence: 99%

“…In an effort to improve the availability of PST, our group analyzed institutional PST practices over a 10-year period. We found that approximately 3% of all patient deaths and 12% of inpatient deaths utilized PST during the EOL [ 27 ]. In general, PST was implemented for refractory pain (33%), anxiety/agitation (17%), respiratory distress (13%) or a combination of these symptoms.…”

Section: Introductionmentioning

confidence: 99%

“…Interestingly, we discovered a practice shift to include the use of dexmedetomidine in place of traditional sedatives like propofol [ 28 ]. Of 24 patients receiving PST, 83% ( n = 20) achieved symptom control with dexmedetomidine and only one patient (4%) required a deeper level of sedation (with propofol) [ 27 ]. Among the 20 patients receiving dexmedetomidine infusions, approximately 50% ( n = 11) required low-dose infusions (dosing range from 0.2 mcg/kg/h to 1 mcg/kg/h).…”

Section: Introductionmentioning

confidence: 99%

See 1 more Smart Citation

Palliative Sedation Therapy in Pediatrics: An Algorithm and Clinical Practice Update

et al. 2022

Self Cite

View full text Add to dashboard Cite

Palliative sedation therapy (PST) is an important clinical intervention for pediatric patients with refractory symptoms and suffering during the end-of-life (EOL) period. Variations in PST implementation including medication selection, limited literature regarding feasibility in various clinical settings, particularly non-intensive care units, and lack of education on evolving definitions and ideal practices may all contribute to the current underutilization of this valuable resource. We therefore offer a clinical algorithm for identifying appropriate patients for PST, ensuring all other modalities for symptom management have been considered and/or optimized, and present a guideline for PST implementation that can be adapted and individualized based on institutional experience and resource availability. Furthermore, through case-based clinical scenarios, we demonstrate how to incorporate this algorithm into EOL practice.

show abstract

“…Additionally, integrative medicine approaches including acupuncture and massage are being incorporated more frequently for pain and other distressing symptoms ( 9 , 10 ). Occasionally, traditional symptom management strategies are insufficient to alleviate suffering, so consideration of palliative sedation therapy may be needed ( 11 ).…”

Section: Introductionmentioning

confidence: 99%

Regional blocks for pain control at the end of life in pediatric oncology

et al. 2023

Self Cite

View full text Add to dashboard Cite

BackgroundPain management at the end of life is a fundamental aspect of care and can improve patients' quality of life. Interventional approaches may be underutilized for pediatric cancer patients.ObjectiveTo describe a single institution's 10 years of experience with regional pain management at the end of life in pediatric oncology.MethodsA retrospective cohort study of 27 patients with pediatric cancer who died between April 2011 and December 2021 and received continuous nerve block (CNB) catheters or single-shot nerve blocks (SSBs) during their last three months of life. The type of blocks, analgesic efficacy, and palliative care involvement were evaluated.ResultsTwenty-two patients (81.5%) had solid tumor diagnoses, including carcinomas, sarcomas, and neuroblastoma. Most (59%) patients received CNB catheters, and 12 patients (44%) received SSBs for pain control. The mean pain score decreases for CNB catheters and SSBs after interventions were −2.5 and −2.8, respectively, on an 11-point scale. Decreases in opioid patient-controlled analgesia dosing requirements were noted in 56% of patients with CNB catheters; likewise, in 25% of patients with SSBs at 24 h and in 8% at 5 days after interventions. Nearly all patients had PC involvement and received care from pain specialists (96% and 93%, respectively). Twenty-three (85%) had physician orders for scope of treatment orders completed before death.ConclusionRegional pain control interventions can be effective and safe for relieving regional pain and suffering in dying children and young adults. The collaboration between palliative care and pain management specialists at the end of life can help alleviate suffering and improve quality of life.

show abstract

Dexmedetomidine and Propofol Use for Palliative Sedation Therapy (PST) in Pediatric Oncology: A Ten-Year Review (GP750)

Cited by 4 publications

References 0 publications

Compassionate de-escalation of life-sustaining treatments in pediatric oncology: An opportunity for palliative care and intensive care collaboration

Compassionate de-escalation of life-sustaining treatments in pediatric oncology: An opportunity for palliative care and intensive care collaboration

Palliative Sedation Therapy in Pediatrics: An Algorithm and Clinical Practice Update

Regional blocks for pain control at the end of life in pediatric oncology

Contact Info

Product

Resources

About