Patient‐controlled analgesia at the end of life at a pediatric oncology institution

Abstract

Background Patient controlled anesthesia (PCA) is increasingly used to manage pain in pediatric cancer patients and is important in the treatment of escalating pain at the end of life. The description of the use of opioid PCA in this population has been limited. Procedure This retrospective chart review of the last 2 weeks of life addressed the following objectives: 1) to describe the patient population treated with opioid PCA; 2) to describe the morphine-equivalent doses (MED) (mg/kg/day); and 3) to describe the pain scores (PS). Results Twenty-eight percent of inpatients used opioid PCA for pain control during the last 2 weeks of life. The mean MED (mg/kg/day) (SD) at 2 weeks prior and the day of death were 10.7 (17.9) and 19 (25.8). The mean MED increased over the last 2 weeks of life for all patients and across age groups and cancer diagnoses (all p<0.05). The mean MED was significantly higher in the younger age group (age <13 vs. age ≥13) on the day of death (p<0.04). There was a significant change in mean PS over the last 2 weeks of life (p<0.001), with the highest PS on the day before death. The most frequently used concurrent medications were benzodiazepines (91%). Conclusions Children and young adults with cancer experience high opioid requirements and significant dose increases during the last 2 weeks of life. Additionally PS increase toward the end of life. Opioid rotation and addition of adjuvant medications merit consideration in the context of escalating opioid requirements.

Patient-Controlled Analgesia for Children With Life-Limiting Conditions in the Community: Results of a Prospective Observational Study

“…We did not find that these measures correlated with PCA use at end-oflife. This finding is consistent with previous literature (1,7). We would suggest this finding indicates measure of pain should be appropriate to the experience of this population, especially prior to death (10) and amenable to the need for proxy scoring.…”

“…To the Editor, The use of patient controlled analgesia (PCA) for children and young people with life-limiting conditions and life-threatening illnesses is an emerging intervention in paediatric palliative care as an alternative to continuous parental infusion with a separate breakthrough analgesia (1,2). In paediatric palliative care PCA is characteristically a continuous infusion of opioid administered via a programmable pump which enables patients to control their pain by use of on-demand supplemental bolus analgesia (2,3).…”

Pain Outcomes After Celiac Plexus Block in Children and Young Adults with Cancer

“…A previous retrospective study at St. Jude reported that mean MED increased over the last 2 weeks of life for all patients and across age groups and cancer diagnoses. 16 The mean MED increased from 10.7 mg/kg/day 2 weeks before death to 19 mg/kg/day at death, with the highest PS on the day before death. These patients were treated with PCA and did not receive neurolytic blocks as part of pain management.…”

Expanded Analysis of a Modified Enhanced Recovery Protocol in Cleft Palatoplasty

“…Secondary end points included LOS, postoperative respiratory suppression, complications, and rate of return to service. Following consultation with our anesthesia pain service and a review of the pediatric pain literature, we chose morphine equivalents normalized per weight as the reporting metric (Anghelescu et al, 2015; Rana et al, 2017; Vaughns et al, 2017; Kattail et al, 2018). For each phase of care, all relevant narcotics (eg, fentanyl, dilaudid, morphine, hydrocodone) were converted in standardized ratios to morphine equivalency for uniform comparison.…”