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Pain Management in Pediatric Postsurgical Patients at Mulago Hospital Kyle Sanders 1 , Michael Lipnick 1 , Mary T. Nabukenya 2 , Janat Tumukunde 2 1 Department of Anesthesia and Perioperative Care, University of California, San Francisco, CA 2 Department of Anesthesiology, Mulago Hospital, Makerere University, Kampala, Uganda GLOBAL HEALTH • Department of Anesthesiology, Mulago Hospital, Makerere University • Dr. Doruk Ozgediz, Department of Surgery, Yale University • Dr. Phyllis Kisa, Department of Surgery, Mulago Hospital, Makerere University ACKNOWLEDGEMENTS Introduction: • In low and middle-income countries (LMICs), the burden of surgical disease exceeds that of HIV/AIDS, tuberculosis, and malaria combined. 4 • Acute pain after surgery is nearly universal, and has a profound impact on patient well-being. 1 • The consequences of poorly-controlled pain include increased risk of: 1 v Deep vein thrombosis and pulmonary embolism v Myocardial infarction v Pneumonia v Delayed wound healing v Increased length of stay in hospital • Underassessment and undertreatment of pain are common in LMICs. 2 5.5 billion people (83% of the world's population) live in countries with low to nonexistent access to opioids. 15% of the world’s population consumes 94% of the world’s opioids. 5 • Pain in children is often disproportionately neglected due to misconceptions about nociception in childhood, lack of effective communication, and fear of addiction. 3,6 Anaesthesia & Analgesia Data Collection Form Patient Information: ID Number:___________ Age:________ M / F Weight: _______kg Diagnosis:__________________ Surgery Date: ___________ Surgery Type (i.e. laparotomy, urethroplasty, etc): _____________________________ Patient status prior to surgery: [ ] inpatient [ ] outpatient Anesthesia type (can select more than one type per case): ❏ General: Isoflurane Sevoflurane Halothane Propofol Ketamine Other:______ ❏ Sedation/MAC: ___________________ ❏ Regional: _________________________ ❏ Local (i.e, did the surgeon inject local anesthetic into the wound): _____________ _______% _ ❏ Neuraxial (spinal, epidural, caudal - medication and dose used): _____________ _______% _ Intraop Analgesia ❏ Fentanyl ________ mcg IV / IM / PO / IN ❏ Morphine ________ mg IV / IM / PO ❏ Ketamine ________ mg IV / IM / PO / IN ❏ Diclofenac ________ mg IV / PO / PR ❏ Pethidine ________ mg IV / IM / PO ❏ Paracetamol ________ mg IV / PO / PR ❏ Ketorolac ________ mg IV / PO / IM ❏ Other: ________ IV / IM / PO / PR Development of Anesthesia and Analgesia Database: Pain Medications Prescribed: Dose Route Frequency Expires__ Fentanyl ________ mcg IV / IM / PO / IN ________ ____ days Morphine ________ mg IV / IM / PO ________ ____ days Ketamine ________ mg IV / IM / PO / IN ________ ____ days Diclofenac ________ mg IV / PO / PR ________ ____ days Pethidine ________ mg IV / IM / PO ________ ____ days Paracetamol ________ mg IV / PO / PR ________ ____ days Ketorolac ________ mg IV / PO / IM ________ ____ days Other: _______________ IV / IM / PO / PR ________ ____ days Pain Medications Administered in First 24 hours after Surgery: Dose Route Date(s) and Time(s) Given ________ Fentanyl ________ mcg IV / IM / PO / IN __________________________________ Morphine ________ mg IV / IM / PO __________________________________ Ketamine ________ mg IV / IM / PO / IN __________________________________ Diclofenac ________ mg IV / PO / PR __________________________________ Pethidine ________ mg IV / IM / PO __________________________________ Paracetamol ________ mg IV / PO / PR __________________________________ Ketorolac ________ mg IV / PO / IM __________________________________ Other: ________________ IV / IM / PO / PR __________________________________ If No Medication Documented, Why? (Circle): • None charted • Chart Missing • Patient Discharge/Transfer • Patient Ran Away • Other:_______ Documentation of Pain Assessment in Chart: ❏ Yes Pain Score (with date and time noted): ________ ________ ________ ________ ❏ No Future Directions: • Obtain IRB approval to pilot Anesthesia and Analgesia Data Collection Form • Explore qualitative aspects of pain management, including parental and nursing surveys regarding perceptions of pain • QI initiatives addressing standardization of medication dosages, recognition of opioid overdose, standardized pain assessment scales Objective: • Mulago Hospital is a national referral center in Kampala, Uganda, with an active pediatric surgical service. There is currently no documentation of the status of pain management on the pediatric surgical ward. • The goal of this project is to assess feasibility of characterizing the current state of pain management Observations: • Literature review and anecdotal reports/interviews identified substantial barriers to adequate pain control, including: medication availability, overburdened nursing staff, inadequate knowledge of drug dosing and frequency, inadequate pain assessment, and fear of addiction. • Many LMICs have restrictive laws against the use of opioids based on fear of misuse and addiction. Ugandan hospitals, in contrast, typically have reliable access to oral morphine as a result of strong advocacy in the field of palliative care. • Documentation of intraoperative anesthetic and analgesic medication administration is excellent. Medications and dosages are recorded on a paper record, allowing for the possibility of retrospective data collection. • The Department of Surgery at Yale University has developed a database collecting pediatric surgical data at Mulago Hospital, into which anesthetic data can be integrated. • Potential limitations include: v Limited use of objective pain scales (FLACC, FPS, NRS). Pain scores not recorded in chart. v Inconsistent documentation of postoperative analgesic medication administration v Low fidelity between analgesics prescribed and those documented as given by nursing staff. It is unclear whether this represents lack of administration, lack of documentation, or both. v Parents are frequently responsible for administering self-purchased pain medications, complicating documentation practices. v Inherent risk of unintended consequences when encouraging pain control in a setting with limited monitoring capabilities. References: 1. Apfelbaum JL, Chen C, Mehta SS, Gan TJ. Postoperative Pain Experience: Results from a National Survey Suggest Postoperative Pain Continues to Be Undermanaged. Anesth Analg 2003;97:534–40 2. Ballantyne J, Cousins M, Giamberardino M, et al: “Managing Acute Pain in the Developing World,” Pain Clinical Updates. Vol. XIX, Issue 3. June 2001. 3. Cohen et al., “Evidence-Based Assessment of Pediatric Pain.” Journal of Pediatric Psychology 33(9) pp. 939-955, 2008 4. Debas, H. T., P. Donkor, A. Gawande, D. T. Jamison, M. E. Kruk, and C. N. Mock, editors. 2015. Essential Surgery. Disease Control Priorities, third edition, volume 1. Washington, DC: World Bank. 5. Verghese ST, Hannallah RS. Acute Pain Management in Children. J Pain Res. 2010; 3: 105–123 6. Seya, et al. “A first comparison between the consumption of and the need for opioid analgesics at country, regional, and global levels” J Pain Palliat Care Pharmacother. 2011;25(1):6-18. “WHO Model List of Essential Medicines.” World Health Organization. April 2015. WHO Essential Medication Available on Ward Cost to Purchase at Pharmacy Morphine (oral) x x n/a Morphine (IV) x n/a Acetaminophen (rectal) x x 500 mg x 100 pills 5 USD Ketamine x n/a Ibuprofen x 400 mg x 60 pills 3.86 USD Pain & Policy Studies Group. Opioid consumption maps—Morphine equivalence (ME), mg/capita, 2014 Global Consumption of Morphine Equivalents

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Page 1: UCSF Dept of Anesthesia - Pain Management in Pediatric ......Pain Management in Pediatric Postsurgical Patients at MulagoHospital Kyle Sanders1, Michael Lipnick1, Mary T. Nabukenya2,

PainManagementinPediatricPostsurgicalPatientsatMulago HospitalKyleSanders1,MichaelLipnick1,MaryT.Nabukenya2,Janat Tumukunde21DepartmentofAnesthesiaandPerioperativeCare,UniversityofCalifornia,SanFrancisco,CA

2DepartmentofAnesthesiology,Mulago Hospital,Makerere University,Kampala,Uganda

GLOBALHEALTH

• DepartmentofAnesthesiology,Mulago Hospital,Makerere University

• Dr.Doruk Ozgediz,DepartmentofSurgery,YaleUniversity

• Dr.PhyllisKisa,DepartmentofSurgery,Mulago Hospital,Makerere University

ACKNOWLEDGEMENTS

Introduction:

• Inlowandmiddle-incomecountries(LMICs),theburdenofsurgicaldiseaseexceedsthatofHIV/AIDS,tuberculosis,andmalariacombined.4

• Acutepainaftersurgeryisnearlyuniversal,andhasaprofoundimpactonpatientwell-being.1

• Theconsequencesofpoorly-controlledpainincludeincreasedriskof:1

v Deepveinthrombosisandpulmonaryembolismv Myocardialinfarctionv Pneumoniav Delayedwoundhealingv Increasedlengthofstayinhospital

• Underassessmentandundertreatment ofpainarecommoninLMICs.2 5.5billionpeople(83% of theworld'spopulation)liveincountrieswithlowtononexistentaccesstoopioids.15%oftheworld’spopulationconsumes94%oftheworld’sopioids.5

• Paininchildrenisoftendisproportionatelyneglectedduetomisconceptionsaboutnociceptioninchildhood,lackofeffectivecommunication,andfearofaddiction.3,6

Anaesthesia & Analgesia Data Collection Form

Patient Information: ID Number:___________ Age:________ M / F Weight: _______kg Diagnosis:_______________________ Surgery Date: ___________ Surgery Type (i.e. laparotomy, urethroplasty, etc): ___________________________________

Patient status prior to surgery: [ ] inpatient [ ] outpatient

Anesthesia type (can select more than one type per case):

❏ General: Isoflurane Sevoflurane Halothane Propofol Ketamine Other:______________

❏ Sedation/MAC: ___________________

❏ Regional: _________________________

❏ Local (i.e, did the surgeon inject local anesthetic into the wound): _____________ _______% ______ mL

❏ Neuraxial (spinal, epidural, caudal - medication and dose used): _____________ _______% ______ mL

Intraop Analgesia

❏ Fentanyl ________ mcg IV / IM / PO / IN

❏ Morphine ________ mg IV / IM / PO

❏ Ketamine ________ mg IV / IM / PO / IN

❏ Diclofenac ________ mg IV / PO / PR

❏ Pethidine ________ mg IV / IM / PO

❏ Paracetamol ________ mg IV / PO / PR

❏ Ketorolac ________ mg IV / PO / IM

❏ Other: ________ IV / IM / PO / PR

DevelopmentofAnesthesiaandAnalgesiaDatabase:

Pain Medications Prescribed: Dose Route Frequency Expires__

Fentanyl ________ mcg IV / IM / PO / IN ________ ____ days

Morphine ________ mg IV / IM / PO ________ ____ days

Ketamine ________ mg IV / IM / PO / IN ________ ____ days

Diclofenac ________ mg IV / PO / PR ________ ____ days

Pethidine ________ mg IV / IM / PO ________ ____ days

Paracetamol ________ mg IV / PO / PR ________ ____ days

Ketorolac ________ mg IV / PO / IM ________ ____ days

Other: _______________ IV / IM / PO / PR ________ ____ days

Pain Medications Administered in First 24 hours after Surgery: Dose Route Date(s) and Time(s) Given ________

Fentanyl ________ mcg IV / IM / PO / IN __________________________________

Morphine ________ mg IV / IM / PO __________________________________

Ketamine ________ mg IV / IM / PO / IN __________________________________

Diclofenac ________ mg IV / PO / PR __________________________________

Pethidine ________ mg IV / IM / PO __________________________________

Paracetamol ________ mg IV / PO / PR __________________________________

Ketorolac ________ mg IV / PO / IM __________________________________

Other: ________________ IV / IM / PO / PR __________________________________

If No Medication Documented, Why? (Circle):

• None charted • Chart Missing • Patient Discharge/Transfer • Patient Ran Away • Other:_______

Documentation of Pain Assessment in Chart: ❏ Yes Pain Score (with date and time noted): ________ ________ ________ ________

❏ No

FutureDirections:

• ObtainIRBapprovaltopilotAnesthesiaandAnalgesiaDataCollectionForm

• Explorequalitativeaspectsofpainmanagement,includingparentalandnursingsurveysregardingperceptionsofpain

• QIinitiativesaddressingstandardizationofmedicationdosages,recognitionofopioidoverdose,standardizedpainassessmentscales

Objective:

• Mulago HospitalisanationalreferralcenterinKampala,Uganda,withanactivepediatricsurgicalservice.Thereiscurrentlynodocumentationofthestatusofpainmanagementonthepediatricsurgicalward.

• Thegoalofthisprojectistoassessfeasibilityofcharacterizingthecurrentstateofpainmanagement

Observations:

• Literaturereviewandanecdotalreports/interviewsidentifiedsubstantialbarrierstoadequatepaincontrol,including:medicationavailability,overburdenednursingstaff,inadequateknowledgeofdrugdosingandfrequency,inadequatepainassessment,andfearofaddiction.

• ManyLMICshaverestrictivelawsagainsttheuseofopioidsbasedonfearofmisuseandaddiction.Ugandanhospitals,incontrast,typicallyhavereliableaccesstooralmorphineasaresultofstrongadvocacyinthefieldofpalliativecare.

• Documentationofintraoperativeanestheticandanalgesicmedicationadministrationisexcellent.Medicationsanddosagesarerecordedonapaperrecord,allowingforthepossibilityofretrospectivedatacollection.

• TheDepartmentofSurgeryatYaleUniversityhasdevelopedadatabasecollectingpediatricsurgicaldataatMulago Hospital,intowhichanestheticdatacanbeintegrated.

• Potentiallimitationsinclude:

v Limiteduseofobjectivepainscales(FLACC,FPS,NRS).Painscoresnotrecordedinchart.v Inconsistentdocumentationofpostoperativeanalgesicmedicationadministrationv Lowfidelitybetweenanalgesicsprescribedandthosedocumentedasgivenbynursingstaff.

Itisunclearwhetherthisrepresentslackofadministration,lackofdocumentation,orboth.v Parentsarefrequentlyresponsibleforadministeringself-purchasedpainmedications,

complicatingdocumentationpractices.v Inherentriskofunintendedconsequenceswhenencouragingpaincontrolinasettingwith

limitedmonitoringcapabilities.

References:1. Apfelbaum JL,ChenC,MehtaSS,Gan TJ.PostoperativePainExperience:ResultsfromaNationalSurveySuggestPostoperativePain

ContinuestoBeUndermanaged.Anesth Analg 2003;97:534–402. Ballantyne J,CousinsM,Giamberardino M,etal:“ManagingAcutePainintheDevelopingWorld,”PainClinicalUpdates.Vol.XIX,Issue

3.June2001.3. Cohenetal.,“Evidence-BasedAssessmentofPediatricPain.”JournalofPediatricPsychology33(9)pp.939-955,20084. Debas,H.T.,P.Donkor,A.Gawande,D.T.Jamison,M.E.Kruk,andC.N.Mock,editors.2015. EssentialSurgery.DiseaseControl

Priorities,thirdedition,volume1.Washington,DC:WorldBank.5. Verghese ST,Hannallah RS.AcutePainManagementinChildren.JPainRes.2010;3:105–1236. Seya,etal.“Afirstcomparisonbetweentheconsumption of andtheneedforopioidanalgesicsatcountry,regional,andgloballevels”

JPain Palliat Care Pharmacother. 2011;25(1):6-18. “WHOModelListofEssentialMedicines.”WorldHealthOrganization.April2015.

WHO EssentialMedication

AvailableonWard

CosttoPurchaseatPharmacy

Morphine(oral) x x n/a

Morphine(IV) x n/a

Acetaminophen(rectal)

x x 500mgx100pills5USD

Ketamine x n/a

Ibuprofen x 400mgx60pills3.86USD

Pain&PolicyStudiesGroup.Opioidconsumptionmaps—Morphineequivalence(ME),mg/capita,2014

GlobalConsumptionofMorphineEquivalents

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