Laura L. Burgoyne

The Safety of Patient-controlled Analgesia by Proxy in Pediatric Oncology Patients

Between February 1999 and December 2003, we studied the use of patient-controlled analgesia (PCA) to control pain in 1011 children and young adults with cancer, by evaluating 4972 24-h periods of PCA usage, 576 of which involved PCA by proxy. Selection of patients for PCA by proxy was based on younger age group, neuromuscular limitation, expectation of repeated painful procedures, and terminal disease. We measured the incidence of respiratory and neurological complications related to the use of PCA. Major complications were observed during 70 of the 4972 24-h observations, with 28 of 4972, or 0.56%, involving respiratory complications, 35 of 4972, or 0.7%, involving neurological complications, and 7 of 4972 24-h observations, or 0.14%, involving both respiratory and neurological complications. In the PCA by proxy group, two respiratory complications and two neurological complications were observed. Reversal of opioid-related respiratory or neurological effects with naloxone was required in three instances, two in the standard PCA group and one in the PCA by proxy group. Recommendations to ensure continuing safety include careful patient selection, education of proxy users, appropriate documentation, and institutional guidelines.

Clinical and Diagnostic Imaging Findings Predict Anesthetic Complications in Children Presenting with Malignant Mediastinal Masses

Background:  The presence of a mediastinal mass in a child poses significant anesthesia‐related risks including death. To optimize outcome clinicians must be able to predict which patients are at highest risk of anesthetic complications.

Safe Anesthesia for Radiotherapy in Pediatric Oncology: St. Jude Children's Research Hospital Experience, 2004–2006

PURPOSE To determine the incidence of anesthesia-related complications in children undergoing radiotherapy and the associated risk factors. METHODS AND MATERIALS We retrospectively investigated the incidence and types of anesthesia-related complications and examined their association with age, weight, oncology diagnosis, type of anesthetic (propofol vs. propofol and adjuncts), total propofol dose, anesthetic duration, type of radiotherapy procedure (simulation vs. radiotherapy) and patient position (prone vs. supine). RESULTS Between July 2004 and June 2006, propofol was used in 3,833 procedures (3,611 radiotherapy sessions and 222 simulations) in 177 patients. Complications occurred during 49 anesthetic sessions (1.3%). On univariate analysis, four factors were significantly associated with the risk of complications: procedure duration (p <0.001), total propofol dose (p <0.001), use of adjunct agents (vs. propofol alone; p = 0.029), and simulation (vs. radiotherapy; p = 0.014). Patient position (prone vs. supine) was not significantly associated with the frequency of complications (odds ratio, 0.71; 95% confidence interval, 0.33-1.53; p = 0.38). On multivariate analysis, the procedure duration (p <0.0001) and total propofol dose (p < or =0.03) were the most significant risk factors after adjustment for age, weight, anesthetic type, and procedure type. We found no evidence of the development of tolerance to propofol. CONCLUSION The rate of anesthesia-related complications was low (1.3%) in our study. The significant risk factors were procedure duration, total propofol dose, the use of adjunct agents with propofol, and simulation (vs. radiotherapy).

Intervention steps for treating laryngospasm in pediatric patients

Background:  Laryngospasm, a potentially life‐threatening complication of anesthesia, is reported more commonly in children (17.4/1000) than in the general population (8.7/1000). However, there are no clinical data on the optimal type and sequence of therapeutic interventions. We therefore characterized the interventions used at St. Jude Children’s Research Hospital.

How well do pediatric anesthesiologists agree when assigning ASA physical status classifications to their patients

Background:  The scope and application of the American Society of Anesthesiologists Physical Status (ASA PS) classification has been called into question and interobserver consistency even by specialist anesthesiologists has been described as only fair. Our purpose was to evaluate the consistency of the application of the ASA PS amongst a group of pediatric anesthesiologists.

Phantom limb pain in young cancer-related amputees: recent experience at St Jude children's research hospital.

Objectives:This study in children and young adults having cancer-related amputation aimed to examine the incidence of phantom limb pain (PLP) in the first year after amputation and also the proportion of patients who had preamputation pain. Methods:A retrospective review of medical records was undertaken. The proportion of patients with PLP was reported. Fisher exact test was used to examine the association between PLP and the presence of preamputation pain and between PLP and age (⩽18 y vs. >18 y). Results:Twenty-six amputations were performed on 25 patients. During the year after amputation, 76% of patients had experienced PLP at some time. After 1 year, though, only 10% still had PLP. Preamputation pain was present in 64% of patients. Although both of our patients with PLP at 1 year were young adults (older than or equal to 18 y) and both had preamputation pain, we found no statistically significant associations between age or the presence of preamputation pain with PLP. Discussion:PLP after cancer-related amputation in children and young adults seems to be common but generally short lived in most patients.

Parent-controlled PCA for pain management in pediatric oncology: Is it safe?

Patient-controlled analgesia offers safe and effective pain control for children who can self-administer medication. Some children may not be candidates for patient-controlled analgesia (PCA) unless a proxy can administer doses. The safety of proxy-administered PCA has been studied, but the safety of parent-administered PCA in children with cancer has not been reported. In this study, we compare the rate of complications in PCA by parent proxy versus PCA by clinician (nurse) proxy and self-administered PCA. Our pediatric institution’s quality improvement database was reviewed for adverse events associated with PCA from 2004 through 2010. Each PCA day was categorized according to patient or proxy authorization. Data from 6151 PCA observation days were included; 61.3% of these days were standard PCA, 23.5% were parent-proxy PCA, and 15.2% were clinician-proxy PCA days. The mean duration of PCA use was 12.1 days, and the mean patient age was 12.3 years. The mean patient age was lower in the clinician-proxy (9.4 y) and parent-proxy (5.1 y) groups, respectively. The complication rate was lowest in the parent-proxy group (0.62%). We found that proxy administration of PCA by authorized parents is as safe as clinician administered and standard PCA at our pediatric institution.

Isosulfan blue causes factitious methemoglobinemia in an infant

A 9 month‐old girl was given subcutaneous isosulfan blue to outline lymphatic channels during surgery for thoracic duct ligation. Her pulse oximetry values rapidly declined to a nadir of 85%, 35 min after dye injection. Arterial blood gases revealed methemoglobinemia ([MetHb] = 6.5%). Although abnormal pulse oximetry has already been reported in association with isosulfan blue, methemoglobinemia has not previously been reported. The absorption spectrum for isosulfan blue was determined and when superimposed on that of methemoglobin it was found to have an overlying peak. Interference by the dye was postulated to have caused the abnormal methemoglobin result. The phenomenon was simulated in vitro by adding isosulfan blue to whole blood, and analysing it in the same blood gas analyser as was used for the case, as well as another for comparison. One blood gas analyser reported elevated methemoglobin concentration and the other did not. The samples were sent to a reference laboratory using a chemical method to detect methemoglobin to confirm that the elevated methemoglobin level was spurious.

Near‐fatal acute bronchovenous fistula in a child undergoing radiofrequency ablation of a metastatic lung tumor

SIR—Radiofrequency ablation (RFA) of solid tumors was pioneered in the early 1990s for the treatment of malignant lesions of the lung and liver (1). Serious acute complications have been described as rare (2) and include pneumothorax, bleeding, and air embolism, and are mostly reported in adults (2,3). We wish to report a near-fatal episode of massive hemoptysis and air embolism in a child undergoing RFA of lung metastases. The patient was a 4-year-old male child who had been diagnosed with stage IV metastatic hepatoblastoma 3 years previously. Despite multiple prior surgeries (resection of the left lobe of the liver and three thoracotomies with wedge resections), extensive treatment with chemotherapy and an unrelated donor stem cell transplantation, progression of disease occurred, with new lung metastases noted in the left lung on computed tomography (CT) of the chest (Figure 1a). The patient had an episode of respiratory failure requiring 30 days of mechanical ventilation 3 months previously, and together with a history of extensive previous chest surgery, no further surgery was deemed appropriate to treat the newly discovered metastases in the lungs. The patient’s family remained committed to pursuing curative treatment, so RFA of the lung tumors was offered. Immediately before the RFA procedure, his vital signs were: weight 12.8 kg, BP 91 ⁄ 66 mmHg, HR 80 bÆmin, RR 32, SpO2 99% on room air, and temperature 36.3 C. Physical examination was otherwise normal. His hemoglobin was 9.6 gÆdl, platelets 116 · 10 l, INR 1.0, and electrolytes, BUN, and creatinine were normal. Anesthetic induction consisted of propofol 30 mg, fentanyl 20 lg, and rocuronium 10 mg via a central line. He was intubated with a size 5 uncuffed oral endotracheal tube, and an air leak at 12 cm H2O was noted. Anesthesia was maintained with 2–3% sevoflurane in an oxygen ⁄ air mixture to provide a FiO2 of 30–50% within a circle breathing circuit. After approximately 90 min, RFA of the larger lung nodule had already been completed and the smaller

The Safety of Concurrent Administration of Opioids via Epidural and Intravenous Routes for Postoperative Pain in Pediatric Oncology Patients

Supplementation of epidural opioid analgesia with intravenous opioids is usually avoided because of concern about respiratory depression. However, the choice of adjunct analgesic agents for pediatric oncology patients is limited. Antipyretic drugs may mask fever in neutropenic patients, and nonsteroidal anti-inflammatory agents may exert antiplatelet effects and interact with chemotherapeutic agents. We examined the safety of concurrent use of epidural and intravenous opioids in a consecutive series of 117 epidural infusions in pediatric patients and compared our findings to those reported by other investigators. We observed a 0.85% rate of clinically significant respiratory complications. The single adverse event was associated with an error in dosage. In our experience, the supplementation of epidural opioid analgesia with intravenous opioids has been a safe method of postoperative pain control for pediatric patients with cancer.