Pain in Children

Patricia A. McGrath PhD , Stephen C. Brown MD , in Pain Management Secrets (Third Edition), 2009

16 Describe the role of continuous infusion in pain management for children

Continuous infusion has several advantages over intermittent SQ, IM, and IV routes. This method circumvents repetitive injections, prevents delays in analgesic drug administration, and provides continuous levels of pain control without children experiencing increased side effects at peak level and pain breakthroughs at trough levels. Continuous infusion should be considered in the following circumstances: children have pain for which oral and intermittent parenteral opioids do not provide satisfactory pain control; intractable vomiting prevents oral medications; IV lines are not desirable; and children would like to remain at home despite severe pain. Children receiving a continuous infusion should continue to receive "rescue doses" to control breakthrough pain, as necessary.

Read full chapter

URL:

https://www.sciencedirect.com/science/article/pii/B9780323040198000305

PERIOPERATIVE EPIDURAL ANALGESIA

Melissa A. Rockford , Martin L. DeRuyter , in Current Therapy in Pain, 2009

ADMINISTRATION

Continuous infusions have been the primary approach to postoperative epidural analgesia. Advancement in infusion pumps has allowed for patient-controlled epidural analgesia (PCEA), employing the same benefits found with IV opioid patient-controlled analgesia (IV PCA). Continuous infusions, although the mainstay, are not without management issues. Namely, failure rates for thoracic and lumbar epidurals are reportedly as high as 32% and 27%, respectively. 5 Catheter malfunction and displacement, nursing care, and attention to the infusion pump all demand utilization of limited resources. The recent introduction of liposomal morphine administered by single injection has been shown to provide significant prolonged analgesia and avoids these concerns, but it is not to be used without caution.

Read full chapter

URL:

https://www.sciencedirect.com/science/article/pii/B9781416048367000110

Management of Acute and Postoperative Pain

Steven D. Waldman , in Pain Management, 2007

Continuous Infusion

Continuous infusion of narcotics achieves a high level of pain relief when the minimal effective analgesic concentration has been reached. 11, 12 Peaks and valleys of effect are decreased with this route of administration, which results in fewer side effects than are seen with intravenous bolus or intramuscular administration of narcotics. Generally, the level of patient satisfaction is high.

One disadvantage of continuous infusions of narcotics is the significant delay in onset of analgesic activity if a bolus dose is not given with the infusion. Another is that the cost, in terms of infusions and the labor required during setup and monitoring, is considerable. Also, the nursing staff may express some resistance to this method because of a perceived possibility of an increased risk of respiratory depression and other side effects. 13

Read full chapter

URL:

https://www.sciencedirect.com/science/article/pii/B9780721603346500248

Pain, Postoperative

Raymond S. Sinatra , in Encyclopedia of the Neurological Sciences, 2003

Continuous Epidural Analgesia

Continuous infusion of epidural opioids, or opioids plus dilute local anesthetics, allows more precise titration and extended duration of neuraxial analgesia. Continuous infusion techniques also provide therapeutic versatility since short-duration opioids such as fentanyl and dilute local anesthetic solutions may be administered.

Epidural infusions of morphine and hydromorphone offer effective and uniform analgesia; however, hydromorphone is associated with less sedation and pruritus. Lipophilic opioids are commonly administered as continuous epidural infusions since their rapid onset and short duration facilitate analgesic titration. Improved analgesic effectiveness may be achieved by combining epidural fentanyl with dilute solutions of bupivacaine.

Epidural infusion of local anesthetics such as ropivacaine or infusions of the α-adrenergic analgesic clonidine may be considered in patients who are exquisitely sensitive to opioid-related adverse events. However, these agents are associated with sensory/motor blockade, sympathetic blockade, and hypotension.

Read full chapter

URL:

https://www.sciencedirect.com/science/article/pii/B0122268709017081

Use of Diuretics in Chronic Kidney Disease Patients

Arthur Greenberg , in Chronic Renal Disease, 2015

E. Administer the Drug via Continuous Intravenous Infusion

Continuous infusion of a loop agent may offer the advantage of maintaining a therapeutic level of diuretic over a more extended period than bolus administration. To some degree, bolus administration is inefficient. The very high blood level occurring soon after administration may be well above the plateau level of the sigmoid-shaped dose response curve. Toward the end of the dosing interval, the blood level may be below the threshold for efficacy. Compared to bolus dosing, continuous infusion of bumetanide has been shown to produce a greater sodium loss. 42 Furosemide bolus vs. continuous infusion was examined in a population of CKD patients given either a bolus dose or the same total dose of diuretic with 25% given as a loading dose and 75% infused continuously over 4 hours. The continuous infusion protocol led to significantly greater absolute and fractional sodium excretion and a larger diuresis. 43 However, repeated bolus dosing can certainly be effective if urine output is monitored and the dose and frequency adjusted. One clinical advantage of continuous dosing is that it requires less attention compared to repeated bolus dosing on an as needed basis. Having an effective continuous dose running "in the background" may be advantageous compared to a dosing scheme that requires active intervention and in which repeat bolus dosing may be delayed. In a different patient population, acute decompensated CHF, no efficacy difference was found with continuous compared to bolus dosing when both were given on a regular basis per protocol. 44

The risk of diuretic ototoxicity is low with current doses of loop diuretics. Reversible ototoxicity may be noted when drug accumulates due to CKD. This is more likely with the higher peak levels achieved with bolus dosing. Continuous IV dosing may be safer in that regard. 45,46

Read full chapter

URL:

https://www.sciencedirect.com/science/article/pii/B9780124116023000561

Anesthetics, local

In Meyler's Side Effects of Drugs (Sixteenth Edition), 2016

Interpleural anesthesia

Interpleural administration of local anesthetics has been followed by Horner's syndrome and increased skin temperature, apparently pointing to an effect on the sympathetic nervous system [281]. Pneumothorax or infection can also result. Interpleural administration of local anesthetics can produce high serum drug concentrations and a risk of systemic toxicity [282], possibly increased by the addition of adrenaline [283,284].

Continuous infusion of local anesthetics via an interpleural catheter can be used to provide effective postoperative pain relief after breast surgery. Bradycardia and asystole have been reported with this technique [ 285].

•

An otherwise fit 51-year-old woman had an elective free TRAM flap breast reconstruction following right mastectomy, with interpleural administration of bupivacaine   +   adrenaline for postoperative analgesia. On the first postoperative day she developed symptomatic bradycardia leading to hypotension, which progressed to asystole. The electrocardiogram showed third-degree block with ventricular arrest, which was treated with a temporary pace maker.

No cardiac abnormalities were found, and it was assumed that these symptoms reflected local anesthetic toxicity.

Read full chapter

URL:

https://www.sciencedirect.com/science/article/pii/B9780444537171016772

Side Effects of Drugs Annual 32

Stephan A. Schug , Hari Krshnan , in Side Effects of Drugs Annual, 2010

Cardiovascular

Continuous infusion of local anesthetics via an interpleural catheter can be used to provide effective postoperative pain relief after breast surgery. Bradycardia and asystole have been reported with this technique (26 A).

•

An otherwise fit 51-year-old woman had an elective free transverse rectus abdominis myocutaneous (TRAM) flap breast reconstruction following right mastectomy, with interpleural administration of bupivacaine   +   adrenaline for postoperative analgesia. On the first postoperative day she developed symptomatic bradycardia leading to hypotension, which progressed to asystole. The electrocardiogram showed third-degree block with ventricular arrest, which was treated with a temporary pacemaker.

No cardiac abnormalities were found, and it was assumed that these symptoms reflected local anesthetic toxicity.

Read full chapter

URL:

https://www.sciencedirect.com/science/article/pii/S0378608010320113

Paravertebral Block

Sang-Sik Choi MD , ... Mi-Kyung Lee MD, PhD , in Minimally Invasive Percutaneous Spinal Techniques, 2010

Continuous Infusion

Continuous infusion is performed with disposable elastometric infusion pumps, delivering 0.2% to 0.375% ropivacaine or 0.25% bupivacaine at a rate of 0.1  mL/kg/hr in children and 4 to 8   mL/hr in adults. Patient-controlled analgesia may be used with satisfactory results. The infusion rates are adjusted over the first 24 hours to obtain optimal analgesia and minimal motor block.

If pain relief is not satisfactory and "breakthrough" pain occurs, an additional bolus of 0.2% to 0.375% ropivacaine 10   mL can be injected through the catheter; this may be repeated every 30 minutes up to a maximum of 3 bolus injections per 6-hour period.

Read full chapter

URL:

https://www.sciencedirect.com/science/article/pii/B9780702029134000124

Protein and Amino Acids in Human Nutrition

L. Hambræus , in Reference Module in Biomedical Sciences, 2014

Metabolic Studies Using Stable Isotope Technique

Labeling amino acids with stable isotopes, 13C and 15N, makes it possible to perform studies of protein turnover in whole body as well as in selected organs, that is, liver and skeletal muscle (Wolfe and Chinkes, 2004 ). Continuous infusion to reach steady state where the labeled amino acid is mixed in the amino acid pool is used in combination with measuring excretion of the stable isotopes through metabolites in urine ( 15N in urea and ammonia) and breath (13C in CO2). Labeling amino acids with 15N is of most value in long-term field studies, while 13C labeling is used in short-term studies where continuous sampling of blood, urine, and breath is possible to perform. 13C-leucine, which is essentially metabolized in the muscle, is used for muscle protein turnover studies and 13C-phenylalanine for liver protein turnover studies (Duggleby and Waterlow, 2005).

The concept of IAAO was based on the earlier concept of limiting amino acid (Elango et al., 2008). A labeled essential amino acid, often 13C-phenylalanine, is used as IAAO at various protein/amino acid intakes. As long as the intake of a limiting amino acid is below requirement, it restricts the protein synthesis and consequently also the use of the indicator amino acid for protein synthesis. The surplus of this is then oxidized as it cannot be stored. Increasing the protein and/or the limiting amino acid intake will lead to increased protein synthesis and more of the administered indicator aa will be used and less oxidized until protein balance is reached and the IAAO reaches a steady state. This breaking point indicates that requirement for protein synthesis is met.

Protein–Energy Metabolic Studies

Continuous infusion of 13C-labeled amino acids in 24-h metabolic studies under strict control of the energy balance has been used to perform studies on macronutrient utilization and the impact of physical activity at normal and high protein intakes at isocaloric intakes. The setup of such metabolic studies is shown in Figure 1. This illustrates the UPPCAL setup for studies using stable isotope technique for measuring protein turnover, direct (suit) calorimetry and indirect respiratory calorimetry for energy balance registration, and an electronic ergometer bike for standardized physical activity. UPPCAL stands for the energy–metabolic unit at Uppsala University, Sweden, where the studies were performed in a joint venture with MIT in Cambridge, Mass (Forslund et al., 1998).

Figure 1. The UPPCAL setup for 24-h metabolic balance studies. Stable isotope technique for measuring protein turnover using continuous infusion and collection of breath samples and blood specimens at regular intervals; direct suit calorimetry and indirect respiratory calorimetry for energy balance control; electronic ergometer bike for standardized physical activity. A collaborative project between MIT, Cambridge, USA, and Uppsala University, Sweden.

Read full chapter

URL:

https://www.sciencedirect.com/science/article/pii/B9780128012383000283

A Worldwide Yearly Survey of New Data in Adverse Drug Reactions

T. Nakaki , in Side Effects of Drugs Annual, 2016

Skin

Continuous infusion of levodopa/carbidopa intestinal gel is an effective treatment for patients with advanced Parkinson's disease that cannot be further improved by oral therapy. To evaluate the safety and tolerability of a device (T-Port®) for the intestinal infusion of levodopa/carbidopa gel in patients with 24 advanced Parkinson's disease. Post-operative complications were similar to endoscopic gastrojejunostomy placement (four peritoneal irritation, one pocket pain). Eight patients with prior experience with the endoscopic gastrojejunostomy preferred the intestinal infusion of levodopa/carbidopa gel. The total device experience was 83.6 years, and the average survival time was 3.6 (range 1.1–5.2) years. Two patients had died due to non-device-related reasons. Sixteen devices had been explanted due to 15 stoma reactions (14 inflammations and one infection) and one tilting of the device. The number of adverse device effects proved to be significantly lower as compared to the endoscopic gastrojejunostomy literature data [29c].

Read full chapter

URL:

https://www.sciencedirect.com/science/article/pii/S0378608016300290