PR1-162
Creating an Outpatient: A Multimodal Approach to Opiate Wean in Complex Pediatric Cancer Pain
Maves G, Ross E
UNC Hospitals, Chapel Hill, NC, USA
Cancer is the second leading cause of death in children. Severe and difficult to control pain often presents in end-stage cancer, particularly at the end of life. Wolfe et al estimated "89% of children (with cancer) experienced substantial suffering... with fewer than 30% of parents reporting treatment for pain as successful". Treatment of pain in this patient population often requires a multimodal approach to achieve adequate analgesia while minimizing side effects.
We present a 16-year-old female with a history of Ewing Sarcoma of the pelvis with metastatic lesions to her left distal femur. She had recently been admitted due to inability to control pain on an oral regimen, and was discharged home on a hydromorphone PCA by the PEDS Oncology service. She was readmitted shortly thereafter with a pain crisis of her distal femur lesions requiring large escalations in her opiate needs with decreasing efficacy. Our pediatric acute pain team was consulted to assist in transitioning from her home hydromorphone PCA regimen to an oral regimen in hopes of qualifying for a phase I clinical trial at an outside institution.
In addition to her parenteral opioids, she was on many adjunct pain medications. She had previously failed attempts at oral (MS Contin, Oxycodone) and transcutaneous (Fentanyl patch) opioid therapy due to uncontrollable emesis and lack of pain relief. It was determined she was not a candidate for an intrathecal pump. Eventually, she was transferred to our intensive care unit, where a femoral nerve catheter was placed and ropivacaine was infused. In addition, ketamine and propofol infusions were started to aid in an expedited wean of her opioid tolerance and help with intractable nausea and vomiting. While on these infusions, she was able to maintain normal cognition and participate in physical therapy. Prior to her opioid wean she had used 258mg morphine equivalents in the previous 24h, consisting primarily of hydromorphone. At discharge, 2 weeks after starting her opioid wean, she was on a stable oral/transdermal regimen of 100mg morphine equivalents per 24 hours consisting of a fentanyl patch and oral methadone which she tolerated without significant side effects. At discharge, she was transferred to an outside hospital institution for evaluation for a phase I clinical trial.
Pain related to cancer can be difficult to control, particularly in the pediatric population. These patients often exhibit rapid increases in their opioid needs as their disease process progresses. Nerve block catheters, Ketamine, and propofol infusions offer a unique way to potentially lessen opioid tolerance and hyperalgesia in patients with refractory cancer-related pain.
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