Abstract P-395: A STRUCTURED APPROACH TO REFRACTORY PAIN AND OTHER DISTRESSING SYMPTOMS IN CRITICALLY-ILL CHILDREN

Abstract

Aims & Objectives: Pain refractory to properly titrated multimodal analgesics, and other difficult-to-control distressing symptoms may occur in the PICU, usually in children with advanced cancer causing malignant effusions, obstruction or osseous metastases, and in children with sequelae of neurologic disorders. This may constitute a barrier to transfer to other healthcare settings. Methods Methods: A literature search was performed utilizing the PubMed engine through January of 2018, querying terms relevant to refractory symptoms in critically-ill patients. Results There is an emerging body of experience in critical care. Impeccable assessment, appropriate integration of pharmacologic (non-opioid, opioid and adjuvant medications) and non-pharmacologic (integrative) measures consistent with WHO guidelines are key. Inadequate perioperative analgesia may precipitate refractory pain and dystonia. Delirium, opioid-associated neurotoxicity and hyperalgesia should be considered when escalating pain is encountered. Titratable intravenous agents may be effective. Dexmedetomidine, along with environmental measures, may mitigate delirium. This agent, Ketamine and lidocaine can be transitioned to enteral formulations or analogs, facilitating transfer. Medications (dexamethasone, octreotide) and Interventions to vent, stent and decompress may palliate malignant effusions or obstruction. Neuroaxial (epidural, intrathecal) techniques using opioids, adjuvants or ziconotide may be appropriate. Recently described image-guided percutaneous neuroablative procedures (myelotomy, cordotomy) appear to be safe and effective. Respite (overnight) or intermittent (hours / days) sedation can be attempted in selected patients prior to institution of traditional unidirectional, continuous palliative sedation. Conclusions A structured, multidisciplinary, individualized approach to care may achieve rapid control of complex symptoms, facilitating transfer from PICU to other inpatient or hospice settings.