Latest / Pediatrics Now: Cases Updates and Discussions for the Busy Pediatric Practitioner / Grand Rounds: When Kids Hurt: Modern Approaches to Chronic Pediatric Pain

Transcript

Grand Rounds: When Kids Hurt: Modern Approaches to Chronic Pediatric Pain · Pediatrics Now: Cases Updates and Discussions for the Busy Pediatric Practitioner

• 0:01
  I'm Holly Wehment, and this is Pediatrics Now, cases, updates,
• 0:06
  and discussions for the busy pediatric practitioner.
• 0:09
  Brought to you by University Health's new Women's and Children's Hospital and
• 0:14
  the Department of Pediatrics at UT Health San Antonio.
• 0:18
  Today, I'm bringing you Grand Rounds. Let's listen in.
• 0:22
  It is my pleasure to introduce Dr. Magadmina, who is board certified in anesthesiology
• 0:27
  and pain management. and has been practicing in San Antonio.
• 0:31
  He's originally from Egypt, where he received his medical degree with honors
• 0:34
  from Ainsham's University School of Medicine in 1991.
• 0:38
  He completed his residency training at UT Health Houston, where he served as
• 0:42
  chief resident for the Department of Anesthesiology in 2000 and received the
• 0:46
  award for best resident for regional anesthesia.
• 0:48
  He also completed pain management fellowship at UT Health San Antonio in 2001
• 0:53
  and has been practicing in San Antonio for the last 20 years, 20 plus years.
• 0:57
  In addition to pain management and anesthesiology, he has significant experience
• 1:01
  in teaching, as he currently serves as clinical associate professor at UTEPGA.
• 1:05
  Dr. Mina's medical memberships include associate faculty of the American Society
• 1:09
  of Regional Anesthesiologists and Pain Management,
• 1:12
  the American Society of Anesthesiologists, Texas Pain Society,
• 1:15
  and he is vice president of the Texas Pain Society chapter in San Antonio,
• 1:19
  where he also teaches ultrasound courses.
• 1:22
  Also, Dr. Mina is a chair of pain medicine department at the South Texas Spine and Surgical Hospital.
• 1:27
  And has written multiple chapters concerning
• 1:29
  pediatric pain medication in decision-making and pain management.
• 1:33
  So you can see Dr. Amina wears many hats. Otherwise, in his personal time,
• 1:37
  he enjoys being around his two children who are currently in medical school.
• 1:39
  He's also heavily involved in his church community as organized and participated
• 1:43
  in multiple medical admission trips in Africa.
• 1:46
  So everyone, please welcome Dr. Amina.
• 1:50
  Thank you, Dr. Ranj, for this kind of introduction. That's too many words and too many hats.
• 1:55
  Maybe I don't deserve them, but thanks for all the department and having me.
• 2:00
  Dr. Kamat, I just spoke to earlier.
• 2:03
  Thanks for Ms. Delia for coordinating this, and Dr. Fakhri who maybe initiated the conversation.
• 2:10
  But I love coming to the department.
• 2:12
  This may be years back, I was just talking.
• 2:16
  Maybe Dr. Tomlinson also invited me a few years back in person.
• 2:20
  Looking forward to join you in person at some point. But pediatric pain has
• 2:25
  been my passion for many years.
• 2:27
  Actually, before another head, Dr.
• 2:30
  Ranch, before becoming an anesthesiologist,
• 2:32
  I was doing an internship in internal medicine pediatrics.
• 2:36
  And then the pediatric chair that's in Houston called me right in the middle of residence.
• 2:42
  Hey, we want you to stay with us. We love working.
• 2:46
  She tried to convince me to stay in the pediatric department,
• 2:49
  and I kind of wiggled my way out of it into anesthesia.
• 2:54
  But love, always work with the pediatric world.
• 2:58
  As we start this talk about chronic pediatric pain, so you see my passion comes
• 3:06
  again and goes to the pediatric world. I'm trying to advance this slide.
• 3:15
  This is my disclosures. I work for a consultant for a legal firm called Juris
• 3:20
  Medicus, and I am part of the board of directors at the surgical hospital spine that I work at.
• 3:28
  Objectives for today's talk include discussion of recognition of chronic pediatric
• 3:36
  pain, how do we kind of finalize that diagnosis, the multimodal approaches,
• 3:43
  most importantly incorporating physical therapy modalities, the pharmacological tools.
• 3:48
  We'll touch on interventions, but as we go throughout the talk,
• 3:51
  you'll find that non-interventional modalities serves best for the pediatric world.
• 3:58
  These are a couple of my patients here as a father and son,
• 4:01
  and collaborative work always between the families, key role to get everybody
• 4:06
  on board and the support of the family as we engage into the pediatric,
• 4:12
  dive into pediatric pain.
• 4:15
  All right. So what are the contributing factors or how to define chronic pain?
• 4:24
  This was described by Dr. Perquin in 2000.
• 4:27
  The Europeans and the Canadians are far more advanced in the diagnosis and workup
• 4:33
  of pediatric pain in general.
• 4:36
  So the definition was more than three months of pain, usually about 15 to 20% of the pediatric world.
• 4:44
  And when we say chronic benign pediatric pain, this is the pain that is not
• 4:51
  associated with significant pathology, different from cancer-related pain and et cetera.
• 4:58
  So like you see here, it's headaches, the recurrent headache population,
• 5:02
  the recurrent abdominal pain that keeps repeatedly admitted to the hospital
• 5:06
  with negative workup, musculoskeletal pain like fibromyalgia or this widespread
• 5:13
  autonomic dysfunction,
• 5:15
  widespread pain, all this will fall under the chronic benign pain.
• 5:19
  Definitely, there's a significant socioeconomic burden. This was described by
• 5:24
  Friedrich Schaaf in 2016.
• 5:26
  And definitely, you could feel it. I could feel it. Everybody could feel it.
• 5:30
  These patients and their families go from one hospital to the other.
• 5:34
  Here in San Antonio, because I'm affiliated with most of the hospitals.
• 5:37
  I'll see them at the children's hospital, San Antonio downtown, and then at university.
• 5:42
  And then they will go to Methodist across the street and then the Baptist.
• 5:45
  And they keep cycling and cycling.
• 5:47
  And then I meet them in each hospital and say, oh, we just saw you last week.
• 5:50
  So a lot of work, but sometimes it's repeated.
• 5:54
  Predisposing factors. Yeah, there's a lot of the child and parents play a role,
• 5:59
  the psychology of the parents definitely are contributing factors.
• 6:03
  The school, the teacher, peer interactions, all these are...
• 6:08
  Contributing factors. You see here, there's one of the children also,
• 6:11
  ISO, probably from your department, or chose a patient with epidermolysis pellosis
• 6:18
  spread all across her skin.
• 6:22
  This is just her hand. I have a few of these patients.
• 6:26
  The youngest is probably a few months old. He was diagnosed even as a neonate.
• 6:30
  He had to put a tracheostomy because the lesions are across his mouth. He couldn't breathe.
• 6:36
  And so even as a neonate, tracheostomy is required.
• 6:42
  Other etiologies we see here, recurrent pain syndromes. We talked about the
• 6:47
  headaches and abdominal pain. Medical illnesses.
• 6:50
  So there are specific entities like juvenile rheumatoid arthritis,
• 6:54
  sickle cell disease, neuropathic pain.
• 6:57
  This child here has been diagnosed with CRPS, complex regional pain syndrome.
• 7:02
  She has club feet, and with multiple reconstructive surgeries,
• 7:08
  she developed what we call complex regional pain syndrome, or the old nomenclature
• 7:12
  RSD, reflex sympathetic dystrophy.
• 7:16
  Cancer, of course, is a contributing factor or chemo-related therapies.
• 7:22
  And we did share definitely a few patients from the HIM-ONC team, Dr. Tomlinson, Dr.
• 7:28
  Shah, and the oncology team, we share some sickle cell disease together,
• 7:33
  patients, and we try to navigate through their pain management.
• 7:39
  Here's, you know, overall of the teams.
• 7:45
  So when it comes to, just like in adult pain, pediatric pain is a multidisciplinary team.
• 7:52
  And when I trained here at university,
• 7:53
  here in San Antonio, our pain department had everybody on board.
• 7:57
  The psychologist was there on campus, in the clinic.
• 8:02
  The physical therapist was there. We all worked as a team together,
• 8:05
  and the patient would go from one provider to the other health professional.
• 8:11
  So definitely a team of—this is the picture here of the chairman of the department, Dr.
• 8:17
  Ekman, the Department of Anesthesia, the head of the pain program,
• 8:20
  and a couple of my fellow faculty.
• 8:23
  Non-physicians are always included, like psychologists, physical therapists,
• 8:28
  occupational, nutritionists.
• 8:30
  I'm trying to negotiate now a bit for a nutritionist to come and join our practice
• 8:35
  because the dietician or nutritional help is of great support,
• 8:41
  particularly in the pediatric world. And I see Dr.
• 8:45
  Ranch, a nephrologist, definitely would try to navigate through their blood pressure and obesity.
• 8:52
  And I say, hey, let's try just lifestyle changes, diet modifications,
• 8:56
  sleep adjustments before actually embark onto medications and so forth.
• 9:04
  When we look at other comorbidities, because they do have other comorbidities.
• 9:08
  Multidisciplinary psychosocial rehabilitation is essential for functional restoration.
• 9:14
  So one of the big parts here in pediatric pain is functional restoration. When these kids are.
• 9:20
  Develop or start getting labeled chronic pain. They become shy.
• 9:24
  They step away from their peers, from their parents. They try to be isolated.
• 9:30
  So one of the key factors, getting them back to school, to their physical functioning and so forth.
• 9:35
  In summary, physical therapy modalities are, you see here, it's the key. I labeled it number one.
• 9:42
  Then you have to have incorporate behavioral approaches.
• 9:45
  These are important, I would say, not just in the way I'm going to discuss,
• 9:50
  but in importance, from more important to least important.
• 9:56
  So you'll see interventionals, modalities are the least important,
• 9:59
  and you see it here, number five.
• 10:01
  So there are interventions, but I think they play the least role.
• 10:06
  Behavioral approaches, mind modalities, integrative medicine,
• 10:09
  hypnosis, acupuncture play a good role.
• 10:12
  Pharmacological, you see, are labeled number four. So they do have a role,
• 10:16
  but kind of towards the end. And this is here with my fellows a few years ago that we were training.
• 10:22
  We had a good program and we used to have six fellows at a time and maybe a
• 10:27
  couple came from the military.
• 10:28
  This is in one of our workshops with the fellows a few years ago.
• 10:33
  All right, we'll start with physical therapy modalities, like we said,
• 10:38
  our key to restore functionality and get the kiddo back to where they need to
• 10:45
  be with their peers and activity.
• 10:48
  Working with the physical therapists, always back to school, attendance.
• 10:54
  There's a high role, we found over the years, of aquatic therapy.
• 11:00
  Children love to be in the water, and this is one of the great tools we incorporate
• 11:08
  into one of the tools you could add.
• 11:12
  So in the hospital, it cannot be done, and that might be one of the tickets
• 11:17
  we use to help children get out of the hospital when they're being admitted
• 11:22
  for, and the workup is negative.
• 11:24
  I would come and say to the family, hey, maybe part of the role is aquatic therapy,
• 11:28
  but you need to be, this will be done outside the hospital and in a certain location.
• 11:34
  And we actually, over the years, were able to collaborate with multiple locations
• 11:40
  here in town, like the YMCA, several locations where we can engage the kids.
• 11:46
  There's a facility called Auditorium here in town.
• 11:48
  They're very cheap. Now, remember, most of these kids come from not well-funded
• 11:55
  families. They are either Medicaid and they are poor socioeconomic,
• 11:59
  so they don't have a lot of funds to travel.
• 12:02
  And the aquatic program or physical therapy might not be available.
• 12:05
  So you have to work with them to encourage them to find a place within.
• 12:10
  And we see patients like from a place from La Vernia or from the Valley or Seguin
• 12:17
  or whatnot. and they don't have all the medallis, but you have to work with them.
• 12:21
  And it takes time, takes a lot of collaboration to find the perfect team.
• 12:25
  You see here, a couple of the pediatric patients.
• 12:27
  The one on the right, you see here with the white gown is a child we saw from
• 12:31
  the hematopatement or the PD ortho.
• 12:34
  I think PD ortho, he had an amputation.
• 12:36
  So you see his left foot and ankle. He has a prosthetic. He had, I think, an arm.
• 12:44
  A sarcoma or some sort of a tumor on his left lower extremity.
• 12:48
  He had a baloney amputation.
• 12:50
  He's a 14-year-old kid and developed phantom pain and complex regional pain
• 12:55
  syndrome at the amputation side.
• 13:01
  So here is working with physical therapy and getting into the hospital,
• 13:05
  and he has an epidural catheter to mitigate post-amputation pain.
• 13:11
  By the way, this is like a year from the amputation, So it did not develop right away.
• 13:15
  Remember, we're talking about chronic. So this is not an acute post-amputation pain.
• 13:20
  This is like a year or two years later after, and the child either cannot use
• 13:25
  the prosthetic or even use it either on a wheelchair. And we're trying to get
• 13:30
  him up and walking using the prosthetic you see here.
• 13:34
  Same thing with the other image, another child walking with physical therapy.
• 13:39
  Now, these kids, when they're engaged in physical therapy, I usually have them sending me pictures.
• 13:45
  So this is probably a picture from the moms or the parents or whatnot.
• 13:49
  I want the kiddo, I want to see them up and down the hall every day working
• 13:54
  with physical therapy during their admission.
• 13:57
  And I watch them every day when we make rounds. I like to participate and see them up and walking.
• 14:03
  I know some hospitals offer pets that come and maybe help the kid who got out
• 14:10
  of the bed and walk around with the pets and take them.
• 14:12
  Some hospitals have even an outdoor seating area where they can go and enjoy
• 14:16
  the sun. These are all very beneficial.
• 14:19
  Skip here. We go to pharmacological approaches. Yes, they do have a role.
• 14:25
  It was second on my list of preference. And this is a kid again with complex
• 14:30
  reason of pain syndrome.
• 14:31
  You see the foot, very scaly, change of colors. They become very sensitive.
• 14:37
  It was after a very trivial trauma. And over the years, we collaborated,
• 14:43
  both pediatric departments and even a lot of pediatricians here,
• 14:48
  I even approached the San Antonio Pediatric Society and introduced them about
• 14:53
  early diagnosis of coronacrisional pain syndrome.
• 14:57
  Which helps in the early interventions and modifications. So what medications
• 15:02
  do we use? You see here how we include it.
• 15:05
  We can start with basic analgesics, Tylenol and Motrin.
• 15:11
  Adjuvant medications we use quite a bit, including the gabapentoids,
• 15:15
  titricyclics, lodos and metriptyline, lidocaine patches, melatonin for sleep adjustments.
• 15:22
  Benzos and muscle relaxants do be 12 years old, but I have kids as young as
• 15:27
  maybe 9 or 10, and this has to come in full disclosure with the family.
• 15:32
  When we discuss these medications, whether it's the ketamine or the gabapentin,
• 15:37
  we'll tell them, you know, we don't have enough studies, but this is probably
• 15:42
  our best bet, and we will, you know, start a low dose.
• 15:46
  Like, for example, the gabapentin, these kids with the epidermolysis pellosis,
• 15:51
  We start them even at three months or two months on gabapentin.
• 15:56
  Are there studies? I don't see much, but we just talk with the family and say,
• 16:01
  hey, this is our best bet. If it was my child, it's what I would do.
• 16:05
  These are the side effects. And we get an agreement from the family on owning
• 16:09
  these medications, particularly if they're used outside the realm or the approvals.
• 16:15
  The families understand opioids have very little role in the chronic benign
• 16:22
  pain, and there's clear CDS guidelines about use of opioids.
• 16:30
  You should all be aware of it, but do have a role in maybe a sickle cell.
• 16:36
  Of course, we see those sickle cell patients, and we work together with the
• 16:40
  oncology, heme, onc department here.
• 16:42
  They're on doses of methadone, for example. We navigate through this,
• 16:46
  cancer-related patients.
• 16:49
  And I have few kids with juvenile rheumatoid arthritis that ended up on some sort of an opioid.
• 16:56
  Here is collaborative work over
• 16:58
  the years. This is a kid. You see the one wearing purple in the screen.
• 17:03
  I inherited her with cerebral palsy, maybe when she was 10 or 12 years old.
• 17:09
  We worked with her through the years. She's still come to see us.
• 17:13
  By the way, I got permission from the family to share these photos with you all.
• 17:16
  And when I do these presentations elsewhere, this is a kid here.
• 17:21
  I was telling you, a few months old with epidermolysis bullosis.
• 17:25
  I'm carrying him on my hands and his hands are all covered because,
• 17:30
  of course, he'll rip off his hands and his feet are covered because of the rash and the significance.
• 17:37
  And he has a feeding tube. That tube is a feeding tube.
• 17:40
  And he probably, I remember, he has a tracheostomy as well because of the disease affecting his face.
• 17:47
  But this kid here, you see, with the cerebral palsy, we got her through graduation.
• 17:51
  And she currently works at one of the local Whataburgers. I think she's in 24 years now.
• 17:57
  I've seen her, I've taken care of her for at least 10 plus years.
• 18:01
  She comes through our practice.
• 18:03
  All right, interventions. We do have a role.
• 18:11
  Fluoroscopic-guided procedures we typically use or ultrasound-guided procedures.
• 18:16
  This is one of our, two of our fellows here. We're teaching them,
• 18:20
  placing, doing their procedures.
• 18:22
  The kid with the foot up in the air, that's one of the kids with complex reasons
• 18:26
  of pain syndromes, and they don't like anything touching their feet.
• 18:31
  It's up in the air. We're here. She's in the procedure room.
• 18:35
  We're about to do a fluoroscopic-guided epidural catheter to give her a sensory
• 18:41
  and some sort of, you need a sympathetic and a sensory block.
• 18:46
  Botox injections have been published. There's a great colleague of mine, Dr.
• 18:51
  Shah in UCLA, who published a lot of data about using Botox for pediatric headaches.
• 18:58
  And it is currently used. I use some of it.
• 19:02
  It's hard to get approved. It's
• 19:03
  very expensive, but it can be utilized for chronic headaches in children.
• 19:09
  Peripheral nerve stimulation is a new horizon for peripheral neuropathic pain.
• 19:16
  So dorsal root ganglion stimulation has a role in complex regional pain syndrome
• 19:22
  when other medallies of treatment have failed.
• 19:25
  This is a new horizon where you put the leads or epidural leads instead of the dorsal column.
• 19:31
  The lead goes right on the dorsal root ganglion for patients with complex regional pain syndrome.
• 19:38
  I am hesitant to do this myself. I give it to the neurosurgeons when it comes
• 19:43
  to dorsal root ganglion stimulation.
• 19:45
  This is a question probably in the questionnaire coming at the end of the talk,
• 19:49
  so let's remember DRG for refractory complex reason of pain syndrome.
• 19:56
  We see a lot of patients with occipital neuralgia, with headaches,
• 19:59
  and these in pediatric neurology from the department here you share with us,
• 20:04
  and they benefit quite a bit from occipital nerve blocks.
• 20:07
  So remember, greater occipital nerve blocks, and even we do ablation for these
• 20:12
  occipital nerves in patients with occipital headaches, virtual reality has some role.
• 20:19
  It's one of the publications we presented at the American Side Regional Aesthesia.
• 20:24
  This was in 2018, okay, so many years ago.
• 20:28
  So over the years, we inherited, I think, over 200 kids with complex regional pain syndrome.
• 20:36
  The youngest I've seen was a three-year-old kiddo that was referred to us by
• 20:43
  the PD ortho team at CHOSA after multiple reconstructive surgery for club feet,
• 20:49
  developed now CRPS of both feet.
• 20:53
  We put an epidural catheter for the child at the hospital because he couldn't walk.
• 20:59
  Now his feet is corrected, but he can't walk because of the sensitivity.
• 21:03
  Usually it's a 24, 48-hour admission to get them to be able to work with the
• 21:08
  physical therapy and walk on their feet. but that was the youngest kid,
• 21:12
  and it was part of this publication, which included 100 kids.
• 21:17
  Over a 10-year period. And here's the fluoroscopic guided procedure with the
• 21:22
  catheter towards the left side and the nerve roots coming.
• 21:26
  So we try to be specific targeting the nerve roots towards the extremity,
• 21:31
  whether it's the foot, knee, and ankle, just to get a sensory block to be able
• 21:36
  to endure the physical therapy,
• 21:40
  facilitate the physical therapy for the desensitization and so forth.
• 21:45
  So headaches here, we talked again about the headaches. Don't forget about Botox.
• 21:49
  We talked about here is my colleague, Dr.
• 21:51
  Shah from 2021, published utilizing Botox for headaches.
• 21:57
  And also GER occipital nerve blocks for occipital headaches can be utilized.
• 22:03
  This is published in Child Neurology 2021.
• 22:06
  So one of my patients here with chronic headaches, this picture is probably
• 22:12
  15 years ago. So I know it's my old office, but this is after working with,
• 22:18
  this is six months from us working together.
• 22:20
  Of course she comes first, she doesn't wanna talk, she doesn't wanna do anything,
• 22:24
  but with time and different modalities,
• 22:27
  And this is something we have to reiterate to the family. It's not a switch.
• 22:33
  They have got chronic pain. We've got to work together. It's like going to school.
• 22:39
  It's got to take a year, maybe six months. I don't know. But we've got to work
• 22:43
  together and navigate through this pain and finally get this child to be happy exercising.
• 22:49
  She's off medications. But six months before this picture, she was on tons of
• 22:53
  medicine. We worked with her for maybe six months to a year.
• 22:57
  Finally, she's off medicine, she's going back to school, she's getting into
• 23:02
  a driver's license, et cetera, et cetera.
• 23:04
  So it takes time and an effort and patience, patience, patience to get them there.
• 23:10
  We talked about peripheral nerve stimulation, just one key item here to take back home.
• 23:16
  It's still under a lot of investigation. There's only case reports,
• 23:23
  but no studies as far as pediatric pain.
• 23:27
  There's very few pediatric paperwork on that, just case reports in the literature.
• 23:34
  Remember, dorsal root ganglion stimulation for refractory pain.
• 23:39
  This is the mechanism of action for peripheral nerve stimulation,
• 23:43
  usually targeting large A, alpha, and beta fibers, which gives them that kind
• 23:51
  of stimulation to mitigate the pain,
• 23:55
  sparing the small C, which are the pain fibers, are myelinated in delta.
• 24:01
  Okay, DRG, we talked about it. There are a few trials, and I usually reserve
• 24:06
  this for the refractory patient that failed the typical standard spinal cord stimulation.
• 24:12
  So we do, if it's a standard spinal cord stimulator, we will do it.
• 24:16
  But when it comes to DRG, I'll defer that to our neurosurgeon colleagues.
• 24:21
  By the way, on my first appointment at UT came as an invite from Dr.
• 24:27
  Tarasovich, if you're all aware of her. She's head of the pediatric neurosurgery team here at UT.
• 24:34
  Also, one day, that's probably 15, 20 years ago, inherited the patient from
• 24:38
  her with headaches from hydrocephalus.
• 24:40
  And then we talked together on the phone and said, hey, I want you to come over
• 24:44
  at UT and have a clinic in our department.
• 24:46
  So she invited me, and we had clinic for maybe two, three years,
• 24:50
  right before the time of COVID, so probably from 2019 through 2021, maybe.
• 24:57
  And then when COVID hit, clinics closed, and it was very difficult to come back.
• 25:02
  But we still share patients.
• 25:04
  Matter of fact, I just called her yesterday about a patient that she will be seeing from our end.
• 25:10
  So that's Isabella Tarasovic and the Pediatric Neurosurgery Department.
• 25:14
  So when it comes to DRG, I'll send it to her if it needs for the CRPS or Complex
• 25:20
  Rational Pain Syndrome patient.
• 25:23
  Virtual reality plays a role. So I have a child yesterday in clinic with chronic
• 25:28
  headaches, and she's on one of those injectables, and I'm not trying to market them.
• 25:34
  I don't know if any of the pediatric neurology team is here,
• 25:37
  but she's one of those injectables monthly.
• 25:41
  Over time, the child developed phobia and anxiety from the needles,
• 25:46
  so she doesn't want to do the injection, although it helps her.
• 25:50
  It mitigated her pain. Again, this is outside the box of utilizing.
• 25:53
  We use these in adults, but now we're trying it even in teenagers.
• 25:58
  So I told the mom, okay, let's start virtual reality.
• 26:01
  I mean, as soon as she sees the vial or the syringe coming out,
• 26:05
  then it gets screamed. This is a teenage kiddo, 15.
• 26:08
  So we met with her a couple of times in clinic.
• 26:12
  And this is kind of where virtual reality, to get them maybe outside this fear of pain.
• 26:20
  Some families I know cannot afford it, but it's a certain role that can get them active.
• 26:26
  And this kid, it worked for her. So we got to engage in the virtual reality thingy.
• 26:31
  And after a few times, the mom actually has to bring her to our clinic.
• 26:36
  So I do the injection, which could be done by the mom or the child at home.
• 26:41
  But for the first few times, I said, okay, that's fine.
• 26:44
  Just bring your virtual reality here into clinic, get engaged and play tennis or do something.
• 26:50
  And then we'll sneak in. And without your notes, we gave the sub-Q injection.
• 26:57
  So it can play a role. We have to kind of figure out which family could afford it.
• 27:03
  But it gets the child out of their fear, out of the restrictions and limitations.
• 27:10
  These are my colleagues, which I worked with over the years.
• 27:13
  On the far left corner, there's Dr.
• 27:15
  Isabella Teresavich, and one of our first patients, and this is actually in
• 27:20
  her clinic here in the neurosurgery department.
• 27:23
  I remember it was on the second floor in the Rio Tower, and one of our first
• 27:26
  patients we saw here in UT, he has a CRPS of the right foot.
• 27:32
  This kid was in a motor vehicle accident and gun shooting. He was in the department
• 27:37
  here in UT for maybe over six months in the ICU, had a liver resection,
• 27:43
  spleen resection, yada, yada, spinal cord injury.
• 27:46
  And then when he was about to start getting to walk six months into the hospital,
• 27:51
  they figured out he has a CRPS of the foot.
• 27:54
  We couldn't tell, you know, he's been in bed in ICU.
• 27:58
  And when he starts walking, he couldn't bear weight on the right foot.
• 28:03
  You see here, that's the foot that had the CRPS. So we treated him actually
• 28:06
  at university. He was one of our first pediatric CRPS cases at university.
• 28:11
  You've got an epidural catheter. These are my colleagues, the head of the ASRA
• 28:15
  Society, American Society of Arrugia Anesthesia.
• 28:19
  On the far right corner, on the bottom, this is my mentor in UT Houston.
• 28:24
  I still meet with him, Dr. Pivaliza. This is last year.
• 28:28
  And my son next to him, and then one of the neurosurgeons we work with.
• 28:33
  So, you know, you've got to connect with people that are compassionate about
• 28:38
  pediatric pain, that help you over the years and guide you through it.
• 28:43
  And this is my family. And I'm always gratitude to all of them because they
• 28:49
  make this happen to me, my wife, my son, and my daughter.
• 28:53
  There's a picture a few years ago in Egypt when I took them to see where we originally came from.
• 28:59
  And I think we'll stop here, Dr. Ranch, and whatever you want to take it from
• 29:04
  here. Thank you all for having me.
• 29:08
  Thank you very much, Dr. Mayer, for that wonderful overview.
• 29:12
  I'm pretty sure everyone in the audience has at least one patient still with
• 29:16
  chronic pain, and so we're glad to hopefully have more avenues for treatment for these poor kids.
• 29:22
  But I'd love to open it up to the audience for questions. You can raise your
• 29:26
  hand, unmute yourself, or place it in the chat.
• 29:32
  Dr. Mina, thank you, as always, for educating us and taking that time to help
• 29:40
  manage the pediatric hospitalist patients that we care for.
• 29:45
  My question is, and I'm sorry if you might have gone over this,
• 29:49
  I had to take a quick phone call.
• 29:52
  Is there some sort of, you know,
• 29:55
  protocol when we do get these high pain kids that we could work through as far
• 30:03
  as like access to when you're coming in with a considerable amount of pain,
• 30:09
  our management, this is what we're going to, you know, go through with these patients.
• 30:14
  Because sometimes we do find there can be us having to turn to opioids,
• 30:20
  which we don't want to do, and it makes it pretty difficult.
• 30:23
  But just trying to see if there is a way to streamline these sort of situations.
• 30:30
  Thank you. Wonderful question. I don't have the names who are speaking, so I apologize.
• 30:36
  I could recognize you, but thank you. Oh, this Mandy Spatek.
• 30:40
  Sorry, Mandy Spatek. Oh, Dr. Spatek. Yes. Thank you.
• 30:44
  Yeah, we do share quite a bit of patient. Thank you, Dr. Spatek. Yes.
• 30:48
  If it comes to the opioid role, unless they have an acute event that really
• 30:57
  requires IV medications, maybe we could start there.
• 31:02
  But once the acute process is down, go back strictly to oral.
• 31:11
  Always push on the oral, talk with the family, say this is what they're taking at home.
• 31:19
  And we do the same thing with adults. If the child is able to tolerate oral,
• 31:26
  let's work on the oral route, maybe navigate with his current regimen,
• 31:32
  escalate it a little bit using, again, the oral route, because it'll be easier on the discharge.
• 31:37
  So once we, I know this is what's happening. When they come in,
• 31:41
  they want to be on IV medicine, but we will, if, so number one is if,
• 31:46
  do they really need an IV?
• 31:47
  Okay, yes, start IV process, but maybe give it 24, 48 hours.
• 31:51
  The acute process has been mitigated.
• 31:53
  Now we're back to square one. Let's start switching ASAP to the oral.
• 32:00
  Escalate the oral as much as we can and escalate a few things.
• 32:04
  You know, it doesn't have to be the opioids. maybe escalate the, um,
• 32:09
  the anti-epileptic, the gaba pintoids, the lyrica, the what,
• 32:13
  uh, the, yeah, the pregablet, maybe at a most relaxing, uh, may try to find some other avenues.
• 32:21
  Uh, that would be my thought process from day one.
• 32:25
  I want this kid, the chargeable, uh, easy in the next two, one or two days.
• 32:31
  That's my, uh, key point.
• 32:38
  Thank you for that. There is a question in the chat. Dr.
• 32:41
  Jeremy Pellman asks, are you aware of an intensive inpatient pain treatment
• 32:45
  center in Texas where we could hospitalize our most refractory patients?
• 32:51
  Um, not that I'm aware of, um, even Texas children in Houston that I collaborate a lot of patients.
• 32:59
  There are a couple of my colleagues there, uh, but they do not have an,
• 33:04
  where it is, they could be admitted. They will treat them as an outpatient.
• 33:09
  So outside within even the whole state of Texas, I don't know about Dallas,
• 33:14
  uh, but Even in Houston, they have a robust pediatric program with Texas children.
• 33:20
  And I, by the way, I trained there as a resident when I was in my residency.
• 33:24
  I am not aware of. So usually these kids will end up in Mayo Clinic up in Minnesota
• 33:30
  or Jacksonville or somewhere where they have that, yes, the full multimodal admission.
• 33:36
  They spend there a week, the whole nine yards. Now,
• 33:40
  to scale it a little down, I do admit these kids under my admission privileges
• 33:48
  in a couple of hospitals we work in town,
• 33:50
  but they don't have the full typical multidisciplinary where they get that whole
• 33:58
  four or five days of pain management, the specialist.
• 34:01
  So, yes, so I do it on a miniature scale on my end.
• 34:06
  We admit them for a brief two, three days, workup. Usually it's associated with an intervention.
• 34:13
  Like you see these kids, we admit them for a specific intervention for an epidural
• 34:17
  catheter or a nerve ablation, and then we get them with physical therapists,
• 34:21
  mostly, and maybe a dietician.
• 34:23
  We don't have a therapist, a psychotherapist or psychiatrist that could come
• 34:28
  and see them while in the hospital. I think this is one area we're missing,
• 34:32
  but the robust admission, I don't see anything in Texas. It's outside.
• 34:38
  We have a miniature scale. I do some of it. I'm not sure about the children's hospital.
• 34:44
  I can reach out to the head there and ask him, it's Dr. Huang.
• 34:50
  But I remember I sent him a couple of patients, but they treated him as an outpatient.
• 34:57
  Thank you. A couple more questions in the chat. First, Dr.
• 35:01
  Janet Williams asks if you could please comment on the role of hypnosis or acupuncture
• 35:06
  in treatment of these kids.
• 35:08
  Oh, wonderful. Thanks, Dr. Williams. That's a wonderful question.
• 35:12
  Thank you. Yes, this is a great avenue.
• 35:14
  And like I said in the beginning of our talk, physical therapy modalities,
• 35:19
  acupuncture, hypnosis play a great role. There's a lot of publications.
• 35:26
  I can't remember the names off
• 35:27
  the top of my head, but it mitigates acute pain as well as chronic pain.
• 35:33
  There are several publications for patients in the ICU and postoperative tonsillectomy or appendectomy.
• 35:41
  Yes, not all specialists.
• 35:47
  Back in the day when I trained, I used to do hypnosis. It was my chairman, it was Dr.
• 35:52
  Ramamurthy, whose wife was actually a pediatrician and she was probably part of the department.
• 35:57
  I can't remember his wife's name, but Ramamurthy, it was the name,
• 36:00
  and his wife was chief of the NICU, matter of fact, she was in the NICU department.
• 36:05
  I remember her from those days.
• 36:07
  Yes, we do rely on that.
• 36:11
  I do a lot of acupuncture, so yes, I will talk with the family now remembered.
• 36:18
  They do play a role. It depends on their family's acceptance and willing to participate it.
• 36:23
  Some kids are very, very needle freaks.
• 36:27
  So acupuncture to them is a little bit of an issue.
• 36:30
  Some kids, like when we do the Botox injections, adults cry,
• 36:35
  but I kid a kid because of her headaches, she'll say, do whatever.
• 36:38
  And when you do the Botox injections, she does well, even without sedation, without anything.
• 36:44
  So if the kid really is interested and focused into the deal,
• 36:49
  yes, they will participate with acupuncture.
• 36:51
  If it's for hypnosis, I'll refer them out. I don't do it myself,
• 36:55
  but Rama Murthy taught me how to do it back in the day in 2001,
• 37:00
  but I don't do it now. Yeah, refer them out.
• 37:06
  Thank you. I'm going to combine the next two questions from Dr.
• 37:10
  Andrew Meyer and Dr. Rob Sanders.
• 37:12
  They ask, have you heard about new drugs that target sodium channels for peripheral
• 37:17
  pain, such as, I'm going to mess this up, suzetrogene, a selective NAV one-point hit blocker?
• 37:23
  And also, Dr. Sanders asked on your thoughts on methoxyflurane for acute pain.
• 37:29
  Well, thanks, Dr. Sanders. Dr. Myers, yes, the sodium channel blockers can play
• 37:35
  a role, but it's mostly acute pain.
• 37:39
  I'm not aware of data in the pediatric world.
• 37:43
  But yeah, like I said, if you are interested in medicine and use it and feel
• 37:49
  it might alleviate some of the pain, I will discuss with the families and we
• 37:54
  try this, that, and the other.
• 37:55
  There's this new soline channel blocker. We can give it a try.
• 38:00
  I'm not very robust on the dosage for pediatrics, but we can always,
• 38:08
  based on their weight and so forth, try a small dose, discuss with the family,
• 38:12
  say, hey, there's not a lot on literature, but we can give it a try and so forth.
• 38:16
  Yeah, it could be worth a trial.
• 38:18
  That's on the sodium channel blockers.
• 38:22
  The other questions was, I forgot what it was.
• 38:27
  Methylfluorane for acute pain? I'm not aware for that. I'm not aware.
• 38:32
  I could look into it, but I'm sorry.
• 38:35
  Is it whatever Dr. Sanders or Marshall, I'm not aware of it. No, it's all right.
• 38:38
  It's a self-administered inhaled pain medicine that a lot of times they use in Europe.
• 38:47
  It's an inhaled anesthesia medicine, but it's been shown to be very effective
• 38:53
  for acute pain. In Europe? In Europe?
• 38:57
  Yeah. What is it called again?
• 39:02
  Methoxyflurane or Pembarax. Okay. I'll look into it. Now, a lot of these medications, yes.
• 39:08
  If you know something that Europe's or the Canadians are using,
• 39:12
  like I said, the Europeans are much more advanced than the Canadians.
• 39:15
  So when I go to all these meetings, like the ASA meeting, which is the national
• 39:18
  meeting, there's like 10,000 anesthesiologists. They come from Europe and Canada, everywhere.
• 39:23
  Yeah. The Canadians and the Europeans are far advanced and they have a lot of
• 39:26
  tools. So if you find a drug that works, you can work with a local pharmacy here, like I said.
• 39:32
  And if they can do it, a compounding pharmacy, and there's literature from Europe,
• 39:38
  I'll share with the patient.
• 39:39
  Say, hey, this is used in Europe. Can we use it here?
• 39:43
  And if I find a pharmacy that will work with, like Oakdale Pharmacy,
• 39:47
  I'm not marketing for any specific pharmacy.
• 39:50
  Yes, find the medicine, work with it, pull the literature, share with the patient,
• 39:54
  and say, hey, we can try this. And I will, but again, the question mark,
• 39:59
  who's paying for all of this?
• 40:01
  Will the family pay for it? How much is it going to cost? Insurance will not pay for it.
• 40:05
  Again, that answers my question on the acupuncture and the hypnosis.
• 40:10
  Insurance doesn't pay for any of that. And these kids are Medicaid or very poorly
• 40:15
  funded. So I have to kind of be careful when I'm discussing things because I
• 40:20
  don't want to give them hope.
• 40:21
  And then they come and say, well, I can't afford it. It costs me 50 bucks a
• 40:26
  week or whatnot. Like the ketamine, for example.
• 40:29
  The ketamine nasal spray we navigate with the compounding pharmacy.
• 40:34
  It's all off insurance. This is not covered.
• 40:38
  The families will pay between 50 to 100 a month. So some families can afford, some don't.
• 40:43
  And I'm assuming these other medications will cost somewhere in that range.
• 40:48
  It's worth a trial. Yes.
• 40:54
  Thank you for that. Okay. Well, if there's no additional questions, Dr.
• 41:00
  Amine, thank you again for that wonderful overview.
• 41:03
  I'm sure I'll be sending more kids to you, knowing that we have you available to help these kids out.
• 41:12
  Thank you so much for listening to that great talk.
• 41:16
  Don't forget to click on the link in this podcast for free credit.
• 41:19
  That may include CME, MOC, or ethics credit, depending on our topic or podcast.
• 41:25
  Our sister podcast is Pediatrics Now for Parents.
• 41:29
  That's meant to be one less thing you have to say in the exam room.
• 41:32
  That's also found wherever you listen.
• 41:36
  Coming up next week, I interview Benjamin Hall, war correspondent.
• 41:41
  He was in a bombing in the war in Ukraine and severely injured.
• 41:46
  He now spreads a message of hope and resiliency in the face of crisis and stress,
• 41:53
  a message that can uplift us all.
• 41:56
  That's coming up next week on Pediatrics Now. I'll see you soon.
• 42:02
  Thank you so much for listening.