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Scandinavian Journal of Pain

Official Journal of the Scandinavian Association for the Study of Pain

Editor-in-Chief: Breivik, Harald


CiteScore 2017: 0.84

SCImago Journal Rank (SJR) 2017: 0.401
Source Normalized Impact per Paper (SNIP) 2017: 0.452

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1877-8879
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Volume 17, Issue 1

Issues

Pregabalin as adjunct in a multimodal pain therapy after traumatic foot amputation — A case report of a 4-year-old girl

Stephanie Wössner
  • Department of Anaesthesiology, Kantonsspital St. Gallen, Rorschacher Strasse 95, CH-9007 St. Gallen,Kantonsspital Switzerland
  • Paediatric Anaesthesia, Ostschweizer Kinderspital, Claudiusstrasse 6, 9006 St. Gallen Claudiusstrasse, Switzerland
  • Other articles by this author:
  • De Gruyter OnlineGoogle Scholar
/ Kirsten Weber
  • Department of Paediatric Surgery, Ostschweizer Kinderspital, Claudiusstrasse 6, 9006 St. Gallen,Claudiusstrasse Switzerland
  • Other articles by this author:
  • De Gruyter OnlineGoogle Scholar
/ Anna C. Steinbeck
  • Department of Paediatric Cardiology, Klinikum Groβhadern, University of Munich, Marchioninistraβe 15, 81377 Munich,Munich Germany
  • Other articles by this author:
  • De Gruyter OnlineGoogle Scholar
/ Markus Oberhauser
  • Department of Anaesthesiology, Kantonsspital St. Gallen, Rorschacher Strasse 95, CH-9007 St. Gallen,Kantonsspital Switzerland
  • Paediatric Anaesthesia, Ostschweizer Kinderspital, Claudiusstrasse 6, 9006 St. Gallen Claudiusstrasse, Switzerland
  • Other articles by this author:
  • De Gruyter OnlineGoogle Scholar
/ Matthias Feuerecker
  • Corresponding author
  • Department of Anaesthesiology, Kantonsspital St. Gallen, Rorschacher Strasse 95, CH-9007 St. Gallen,Kantonsspital Switzerland
  • Paediatric Anaesthesia, Ostschweizer Kinderspital, Claudiusstrasse 6, 9006 St. Gallen Claudiusstrasse, Switzerland
  • Department of Anaesthesiology, Klinikum Groβhadern, University of Munich, Marchioninistraβe 15, 81377 Munich,Munich Germany
  • Email
  • Other articles by this author:
  • De Gruyter OnlineGoogle Scholar
Published Online: 2017-10-01 | DOI: https://doi.org/10.1016/j.sjpain.2017.09.001

Abstract

Background and purpose

The purpose of this case report is to describe a multimodal pain therapeutic concept including the adjunct use of pregabalin in a 4.5 year-old child after forefoot amputation.

Phantom limb pain and sensation is a complex pain syndrome that is difficult to treat and prevent. 70–75% of all children develop such a pain syndrome after amputation. We describe here a paediatric patient who underwent forefoot amputation following traumatic foot injury and received multimodal pain therapy including pregabalin.

The current experiment aimed at studying effects of empathic communication, and more specifically validation, on recall during a pain test and possible mediators and moderators of this effect.

Methods

A 4.5 year-old otherwise healthy girl suffered severe injuries of the right foot and lower leg during a motor vehicle accident. Due to development of severe necrosis, forefoot amputation had to be performed during the hospital stay.

Results

Initial pain therapy included paracetamol, ibuprofen, metamizol, morphine and fentanyl. With mounting pain and anxiety, regional anaesthesia of the distal sciatic nerve was administered in combination with a ketamine and morphine patient controlled analgesia pump (PCA). The peripheral blockade of the distal sciatic nerve was placed with the guidance of ultrasound and nerve stimulator. The PCA concept included a continuous basal rate combined with a bolus function. Although the regional anaesthesia was well positioned and functioning, there was inadequate pain control. The pain was described by the patient as short, highly intense and sharp sensations with intensity on the visual analogue scale (VAS) of 10 (out of 10). Furthermore, she suffered from anxiety episodes and sleep disturbance. The medical team decided to treat with pregabalin to resolve these issues while awaiting amputation (Lisfranc line). She received psychological counselling as adjunct treatment. This multimodal concept enabled an early and efficient pain reduction pre- and post-amputation and allowed for the possibility of a hospital discharge without any opioid pain medication.

Conclusion

The multimodal pain therapy including pregabalin was well tolerated, safe and highly effective in this case of traumatic limb injury and subsequent amputation. The use of pregabalin allowed significant pain and anxiety reduction for the patient.

Implications

Pregabalinis frequentlyused in adult patients for severe complex pain syndromes. There are only few reports of such adjunct medication (pregabalin) in paediatric pain syndromes. These reports focus mainly on the paediatric oncologic population. The case reported here encourages physicians to consider adjunct medications when treating complex pain, which are well established in the adult population. The benefits of such therapy in complex pain and anxiety can be extended to the paediatric population in select cases. Of course, one must always take into account that many routine medications used in children are well established but are off-label use. The authors are well aware of this problem and have conducted a critical literature review prior to pregabalin administration, including the search for randomized trials examining safety and tolerability. The parents or legal guardians of a minor must be thoroughly informed and consent to such a constellation of medical treatment.

Keywords: Paediatric traumatic limb amputation; Multimodal pain therapy; Regional anaesthesia; Ketamine; Pregabalin

References

  • [1]

    Jensen TS, Krebs B, Nielsen J, Rasmussen P. Phantom limb, phantom pain and stump pain in amputees during the first 6 months following limb amputation. Pain 1983;17:243–56.CrossrefPubMedGoogle Scholar

  • [2]

    Shukla GD, Sahu SC, Tripathi RP, Gupta DK. Phantom limb: a phenomenological study. BrJ Psychiatry 1982;141:54–8.CrossrefGoogle Scholar

  • [3]

    Sherman RA, Sherman CJ, Parker L. Chronic phantom and stump pain among American veterans: results of a survey. Pain 1984;18:83–95.CrossrefPubMedGoogle Scholar

  • [4]

    Krane EJ, Heller LB. The prevalence of phantom sensation and pain in pediatric amputees. J Pain Symptom Manag 1995;10:21–9,http://dx.doi.org/10.1016/0885-3924(94)00062-P.Crossref

  • [5]

    Boyle M, Tebbi CK, Mindell ER, Mettlin CJ. Adolescent adjustment to amputation. Med Pediatr Oncol 1982;10:301–12.PubMedGoogle Scholar

  • [6]

    Weeks SR, Anderson-Barnes VC, Tsao JW. Phantom limb pain: theories and therapies. Neurologist 2010;16:277–86,http://dx.doi.org/10.1097/NRL.0b013e3181edf128.PubMedCrossrefWeb of Science

  • [7]

    Fisher A, Meller Y. Continuous postoperative regional analgesia by nerve sheath block for amputation surgery - a pilot study. Anesth Analg 1991;72:300–3.Google Scholar

  • [8]

    Hayes C, Armstrong-Brown A, Burstal R. Perioperative intravenous ketamine infusion for the prevention of persistent post-amputation pain: a randomized, controlled trial. Anaesth Intensive Care 2004;32:330–8.Google Scholar

  • [9]

    Wu CL, Tella P, Staats PS, Vaslav R, Kazim DA, Wesselmann U, Raja SN. Analgesic effects ofintravenous lidocaine and morphine on postamputation pain: a randomized double-blind, active placebo-controlled, crossover trial. Anesthesiology 2002;96:841–8.CrossrefGoogle Scholar

  • [10]

    Taylor CP, Angelotti T, Fauman E. Pharmacology and mechanism of action of pregabalin: the calcium channel alpha2-delta (alpha2-delta) subunit as a target for antiepileptic drug discovery. Epilepsy Res 2007;73:137–50,http://dx.doi.org/10.1016/j.eplepsyres.2006.09.008.PubMedCrossref

  • [11]

    Mann D, Liu J, Chew ML, Bockbrader H, Alvey CW, Zegarac E, Pellock J, Pitman VW. Safety, tolerability, and pharmacokinetics of pregabalin in children with refractory partial seizures: a phase 1, randomized controlled study. Epilepsia 2014;55:1934–43,http://dx.doi.org/10.1111/epi.12830.Web of SciencePubMedCrossref

  • [12]

    Vondracek P, Oslejskova H, Kepak T, Mazanek P, Sterba J, Rysava M, Gal P. Efficacy of pregabalin in neuropathic pain in paediatric oncological patients. Eur J PaediatrNeurol 2009;13:332–6,http://dx.doi.org/10.1016/j.ejpn.2008.06.011.

  • [13]

    Saltik S, Sozen HG, Basgul S, Karatoprak EY, Icagasioglu A. Pregabalin treatment of a patient with complex regional pain syndrome. Pediatr Neurol 2016;54:88–90,http://dx.doi.org/10.1016/j.pediatrneurol.2014.01.015.CrossrefWeb of SciencePubMed

About the article

Department of Anaesthesiology, University of Munich, Marchioninistrasse 15, 81377 Munich, Germany


Received: 2017-05-24

Revised: 2017-08-30

Accepted: 2017-09-01

Published Online: 2017-10-01

Published in Print: 2017-10-01


Consent:For this publication, a written informed consent was obtained from the patient’s parents who are the legal representatives. The consent also includes the publication of images of the injured extremity. A copy of the written consent is available for review by the Editor-in-Chief of this Journal.

Conflict of interest: All authors declare that there is no competing interest.

Authors’ contributions:SW, KW, MO, MF carried out the treatment and the critical literature review for the use of pregabalin. SW, AS, MO, MF drafted the manuscript. Specific and very significant advice regarding therapy was given by AS. All authors carefully approved the final manuscript.

Funding: This work was financially supported by internal resources of the Department of Anaesthesiology of the Kantonsspital St. Gallen.


Citation Information: Scandinavian Journal of Pain, Volume 17, Issue 1, Pages 146–149, ISSN (Online) 1877-8879, ISSN (Print) 1877-8860, DOI: https://doi.org/10.1016/j.sjpain.2017.09.001.

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