American Society of Regional Anesthesia and Pain Medicine August 2017 - 15

TCAs to rule out arrhythmias and after dose escalation, as there is
a risk of sudden death due to dysrhythmia.40 Other antidepressants
can be used for neuropathic pain, such as serotonin and
norepinephrine reuptake inhibitors (duloxetine and venlafaxine).
N-methyl-D-aspartate (NMDA) receptors play a role in management
of hyperalgesia and chronic pain. NMDA receptor blockers
include ketamine, methadone, memantine, dextromethorphan,
and amantadine. Ketamine is an NMDA receptor blocker, opioid
receptor agonist, and a serotonin/norepinephrine reuptake inhibitor.
Subanesthetic doses can be useful for neuropathic pain and
attenuation of opioid induced hyperalgesia.41 Other NMDA receptor
blockers, such as dextromethorphan and memantine, have not been
commonly used in pediatric and studies thus far are equivocal.42-44
Local anesthetics have a membrane stabilizing effect by blocking
sodium channels. Lidocaine, a nonselective sodium channel
blocker, has been used for surgical pain, cancer pain, and
neuropathic pain.45,46 There are few case reports of use of lidocaine
infusion for pediatric neuropathic pain. Massey et al reported
excellent pain relief in a 5-year-old child with terminal cancer using
lidocaine infusion,47 and Nathan et al reported significant pain relief
and improved function of an 11-year-old child with multiple daily
painful episodes due to erythromelalgia after administration of
lidocaine infusion and then transitioned to oral mexiletine, an oral
analog of lidocaine.48
SUMMARY
In summary, chronic pain involves complex interactions of biological,
psychological, and social factors. Untreated pain during infancy and
childhood leads to hypersensitivity to pain through a "rewiring" of
the peripheral as well as central nervous system, leading to lasting
changes in pain perception.49,50 Failure to control pain can have
lifelong implications, including poor coping strategies.
Pediatric chronic pain management requires a comprehensive,
multidisciplinary approach. This includes both nonpharmacologic
and pharmacologic treatments as necessary, with a team of pain
management physicians, integrative health specialists, child life
specialists, physical therapists, psychologists, social workers, and
acupuncturists.
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https://nccih.nih.gov/health/integrative-health http://www.iasp-pain.org/Taxonomy#Pain
Table of Contents for the Digital Edition of American Society of Regional Anesthesia and Pain Medicine August 2017
