title: Dexmedetomidine and hydromorphone: a novel pain management strategy for the oncology ward setting during anti-GD2 immunotherapy for high-risk neuroblastoma in children.
abstract: BACKGROUND
  Treatment of neuroblastoma with targeted immunotherapy using chimeric anti-GD2 monoclonal antibodies (ch14.18) is associated with significant pain requiring management with a high-dose opioid infusion. We present a case series of six children, for whom dexmedetomidine and hydromorphone infusions safely and effectively reduced the pain of ch14.18 therapy in the oncology ward setting.
  
  
  METHODS
  The ch14.18 infusion is administered for ≥ 10 hr over four consecutive days in each of 5 cycles. Hydromorphone (2-8 mcg.kg(-1) .hr(-1) ) and dexmedetomidine (0.1-0.6 mcg.kg(-1) .hr(-1) ) infusions were commenced 1 hr before starting ch14.18 immunotherapy and titrated to optimal clinical effect. One hour after stopping the ch14.18 infusion, dexmedetomidine was discontinued and hydromorphone weaned as tolerated. This strategy was supervised by the Acute Pain Service with strict monitoring and nursing policies. Patient charts were reviewed for evidence of side effects and quality of analgesia.
  
  
  RESULTS
  Data from six patients, with median (range) age of 3.5 (2-12) years are reported. Median (range) utilization of hydromorphone was 2.9 (2.0-4.7) mcg.kg(-1) .hr(-1) , and of dexmedetomidine was 0.17 (0.10-0.20) mcg.kg(-1) .hr(-1) . A drop in mean arterial pressure ≥ 30% below baseline was identified during 30% of treatment days, but only prompted interrupting or reducing the ch14.18 infusion on 7% of treatment days; only one episode of grade 3 hypotension was recorded during this series. Hypoxemia occurred during 8% and bradycardia during 4% of treatment days.
  
  
  CONCLUSIONS
  Dexmedetomidine infusion may be an effective and safe pain management adjunct to opioid therapy for the pain of ch14.18 infusion.
authors.affiliation: Department of Electrical and Computer Engineering, University of British Columbia, Vancouver, Canada.
authors.forename: Matthias
authors.initials: M
authors.lastname: Görges
authors.forename: Nicholas
authors.initials: N
authors.lastname: West
authors.forename: Rebecca
authors.initials: R
authors.lastname: Deyell
authors.forename: Pamela
authors.initials: P
authors.lastname: Winton
authors.forename: Wesley
authors.initials: W
authors.lastname: Cheung
authors.forename: Gillian
authors.initials: G
authors.lastname: Lauder
mesh_terms: D018712:Analgesics, Non-Narcotic / Q000627:therapeutic use; D000701:Analgesics, Opioid / Q000627:therapeutic use; D000911:Antibodies, Monoclonal / Q000009:adverse effects*; D002648:Child; D002675:Child, Preschool; D020927:Dexmedetomidine / Q000627:therapeutic use*; D004359:Drug Therapy, Combination; D005260:Female; D005500:Follow-Up Studies; D005732:Gangliosides / Q000276:immunology*; D006801:Humans; D004091:Hydromorphone / Q000627:therapeutic use*; D007167:Immunotherapy; D008297:Male; D009447:Neuroblastoma / Q000150:complications / Q000276:immunology / Q000628:therapy*; D010146:Pain / Q000139:chemically induced / Q000188:drug therapy*; D059408:Pain Management; D011379:Prognosis
chemical_list: D018712:Analgesics, Non-Narcotic; D000701:Analgesics, Opioid; D000911:Antibodies, Monoclonal; D005732:Gangliosides; C019403:ganglioside, GD2; D020927:Dexmedetomidine; C112746:dinutuximab; D004091:Hydromorphone
keywords: anesthesia; immunotherapy; neuroblastoma; pain; pain medicine; pediatric oncology