Magnesium Sulfate as Adjuvant Analgesia and Its Effect on Opiate Use of Post-operative Transplant Patients in the Pediatric ICU
This study will be a prospective analysis of a post-operative transplant cohort in the PICU to determine whether using magnesium sulfate as an analgesic adjuvant can decrease overall opiate requirement in this patient population. It will indirectly also look at opiate-induced side effects, effects on overall PICU course, and applicability/safety of a magnesium infusion in pediatric patients. It is well known that post-operative analgesia in children is one of many challenges faced by surgeons and intensivists, both due to the invasiveness of procedures as well as the biopsychosocial variance in these populations. TPIAT (total pancreatectomy and islet autotransplantation) and liver transplant patients at our institute have protocols designed for their management, part of which includes continuous opiate dosing, other adjuvants (such as tylenol, ketorolac, ketamine), and sometimes paravertebral nerve blocks. All of these medications, despite their benefits, come with their own unique side effect profile. Opiates remain no stranger to this, in addition to a distinct growing shortage nationwide. Magnesium sulfate has been cited as a potential source of adjuvant analgesia by its action on the NMDA receptor. Pediatric populations where magnesium has shown potential analgesic benefit include post-tonsillectomy, post-osteotomy (cerebral palsy), post-operative scoliosis repair, sickle cell, and hsevere headache management. Literature also supports use in adult populations, which includes more expansive operative cohorts. Added benefit of magnesium is its overall safety profile (symptoms not present until levels significantly above normal indices), cost-effectiveness, and incidental overall prevalence of hypomagnesemia within PICU populations. We plan to implement a magnesium therapy protocol to all of our liver and TPIAT transplant children in the pediatric ICU with dosing that has been used both efficaciously (in comparison to available adult data) and safely (in comparison to other pediatric studies). This will be done via a bolus dose in the operating room followed by infusion dosing for the next 48 hours. Magnesium levels will be checked serially to ensure they remain below toxic levels. We will track opiate dosage metrics throughout their post-operative ICU admission, as well as other secondary outcomes listed elsewhere. The control will be a retrospective chart review of the same primary and secondary outcome measures from previous post-transplant patients in this PICU. The study protocol has been approved by the U.S Food & Drug Administration, which will also be involved in monitoring of the study.
•Be scheduled for and receive a liver transplant or total pancreatectomy and islet cell autotransplantation Control Group:
•Received a liver transplant or total pancreatectomy and islet cell autotransplantation.
• Pregnant or unwilling to abstain from sex if not practicing birth control during participation in the study.
• Presence of a condition or abnormality that in the opinion of the Investigator would compromise the safety of the patient or the quality of the data.
• Known allergic reactions to components of the MgSO4
• History of heart block or myasthenia graves in past medical history.
• Presence of cardiac pacemaker
• Any patient with preoperative creatinine level > 1.5x upper limit of normal. Control Group:
• Any patient who had filed as research-exempt (opt-out of research previously).
• Any patient with preoperative creatinine level > 1.5x upper limit of normal.
Drug: Magnesium sulfate