P3B056: Pain Control During Dinutuximab Infusions

Purpose/Objectives: Dinutuximab is a monoclonal antibody therapy for children with high-risk neuroblastoma. It is administered as a continuous infusion over four days for 10-20 hours each day. Patients often receive multiple cycles and are hospitalized for each. The palliative care team assists with symptom management, particularly pain. Dinutuximab targets a protein on neuroblastoma cells that is also present on neurons and peripheral nerve fibers, thus causing substantial pain with administration. Pain can occur anywhere but is most often in the abdomen and resolves after the infusion ends. Patients require opioid medication via patient-controlled analgesia (PCA) and tend to require higher than usual doses. Previous pain management approaches at our institution provided insufficient pain control, necessitating multiple increases in PCA dosing during the first day of the infusion. This project had two goals: 1) standardization of the PCA regimen and 2) improved pain control within the first 24 hours of therapy.

Design/Methods: Our new QI protocol included a loading dose of opioid 30 minutes prior to the start of the dinutuximab infusion and initiating the PCA during the infusion at slightly higher than typical starting doses. We also created a ‘dot phrase’ for the electronic medical record (EMR) to place in our notes that outlined our pain management plan and clear guidelines for when to contact the palliative care team. Our outcome measures were average pain scores, PCA demand doses attempted in the first 4 hours and first 24 hours of the infusion, and number of changes to PCA dosing in the first 24 hours, all of which were collected retrospectively from the EMR.

Results: We collected data for 67 cycles of dinutuximab for 15 patients. Through run chart data analysis for the first cycle only and then all cycles combined, we observed the following: 1) standard pain scores do not accurately measure subjective experience and vary widely across patients; 2) after implementing the protocol there was a trend toward fewer demands attempted in the first 4 hours of the infusion over all cycles compared to before the intervention; and 3) patients tended to require fewer PCA dosing changes during the first 24 hours of the first cycle than they needed before use of the protocol. Having the protocol documented in the patient chart increased transparency of the new approach for all clinicians involved in patient care. Subjective reports from palliative care and oncology providers indicated improved communication between specialties.

Conclusion/Discussion: We believe that implementing a standardized protocol improved patient care and enhanced communication among all disciplines during dinutuximab infusions.