Anaesthesia and pain management in cerebral palsy

Effect of general anesthesia in patients with cerebral palsy at the turn of the new millennium: a population-based study evaluating perioperative outcome and brief overview of anesthetic implications of this coexisting disease

The severity of preoperative cerebral palsy appears to correlate directly with postoperative complications. The primary aim of this study was to characterize the frequency of perioperative morbidity and mortality in cerebral palsy patients undergoing anesthesia. This was accomplished by undertaking a systematic review of the Mayo Database. The risk for perioperative adverse events was 63.1% (95% confidence interval 59.8%-66.5%). However, it deserves clarification that hypothermia and clinically significant yet non-life-threatening hypotension represented the majority (80%) of these complications. When these 2 events are excluded, the rate of adverse perioperative events was 13.1% (95% confidence interval 10.8%-15.5%). Risk factors associated with increased risk included American Society of Anesthesiologists physical status score exceeding 2, history of seizures, upper airway hypotonia, general surgery procedures, and adults. Our findings are useful to counsel patients with cerebral palsy, their caregivers, and their guardians regarding the risk of general anesthesia.

Perioperative management of the paediatric patient with coexisting neuromuscular disease

Children with neuromuscular diseases present a wide range of clinical manifestations and clinical implications for the anaesthesiologist. Neuromuscular diseases in children affect muscle strength by either directly weakening the muscle fibrils or indirectly by a degenerative nerve supply and weak neuromuscular junction. Of the more than 200 neuromuscular disorders known, the vast majority are genetic in origin. This review focuses on four of the more common neuromuscular disorders with emphasis on their pathophysiology and clinical implications for anaesthesiologists: malignant hyperthermia, the muscular dystrophies (Duchenne's, Becker's, and Emery-Dreifuss), mitochondrial disorders, and cerebral palsy.

[Postoperative pain assessment in special patient groups: part II. Children with cognitive impairment]

Postoperative pain assessment in children with cognitive impairment poses major challenges to healthcare professionals.Children with moderate to severe cognitive impairment are generally unable to communicate effectively and to self-report the level of pain. Difficulties assessing pain have led to their exclusion from clinical trials and rendered them vulnerable to insufficient treatment of pain.The realization of pain is a particularly important step forward for a better care of children with cognitive impairment.Scales based on a child's own perception of pain and its severity play a limited role in this vulnerable population and pain assessment tools which rely on observing pain behavior are essential. The r-FLACC, which is reliable and valid, includes specific behavioral descriptors and can be used simply and effectively postoperatively in clinical practice. Our task has to be assessing pain as a routine procedure in cognitively impaired children as a keystone for an improved and successful pain management in this very sensitive patient population.

Effect of caudal block on sevoflurane requirement for lower limb surgery in children with cerebral palsy

BACKGROUND

Caudal block is a widely used technique for providing perioperative pain management in children. In this randomized double-blinded study, we evaluated the effects of preoperative caudal block on sevoflurane requirements in children with cerebral palsy (CP) undergoing lower limb surgery while bispectral index (BIS) values were maintained between 45 and 55.

METHODS

52 children undergoing Achilles-tendon lengthening were randomized to receive combined general-caudal anesthesia (caudal group, n = 27) or general anesthesia alone (control group, n = 25). Caudal block was performed with a single dose of 0.7 ml·kg(-1) of 1.0% lidocaine containing epinephrine at 5 μg·ml(-1). The control group received no preoperative caudal block. The endtidal sevoflurane concentrations (ET(sev)) were adjusted every minute to maintain the BIS values between 45 and 55.

RESULTS

The ET(sev) required to maintain the BIS values were not significantly different between the control and caudal groups after induction of anesthesia [2.1 (0.2) vs 2.2 (0.4); P = 0.773]. However, significantly higher ET(sev) was observed in the control group before surgical incision [2.0 (0.2) vs 1.8 (0.3); P = 0.013] and during the first 20 min after surgical incision [2.2 (0.3) vs 1.4 (0.3); P < 0.001]. There was no significant difference in BIS values between the control and caudal groups throughout the study period (P > 0.05). In the caudal group, the caudal block was successful in 25 of 27 (92.6%) patients.

CONCLUSIONS

Caudal block effectively reduced sevoflurane requirements by 36% compared to general anesthesia alone in children with CP undergoing lower limb surgery while BIS values were maintained between 45 and 55.

Effectiveness of an anesthetic continuous-infusion device in children with cerebral palsy undergoing orthopaedic surgery

BACKGROUND

Effective postoperative pain management is a vital component of orthopaedic surgical care in the pediatric population. In children with cognitive impairments pain management can be difficult, making these children vulnerable to ineffectively managed postoperative pain. This prospective, randomised study evaluated the use of a local anesthetic continuous infusion device (pain pump) to manage postoperative pain in children with cerebral palsy (CP) undergoing lower extremity orthopaedic surgical procedures.

METHODS

Children with a diagnosis of CP who were undergoing select orthopaedic outpatient procedures were enrolled in this study. Postoperatively, patients were randomised to receive either a pain pump in addition to oral analgesics or oral analgesics only. Patient's parents were asked to record the amount of medication administered and assess pain intensity with the use of a modified visual analogue scale for 3 days postoperatively. Parents also completed an overall pain management satisfaction questionnaire at the end of the study participation period.

RESULTS

Fifty-four patients were enrolled in this study and data were analyzed on 37 patients. The mean daily pain intensity in the pain pump group was significantly lower for the day of surgery and for 2 days postoperatively, and there was an overall significant difference between the groups (P<0.0001). The amount of analgesic medication administered was significantly lower for the first 2 postoperative days, but there was not a significant difference between the 2 groups overall (P=0.29). Parent satisfaction with both pain management techniques was high and responses were similar between the 2 groups.

CONCLUSIONS

Children with CP present unique postoperative pain management concerns that can be effectively addressed through the use of multimodal analgesic techniques. This study found that the pain pump is an effective pain management technique that significantly reduces pain intensity in children with CP after lower extremity orthopaedic procedures.

LEVEL OF EVIDENCE

Therapeutic Level II.

Effects of magnesium sulphate on intraoperative neuromuscular blocking agent requirements and postoperative analgesia in children with cerebral palsy

BACKGROUND

In this double-blind, randomized, placebo-controlled study, we evaluated the effects of magnesium sulphate on neuromuscular blocking agent requirements and analgesia in children with cerebral palsy (CP).

METHODS

We randomly divided 61 children with CP undergoing orthopaedic surgery into two groups. The magnesium group (Group M) received magnesium sulphate 50 mg kg(-1) i.v. as a bolus and 15 mg kg(-1) h(-1) by continuous infusion during the operation. The control group (Group S) received the same amount of isotonic saline. Rocuronium was administered 0.6 mg kg(-1) before intubation and 0.1 mg kg(-1) additionally when train-of-four counts were 2 or more. I.V. fentanyl and ketorolac were used to control postoperative pain. Total infused analgesic volumes and pain scores were evaluated at postoperative 30 min, and at 6, 24, and 48 h.

RESULTS

The rocuronium requirement of Group M was significantly less than that of Group S [0.29 (0.12) vs 0.42 (0.16) mg kg(-1) h(-1), P<0.05]. Cumulative analgesic consumption in Group M was significantly less after operation at 24 and 48 h (P<0.05), and pain scores in Group M were lower than in Group S during the entire postoperative period (P<0.05). Serum magnesium concentrations in Group M were higher until 24 h after operation (P<0.05). The incidence of postoperative nausea and vomiting and rescue drug injections was similar in the two groups. No shivering or adverse effects related to hypermagnesaemia were encountered.

CONCLUSIONS

I.V. magnesium sulphate reduces rocuronium requirements and postoperative analgesic consumption in children with CP.

Innovative use of perianesthesia nurses in imaging services: meeting the needs of children with disabilities

A new imaging center was established within a children's specialty hospital that provides services for children and adults with childhood-onset disabilities. New services in this advanced imaging center include computed tomography, magnetic resonance imaging, fluoroscopy, and ultrasound. Individuals with disabilities are particularly at risk for complications during procedures requiring sedation and anesthesia. The perianesthesia nurses' role was developed to support the sedation needs of this population during imaging services. Perianesthesia nurses developed an advanced imaging screening process to prepare patients for sedation during imaging services. With these processes, the new Advanced Imaging Center is providing timelier and better coordinated imaging services.

Pain in adults with cerebral palsy: impact and solutions

Studies of health in adults with cerebral palsy (CP) have identified pain as a significant concern. Investigations regarding incidence, intensity, and location in adults with CP found that increasing age and inactivity appeared to be related to pain. Activity and participation in adults with CP seem to be only moderately affected by presence of pain. Various sources of pain have been identified in adults with CP but have not been well studied. These include orthopedic issues, poor bone mineral density and related fractures, dental and jaw problems, and nutrition-related pain. Limited healthcare utilization studies suggest that adults with CP use healthcare services, especially preventative and rehabilitative services less, and do not consult physicians regarding pain. Medication solutions for chronic pain are not well studied. Botulinum toxin and intrathecal baclofen have been demonstrated to minimize pain; however, the impact of other medications needs further investigation. Other interventions for pain include small studies examining the use of biofeedback and exercise. Larger studies are needed to establish effectiveness. In order to prevent future generations of adults with CP from experiencing high levels of pain, environmental sources of pain need more specific study, as do interventions that are affordable and easily accessed.

Successful and safe delivery of anesthesia and perioperative care for children with complex special health care needs

STUDY OBJECTIVE

To determine the utilization of anesthesia resources by children with complex special health care needs.

DESIGN

Observational, inception cohort study of medical records.

SETTING

Urban, pediatric, tertiary-care hospital.

MEASUREMENTS

All general anesthetic cases were screened for preexisting complex special health care needs. Medical records were reviewed for demographic, clinical, and outcome data.

MAIN RESULTS

435 children with complex special health care needs accounted for 479 delivered general anesthetic cases. This figure represented 14% of the total 3,437 cases presenting during the study period. It also represented 22% (49 of 224) of all cancellations. Down syndrome was the most identifiable developmental disorder (n = 43, 9%). Another 143 (30%) cases showed preexisting technology dependence. Scheduled surgical procedures (n = 425, 89%) comprised the majority of cases. Intraoperative and recovery room complications occurred in 6 (1%) and 133 (28%) cases, respectively. Eleven (2.3%) cases required unplanned post-anesthetic hospital ward or pediatric intensive care unit admission. Documentation of health care proxy or resuscitation status was not identified in any child under 18 years, and in only 4 of 33 children older than 18 years.

CONCLUSIONS

Children with complex special health care needs represented one out of 7 of all pediatric general anesthetic cases at a tertiary-care, academic center.

Risks of general anesthesia for the special needs dental patient

The risk of dental rehabilitation under general anesthesia has multiple contributing factors. The literature has addressed the general anesthetic risk of dental general anesthesia and sedation in the operating room and the office settings, but more studies are needed to address the special needs population in particular. There is still a great need for more studies to assess the risk versus benefit for special need population as well as to stratify such risk in order to assist care providers in decision making as well as in sharing such risk concerns with patients, caretakers, and guardians. One recommended approach is to conduct a national retrospective study of patients treated under general anesthesia in the past 10 years in all the various settings and assess the associated risks and complications related to their physical status and the underlying physical and mental disabilities. The product of such a study could be a stratification of risk versus benefit as well as some guidelines for decision making as far as which kind of procedures should be conducted under general anesthesia while weighing the level of risk for the particular patient. Although access to care is not a direct risk factor, it can certainly deter timely treatment and intervention for patients with special needs.

Nerve palsy after hamstring lengthening in patients with cerebral palsy

BACKGROUND

The purpose of this study was to assess the incidence of, risk factors for, and treatment of nerve palsy after hamstring lengthening in children with cerebral palsy.

METHODS

A medical record review of patients with cerebral palsy who had hamstring lengthening between 1994 and 2005 was performed. Data included the preoperative popliteal angle, the presence of a knee flexion contracture, postoperative pain management, and type of immobilization. The presence of postoperative nerve palsy was established based on the recording of numbness, loss of motor function in the foot, or hypersensitivity of the foot in the inpatient record or the postoperative clinic notes. The need for medical management and time to resolution of symptoms were noted.

RESULTS

A total of 292 children underwent 329 hamstring lengthening surgeries. The mean age at surgery was 9.5 years (range, 2.5-18 years). Twenty-eight patients (9.6%) experienced postoperative nerve palsy. Time to recognition of the palsy ranged from 4 hours to 72 days. Patients diagnosed within 24 hours had loss of motor function and/or lack of sensation of the toes. Patients diagnosed from 8 to 72 days postoperatively had dysesthesias of the feet. Treatment of early palsies consisted of the removal of immobilization, bivalving of casts, or wedging casts into flexion. Fourteen of 28 patients were treated with Neurontin. Twenty-two of 25 patients with adequate follow-up recovered nerve function. Older children, noncommunicative patients, nonambulatory patients, and those who had epidural pain management were at statistically significant higher risk for postoperative palsy. The trend for palsies in spastic quadriplegic patients and after repeat lengthening procedures did not reach significance. There was no significant relationship between popliteal angle or the presence of a knee flexion contracture and development of nerve palsy.

CONCLUSIONS

Nerve palsy occurred in 9.6% of patients undergoing hamstring lengthening. Although the greatest risk was in noncommunicative adolescents who were nonambulatory, a small number of younger ambulatory patients developed palsies as well, so that all patients must be considered at risk. Vigilance in patients with epidural pain control to avoid excessive hip flexion and/or knee extension is warranted. Treatment is immediate knee flexion. Resolution of symptoms occurred in 82.1% of patients.

Subarachnoid placement of stem cells in neurological disorders

BACKGROUND

"Medically untreatable neurological disorders" is an area where stem cell (SC) therapy has generated hope in the last decade. Among various routes for SC infusion, subarachnoid placement via the lumbar route is particularly challenging because of technical difficulties in this group of patients. We carried out a prospective, single-center, clinical study to analyze the technical difficulties and short- and long-term effects of SC infusion in various neurological conditions.

PATIENTS AND METHODS

One hundred eighty patients underwent subarachnoid placement of SCs between December 2005 and October 2007. Technical difficulties in the form of localization of subarachnoid space, number of attempts, and postprocedural complications were evaluated. Functional evaluation was done with Hauser Ambulation Index by the SC transplant team on a regular basis. The Institutional Review Board approved of informed consent forms and study protocol.

RESULTS

Of 180 patients, we encountered technical difficulties in 52 (29%) in the form of general anesthesia supplementation and difficulty localizing the lumbar space. In 102 (56.6%) patients, side effects were observed (headache, low-grade fever, and meningism), which resolved with symptomatic treatment within 24 hours. On long-term follow-up, functional indices improved in 57 (31.67%) patients, including 54 patients with traumatic paraplegia/quadriplegia, two with cerebral palsy, and one with viral encephalitis.

CONCLUSION

Subarachnoid placement of SCs is safe with no long term adverse effects.

[Botulinum toxin for postoperative care after limb surgery in cerebral palsy children]

PURPOSE OF THE STUDY

Spasticity can be the cause of pain in cerebral palsy (CP) children who may suffer increased postoperative pain after orthopedic surgery. Moreover, symptoms can be worsened by abnormal movements, cast immobilization or anxiety. Spasticity must therefore be treated after surgery in CP children. A randomized study has demonstrated that when these children undergo surgical tenotomy, preoperative injections of botulinum toxin have a beneficial effect in terms of pain relief. The aim of this study was to assess the benefit regarding pain and comfort provided by preoperative use of botulinum toxin in total-body CP children undergoing bone surgery.

MATERIAL AND METHODS

Two successive groups of nine total-body CP children were compared in a retrospective study. All patients underwent an orthopedic surgery involving a bone or a multilevel procedure. The second group was treated before surgery with multisite injections of botulinum toxin. The main outcome criteria studied were: efficiency and adverse effects of botulinum toxin, duration of hospital stay and pain, length of level III analgesic treatment (morphine), sleep quality, and skin lesions under cast immobilization. The two groups were similar for mean age (8.7+/-2.04 versus 10.9+/-4.37 years) and mean body weight (20+/-5.6 versus 26+/-7.7 kg). Mean botulinum toxin (Botox/kg) in the second group was 11.6 U (range 9.7-14.8). Average time from preoperative botulinum toxin injections to surgery was 27 days (range 23-31).

RESULTS

There was no significant difference between the two groups, except for the botulinum toxin treatment. The Aschworth scale confirmed the clinical efficiency of the preoperative injections, with no adverse effects. After the surgical procedure, all patients but two had cast immobilization (orthopedic traction, in botulinum group). The mean duration was six weeks in both groups. There was no significant difference in duration of the hospital stay: 7.33+/-1.5 versus 7.88+/-1.7 days and duration of level III analgesic treatment (4.33+/-1.9 versus 4.16+/-2.5 days). The duration of pain symptoms decreased significantly from 6.87+/-2.9 to 2.22+/-1.7 days and sleep quality improved from 7/9 to 1/9 patients with disturbed sleep. Four under-cast skin lesions were noted in the first group but none in the bolulinum group.

DISCUSSION

We cannot confirm that botulinum toxin before bone surgery induces lesser consumption of analgesic drugs. Our results do however support the hypothesis that treatment of spasticity using preoperative injections of botulinum toxin decreases the duration of postoperative pain and improves the children's comfort. Moreover, postoperative under-cast skin lesions can be prevented. This work suggests that improved patient comfort and pain relief could be achieved by using multisite botulinum toxin injections before orthopedic surgery in spastic total-body CP children.

Communication with patients before anesthesia and obtention of preanesthetic consent

Communication in medicine deserves greater attention than it usually receives. The physician's obligation to obtain informed consent for clinical care and research forces the issue out into the open. Recognition that communication can have legal and economic impacts suggests communication skills should be cultivated as a medical art. This review places communication issues in anesthesia practice, especially those related to informed consent, in an historical, and when possible, scientific context.

Clinically unrecognized intravascular placement of epidural catheter in a child--an argument for the use of radio-opaque contrast?

An epidural catheter was inserted after induction of anesthesia in a 28.2 kg 9-year-old boy scheduled to undergo bilateral femoral varus derotational osteotomies. There was no gravity free flow of blood down the catheter and there was no blood aspirated with a 2 ml syringe. After a negative test dose of a 4 ml solution of 0.25% levobupivacaine with epinephrine 1 : 200 000, a further 8 ml was administered via the epidural catheter. No significant increase in heart rate was noted. On surgical skin incision the heart rate increased from 94 to 116 b.min(-1) and blood pressure increased from 104/44 to 116/46 mmHg. A further 3 ml 0.25% levobupivacaine with epinephrine and clonidine 2 mug.kg(-1) were administered via the epidural catheter. The operation continued uneventfully although it was noted that the heart rate increased intermittently during the procedure. In view of the unexplained tachycardia and a history of cerebral palsy with the potential for postoperative muscle spasms, it was felt important to have a reliable epidural. To confirm placement, 2 ml of Isovue 300 (Iopamidol) was administered via the epidural catheter. X-ray screening demonstrated intravascular placement and the rapid disappearance of contrast. The catheter was removed and reinserted. Contrast demonstrated good spread in the epidural space. The merits of screening with contrast for epidural catheter placement in children are discussed.

Parental report of pain and associated limitations in ambulatory children with cerebral palsy

OBJECTIVE

To document parental reports about pain in children with cerebral palsy (CP).

DESIGN

A cross-sectional descriptive study.

SETTING

Motion analysis laboratory.

PARTICIPANTS

Seventy-seven ambulatory children with CP (44 boys, 33 girls; age range, 3-17y) presenting as consecutive assessments.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Parents completed (1) a semistructured interview, (2) the Pediatric Outcome Data Collection Instrument (PODCI), (3) the Child Behavior Checklist (CBCL), (4) the Behavior Rating Inventory of Executive Functioning (BRIEF), and (5) Gillette Functional Assessment Questionnaire. Two dichotomous PODCI pain and comfort questions were estimates of pain frequency and impact.

RESULTS

Sixty-one percent reported "pain over the last week," and 33% reported "pain interfered with normal activities." Pain did not differ by topographic classification. Girls had more pain. "Pain that interfered with normal activities" was associated with limitations in activities of daily living and physical education. Social problems and attention problems on the CBCL and the initiate scale on the BRIEF were associated with pain that interfered with activity.

CONCLUSIONS

Pain in children with CP is frequent and associated with behavioral and social consequences. Sex is a risk factor; girls experience more pain. Intervention strategies that successfully support transition into adulthood are needed.

Pain in children who have life-limiting conditions

Children and adolescents who have life-limiting conditions are vulnerableto acute and chronic pain problems. Many compounding and complicatingfactors often need to be explored in this setting. Barriers to effective painmanagement include poor assessment and measurement of pain anda lack of specialist knowledge. Fears regarding the use of opioids and theirassociation with the end of life must be addressed openly and with clarity.Day-to-day management should include continual appraisal of pain issuesif quality of life is to be maximized. Pain is a complicated phenomenon. The impact of pain and the compli-cated dynamic of suffering in children and young people who have life-lim-iting conditions must not be underestimated. The clinician must be vigilantand take responsibility for all aspects of pain management in these patients.

Near-death experience in a boy undergoing uneventful elective surgery under general anesthesia

Near-death experience (NDE) is a complex subjective experience, which may include affective elements such as a sense of peacefulness, paranormal components such as a sensation of floating out of the body, and a perception of being in a dark tunnel and seeing a brilliant light. It is usually reported to occur in association with a wide range of life-threatening situations, as for instance, cardiopulmonary resuscitation. We report on an episode of NDE that occurred in a 12-year-old boy who underwent a general anesthesia for an elective uncomplicated surgery. To our knowledge, this is the first case of NDE in a child that has been reported in this context.

The evaluation of propofol dosage for anesthesia induction in children with cerebral palsy with bispectral index (BIS) monitoring

BACKGROUND

We designed a randomized prospective study to investigate whether developmentally delayed children with cerebral palsy (CP) need a lower dosage of propofol for induction than normal children using bispectral index (BIS) monitoring criteria.

METHODS

After approval by the University Ethical Committee and written informed consent obtained from parents, 20 children with noncommunicative/nonverbal CP and 20 normal children requiring general anesthesia for elective orthopedic surgery were enrolled in the study. The patients were not premedicated. BIS leads were placed before the induction of anesthesia. Propofol was administered at a rate of 20 mg.30 s(-1) (i.e. 40 mg.min(-1)). When BIS value had reached a steady number of 35-45, infusion was stopped.

RESULTS

There was no significant difference between Group N and Group CP in age and sex distribution (P > 0.05), however children in Group CP weighed less than Group N (P = 0.05). The propofol dosage for induction was significantly lower in Group CP than Group N (P = 0.03). There were no differences in propofol doses administered to children using anticonvulsants and those not on anticonvulsants in Group CP. BIS values were comparable between the two groups (i.e. Group N and Group CP) at baseline and after propofol administration.

CONCLUSIONS

Our data suggest that noncommunicative/nonverbal children with CP require less propofol to obtain the same BIS values (i.e. 35-45) than do otherwise healthy children.

Botox in urology

Lower urinary tract dysfunction is one of the challenging problems facing urologists and patients. Several treatment trials have been introduced in the literature, but none has proven to be as effective as being a gold standard treatment for such conditions. We reviewed the literature regarding the use of botulinum toxin (BTx) type A as a current treatment of lower urinary tract conditions described below. The toxin has been shown to be safe and effective in the treatment of conditions caused by increased muscle tonicity. Indications for the urological use of BTx and future applications are also considered.

The management of oromandibular motor disorders and facial spasms with injections of botulinum toxin

Although much work is yet to be done in this area, nine general conclusions can be derived: 1. Local site-of-injection side effects from botulinum toxin injections are rare, assuming proper technique is used. 2. The two most common medication-related side effects from botulinum toxin orofacial injections are alterations in salivary consistency and inadvertent weakness of the swallowing, speech, and facial muscles. These complications are injection site-specific (eg, more common with lateral pterygoid injections and palatal and tongue muscle injections) and dose-dependent problems. These problems are bothersome but are not contraindications for the therapy if it is needed. 3. The data presented in this article are mostly case series-based and open trial-based information that is promising, but randomized, blinded, controlled trials are needed to establish the true efficacy of this method for the orofacial motor and pain disorders. 4. The novice should begin with injection of muscles he or she can inject with low risk of incorrect placement. The hard-to-find muscles should be avoided when starting out. The novice clinician should inject and dissect a few cadavers to improve injection technique. 5. The general latency for botulinum toxin type A is 1 week, its duration is 2 to 3 months, and it is recommended that injection be done no more than once every 12 weeks to avoid development of antibodies against the toxin. 6. Depending on the target muscle, injection dose is 10 to 50 U of Botox type A per site with a total dose of 200 U in the masticatory system. More than this can be used (400 U maximum) if other sites in the head and neck are included in the injection protocol. 7. Regarding injecting painful muscles that do not exhibit palpable muscle hardness or EMG-determined spasticity or observable involuntary movements but have chronic myofascial trigger points or the patient localizes them as the site of their chronic daily headache pain, botulinum toxin injections might be helpful used in this manner, but conclusive data for this controversial application of botulinum toxin are still missing. 8. Hemifacial spasm has the largest number of open-label, clinical trials, some of which have a 10-year follow-up. The conclusions reached by all of these reports is that treatment of hemifacial spasm with repeated injections of botulinum toxin has been highly successful and that the dose and relative effect of the injections are stable over time. 9. Although EMG-guided injection may be useful, EMG is neither practical nor needed in most situations for orofacial injections because most of the orofacial muscles are easily palpable muscles or have definitive bony landmarks to help with the localization process.

[Efficacy and safety of inhalation premixed nitrous oxide and oxygen for the management of procedural diagnostic pain in neuropediatrics]

AIM

We studied the use of premixed nitrous oxide and oxygen in 80 patients with neurologic diseases.

PATIENTS AND METHODS

Mean ages ranged 10 +/- 5 yrs. Twenty-three patients (29%) were mentally retardated among which 17 of them presented with severe epilepsy. Painful procedures consisted of: lumbar punctures (80%), intravenous access (7), gastric endoscopy (6), skin biopsy (4), gastrostomy tube management (3). High-risk children were continuously monitored using ECG, non invasive blood pressure and transcutaneous oxygen saturation. We studied acceptation of the inhalation, vital signs, satisfaction of children, parents, medical and nursing staffs; side effects were compared with a group of healthy children undergoing venous access before induction of anesthesia.

RESULTS AND DISCUSSION

Acceptation increased with age. No significant changes in vital signs variables were observed. Satisfaction rate regarding the method was 88% for all children, parents, physicians and nurses. No serious undesirable event (as respiratory depression, seizure, inhalation of gastric content) occurred in these patients. The more frequent side-effects were: drowsiness during and after inhalation (35 and 9% respectively in the handicapped patients); nausea and vomiting (8%), headaches (3%), were more frequent than reported in literature but there were 25% of meningitis among our patients.

CONCLUSION

Premixed nitrous oxide and oxygen was effective for reducing procedural pain and anxiety in children with neurological disorders, even in severely handicapped patients, with minor side-effects.

Reversible coma in children after improper baclofen pump insertion

We report the occurrence of delayed postoperative coma in five of nine consecutive children following surgery for insertion of baclofen infusion pumps. We suspect that improper technique resulted in an inadvertent administration of an intrathecal baclofen bolus. We suggest ways to minimize this risk.

Dealing with uncertainty: parental assessment of pain in their children with profound special needs

BACKGROUND

Despite advances in the assessment and management of children's pain, children with profound special needs are especially vulnerable to poor pain management. Their underpinning condition often severely compromises their ability to express pain through the usual verbal and behavioural routes. The lack of any appropriate framework for assessment results in a suboptimum and inaccurate approach to an important aspect of their care.

PURPOSE

The purpose of the study was to explore the ways in which parents of children with profound special needs assess and manage their children's pain.

METHODS

Qualitative case study design underpinned the study using guided interviews with the 15 parents/carers (of 12 children aged 5-16 years with profound special needs).

ETHICAL APPROVAL

Ethics Committee approval was gained.

FINDINGS

A number of themes emerged from the data including learning to live with pain, dealing with uncertainty, expression of pain and making decisions.

CONCLUSIONS

Parents felt that their child had learned to live with significant levels of chronic and acute pain. Assessment of pain was an uncertain and complex process requiring parents to draw on skills and knowledge developed over a number of years. Parents used different strategies for both the assessment and management of pain based on an intimate knowledge of their child's usual nonpain state. Even with a limited repertoire of behaviours available to them, children were able to express pain. Parents often felt isolated in relation to pain management and under-used as a resource by health professionals.

Complicated negative pressure pulmonary oedema in a child with cerebral palsy

A 3-year-old child with cerebral palsy developed postextubation upper airway obstruction secondary to laryngospasm and/or masseteric spasm,which may have been triggered by the muscular spasticity and the slow recovery from inhalational anaesthesia associated with cerebral palsy. This upper airway obstruction was followed by negative pressure pulmonary oedema. The patient improved on mechanical ventilation; however, his condition was complicated with the occurrence of bilateral pneumothoraces. After release of the pneumothoraces and reexpansion of the lungs, the child developed reexpansion pulmonary oedema, culminating in acute lung injury.

Anesthetic management for a patient with Jansky-Bielschowsky disease

PURPOSE

To describe the anesthetic management of a patient with Jansky-Bielschowsky disease (JBD), the late infantile form of neuronal ceroid lipofuscinosis, characterized by dementia, severe and drug resistant grand mal, myoclonic seizures, and blindness.

CLINICAL FEATURES

A 14-yr-old girl with JBD was scheduled for resection of a gingival tumour and an infected sinus in the sacral area. Her preanesthetic examination revealed extreme muscle atrophy and dementia. Grand mal, myoclonic seizures, and upper airway obstruction were frequent. Following iv induction with thiamylal, anesthesia was maintained with sevoflurane, N(2)O and O(2). Her trachea was intubated without using muscle relaxants. Muscle relaxants were not used during the operation. Apart from an intractable hypothermia, the intraoperative course was uneventful. The emergence of anesthesia was smooth, except for persisting seizures.

CONCLUSION

General anesthesia using thiamylal and sevoflurane provided satisfactory conditions during operation in a patient with JBD. Intraoperative hypothermia required particular attention.

Management of chronic pain in children

OBJECTIVES

To describe the demography, clinical characteristics, treatment, functional limitations and outcomes of patients referred to a paediatric multidisciplinary pain clinic.

DESIGN

Prospective data collection, descriptive study.

PATIENTS AND SETTING

Tertiary referral centre pain clinic (Royal Children's Hospital, Melbourne) over two years (March 1998 - March 2000).

MAIN OUTCOME MEASURES

Pain profile; functional disability (school absenteeism, sleep disturbance and inability to perform sport); treatments received; outcome.

RESULTS

207 patients (mean age, 13.1 years; 73% females; 29% rural residents) were referred in the two years. Concomitant medical conditions were present in 106/207 (51%) patients, the commonest being cerebral palsy or spasticity (22 patients) and malignancy (18). Complex regional pain syndrome was diagnosed in 44 patients. Functional disability due to pain included school absenteeism (95% of school attenders), sleep disruption (71% of all patients) and inability to perform sport (90% of those able to participate in sport previously). Of the 105 patients who missed five or more days of school because of pain, 93 attended school regularly after treatment. Sleep disturbance improved in 129/146 (88%) patients, and 129/147 (88%) resumed sporting activity after multidisciplinary intervention. Outcome was classified as good in 134 patients (65%), moderate in 32 (15%) and poor in 16 (8%).

CONCLUSIONS

Chronic pain in children and adolescents often results in considerable functional disability. Functional improvement can be achieved using a multidisciplinary approach to pain management in children.