Acute pain management in children

Opioid Use in Children

Limited guidance on opioid use exists in the pediatric population, causing medication safety concerns for pain management in children and adolescents. Opioid misuse and use disorder continue to greatly affect adolescents and young adults in the United States, furthering the apprehension of their use. Pediatric Pharmacy Advocacy Group (PPAG) recommends pharmacists contribute their knowledge to pain management in children, including the discussion of appropriate use of non-opioid alternatives for pain and when to recommend coprescribing of naloxone. PPAG also supports the review of electronic prescription drug-monitoring programs prior to opioid prescribing and dispensing by both prescribers and pharmacists. Education by pharmacists of children and their families regarding proper administration, storage, and disposal, as well as the awareness of opioid misuse and use disorder among adolescents and young adults, is key to prevention. If opioid use disorder is diagnosed, PPAG encourages improved access among adolescents to evidence-based medications including methadone, buprenorphine, and naltrexone. Furthermore, pharmacists should assist in screening and referral to evidence-based treatment.

Regional anesthesia to ameliorate postoperative analgesia outcomes in pediatric surgical patients: an updated systematic review of randomized controlled trials

Regional anesthesia is becoming increasingly popular among anesthesiologists in the management of postoperative analgesia following pediatric surgery. The main objective of this review was to systematically evaluate the last 5 years of randomized controlled trials on the role of regional anesthesia techniques in alleviating postoperative pain associated with various pediatric surgical procedures. Forty studies on 2,408 pediatric patients were evaluated. The majority of the articles published from 2013 to 2017 reported that the use of regional anesthesia minimized postoperative pain and reduced opioid consumption. Only a few surgical procedures (cholecystectomy, inguinal hernia repair, and non-laparoscopic major abdominal surgery) reported no significant difference in the postoperative pain relief compared with the standard anesthetic management. The growing number of randomized controlled trials in the pediatric literature is very promising; however, additional confirmation is needed to reinforce the use of specific regional anesthesia techniques to provide optimal postoperative pain relief for a few surgical procedures (reconstructive ear surgery, chest wall deformity, hypospadias, umbilical hernia, cleft palate repair) in pediatric patients. More randomized controlled trials are needed to establish regional anesthesia as an essential component of postoperative analgesia management in children.

Pain Management for Nasogastric Intubation in Pediatrics

Nasogastric (NG) intubation is a common yet one of the most uncomfortable minor procedures done in children and adults alike. A variety of analgesics, such as ketamine, lidocaine, and nitrous oxide, have been shown to reduce pain in various minor pediatric procedures. This retrospective study explores how often various pain management practices are used, either alone or in combination. The study examines NG intubation in pediatrics in one pediatric academic health system. The comfort measures used include analgesics, distraction, child life, swaddling, nitrous oxide, and others. Pharmacological intervention (analgesics) and distraction were most frequently used. Larger randomized studies should be conducted to determine the best practices for comfort measures for NG intubation in order to achieve maximal pain and anxiety reduction for children of various ages.

Assessing pain in children in the perioperative setting

Pain assessment and management in children is challenging for a number of reasons. This paper aims to identify these challenges and highlight strategies for effective pain assessment and management in children in the perioperative setting.

Dermatochirurgie bei Kindern: Gegenwärtiger Stand zu Indikation, Anästhesie, Analgesie und potentiellen perioperativen Komplikationen

HINTERGRUND

Anders als Erwachsene benötigen Kinder bei dermatochirurgischen Eingriffen besondere Aufmerksamkeit; die Anwendung verschiedener Analgetika, Anästhetika oder Sedativa erfordert eine gründliche Kenntnis von Pharmakokinetik und -dynamik der Medikamente. Außerdem können Medikamente zur Sedierung/Allgemeinanästhesie bei operierten Kindern zu Anästhesie- oder Analgesie-bedingten Komplikationen einschließlich Störungen der geistigen Entwicklung führen. ZIEL: Auf Basis unserer klinischen Erfahrung und einer Literaturübersicht stellen wir die gängigsten in der pädiatrischen Dermatochirurgie verwendeten Analgetika, Anästhetika und Sedativa dar und diskutieren Risiken und Komplikationen nach dermatochirurgischen Eingriffen.

ERGEBNISSE

Topische Anästhetika können bei Kindern für oberflächliche dermatologische Eingriffe oder vor einer Infiltrationsanästhesie eingesetzt werden. Die Berechnung der empfohlenen Maximaldosen auf Basis des Körpergewichts ist erforderlich, um eine Überdosierung von Lokalanästhetika zu vermeiden. Die Allgemeinanästhesie gilt bei der Dermatochirurgie als sicher und hat eine geringe Nebenwirkungsrate. Allerdings ist bei Kindern im ersten Lebensjahr aufgrund potentieller langfristiger neurologischer Nebenwirkungen Vorsicht angebracht. NSAR und Opioide spielen bei der Analgesie von Kindern eine bedeutende Rolle.

SCHLUSSFOLGERUNGEN

Dieser Artikel gibt eine Übersicht über die derzeit verfügbaren Daten zu Analgesie, Anästhesie und Komplikationen, die im Rahmen der pädiatrischen Dermatochirurgie auftreten können. Diese Daten können dabei helfen, die Sicherheit und Qualität der Versorgung zu optimieren und die Beratung der Eltern zu verbessern.

Dermatologic surgery in children: an update on indication, anesthesia, analgesia and potential perioperative complications

BACKGROUND

Children undergoing dermatosurgical procedures require, unlike adults, particular attention; the administration of various analgesics, anesthetics or sedatives requires a thorough knowledge of drug pharmacokinetics and pharmacodynamics. Furthermore, there are concerns that drugs used for sedation/general anesthesia may result in anesthetic/analgesic complications in children undergoing surgery, with a risk of impaired mental development.

OBJECTIVES

Based on our clinical experience and a literature review, we illustrate the most commonly used analgesic, anesthetic and sedative drugs in pediatric dermatosurgery, and identify risk factors and complications following dermatosurgical procedures.

RESULTS

Topical anesthetics can be used in children for superficial dermatologic procedures or prior to infiltration anesthesia. Maximum recommended doses based on body weight should be calculated in order to avoid overdosage of local anesthetics. General anesthesia in dermatosurgery is considered safe and has a low rate of side effects. However, caution is advised in children under the age of one due to potential long-term neurological side-effects. NSAIDs and opioids play a significant role in analgesia for children.

CONCLUSIONS

This article reviews currently available data on analgesia, anesthesia and complications that may arise in pediatric dermatosurgery. These data may be useful in optimizing the safety and quality of care and in improving parent counseling.

Safety of Patient-Controlled Analgesia After Surgery in Children And Adolescents: Concerns And Potential Solutions

Patient-controlled analgesia (PCA) is common practice for acute postoperative pain management. Postoperative PCA use decreases pain intensity and improves patient satisfaction when compared to non-PCA routes of medication administration. Although PCA has several advantages regarding efficacy and safety, adverse events remain a concern. Programming errors and protocols, patient monitoring, and PCA by proxy or with continuous infusion are recurring silent dangers of PCA use in children and adolescents. Innovative considerations need to be emphasized for future improvement of PCA devices for elective surgical patients. With technology within the healthcare setting advancing at a fast pace, smart pump technology is something to look forward to.

Opioids for chronic non-cancer pain in children and adolescents

BACKGROUND

Pain is a common feature of childhood and adolescence around the world, and for many young people, that pain is chronic. The World Health Organization guidelines for pharmacological treatments for children's persisting pain acknowledge that pain in children is a major public health concern of high significance in most parts of the world. While in the past, pain was largely dismissed and was frequently left untreated, views on children's pain have changed over time, and relief of pain is now seen as importantWe designed a suite of seven reviews on chronic non-cancer pain and cancer pain (looking at antidepressants, antiepileptic drugs, non-steroidal anti-inflammatory drugs, opioids, and paracetamol as priority areas) in order to review the evidence for children's pain utilising pharmacological interventions in children and adolescents.As the leading cause of morbidity in children and adolescents in the world today, chronic disease (and its associated pain) is a major health concern. Chronic pain (lasting three months or longer) can arise in the paediatric population in a variety of pathophysiological classifications: nociceptive, neuropathic, idiopathic, visceral, nerve damage pain, chronic musculoskeletal pain, and chronic abdominal pain, and other unknown reasons.Opioids are used worldwide for the treatment of pain. They bind to opioid receptors in the central nervous system (mu, kappa, delta, and sigma) and can be agonists, antagonists, mixed agonist-antagonists, or partial agonists. Opioids are generally available in healthcare settings across most high-income countries, but access may be restricted in low- and middle-income countries. For example, opioids currently available in the UK include: buprenorphine, codeine, fentanyl, hydromorphone, methadone, morphine, oxycodone, and tramadol. Opioids are used in varying doses (generally based on body weight for paediatric patients) by means of parenteral, transmucosal, transdermal, or oral administration (immediate release or modified release). To achieve adequate pain relief in children using opioids, with an acceptable grade of adverse effects, the recommended method is a lower dose gradually titrated to effect in the child.

OBJECTIVES

To assess the analgesic efficacy and adverse events of opioids used to treat chronic non-cancer pain in children and adolescents aged between birth and 17 years, in any setting.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) via the Cochrane Library, MEDLINE via Ovid, and Embase via Ovid from inception to 6 September 2016. We also searched the reference lists of retrieved studies and reviews, and searched online clinical trial registries.

SELECTION CRITERIA

Randomised controlled trials, with or without blinding, of any dose and any route, treating chronic non-cancer pain in children and adolescents, comparing opioids with placebo or an active comparator.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed studies for eligibility. We planned to use dichotomous data to calculate risk ratio and number needed to treat, using standard methods. We assessed GRADE (Grading of Recommendations Assessment, Development and Evaluation) and planned to create a 'Summary of findings' table.

MAIN RESULTS

No studies were eligible for inclusion in this review. We rated the quality of the evidence as very low. We downgraded the quality of evidence by three levels due to the lack of data reported for any outcome.

AUTHORS' CONCLUSIONS

There was no evidence from randomised controlled trials to support or refute the use of opioids to treat chronic non-cancer pain in children and adolescents. We are unable to comment about efficacy or harm from the use of opioids to treat chronic non-cancer pain in children and adolescents.We know from adult randomised controlled trials that some opioids, such as morphine and codeine, can be effective in certain chronic pain conditions.This means that no conclusions could be made about efficacy or harm in the use of opioids to treat chronic non-cancer pain in children and adolescents.

Opioids for cancer-related pain in children and adolescents

BACKGROUND

Pain is a common feature of childhood and adolescence around the world, and for many young people, that pain is chronic. The World Health Organization (WHO) guidelines for pharmacological treatments for children's persisting pain acknowledge that pain in children is a major public health concern of high significance in most parts of the world. Views on children's pain have changed over time and relief of pain is now seen as important. In the past, pain was largely dismissed and was frequently left untreated, and it was assumed that children quickly forgot about painful experiences.We designed a suite of seven reviews in chronic non-cancer pain and cancer pain (looking at antidepressants, antiepileptic drugs, non-steroidal anti-inflammatory drugs, opioids, and paracetamol) to review the evidence for children's pain using pharmacological interventions.As one of the leading causes of mortality and morbidity for children and adolescents in the world today, childhood cancer (and its associated pain) is a major health concern. Cancer pain in infants, children, and adolescents is primarily nociceptive pain with negative long term effects. Cancer-related pain is generally caused directly by the tumour itself such as compressing on the nerve or inflammation of the organs. Cancer-related pain generally occurs as a result of perioperative procedures, nerve damage caused by radiation or chemotherapy treatments, or mucositis. However, this review focused on pain caused directly by the tumour itself such as nerve infiltration, external nerve compression, and other inflammatory events.Opioids are used worldwide for the treatment of pain. Currently available opioids include: buprenorphine, codeine, fentanyl, hydromorphone, methadone, morphine, oxycodone, and tramadol. Opioids are generally available in healthcare settings across most developed countries but access may be restricted in developing countries. To achieve adequate pain relief in children using opioids, with an acceptable grade of adverse effects, the recommended method is to start with a low dose gradually titrated to effect or unacceptable adverse effect in the child.

OBJECTIVES

To assess the analgesic efficacy, and adverse events, of opioids used to treat cancer-related pain in children and adolescents aged between birth and 17 years, in any setting.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) via the Cochrane Register of Studies Online, MEDLINE via Ovid and Embase via Ovid from inception to 22 February 2017. We also searched the reference lists of retrieved studies and reviews, and searched online clinical trial registries.

SELECTION CRITERIA

Randomised controlled trials (RCTs), with or without blinding, of any dose, and any route, treating cancer-related pain in children and adolescents, comparing opioids with placebo or an active comparator.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed studies for eligibility. We planned to use dichotomous data to calculate risk ratio and number needed to treat for one additional event, using standard methods. We assessed GRADE (Grading of Recommendations Assessment, Development and Evaluation) and planned to create a 'Summary of findings' table.

MAIN RESULTS

No studies were identified that were eligible for inclusion in this review (very low quality evidence). Several studies tested opioids on adults with cancer-related pain, but none in participants aged from birth to 17 years.We rated the quality of evidence as very low, downgraded due to a lack of available data; no analyses could be undertaken.

AUTHORS' CONCLUSIONS

No conclusions can be drawn about efficacy or harm in the use of opioids to treat cancer-related pain in children and adolescents. As a result, there is no RCT evidence to support or refute the use of opioids to treat cancer-related pain in children and adolescents.

Evidence and consensus recommendations for the pharmacological management of pain in India

Despite enormous progress in the field of pain management over the recent years, pain continues to be a highly prevalent medical condition worldwide. In the developing countries, pain is often an undertreated and neglected aspect of treatment. Awareness issues and several misconceptions associated with the use of analgesics, fear of adverse events - particularly with opioids and surgical methods of analgesia - are major factors contributing to suboptimal treatment of pain. Untreated pain, as a consequence, is associated with disability, loss of income, unemployment and considerable mortality; besides contributing majorly to the economic burden on the society and the health care system in general. Available guidelines suggest that a strategic treatment approach may be helpful for physicians in managing pain in real-world settings. The aim of this manuscript is to propose treatment recommendations for the management of different types of pain, based on the available evidence. Evidence search was performed by using MEDLINE (by PubMed) and Cochrane databases. The types of articles included in this review were based on randomized control studies, case-control or cohort studies, prospective and retrospective studies, systematic reviews, meta-analyses, clinical practice guidelines and evidence-based consensus recommendations. Articles were reviewed by a multidisciplinary expert panel and recommendations were developed. A stepwise treatment algorithm-based approach based on a careful diagnosis and evaluation of the underlying disease, associated comorbidities and type/duration of pain is proposed to assist general practitioners, physicians and pain specialists in clinical decision making.

Opioids for cancer‐related pain in children and adolescents

This is a protocol for a Cochrane Review (Intervention). The objectives are as follows:

To assess the analgesic efficacy, and adverse events, of opioids used to treat cancer pain in children and adolescents between birth and 17 years, in any setting.

Comparison of single-dose nalbuphine versus tramadol for postoperative pain management in children: a randomized, controlled trial

Background

Acute postoperative pain control in children is an essential component of postoperative care, particularly in daycare procedures. Giving patients continuous narcotic analgesics can be risky; however, a single dose may be sufficient.

Methods

This study used a prospective, randomized controlled design and was conducted at the Pediatric Surgery Unit, Services Hospital, Lahore. In total, 150 patients who underwent inguinal herniotomy (age range: 1–12 years) were randomly assigned to two groups: group A (nalbuphine) and group B (tramadol). Patients were given a single dose of either nalbuphine (0.2 mg/kg) or tramadol (2 mg/kg) immediately after surgery and pain was measured at 0, 1, 2, 4, and 8 h.

Results

The demographic characteristics were similar between the two groups. The mean pain score was lower in group A than in group B at 0 and 1 h (P < 0.05). However, at 4 h and 8 h, the pain scores in group A were still lower, but not significantly. In all, 9 patients (12.0%) required rescue analgesics in group A compared to 16 patients (21.3%) in group B (P = 0.051). The mean time for requirement of rescue analgesics was 6.5 ± 0.5 h in group A and 5.3 ± 1.7 h in group B (P = 0.06).

Conclusions

A single dose of nalbuphine is sufficient, and superior to tramadol, for postoperative pain management in children who have undergone daycare procedures.

Assessment and management of pain in pediatric otolaryngology

INTRODUCTION

Pain is a disease by itself and it's a public health concern of major implication in children, not just because of the emotional component of the child and his family, but also due to the potential morbidity and mortality involving it. A proper assessment of pain it's a challenge in the pediatric population, due to their lack of understanding and verbalization of hurt. Additionally, a satisfactory treatment of pediatric pain can be arduous due to a lack of clinical knowledge, insufficient pediatric research, and the fear to opioid side effects and addiction.

OBJECTIVES

The aim of this review is to address the current definitions of pain, its physiological mechanisms and the consequences of its inadequate management, as well as, to guide the clinicians in the assessment and management of pain in the pediatric population at otolaryngology services.

METHODOLOGY

Narrative review by selective MeSH search terms: Children, Pediatrics, Otolaryngology, Pain measurement, Pain Management, Analgesics and Analgesia, from databases: MEDLINE/PubMed, Cochrane, ISI, Current Contents, Scielo and LILACS, between January 2000 and May 2016.

RESULTS

129 articles were reviewed according to the requirements of the objectives. Pain measurement is a challenge in children as there are no physical signs that constitute an absolute or specific indicator of pain, and its diagnosis must rely on physiological, behavioral and self-report methods. Regarding treatment, a suitable alternative are the non-pharmacological cognitive/behavioral therapies helped by pharmacological therapies tailored to the severity of pain and the child's age. We provide evidence-based recommendations on pain treatment, including non-opioid analgesics, opioid analgesics and adjuvant medicines to improve the management of pain in children in otolaryngology services.

CONCLUSIONS

We present a global review about assessment and management of pain in pediatric otolaryngology, which leads to future specific reviews on each topic. Research gaps on pain assessment and pharmacological interventions in neonates, infants and children are very wide and it should be promoted ethical and safe research on pain control in this population.

Efficacy and Safety of Clonidine as an Adjuvant to Bupivacaine for Caudal Analgesia in Paediatric Infra-Umbilical Surgeries

INTRODUCTION

Caudal analgesia, has gained popularity in paediatric intraoperative and postoperative pain management, more so with the use of adjuvants to prolong its duration, each of them having various results. Clonidine, an alpha2-adrenergic agonist is being used for its analgesic effects in various doses with 0.25% Bupivacaine.

AIM

The study was conducted to compare the analgesic efficacy, haemodynamic safety and side effects of 1 μg/kg Clonidine added to 1 ml/kg of 0.125% Bupivacaine solution for caudal analgesia.

MATERIALS AND METHODS

A prospective, randomised, double-blind, controlled study was carried out in 60 children of ASA Physical Status I, aged 1-10 years, scheduled for infraumbilical operations in a tertiary care centre. They were randomly assigned for caudal analgesia, to either group B: 1ml/kg of 0.125% Bupivacaine solution or group BC: 1ml/kg of 0.125% Bupivacaine and preservative free Clonidine 1μ/kg. All were premedicated with midazolam 0.75 mg/kg orally 30 minutes prior to induction of anaesthesia. Heart rate (HR), Mean Arterial blood Pressure (MAP) and oxygen saturation (SpO2) were monitored. General anaesthesia was induced with thiopentone (1.25%) 5mg/kg and inhalation of oxygen, nitrous oxide and sevoflurane. Postoperative pain, sedation and motor block was assessed by the various scores and patients were monitored for adverse effects.

RESULTS

The mean duration of postoperative analgesia was 3 times longer in group BC. Group B received significantly more doses of rescue analgesic than group BC (p-value of 0.004). There was no significant bradycardia, hypotension, sedation or urinary retention in either of the groups. There was no residual motor blockade at 6 hours. Incidence of vomiting was similar in both the groups.

CONCLUSION

Caudal Clonidine in the dose of 1 μg/kg in children is a satisfactory and efficacious adjuvant to caudal Bupivacaine for producing prolonged postoperative analgesia with minimum side effects.

Importance of the use of protocols for the management of analgesia and sedation in pediatric intensive care unit

Summary Introduction: Analgesia and sedation are essential elements in patient care in the intensive care unit (ICU), in order to promote the control of pain, anxiety and agitation, prevent the loss of devices, accidental extubation, and improve the synchrony of the patient with mechanical ventilation. However, excess of these medications leads to rise in morbidity and mortality. The ideal management will depend on the adoption of clinical and pharmacological measures, guided by scales and protocols. Objective: Literature review on the main aspects of analgesia and sedation, abstinence syndrome, and delirium in the pediatric intensive care unit, in order to show the importance of the use of protocols on the management of critically ill patients. Method: Articles published in the past 16 years on PubMed, Lilacs, and the Cochrane Library, with the terms analgesia, sedation, abstinence syndrome, mild sedation, daily interruption, and intensive care unit. Results: Seventy-six articles considered relevant were selected to describe the importance of using a protocol of sedation and analgesia. They recommended mild sedation and the use of assessment scales, daily interruptions, and spontaneous breathing test. These measures shorten the time of mechanical ventilation, as well as length of hospital stay, and help to control abstinence and delirium, without increasing the risk of morbidity and morbidity. Conclusion: Despite the lack of controlled and randomized clinical trials in the pediatric setting, the use of protocols, optimizing mild sedation, leads to decreased morbidity.

Gynecologic Surgery in the Pediatric and Adolescent Populations: Review of Perioperative and Operative Considerations

Gynecologists are often consulted on pediatric and adolescent patients who may require a surgical treatment for a gynecologic diagnosis. This patient population can present an interesting challenge for a nonpediatrician. It is helpful to review the differences in anatomy, alterations in drug dosing, surgical limitations, and counseling and consent requirements in this patient population before proceeding with a surgical treatment. This is a review of preoperative, intraoperative, and postoperative considerations for gynecologic surgery in the pediatric and adolescent patient population.

Differences in Pediatric Pain Management by Unit Types

PURPOSE

The purpose of this study was to determine differences in pediatric pain management by unit type in hospitals across the United States. The aims were to (a) compare unit-type rates of assessment, intervention, and reassessment (AIR), and (b) describe differences in assessment tools and intervention use by unit type.

DESIGN

The study used a cross-sectional design. A secondary analysis of 2013 data from the National Database of Nursing Quality Indicators (NDNQI®) pain AIR cycle indicator was conducted. The sample included 984 pediatric units in 390 hospitals.

METHODS

Data were gathered via retrospective chart review on the pain assessment tool used, presence of pain, interventions, and reassessment. Descriptive statistics and the Kruskal-Wallis one-way analysis of variance test were conducted. Post-hoc analyses included the Wilcoxon-rank sum test with Bonferroni correction.

FINDINGS

Across all units the mean unit-level percentage of patients assessed for pain was 99.6%. Of those patients assessed, surgical units had the highest average unit-level percentage of patients with pain, while Level 4 neonatal intensive care units (NICUs) had the lowest. The most commonly used assessment tool among all units was the Faces, Legs, Activity, Crying, and Consolability (FLACC) Scale. The Neonatal Pain, Agitation, and Sedation Scale (N-PASS) and Neonatal Infant Pain Scale (NIPS) specifically developed for infants were more commonly used across NICU unit types. The mean unit-level percentage of patients with pain receiving an intervention was 89.4%, and reassessment was 83.6%. Overall, pharmacologic methods were the most common pain intervention, while music was the least common.

CONCLUSIONS

Assessments were performed routinely, yet interventions and reassessments were not. Pain AIR cycle completion varied by unit type. Pain was also widely present across many unit types, and pharmacologic methods were most frequently used.

CLINICAL RELEVANCE

Frontline nurses are instrumental to pain management and have the ability to improve patient care and outcomes by effectively managing pain. A comprehensive understanding of it provides valuable insight into improving our practice to produce the best outcomes for pediatric patients.

Management of acute pediatric pain in the emergency department

PURPOSE OF REVIEW

This article provides a summary of recommendations for the multimodal and multidisciplinary approach to acute pediatric pain management and highlights recent research on this topic.

RECENT FINDINGS

Recent literature has focused on updating recommendations for the use of various analgesics in the pediatric population. While codeine is no longer recommended due to increasing evidence of adverse effects, the more liberal use of intranasal fentanyl is now encouraged because of the ease of administration and rapid delivery. The evidence base for the use of ultrasound-guided regional nerve blocks by qualified providers in the acute pediatric pain setting continues to grow.

SUMMARY

The pediatric emergency medicine provider should be able to assess pain and develop individualized pain plans by utilizing a range of nonpharmacologic and pharmacologic strategies. Knowledge of the most recent literature and changes in recommendations for various pain medications is essential.

Effect of Preoperative Oral Amantadine on Acute and Chronic Postoperative Pain After Mandibular Fracture Surgery

BACKGROUND

Postoperative pain from open reduction and internal fixation of mandibular fracture is a serious issue. Amantadine is an N-methyl-D-aspartic acid or N-methyl-D-aspartate (NMDA) receptor antagonist that can be effective against postoperative pain.

OBJECTIVES

The present study examined the efficacy of amantadine in alleviating the postoperative pain of mandibular fracture surgery.

PATIENTS AND METHODS

In this double-blind study, 60 patients (ASA physical status I-II) were randomly divided into two groups. The mean ages of the participants were 31.2 ± 13.1 years and 32.3 ± 18.1 years, respectively. The male/female ratios were 24/6 and 26/4, respectively, in the case and control groups. Randomization was based on a single sequence of random assignments using computer-generated random numbers. Group I was given oral amantadine 100 mg 1 hour before surgery, and group II received a placebo at the identical time. Through PCA pumps, patients received a bolus dose of morphine at 0.02 mg/kg body weight, to a maximum of 1.5 mg. PCA pumps were set at 6 minutes lockout intervals and a maximum dose of 0.15 mg/kg/h, to a maximum of 10 mg/h. Pain was assessed using a visual analog scale (VAS) at 0, 2, 4, 6, 12, and 24 hours and 1, 2, 3, 4, 5, and 6 months after surgery. The amounts of analgesic consumed were recorded for the first 24 hours, and for 6 months after surgery.

RESULTS

There were no significant differences between the two groups with respect to age, gender, nausea and vomiting, sleep quality, blood pressure, and heart rate. No significant differences were observed between the two groups in pain scores (P = 0.39) and analgesic consumption (P = 0.78).

CONCLUSIONS

The results suggest that a single dose of preoperative oral amantadine did not reduce acute or chronic postoperative pain, nor analgesic consumption.

Validation of a New "Objective Pain Score" Vs. "Numeric Rating Scale" For the Evaluation of Acute Pain: A Comparative Study

Background:

Pain scores are used for acute pain management. The assessment of pain by the patient as well as the caregiver can be influenced by a variety of factors. The numeric rating scale (NRS) is widely used due to its easy application. The NRS requires abstract thinking by a patient to assign a score to correctly reflect analgesic needs, and its interpretation is subject to bias.

Objectives:

The study was done to validate a 4-point objective pain score (OPS) for the evaluation of acute postoperative pain and its comparison with the NRS.

Patient and Methods:

A total of 1021 paired readings of the OPS and NRS of 93 patients who underwent laparotomy and used patient-controlled analgesia were evaluated. Acute pain service (APS) personnel recorded the OPS and NRS. Rescue analgesia was divided into two incremental levels (level 1-paracetamol 1 g for NRS 2 - 5 and OPS 3, Level 2-Fentanyl 25 mcg for NRS ≥ 6 and OPS 1 and 2). In cases of disagreement between the two scores, an independent consultant decided the rescue analgesia.

Results:

The NRS and OPS agreed across the range of pain. There were 25 disagreements in 8 patients. On 24 occasions, rescue analgesia was increased from level 1 to 2, and one occasion it was decreased from level 2 to 1. On all 25 occasions, the decision to supplement analgesia went in favor of the OPS over the NRS. Besides these 25 disagreements, there were 17 occasions in which observer bias was possible for level 2 rescue analgesia.

Conclusions:

The OPS is a good stand-alone pain score and is better than the NRS for defining mild and moderate pain. It may even be used to supplement NRS when it is indicative of mild or moderate pain.

A mixed-method study of pain management practice in a UK children's hospital: identification of barriers and developing strategies to maintain effective in-patient paediatric pain management

AIM

To assess Acute Pain Service and paediatric pain management efficacy in a UK specialist paediatric hospital to inform wider recommendations for future sustainability.

BACKGROUND

UK paediatric acute pain services vary. Although comprehensive pain management guidelines exist, consensus on the best model of care is lacking. Worldwide, medical and pharmacological advances and rapid patient turnover have increased the challenges of managing hospitalized children's pain. Simultaneously nurses, who deliver the bulk of pain management, have experienced reduction in skill mix and training opportunities. Specialist Acute Pain Services have evolved to meet these demands; their overall efficacy is unknown.

DESIGN

This mixed-methods study explores pain management practice at a UK paediatric hospital to assess current efficacy and future sustainability.

METHOD

A 2013 case note review of all Acute Pain Services referrals over 14 days were compared with an interval sample of concurrent non-referred inpatient children; seven semi-structured interviews were conducted with a range of clinical staff.

RESULTS

Twenty-two referrals of 15 children were made; 15 comparison children were identified. All 30 children (100%) were appropriately referred/non-referred. Acute Pain Services cases experienced higher pain levels, were more likely to have long term conditions, longer hospital stay and repeat admissions. Three key themes emerged through interview analysis: 'addressing pain', 'changing contexts' 'pain as an "expert" skill'. Increased specialization, reduced clarity between different pain modalities and decreased training opportunities had resulted in potentially unsustainable APS dependence.

Does Montelukast Have an Effect on Post-tonsillectomy Pain Control in Children? A Randomized Trial Study

OBJECTIVE

Tonsillectomy surgery is associated with severe postoperative pain that usually requires analgesics including opioids. Pain control is still a big problem after tonsillectomy surgery. We aimed to evaluate the efficacy of preemptive analgesia using montelukast for pediatric post-tonsillectomy pain management. This is the first-time use of montelukast in post-tonsillectomy pain.

STUDY DESIGN

Double-blind, controlled-randomized study.

SETTINGS

University teaching and research hospital.

SUBJECTS AND METHODS

A total of 60 children, aged 5 to 15 years, American Society of Anesthesiologist class I-II, scheduled for elective tonsillectomy were enrolled in this clinical trial study. The patients were randomized into 2 groups: the montelukast group (group M, n = 30) and control group (group C, n = 30). Group M recieved an oral montelukast tablet and group C recieved placebo at 2400pm on the morning before surgery. Post-tonsillectomy pain was evaluated with the Wong-Baker FACES Scale during the 24 hours after surgery. Patients' intraoperative hemodynamic parameters and intraoperative and postoperative complications were recorded.

RESULTS

There were statistically significant differences between group C and group M for Wong-Baker FACES pain rating scale scores (P < .05). In the 24 hours after surgery, the total number of patients using rescue analgesics was higher in group C than in group M, and the difference was statistically significant (P < .001). There was no significant difference in demographic parameters (P > .05). There were no significant differences in postoperative nausea and vomiting, otalgia, trismus, fever, or halitosis between the groups (P > .05).

CONCLUSION

Preemptive montelukast can be used safely to reduce the serious pain caused by tonsillectomy in children.

Pediatric Pain Management in the Emergency Department: The Triage Nurses' Perspective

Understanding triage nurses' perspectives of pain management is essential for timely pain care for children in the emergency department. Objectives of this study were to describe the triage pain treatment protocols used, knowledge of pain management modalities, and barriers and attitudes towards implementation of pain treatment protocols.

METHODS

A paper-based survey was administered to all triage nurses at three Canadian pediatric emergency departments, between December 2011 and January 2012.

RESULTS

The response rate was 86% (n=126/147). The mean respondent age was 40 years (standard deviation [SD] 9.3) with 8.6 years (SD 7.7) of triage experience. General triage emergency department (GTED) nurses rated adequacy of triage pain treatment lower than pediatric-only triage emergency department (PTED) nurses (P < .001). GTED nurses reported a longer acceptable delay between triage time and administration of analgesia than PTED nurses (P < .002). Most nurses rated more comfort with a protocol involving administration of acetaminophen (97 mm, interquartile range [IQR] 92, 99) or ibuprofen (97 mm, IQR 93, 100) than for oral morphine (67 mm, IQR 35, 94) or oxycodone (57 mm, IQR 15, 81). The top three reported barriers to triage-initiated pain protocols were monitoring capability, time, and access to medications. Willingness to implement a triage-initiated pain protocol was rated as 81 mm (IQR 71, 96).

DISCUSSION

Triage nurses are willing to implement pain protocols for children in the emergency department, but differences in comfort and experience exist between PTED and GTED nurses. Provision of triage initiated pain protocols and associated education may empower nurses to improve care for children in pain in the emergency department.

Intranasal fentanyl for the management of acute pain in children

BACKGROUND

Pain is the most common symptom in the emergency setting; however, timely management of acute pain in children continues to be suboptimal. Intranasal drug delivery has emerged as an alternative method of achieving quicker drug delivery without adding to the distress of a child by inserting an intravenous cannula.

OBJECTIVES

We identified and evaluated all randomized controlled trials (RCTs) and quasi-randomized trials to assess the effects of intranasal fentanyl (INF) versus alternative analgesic interventions in children with acute pain, with respect to reduction in pain score, occurrence of adverse events, patient tolerability, use of "rescue analgesia," patient/parental satisfaction and patient mortality.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (2014, Issue 1); MEDLINE (Ovid SP, from 1995 to January 2014); EMBASE (Ovid SP, from 1995 to January 2014); the Cumulative Index to Nursing and Allied Health Literature (CINAHL) (EBSCO Host, from 1995 to January 2014); the Latin American and Caribbean Health Science Information Database (LILACS) (BIREME, from 1995 to January 2014); Commonwealth Agricultural Bureaux (CAB) Abstracts (from 1995 to January 2014); the Institute for Scientific Information (ISI) Web of Science (from 1995 to January 2014); BIOSIS Previews (from 1995 to January 2014); the China National Knowledge Infrastructure (CNKI) (from 1995 to January 2014); International Standard Randomized Controlled Trial Number (ISRCTN) (from 1995 to January 2014); ClinicalTrials.gov (from 1995 to January 2014); and the International Clinical Trials Registry Platform (ICTRP) (to January 2014).

SELECTION CRITERIA

We included RCTs comparing INF versus any other pharmacological/non-pharmacological intervention for the treatment of children in acute pain (aged < 18 years).

DATA COLLECTION AND ANALYSIS

Two independent review authors assessed each title and abstract for relevance. Full copies of all studies that met the inclusion criteria were retrieved for further assessment. Mean difference (MD), odds ratio (OR) and 95% confidence interval (CI) were used to measure effect sizes. Two review authors independently assessed and rated the methodological quality of each trial using the tool of The Cochrane Collaboration to assess risk of bias, as per Chapter 8 of the Cochrane Handbook for Systematic Reviews of Interventions.

MAIN RESULTS

Three studies (313 participants) met the inclusion criteria. One study compared INF versus intramuscular morphine (IMM); another study compared INF versus intravenous morphine (IVM); and another study compared standard concentration INF (SINF) versus high concentration INF (HINF). All three studies reported a reduction in pain score following INF administration. INF produced a greater reduction in pain score at 10 minutes post administration when compared with IMM (INF group pain score: 1/5 vs IMM group pain score: 2/5; P value 0.014). No other statistically significant differences in pain scores were reported at any other time point. When INF was compared with IVM and HINF, no statistically significant differences in pain scores were noted between treatment arms, before analgesia or at 5, 10, 20 and 30 minutes post analgesia. Specifically, when INF was compared with IVM, both agents were seen to produce a statistically significant reduction in pain score up to 20 minutes post analgesia. No further reduction in pain score was noted after this time. When SINF was compared with HINF, a statistically and clinically significant reduction in pain scores over study time was observed (median decrease for both groups 40 mm, P value 0.000). No adverse events (e.g. opiate toxicity, death) were reported in any study following INF administration. One study described better patient tolerance to INF compared with IMM, which achieved statistical significance. The other studies described reports of a "bad taste" and vomiting with INF. Overall the risk of bias in all studies was considered low.

AUTHORS' CONCLUSIONS

INF may be an effective analgesic for the treatment of patients with acute moderate to severe pain, and its administration appears to cause minimal distress to children. However, this review of published studies does not allow any definitive conclusions regarding whether INF is superior, non-inferior or equivalent to intramuscular or intravenous morphine. Limitations of this review include the following: few eligible studies for inclusion (three); no study examined the use of INF in children younger than three years of age; no study included children with pain from a "medical" cause (e.g. abdominal pain seen in appendicitis); and all eligible studies were conducted in Australia. Consequently, the findings may not be generalizable to other healthcare settings, to children younger than three years of age and to those with pain from a "medical" cause.

Cross-sectional study on differences in pain perception and behavioral distress during venipuncture between italian and chinese children

Venipuncture is perhaps the scariest aspect of hospitalization for children as it causes pain and high levels of behavioral distress. Pain is a complex experience which is also influenced by social factors such as cultural attitudes, beliefs and traditions. Studies focusing on ethnic/cultural differences in pain perception and behavioral distress show controversial results, in particular with regards to children. The aim of this paper is to evaluate differences in pain perception and behavioral manifestations between Italian and Chinese children undergoing a venipuncture, through a cross-sectional study. Behavioral distress and self-reported pain were measured in Chinese and Italian outpatient children during a standardized blood-drawing procedure, using the Observational Scale of Behavioral Distress (OSBD) and pain scales. We observed 332 children: 93 Chinese and 239 Italian. Chinese children scored higher than Italians on pain scales - mean scores 5.3 (95%CI 4.78-5.81) vs. 3.2 (95%CI 2.86-3.53) - but lower mean OSBD scores - mean 4.1 (95%CI 3.04-5.15) vs. 8.1 (95%CI 7.06-9.14). Our data suggest that Chinese children experience higher levels of pain than their Italian peers, although they show more self-control in their behavioral reaction to pain when experiencing venipuncture.

A randomized-controlled, double-blind comparison of the postoperative analgesic efficacy of caudal bupivacaine and levobupivacaine in minor pediatric surgery

BACKGROUND

We compared the postoperative analgesic efficacy of caudal levobupivacaine with bupivacaine in pediatric subumbilical surgery.

METHODS

Sixty American Society of Anesthesiologists I-II patients scheduled for elective minor surgery (1.5-7 years old) were randomly divided into three groups to receive caudal injections of study drugs at 0.5 ml/kg. All patients received 0.1 mg/kg oral midazolam 30 min before surgery. Group B received 0.125% bupivacaine, group L received 0.125% levobupivacaine, and group LF received 0.125% levobupivacaine + 0.5 µg/kg fentanyl. Blood pressure, heart rate and sedation (using a four-scale sedation score) were monitored perioperatively. During the postoperative period, an anesthesiologist blinded to the study groups used the Children's and Infants' Postoperative Pain Scale to monitor patients' pain and degree of sedation. The time before the first rescue analgesic was recorded as well as any side effects over the next 24 h.

RESULTS

The four-scale sedation and postoperative pain scale scores in all groups were identical. Blood pressure and heart rate measured at 15 min postoperatively were lower, and time to first rescue analgesic was longer, in Group LF compared to the others.

CONCLUSIONS

Caudal 0.5 ml/kg of 0.125% bupivacaine and levobupivacaine are equally effective for postoperative analgesia after subumbilical surgeries in pediatric patients. Addition of fentanyl may lower the required amount of local anesthetics.

Procedure-related pain in children in a Danish University Hospital. A qualitative study

BACKGROUND

Children being cared for in hospital often undergo multiple diagnostic and therapeutic procedures. Procedure-related pain, anxiety, and distress may consequently place a significant burden on the children. Although standards for pain management exist, procedure-related pain remains inadequately treated.

OBJECTIVE

To determine the frequency and pain intensity of procedures in children, as well as the associated pharmacologic interventions to manage the pain in a Danish University Hospital.

METHODS

During a 3-month period in 2013, a structured questionnaire was used to prospectively record all procedures performed on children from 1 month to 18 years of age. Directly after the procedure, the pharmacologic pain management interventions and the pain intensity were recorded. Pain intensity was measured by using age-appropriate pain scales. Positioning and prior experience with the procedure were recorded.

RESULTS

Of the 316 children included in the study, 72% experienced none to mild pain, 8.5% experienced moderate to severe pain during the procedures, and 65% had a pharmacologic pain management intervention. Significant higher median VAS score was found during venipuncture in the children sitting on the lap of their parents compared with other positions (P < 0.05), and significant lower median VAS score was found in children who had experienced the procedure before (P < 0.05).

CONCLUSION

Most children experienced mild pain during procedures. The children's positioning during the procedure and prior experience with the procedure seem to influence their experience of procedural pain and it is therefore essential that therapy is tailored for each child and includes a multimodal approach.

Postoperative pain management in children and infants: an update

Many factors contribute to suboptimal pain management in children. Current evidence suggests that severe pain in children has significant long-lasting effects, even more so than in adults. In particular, recent evidence suggests a lack of optimal postoperative pain management in children, especially following ambulatory surgery. This review provides simple guidelines for the management of postoperative pain in children. It discusses the long-term effects of severe pain and how to evaluate pain in both healthy and neurologically impaired children, including neonates. Currently available treatment options are discussed with reference to the efficacy and side effects of opioid and non-opioid and regional analgesic techniques. The impact of preoperative anxiety on postoperative pain, and the efficacy of some nonpharmacological techniques such as hypnosis or distraction, are also discussed. Finally, basic organizational strategies are described, aiming to promote safer and more efficient postoperative pain management in children.

Critical incidents related to opioid infusions in children: a five-year review and analysis

PURPOSE

Opioids have a narrow therapeutic index and have the potential to cause significant harm. Developmental and pharmacogenetic factors put children, and especially infants, at increased risk of complications. We performed a retrospective root cause analysis to identify the factors associated with critical incidents in children receiving opioid infusions in a tertiary care children's hospital.

METHODS

Following institutional ethical approval, we identified potential critical incidents during 2004 to 2009 from patient safety and pharmacy data. Patients' medical charts were reviewed and a timeline of events that occurred before, during, and following each incident was generated. A safety assessment code score was assigned to each incident according to its severity and probability of recurrence, and incidents with a score ≥ 8 were selected for root cause analysis. Root causes were identified and classified, formal causal statements were written, and action plans were recommended.

RESULTS

One hundred and sixty-six medical charts were reviewed, and 58 of these included one (45/58) or more (13/58) relevant critical incidents. The resulting harms were of minor to moderate severity. Fourteen incidents were submitted for detailed analysis, from which 31 root causes were identified. The most frequent and significant root causes involved defects in pre-printed order sheets, lack of a nursing guidelines for infusions (rate, adjustment, weaning), and inadequate guidelines for monitoring and recording pain, vital signs, and arousal scores.

DISCUSSION

The root causes of a range of critical incidents have been identified, and these have been used to generate recommendations for improving both patient safety and quality of analgesia for children receiving opioid infusions for acute pain management.

Degree of knowledge of health care professionals about pain management and use of opioids in pediatrics

OBJECTIVE

To evaluate the degree of knowledge about pain management and opioids use by professionals working at three pediatric units.

DESIGN

This is a cross-sectional study.

SETTING

This study was carried out at three pediatric units (pediatrics, intensive care unit, and oncology) of Hospital de Clínicas de Porto Alegre, which is a university hospital located in southern Brazil.

SUBJECT

The subjects of this study include physicians, pharmacists, physiotherapists, nurses, nursing technicians, and nursing assistants.

METHODS

Cross-sectional study carried out in a university hospital in southern Brazil. A self-applicable semi-structured questionnaire was handed out to 182 professionals from December 2011 to March 2012.

RESULTS

The response rate was 67% (122); the average percentage of correct answers was 63.2 ± 1.4%. The most frequent errors were: an opioid must not be used if the cause of pain is unknown (47%; 54/115); patients often develop respiratory depression (42.3%; 22/52); and confusion about symptoms of withdrawal, tolerance, and dependency syndromes (81.9%; 95/116). Only 8.8% (10/114) reported the use of pain scales to identify pain in children. The most often cited hindrance to control pain was the difficulty to measure and spot pain in pediatric patients. Finally, 50.8% (62/122) of them did not have any previous training in pain management.

CONCLUSIONS

Problems in the processes of pain identification, measurement, and treatment have been found. Results suggest that there is a need for both an investment in continuing education of professionals and the development of protocols to optimize the analgesic therapy, thus preventing increased child suffering.

A comparison of spinal anesthesia characteristics following intrathecal bupivacaine or levobupivacaine in lumbar disc surgery

PURPOSE

While bupivacaine is the most frequently used local anesthetic for spinal anesthesia, use of levobupivacaine in clinical practice has advanced recently. The aim of our study was to compare the clinical and anesthetic effects of isobaric bupivacaine and isobaric levobupivacaine when administered intrathecally in patients undergoing lumbar disc surgery.

METHODS

ASA I-III, 60 patients were enrolled in this study. Only patients with unilateral single-level (L4-5) lumbar disc hernia were selected and operated in each group and all were operated by the same surgeon. Patients were randomized into two groups, as group B (n = 30): 15 mg 0.5% isobaric bupivacaine, or group L (n = 30): 15 mg 0.5% isobaric levobupivacaine received intrathecally. The level of sensory block dermatome, degree of motor block, intraoperative sensory and motor block characteristics, and postoperative recovery times of spinal anesthesia were evaluated. The satisfaction scores of the surgeon and patients, intraoperative hemodynamic changes, intraoperative and postoperative complications were recorded.

RESULTS

The maximum level of sensory blockade was significantly higher in the levobupivacaine group (group L 7 ± 1.63, group B 8.6 ± 1.76 thoracic dermatome, p < 0.05). There was no significant difference in the onset time of sensory (group L 6 ± 3 min, group B 9 ± 4 min) and motor (in group L 7 ± 3 min, in group B 10 ± 4 min) blockade (p > 0.05). There was no significant difference between the groups regarding duration of operation (group L 49 ± 7.3 min, group B 52 ± 8.1, p > 0.05). Recovery times of sensory (175 ± 57 min) and motor (216 ± 59 min) blockade were significantly shorter in the levobupivacaine group (p < 0.05). Mobilization was also earlier in the levobupivacaine group (339 ± 90 min, p < 0.05). Patients' satisfaction and intraoperative, postoperative complications were similar between the two groups.

CONCLUSIONS

Our results showed that block recovery time was shorter in the levobupivacaine group, this may be a disadvantage for longer operative procedures. But with proper patient selection this can be eliminated. Recovery time was shorter in levobupivacaine group. Therefore, postoperative neurological examination can be done earlier. In addition, early mobilization can be an advantage for postoperative recovery.

Administration of paracetamol versus dipyrone by intravenous patient-controlled analgesia for postoperative pain relief in children after tonsillectomy

BACKGROUND AND OBJECTIVE

We compared the efficacy of intravenous (IV) paracetamol versus dipyrone via patient-controlled analgesia (PCA) for postoperative pain relief in children.

METHODS

The study was composed of 120 children who had undergone elective tonsillectomy after receiving general anesthesia. Patients were divided into 3 groups according to the dosage of postoperative intravenous-patient-controlled analgesia: paracetamol, dipyrone, or placebo. Pain was evaluated using a 0- to 100-mm visual analog scale and 1- to 4-pain relief score at 30 min, 1, 2, 4, 6, 12, and 24h postoperatively. Pethidine (0.25 mg kg(-1)) was administered intravenously to patients requiring rescue analgesia. Pethidine requirements were recorded during the first 24h postoperatively, and treatment related adverse effects were noted.

RESULTS

Postoperative visual analog scale scores were significantly lower with paracetamol group compared with placebo group at 6h (p<0.05), dipyrone group compared with placebo group at 30 min and 6h (p<0.05). No significant differences regarding visual analog scale values at 1, 2, 4, 12, and 24h were found. No significant differences were found between groups with respect to pain relief score (p>0.05). Postoperative pethidine requirements were significantly lower with paracetamol and dipyrone groups compared with placebo group (62.5%, 68.4% vs 90%, p<0.05). No significant differences were found between groups with respect to nausea, vomiting and the any other adverse effects of the drugs (p>0.05).

CONCLUSIONS

Paracetamol and dipyrone have well tolerability profile and effective analgesic properties when administered IV-PCA for postoperative analgesia in children after tonsillectomy.

The efficacy of intravenous paracetamol versus dipyrone for postoperative analgesia after day-case lower abdominal surgery in children with spinal anesthesia: a prospective randomized double-blind placebo-controlled study

BACKGROUND

A multimodal and preventative approach to providing postoperative analgesia is becoming increasingly popular for children and adults, with the aim of reducing reliance on opioids. We conducted a prospective, randomized double-blind study to compare the analgesic efficacy of intravenous paracetamol and dipyrone in the early postoperative period in school-age children undergoing lower abdominal surgery with spinal anesthesia.

METHODS

Sixty children scheduled for elective lower abdominal surgery under spinal anesthesia were randomized to receive either intravenous paracetamol 15 mg/kg, dipyrone 15 mg/kg or isotonic saline. The primary outcome measure was pain at rest, assessed by means of a visual analog scale 15 min, 30 min, 1 h, 2 h, 4 h and 6 h after surgery. If needed, pethidine 0.25 mg/kg was used as the rescue analgesic. Time to first administration of rescue analgesic, cumulative pethidine requirements, adverse effects and complications were also recorded.

RESULTS

There were no significant differences in age, sex, weight, height or duration of surgery between the groups. Pain scores were significantly lower in the paracetamol group at 1 h (P = 0.030) and dipyrone group at 2 h (P = 0.010) when compared with placebo. The proportion of patients requiring rescue analgesia was significantly lower in the paracetamol and dipyrone groups than the placebo group (vs. paracetamol P = 0.037; vs. dipyrone P = 0.020). Time to first analgesic requirement appeared shorter in the placebo group but this difference was not statistically significant, nor were there significant differences in pethidine requirements, adverse effects or complications.

CONCLUSION

After lower abdominal surgery conducted under spinal anesthesia in children, intravenous paracetamol appears to have similar analgesic properties to intravenous dipyrone, suggesting that it can be used as an alternative in the early postoperative period.

TRIAL REGISTRATION

Clinical Trials.gov. Identifier: NCT01858402.

Intravenous paracetamol and dipyrone for postoperative analgesia after day-case tonsillectomy in children: a prospective, randomized, double blind, placebo controlled study

Tonsillectomy is associated with severe postoperative pain for which, several drugs are employed for management.

Objective

In this double-blind, placebo-controlled study we aimed to evaluate the efficacy of intravenous paracetamol and dipyrone when used for post-tonsillectomy analgesia in children.

Method

120 children aged 3-6 yr, undergoing tonsillectomy with or without adenoidectomy and/ or ventilation tube insertion were randomized to receive intraoperative infusions of paracetamol (15 mg/kg), dipyrone (15 mg/kg) or placebo (0.9% NaCl). Evaluation was carried out at 0.25, 0.50, 1, 2, 4, 6h postoperatively. Pethidine 0.25 mg/kg was utilized as rescue analgesic. Cumulative pethidine requirement was the primary outcome. Pain intensity measurement, pain relief, sedation level, nausea and vomiting, postoperative bleeding and any other adverse effects were noted.

Results

No significant difference was found in pethidine requirement between paracetamol and dipyrone groups. Cumulative pethidine requirement was significantly less in paracetamol and dipyrone groups vs. placebo. No significant difference was observed between groups in postoperative pain intensity scores throughout the study.

Conclusion

Intravenous paracetamol is found to have a similar analgesic efficacy as intravenous dipyrone and they both help to reduce the opioid requirement for postoperative analgesia in pediatric day-case tonsillectomy.

[Opioid-sparing effect of ketamine during tonsillectomy in children]

INTRODUCTION

In the adult population, Ketamine is currently used as an antihyperalgesic and opioid-sparing agent during the perioperative period. However, for doses of ketamine up to 0.5mg/kg, these effects have not been found in pediatric population. The aim of the present study was to evaluate the efficacy of a preoperative bolus of 1mg/kg of ketamine on postoperative pain intensity and morphine consumption in children undergoing tonsillectomy.

METHODS

We have undertaken a retrospective comparison of 60 consecutive children operated for tonsillectomy in our institution before (first 30 patients) and after (last 30 patients) the introduction of a preoperative bolus of 1mg/kg of ketamine. Data collected were: age, ASA score, dose of intraoperative sufentanil, OPS score during PACU stay and the first postoperative day, morphine consumption during PACU stay and the first postoperative day, psychodysleptic manifestations, pain at first solid oral intake and postoperative respiratory complications or haemorrhage.

RESULTS

No difference was found between the two groups in terms of demographic characteristics. Perioperative doses of sufentanil, postoperative opioid consumption or pain score in PACU or during 24hours were similar between the two groups. The two groups did not differ in terms of pain at first oral intake, or other adverse effects.

CONCLUSION

These results suggest that 1mg/kg of ketamine administered right after anaesthesia induction in children undergoing tonsillectomy did not result in an opioid sparing effect.

Managing procedural pain in pediatric patients

PURPOSE OF REVIEW

To review recent research on the management of acute procedural pain in pediatric patients.

RECENT FINDINGS

Pediatric patients experience pain with the same or greater intensity as their adult counterparts. Recent studies have acknowledged the importance of people's beliefs about pain and of a multidisciplinary approach to the assessment and treatment of acute pain.

SUMMARY

Pediatric patients experience pain from procedures related to their care. Pediatricians should educate themselves regarding the accurate assessment of pain, and the pharmacologic and nonpharmacologic methods of managing acute pain.

Pain management in dermatologic procedures: before and after

BACKGROUND

Periprocedural analgesic therapy is an often overlooked, but critical component of ensuring adequate surgical patient care and overall satisfaction with surgical outcomes. Adequate pain management requires thorough assessment of pain and complete knowledge and understanding of the various therapeutic agents available.

OBJECTIVES

To further the knowledge and understanding of current strategies in pain management.

METHODS

A literature review was conducted through PubMed to define current pain assessment and management strategies.

RESULTS AND CONCLUSIONS

Appropriate pain assessment leads to the selection of optimal pharmacologic options for pain control in the acute postoperative setting.

Addition of clonidine in caudal anesthesia in children increases duration of post-operative analgesia

Background:

Pain in infancy is a developmental process. Due to the underdeveloped pain pathways in the spinal cord, the threshold of stimulation and sensation of pain is low at birth and has potential impacts on increasing the central effects of pain. Primary trauma during infancy can cause long term changes in structure and function of pain pathways that continue until adulthood. Lack of pain management in children can result in morbidity and mortality.

Objectives:

In this study we examined the duration of post-operative analgesia in children when clonidine is added to bupivacaine in caudal anesthesia.

Materials and Methods:

In this clinical trial, 40 children aged 1-8 years who were candidates for elective inguinal hernia repair were studied. Induction and maintenance of anesthesia were achieved using sodium thiopenthal, halothane and nitrous oxide. Children were randomly divided into 2 groups in a double-blind fashion, and were given caudal anesthesia with 0.125% bupivacaine (1ml/kg) alone or b bupivacaine plus 2 μg/kg clonidine. Blood pressure and heart rate were recorded peri-operatively. Analgesia was evaluated using objective pain scale (OPS) and sedation was assessed using Ramsay sedation scale (RSS). Acetaminophen was administered rectally for cases with OPS score greater than five.

Results:

Duration of analgesia was found to be significantly longer in the group given bupivacaine plus clonidine (mean 417.50 min vs. 162.00 min).

Peri-operative hypotension or bradycardia, post-operative respiratory depression, nausea or vomiting were not recorded in any patient.

Conclusions:

We concluded that addition of clonidine to bupivacaine prolongs the duration of post-operative analgesia without any respiratory or hemodynamic side-effects.

[Perioperative pain management in major reconstructive surgery in pediatric urology: a plea for continuous epidural anesthesia]

Regional analgesia is firmly established in modern pediatric anesthetic practice and its popularity continues to grow. In our department continuous epidural anesthesia (CEA) is a frequently used technique of pain management following major reconstructive procedures of the lower urinary tract. The aim of this study was to investigate the efficacy, safety, and potential benefits of CEA over standard analgesics.We retrospectively reviewed the records of 21 infants who underwent single-stage bladder exstrophy repair in our department. In 15 children an epidural catheter was placed preoperatively for CEA; 6 patients treated without CEA served as controls. Total doses of narcotics and analgesics, length of intensive care unit (ICU) stay and ventilatory assistance, time to first bowel activity, anticholinergic requirements, and CEA-related side effects were documented and compared for both groups.Children given epidural anesthesia required six- to tenfold lower doses of morphine intra- and postoperatively compared to those without CEA; ventilatory support upon completion of surgery was remarkably shorter (59 versus 210 min) in the CEA group as well as ICU stay (1.1 versus 1.8 days). The total consumption of anticholinergics was twice as high as in patients without CEA. There were no relevant CEA-related complications.Being a retrospective audit of practice in our institution with a small number of patients, our results are in line with previously published data on CEA in pediatric patients. CEA has been shown to significantly reduce the need for anesthetics and morphine and allows early extubation with all subsequent advantages for a speedy recovery post surgery. Thus, the technique is to be recommended as a safe and efficacious method for pain management following major reconstructive surgery in pediatric urology. Importantly, this type of anesthesia should be performed only by experienced anesthesiologists in institutions where appropriate equipment, staff, and monitoring are available.