Postoperative behavioral changes in children after adenoidectomy

A comprehensive examination of the immediate recovery of children following tonsillectomy and adenoidectomy

OBJECTIVES

Using multiple well-validated measures and a large sample size, the goal of this paper was to describe the immediate clinical and behavioral recovery of children following tonsillectomy with or without an adenoidectomy (T&A) during the first two weeks following surgery.

STUDY DESIGN

Observational, longitudinal study.

SETTING

Four major pediatric hospitals in the U.S. consisting of Children's Hospital of Orange County, Children's Hospital of Los Angeles, Lucile Packard Children's Hospital, and Children's Hospital Colorado.

SUBJECTS

and Methods: Participants included 827 patients between 2 and 15 years of age who underwent tonsillectomy with or without adenoidectomy surgery. Baseline and demographic information were gathered prior to surgery, and measures of clinical, behavioral, and physical recovery were recorded immediately following and up through two weeks after surgery.

RESULTS

Pain following T&A was clinically significant through the first post-operative week and nearly resolved by the end of the second week. Negative behavioral changes were highly prevalent after surgery (75.6% of children at Day 0) through the first week (63.9% at Week 1), and over 20% of children continued to evidence new onset negative behavioral changes at two weeks post-operatively. Children were rated as experiencing significant functional impairment in the immediate three days following surgery and most children returned to baseline functioning by the end of the second week.

CONCLUSIONS

Results of this study suggest that children show immediate impairment in functioning and experience clinically significant pain throughout the first week following T&A, and new onset maladaptive behavioral changes persisting even up to the two-week assessment period.

Resilience in children and their parents enduring pediatric medical traumatic stress

Due to the general lack of familiarity with the concept in the medical field, resilience is rarely considered in pediatric medical traumas. Resilience is an ability that enables recovery after adversities such as traumas, surgeries, serious health problems, or social issues. Stress from medical traumas encompasses both the psychological and physical responses of children and their families. Lack of resilience in children with medical traumatic stress may contribute to poor adjustment, slow recovery, disruptive behaviors, and psychiatric disorders. Furthermore, persistent parental distress increases the child's risk of low resilience. Consequently, these patients and their parents require early identification. This is achievable using a common stress measure such as the Perceived Stress Scale. Moreover, health care providers can screen patients' risks for low resilience, which include few social contacts, poor family functioning, and low cohesion among family members. Findings from the stress scale and screened risks could indicate the need for additional psychosocial support at the time of diagnosis of a serious illness, soon after injuries, and before and after operations. Such interventions can include decreasing distress, counseling children and their parents, and enabling strong connections to health care providers. Health care providers can help parents to minimize distress and adjust to their child's illness, thereby supporting the child's resilience, adjustment, and recovery.

Rectal route in the 21st Century to treat children

The rectal route can be considered a good alternative to the oral route for the paediatric population because these dosage forms are neither to be swallowed nor need to be taste-masked. Rectal forms can also be administered in an emergency to unconscious or vomiting children. Their manufacturing cost is low with excipients generally regarded as safe. Some new formulation strategies, including mucoadhesive gels and suppositories, were introduced to increase patient acceptability. Even if recent paediatric clinical studies have demonstrated the equivalence of the rectal route with others, in order to enable the use of this promising route for the treatment of children in the 21st Century, some effort should be focused on informing and educating parents and care givers. This review is the first ever to address all the aforementioned items, and to list all drugs used in paediatric rectal forms in literature and marketed products in developed countries.

Effect of tonsillar fossa closure on postoperative pain and bleeding risk after tonsillectomy

OBJECTIVE

To determine if closing the tonsil fossa after tonsillectomy leads to less pain and bleeding.

STUDY DESIGN

Interventional, Randomized, Single Blind, Active Control, Single Group Assignment, Safety/Efficacy Study.

FOLLOW-UP

2 months.

METHODS

Generalized Estimating Equations (GEE) analyzed effects of tonsillar pillar closure, surgeon experience and interaction on outcomes.

SETTING

Primarily academic tertiary care referral center, institutional practice, primarily children, both ambulatory and hospitalized care.

SUBJECTS

763 subjects (age 8-264 months) undergoing tonsillectomy.

EXCLUSIONS

suspected malignancy or active peritonsillar abscess. At the discretion of the attending surgeon, patients undergoing tonsillectomy during the 4 year study period were offered participation. A computer selected the side closed. 131 subjects withdrew (complete lack of follow-up information) after the first 72 h.

INTERVENTION

3-0 chromic sutures on tapered needles to close one tonsillar fossa. The subject was not told which side was closed.

MAIN OUTCOME MEASURES

postoperative bleeding (at any time) and pain reported was sought on days 1, 7, 14, 21, and 28.

RESULTS

Closure of the tonsillar fossa did not change the risk of bleeding. Closing the tonsillar fossa had a 40% increase in the odds ratio of postoperative pain. In the tonsillar fossa sides left open, greater surgeon experience decreased the risk of bleeding. In closed sides, enriched surgeon experience increased the risk of bleeding (p<.0.05).

CONCLUSIONS

Suture closure of the tonsillar fossa after tonsillectomy does not reduce the risk of bleeding. Additionally, closing the tonsillar fossa increased postoperative pain.

LEVEL OF EVIDENCE

1b (individual randomized controlled trial).

Ketoprofen pharmacokinetics, efficacy, and tolerability in pediatric patients

The NSAID ketoprofen is used widely in the management of inflammatory and musculoskeletal conditions, pain, and fever in children and adults. Pharmacokinetic studies show that drug exposure after a single intravenous dose is similar in children and adults (after dose normalization), and thus similar mg/kg bodyweight dosing may be used in children and adults. Ketoprofen crosses the blood-brain barrier and therefore has the potential to cause central analgesic effects. Ketoprofen has been investigated in children for the treatment of pain and fever, peri- and postoperative pain, and inflammatory pain conditions. The results of four clinical trials in febrile conditions with the oral syrup formulation indicate that ketoprofen is as effective as acetaminophen (paracetamol) and ibuprofen, allowing children to rapidly return to daily activities with improvements in sleep quality and appetite. Studies of ketoprofen in the management of postoperative pain indicate that ketoprofen is a highly effective analgesic when administered perioperatively for a variety of surgical types, by a variety of routes, and whether given preoperatively or postoperatively. For adenoidectomy, intravenous ketoprofen provided superior postoperative analgesic efficacy compared with placebo. Analgesic efficacy was similar with intravenous, intramuscular, or rectal routes of administration, but oral administration just before surgery was inferior to intravenous administration in this setting. In patients undergoing a tonsillectomy, intravenous ketoprofen was superior to intravenous tramadol in terms of the need for postoperative rescue analgesia, but did not remove the need for rescue opioid therapy in these patients. Intravenous ketoprofen had superior postoperative analgesic efficacy to placebo when given as an adjuvant to epidural sufentanil analgesia after major surgery. Oral ketoprofen has shown efficacy in the treatment of juvenile rheumatoid arthritis. Ketoprofen is generally well tolerated in pediatric patients. Most of the adverse events reported are mild and transient, and are similar to those observed with other NSAIDs. Long-term tolerability has not yet been fully established in children, but data from three studies in >900 children indicate that oral ketoprofen is well tolerated when administered for up to 3 weeks after surgery. In conclusion, ketoprofen is effective and well tolerated in children for the control of post-surgical pain and for the control of pain and fever in inflammatory conditions.

Behavior and quality of life measures after anesthesia for tonsillectomy or ear tube insertion in children

BACKGROUND

Past research examining the psychosocial impact of general anesthesia and day case surgery on children has been hampered by a lack of valid and reliable assessment tools.

AIM

The purpose of the current study was to assess the feasibility of using a well-validated scale (i.e. the Pediatric Quality of Life Inventory Generic Core Scales Version 4.0, PedsQL) in the perioperative setting and to establish changes seen in a sample of children having day case surgery when using this scale.

METHOD

Eighty-nine children (aged 3-12 years) scheduled for general anesthesia for day case tonsillectomy or ear tube insertions were recruited into a prospective study in Melbourne, Australia. Parents completed the PedsQL and the Post Hospitalization Behavioral Questionnaire (PHBQ), and children completed the PedsQL (child self-report) at baseline (preanesthesia), 7 days following anesthesia and 30 days following anesthesia.

RESULTS

The response rate at day 7 and day 30 was modest but when returned the PedsQL and PHBQ had minimal missing data. On the PedsQL, parents rated children's physical functioning as worse at day 7 than at baseline but psychosocial functioning did not differ significantly from baseline. At 30 days, both physical and psychosocial functioning was rated by parents to be better than baseline levels. From children's perspective, there was little evidence of a change in their physical or psychosocial functioning on the self-report PedsQL at day 7, but by day 30 both physical and psychosocial functioning was above baseline levels. A similar pattern was observed on the PHBQ, with little difference in ratings of behavioral problems between baseline and day 7, but less behavioral problems reported at day 30 compared with baseline.

CONCLUSIONS

The PedsQL is feasible for use in the perioperative setting. Future studies should take into account the possibility that deterioration of psychosocial functioning is uncommon at 1 -month postsurgery compared to the preoperative baseline.

[Pain and postoperative behavioural changes following adenoidectomy and ear tube placement in children]

OBJECTIVES

The purpose of this study was to evaluate postoperative pain in the hospital and at home as well as behavioural changes at home following outpatient adenoidectomy (VG) and ear tube (ATT) surgery.

STUDY DESIGN

Prospective cohort study.

PATIENTS AND METHODS

Sixty-four children (mean age 4.3+/-2.4 years): 28 VG, 16 (ATT), 20 dual surgeries (VG-ATT). Postoperative pain was evaluated (arrival in recovery room, departure from wake-up room, departure from hospital) using the Objective Pain Scale (OPS). Parents evaluated their child's pain at home over a period of seven days using a numeric pain scale. Behavioural changes were measured with the Post-Hospital Behaviour Questionnaire (PHBQ).

RESULTS

At arrival in the recovery room, OPS=3.5 [0-6]. A statistically significant difference (p<0.05) was shown between the VG group (OPS=5 [2.25-7.75]), and the ATT (OPS=0 [0-5.5]) and VG-ATT (OPS=2 [0-5.75]) groups. OPS was 1.0 [0-2] when leaving the recovery room, and OPS was 0 [0-1] when leaving the hospital. Numeric pain scale scores recorded at home were extremely low. Postoperatively, 75% of parents at Day 1 and 40.6% at Day 7 reported at least one postoperative behavioural change.

DISCUSSION

In all three groups, parents reported frequent postoperative behaviour changes despite adequate analgesia.

CONCLUSION

The relatively high frequency of postoperative behaviour changes in this population demonstrates the need to systematically evaluate those changes in order to improve overall paediatric care.

A tale of two countries: comparison of the perceptions of analgesics among Finnish and American parents

Our purpose was to compare parental perceptions regarding children's analgesics in Finland and the USA. Data were collected from 315 Finnish and 110 American parents of children undergoing surgery using questionnaires. Cross-tabulation, and chi2 were used in the analysis. Parents thought that analgesia should be given regularly, but more American than Finnish parents thought analgesics should be given to the child before the pain becomes severe. Additionally, more American than Finnish parents stated that children easily become dependent on analgesics and that analgesics for home use may be dangerous for children. Nurses should be aware of parents' incorrect perceptions which may be barriers to children's pain relief.

Child behaviour after anaesthesia: associated risk factors

AIM

To identify hospital care factors which are associated with problematic behaviours in children after hospitalization.

METHOD

A cohort of 340 children ages 2-13 was studied in connection with elective procedures which included anaesthesia.

DATA COLLECTED

sociodemographic, type of procedure, anaesthesia induction technique and premedication. Staff and parents assessed child anxiety at induction of anaesthesia, pain, anxiety and nausea in recovery room and hospital ward. Parents assessed their child's pain and nausea and the behaviour measured with the Post Hospital Behavioural Questionnaire two weeks after hospitalization.

RESULTS

One-third (34.4 %) of the children developed at least one problematic behaviour, measured by the PHBQ subscales. Multiple logistic regression identified the following risk factors: age <5, pain at home but not at hospital, nausea, child anxiety at anaesthesia induction, postoperative nausea, postoperative distress, previous hospitalizations, living in a one adult family and having some previous problematic behaviours. Moderate-to-severe pain at home, but not at hospital, was associated with the greatest risk (OR 6.39 CI: 3.53-11.6). Previous anaesthesia, midazolam use in premedication and living in rural areas seemed to be protective factors.

CONCLUSION

Pain at home but not in hospital is a strong risk factor for the onset or worsening of problematic behaviour after childhood hospitalization, which included anaesthesia. Proactive interventions are suggested to prevent this by improving pain treatment at home.

Psychological effects of repeated general anesthesia in children

BACKGROUND

Although methods for reducing preoperative anxiety have been a major interest of pediatric anesthesiologists, there are no reports of the effects of repeated anesthesia on psychological development of children.

METHODS

To determine the overall effect of multiple anesthetics on the psychology of children, we undertook to compare the children undergoing repeated anesthesia (Group S) for the treatment of corrosive esophagitis with a control group (Group C) with chronic renal disease and frequent hospital admissions. Psychological tests and diagnosis of children Group S (n = 23) were compared prospectively with Group C (n = 20). All children had been appropriately treated over the previous 5 years and 50% of patients in Group C had general anesthesia once and those in Group S underwent at least 5 GAs. Parents completed a child behavior checklist (CBCL) and Marital Conflict Questionnaire; the children were evaluated by a child psychiatrist using DSM-IV criteria and completed the Child Depression Inventory (CDI).

RESULTS

The children in Group S underwent a total of 251 (11 +/- 7) GAs over 4-60 months. The incidence of psychopathology was nine and 10 children in groups S and C, respectively. The CBCL and CDI scores were parallel with a psychiatric diagnosis. Marital conflict scores were higher in Group S.

CONCLUSIONS

Both chronic disease states affect psychology of children. Repeated anesthesia in addition to chronic disease does not seem to disturb the child's psychological health further when tentative and precautious approach modalities are undertaken.

Current management of pediatric postoperative pain

Pain is a common complaint in children after surgery. Four out of five children require analgesia even after minor surgery, and after more extensive surgery, significant postoperative pain may last for weeks. Severe pain during, and after surgery may aggravate long-lasting negative effects to the body and mind. In order to prevent harmful effects, all children should be provided with effective analgesia. Pain management should be safe and easy to administer. Postoperative pain management in children has improved substantially during the last 5 years. Recent trials indicate that children may undergo major surgery with minimal untoward effects when effective proactive pain management is provided. This review will focus on new clinical strategies on pain management in children. Since most pediatric surgery is performed as a day-case or short-stay basic recommendations for parental guidance and pain management after discharge are also presented.

Safety of ketorolac in neonates and infants after cardiac surgery

BACKGROUND

Ketorolac is an injectable nonsteroidal anti-inflammatory drug that is often used as a transitional short-term analgesic to treat moderate pain and to decrease opioid use. There is a paucity of literature documenting the safety of using ketorolac in neonates and infants after cardiac surgery.

METHODS

A retrospective chart review was performed which identified all patients <6 months of age who received ketorolac after cardiac surgery. Patients' demographic, surgical, and dosing data were collected. A Student's t-test was used to identify significant differences in renal and hematologic laboratory values at baseline and at 48 h of treatment.

RESULTS

A total of 53 children <6 months of age received at least one dose of ketorolac after cardiac surgery. Eleven of 53 children (21%) were <1 month of age. The blood urea nitrogen/serum creatinine (SCr) levels increased from baseline at 48 h of therapy in all infants, but stayed within normal limits. The largest increase in SCr level from baseline on any day of ketorolac therapy was 26 micromol x l(-1) (0.3 mg x dl(-1)) which occurred in two neonates. Four patients (three infants and one neonate) had minor episodes of bleeding while being treated with ketorolac. There were no clinically significant changes in hemoglobin, hematocrit or platelet count. None of these episodes caused hemodynamic instability nor required transfusion of blood products.

CONCLUSIONS

Ketorolac was used safely in neonates and infants who have had cardiac surgery at our institution. Ketorolac was not associated with any adverse hematologic or renal effects. Prospective investigation is warranted to further assess the safety and effectiveness of ketorolac in this patient population.

Comparison of Oxycodone Pharmacokinetics after Buccal and Sublingual Administration in Children

OBJECTIVE

We evaluated and compared the pharmacokinetics of two oral administration routes of oxycodone parenteral liquid (10 mg/mL)--single buccal and sublingual administration--in 30 generally healthy awake children, aged 6-91 months.

METHODS

Two groups of children undergoing inpatient surgery were enrolled. In a randomised fashion, children received a single dose of oxycodone 0.2 mg/kg buccally (n = 15) or sublingually (n = 15). Regular blood samples were collected for up to 12 hours, and plasma was analysed for oxycodone, oxymorphone and noroxycodone using gas chromatography-mass spectrometry.

RESULTS

Bioavailability was similar after administration at the two instillation sites. The area under the plasma concentration-time curve from time zero extrapolated to infinity (AUCinfinity) was 2400-8000 ng x min/mL (median 4200 ng x min/mL) in the buccal group and 2700-7900 ng x min/mL (median 5500 ng x min/mL) in the sublingual group. After buccal administration, maximum plasma concentration (Cmax) was 5.4-39 ng/mL (16 ng/mL) after buccal and 5.5-42 ng/mL (22 ng/mL) after sublingual administration. Twelve of the 15 children in both groups reached the oxycodone analgesic concentration of 12 ng/mL, which was sustained for 43-209 minutes (median 160 minutes) in the children with buccal oxycodone and for 32-262 minutes (median 175 minutes) in the children with sublingual oxycodone. The terminal elimination half-lives were closely similar in the two groups: 104-251 minutes (median 140 minutes) in the buccal group and 110-190 minutes (150 minutes) in the sublingual group.

CONCLUSION

The results of this study show that in young children the absorption of oxycodone is similar after buccal and sublingual instillation.

Day-case adenoidectomy: outcomes are improved using suction coagulation and prophylactic anti-emetic treatment

In 2004, the Department of Health published 10 High Impact Changes across the NHS. Of these, the first was treating day surgery as the norm for elective operations, releasing up to half a million in-patient beds each year. Adenoidectomy is an operation commonly performed in children for upper respiratory tract obstruction and as part of the surgical management of otitis media with effusion. Many surgeons consider the traditional curettage adenoidectomy as an unsatisfactory operation because it is performed blind, and is associated with varying reported levels of post-operative bleeding. Concern about the risk of bleeding and the frequent occurrence of post-operative nausea and vomiting have discouraged many surgeons from adopting adenoidectomy as a day-case procedure. We have audited the management and discharge of a cohort of 72 children undergoing traditional curettage adenoidectomy. Based on the results, we have completed the audit loop, by managing a second cohort of 77 children by suction coagulation adenoidectomy. An anaesthetic protocol has been designed to reduce post-operative nausea and vomiting, and facilitate same day discharge from hospital. The rate of post-operative nausea and vomiting fell from 21 to 1.3%, and the post-operative bleeding from 9.7% to nil. Discharge on the day of operation rose from 40.3 to 100%. Our audit confirms that these measures permit safe, day-case adenoidectomy.

Postoperative behavioral changes following anesthesia with sevoflurane

BACKGROUND

Behavioral disturbance following hospitalization is a relatively frequent event, some children still having negative behavioral changes (NBC) 1 month following their operation. Sevoflurane has a propensity to induce 'excitement' during induction of anaesthesia, and delirium in the immediate postoperative phase. The aim of this study was to evaluate whether this translates into prolonged behavioral change.

METHODS

A total of 120 children presenting for daycase surgical procedures under anesthesia were included in the study. Children were randomized to induction and maintenance of anesthesia with sevoflurane or halothane. No additional sedative drugs were administered. Postoperative behavioral change was assessed using the Post-Hospital Behavior Questionnaire (PHBQ) on postoperative days 1, 7 and 30.

RESULTS

The Sevoflurane group (n = 63) were more distressed on emergence of anesthesia than the Halothane group (n = 57) (P < 0.05). About 58.3, 46.8 and 38.3% of all children exhibited NBC on postoperative days 1, 7 and 30, respectively. There was no association between anesthetic agent and behavior. There was a significant relationship between decreasing age and NBC (P < 0.005).

CONCLUSIONS

Children anesthetized with sevoflurane exhibit more immediate postoperative distress than those anesthetized with halothane. This difference is not carried over into the longer posthospital period. Negative behavioral changes occur more frequently with decreasing age.