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Moreira E, Rodrigues M, Beça G. Pain Management Strategies for Botulinum Toxin Type A Injections in Children: A Comprehensive National Survey and Procedural Protocol. Cureus 2023; 15:e48311. [PMID: 38058339 PMCID: PMC10697500 DOI: 10.7759/cureus.48311] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/05/2023] [Indexed: 12/08/2023] Open
Abstract
INTRODUCTION Botulinum toxin type A injections are a first-line treatment for spasticity in children. Our purpose is to delineate the national landscape concerning pain management for botulinum toxin type A injections in pediatric patients and to formulate a protocol grounded in current scientific evidence. METHODS We conducted a nationwide survey targeting physical medicine and rehabilitation specialists performing botulinum toxin type A injections for focal spasticity in children in Portugal. We conducted a literature review to compare the survey results with clinical guidelines, good practice manuals, and protocols published in the literature. Finally, we developed a procedural protocol for pain management in botulinum toxin procedures. RESULTS The survey was completed by 17 out of 18 identified specialists. All but one use some form of periprocedural analgesia. Five do not use any type of sedation. The majority do not assess pain during the procedures. From the reviewed articles, we obtained 23 articles, 19 of which provided data for detailed analysis. CONCLUSIONS A prevailing concern centers around pain management during botulinum toxin procedures in children. Nevertheless, a distinct absence of uniformity persists in appraising and managing procedure-related pain. This notion is further underscored by the marked heterogeneity and paucity of published literature within this realm. The systematic implementation of a procedural protocol thus becomes highly crucial.
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Affiliation(s)
- Elisa Moreira
- Physical and Rehabilitation Medicine, Centro Hospitalar Tondela Viseu, Viseu, PRT
| | - Margarida Rodrigues
- Spinal Cord Injuries Department, Centro de Reabilitação do Norte - Centro Hospitalar de Vila Nova de Gaia Espinho, Porto, PRT
| | - Gustavo Beça
- Physical Medicine and Rehabilitation, Centro de Reabilitação do Norte - Centro Hospitalar de Vila Nova de Gaia Espinho, Porto, PRT
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Parker LE, Wallace K, Thevathasan A, Funk E, Pratt M, Thamby J, Tran L, Prange L, Uchitel J, Boggs A, Minton M, Jasien J, Nagao KJ, Richards A, Cruse B, De-Lisle Dear G, Landstrom AP, Mikati MA. Characterization of sedation and anesthesia complications in patients with alternating hemiplegia of childhood. Eur J Paediatr Neurol 2022; 38:47-52. [PMID: 35390560 DOI: 10.1016/j.ejpn.2022.03.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2021] [Revised: 02/05/2022] [Accepted: 03/17/2022] [Indexed: 01/03/2023]
Abstract
BACKGROUND Alternating hemiplegia of childhood (AHC) pathophysiology suggests predisposition to sedation and anesthesia complications. GOALS Hypotheses: 1) AHC patients experience high rates of sedation-anesthesia complications. 2) ATP1A3 mutation genotype positivity, age, and AHC severity correlate with more severe complications. 3) Prior short QTc correlates with cardiac rhythm complications. METHODS Analysis of 34 consecutive AHC patients who underwent sedation or anesthesia. Classification of complications: mild (not requiring intervention), moderate (intervention), severe (intervention, risk for permanent injury or potential life-threatening emergency). STATISTICS Fisher Exact test, Spearman correlations. RESULTS These patients underwent 129 procedures (3.79 ± 2.75 procedures/patient). Twelve (35%) experienced complications during at least one procedure. Fourteen/129 procedures (11%) manifested one or more complications (2.3% mild, 7% moderate, 1.6% severe). Of the total 20 observed complications, six (33.3%) were severe: apneas (2), seizures (2), bradycardia (1), ventricular fibrillation that responded to resuscitation (1). Moderate complications: non-life-threatening bradycardias, apneas, AHC spells or seizures. Complications occurred during sedation or anesthesia and during procedures or recovery periods. Patients with disease-associated ATP1A3 variants were more likely to have moderate or severe complications. There was no correlation between complications and age or AHC severity. Presence of prior short QTc correlated with cardiac rhythm complications. After this series was analyzed, another patient had severe recurrent laryngeal dystonia requiring tracheostomy following anesthesia with intubation. CONCLUSIONS During sedation or anesthesia, AHC patients, particularly those with ATP1A3 variants and prior short QTc, are at risk for complications consistent with AHC pathophysiology. Increased awareness is warranted during planning, performance, and recovery from such procedures.
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Affiliation(s)
- Lauren E Parker
- Department of Pediatrics, Division of Neurology, Duke University School of Medicine, Durham, NC, United States; Department of Pediatrics, Division of Cardiology, and Department of Cell Biology, Duke University School of Medicine, Durham, NC, United States
| | - Keri Wallace
- Department of Pediatrics, Division of Neurology, Duke University School of Medicine, Durham, NC, United States
| | - Arthur Thevathasan
- Department of Neurology, Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Emily Funk
- Department of Anesthesiology, Duke University School of Medicine, Durham, NC, United States
| | - Milton Pratt
- Department of Pediatrics, Division of Neurology, Duke University School of Medicine, Durham, NC, United States
| | - Julie Thamby
- Department of Pediatrics, Division of Neurology, Duke University School of Medicine, Durham, NC, United States
| | - Linh Tran
- Department of Pediatrics, Division of Neurology, Duke University School of Medicine, Durham, NC, United States
| | - Lyndsey Prange
- Department of Pediatrics, Division of Neurology, Duke University School of Medicine, Durham, NC, United States
| | - Julie Uchitel
- Department of Pediatrics, Division of Neurology, Duke University School of Medicine, Durham, NC, United States
| | - April Boggs
- Department of Pediatrics, Division of Neurology, Duke University School of Medicine, Durham, NC, United States
| | - Melissa Minton
- Department of Pediatrics, Division of Neurology, Duke University School of Medicine, Durham, NC, United States
| | - Joan Jasien
- Department of Pediatrics, Division of Neurology, Duke University School of Medicine, Durham, NC, United States
| | - Kanae Jennifer Nagao
- Department of Neurology, Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Amanda Richards
- Department of Otolaryngology, Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Belinda Cruse
- Department of Neurology, Royal Melbourne Hospital, Melbourne, Victoria, Australia; Department of Medicine (Royal Melbourne Hospital), Faculty of Medicine, Health and Dentistry, The University of Melbourne, Melbourne, Victoria, Australia
| | - Guy De-Lisle Dear
- Department of Anesthesiology, Duke University School of Medicine, Durham, NC, United States
| | - Andrew P Landstrom
- Department of Pediatrics, Division of Cardiology, and Department of Cell Biology, Duke University School of Medicine, Durham, NC, United States
| | - Mohamad A Mikati
- Department of Pediatrics, Division of Neurology, Duke University School of Medicine, Durham, NC, United States.
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Sozbilen MC, Evren Sahin K. Long-term efficacy and safety of repeated botulinum toxin a applications based on function and anesthesia type in children with cerebral palsy. J Orthop 2021; 29:22-27. [PMID: 35027815 PMCID: PMC8731691 DOI: 10.1016/j.jor.2021.12.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2021] [Revised: 12/27/2021] [Accepted: 12/28/2021] [Indexed: 01/03/2023] Open
Abstract
PURPOSE This study evaluates the motor development of patients undergoing three or more repeated Botulinum toxin A (BoNT-A) applications in a tertiary pediatric hospital as well as the safety of three different types of anesthesia. METHODS Seventy-five children who underwent BoNT-A applications at least three consecutive times at six-month intervals and a total of 320 procedures were examined. Gross Motor Function Classification System (GMFCS) was employed in motor development evaluation. The three anesthesia methods (sedation analgesia, anesthesia with larengeal mask [LMA] and inhalation mask) were compared in terms of sedation, procedure, recovery, and total operation room time. RESULTS Following the procedures, significant motor development was observed in 60 (80%) patients. In sedation analgesia group during the first three procedures, the recovery time was seen to be significantly shorter, while there was no difference between the anesthesia methods of any procedures following the fourth. Regardless of the type of anesthesia, the recovery times of those having undergone six or more procedures were longer than those with less than six procedures. CONCLUSIONS As repeated BoNT-A application provides motor step progress, it can be applied safely and effectively under anesthesia. Sedation analgesia provides an easier recovery compared to LMA and mask only within the first three applications. However, recovery time increases with four or more repeated applications, specifically increasing as the number of applications increases. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Murat Celal Sozbilen
- Department of Orthopaedic Surgery, School of Medicine Hospital, Ege University, Bornova, Izmir, Turkey,Corresponding author.
| | - Kubra Evren Sahin
- Department of Anesthesiology and Reanimation, Dr Behcet Uz Child Diseases and Surgery Research and Training Hospital, Konak, Izmir, Turkey
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Guo P, Ran Y, Ao X, Zou Q, Tan L. Incidence of Adverse Effects of Propofol for Procedural Sedation/Anesthesia in the Pediatric Emergency Population: A Systematic Review and Meta-Analysis. COMPUTATIONAL AND MATHEMATICAL METHODS IN MEDICINE 2021; 2021:3160154. [PMID: 34976104 PMCID: PMC8718282 DOI: 10.1155/2021/3160154] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/10/2021] [Revised: 10/16/2021] [Accepted: 11/05/2021] [Indexed: 11/24/2022]
Abstract
BACKGROUND To investigate the incidence of adverse effects of propofol among pediatric population for sedation or anesthesia. METHODS We performed Cochrane Library, PubMed, CNKI, VIP, and Wanfang databases to research relevant literature. We did sensitivity analysis to assess the incidence of adverse effects of propofol among pediatric population for sedation or anesthesia. RESULTS In 132 studies, eight RCTs were included in this analysis. The result showed that adverse events (bradypnea, hypotension, hypertension, and apnea) were significantly improved in the pediatric emergency population in the propofol group, but it had no effect on the incidence of cough attacks, desaturation, agitation, stridor, and laryngospasm. Furthermore, the subgroup analysis showed that those who received propofol for had decreased adverse effects compared with the patients who received ketamine treatment (SMD = 0.44, 95%CI = [0.28, 0.67], I 2 = 0%, and P = 0.0002), which demonstrated that propofol could decrease the incidence of adverse effects compared with ketamine and ketofol. CONCLUSIONS The study demonstrated that propofol may decrease the incidence of bradypnea, hypotension, hypertension, and apnea, but it had no effect on the incidence of cough attacks, desaturation, agitation, stridor, and laryngospasm. Furthermore, more large RCTs are needed to assess incidence of adverse effects of propofol among pediatric population.
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Affiliation(s)
- Pengfei Guo
- Department of Emergency, Children's Hospital of Chongqing Medical University, Chongqing 400014, China
| | - YingChun Ran
- Department of Emergency, Children's Hospital of Chongqing Medical University, Chongqing 400014, China
| | - Xiaoxiao Ao
- Department of Emergency, Children's Hospital of Chongqing Medical University, Chongqing 400014, China
| | - Qing Zou
- Department of Emergency, Children's Hospital of Chongqing Medical University, Chongqing 400014, China
| | - Liping Tan
- Department of Emergency, Children's Hospital of Chongqing Medical University, Chongqing 400014, China
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León-Valenzuela A, Román Malo C, González López M, Sánchez Palacios J, Sánchez Tarifa P, Del Pino Algarrada R. [Sevoflurane sedation protocol in children with cerebral palsy undergoing botulinum toxin-A injections]. Rehabilitacion (Madr) 2021; 55:266-272. [PMID: 33468348 DOI: 10.1016/j.rh.2020.09.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2020] [Revised: 09/21/2020] [Accepted: 09/23/2020] [Indexed: 11/30/2022]
Abstract
OBJECTIVE This study aimed to describe our experience with a protocol based on sevoflurane sedation to control pain and agitation during botulinum toxin-A (BoNT-A) infiltration in children with cerebral palsy (CP), especially in terms of safety and efficacy. MATERIAL AND METHODS We conducted a retrospective observational study of patients diagnosed with CP who underwent BoNT-A infiltration with sevoflurane sedation from November 2012 to December 2019. Demographic, clinical and functional characteristics, the effectiveness of sedation, adverse events (AE) and professional satisfaction were reviewed. RESULTS A total of 387 sedations were successfully performed in 74 patients. Effective sedation was achieved in 100% of procedures, facilitating collaboration during infiltration and improving professional satisfaction. AE were reported in 6.02% of the procedures, the most frequent being nausea and vomiting (3.88%) and transient hypoxemia (2.07%). There were no severe AE. No association was found between the incidence of AE and the clinical and functional variables or risk before anaesthesia. CONCLUSION Sevoflurane sedation shows promising results in terms of safety and effectiveness for the management of agitation and pain during BoNT-A infiltration in our daily clinical practice. In addition, it can facilitate infiltration, allowing examination under sedation and multilevel infiltration with good tolerance.
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Affiliation(s)
- A León-Valenzuela
- Unidad Gestión Clínica Medicina Física y Rehabilitación, Hospital Universitario Puerto Real, Puerto Real, Cádiz, España; Departamento Materno Infantil, Facultad de Medicina, Universidad de Cádiz, Cádiz, España; Grupo iRehab, Instituto de Investigación e Innovación Biomédica de Cádiz, Cádiz, España.
| | - C Román Malo
- Unidad Gestión Clínica Medicina Física y Rehabilitación, Hospital Universitario Puerta del Mar, Cádiz, España
| | - M González López
- Unidad Gestión Clínica Medicina Física y Rehabilitación, Hospital Universitario Puerto Real, Puerto Real, Cádiz, España
| | - J Sánchez Palacios
- Unidad Gestión Clínica Medicina Física y Rehabilitación, Hospital Universitario Puerta del Mar, Cádiz, España
| | - P Sánchez Tarifa
- Unidad Gestión Clínica Medicina Física y Rehabilitación, Hospital Universitario Puerta del Mar, Cádiz, España
| | - R Del Pino Algarrada
- Unidad Gestión Clínica Medicina Física y Rehabilitación, Hospital Universitario Puerto Real, Puerto Real, Cádiz, España; Grupo iRehab, Instituto de Investigación e Innovación Biomédica de Cádiz, Cádiz, España
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Nugud A, Alhoot S, Agabna M, Babiker MOE, El Bashir H. Analgesia and sedation modalities used with botulinum toxin injections in children with cerebral palsy: a literature review. Sudan J Paediatr 2021; 21:6-12. [PMID: 33879937 DOI: 10.24911/sjp.106-1604549033] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Cerebral palsy (CP) is a non-progressive motor dysfunction leading to multiple morbidities, including spasticity, which can be managed with botulinum toxin injection (BTI). This literature review aims to examine published studies on the efficacy and safety of different interventions used to reduce pain and anxiety associated with BTI in children with CP. A literature review of all published evidence in English language, or with an English translation between 1999 and 2019, using PubMed, EBSCO host, and Medline databases was carried out. All identified papers were screened for inclusion criteria. Data from included papers were entered and analyzed on an Excel database. Twenty-one studies conducted in multiple clinical settings identified 10 different analgesia and sedation modalities including intravenous ketamine, midazolam, inhaled nitrous oxide, general anesthesia, and Eutectic Mixture of Local Anesthetics (EMLA®) cream. Most of the studies were descriptive with the exception of two clinical trials and one qualitative study. All interventions had some adverse effects, but they were generally mild and no long-term sequelae were reported. The combination of inhaled nitrous oxide with EMLA® cream showed promising primary results. However, ketamine and midazolam combination could be a safe alternative. Currently, there is no sufficient data to draw on the superiority of any modality. Further high-quality studies are warranted.
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Affiliation(s)
- Ahmed Nugud
- Neurosciences Center of Excellence, Al Jalila Children's Specialty Hospital, Dubai, UAE
| | - Shahad Alhoot
- Mohammed Bin Rashid University of Medicine and Health Sciences, Dubai, UAE
| | - Maha Agabna
- Neurosciences Center of Excellence, Al Jalila Children's Specialty Hospital, Dubai, UAE
| | - Mohamed O E Babiker
- Neurosciences Center of Excellence, Al Jalila Children's Specialty Hospital, Dubai, UAE
| | - Haitham El Bashir
- Neurosciences Center of Excellence, Al Jalila Children's Specialty Hospital, Dubai, UAE
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