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Sykes AG, Oviedo P, Rooney AS, Gollin G. An assessment of dexmedetomidine as an opioid-sparing agent after neonatal open thoracic and abdominal operations. J Perinatol 2022; 42:307-312. [PMID: 34312472 DOI: 10.1038/s41372-021-01175-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2021] [Revised: 07/12/2021] [Accepted: 07/16/2021] [Indexed: 11/09/2022]
Abstract
OBJECTIVE To evaluate the efficacy of dexmedetomidine as an opioid-sparing agent in infants following open thoracic or abdominal operations. METHODS Retrospective review of postoperative neonates who received IV acetaminophen with or without dexmedetomidine. The primary outcome was opioid dosage within the first ten postoperative days. Secondary outcomes included times to extubation, full feedings and discharge. RESULTS 112 infants met inclusion criteria. Those managed with dexmedetomidine received 1.8-4.3 times more opioid on postoperative days 1-3, had longer times to extubation and trended towards longer lengths of hospital stay than infants who were not. Opioid was dosed >0.2 ME/kg on only 23% of days when the acetaminophen dose was >40 mg/kg/day and 10% of days when the acetaminophen dose was >45 mg/kg. CONCLUSION Dexmedetomidine may not be opioid sparing after major operations in neonates and its use delays recovery. IV acetaminophen dosed at 40 mg/kg/day or greater may yield the most substantial opioid-sparing effect.
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Affiliation(s)
| | - Parisa Oviedo
- University of California San Diego School of Medicine, San Diego, CA, USA
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Oliver JA, Oliver LA, Aggarwal N, Baldev K, Wood M, Makusha L, Vadivelu N, Lichtor L. Ambulatory Pain Management in the Pediatric Patient Population. Curr Pain Headache Rep 2022; 26:15-23. [PMID: 35129824 DOI: 10.1007/s11916-022-00999-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/09/2021] [Indexed: 11/28/2022]
Abstract
PURPOSE OF REVIEW Outpatient surgery in the pediatric population has become increasingly common. However, many patients still experience moderate to severe postoperative pain. A poor understanding of the extent of pain after pediatric ambulatory surgery and the lack of randomized control studies of pain management of the outpatient necessitate this review of scientific evidence and multimodal analgesia. RECENT FINDINGS A multimodal approach to pain management should be applied to the ambulatory setting to decrease postoperative pain. These include non-pharmacological techniques, multimodal pharmacologics, and neuraxial and peripheral nerve blocks. Postoperative pain management in pediatric ambulatory surgical patients remains suboptimal at most centers due to limited evidence-based approach to postoperative pain control. Pediatric ambulatory pain management requires a multipronged approach to address this inadequacy.
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Affiliation(s)
- Jodi-Ann Oliver
- Department of Anesthesiology, Yale University, New Haven, CT, 06520, USA
| | - Lori-Ann Oliver
- Department of Anesthesiology, Yale University, New Haven, CT, 06520, USA
| | - Nitish Aggarwal
- Department of Anesthesiology, Yale University, New Haven, CT, 06520, USA.
| | - Khushboo Baldev
- Department of Anesthesiology, Yale University, New Haven, CT, 06520, USA
| | - Melanie Wood
- Department of Anesthesiology, Yale University, New Haven, CT, 06520, USA
| | - Lovemore Makusha
- Department of Anesthesiology, Stanford University, Pao Alto, CA, USA
| | - Nalini Vadivelu
- Department of Anesthesiology, Yale University, New Haven, CT, 06520, USA
| | - Lance Lichtor
- Department of Anesthesiology, Yale University, New Haven, CT, 06520, USA
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Morris JL, Bernard F, Bérubé M, Dubé JN, Houle J, Laporta D, Morin SN, Perreault M, Williamson D, Gélinas C. Determinants of pain assessment documentation in intensive care units. Can J Anaesth 2021; 68:1176-1184. [PMID: 34105066 DOI: 10.1007/s12630-021-02022-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2020] [Revised: 03/28/2021] [Accepted: 04/13/2021] [Indexed: 10/21/2022] Open
Abstract
PURPOSE The underassessment of pain is a major barrier to effective pain management, and the lack of pain assessment documentation has been associated with negative patient outcomes. This study aimed to 1) describe the contextual factors related to pain assessment and management in five Québec intensive care units (ICUs); 2) describe their pain assessment documentation practices; and 3) identify sociodemographic and clinical determinants related to pain assessment documentation. METHODS A descriptive-correlational retrospective design was used. Sociodemographic data (i.e., age, sex), clinical data (i.e., diagnosis, mechanical ventilation, level of consciousness, severity of illness, opioids, sedatives), and pain assessments were extracted from 345 medical charts of ICU admissions from five teaching hospitals between 2017 and 2019. Descriptive statistics and multiple linear regression were performed. RESULTS All sites reported using the 0-10 numeric rating scale, but the implementation of a behavioural pain scale was variable across sites. A median of three documented pain assessments were performed per 24 hr, which is below the minimal recommendation of eight to 12 pain assessments per 24 hr. Overall, pain assessment was present in 70% of charts, but only 20% of opioid doses were followed by documented pain reassessment within one hour post-administration. Higher level of consciousness (β = 0.37), using only breakthrough doses (β = 0.24), and lower opioid doses (β = -0.21) were significant determinants of pain assessment documentation (adjusted R2 = 0.25). CONCLUSION Pain assessment documentation is suboptimal in ICUs, especially for patients unable to self-report or those receiving higher opioid doses. Study findings highlight the need to implement tools to optimize pain assessment and documentation.
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Affiliation(s)
- Jenna L Morris
- Ingram School of Nursing, McGill University, Montréal, QC, Canada
| | - Francis Bernard
- Faculty of Medicine, Université de Montréal, Neuro Intensive Care Unit and Research Centre, Hôpital du Sacré-Coeur de Montréal, CIUSSS Nord-Ile-Montréal, Montréal, QC, Canada
| | - Mélanie Bérubé
- Faculty of Nursing, Université Laval, Québec City, QC, Canada
- CHU de Québec - Université Laval Research Center (Hôpital de l'Enfant-Jésus), Population Health and Optimal Practices Research Unit, Québec City, QC, Canada
| | - Jean-Nicolas Dubé
- Faculty of Medicine (campus Mauricie), Université de Montréal, Montréal, QC, Canada
- Department of Specialized Medicine, CIUSSS Mauricie-Centre-du-Québec, Centre hospitalier affilié universitaire régional, Trois-Rivières, QC, Canada
| | - Julie Houle
- Department of Nursing, Université du Québec à Trois-Rivières, Trois-Rivières, QC, Canada
- Medical and Clinical Research, CIUSSS Mauricie-Centre-du-Québec, Trois-Rivières, QC, Canada
| | - Denny Laporta
- Faculty of Medicine, Respiratory Division, McGill University, Department of Medicine, Division of Adult Critical Care, Jewish General Hospital, CIUSSS West-Central-Montreal, Montréal, QC, Canada
| | - Suzanne N Morin
- Department of Medicine, Center for Outcomes Research and Evaluation, Research Institute of McGill University Health Centre, McGill University, Montréal, QC, Canada
| | - Marc Perreault
- Faculté de Pharmacie, Université de Montréal, Montréal, QC, Canada
- Department of Pharmacy, McGill University Health Center, Montréal, QC, Canada
| | - David Williamson
- Faculté de Pharmacie, Université de Montréal, Montréal, QC, Canada
- Department of Pharmacy and Research Centre, Hôpital du Sacré-Cœur de Montréal, CIUSSSS Nord-Ile-Montréal, Montréal, QC, Canada
| | - Céline Gélinas
- Ingram School of Nursing, McGill University, Montréal, QC, Canada.
- Centre for Nursing Research and Lady Davis Institute, Jewish General Hospital, CIUSSS West-Central-Montreal, Montréal, QC, Canada.
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Abstract
PURPOSE OF REVIEW This article summarizes recent data related to the safety and efficacy of postoperative analgesia in children that influence clinical practice recommendations. RECENT FINDINGS Postoperative pain continues to be experienced by hospitalized children and following discharge after short stay or ambulatory surgery. Updated recommendations for post-tonsillectomy analgesia exclude codeine and suggest regular administration of paracetamol and NSAID, but evidence for the most appropriate dose and type of opioid for rescue analgesia is limited. The incidence of opioid-related respiratory depression/oversedation in hospitalized children ranges from 0.11 to 0.41%, with recent large series identifying high-risk groups and contributory factors that can be targeted to minimize the risk of serious or permanent harm. Data demonstrating feasibility and safety of regional analgesic techniques is increasing, but additional and procedure-specific evidence would improve technique selection and inform discussions of efficacy and safety with patients and families/carers. Persistent postsurgical pain is increasingly recognized following major surgery in adolescents. Evaluation of potential predictive factors in clinical studies and investigation of underlying mechanisms in laboratory studies can identify targets for both pharmacological and nonpharmacological interventions. SUMMARY Recommendations for postoperative pain in children continue to evolve, with data incorporated from randomized controlled trials, case series and large audits. Management of pain following surgery in children needs to not only encompass efficacy and safety in the immediate perioperative period, but also consider pain following discharge after ambulatory surgery and the potential risk of persistent postsurgical pain following major surgery.
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Görges M, West NC, Christopher NA, Koch JL, Brodie SM, Lowlaavar N, Lauder GR, Ansermino JM. An Ethnographic Observational Study to Evaluate and Optimize the Use of Respiratory Acoustic Monitoring in Children Receiving Postoperative Opioid Infusions. Anesth Analg 2016; 122:1132-40. [PMID: 26745756 DOI: 10.1213/ane.0000000000001127] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Respiratory depression in children receiving postoperative opioid infusions is a significant risk because of the interindividual variability in analgesic requirement. Detection of respiratory depression (or apnea) in these children may be improved with the introduction of automated acoustic respiratory rate (RR) monitoring. However, early detection of adverse events must be balanced with the risk of alarm fatigue. Our objective was to evaluate the use of acoustic RR monitoring in children receiving opioid infusions on a postsurgical ward and identify the causes of false alarm and optimal alarm thresholds. METHODS A video ethnographic study was performed using an observational, mixed methods approach. After surgery, an acoustic RR sensor was placed on the participant's neck and attached to a Rad87 monitor. The monitor was networked with paging for alarms. Vital signs data and paging notification logs were obtained from the central monitoring system. Webcam videos of the participant, infusion pump, and Rad87 monitor were recorded, stored on a secure server, and subsequently analyzed by 2 research nurses to identify the cause of the alarm, response, and effectiveness. Alarms occurring within a 90-second window were grouped into a single-alarm response opportunity. RESULTS Data from 49 patients (30 females) with median age 14 (range, 4.4-18.8) years were analyzed. The 896 bedside vital sign threshold alarms resulted in 160 alarm response opportunities (44 low RR, 74 high RR, and 42 low SpO2). In 141 periods (88% of total), for which video was available, 65% of alarms were deemed effective (followed by an alarm-related action within 10 minutes). Nurses were the sole responders in 55% of effective alarms and the patient or parent in 20%. Episodes of desaturation (SpO2 < 90%) were observed in 9 patients: At the time of the SpO2 paging trigger, the RR was >10 bpm in 6 of 9 patients. Based on all RR samples observed, the default alarm thresholds, to serve as a starting point for each patient, would be a low RR of 6 (>10 years of age) and 10 (4-9 years of age). CONCLUSIONS In this study, the use of RR monitoring did not improve the detection of respiratory depression. An RR threshold, which would have been predictive of desaturations, would have resulted in an unacceptably high false alarm rate. Future research using a combination of variables (e.g., SpO2 and RR), or the measurement of tidal volumes, may be needed to improve patient safety in the postoperative ward.
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Affiliation(s)
- Matthias Görges
- From the Departments of *Electrical and Computer Engineering and †Anesthesiology, Pharmacology, and Therapeutics, University of British Columbia, Vancouver, British Columbia, Canada; and ‡Department of Neurosciences and Surgery, BC Children's Hospital, Vancouver, British Columbia, Canada
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