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Wang H, An J, Zhong S, Qiao S, Zhang L, Zhao L, Wang C. The influence of COMT and ABCB1 gene polymorphisms on sufentanil analgesic effect for postoperative pain in children with fracture. Medicine (Baltimore) 2024; 103:e37980. [PMID: 38669362 PMCID: PMC11049768 DOI: 10.1097/md.0000000000037980] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2024] [Accepted: 04/01/2024] [Indexed: 04/28/2024] Open
Abstract
The aim of this observational study was to investigate the effects of catechol-O-methyltransferase (COMT) and ATP-binding cassette transporter B1 (ABCB1) gene polymorphisms on the postoperative analgesic effect of sufentanil in Chinese Han pediatric patients with fractures. A total of 185 pediatric patients who underwent fracture surgery were included. Polymerase chain reaction-restriction fragment length polymorphism was used to detect the polymorphisms of COMT and ABCB1 genes. Sufentanil was used for postoperative analgesia. The pain level of the patients was evaluated using the face, legs, activity, cry, and consolability scale before surgery, during awakening, at 2, 6, 12, and 24 hours after surgery. The postoperative Ramsay sedation score, sufentanil consumption, and incidence of adverse reactions were also recorded. Pediatric patients with different genotypes of ABCB1 and COMT showed no statistically significant differences in general data such as age, gender, weight, height, surgical duration, and American Society of Anesthesiologists classification (P > .05). There were no statistically significant differences in sedation scores after surgery between different genotypes of ABCB1 and COMT (P > .05). Among patients with CC genotype in ABCB1, the pain scores and total consumption of sufentanil at awakening, 2 and 6 hours after surgery were higher compared to TT and CT genotypes (P < .05), while there were no statistically significant differences between TT and CT genotypes (P > .05). Among patients with AA genotype in COMT, the pain scores and total consumption of sufentanil at awakening, 2, 6, 12, and 24 hours after surgery were higher compared to AG and GG genotypes (P < .05), while there were no statistically significant differences between AG and GG genotypes (P > .05). There were no statistically significant differences in adverse reactions between different genotypes of ABCB1 and COMT (P > .05). The polymorphisms of COMT gene rs4680 and ABCB1 gene rs1045642 are associated with the analgesic effect and consumption of sufentanil in pediatric patients after fracture surgery.
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MESH Headings
- Humans
- Sufentanil/therapeutic use
- Sufentanil/administration & dosage
- Catechol O-Methyltransferase/genetics
- Pain, Postoperative/drug therapy
- Pain, Postoperative/genetics
- Male
- Female
- ATP Binding Cassette Transporter, Subfamily B/genetics
- Child
- Fractures, Bone/surgery
- Fractures, Bone/genetics
- Analgesics, Opioid/therapeutic use
- Analgesics, Opioid/administration & dosage
- Analgesics, Opioid/adverse effects
- Genotype
- Child, Preschool
- Pain Measurement
- Polymorphism, Genetic
- Adolescent
- Polymorphism, Single Nucleotide
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Affiliation(s)
- Hui Wang
- Department of Anesthesiology, Children’s Hospital of Nanjing Medical University, Nanjing, China
- Department of Anesthesiology, Gusu School Nanjing Medical University, Suzhou, China
| | - Jianzhong An
- Department of Anesthesiology, Suzhou Science & Technology Town Hospital, Suzhou, China
| | - Shan Zhong
- Department of Anesthesiology, Children’s Hospital of Nanjing Medical University, Nanjing, China
| | - Shigang Qiao
- Department of Anesthesiology, Suzhou Science & Technology Town Hospital, Suzhou, China
| | - Li Zhang
- Department of Anesthesiology, Children’s Hospital of Nanjing Medical University, Nanjing, China
| | - Longde Zhao
- Department of Anesthesiology, Children’s Hospital of Nanjing Medical University, Nanjing, China
| | - Chen Wang
- Department of Anesthesiology, Gusu School Nanjing Medical University, Suzhou, China
- Department of Anesthesiology, Suzhou Science & Technology Town Hospital, Suzhou, China
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Khalifa SB, Slimene AB, Blaiti H, Kaddour R, Hassen AF, Pardessus P, Brasher C, Dahmani S. The potentiating effect of intravenous dexamethasone upon preemptive pudendal block analgesia for hypospadias surgery in children managed with Snodgrass technique: a randomized controlled study : Dexamethasone for pain management in children. BMC Anesthesiol 2024; 24:145. [PMID: 38627668 PMCID: PMC11020812 DOI: 10.1186/s12871-024-02536-3] [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: 09/25/2023] [Accepted: 04/10/2024] [Indexed: 04/19/2024] Open
Abstract
INTRODUCTION Evidence regarding the potentiating effects of intravenous dexamethasone on peripheral regional anesthesia in children is sparse. The objective of the current study was to investigate the potentiating effect of intravenous dexamethasone upon pudendal block during surgical correction of hypospadias using Snodgrass technique. METHODS The study consisted of a monocentric, randomized controlled, double-blinded study. Patients were randomized to receive either intravenous dexamethasone 0.15 mg.kg- 1 (D group) or a control solution (C group). Both groups received standardized anesthesia including a preemptive pudendal block performed after the induction of anesthesia. The primary outcome was the proportion of patients needing rescue analgesia. Secondary outcomes were other pain outcomes over the first 24 postoperative hours. RESULTS Overall, 70 patients were included in the study. Age were 24 [24; 36] and 26 [24; 38] months in the D and C groups, respectively (p = 0.4). Durations of surgery were similar in both groups (60 [30; 60], p = 1). The proportion of patients requiring rescue analgesia was decreased in the D group (23% versus 49%, in D and C groups respectively, p = 0.02). The first administration of rescue analgesia was significantly delayed in the D group. Postoperative pain was improved in the D group between 6 and 24 h after surgery. Opioid requirements and the incidence of vomiting did not significantly differ between groups. CONCLUSION Associating intravenous dexamethasone (0.15 mg.kg- 1) to pudendal block during hypospadias surgery improves pain control over the first postoperative day. Further studies are needed in order to confirm these results. CLINICALTRIALS GOV IDENTIFIER NCT03902249. A. WHAT IS ALREADY KNOWN dexamethasone has been found to potentiate analgesia obtained with regional anesthesia in children. B. WHAT THIS ARTICLE ADDS: intravenous dexamethasone was found to improve analgesia with a preemptive pudendal block during hypospadias surgery. C. IMPLICATIONS FOR TRANSLATION: results of this study indicate that intravenous dexamethasone could be used as an adjunct to pudendal block.
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Affiliation(s)
- Sonia Ben Khalifa
- Department of Anesthesia and Intensive Care, Robert Ballanger Hospital, 1 boulevard Robert Ballanger, Aulnay-Sous-Bois, 93602, France
| | - Ahmed Ben Slimene
- Department of Anesthesia and Intensive Care, Children Hospital, Boulevard 9 avril, Baab Saadoun, Tunis, Tunisia
| | - Hajer Blaiti
- Department of Anesthesia and Intensive Care, Children Hospital, Boulevard 9 avril, Baab Saadoun, Tunis, Tunisia
| | - Refka Kaddour
- Department of Anesthesia and Intensive Care, Robert Ballanger Hospital, 1 boulevard Robert Ballanger, Aulnay-Sous-Bois, 93602, France
| | - Amjed Fekih Hassen
- Department of Anesthesia and Intensive Care, Children Hospital, Boulevard 9 avril, Baab Saadoun, Tunis, Tunisia
| | - Pierre Pardessus
- Université de Paris-Cité, Paris, France
- Department of Anesthesia and Intensive Care, Robert Debré Hospital, 48 boulevard Sérurier, Paris, 75019, France
- FHU I2D2. Robert Debré Hospital, 48 boulevard Sérurier, Paris, 75019, France
| | - Christopher Brasher
- Department of Anesthesia & Pain Management, Royal Children's Hospital, Melbourne, Australia
- Anesthesia and Pain Management Research Group, Murdoch Children's Research Institute, Parkville, Australia
- Department for Integrated Critical Care, University of Melbourne, Melbourne, Australia
| | - Souhayl Dahmani
- Department of Anesthesia and Intensive Care, Robert Ballanger Hospital, 1 boulevard Robert Ballanger, Aulnay-Sous-Bois, 93602, France.
- Université de Paris-Cité, Paris, France.
- Department of Anesthesia and Intensive Care, Robert Debré Hospital, 48 boulevard Sérurier, Paris, 75019, France.
- FHU I2D2. Robert Debré Hospital, 48 boulevard Sérurier, Paris, 75019, France.
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Osorio D, Maldonado D, Rijs K, van der Marel C, Klimek M, Calvache JA. Efficacy of different routes of acetaminophen administration for postoperative pain in children: a systematic review and network meta-analysis. Can J Anaesth 2024:10.1007/s12630-024-02760-y. [PMID: 38622469 DOI: 10.1007/s12630-024-02760-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2023] [Revised: 01/30/2024] [Accepted: 02/14/2024] [Indexed: 04/17/2024] Open
Abstract
PURPOSE Acetaminophen is the most common drug used to treat acute pain in the pediatric population, given its wide safety margin, low cost, and multiple routes for administration. We sought to determine the most efficacious route of acetaminophen administration for postoperative acute pain relief in the pediatric surgical population. METHODS We conducted a systematic review of randomized controlled trials (RCTs) that included children aged between 30 days and 17 yr who underwent any type of surgical procedure and that evaluated the analgesic efficacy of different routes of administration of acetaminophen for the treatment of postoperative pain. We searched MEDLINE, CENTRAL, Embase, CINAHL, LILACs, and Google Scholar databases for trials published from inception to 16 April 2023. We assessed the risk of bias in the included studies using the Cochrane Risk of Bias 1.0 tool. We performed a frequentist network meta-analysis using a random-effects model. Our primary outcome was postoperative pain using validated pain scales. RESULTS We screened 2,344 studies and included 14 trials with 829 participants in the analysis. We conducted a network meta-analysis for the period from zero to two hours, including six trials with 496 participants. There was no evidence of differences between intravenous vs rectal routes of administration of acetaminophen (difference in means, -0.28; 95% confidence interval [CI], -0.62 to 0.06; very low certainty of the evidence) and intravenous vs oral acetaminophen (difference in means, -0.60; 95% CI, -1.20 to 0.01; low certainty of the evidence). For the comparison of oral vs rectal routes, we found evidence favouring the oral route (difference in means, -0.88; 95% CI, -1.44 to -0.31; low certainty of the evidence). Few trials reported secondary outcomes of interest; when comparing the oral and rectal routes in the incidence of nausea and vomiting, there was no evidence of differences (relative risk, 1.20; 95% CI, 0.81 to 1.78). CONCLUSION The available evidence on the effect of the administration route of acetaminophen on postoperative pain in children is very uncertain. The outcomes of postoperative pain control and postoperative vomiting may differ very little between the oral and rectal route. Better designed and executed RCTs are required to address this important clinical question. STUDY REGISTRATION PROSPERO (CRD42021286495); first submitted 19 November 2021.
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Affiliation(s)
- Danilo Osorio
- Department of Anesthesiology, Universidad del Cauca, Popayán, Colombia
| | - Diana Maldonado
- Department of Anesthesiology, Pontificia Universidad Javeriana, Bogotá, Colombia
| | - Koen Rijs
- Department of Anesthesiology, Erasmus University MC, Rotterdam, The Netherlands
| | | | - Markus Klimek
- Department of Anesthesiology, Erasmus University MC, Rotterdam, The Netherlands
| | - Jose A Calvache
- Department of Anesthesiology, Universidad del Cauca, Popayán, Colombia.
- Department of Anesthesiology, Erasmus University MC, Rotterdam, The Netherlands.
- Department of Anesthesiology, Erasmus University MC, Dr. Molewaterplein 40, 3015 GD, Postbus 2040, 3000 CA, Rotterdam, The Netherlands.
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Sakthivel M, Su V, Nataraja RM, Pacilli M. Newborn and Infant Parasympathetic Evaluation (NIPE™) Monitor for Assessing Pain During Surgery and Interventional Procedures: A Systematic Review. J Pediatr Surg 2024; 59:672-677. [PMID: 38158253 DOI: 10.1016/j.jpedsurg.2023.12.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2023] [Accepted: 12/03/2023] [Indexed: 01/03/2024]
Abstract
BACKGROUND The heart rate variability-derived Newborn Infant Parasympathetic Evaluation (NIPE) monitor has been designed to be an objective, non-invasive tool for the assessment of pain and discomfort in children under 2 years of age. The aim of this systematic review was to evaluate the ability of NIPE to assess pain in neonates and infants during surgical and/or painful procedures. METHODS A systematic review (2010-2023) was conducted using PRISMA guidelines. Studies containing children above 2-years-old were excluded. The ROBINS-I (Risk of Bias in Non-randomised Studies of Interventions) tool was used to assess the quality of included studies. RESULTS 9 databases were searched identifying 470 articles, 460 did not meet the inclusion criteria and were excluded; therefore, 10 studies with 548 participants were included. NIPE was used to assess intraoperative and postoperative pain for surgery under general anaesthesia (5 studies), as well as acute and prolonged pain from other interventional procedures (5 studies). For surgery under general anaesthesia: NIPE has shown to detect nociceptive events (e.g., skin incision, intubation), insufficient analgesia intraoperatively and to predict early postoperative pain. For painful interventional procedures: NIPE has shown to detect acute pain with a high sensitivity and negative predictive value. CONCLUSION NIPE has been used to assess pain in surgery and for various painful procedures. NIPE can detect intraoperative pain and reflect early postoperative pain. NIPE may be useful in evaluating procedural pain, however with heterogenous outcomes, more studies are required to confirm its efficacy. TYPE OF STUDY Systematic Review. LEVEL OF EVIDENCE Level II.
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Affiliation(s)
- Mahesh Sakthivel
- Department of Paediatric Surgery, Monash Children's Hospital, Melbourne, Australia; Department of Paediatrics, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Australia
| | - Virginia Su
- Department of Paediatric Surgery, Monash Children's Hospital, Melbourne, Australia; Department of Paediatrics, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Australia
| | - Ramesh M Nataraja
- Department of Paediatric Surgery, Monash Children's Hospital, Melbourne, Australia; Department of Paediatrics, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Australia; Department of Surgery, Faculty of Medicine, Nursing and Health Sciences., Monash University, Melbourne, Australia
| | - Maurizio Pacilli
- Department of Paediatric Surgery, Monash Children's Hospital, Melbourne, Australia; Department of Paediatrics, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Australia; Department of Surgery, Faculty of Medicine, Nursing and Health Sciences., Monash University, Melbourne, Australia.
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Kiskaddon AL, Goldenberg NA, Abel T, Fierstein JL, Khayat D, Quintessenza JA, Stock AC. Ketorolac Dosing and Outcomes in Neonates Following Congenital Heart Surgery: A Retrospective Analysis. Crit Care Explor 2024; 6:e1078. [PMID: 38633134 PMCID: PMC11023609 DOI: 10.1097/cce.0000000000001078] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/19/2024] Open
Abstract
BACKGROUND Pain management is essential for postoperative surgery. Given the association of opioids with adverse outcomes, interest in the use of nonopioid analgesics, such as ketorolac, has increased. Published data on use in neonates are limited. OBJECTIVES To describe ketorolac dosing and safety and efficacy outcomes in the first 48 hours postcardiac surgery in neonates. DESIGN We performed a single-center retrospective cohort study of neonates (ages < 28 d) who received ketorolac following cardiac surgery from November 2020 to July 2023 (inclusive). The primary safety outcome was a clinically significant decline in renal function, as defined by the composite of an increase in serum creatinine by greater than or equal to 0.3 mg/dL from baseline within 96 hours of ketorolac initiation and urine output less than or equal to 0.5 mL/kg/hr for 6 hours. The secondary safety outcome was clinically significant bleeding, defined as the composite of major bleeding by the International Society on Thrombosis and Hemostasis pediatric criteria and severe/fatal bleeding by the criteria of Nellis et al (2019). Efficacy was measured by opioid utilization based on a standardized pain score-driven analgesia protocol. INTERVENTIONS Ketorolac was administered at 0.5 mg/kg every 6 hours as per an institutional clinical management algorithm. MEASUREMENTS AND MAIN RESULTS Thirty-nine patients met the eligibility criteria. The median ketorolac dose was 0.5 mg/kg/dose, and median (interquartile range [IQR]) duration of therapy was 48 hours (6-48 hr). No patients experienced a significant decline in renal function, and there were no clinically significant bleeding events. The median (IQR) IV morphine milligram equivalents (MMEs)/kg/d of opioid administration was 0.2 MME/kg/d (0.1-0.25 MME/kg/d) at the time of ketorolac initiation and 0.1 MME/kg/d (0.1-0.2 MME/kg/d) at 48 hours post-ketorolac initiation. CONCLUSIONS If validated prospectively, these findings suggest that a ketorolac regimen of 0.5 mg/kg/dose every 6 hours in neonates postcardiac surgery may be safe with regard to renal function and bleeding risk. Additional randomized studies would be needed to determine efficacy with regard to opioid-sparing capacity.
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Affiliation(s)
- Amy L Kiskaddon
- Department of Pharmacy, Johns Hopkins All Children's Hospital, St. Petersburg, FL
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD
- Institute for Clinical and Translational Research, Johns Hopkins All Children's Hospital, St. Petersburg, FL
- Heart Institute, Johns Hopkins All Children's Hospital, St. Petersburg, FL
| | - Neil A Goldenberg
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD
- Institute for Clinical and Translational Research, Johns Hopkins All Children's Hospital, St. Petersburg, FL
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
- Cancer and Blood Disorders Institute, Johns Hopkins All Children's Hospital, St. Petersburg, FL
| | - Trent Abel
- Department of Pharmacy, Johns Hopkins All Children's Hospital, St. Petersburg, FL
| | - Jamie L Fierstein
- Epidemiology and Biostatistics Shared Resource, Institute for Clinical and Translational Research, Johns Hopkins All Children's Hospital, St. Petersburg, FL
| | - Delia Khayat
- University of Florida College of Pharmacy, Gainesville, FL
| | | | - Arabela C Stock
- Heart Institute, Johns Hopkins All Children's Hospital, St. Petersburg, FL
- Division of Cardiac Critical Care, Heart Institute, Johns Hopkins All Children's Hospital, St. Petersburg, FL
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Rede FM, Goshu EM, muzien SJ. Severity and associated factors of postoperative pain in paediatric surgical patients aged 2 months-7 years at selected Addis Ababa Public Hospitals: a multicenter prospective longitudinal study. Ann Med Surg (Lond) 2024; 86:1275-1282. [PMID: 38463099 PMCID: PMC10923381 DOI: 10.1097/ms9.0000000000001742] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2023] [Accepted: 01/08/2024] [Indexed: 03/12/2024] Open
Abstract
Background Postoperative pain is a common and distressing consequence of surgery in children. It can lead to suffering, prolonged recovery, impaired physical functioning, and even chronic pain. Effective postoperative pain management is crucial for improving patient outcomes. However, several factors hinder the accurate assessment and management of pain in children, particularly in low-income countries. This study aims to evaluate the severity of postoperative pain in paediatric patients and identify its predictors. Materials and methods A longitudinal study was conducted on 235 paediatric surgical patients aged 2 months-7 years in Public Hospitals of Addis Ababa from January to April 2023. The primary outcome, pain severity, was assessed at three different times using a pain assessment tool. Cochran's q-test was used to compare postoperative pain incidences. The Generalized Estimating Equation was used to determine predictor variables' effects on pain severity over time. The study demonstrated the direction of association and significance using an AOR with a 95% CI at a P value of 0.05. Result The incidence of moderate to severe postoperative pain was 36.6% at 12 h, 20% at 24 h, and 10% at 36 h. Patients with preoperative pain and preoperative anxiety were more likely to experience moderate to severe postoperative pain [adjusted odds ratio (AOR)=3.41, CI=1.15, 10.00 and AOR=2.28, CI=1.219, 4.277, respectively). Intraoperative predictors of postoperative pain severity included longer duration of surgery (AOR=6.62, CI=1.90, 23.00) and major surgery (AOR=5.2, CI=2.11, 12.88). Postoperative pain severity was reduced in patients receiving multimodal analgesia (AOR=0.24; CI=0.091, 0.652) and in patients assessed frequently in the postoperative period (AOR=0.09; CI=0.022, 0.393). Conclusion A significant portion of paediatric surgical patients in this study experienced high levels of postoperative pain, particularly within the first 24 h. The most influential factors affecting pain severity were postoperative pain management strategies and assessment practices.
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Affiliation(s)
- Fassil Mihretu Rede
- Wollo University, College of Medicine and Health Sciences, Department of Anesthesia, Dessie
| | - Eyayalem Melese Goshu
- Addis Ababa University, College of Health Sciences, Department of Anesthesia, Addis Ababa, Ethiopia
| | - Sulaiman Jemal muzien
- Addis Ababa University, College of Health Sciences, Department of Anesthesia, Addis Ababa, Ethiopia
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Pessano S, Gloeck NR, Tancredi L, Ringsten M, Hohlfeld A, Ebrahim S, Albertella M, Kredo T, Bruschettini M. Ibuprofen for acute postoperative pain in children. Cochrane Database Syst Rev 2024; 1:CD015432. [PMID: 38180091 PMCID: PMC10767793 DOI: 10.1002/14651858.cd015432.pub2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2024]
Abstract
BACKGROUND Children often require pain management following surgery to avoid suffering. Effective pain management has consequences for healing time and quality of life. Ibuprofen, a frequently used non-steroidal anti-inflammatory drug (NSAID) administered to children, is used to treat pain and inflammation in the postoperative period. OBJECTIVES 1) To assess the efficacy and safety of ibuprofen (any dose) for acute postoperative pain management in children compared with placebo or other active comparators. 2) To compare ibuprofen administered at different doses, routes (e.g. oral, intravenous, etc.), or strategies (e.g. as needed versus as scheduled). SEARCH METHODS We used standard Cochrane search methods. We searched CENTRAL, MEDLINE, Embase, CINAHL and trials registries in August 2023. SELECTION CRITERIA We included randomised controlled trials (RCTs) in children aged 17 years and younger, treated for acute postoperative or postprocedural pain, that compared ibuprofen to placebo or any active comparator. We included RCTs that compared different administration routes, doses of ibuprofen and schedules. DATA COLLECTION AND ANALYSIS We adhered to standard Cochrane methods for data collection and analysis. Our primary outcomes were pain relief reported by the child, pain intensity reported by the child, adverse events, and serious adverse events. We present results using risk ratios (RR) and standardised mean differences (SMD), with the associated confidence intervals (CI). We used GRADE to assess the certainty of the evidence. MAIN RESULTS We included 43 RCTs that enroled 4265 children (3935 children included in this review). We rated the overall risk of bias at the study level as high or unclear for 37 studies that had one or several unclear or high risk of bias judgements across the domains. We judged six studies as having a low risk of bias across all domains. Ibuprofen versus placebo (35 RCTs) No studies reported pain relief reported by the child or a third party, or serious adverse events. Ibuprofen probably reduces child-reported pain intensity less than two hours postintervention compared to placebo (SMD -1.12, 95% CI -1.39 to -0.86; 3 studies, 259 children; moderate-certainty evidence). Ibuprofen may reduce child-reported pain intensity, two hours to less than 24 hours postintervention (SMD -1.01, 95% CI -1.24 to -0.78; 5 studies, 345 children; low-certainty evidence). Ibuprofen may result in little to no difference in adverse events compared to placebo (RR 0.79, 95% CI 0.51 to 1.23; 5 studies, 384 children; low-certainty evidence). Ibuprofen versus paracetamol (21 RCTs) No studies reported pain relief reported by the child or a third party, or serious adverse events. Ibuprofen likely reduces child-reported pain intensity less than two hours postintervention compared to paracetamol (SMD -0.42, 95% CI -0.82 to -0.02; 2 studies, 100 children; moderate-certainty evidence). Ibuprofen may slightly reduce child-reported pain intensity two hours to 24 hours postintervention (SMD -0.21, 95% CI -0.40 to -0.02; 6 studies, 422 children; low-certainty evidence). Ibuprofen may result in little to no difference in adverse events (0 events in each group; 1 study, 44 children; low-certainty evidence). Ibuprofen versus morphine (1 RCT) No studies reported pain relief or pain intensity reported by the child or a third party, or serious adverse events. Ibuprofen likely results in a reduction in adverse events compared to morphine (RR 0.58, 95% CI 0.40 to 0.83; risk difference (RD) -0.25, 95% CI -0.40 to -0.09; number needed to treat for an additional beneficial outcome (NNTB) 4; 1 study, 154 children; moderate-certainty evidence). Ibuprofen versus ketorolac (1 RCT) No studies reported pain relief or pain intensity reported by the child, or serious adverse events. Ibuprofen may result in a reduction in adverse events compared to ketorolac (RR 0.51, 95% CI 0.27 to 0.96; RD -0.29, 95% CI -0.53 to -0.04; NNTB 4; 1 study, 59 children; low-certainty evidence). AUTHORS' CONCLUSIONS Despite identifying 43 RCTs, we remain uncertain about the effect of ibuprofen compared to placebo or active comparators for some critical outcomes and in the comparisons between different doses, schedules and routes for ibuprofen administration. This is largely due to poor reporting on important outcomes such as serious adverse events, and poor study conduct or reporting that reduced our confidence in the results, along with small underpowered studies. Compared to placebo, ibuprofen likely results in pain reduction less than two hours postintervention, however, the efficacy might be lower at two hours to 24 hours. Compared to paracetamol, ibuprofen likely results in pain reduction up to 24 hours postintervention. We could not explore if there was a different effect in different kinds of surgeries or procedures. Ibuprofen likely results in a reduction in adverse events compared to morphine, and in little to no difference in bleeding when compared to paracetamol. We remain mostly uncertain about the safety of ibuprofen compared to other drugs.
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Affiliation(s)
- Sara Pessano
- Pediatric Clinic and Endocrinology Unit, IRCCS Istituto G. Gaslini, Genoa, Italy
| | - Natasha R Gloeck
- Health Systems Research Unit, South African Medical Research Council, Cape Town, South Africa
| | - Luca Tancredi
- Geriatrie, Hessing Stiftung, Augsburg, Germany
- Medical School, Regiomed, Coburg, Germany
| | - Martin Ringsten
- Cochrane Sweden, Department of Research and Education, Skåne University Hospital, Lund University, Lund, Sweden
| | - Ameer Hohlfeld
- Health Systems Research Unit, South African Medical Research Council, Cape Town, South Africa
| | - Sumayyah Ebrahim
- Health Systems Research Unit, South African Medical Research Council, Cape Town, South Africa
- Department of Surgery, School of Clinical Medicine, University of KwaZulu-Natal, Durban, South Africa
| | | | - Tamara Kredo
- Health Systems Research Unit, South African Medical Research Council, Cape Town, South Africa
- Cochrane South Africa, South African Medical Research Council, Cape Town, South Africa
- Division of Clinical Pharmacology, Department of Medicine and Division of Epidemiology and Biostatistics, Department of Global Health, Stellenbosch University, Cape Town, South Africa
| | - Matteo Bruschettini
- Cochrane Sweden, Department of Research and Education, Skåne University Hospital, Lund University, Lund, Sweden
- Paediatrics, Department of Clinical Sciences Lund, Lund University, Skåne University Hospital, Lund, Sweden
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Kiskaddon AL, Stock AC, Fierstein JL, Miller A, Quintessenza JA, Goldenberg N. Ketorolac in neonates and infants following congenital heart surgery: a retrospective review. Cardiol Young 2023:1-7. [PMID: 38131146 DOI: 10.1017/s1047951123004262] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2023]
Abstract
INTRODUCTION Pain management is essential in the immediate post-surgical period. We sought to describe the ketorolac dose regimen in neonates and infants following cardiac surgery. Secondary outcomes included renal dysfunction, bleeding, and pain management. METHODS We performed a single-centre retrospective cohort study of neonates and infants (aged < 12 months) who received ketorolac following cardiac surgery, from November 2020 through November 2021 (inclusive). Ketorolac was administered at 0.5 mg/kg every 6 hours. Safety was defined by absence of a clinically significant decline in renal function (i.e., increase in serum creatinine [SCr] by ≥ 0.3 mg/dL from baseline within 48 hours and/or urine output ≤ 0.5 mL/kg/hour for 6 hours) and absence of clinically significant bleeding defined as major by International Society on Thrombosis and Hemostasis paediatric criteria or Severe/Fatal Bleeding Events by Nellis et al. Efficacy measures included pain scores and opioid utilisation. RESULTS Fifty-five patients met eligibility criteria. The median (range) dose and duration of ketorolac administration was 0.5 mg/kg/dose for 48 (6-90) hours. Among all patients, there was not a statistically significant difference observed in median SCr within 48 hours of baseline (p > .9). There were no major or severe bleeding events. The median (range) opioid requirements (morphine intravenous equivalents per kg per day) at 48 hours post-ketorolac initiation was 0.1 (0-0.8) mg/kg/day. CONCLUSIONS If validated prospectively, these findings suggest that a ketorolac regimen 0.5 mg/kg/dose every 6 hours in neonates and infants post-cardiac surgery may be safe with regard to renal function and bleeding risk, and effective regarding opioid-sparing capacity.
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Affiliation(s)
- Amy L Kiskaddon
- Department of Pharmacy, Johns Hopkins All Children's Hospital, St. Petersburg, FL, USA
- Division of Cardiology, Department of Pediatrics, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Arabela C Stock
- Division of Cardiac Critical Care, Heart Institute, Johns Hopkins All Children's Hospital, St. Petersburg, FL, USA
- Heart Institute, Johns Hopkins All Children's Hospital, St. Petersburg, FL, USA
| | - Jamie L Fierstein
- Institute for Clinical and Translational Research, Epidemiology and Biostatistics Shared Resource, Johns Hopkins All Children's Hospital, St. Petersburg, FL, USA
| | - Alexandra Miller
- Institute for Clinical and Translational Research, Epidemiology and Biostatistics Shared Resource, Johns Hopkins All Children's Hospital, St. Petersburg, FL, USA
| | | | - Neil Goldenberg
- Institute for Clinical and Translational Research, Epidemiology and Biostatistics Shared Resource, Johns Hopkins All Children's Hospital, St. Petersburg, FL, USA
- Division of Hematology, Departments of Medicine and Pediatrics, Johns Hopkins School of Medicine, Baltimore, MD, USA
- Cancer and Blood Disorders Institute, Johns Hopkins All Children's Hospital, St. Petersburg, FL, USA
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9
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Lisanti AJ, Vittner DJ, Peterson J, Van Bergen AH, Miller TA, Gordon EE, Negrin KA, Desai H, Willette S, Jones MB, Caprarola SD, Jones AJ, Helman SM, Smith J, Anton CM, Bear LM, Malik L, Russell SK, Mieczkowski DJ, Hamilton BO, McCoy M, Feldman Y, Steltzer M, Savoca ML, Spatz DL, Butler SC. Developmental care pathway for hospitalised infants with CHD: on behalf of the Cardiac Newborn Neuroprotective Network, a Special Interest Group of the Cardiac Neurodevelopmental Outcome Collaborative. Cardiol Young 2023; 33:2521-2538. [PMID: 36994672 PMCID: PMC10544686 DOI: 10.1017/s1047951123000525] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/31/2023]
Abstract
Infants and children born with CHD are at significant risk for neurodevelopmental delays and abnormalities. Individualised developmental care is widely recognised as best practice to support early neurodevelopment for medically fragile infants born premature or requiring surgical intervention after birth. However, wide variability in clinical practice is consistently demonstrated in units caring for infants with CHD. The Cardiac Newborn Neuroprotective Network, a Special Interest Group of the Cardiac Neurodevelopmental Outcome Collaborative, formed a working group of experts to create an evidence-based developmental care pathway to guide clinical practice in hospital settings caring for infants with CHD. The clinical pathway, "Developmental Care Pathway for Hospitalized Infants with Congenital Heart Disease," includes recommendations for standardised developmental assessment, parent mental health screening, and the implementation of a daily developmental care bundle, which incorporates individualised assessments and interventions tailored to meet the needs of this unique infant population and their families. Hospitals caring for infants with CHD are encouraged to adopt this developmental care pathway and track metrics and outcomes using a quality improvement framework.
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Affiliation(s)
- Amy J. Lisanti
- Department of Family and Community Health, University of Pennsylvania School of Nursing, Philadelphia, PA, USA, Research Institute, Children’s Hospital of Philadelphia, Philadelphia, PA, USA
| | - Dorothy J. Vittner
- Egan School of Nursing and Health Studies, Fairfield University Fairfield, CT, USA, Connecticut Children’s, Hartford, CT, USA
| | | | - Andrew H. Van Bergen
- Advocate Children’s Heart Institute, Advocate Children’s Hospital, Oak Lawn, IL, USA
| | - Thomas A. Miller
- Department of Pediatrics, Maine Medical Center, Portland, ME, USA
| | - Erin E. Gordon
- DO, Inpatient Cardiac Neurodevelopment Program, Division of Critical Care Medicine, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Karli A Negrin
- Department of Therapeutic and Rehabilitative Services, Nemours Children Hospital, Wilmington, Delaware, USA
| | - Hema Desai
- Rehabilitation Services, CHOC Children’s Hospital, Orange, CA, USA
| | - Suzie Willette
- Department of Speech-Language Pathology, Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, IL, USA
| | - Melissa B Jones
- Cardiac Critical Care, Children’s National Hospital, Washington DC USA
| | - Sherrill D. Caprarola
- Heart Institute, Children’s Hospital Colorado, University of Colorado, Aurora, CO, USA
| | - Anna J. Jones
- Office of Advanced Practice Providers, UT Southwestern Medical Center, Dallas, TX, USA, Heart Center, Children’s Health, Dallas, TX, USA
| | - Stephanie M. Helman
- Department of Acute and Tertiary Care, University of Pittsburgh School of Nursing, Pittsburgh, PA, USA
| | - Jodi Smith
- Parent Representative, The Mended Hearts, Inc., Program Director, Richmond, VA, USA
| | - Corinne M. Anton
- Department of Psychology and Psychiatry, University of Texas Southwestern Medical Center, Dallas, Texas, USA, Department of Cardiology, Children’s Health, Dallas, Texas, USA
| | - Laurel M. Bear
- Department of Pediatrics, Medical College of Wisconsin, Children’s Wisconsin, Milwaukee, WI, USA
| | - Lauren Malik
- Department of Acute Care Therapy Services, Primary Children’s Hospital, Salt Lake City, UT, USA
| | - Sarah K. Russell
- Department of Therapeutic and Rehabilitative Services, Nemours Children Hospital, Wilmington, DE, USA
| | - Dana J. Mieczkowski
- Department of Therapeutic and Rehabilitative Services, Nemours Children Hospital, Wilmington, DE, USA
| | - Bridy O. Hamilton
- Department of Therapeutic and Rehabilitative Services, Nemours Children Hospital, Wilmington, Delaware, USA
| | - Meghan McCoy
- Pediatric and Congenital Heart Center, Duke University Hospital, Durham, NC, USA
| | - Yvette Feldman
- Nursing & Patient Care Center of Excellence, St. Luke’s Health System, Boise, ID, USA
| | - Michelle Steltzer
- Single Ventricle Center of Excellence, Ann & Robert H. Lurie Children’s Hospital, Chicago, IL, USA
| | - Melanie L Savoca
- Department of Clinical Nutrition, Children’s Hospital of Philadelphia, Philadelphia, PA, USA
| | - Diane L. Spatz
- Department of Family & Community Health, University of Pennsylvania School of Nursing, The Center for Pediatric Nursing Research and Evidence Based Practice, Children’s Hospital of Philadelphia, Philadelphia, PA, USA
| | - Samantha C. Butler
- Department of Psychiatry (Psychology), Boston Children’s Hospital, Harvard Medical School, Boston, MA, USA
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10
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Pardessus P, Loiselle M, Silins V, Horlin AL, Brouns K, Marsac L, Fait C, Ilharreborde B, Julien-Marsollier F, Dahmani S. The association between intraoperative fluid management and perioperative allogenic blood transfusion during adolescent idiopathic scoliosis surgery. Paediatr Anaesth 2023; 33:829-836. [PMID: 37386846 DOI: 10.1111/pan.14722] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2023] [Revised: 06/20/2023] [Accepted: 06/21/2023] [Indexed: 07/01/2023]
Abstract
INTRODUCTION Bleeding and transfusion remain important concerns during surgical correction of scoliosis even when multiple conservative strategies, such as preoperative recombinant erythropoietin and/or antifibrinolytic agents, are used. The current work aimed to determine the impact of other potential risk factors, especially the volume of intraoperative fluid intake, on the perioperative risk of allogenic transfusion during surgical correction of adolescent idiopathic scoliosis. METHODS This prospective study included all cases of adolescent idiopathic scoliosis operated in a single center during 2 years (2018-2020). Predictors analyzed were as follows: body mass index, preoperative hemoglobin concentration, thoracoplasty, preoperative halo-gravity, volume of intraoperative crystalloid administration, use of esophageal Doppler (for goal-directed fluid therapy), and duration of surgery. Statistical analyses were performed using a multivariable logistic regression model. RESULTS Two hundred patients were included in the analysis. Multivariable analysis found: an increased volume of intraoperative crystalloid administration as a significant predictor of allogenic blood transfusion. Receiving operator characteristics analysis found the model exhibiting an area under the curve of 0.85 (95% confidence interval: 0.75-0.95). Optimizing stroke volume using esophageal Doppler was associated with a decrease in intraoperative crystalloid intake. CONCLUSION These results indicate a statistical association between the increase in crystalloid intake and the risk of allogenic blood transfusion during surgical correction of adolescent idiopathic scoliosis. Controlled studies are needed to address the causative relation between intraoperative fluid intake and the risk of allogenic transfusion.
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Affiliation(s)
- Pierre Pardessus
- Université de Paris-Cité, Paris, France
- Department of Anesthesia and Intensive Care, Robert Debré Hospital, Paris, France
| | - Maud Loiselle
- Université de Paris-Cité, Paris, France
- Department of Anesthesia and Intensive Care, Robert Debré Hospital, Paris, France
| | - Vilnis Silins
- Université de Paris-Cité, Paris, France
- Department of Anesthesia and Intensive Care, Robert Debré Hospital, Paris, France
| | - Anne-Laure Horlin
- Université de Paris-Cité, Paris, France
- Department of Anesthesia and Intensive Care, Robert Debré Hospital, Paris, France
| | - Kelly Brouns
- Université de Paris-Cité, Paris, France
- Department of Anesthesia and Intensive Care, Robert Debré Hospital, Paris, France
| | - Lucile Marsac
- Université de Paris-Cité, Paris, France
- Department of Anesthesia and Intensive Care, Robert Debré Hospital, Paris, France
| | - Charlotte Fait
- Université de Paris-Cité, Paris, France
- Department of Anesthesia and Intensive Care, Robert Debré Hospital, Paris, France
| | - Brice Ilharreborde
- Université de Paris-Cité, Paris, France
- FHU I2D2. Robert Debré Hospital, Paris, France
- Department of orthopedic surgery, Robert Debré Hospital, Paris, France
| | - Florence Julien-Marsollier
- Université de Paris-Cité, Paris, France
- Department of Anesthesia and Intensive Care, Robert Debré Hospital, Paris, France
- FHU I2D2. Robert Debré Hospital, Paris, France
| | - Souhayl Dahmani
- Université de Paris-Cité, Paris, France
- Department of Anesthesia and Intensive Care, Robert Debré Hospital, Paris, France
- FHU I2D2. Robert Debré Hospital, Paris, France
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11
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Fang J, Wu W, Liu J, Zhang S. Deep learning-guided postoperative pain assessment in children. Pain 2023; 164:2029-2035. [PMID: 37146182 PMCID: PMC10436358 DOI: 10.1097/j.pain.0000000000002900] [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: 04/16/2022] [Revised: 10/25/2022] [Accepted: 12/05/2022] [Indexed: 05/07/2023]
Abstract
ABSTRACT Current automated pain assessment methods only focus on infants or youth. They are less practical because the children who suffer from postoperative pain in clinical scenarios are in a wider range of ages. In this article, we present a large-scale Clinical Pain Expression of Children (CPEC) dataset for postoperative pain assessment in children. It contains 4104 preoperative videos and 4865 postoperative videos of 4104 children (from 0 to 14 years of age), which are collected from January 2020 to December 2020 in Anhui Provincial Children's Hospital. Moreover, inspired by the dramatic successful applications of deep learning in medical image analysis and emotion recognition, we develop a novel deep learning-based framework to automatically assess postoperative pain according to the facial expression of children, namely Children Pain Assessment Neural Network (CPANN). We train and evaluate the CPANN with the CPEC dataset. The performance of the framework is measured by accuracy and macro-F1 score metrics. The CPANN achieves 82.1% accuracy and 73.9% macro-F1 score on the testing set of CPEC. The CPANN is faster, more convenient, and more objective compared with using pain scales according to the specific type of pain or children's condition. This study demonstrates the effectiveness of deep learning-based method for automated pain assessment in children.
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Affiliation(s)
- Jihong Fang
- Anhui Provincial Children's Hospital, Hefei, Anhui, China
| | - Wei Wu
- Anhui Provincial Children's Hospital, Hefei, Anhui, China
| | - Jiawei Liu
- University of Science and Technology of China, Hefei, Anhui, China
| | - Sicheng Zhang
- University of Science and Technology of China, Hefei, Anhui, China
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12
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Holladay J, Winch P, Morse J, Anderson BJ, McKee CT, Rice-Weimer J, Tobias JD. Acetaminophen pharmacokinetics in infants and children with congenital heart disease. Paediatr Anaesth 2023; 33:46-51. [PMID: 36264219 PMCID: PMC10100048 DOI: 10.1111/pan.14579] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2022] [Revised: 10/11/2022] [Accepted: 10/16/2022] [Indexed: 01/20/2023]
Abstract
BACKGROUND Acetaminophen is routinely used for perioperative analgesia in children undergoing major surgical procedures. There are few estimates of acetaminophen pharmacokinetic parameters in children with congenital heart disease, especially those with cyanotic heart disease. AIMS The current study prospectively investigated differences in acetaminophen pharmacokinetics following surgery using cardiopulmonary bypass in children with cyanotic and acyanotic congenital heart disease. METHODS Children (2-6 years, 9-23 kg) presenting for median sternotomy for Fontan palliation (cyanotic patients) or two ventricle surgical repair (acyanotic patients) were eligible for inclusion. A single intravenous dose of acetaminophen (15 mg/kg) was administered at the start of sternal closure after separation from cardiopulmonary bypass. The time-course of acetaminophen concentrations were described using non-linear mixed effects models. One and two-compartment disposition models with first-order elimination were tested. Pharmacokinetic parameter estimates were scaled using allometry and standardized to a 70 kg person. RESULTS There were 208 acetaminophen concentrations assayed from 30 children, 15 with cyanotic, and 15 with acyanotic heart disease. A 2-compartment model best described acetaminophen PK. Parameter estimates (population parameter variability, PPV%; 95% confidence interval, CI) were clearance CL 15.3 L.h-1.70 kg-1 (22.2%; 13.8-16.7), intercompartment clearance Q 45.4 L.h-1.70 kg-1 (22.4%; 25.2-61.9), central volume of distribution V1 33.5 L.70 kg-1 (23.2%; 25.9-38.8), peripheral volume of distribution V2 32.1 L.70 kg-1 (21.7%; 25.9-38.8). Neither clearance nor volume parameters differed between cyanotic and acyanotic patients. CONCLUSIONS Acetaminophen pharmacokinetics were characterized using a 2-compartment model with first-order elimination following cardiac bypass surgery in children. Population pharmacokinetic parameter estimates were similar to other studies in children. No differences were detected between patients with cyanotic and acyanotic heart disease.
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Affiliation(s)
- Jay Holladay
- Department of Anesthesiology & Pain Medicine, Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Peter Winch
- Department of Anesthesiology & Pain Medicine, Nationwide Children's Hospital, Columbus, Ohio, USA.,Department of Anesthesiology & Pain Medicine, The Ohio State University College of Medicine, Columbus, Ohio, USA
| | - James Morse
- Department of Anesthesiology, University of Auckland, Auckland, New Zealand
| | - Brian J Anderson
- Department of Anesthesiology, University of Auckland, Auckland, New Zealand
| | - Christopher T McKee
- Department of Anesthesiology & Pain Medicine, Nationwide Children's Hospital, Columbus, Ohio, USA.,Department of Anesthesiology & Pain Medicine, The Ohio State University College of Medicine, Columbus, Ohio, USA
| | - Julie Rice-Weimer
- Department of Anesthesiology & Pain Medicine, Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Joseph D Tobias
- Department of Anesthesiology & Pain Medicine, Nationwide Children's Hospital, Columbus, Ohio, USA.,Department of Anesthesiology & Pain Medicine, The Ohio State University College of Medicine, Columbus, Ohio, USA
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13
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Cardiovascular Effects of Adding Epinephrine to Bupivacaine in Children Undergoing Caudal Block: A Double-blind Randomized Clinical Trial. Neuromodulation 2022. [DOI: 10.5812/ipmn-134053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Background: Caudal block is a common, safe, and effective anesthetic technique for lower abdominal, urological, and lower extremity surgeries in pediatrics. Objectives: This study aimed to evaluate the cardiovascular effects of adjuvant epinephrine in the caudal block on heart rate and blood pressure changes in children. Methods: This double-blind, randomized clinical trial was performed on 60 children who underwent elective infra-umbilical surgeries. They were under general anesthesia with midazolam, fentanyl, lidocaine, and propofol. The patients were ventilated through laryngeal mask airway (LMA), and anesthesia was maintained with sevoflurane in O2 and N2O mixture. The intervention group received a caudal block with 0.2% bupivacaine and 1/200000 epinephrine (1 mL/kg), while the control group received a caudal block without epinephrine. Heart rate, blood pressure, and ECG were monitored before the block and in the first, fifth, and 20th minutes after surgery. Results: The two groups showed no statistically significant differences in demographics and systolic and diastolic blood pressures. However, sinus arrhythmia was more prevalent in the study group in the first minute after the block (P < 0.001). No differences were observed in the incidence of arrhythmia in the fifth and 20th minutes after the block. Conclusions: It appears that epinephrine as an adjuvant to the caudal block does not have long-lasting effects after the block, except sinus tachycardia in the first minute. Considering that no changes in blood pressure and other hemodynamic parameters were observed, it seems that epinephrine can be used safely in the caudal block in pediatric patients.
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14
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Byun S, Morris S, Pather N. Magnetic resonance imaging study of the sciatic nerve variation in the pediatric gluteal region: Implications for the posterior approach of the sciatic nerve blockade. Paediatr Anaesth 2022; 32:1355-1364. [PMID: 35986899 PMCID: PMC9804702 DOI: 10.1111/pan.14545] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2021] [Revised: 06/22/2022] [Accepted: 08/16/2022] [Indexed: 01/07/2023]
Abstract
INTRODUCTION In pediatric patients, the sciatic nerve is one of the most commonly blocked peripheral nerves during orthopedic procedures of the lower limb. Ultrasound guidance is the current standard for a successful localization of the sciatic nerve in the gluteal region. Relevant anatomical landmarks are also used to determine the nerve location when ultrasound is not available or inadequate. However, reports have demonstrated paucity of information regarding the sciatic nerve location and variation in the hip throughout pediatric development. This imaging study aimed to document and analyze the relative morphometric relationship of the sciatic nerve in the pediatric gluteal region throughout development. METHODS The location of the sciatic nerve in relation to bony landmarks was measured in 84 pediatric magnetic resonance imaging of patients aged 0.7-15.8 years. RESULTS The sciatic nerve was identified medial to the most lateral point of greater trochanter at the level of ischial spine and the tip of coccyx. The strong positive correlation between sciatic nerve to landmark distances and age and stature demonstrated linear variation between sciatic nerve location with age and growth of children. To predict the nerve location in the gluteal region, regression equations using patient age were created, having implications for the posterior approach of the sciatic nerve blockade in children. Clinically significant differences were found between sexes, specifically in the older age group. CONCLUSION Despite the small sample size of younger age group, this study is the first to document the morphometric changes of the sciatic nerve in the gluteal region across pediatric development and may be useful for providing confirmatory guidelines for nerve location when ultrasound is not accessible or cannot be utilized for practice.
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Affiliation(s)
- Sarang Byun
- Department of Anatomy, School of Medical SciencesMedicine and HealthUNSW SydneySydneyNew South WalesAustralia
| | - Sarah Morris
- Department of Medical ImagingSydney Children's HospitalRandwickNew South WalesAustralia
| | - Nalini Pather
- Department of Anatomy, School of Medical SciencesMedicine and HealthUNSW SydneySydneyNew South WalesAustralia
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15
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Wang C, Liu LD, Bai X. Bibliometric and Visual Analysis of the Current Status and Trends of Postoperative Pain in Children from 1950-2021. J Pain Res 2022; 15:3209-3222. [PMID: 36267350 PMCID: PMC9578501 DOI: 10.2147/jpr.s380842] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2022] [Accepted: 10/04/2022] [Indexed: 11/05/2022] Open
Abstract
Background Postoperative pain in children has been overlooked for a long time. The knowledge structure, research hotspots and trends related to postoperative pain in children are unclear and have not been systematically summarized. Purpose We aimed to analyze the current state of research on postoperative pain in children and to conduct in-depth mining of the knowledge structure. Methods The PubMed database for publications on postoperative pain in children between 1950 and 2021 was searched. Bibliographic Item Co-Occurrence Matrix Builder (BICOMB) was performed to obtain the co-word matrix and co-occurrence matrix. The H-index method was used to extract high-frequency main Medical Subject Headings (MeSH) terms/subheadings. Results The high-frequency MeSH terms were analyzed by biclustering, strategic diagram and social network analyses. Totally, 4022 publications were retrieved. The analysis showed that 60 countries or regions published relevant documents, with the United States publishing the most significant number of papers. Totally, 811 journals published relevant papers, with Pediatric Anesthesia ranking first. Moreover, we extracted 43 high-frequency main MeSH terms/subheadings and clustered them into five categories: overview, aetiology and epidemiology, pharmacotherapy, opioid administration and dosing, and prevention and control of postoperative pain in children. Conclusion Pharmacological treatments, pain prevention and control are the focus of research and are becoming increasingly mature. Opioid stewardship and regional anesthesia is the trend and focus of future research. Our study offers a better understanding of the current status and knowledge structure of postoperative pain in children and provides a reference for improving postoperative pain management in children in the future.
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Affiliation(s)
- Cong Wang
- Department of Anesthesiology, Shengjing Hospital of China Medical University, Shenyang, People’s Republic of China
| | - Li-Dan Liu
- Department of Anesthesiology, Shengjing Hospital of China Medical University, Shenyang, People’s Republic of China
| | - Xue Bai
- Department of Health Management, Shengjing Hospital of China Medical University, Shenyang, People’s Republic of China,Correspondence: Xue Bai, Department of Health Management, Shengjing Hospital of China Medical University, No. 36 Sanhao Street, Heping District, Shenyang, 110004, People’s Republic of China, Email
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16
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Pessano S, Kredo T, Bruschettini M, Gloeck NR. Ibuprofen for acute postoperative pain in children. Hippokratia 2022. [DOI: 10.1002/14651858.cd015432] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Sara Pessano
- Neonatal Intensive Care Unit, Department Mother and Child; IRCCS Istituto Giannina Gaslini; Genoa Italy
| | - Tamara Kredo
- Cochrane South Africa; South African Medical Research Council; Cape Town South Africa
| | - Matteo Bruschettini
- Cochrane Sweden, Research and Development; Skåne University Hospital, Lund University; Lund Sweden
- Department of Clinical Sciences Lund; Paediatrics, Lund University, Skåne University Hospital; Lund Sweden
| | - Natasha R Gloeck
- Cochrane South Africa; South African Medical Research Council; Cape Town South Africa
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17
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Sharma N, Arahna VP, Saxena S, Ateef M, Samuel AJ. Scoping out the scope of scoping reviews in neonatal and pediatric pain management: A scoping review methodological framework. J Pediatr Surg 2022; 57:1599-1608. [PMID: 34876296 DOI: 10.1016/j.jpedsurg.2021.11.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2021] [Revised: 11/12/2021] [Accepted: 11/14/2021] [Indexed: 11/18/2022]
Abstract
PURPOSE This methodological framework was purposed to discuss the considerations for conducting scoping review for neonatal and pediatric pain management (NPPM) from the perspectives of Arksey and O' Malley and Joanna Briggs Institute (JBI) framework. Till now, there is no scoping review or standard methods are available for identifying, prioritizing, or reporting research gaps in the area of NPPM. METHODS AND RESULTS Scoping reviews were utilized to map the literature comprehensively across a range of study designs in a particular area. This methodological framework describes the methods used to identify, prioritize, and display research gaps in the area of NPPM. Different methods to determine research gaps have been described in this framework. This scoping review methodological framework also discussed methods for conducting scoping review in two levels with methodological considerations given by Arksey and O'Malley, and JBI Institute. Search terms and search terminologies are described to conduct scoping review effectively for NPPM. Through, this standard scoping review methodological considerations, the general understanding and current advances in NPPM can be widened. CONCLUSION This methodological framework describes the methods for conducting scoping review effectively in the area of NPPM. LEVEL OF EVIDENCE Not applicable.
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Affiliation(s)
- Neha Sharma
- Department of Pediatric and Neonatal Physiotherapy, Maharishi Markandeshwar Institute of Physiotherapy and Rehabilitation, Maharishi Markandeshwar (Deemed to be University), Mullana, Haryana 133207, India.
| | - Vencita Priyanka Arahna
- Department of Pediatric and Neonatal Physiotherapy, Maharishi Markandeshwar Institute of Physiotherapy and Rehabilitation, Maharishi Markandeshwar (Deemed to be University), Mullana, Haryana 133207, India.
| | - Shikha Saxena
- School Based Rehabilitation Services, Physiotherapy Division, Communicare Therapy Inc., Ottawa , Canada.
| | - Mahamed Ateef
- Department of Physical Therapy and Health Rehabilitation, College of Applied Medical Sciences, Majmaah University, Al Majmaah 11952, Saudi Arabia.
| | - Asir John Samuel
- Department of Pediatric and Neonatal Physiotherapy, Maharishi Markandeshwar Institute of Physiotherapy and Rehabilitation, Maharishi Markandeshwar (Deemed to be University), Mullana, Haryana 133207, India.
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Neumann C, Babasiz T, Straßberger-Nerschbach N, Schindler E, Reuter C, Weinhold L, Wittmann M, Hilbert T, Klaschik S. Comparison of the Newborn Infant Parasympathetic Evaluation (NIPE™) index to changes in heart rate to detect intraoperative nociceptive stimuli in healthy and critically ill children below 2 years: An observational study. Paediatr Anaesth 2022; 32:815-824. [PMID: 35332622 DOI: 10.1111/pan.14446] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2021] [Revised: 02/24/2022] [Accepted: 03/08/2022] [Indexed: 11/30/2022]
Abstract
BACKGROUND The validity of current tools for intraoperative objective assessment of nociception/antinociception balance during anesthesia in young and very young surgery children is unknown. AIM Primary aim of the study was to test the hypothesis that the Newborn Infant Parasympathetic Evaluation (NIPE) index performs better in indicating nociception in anesthetized children below 2 years than changes in heart rate. Secondary aims were to evaluate associations between intraoperative changes in NIPE index values and postoperative pain and emergence delirium. METHODS Fifty-one children aged <2 years who underwent surgery were included in this prospective observational study. Patients were assigned to either group 1 (healthy children, n = 31) or group 2 (critically ill, ventilated premature infants and neonates, n = 20). The NIPE index and heart rate in response to three defined nociceptive stimuli were continuously recorded. Two different scales, Kindliche Unbehagens- und Schmerzskala (KUS) and Pediatric Anesthesia Emergence Delirium (PAED) as well as a Pain Questionnaire were used to assess postoperative pain levels and emergence delirium. RESULTS In total, 110 nociceptive events were evaluated. The analysis revealed a statistically significant association between a decrease in the NIPE index and all nociceptive stimuli, with a sensitivity of 92% and a specificity of 96%. The mean percentage decrease ranged from approx. 15%-30% and was highly statistically significant in both groups and for each of the nociceptive events except for venous puncture (p = .004). In contrast, no consistent change in heart rate was demonstrated. The KUS and PAED scale scores were significantly associated with the duration of anesthesia (p = .04), but not with intraoperative NIPE depression. CONCLUSION The NIPE index was reliable for assessing intraoperative nociception in children aged <2 years and was more reproducible for detecting specific nociceptive stimuli during general anesthesia than heart rate. An effect on postoperative outcome is still elusive.
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Affiliation(s)
- Claudia Neumann
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Bonn, Bonn, Germany
| | - Tamara Babasiz
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Bonn, Bonn, Germany
| | | | - Ehrenfried Schindler
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Bonn, Bonn, Germany
| | - Christian Reuter
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Bonn, Bonn, Germany
| | - Leonie Weinhold
- Department of Medical Biometry, Informatics and Epidemiology, University Hospital Bonn, Bonn, Germany
| | - Maria Wittmann
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Bonn, Bonn, Germany
| | - Tobias Hilbert
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Bonn, Bonn, Germany
| | - Sven Klaschik
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Bonn, Bonn, Germany
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19
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Rosenbloom JM, De Souza E, Perez FD, Xie J, Suarez-Nieto MV, Wang E, Anderson TA. Association of Race and Ethnicity with Pediatric Postoperative Pain Outcomes. J Racial Ethn Health Disparities 2022; 10:1414-1422. [PMID: 35622316 DOI: 10.1007/s40615-022-01327-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2021] [Revised: 05/04/2022] [Accepted: 05/05/2022] [Indexed: 11/24/2022]
Abstract
INTRODUCTION Inequitable variability in healthcare practice negatively affects patient outcomes. Children of color may receive different analgesic medications in the perioperative period, resulting in different outcomes. METHODS Medical records of children 0 to ≤ 18 years old from May 2014 to August 2019 were reviewed. The exposure was racial or ethnic groups: Asian, Black, Hispanic, Pacific Islander, and White non-Hispanic (reference). PRIMARY OUTCOME post-anesthesia care unit mean pain score. SECONDARY OUTCOMES inpatient mean pain score; opioid, antiemetic, and antipruritic administration in the post-anesthesia care unit and inpatient ward. The association of race or ethnicity with outcomes was modeled using multilevel logistic regression, adjusting for confounders and covariates. RESULTS Twenty-nine thousand six hundred fourteen cases are included. In the post-anesthesia care unit, Black, Hispanic, and Pacific Islander children had no significant difference in the odds of receiving opioids or having moderate-severe pain as compared to White non-Hispanic patients; Asian children had lower odds of receiving opioids and lower odds of having a moderate-severe mean pain score. In the inpatient setting, Black, Hispanic, and Pacific Islander children had no significant difference in the odds of receiving opioids or having moderate severe-pain as compared to White non-Hispanic children, but Asian children had lower odds of receiving opioids and of having a moderate-severe mean pain score. CONCLUSIONS Asian children had lower odds of receiving opioids and having moderate-severe pain postoperatively compared to the White non-Hispanic children. These differences may be a function of variation in patient/caregivers culture or healthcare provider care and warrant further investigation.
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Affiliation(s)
- Julia M Rosenbloom
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Elizabeth De Souza
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Felipe D Perez
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - James Xie
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Maria V Suarez-Nieto
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Ellen Wang
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - T Anthony Anderson
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.
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20
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Carlson A, Pham D, Price C, Reisch J, Iskander I, Ambardekar A. Novel use of methadone intraoperatively in pediatric burn patients. J Burn Care Res 2022; 43:1294-1298. [PMID: 35245371 DOI: 10.1093/jbcr/irac022] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Burn injury in children can cause severe and chronic physical and mental sequelae. Opioids are a mainstay in burn pain management but increasing utilization in this country has led to concern for their continued use and potential for dependence. Methadone is a long-acting analgesic that targets the N-methyl-D-aspartate (NMDA) receptor in addition to the mu opioid receptor and has benefit in adult burn patients. However, its use in the pediatric burn population has been less robustly studied. This is a retrospective cohort study at a single Level 1 Burn Center whose primary aim is to compare opioid utilization 36 hours postoperatively between pediatric burn patients who received intraoperative, intravenous methadone and those who did not. Secondary aim was to describe differences in methadone-related complications between the cohorts. There was decreased opioid utilization measured by median morphine equivalents per kilogram (ME/kg) postoperatively in the methadone cohort compared to the control cohort (0.54mg/kg v. 0.77mg/kg, p = 0.18). No adverse events were noted upon chart review. The data suggests methadone use is beneficial in pediatric burn patients, but further prospective studies are warranted on a larger population.
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Affiliation(s)
| | - David Pham
- UT Southwestern Medical Center, Dallas, TX
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21
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Ziesenitz VC, Welzel T, van Dyk M, Saur P, Gorenflo M, van den Anker JN. Efficacy and Safety of NSAIDs in Infants: A Comprehensive Review of the Literature of the Past 20 Years. Paediatr Drugs 2022; 24:603-655. [PMID: 36053397 PMCID: PMC9592650 DOI: 10.1007/s40272-022-00514-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/25/2022] [Indexed: 11/29/2022]
Abstract
Non-steroidal anti-inflammatory drugs (NSAIDs) are commonly used in infants, children, and adolescents worldwide; however, despite sufficient evidence of the beneficial effects of NSAIDs in children and adolescents, there is a lack of comprehensive data in infants. The present review summarizes the current knowledge on the safety and efficacy of various NSAIDs used in infants for which data are available, and includes ibuprofen, dexibuprofen, ketoprofen, flurbiprofen, naproxen, diclofenac, ketorolac, indomethacin, niflumic acid, meloxicam, celecoxib, parecoxib, rofecoxib, acetylsalicylic acid, and nimesulide. The efficacy of NSAIDs has been documented for a variety of conditions, such as fever and pain. NSAIDs are also the main pillars of anti-inflammatory treatment, such as in pediatric inflammatory rheumatic diseases. Limited data are available on the safety of most NSAIDs in infants. Adverse drug reactions may be renal, gastrointestinal, hematological, or immunologic. Since NSAIDs are among the most frequently used drugs in the pediatric population, safety and efficacy studies can be performed as part of normal clinical routine, even in young infants. Available data sources, such as (electronic) medical records, should be used for safety and efficacy analyses. On a larger scale, existing data sources, e.g. adverse drug reaction programs/networks, spontaneous national reporting systems, and electronic medical records should be assessed with child-specific methods in order to detect safety signals pertinent to certain pediatric age groups or disease entities. To improve the safety of NSAIDs in infants, treatment needs to be initiated with the lowest age-appropriate or weight-based dose. Duration of treatment and amount of drug used should be regularly evaluated and maximum dose limits and other recommendations by the manufacturer or expert committees should be followed. Treatment for non-chronic conditions such as fever and acute (postoperative) pain should be kept as short as possible. Patients with chronic conditions should be regularly monitored for possible adverse effects of NSAIDs.
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Affiliation(s)
- Victoria C. Ziesenitz
- grid.5253.10000 0001 0328 4908Pediatric Cardiology and Congenital Heart Diseases, Centre for Child and Adolescent Medicine, University Hospital Heidelberg, Im Neuenheimer Feld 430, 69120 Heidelberg, Germany ,grid.6612.30000 0004 1937 0642Pediatric Pharmacology and Pharmacometrics, University Children’s Hospital Basel, University of Basel, Basel, Switzerland
| | - Tatjana Welzel
- grid.6612.30000 0004 1937 0642Pediatric Pharmacology and Pharmacometrics, University Children’s Hospital Basel, University of Basel, Basel, Switzerland ,grid.411544.10000 0001 0196 8249Pediatric Rheumatology and Autoinflammatory Reference Center, University Hospital Tuebingen, Tuebingen, Germany
| | - Madelé van Dyk
- grid.1014.40000 0004 0367 2697Flinders Centre for Innovation in Cancer, College of Medicine and Public Health, Flinders University, Adelaide, SA Australia
| | - Patrick Saur
- grid.5253.10000 0001 0328 4908Pediatric Cardiology and Congenital Heart Diseases, Centre for Child and Adolescent Medicine, University Hospital Heidelberg, Im Neuenheimer Feld 430, 69120 Heidelberg, Germany
| | - Matthias Gorenflo
- grid.5253.10000 0001 0328 4908Pediatric Cardiology and Congenital Heart Diseases, Centre for Child and Adolescent Medicine, University Hospital Heidelberg, Im Neuenheimer Feld 430, 69120 Heidelberg, Germany
| | - Johannes N. van den Anker
- grid.6612.30000 0004 1937 0642Pediatric Pharmacology and Pharmacometrics, University Children’s Hospital Basel, University of Basel, Basel, Switzerland ,grid.239560.b0000 0004 0482 1586Division of Clinical Pharmacology, Children’s National Hospital, Washington DC, USA ,grid.416135.40000 0004 0649 0805Intensive Care and Department of Pediatric Surgery, Sophia Children’s Hospital, Rotterdam, The Netherlands
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22
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Dudley S, Spence M, Frederick R, Stocks R. Postoperative Use of Ketorolac Improves Pain Management and Decreases Narcotic Use Following Primary Cleft Palate Surgery. Cleft Palate Craniofac J 2021; 59:1371-1376. [PMID: 34514869 DOI: 10.1177/10556656211042168] [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] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To study the efficacy and safety profile of ketorolac in cleft palate surgery. DESIGN Retrospective analysis of patients who underwent primary cleft palate surgery and received either postoperative ketorolac or opioids. SETTING Tertiary care children's hospital. PATIENTS, PARTICIPANTS Eighty-nine patients enrolled who were all younger than 36 months of age, not dependent on a gastrostomy tube, with no history of bleeding disorders, and had undergone their primary cleft palate procedure by one specific surgeon between January 2010 and June 2019. INTERVENTIONS n/a. MAIN OUTCOME MEASURE Morphine equivalent dose (MED), Face, Legs, Activity, Cry, Consolability (FLACC) score, length of stay (LOS), total oral intake (mL), total oral intake/LOS, and postoperative adverse events between ketorolac and no ketorolac groups. RESULTS MED, FLACC score, and LOS were significantly lower in the ketorolac group compared to the no ketorolac group. One patient in the ketorolac group had a bleeding event. CONCLUSIONS Use of ketorolac significantly decreased narcotic usage and pain scores as reported by the FLACC score. Moreover, postoperative bleeding was rare in both ketorolac and no ketorolac groups.
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Affiliation(s)
- Samuel Dudley
- 12326University of Tennessee Health Science Center, Memphis, TN, USA.,Le Bonheur Children's Hospital, Memphis, TN, USA
| | - Matthew Spence
- 12326University of Tennessee Health Science Center, Memphis, TN, USA.,Le Bonheur Children's Hospital, Memphis, TN, USA
| | - Robert Frederick
- 12326University of Tennessee Health Science Center, Memphis, TN, USA.,Le Bonheur Children's Hospital, Memphis, TN, USA
| | - Rosemary Stocks
- 12326University of Tennessee Health Science Center, Memphis, TN, USA.,Le Bonheur Children's Hospital, Memphis, TN, USA
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23
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Ferguson MC, Schumann R, Gallagher S, McNicol ED. Single-dose intravenous ibuprofen for acute postoperative pain in adults. Cochrane Database Syst Rev 2021; 9:CD013264. [PMID: 34499349 PMCID: PMC8428326 DOI: 10.1002/14651858.cd013264.pub2] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Postoperative administration of non-steroidal anti-inflammatory drugs (NSAIDs) reduces patient opioid requirements and, in turn, may reduce the incidence and severity of opioid-induced adverse events (AEs). OBJECTIVES To assess the analgesic efficacy and adverse effects of single-dose intravenous (IV) ibuprofen, compared with placebo or an active comparator, for moderate-to-severe postoperative pain in adults. SEARCH METHODS We searched the following databases without language restrictions: CENTRAL, MEDLINE, Embase and LILACS on 10 June 2021. We checked clinical trials registers and reference lists of retrieved articles for additional studies. SELECTION CRITERIA We included randomized trials that compared a single postoperative dose of intravenous (IV) ibuprofen with placebo or another active treatment, for treating acute postoperative pain in adults following any surgery. DATA COLLECTION AND ANALYSIS We used standard methodological procedures expected by Cochrane. Two review authors independently considered trials for review inclusion, assessed risk of bias, and extracted data. Our primary outcome was the number of participants in each arm achieving at least 50% pain relief over a 4- and 6-hour period. Our secondary outcomes were time to, and number of participants using rescue medication; withdrawals due to lack of efficacy, adverse events (AEs), and for any other cause; and number of participants reporting or experiencing any AE, serious AEs (SAEs), and specific NSAID-related or opioid-related AEs. We were not able to carry out any planned meta-analysis. We assessed the certainty of the evidence using GRADE. MAIN RESULTS Only one study met our inclusion criteria, involving 201 total participants, mostly female (mean age 42 years), undergoing primary, unilateral, distal, first metatarsal bunionectomy (with osteotomy and internal fixation). Ibuprofen 300 mg, placebo or acetaminophen 1000 mg was administered intravenously to participants reporting moderate pain intensity the day after surgery. Since we identified only one study for inclusion, we did not perform any quantitative analyses. The study was at low risk of bias for most domains. We downgraded the certainty of the evidence due to serious study limitations, indirectness and imprecision. Ibuprofen versus placebo Findings of the single study found that at both the 4-hour and 6-hour assessment period, the proportion of participants with at least 50% pain relief was 32% (24/76) for those assigned to ibuprofen and 22% (11/50) for those assigned to placebo. These findings produced a risk ratio (RR) of 1.44 (95% confidence interval (CI) 0.77 to 2.66 versus placebo for at least 50% of maximum pain relief over the 4-hour and 6-hour period (very low-certainty evidence). Median time to rescue medication was 101 minutes for ibuprofen and 71 minutes for placebo (1 study, 126 participants; very low-certainty evidence). The number of participants using rescue medication was not reported within the included study. During the study (1 study, 126 participants), 58/76 (76%) of participants assigned to ibuprofen and 39/50 (78%) assigned to placebo reported or experienced any adverse event (AE), (RR 0.98, 95% CI 0.81 to 1.19; low-certainty evidence). No serious AEs (SAEs) were experienced (1 study, 126 participants; very low-certainty evidence). Ibuprofen versus active comparators Ibuprofen (300 mg) was similar to the active comparator, IV acetaminophen (1000 mg) at 4 hours and 6 hours (1 study, 126 participants). For those assigned to active control (acetaminophen), the proportion of participants with at least 50% pain relief was 35% (26/75) at 4 hours and 31% (23/75) at 6 hours. At 4 hours, these findings produced a RR of 0.91 (95% CI 0.58 to 1.43; very low-certainty evidence) versus active comparator (acetaminophen). At 6 hours, these findings produced a RR of 1.03 (95% CI 0.64 to 1.66; very low-certainty evidence) versus active comparator (acetaminophen). Median time to rescue medication was 101 minutes for ibuprofen and 125 minutes for the active comparator, acetaminophen (1 study, 151 participants; very low-certainty evidence). The number of participants using rescue medication was not reported within the included study. During the study, 8/76 (76%) of participants assigned to ibuprofen and 45/75 (60%) assigned to active control (acetaminophen) reported or experienced any AE, (RR 1.27, 95% CI 1.02 to 1.59; very low-certainty evidence). No SAEs were experienced (1 study, 151 participants; very low-certainty evidence). AUTHORS' CONCLUSIONS There is insufficient evidence to support or refute the suggestion that IV ibuprofen is effective and safe for acute postoperative pain in adults.
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Affiliation(s)
- McKenzie C Ferguson
- Pharmacy Practice, Southern Illinois University Edwardsville, Edwardsville, Illinois, USA
| | - Roman Schumann
- Department of Anesthesia, Critical Care and Pain Medicine, VA Boston Healthcare System, West Roxbury, Massachusetts, USA
| | - Sean Gallagher
- Department of Anesthesiology and Perioperative Medicine, Tufts Medical Center, Boston, Massachusetts, USA
| | - Ewan D McNicol
- Department of Anesthesiology and Perioperative Medicine, Tufts Medical Center, Boston, Massachusetts, USA
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24
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Krunkaityte U, Razlevice I, Lukosiene L, Macas A, Malcius D. Efficacy of postoperative pain management using patient-controlled wound infusion method after laparotomy in children: Three cases. JOURNAL OF PEDIATRIC SURGERY CASE REPORTS 2021. [DOI: 10.1016/j.epsc.2021.101973] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
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25
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Muzzi E, Ronfani L, Bossini B, Lezcano C, Orzan E, Barbi E. Effects of Intraoperative Auditory Stimulation on Pain and Agitation on Awakening After Pediatric Adenotonsillectomy: A Randomized Clinical Trial. JAMA Otolaryngol Head Neck Surg 2021; 147:638-645. [PMID: 34014258 PMCID: PMC8138746 DOI: 10.1001/jamaoto.2021.0870] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Importance Severe pain on awakening (POA) and emergence delirium (ED) are common following pediatric adenotonsillectomy. Effective preventive interventions are lacking. Objective To determine the effects of intraoperative auditory stimulation on reduction of POA and ED after pediatric adenotonsillectomy. Design, Setting, and Participants Single-center, double-blinded, 4-armed, randomized clinical trial of children undergoing adenotonsillectomy from March 2018 to May 2019 at a tertiary care pediatric referral center. Interventions Children were randomized to 1 of the following groups: auditory stimulation with music, auditory stimulation with noise, ambient noise insulation with masking earplugs, and a control group receiving no intervention. Ear inserts were placed in the operating room once general anesthesia was administered. Stimulation parameters were based on the preoperative audiological evaluation and the appropriate fitting of the transduction system, including ambient noise level monitoring. Main Outcomes and Measures The primary outcome was POA levels measured on 10-point scales according to age-appropriate validated tools. The secondary outcome was ED levels assessed according to the Pediatric Anesthesia Emergence Delirium 20-point scale. Results A total of 104 consecutive healthy children (median [interquartile range] age at surgery, 5.0 [3.8-6.4] years) were included in the analysis. Music had a large effect size on POA (0.63; 98% CI, 0.43-0.84) and a medium effect size on ED (0.47; 98% CI, 0.21-0.75), while noise had a medium effect size on POA (0.47; 98% CI, 0.22-0.73) and a large effect size on ED (0.63; 98% CI, 0.44-0.85) compared with controls. The earplugs group showed a small effect size on POA and ED. Considering a clinically meaningful threshold of greater than 4 for POA and 10 or greater for ED at dichotomized analysis, a large effect size was achieved by music (1.39; odds ratio [OR], 0.08; 98% CI, 0.02-0.29; and 0.84; OR, 0.22; 98% CI, 0.06-0.75, respectively) and noise (0.97; OR, 0.17; 98% CI, 0.05-0.6; and 1.48; OR, 0.07; 98% CI, 0.02-0.26, respectively), while earplugs resulted in a small effect size. Conclusions and Relevance In this randomized clinical trial, children undergoing adenotonsillectomy who received intraoperative auditory stimulation demonstrated a clinically meaningful decrease in POA and ED in the immediate postoperative period. Further research is needed to assess whether intraoperative auditory stimulation may decrease POA and ED in children undergoing other types of surgical procedures. Trial Registration ClinicalTrials.gov Identifier: NCT04112979.
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Affiliation(s)
- Enrico Muzzi
- Otorhinolaryngology and Audiology, Institute for Maternal and Child Health, IRCCS Burlo Garofolo, Trieste, Italy
| | - Luca Ronfani
- Clinical Epidemiology and Public Health Research Unit, Institute for Maternal and Child Health, IRCCS Burlo Garofolo, Trieste, Italy
| | | | | | - Eva Orzan
- Otorhinolaryngology and Audiology, Institute for Maternal and Child Health, IRCCS Burlo Garofolo, Trieste, Italy
| | - Egidio Barbi
- University of Trieste School of Medicine, Trieste, Italy
- Department of Pediatrics, Institute for Maternal and Child Health, IRCCS Burlo Garofolo, Trieste, Italy
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26
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Julien-Marsollier F, Assaker R, Michelet D, Camby M, Galland A, Marsac L, Vacher T, Simon AL, Ilharreborde B, Dahmani S. Effects of opioid-reduced anesthesia during scoliosis surgery in children: a prospective observational study. Pain Manag 2021; 11:679-687. [PMID: 34102877 DOI: 10.2217/pmt-2020-0100] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
Aims: Opioid-reduced anesthesia (ORA) was suggested to decrease morphine consumption after adolescent idiopathic scoliosis (AIS) surgery and incidence of chronic pain. Materials & methods: A prospective analysis using the ORA in AIS surgery was performed. Two cohorts were compared: a control group (opioid-based anesthesia) and the ORA group. The main outcome was morphine consumption at day 1. Results: 33 patients operated for AIS using ORA were compared with 36 with opioid-based anesthesia. Morphine consumption was decreased in the ORA group (1.1 mg.kg-1 [0.2-2] vs 0.8 mg.kg-1 [0.3-2]; p = 0.02) at day 1. Persistent neuropathic pain at 1 year was decreased in the ORA group (p = 0.02). Conclusion: The ORA protocol is efficient to reduce postoperative morphine consumption in AIS surgery and preventing neuropathic pain.
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Affiliation(s)
- Florence Julien-Marsollier
- Université de Paris, Paris, France.,Department of Anesthesia & Intensive Care, Robert Debré Hospital, 48 Boulevard Sérurier, 75019, Paris, France.,DMU PROTECT, Robert Debré Hospital, 48 Boulevard Sérurier 75019, Paris, France
| | - Rita Assaker
- Université de Paris, Paris, France.,Department of Anesthesia & Intensive Care, Robert Debré Hospital, 48 Boulevard Sérurier, 75019, Paris, France.,DMU PROTECT, Robert Debré Hospital, 48 Boulevard Sérurier 75019, Paris, France
| | - Daphné Michelet
- Université de Paris, Paris, France.,Department of Anesthesia & Intensive Care, Robert Debré Hospital, 48 Boulevard Sérurier, 75019, Paris, France.,DMU PROTECT, Robert Debré Hospital, 48 Boulevard Sérurier 75019, Paris, France
| | - Matthieu Camby
- Université de Paris, Paris, France.,Department of Anesthesia & Intensive Care, Robert Debré Hospital, 48 Boulevard Sérurier, 75019, Paris, France.,DMU PROTECT, Robert Debré Hospital, 48 Boulevard Sérurier 75019, Paris, France
| | - Anne Galland
- Université de Paris, Paris, France.,Department of Anesthesia & Intensive Care, Robert Debré Hospital, 48 Boulevard Sérurier, 75019, Paris, France.,DMU PROTECT, Robert Debré Hospital, 48 Boulevard Sérurier 75019, Paris, France
| | - Lucile Marsac
- Université de Paris, Paris, France.,Department of Anesthesia & Intensive Care, Robert Debré Hospital, 48 Boulevard Sérurier, 75019, Paris, France.,DMU PROTECT, Robert Debré Hospital, 48 Boulevard Sérurier 75019, Paris, France
| | - Thomas Vacher
- Université de Paris, Paris, France.,Department of Anesthesia & Intensive Care, Robert Debré Hospital, 48 Boulevard Sérurier, 75019, Paris, France.,DMU PROTECT, Robert Debré Hospital, 48 Boulevard Sérurier 75019, Paris, France
| | - Anne-Laure Simon
- Université de Paris, Paris, France.,Department of Orthopedic Surgery, Robert Debré Hospital, 48 Boulevard Sérurier, 75019, Paris, France
| | - Brice Ilharreborde
- Université de Paris, Paris, France.,Department of Orthopedic Surgery, Robert Debré Hospital, 48 Boulevard Sérurier, 75019, Paris, France
| | - Souhayl Dahmani
- Université de Paris, Paris, France.,Department of Anesthesia & Intensive Care, Robert Debré Hospital, 48 Boulevard Sérurier, 75019, Paris, France.,DMU PROTECT, Robert Debré Hospital, 48 Boulevard Sérurier 75019, Paris, France
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27
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McNicol ED, Ferguson MC, Schumann R. Single-dose intravenous ketorolac for acute postoperative pain in adults. Cochrane Database Syst Rev 2021; 5:CD013263. [PMID: 33998669 PMCID: PMC8127532 DOI: 10.1002/14651858.cd013263.pub2] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
BACKGROUND Postoperative pain is common and may be severe. Postoperative administration of non-steroidal anti-inflammatory drugs (NSAIDs) reduces patient opioid requirements and, in turn, may reduce the incidence and severity of opioid-induced adverse events (AEs). OBJECTIVES To assess the analgesic efficacy and adverse effects of single-dose intravenous ketorolac, compared with placebo or an active comparator, for moderate to severe postoperative pain in adults. SEARCH METHODS We searched the following databases without language restrictions: CENTRAL, MEDLINE, Embase and LILACS on 20 April 2020. We checked clinical trials registers and reference lists of retrieved articles for additional studies. SELECTION CRITERIA Randomized double-blind trials that compared a single postoperative dose of intravenous ketorolac with placebo or another active treatment, for treating acute postoperative pain in adults following any surgery. DATA COLLECTION AND ANALYSIS We used standard methodological procedures expected by Cochrane. Our primary outcome was the number of participants in each arm achieving at least 50% pain relief over a four- and six-hour period. Our secondary outcomes were time to and number of participants using rescue medication; withdrawals due to lack of efficacy, adverse events (AEs), and for any other cause; and number of participants experiencing any AE, serious AEs (SAEs), and NSAID-related or opioid-related AEs. For subgroup analysis, we planned to analyze different doses of parenteral ketorolac separately and to analyze results based on the type of surgery performed. We assessed the certainty of evidence using GRADE. MAIN RESULTS We included 12 studies, involving 1905 participants undergoing various surgeries (pelvic/abdominal, dental, and orthopedic), with 17 to 83 participants receiving intravenous ketorolac in each study. Mean study population ages ranged from 22.5 years to 67.4 years. Most studies administered a dose of ketorolac of 30 mg; one study assessed 15 mg, and another administered 60 mg. Most studies had an unclear risk of bias for some domains, particularly allocation concealment and blinding, and a high risk of bias due to small sample size. The overall certainty of evidence for each outcome ranged from very low to moderate. Reasons for downgrading certainty included serious study limitations, inconsistency and imprecision. Ketorolac versus placebo Very low-certainty evidence from eight studies (658 participants) suggests that ketorolac results in a large increase in the number of participants achieving at least 50% pain relief over four hours compared to placebo, but the evidence is very uncertain (risk ratio (RR) 2.81, 95% confidence interval (CI) 1.80 to 4.37). The number needed to treat for one additional participant to benefit (NNTB) was 2.4 (95% CI 1.8 to 3.7). Low-certainty evidence from 10 studies (914 participants) demonstrates that ketorolac may result in a large increase in the number of participants achieving at least 50% pain relief over six hours compared to placebo (RR 3.26, 95% CI 1.93 to 5.51). The NNTB was 2.5 (95% CI 1.9 to 3.7). Among secondary outcomes, for time to rescue medication, moderate-certainty evidence comparing intravenous ketorolac versus placebo demonstrated a mean median of 271 minutes for ketorolac versus 104 minutes for placebo (6 studies, 633 participants). For the number of participants using rescue medication, very low-certainty evidence from five studies (417 participants) compared ketorolac with placebo. The RR was 0.60 (95% CI 0.36 to 1.00), that is, it did not demonstrate a difference between groups. Ketorolac probably results in a slight increase in total adverse event rates compared with placebo (74% versus 65%; 8 studies, 810 participants; RR 1.09, 95% CI 1.00 to 1.19; number needed to treat for an additional harmful event (NNTH) 16.7, 95% CI 8.3 to infinite, moderate-certainty evidence). Serious AEs were rare. Low-certainty evidence from eight studies (703 participants) did not demonstrate a difference in rates between ketorolac and placebo (RR 0.62, 95% CI 0.13 to 3.03). Ketorolac versus NSAIDs Ketorolac was compared to parecoxib in four studies and diclofenac in two studies. For our primary outcome, over both four and six hours there was no evidence of a difference between intravenous ketorolac and another NSAID (low-certainty and moderate-certainty evidence, respectively). Over four hours, four studies (337 participants) produced an RR of 1.04 (95% CI 0.89 to 1.21) and over six hours, six studies (603 participants) produced an RR of 1.06 (95% CI 0.95 to 1.19). For time to rescue medication, low-certainty evidence from four studies (427 participants) suggested that participants receiving ketorolac waited an extra 35 minutes (mean median 331 minutes versus 296 minutes). For the number of participants using rescue medication, very low-certainty evidence from three studies (260 participants) compared ketorolac with another NSAID. The RR was 0.90 (95% CI 0.58 to 1.40), that is, there may be little or no difference between groups. Ketorolac probably results in a slight increase in total adverse event rates compared with another NSAID (76% versus 68%, 5 studies, 516 participants; RR 1.11, 95% CI 1.00 to 1.23; NNTH 12.5, 95% CI 6.7 to infinite, moderate-certainty evidence). Serious AEs were rare. Low-certainty evidence from five studies (530 participants) did not demonstrate a difference in rates between ketorolac and another NSAID (RR 3.18, 95% CI 0.13 to 76.99). Only one of the five studies reported a single serious AE. AUTHORS' CONCLUSIONS The amount and certainty of evidence for the use of intravenous ketorolac as a treatment for postoperative pain varies across efficacy and safety outcomes and amongst comparators, from very low to moderate. The available evidence indicates that postoperative intravenous ketorolac administration may offer substantial pain relief for most patients, but further research may impact this estimate. Adverse events appear to occur at a slightly higher rate in comparison to placebo and to other NSAIDs. Insufficient information is available to assess whether intravenous ketorolac has a different rate of gastrointestinal or surgical-site bleeding, renal dysfunction, or cardiovascular events versus other NSAIDs. There was a lack of studies in cardiovascular surgeries and in elderly populations who may be at increased risk for adverse events.
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Affiliation(s)
- Ewan D McNicol
- Department of Anesthesiology and Perioperative Medicine, Tufts Medical Center, Boston, MA, USA
| | - McKenzie C Ferguson
- Pharmacy Practice, Southern Illinois University Edwardsville, Edwardsville, IL, USA
| | - Roman Schumann
- Department of Anesthesia, Critical Care and Pain Medicine, VA Boston Healthcare System, West Roxbury, Massachusetts, USA
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Chen Y, Min C, Wang Q, Zhou J, Xie A, Shen L, Chen M, Li X. Procedural Pain in Hospitalized Children in a Chinese Children's Hospital. Pain Manag Nurs 2020; 22:414-422. [PMID: 33384240 DOI: 10.1016/j.pmn.2020.11.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2019] [Revised: 11/21/2020] [Accepted: 11/22/2020] [Indexed: 12/01/2022]
Abstract
BACKGROUND Pain prevalence in pediatric hospitals has been investigated in many developed countries, but little is known about this topic in China. AIMS This study sought to describe the frequency and pain intensity of procedures for medical care in hospitalized children in a Chinese children's hospital. DESIGN A cross-sectional study was designed to include interviews with children, their parents and the nurses. SETTINGS This survey was administered in a teaching hospital in southeast China. PARTICIPANTS/SUBJECTS Infants and children up to 16 years old who were admitted to the study units for more than 6 days were eligible for inclusion. METHODS Information regarding patient demographics, painful procedures and pain management strategies was obtained during the day shifts of the children's hospitalization. RESULTS A total of 3886 procedures were performed on 342 children during the data collection period. The reuse of intravenous indwelling needles ( n = 577), removal of tape from the skin (n = 420) and venipuncture on the back of the hand ( n = 401) were the most frequently performed procedures on children. A total of 1941 procedures, accounting for 49.9% (1941/3886) of painful procedures caused moderate to severe pain (pain score ≥4.0). However, only 25.3% (984/3886) received a valid pain assessment, and only 14.4% (560/3886) received pain interventions. CONCLUSIONS Most children, especially those who are younger (<4 years old), experienced moderate or severe pain during their hospitalization, but did not receive appropriate interventions.
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Affiliation(s)
- Yinhua Chen
- Department of Child Health Care, Children's Hospital of Nanjing Medical University, Nanjing, China
| | - Cuiting Min
- Department of Child Health Care, Children's Hospital of Nanjing Medical University, Nanjing, China
| | - Qianqian Wang
- Department of Child Health Care, Children's Hospital of Nanjing Medical University, Nanjing, China
| | - Jing Zhou
- Department of Cardiac Surgery and Ophthalmology, Children's Hospital of Nanjing Medical University, Nanjing, China
| | - Ailing Xie
- Department of Nursing, Children's Hospital of Nanjing Medical University, Nanjing, China
| | - Lingling Shen
- Department of Child Health Care, Children's Hospital of Nanjing Medical University, Nanjing, China
| | - Mengying Chen
- Department of Child Health Care, Children's Hospital of Nanjing Medical University, Nanjing, China
| | - Xiaonan Li
- Department of Child Health Care, Children's Hospital of Nanjing Medical University, Nanjing, China.
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Salekin MS, Zamzmi G, Goldgof D, Kasturi R, Ho T, Sun Y. Multimodal spatio-temporal deep learning approach for neonatal postoperative pain assessment. Comput Biol Med 2020; 129:104150. [PMID: 33348218 DOI: 10.1016/j.compbiomed.2020.104150] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2020] [Revised: 11/23/2020] [Accepted: 11/24/2020] [Indexed: 10/22/2022]
Abstract
The current practice for assessing neonatal postoperative pain relies on bedside caregivers. This practice is subjective, inconsistent, slow, and discontinuous. To develop a reliable medical interpretation, several automated approaches have been proposed to enhance the current practice. These approaches are unimodal and focus mainly on assessing neonatal procedural (acute) pain. As pain is a multimodal emotion that is often expressed through multiple modalities, the multimodal assessment of pain is necessary especially in case of postoperative (acute prolonged) pain. Additionally, spatio-temporal analysis is more stable over time and has been proven to be highly effective at minimizing misclassification errors. In this paper, we present a novel multimodal spatio-temporal approach that integrates visual and vocal signals and uses them for assessing neonatal postoperative pain. We conduct comprehensive experiments to investigate the effectiveness of the proposed approach. We compare the performance of the multimodal and unimodal postoperative pain assessment, and measure the impact of temporal information integration. The experimental results, on a real-world dataset, show that the proposed multimodal spatio-temporal approach achieves the highest AUC (0.87) and accuracy (79%), which are on average 6.67% and 6.33% higher than unimodal approaches. The results also show that the integration of temporal information markedly improves the performance as compared to the non-temporal approach as it captures changes in the pain dynamic. These results demonstrate that the proposed approach can be used as a viable alternative to manual assessment, which would tread a path toward fully automated pain monitoring in clinical settings, point-of-care testing, and homes.
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Affiliation(s)
- Md Sirajus Salekin
- Department of Computer Science and Engineering, University of South Florida, Tampa, FL, USA.
| | - Ghada Zamzmi
- Department of Computer Science and Engineering, University of South Florida, Tampa, FL, USA
| | - Dmitry Goldgof
- Department of Computer Science and Engineering, University of South Florida, Tampa, FL, USA
| | - Rangachar Kasturi
- Department of Computer Science and Engineering, University of South Florida, Tampa, FL, USA
| | - Thao Ho
- College of Medicine Pediatrics, USF Health, University of South Florida, Tampa, FL, USA
| | - Yu Sun
- Department of Computer Science and Engineering, University of South Florida, Tampa, FL, USA
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Julien-Marsollier F, Michelet D, Assaker R, Doval A, Louisy S, Madre C, Simon AL, Ilharreborde B, Brasher C, Dahmani S. Enhanced recovery after surgical correction of adolescent idiopathic scoliosis. Paediatr Anaesth 2020; 30:1068-1076. [PMID: 32750176 DOI: 10.1111/pan.13988] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2020] [Revised: 07/08/2020] [Accepted: 07/19/2020] [Indexed: 12/16/2022]
Abstract
BACKGROUND Few publications in the literature examine enhanced recovery after scoliosis surgery (ERAS) in children, despite significant scientific interest in adults. The objective of the current study was to describe an ERAS protocol for surgical correction of adolescent idiopathic scoliosis (AIS) and its results. METHODS ERAS outcomes were measured in two patient cohorts. Historical controls and ERAS groups were selected from patients managed for scoliosis surgery in 2015 and 2018, respectively. The ERAS protocol included fasting minimization, carbohydrate loading, the avoidance of background morphine infusions, perioperative opioid-sparing protocols, the use of a cooling brace, early physiotherapy, feeding and oral medications, and the early removal of urinary catheters and surgical drains. The main outcome of the study was hospital length of stay. RESULTS Overall, 82 controls and 81 ERAS patients were recruited. ERAS protocols were observed in over 80% of patients for almost items. Median length of hospital stay was significantly lower in the ERAS group (- 3 [95% confidence interval: -2; -4] days). Median morphine consumption was reduced by 25% and 35% on days 2 and 3, respectively. The incidence of PONV did not differ between the two groups, and the incidence of constipation decreased slightly but significantly in the ERAS group on day 2. Pain intensity at rest and movement were lower in the ERAS group at day 2 and 3. CONCLUSIONS The current study suggests an ERAS protocol after adolescent idiopathic scoliosis surgery is associated with reduced hospital length of stay and improved postoperative care.
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Affiliation(s)
- Florence Julien-Marsollier
- Department of Anesthesia and Intensive Care, Robert Debré Hospital, Paris, France.,Université de Paris, Paris, France.,DHU PROTECT, Robert Debré Hospital, Paris, France
| | - Daphné Michelet
- Department of Anesthesia and Intensive Care, Robert Debré Hospital, Paris, France.,Université de Paris, Paris, France.,DHU PROTECT, Robert Debré Hospital, Paris, France
| | - Rita Assaker
- Department of Anesthesia and Intensive Care, Robert Debré Hospital, Paris, France.,Université de Paris, Paris, France.,DHU PROTECT, Robert Debré Hospital, Paris, France
| | - Antoine Doval
- Department of Anesthesia and Intensive Care, Robert Debré Hospital, Paris, France.,Université de Paris, Paris, France.,DHU PROTECT, Robert Debré Hospital, Paris, France
| | - Simon Louisy
- Department of Anesthesia and Intensive Care, Robert Debré Hospital, Paris, France.,Université de Paris, Paris, France.,DHU PROTECT, Robert Debré Hospital, Paris, France
| | | | - Anne-Laure Simon
- Department of Orthopaedic Surgery, Robert Debré Hospital, Paris, France
| | | | - Christopher Brasher
- Department of Anaesthesia & Pain Management, Royal Children's Hospital, Melbourne, Vic., Australia.,Anaesthesia and Pain Management Research Group, Murdoch Children's Research Institute, Melbourne, Vic., Australia.,Centre for Integrated Critical Care, University of Melbourne, Melbourne, Vic., Australia
| | - Souhayl Dahmani
- Department of Anesthesia and Intensive Care, Robert Debré Hospital, Paris, France.,Université de Paris, Paris, France.,DHU PROTECT, Robert Debré Hospital, Paris, France
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Kościelniak-Merak B, Batko I, Kobylarz K, Sztefko K, Tomasik PJ. Intravenous, Perioperatively Administered Lidocaine Regulates Serum Pain Modulators’ Concentrations in Children Undergoing Spinal Surgery. PAIN MEDICINE 2020; 21:1464-1473. [DOI: 10.1093/pm/pnz212] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 08/30/2023]
Abstract
AbstractObjectivesWe analyzed the influence of perioperative, intravenous (i.v.) lidocaine infusion as a part of multimodal anesthesia on concentrations of selected pain modulators.DesignAn observational study.SettingUniversity Children’s Hospital in Cracow, Poland, from May 2015 to May 2018.SubjectsForty-four children undergoing extensive spinal surgery, divided into two groups after surgery: the study group (N = 23), anesthetized generally with lidocaine as a co-analgesic, and the control group (N = 22), anesthetized generally without lidocaine.MethodsWe assessed proinflammatory mediators like neuron growth factor (NGF), high mobility group box 1 (HMGB1), interleukin 6 (IL-6), and FOS protein before, immediately after, six hours and 12–15 hours after surgery. We evaluated pain intensity at corresponding time points using a 10-point numerical/graphical scale.ResultsWe observed that children in the lidocaine group had reduced pain intensity in the resting state and during movement until six hours after surgery when compared with controls. We found lower NGF concentrations in the lidocaine group vs controls only at six hours after surgery. Mean HMGB1 concentrations during the postoperative period in the study group were relatively stable, whereas we observed significant increases at six hours after surgery and a slight decrease at 12–15 hours after surgery in the control group. IL-6 concentrations at six hours were lower in lidocaine patients when compared with controls. We noted a negative correlation between HMGB1, NGF, Il-6, and lidocaine concentrations after surgery. We did not find any differences in FOS protein concentrations between the groups.ConclusionsOur findings suggest that intraoperative and postoperative i.v. lidocaine administration as a part of multimodal anesthesia may reduce inflammatory-dependent postoperative pain intensity.
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Affiliation(s)
- Barbara Kościelniak-Merak
- Department of Clinical Biochemistry, Pediatrics Institute, Jagiellonian University Medical College, Cracow, Poland
| | - Ilona Batko
- Intensive Care Unit, University Children’s Hospital, Cracow, Poland
| | - Krzysztof Kobylarz
- Intensive Care Unit, University Children’s Hospital, Cracow, Poland
- Department of Anesthesiology and Intensive Care, Jagiellonian University Medical College, Cracow, Poland
| | - Krystyna Sztefko
- Department of Clinical Biochemistry, Pediatrics Institute, Jagiellonian University Medical College, Cracow, Poland
| | - Przemysław J Tomasik
- Department of Clinical Biochemistry, Pediatrics Institute, Jagiellonian University Medical College, Cracow, Poland
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Mascarenhas CJ, Liu R, Barr GA. Effects of plant-derived analgesic compounds sinomenine and salvinorin A in infant rats. JOURNAL OF INTEGRATIVE MEDICINE-JIM 2020; 18:174-180. [PMID: 31992510 DOI: 10.1016/j.joim.2020.01.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/25/2019] [Accepted: 07/03/2019] [Indexed: 02/08/2023]
Abstract
OBJECTIVE Premature and ill neonates undergo painful but medically necessary procedures while hospitalized. Although opiate drugs are administered as analgesics, problems associated with their side effects, tolerance, and potential dependence necessitate research into alternative pain-relieving medications. Here we test two plant-derived compounds in infant rats: sinomenine, which targets the Mas-related G-protein-coupled receptor member X2 opioid receptor; and salvinorin A, which is a κ opioid receptor agonist. In adult animals both sinomenine and salvinorin A are analgesic, but neither has been tested in infants. METHODS We used the formalin and thermal plantar tests in rats 7 and 21 days of age (PN7 and PN21) for behavioral signs of pain. In addition, brain sections were stained using Fos immunohistochemistry to examine patterns of brain activation in the midbrain periaqueductal gray and the paraventricular nucleus of the hypothalamus. RESULTS Sinomenine was analgesic in both the formalin and thermal tests on animals 21 days of age. At PN7 only the highest dose elevated response latencies in the thermal test and there were no effects of sinomenine in the formalin test. Analysis of Fos expression in the sinomenine-treated animals showed no drug effect, in contrast to the behavioral results. Salvinorin A was analgesic in the formalin test only at the highest dose at 21 days of age but not in the thermal test at either age. CONCLUSION The increased modest effectiveness of sinomenine in older animals and the minimum salvinorin A drug effect suggest that the compounds act on sites that develop during the preweaning period (sinomenine) or after weaning (salvinorin A).
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Affiliation(s)
- Conrad J Mascarenhas
- Department of Anesthesiology and Critical Care, Children's Hospital of Philadelphia, Philadelphia, PA 19104, USA
| | - Renyu Liu
- Department of Anesthesiology and Critical Care, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Gordon A Barr
- Department of Anesthesiology and Critical Care, Children's Hospital of Philadelphia, Philadelphia, PA 19104, USA; Department of Anesthesiology and Critical Care, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA 19104, USA; Department of Psychology, University of Pennsylvania, Philadelphia, PA 19104, USA.
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Saini A, Maher KO, Deshpande SR. Nonopioid analgesics for perioperative and cardiac surgery pain in children: Current evidence and knowledge gaps. Ann Pediatr Cardiol 2019; 13:46-55. [PMID: 32030035 PMCID: PMC6979012 DOI: 10.4103/apc.apc_190_18] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2018] [Revised: 06/05/2019] [Accepted: 10/08/2019] [Indexed: 11/23/2022] Open
Abstract
Objective: The purpose of this review is to present the available literature on the use of nonopioid analgesics such as nonsteroidal anti-inflammatory drugs in postcardiac surgery pediatric patients, mainly to focus on patients <1 year of age, and to provide the foundation for future research. Materials and Methods: Published studies that address the use on nonopioid medications for postoperative sedation and analgesia in infants and children undergoing cardiac surgery were identified from online sources. Studies were reviewed by two authors independently to assess the quality of the data as well as the evidence. Due to limited availability of such studies, the review was then expanded to include use in noncardiac procedures as well as to expanded age groups. All studies that met the primary objective were included. Results/Data Synthesis: Majority of the studies in the population of interest were related to use of ketorolac. Five studies specifically addressed ketorolac use in cardiac patients. In addition, studies were reviewed for nonopioid analgesia in noncardiac patients and included as a part of the available evidence as in the case of acetaminophen use. Newer agents as well as agents with very limited information were also acknowledged. Conclusion: Nonopioid medications appear to show promise for analgesia in infants undergoing cardiac surgery, with ketorolac being the most potent agent as a potential substitute for opioids. These agents demonstrate a reasonable safety profile even in the very young. There continue to be significant gaps in knowledge before their adoption becomes routine. However, gives the awareness regarding short-term and long-term impact of opioid use in this vulnerable population, and studies of such agents are an urgent need.
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Affiliation(s)
- Ashish Saini
- Pediatric Cardiology, Children's Healthcare of Atlanta, Atlanta, GA, USA
| | - Kevin O Maher
- Division of Pediatric Cardiology, Sibley Heart Center Cardiology, Emory University School of Medicine, Atlanta, GA, USA
| | - Shriprasad R Deshpande
- Heart Transplant and Advanced Cardiac Therapies Program, Children's National Health Institute, Washington, DC, USA
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Tao B, Liu K, Wang D, Ding M, Yang N, Zhao P. Perioperative effects of caudal block on pediatric patients in laparoscopic upper urinary tract surgery: a randomized controlled trial. BMC Pediatr 2019; 19:427. [PMID: 31711451 PMCID: PMC6844040 DOI: 10.1186/s12887-019-1812-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2019] [Accepted: 10/30/2019] [Indexed: 02/07/2023] Open
Abstract
Background While caudal block has been widely used during pediatric lower limbs and lower abdominal surgeries, few studies to date have evaluated the perioperative effects of caudal block on pediatric patients in laparoscopic upper urinary tract surgery. Methods Ninety-six pediatric patients, aged 6 months to 7 years, ASA grade I-II, scheduled to undergo laparoscopic upper urinary tract surgery, were randomized to a non-block group (no caudal block performed), an ROP1.0 group (patients received 1.0 mL/kg of 0.15% ropivacaine) and an ROP1.3 group (patients received 1.3 mL/kg of 0.15% ropivacaine). The primary outcome variable was perioperative fentanyl use. The secondary outcome variables were pain score, hemodynamic fluctuation, the number of patients needing rescue fentanyl and side effects. Results Caudal block with 1.3 mL/kg of 0.15% ropivacaine significantly decreased perioperative fentanyl usage (ROP 1.3 vs. non-caudal block, P < 0.01; ROP 1.3 vs. ROP 1.0, P < 0.05). Moreover, patients in the ROP1.3 group, compared to those without, displayed more stable hemodynamics, lower pain score in the PACU and 8 h after operation, less demand for rescue fentanyl, shorter time of PACU stay. Conclusions Caudal block with 1.3 mL/kg of 0.15% ropivacaine reduced perioperative fentanyl use during laparoscopic upper urinary tract surgery on pediatric patients and produced good postoperative analgesia when compared with no caudal block and caudal block with 1.0 mL/kg of 0.15% ropivacaine. Trial registration Clinical trial number: ChiCTR1800015549, chictr.org.cn.
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Affiliation(s)
- Bingdong Tao
- Department of Anesthesiology, Shengjing Hospital, China Medical University, 36 Sanhao Street Heping District, Shenyang, 110004, Liaoning Province, China
| | - Kun Liu
- Department of Anesthesiology, Shengjing Hospital, China Medical University, 36 Sanhao Street Heping District, Shenyang, 110004, Liaoning Province, China
| | - Dandan Wang
- Department of Anesthesiology, Shengjing Hospital, China Medical University, 36 Sanhao Street Heping District, Shenyang, 110004, Liaoning Province, China
| | - Mengmeng Ding
- Department of Anesthesiology, Shengjing Hospital, China Medical University, 36 Sanhao Street Heping District, Shenyang, 110004, Liaoning Province, China
| | - Ni Yang
- Department of Pediatrics, PICU, Shengjing Hospital, China Medical University, Shenyang, China
| | - Ping Zhao
- Department of Anesthesiology, Shengjing Hospital, China Medical University, 36 Sanhao Street Heping District, Shenyang, 110004, Liaoning Province, China.
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Newman N, Kogan S, Stavsky M, Pintov S, Lior Y. The impact of medical clowns exposure over postoperative pain and anxiety in children and caregivers: An Israeli experience. Pediatr Rep 2019; 11:8165. [PMID: 31579203 PMCID: PMC6769359 DOI: 10.4081/pr.2019.8165] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2019] [Accepted: 06/05/2019] [Indexed: 12/27/2022] Open
Abstract
While postoperative pain management was shown to reduce unwanted physiological and emotional outcomes, pediatric postoperative pain management remains suboptimal. Medical-clowns were shown to be beneficial in many medical contexts including reduction of stress, anxiety and pain. This study was set to assess the effectiveness of medical-clowns on pediatric postoperative pain reduction. Children age 4 or above, planned for elective hernia repair surgery were recruited. Children were randomly divided to a control or medicalclown escorted groups. Demographical and clinical data were collected using questionnaires and electronic sheets. Children escorted by clowns reported lower levels of pain upon admittance, discharge and 12- hours post-surgery. Statistically significant reduction of parental distress and significantly higher serum cortisol levels were observed in the clown-therapy group. Although small, our study supports the possibility that preoperative medical-clown therapy might be a cheap, safe and yet beneficial method for postoperative pain reduction.
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Affiliation(s)
- Nitza Newman
- Pediatric Surgery Department, Faculty of Health Sciences, Soroka University Medical Center, Ben-Gurion University of the Negev, Beer-Sheva
| | - Slava Kogan
- Joyce and Irwing Goldman Medical School, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva
- Soroka Clinical Research Center, Soroka University Medical Center, Beer-Sheva
| | - Moshe Stavsky
- Joyce and Irwing Goldman Medical School, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva
- Soroka Clinical Research Center, Soroka University Medical Center, Beer-Sheva
| | - Shay Pintov
- The Medical School for International Health, Faculty of Health Sciences, Ben Gurion University of the Negev, Beer-Sheva, Israel
| | - Yotam Lior
- Joyce and Irwing Goldman Medical School, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva
- Soroka Clinical Research Center, Soroka University Medical Center, Beer-Sheva
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Tomaszek L, Fenikowski D, Komotajtys H, Gawron D. Ropivacaine/Fentanyl vs. Bupivacaine/Fentanyl for Pain Control in Children after Thoracic Surgery: A Randomized Study. Pain Manag Nurs 2019; 20:390-397. [DOI: 10.1016/j.pmn.2019.02.007] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2018] [Revised: 01/15/2019] [Accepted: 02/23/2019] [Indexed: 01/19/2023]
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Hajdini H, Steurer LM, Balakas K, Ercole PM. A Randomized Controlled Trial to Compare Pain Medications in Children Undergoing Strabismus Surgery. J Perianesth Nurs 2019; 34:1196-1204. [PMID: 31280990 DOI: 10.1016/j.jopan.2019.01.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2018] [Revised: 01/08/2019] [Accepted: 01/28/2019] [Indexed: 11/19/2022]
Abstract
PURPOSE The purpose of this study was to investigate optimal intraoperative combinations of analgesia for children undergoing strabismus surgery. DESIGN A randomized controlled trial was employed to compare the difference in pain after administration of hydromorphone versus fentanyl. METHODS Participants were randomly assigned to either arm of the study. Pain was measured by the revised Faces, Legs, Activity, Cry, and Consolability Scale (rFLACC) tool postoperatively, and the parent was asked about the presence or absence of pain after discharge. FINDINGS A total of 135 children were included in the study. The rFLACC pain score was found to be significantly higher postoperatively among patients receiving fentanyl (P = .011). Pain after discharge was reported more often among patients who received fentanyl (P < .001). CONCLUSIONS Results of this study can be used to change practice to minimize the pain levels both postoperatively and after discharge for children undergoing strabismus surgery.
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Vagnoli L, Bettini A, Amore E, De Masi S, Messeri A. Relaxation-guided imagery reduces perioperative anxiety and pain in children: a randomized study. Eur J Pediatr 2019; 178:913-921. [PMID: 30944985 DOI: 10.1007/s00431-019-03376-x] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2018] [Revised: 03/06/2019] [Accepted: 03/26/2019] [Indexed: 12/13/2022]
Abstract
Several studies have shown the efficacy of psychological interventions in reducing preoperative anxiety in children undergoing surgery. This study aims to investigate the effectiveness of a specific non-pharmacological technique, the relaxation-guided imagery, in reducing both preoperative anxiety and postoperative pain in a sample of 60 children (6-12 years old) undergoing minor surgery who were randomly assigned to the experimental group (N = 30) or the control group (N = 30). The first group received the relaxation-guided imagery, before the induction of general anesthesia; the second group received standard care. The levels of preoperative anxiety and postoperative pain were assessed using, respectively, the modified Yale Preoperative Anxiety Scale and the Face, Legs, Activity, Cry, and Consolability Scale. The results showed a statistically significant difference between groups, with less anxiety and less pain for children included in the experimental group (p < .001; p < .001).Conclusion: Results suggest that relaxation-guided imagery reduces preoperative anxiety and postoperative pain in children. Future studies should focus on developing protocols and studying the eventual reduction of administered drugs for anesthesia and pain. What is Known: • Literature suggests the usefulness of relaxation-guided imagery in reducing anxiety and pain in the perioperative period. • Stronger evidences are needed to support the application of relaxation-guided imagery as routine care in pediatric surgery. What is New: • To our knowledge, this is the first randomized study to investigate the efficacy of relaxation-guided imagery in reducing preoperative anxiety and postoperative pain within a single pediatric sample. • The present study provides stronger evidence in an area that is lacking in research.
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Affiliation(s)
- Laura Vagnoli
- Pediatric Psychology, Meyer Children's Hospital, Via G. Pieraccini 24, 50139, Florence, Italy.
| | - Alessandra Bettini
- Pediatric Psychology, Meyer Children's Hospital, Via G. Pieraccini 24, 50139, Florence, Italy
| | - Elena Amore
- Pediatric Psychology, Meyer Children's Hospital, Via G. Pieraccini 24, 50139, Florence, Italy
| | - Salvatore De Masi
- Clinical Trial Office, Meyer Children's Hospital, Via G. Pieraccini 24, 50139, Florence, Italy
| | - Andrea Messeri
- Pain Service & Palliative Care, Meyer Children's Hospital, Via G. Pieraccini 24, 50139, Florence, Italy
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Abstract
BACKGROUND Acute pain is one of the major complaints reported in pediatric emergency departments and general wards. Recently, both the US Food and Drug Administration and European Medicine Agency emitted some warnings regarding the use of opioids, including codeine, in children. OBJECTIVE The aims of this study were summarizing the main pharmacological aspects of ibuprofen, discussing the current evidence about the use of ibuprofen in different and specific clinical settings, and providing a comparison with acetaminophen and/or codeine, according to available studies. STUDY DESIGN AND METHODS Studies evaluating ibuprofen for the management of acute pain in children were extracted from the PubMed and MEDLINE database within the period ranging from 1985 through 2017. After discussing safety of ibuprofen and its concomitant use with acetaminophen, the specific indications for the clinical practice were considered. RESULTS Ibuprofen resulted to be more effective than acetaminophen, and comparable to the combination acetaminophen-codeine, for the control of acute pain related to musculoskeletal pain. Moreover, similar results have been reported also in the management of toothache and inflammatory diseases of the oral cavity and pharynx. Ibuprofen resulted to be useful as a first approach to episodic headache. Finally, the role of ibuprofen in the management of postoperative pain and, particularly, after tonsillectomy and/or adenoidectomy has been reconsidered recently. CONCLUSIONS Ibuprofen resulted to be the most studied nonsteroidal anti-inflammatory drug in the management of acute pain in children; in general, it showed a good safety profile and provided evidence of effectiveness, despite some differences according to the specific clinical context.
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Byun S, Pather N. Pediatric regional anesthesia: A review of the relevance of surface anatomy and landmarks used for peripheral nerve blockades in infants and children. Clin Anat 2019; 32:803-823. [DOI: 10.1002/ca.23406] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2019] [Revised: 05/08/2019] [Accepted: 05/09/2019] [Indexed: 12/14/2022]
Affiliation(s)
- Sarang Byun
- Department of AnatomySchool of Medical Sciences, Medicine, UNSW Sydney Sydney Australia
| | - Nalini Pather
- Department of AnatomySchool of Medical Sciences, Medicine, UNSW Sydney Sydney Australia
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Nguyen LP, Nguyen L, Austin JP. A Quality Improvement Initiative to Decrease Inappropriate Intravenous Acetaminophen Use at an Academic Medical Center. Hosp Pharm 2019; 55:253-260. [PMID: 32742014 DOI: 10.1177/0018578719841054] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Background: Following availability in the United States in 2011, intravenous acetaminophen (IV APAP) was added to many hospital formularies for multimodal pain control. In 2014, the price of IV APAP increased from $12/g to $33/g and became a top 10 medication expenditure at our institution. Objective: To promote appropriate IV APAP prescribing and reduce costs. Design, Setting, Participants: Quality improvement project at a 562-bed academic medical center involving all inpatient admissions from 2010 to 2017. Interventions: Using Plan-Do-Study-Act (PDSA) methodology, our Pharmacy & Therapeutics (P&T) committee aimed to reduce inappropriate use of IV APAP by refinement of restriction criteria, development of clinical decision support in the electronic medical record, education of clinical staff on appropriate use, and empowerment of hospital pharmacists to enforce restrictions. Measurements: Monthly IV APAP utilization and spending were assessed using statistical process control charts. Balancing measures included monthly usage of IV opioid, IV ketorolac, and oral ibuprofen. Results: Five PDSA cycles were conducted during the study period. Monthly spending on IV APAP decreased from the highest average of $56 038 per month to $5822 per month at study conclusion. Interventions resulted in an 80% annual cost savings, or an approximate savings of $600 000 per year. Usage of IV opioids, IV ketorolac, and oral ibuprofen showed no major changes during the study period. Conclusions: IV APAP can be restricted in a safe and cost effective manner without concomitant increase in IV opioid use.
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Affiliation(s)
| | - Lam Nguyen
- Oregon Health & Science University, Portland, USA
- Doernbecher Children's Hospital, Portland, OR, USA
| | - Jared P Austin
- Oregon Health & Science University, Portland, USA
- Doernbecher Children's Hospital, Portland, OR, USA
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Ferguson MC, Schumann R, Gallagher S, McNicol ED. Single-dose intravenous ibuprofen for acute postoperative pain in adults. Hippokratia 2019. [DOI: 10.1002/14651858.cd013264] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Affiliation(s)
- McKenzie C Ferguson
- Southern Illinois University Edwardsville; Pharmacy Practice; Edwardsville IL USA
| | - Roman Schumann
- Tufts Medical Center; Department of Anesthesiology and Perioperative Medicine; 800 Washington Street Box #298 Boston Massachusetts USA 02111
| | - Sean Gallagher
- Tufts Medical Center; Department of Anesthesiology and Perioperative Medicine; 800 Washington Street Box #298 Boston Massachusetts USA 02111
| | - Ewan D McNicol
- Tufts Medical Center; Department of Anesthesiology and Perioperative Medicine; 800 Washington Street Box #298 Boston Massachusetts USA 02111
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McNicol ED, Ferguson MC, Gallagher S, Schumann R. Single‐dose intravenous ketorolac for acute postoperative pain in adults. Cochrane Database Syst Rev 2019; 2019:CD013263. [PMCID: PMC6379096 DOI: 10.1002/14651858.cd013263] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2023]
Abstract
This is a protocol for a Cochrane Review (Intervention). The objectives are as follows: To assess the analgesic efficacy and adverse effects of single‐dose IV ketorolac, compared with placebo or an active comparator, for moderate‐to‐severe postoperative pain in adults.
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Affiliation(s)
- Ewan D McNicol
- Tufts Medical CenterDepartment of Anesthesiology and Perioperative MedicineBostonUSA
| | | | - Sean Gallagher
- Tufts Medical CenterDepartment of Anesthesiology and Perioperative MedicineBostonUSA
| | - Roman Schumann
- Tufts Medical CenterDepartment of Anesthesiology and Perioperative MedicineBostonUSA
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Hunter JF, Kain ZN, Fortier MA. Pain relief in the palm of your hand: Harnessing mobile health to manage pediatric pain. Paediatr Anaesth 2019; 29:120-124. [PMID: 30444558 DOI: 10.1111/pan.13547] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2018] [Revised: 11/04/2018] [Accepted: 11/12/2018] [Indexed: 12/14/2022]
Abstract
The development and implementation of mobile health (mHealth) interventions provide an opportunity for more optimal management of pediatric pain in the home setting. Leveraging the popularity, mobility, and technological capabilities of digital mobile devices may reduce pediatric pain. Several mHealth applications have already been developed that target the reduction of acute and chronic pediatric pain by digitally delivering intervention strategies in an engaging manner, accumulating pain assessment data, facilitating patient-provider communication, and providing interactive training. Although several mHealth programs have begun to make strides in the management of pediatric pain, there are still many more possibilities for improvement as greater development and adoption of mHealth practices is on the horizon. Recommendations are provided that advocate for continued advancement of pediatric pain mHealth implementation with an emphasis on robust scientific evaluation, a structured approach to development and design elements that enhance engagement. Increased awareness about the positive influence of mHealth along with the encouragement of researchers and healthcare providers to promote and develop mHealth programs has the potential to transform pediatric pain management. This merger of evidence-based pain management strategies and digital technology positions pediatric mHealth to have a profound impact by effectively augmenting standard of care and benefiting healthcare providers, parents, and especially children in need.
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Affiliation(s)
- John F Hunter
- Department of Psychological Science, University of California, Irvine, California
| | - Zeev N Kain
- Center on Stress & Health, School of Medicine, University of California-Irvine, Irvine, California.,Department of Anesthesiology and Perioperative Care, University of California-Irvine, Irvine, California.,Department of Pediatrics, Children's Hospital of Orange County, Orange, California.,Yale Child Study Center, School of Medicine, Yale University, New Haven, Connecticut
| | - Michelle A Fortier
- Center on Stress & Health, School of Medicine, University of California-Irvine, Irvine, California.,Department of Anesthesiology and Perioperative Care, University of California-Irvine, Irvine, California.,Sue & Bill Gross School of Nursing, University of California-Irvine, Irvine, California.,Department of Pediatric Psychology, Children's Hospital of Orange County, Orange, California
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Efficacy of the Game Ready® cooling device on postoperative analgesia after scoliosis surgery in children. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2019; 28:1257-1264. [DOI: 10.1007/s00586-019-05886-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/22/2018] [Accepted: 01/13/2019] [Indexed: 12/13/2022]
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Bellon M, Skhiri A, Julien-Marsollier F, Malbezin S, Thierno D, Hilly J, ElGhoneimi A, Bonnard A, Michelet D, Dahmani S. Paediatric minimally invasive abdominal and urological surgeries: Current trends and perioperative management. Anaesth Crit Care Pain Med 2018; 37:453-457. [DOI: 10.1016/j.accpm.2017.11.013] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2017] [Revised: 09/14/2017] [Accepted: 11/13/2017] [Indexed: 12/20/2022]
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Kim DH, Kim N, Lee JH, Jo M, Choi YS. Efficacy of preemptive analgesia on acute postoperative pain in children undergoing major orthopedic surgery of the lower extremities. J Pain Res 2018; 11:2061-2070. [PMID: 30288096 PMCID: PMC6162994 DOI: 10.2147/jpr.s175169] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Background Children undergoing major orthopedic surgery of the lower extremities can experience severe postoperative pain; yet, the ideal postoperative pain management strategy is unknown. Thus, in this patient population, we investigated the effect of intraoperative epidural infusion of local anesthetic on acute postoperative pain and analgesic consumption. Patients and methods Patients (N=50, 3-12 years) randomly received either ropivacaine 0.15% (preemptive group) or normal saline (control group) as an initial bolus of 0.2 mL/kg, followed by continuous infusion of 0.15 mL/kg/h throughout surgery. Following surgery, patient-controlled epidural analgesia with ropivacaine 0.1% was provided. The main study outcomes were the revised Face, Legs, Activity, Cry, and Consolability pain scores, epidural ropivacaine consumption, and additional analgesic requirements during the first 48 hours postoperatively. Results Forty-seven patients completed the study, 23 in the preemptive group and 24 in the control group, respectively. The revised Face, Legs, Activity, Cry, and Consolability pain scores were significantly lower in the preemptive group only at 30 minutes after postanesthesia care unit arrival and 6 hours after surgery (median difference -1.0, 95% CI -2.0 to -1.0, P=0.001 and median difference -2.0, 95% CI -3.0 to -1.0, P=0.005, respectively). However, they were not significantly different between the groups at 12, 24, and 48 hours postoperatively. Epidural ropivacaine consumption and additional analgesic requirements throughout 48 hours postoperatively were not significantly different between the groups. Conclusion Intraoperative epidural infusion of ropivacaine did not demonstrate preemptive analgesic efficacy within 48 hours postoperatively in children undergoing extensive lower limb orthopedic surgery.
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Affiliation(s)
- Do-Hyeong Kim
- Department of Anesthesiology and Pain Medicine, Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Seoul, Republic of Korea,
| | - Namo Kim
- Department of Anesthesiology and Pain Medicine, Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Seoul, Republic of Korea,
| | - Jae Hoon Lee
- Department of Anesthesiology and Pain Medicine, Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Seoul, Republic of Korea,
| | - Minju Jo
- Department of Anesthesiology and Pain Medicine, Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Seoul, Republic of Korea,
| | - Yong Seon Choi
- Department of Anesthesiology and Pain Medicine, Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Seoul, Republic of Korea,
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Buprenorphine versus Morphine in Paediatric Acute Pain: A Systematic Review and Meta-Analysis. Crit Care Res Pract 2018; 2018:3792043. [PMID: 30159170 PMCID: PMC6109565 DOI: 10.1155/2018/3792043] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2018] [Accepted: 07/09/2018] [Indexed: 11/17/2022] Open
Abstract
INTRODUCTION In lab-based studies, buprenorphine appears to have a ceiling effect on respiratory depression but not on analgesia. There is increasing evidence in adult patients that buprenorphine has no ceiling effect on analgesia or side effects. The aim of this study was to investigate the efficacy and adverse effects of buprenorphine versus morphine in paediatric acute pain. METHODS A systematic review of five databases was performed until May 2018. Only randomised controlled trials were eligible for inclusion. The outcomes of interest included pain, respiratory depression, nausea, sedation, dizziness, and pruritus. RESULTS Four randomised controlled trials (n=195) were included. The only outcome measuring analgesic efficacy was time to breakthrough analgesia. Buprenorphine had a significant increase in time to breakthrough analgesia by 114.98 minutes compared to morphine (95% CI = 42.94 to 187.01; I2 = 0; p=0.002). There was no significant difference in the rates of adverse effects. CONCLUSIONS Buprenorphine provided a longer duration of analgesia than morphine. This in combination with its unique sublingual preparation could prove particularly advantageous in the paediatric population. The studies included are likely underpowered to detect differences in the incidence of adverse effects; therefore, the same precautions should be taken as with any other opioid.
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Pain Management in Pediatric Burn Patients: Review of Recent Literature and Future Directions. J Burn Care Res 2018; 38:335-347. [PMID: 27893572 DOI: 10.1097/bcr.0000000000000470] [Citation(s) in RCA: 48] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Childhood burns are a profoundly traumatic and painful experience. Despite recognition of the prevalence of burn injuries in children and the severity of the associated pain, burn pain remains undertreated. At the same time, more evidence is emerging to suggest that undertreated pain has serious long-term medical and psychiatric consequences, many of which can be ameliorated with improved pain control. Pain in burn patients is, however, notoriously difficult to treat, perhaps because there is a chronic pain aspect underlying the acute pain that accompanies wound care and procedures. This difficulty is compounded by the fact that there are little data to guide decision making in these patients. This article aims to identify the best strategies to guide clinical practice through a review of the past 10 years' development in pediatric burn pain management. However, because clinical investigations remain limited in burned children, we also aim to draw attention to those areas where the data do not identify an optimal approach and further work is needed. Overall, in addition to just the traditional pharmacological approaches to pain, such as acetaminophen, benzodiazepines, and opioids, there is growing evidence to support more widespread use of regional anesthesia and novel technologies such as virtual reality. Starting with an improved understanding of the current state of the literature, we can identify areas of research and important questions whose answers will ultimately improve care and reduce suffering for this unfortunate population of children.
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Giacalone M, Capua T, Shavit I. Short and long arm cast and pain after discharge in children who underwent reduction of distal forearm fracture in the Emergency Department: A study protocol for a randomized comparative effectiveness study. Contemp Clin Trials Commun 2018; 11:46-49. [PMID: 30003167 PMCID: PMC6040576 DOI: 10.1016/j.conctc.2018.06.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2018] [Revised: 05/25/2018] [Accepted: 06/01/2018] [Indexed: 11/30/2022] Open
Abstract
Distal forearm fracture is the most common fracture in childhood. Patients with this type of injury suffer from meaningful pain after Emergency Department (ED) discharge. Previous studies demonstrated that short arm (below-the-elbow) casts perform as well as long arm (above-the-elbow) casts for maintaining the reduction of distal forearm fractures, with a similar rate of complications. Consequently, short casts are the commonly used method of immobilization after closed reduction of a distal forearm fractures in children older than 4 years. However, short casts carry a potential disadvantage; since they cannot prevent supination in a wrist that is held in pronation, and vice versa, their use might be associated with pain. We initiated this study to examine the effect of the type of casting on post discharge pain. We will conduct an open-label randomized, controlled trial comparing short cast immobilization with long cast immobilization in children who had a reduction of distal forearm fracture in the ED. Our hypothesis is that children with distal forearm fractures who are treated with a long cast, experience less pain during the first 48 h after ED discharge than children who are treated with a short cast.
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Affiliation(s)
- Martina Giacalone
- Department of Paediatric Medicine, Anna Meyer Children's University Hospital, Florence, Italy
| | - Tali Capua
- Emergency Department, Dana-Dwek Children's Hospital, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Itai Shavit
- Emergency Department, Ruth Children's Hospital, Rambam Health Care Campus, Haifa, Israel
- Corresponding author. POB 274, Kibutz Maayan Tzvi, 3080500, Israel.
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