Pediatric pain management

Safety Assessment of Prolonged Nerve Catheters in Pediatric Trauma Patients: A Case Series Study

INTRODUCTION

Nerve block catheters (NBCs) are increasingly used for pain management in pediatric trauma patients. While short-term efficacy has been well established, the long-term safety of NBCs is unknown. Methods/Cases: The retrospective chart review includes a cohort of nine pediatric trauma patients aged 3-15 years who received 52 peripheral nerve block catheters and epidurals for pain management. This study aimed to investigate the potential risks associated with the prolonged use of NBCs in pediatric trauma cases.

RESULTS

The NBCs (48 peripheral catheters and 4 epidural catheters) were maintained for about 2 weeks. The number of catheters per patient varied from 1 to 11. The study noted a low frequency of catheter-related complications. No catheter-site infection or local anesthetic toxicity symptoms were reported.

DISCUSSION

These findings suggest that NBCs can be safely maintained for extended periods in pediatric trauma patients without significantly increasing complications. Careful monitoring and adherence to infection control practices remain paramount when implementing extended catheter use.

Analgesic Efficacy of Erector Spinae Plane Block in Pediatric Abdominal Surgery: Guidance with Conventional Method and NOL: Case Series

Background

Erector spinae plane (ESP) block is a regional anesthesia technique that blocks both somatic and visceral nerve fibers. Despite its high analgesic potential, its mechanism of action is not yet fully understood. The ultrasound-guided ESP block, which can be easily performed, makes important contributions to the control of intraoperative pain in pediatric patients undergoing abdominal surgery. The follow-up of pain in the intraoperative period is usually done by evaluating the changes in hemodynamic parameters. Due to physiological differences in pediatric patients, it is more difficult to do this with only hemodynamic changes than in adult patients. Aim: The NOL® (Nociception Level) monitor calculates the nociception/pain score by evaluating many parameters through a proprietary algorithm. Our primary aim was to demonstrate the effectiveness of ESP block with an advanced pain monitor in this patient group; our secondary aim was to investigate the necessity of pain monitors in the pediatric patient group.

Methods

In this case series, we applied intraoperative NOL® monitoring in addition to standard monitoring (ECG, SpO2, heart rate, EtCO₂) in pediatric patients (16 cases) who were scheduled for abdominal surgery and underwent ESP block.

Results

Considering the hemodynamic data, NOL values, postoperative pain scores, side effects, and complications, it was concluded that ESP block can be used safely in this patient group. Although the hemodynamic data and the NOL® index were compatible with each other after a nociceptive stimulus, the NOL index was less affected by other variables and gave the clinician clearer information about pain.

Efficacy of caudal vs intravenous administration of α2 adrenoceptor agonists to prolong analgesia in pediatric caudal block: A systematic review and meta-analysis

BACKGROUND

α₂ adrenoceptor agonists have been proposed as adjuncts to prolong analgesia in pediatric caudal block. The aim of this meta-analysis was to compare the analgesic efficacy of caudal vs intravenous α₂ adrenoceptor agonists during pediatric caudal block.

METHODS

A systematic search, data extraction, bias risk assessment, and pooled data analysis were performed following the PRISMA guidelines. All randomized controlled trials comparing caudal with intravenous α₂ adrenoceptor agonists in pediatric caudal block were included. Relative risk and weighted mean differences (the corresponding 95% confidence intervals) were calculated for dichotomous and continuous data, respectively. Trial sequential analyses were performed to evaluate the credibility of the meta-analysis.

RESULTS

A total of 244 patients in five trials were identified. Compared with the intravenous group (9.56 ± 4.23 hours), the time to the first rescue analgesia was prolonged in the caudal α₂ adrenoceptor agonists group (12.72 ± 5.99 hours) by a weighted mean difference of 2.98 hours [95% confidence interval: 0.59-5.36 hours; P = .01]. The number of children requiring rescue analgesia in the caudal group (64, 66.67%) was lower than that in the intravenous group (80, 81.63%) [relative risk = 0.82; 95% confidence interval: 0.69-0.97; P = .02]. These findings were also verified by trial sequential analysis. There were no significant differences in the side effects.

CONCLUSION

Caudal α₂ adrenoceptor agonists as adjuncts to local anesthetic during pediatric caudal block are more effective than intravenous injection. However, the results were affected by small sample size and significant heterogeneity.

Surgical considerations and challenges in the pediatric and adolescent gynecologic patient

It is important for practitioners to recognize that there are special considerations when performing gynecologic surgery in a pediatric or adolescent patient. A provider must be familiar with differences in anatomy, physiology, surgical technique, and psychosocial concerns. This can be challenging for a provider who does not routinely operate on patients in this population. A minimally invasive surgical approach is preferred in the pediatric and adolescent patient whenever possible. While a good command of laparoscopy in the adult patient is certainly a useful skill when operating on pediatric and adolescent patients, there are technical adaptations and challenges to consider. This chapter reviews the pre-operative preparation, operative technique and challenges, and post-operative care of the surgical pediatric and adolescent gynecologic patient.

Management of refractory pain in hospitalized adolescents with sickle cell disease: changing from intravenous opioids to continuous infusion epidural analgesia

BACKGROUND

Prolonged hospitalizations for sickle cell disease painful episodes are not uncommon, as analgesic options are often suboptimal.

OBSERVATIONS

Seven patients (15.4 ± 3.7 y, 6 females) were treated with epidural analgesia for refractory pain. The median duration of epidural catheter placement was 4 days (interquartile range, 3 to 6 d). Mean pain scores changed from 6.8 ± 2.7 to 4.8 ± 2.2, whereas mean daily parenteral opioid requirements changed from 79.7 ± 100.4 to 13.0 ± 13.1 mg of morphine equivalents.

CONCLUSION

Continuous epidural analgesia is an alternative to continuing intravenous opioids in sickle cell disease patients with refractory pain, and may reduce opioid-related side effects and facilitate transition to oral analgesics.

Inferior alveolar nerve blocks for postoperative pain control after mandibular distraction with osteotomies in a neonate

We describe the use of inferior alveolar nerve blocks (IANBs) for postoperative pain control for a neonate undergoing mandibular distraction and osteotomies. In this case, bilateral IANBs were effective in keeping low pain scores as assessed on the neonatal infant pain scale (NIPS) and the amount of opioid and adjuvant analgesics used. The blocks were assessed to have lasted approximately 24 h making serial blocks for pain control logistically feasible. Additionally, pain control was improved throughout the period of distractor advancement (approximately 7 days). We propose the routine use of this regional technique for improved pain control after this procedure in neonates and suggest that improved pain control may facilitate earlier extubation in this challenging population.

Applications of regional anaesthesia in paediatrics

Advances in the field of paediatric regional anaesthesia have specific applications to both acute and chronic pain management. This review summarizes data regarding the safety of paediatric regional anaesthetic techniques. Current guidelines are provided for performing paediatric regional techniques, with a focus on applications for postoperative pain management. Brief descriptions of relevant anatomy followed by indications for commonly performed blocks are highlighted along with the potential of adverse side-effects.

Managing procedural pain in pediatric patients

PURPOSE OF REVIEW

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

RECENT FINDINGS

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

SUMMARY

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