Comment utiliser les morphiniques en périopératoire ? Spécificités pédiatriques

Single shot intercostal block for pain management in pediatric patients undergoing the Nuss procedure: a double-blind, randomized, controlled study

PURPOSE

The aim of this study was to investigate the efficacy of a single shot intercostal block for pain control in pediatric patients undergoing the Nuss procedure.

METHODS

A double-blind, randomized, controlled study was performed. Thirty patients received a single shot bilateral intercostal block with levobupivacaine (L group) and 30 patients with 0.9 % saline (S group). Standardized baseline analgesia was applied for all patients. Morphine consumption, pain scores, respiratory depression, nausea and vomiting, and urinary retention were recorded every 3h for 48h after surgery.

RESULTS

The loading dose of morphine was lower (p<0.00001) in the L group. There were significantly lower morphine doses up to 6h after surgery and VAS scores up to 3h after surgery in the L group (p<0.001 and p=0.0003, respectively). The incidence of nausea and vomiting was lower in the L group (<0.00001). The incidence of urinary retention was lower in the L group (p=0.019).

CONCLUSIONS

A single shot IB is an effective additional treatment for pediatric patients undergoing the Nuss procedure and results in the reduced consumption of morphine, less postoperative pain, and fewer opioid-related adverse effects.

MORPHIT: an observational study on morphine titration in the postanesthetic care unit in children

BACKGROUND

Little information is available on the titration of morphine postoperatively in children. This observational study describes the technique in terms of the bolus dose, the number of boluses required, the time to establish analgesia, and side effects noted.

METHODS

Morphine was administered if pain score (VAS or FLACC) was >30. Patients weighing less than 45 kg received a 50 μg·kg(-1) bolus of morphine with subsequent boluses of 25 μg kg(-1) as required. Patients weighing over 45 kg received boluses of 2 mg. Pain and Ramsay scores were recorded up to 90 min after the end of the titration and any side effect or complication was noted. Data are presented as the median [interquartile Q1-Q3 range].

RESULTS

Overall, 103 children were studied. The median age was 4.2 years [0.8-12.2 years]. The median weight was 15.5 kg [8.2-35.0 kg]. The protocol was effective for pain control with a significant decrease in pain scores over time. The median pain score (VAS or FLACC) was 70 [50-80] prior to the initial bolus and 0 [0-10] 90 min after the last bolus. Median Ramsay score was 1 [1-2] before the initial bolus administration and 4 [2-4] at 90 min. The median total dose of morphine was 100 [70-140] μg·kg(-1) , and the median number of boluses was 3 [2-5]. Side effects were observed in 17% of cases. No serious complications were observed.

CONCLUSIONS

Our study of morphine titration for children shows that our protocol was effective for pain control with a significant decrease in pain scores over time. No serious complications were encountered. More studies on larger cohorts of patients are needed to confirm the efficacy and safety of this protocol.