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Prescott MG, Iakovleva E, Simpson MR, Pedersen SA, Munblit D, Vallersnes OM, Austad B. Intranasal analgesia for acute moderate to severe pain in children - a systematic review and meta-analysis. BMC Pediatr 2023; 23:405. [PMID: 37596559 PMCID: PMC10436645 DOI: 10.1186/s12887-023-04203-x] [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] [Received: 01/12/2023] [Accepted: 07/22/2023] [Indexed: 08/20/2023] Open
Abstract
BACKGROUND Children in acute pain often receive inadequate pain relief, partly from difficulties administering injectable analgesics. A rapid-acting, intranasal (IN) analgesic may be an alternative to other parenteral routes of administration. Our review compares the efficacy, safety, and acceptability of intranasal analgesia to intravenous (IV) and intramuscular (IM) administration; and to compare different intranasal agents. METHODS We searched Cochrane Library, MEDLINE/PubMed, Embase, Web of Knowledge, Clinicaltrials.gov, Controlled-trials.com/mrcr, Clinicaltrialsregister.eu, Apps.who.int/trialsearch. We also screened reference lists of included trials and relevant systematic reviews. Studies in English from any year were included. Two authors independently assessed all studies. We included randomised trials (RCTs) of children 0-16, with moderate to severe pain; comparing intranasal analgesia to intravenous or intramuscular analgesia, or to other intranasal agents. We excluded studies of procedural sedation or analgesia. We extracted study characteristics and outcome data and assessed risk of bias with the ROB 2.0-tool. We conducted meta-analysis and narrative review, evaluating the certainty of evidence using GRADE. Outcomes included pain reduction, adverse events, acceptability, rescue medication, ease of and time to administration. RESULTS We included 12 RCTs with a total of 1163 children aged 3 to 20, most below 10 years old, with a variety of conditions. Our review shows that: - There may be little or no difference in pain relief (single dose IN vs IV fentanyl MD 4 mm, 95% CI -8 to 16 at 30 min by 100 mm VAS; multiple doses IN vs IV fentanyl MD 0, 95%CI -0.35 to 0.35 at 15 min by Hannallah score; single dose IN vs IV ketorolac MD 0.8, 95% CI -0.4 to 1.9 by Faces Pain Scale-Revised), adverse events (single dose IN vs IV fentanyl RR 3.09, 95% CI 0.34 to 28.28; multiple doses IN vs IV fentanyl RR 1.50, 95%CI 0.29 to 7.81); single dose IN vs IV ketorolac RR 0.716, 95% CI 0.23 to 2.26), or acceptability (single dose IN vs IV ketorolac RR 0.83, 95% CI 0.66 to 1.04) between intranasal and intravenous analgesia (low certainty evidence). - Intranasal diamorphine or fentanyl probably give similar pain relief to intramuscular morphine (narrative review), and are probably more acceptable (RR 1.60, 95% CI 1.42 to 1.81) and tolerated better (RR 0.061, 95% CI 0.03 to 0.13 for uncooperative/negative reaction) (moderate certainty); adverse events may be similar (narrative review) (low certainty). - Intranasal ketamine gives similar pain relief to intranasal fentanyl (SMD 0.05, 95% CI -0.20 to 0.29 at 30 min), while having a higher risk of light sedation (RR 1.74, 95% CI 1.30 to 2.35) and mild side effects (RR 2.16, 95% CI 1.72 to 2.71) (high certainty). Need for rescue analgesia is probably similar (RR 0.85, 95% CI 0.62 to 1.17) (moderate certainty), and acceptability may be similar (RR 1.15, 95% CI 0.89 to 1.48) (low certainty). CONCLUSIONS Our review suggests that intranasal analgesics are probably a good alternative to intramuscular analgesics in children with acute moderate to severe pain; and may be an alternative to intravenous administration. Intranasal ketamine gives similar pain relief to fentanyl, but causes more sedation, which should inform the choice of intranasal agent.
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Affiliation(s)
- Marcus Glenton Prescott
- Department of Public Health and Nursing, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology (NTNU), Trondheim, Norway.
- Emergency Department, St. Olavs Hospital, Trondheim, Norway.
- Trondheim Municipal Out of Hours Primary Care Service, Trondheim, Norway.
| | - Ekaterina Iakovleva
- Department of Pediatrics and Pediatric Infectious Diseases, Institute of Child´s Health, Sechenov First Moscow State Medical University (Sechenov University), Moscow, Russia
| | - Melanie Rae Simpson
- Department of Public Health and Nursing, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology (NTNU), Trondheim, Norway
| | - Sindre Andre Pedersen
- Library Section for Medical and Health Sciences, NTNU University Library, Norwegian University of Science and Technology (NTNU), Trondheim, Norway
| | - Daniel Munblit
- Department of Pediatrics and Pediatric Infectious Diseases, Institute of Child´s Health, Sechenov First Moscow State Medical University (Sechenov University), Moscow, Russia
- Florence Nightingale Faculty of Nursing, Midwifery and Palliative Care, Care for Long Term Conditions Division, King´s College London, London, UK
| | - Odd Martin Vallersnes
- Department of General Practice, University of Oslo, Oslo, Norway
- Oslo Municipal Out of Hours Primary Care Service, Oslo, Norway
| | - Bjarne Austad
- Department of Public Health and Nursing, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology (NTNU), Trondheim, Norway
- Trondheim Municipal Out of Hours Primary Care Service, Trondheim, Norway
- Øya Medical Center, Trondheim, Norway
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Shih MC, Long BD, Pecha PP, White DR, Liu YC, Brennan E, Nguyen MI, Clemmens CS. A scoping review of randomized clinical trials for pain management in pediatric tonsillectomy and adenotonsillectomy. World J Otorhinolaryngol Head Neck Surg 2023; 9:9-26. [PMID: 37006744 PMCID: PMC10050970 DOI: 10.1002/wjo2.54] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2021] [Accepted: 12/23/2021] [Indexed: 12/15/2022] Open
Abstract
Objectives To examine the volume, topics, and reporting trends in the published literature of randomized clinical trials for pharmacologic pain management of pediatric tonsillectomy and adenotonsillectomy and to identify areas requiring further research. Data Sources PubMed (National Library of Medicine and National Institutes of Health), Scopus (Elsevier), CINAHL (EBSCO), and Cochrane Library (Wiley). Methods A systematic search of four databases was conducted. Only randomized controlled or comparison trials examining pain improvement with a pharmacologic intervention in pediatric tonsillectomy or adenotonsillectomy were included. Data collected included demographics, pain-related outcomes, sedation scores, nausea/vomiting, postoperative bleeding, types of drug comparisons, modes of administration, timing of administration, and identities of the investigated drugs. Results One hundred and eighty-nine studies were included for analysis. Most studies included validated pain scales, with the majority using visual-assisted scales (49.21%). Fewer studies examined pain beyond 24 h postoperation (24.87%), and few studies included a validated sedation scale (12.17%). Studies have compared several different dimensions of pharmacologic treatment, including different drugs, timing of administration, modes of administration, and dosages. Only 23 (12.17%) studies examined medications administered postoperatively, and only 29 (15.34%) studies examined oral medications. Acetaminophen only had four self-comparisons. Conclusion Our work provides the first scoping review of pain and pediatric tonsillectomy. With drug safety profiles considered, the literature does not have enough data to determine which treatment regimen provides superior pain control in pediatric tonsillectomy. Even common drugs like acetaminophen and ibuprofen require further research for optimizing the treatment of posttonsillectomy pain. The heterogeneity in study design and comparisons weakens the conclusions of potential systematic reviews and meta-analyses. Future directions include more noninferiority studies of unique comparisons and more studies examining oral medications given postoperatively.
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Affiliation(s)
- Michael C. Shih
- Department of Otolaryngology—Head and Neck SurgeryMedical University of South CarolinaCharlestonSouth CarolinaUSA
- Baylor College of MedicineHoustonTexasUSA
| | - Barry D. Long
- Department of Otolaryngology—Head and Neck SurgeryMedical University of South CarolinaCharlestonSouth CarolinaUSA
- Department of Otolaryngology—Head and Neck SurgeryVirginia Commonwealth University School of MedicineRichmondVirginiaUSA
| | - Phayvanh P. Pecha
- Department of Otolaryngology—Head and Neck SurgeryMedical University of South CarolinaCharlestonSouth CarolinaUSA
| | - David R. White
- Department of Otolaryngology—Head and Neck SurgeryMedical University of South CarolinaCharlestonSouth CarolinaUSA
| | - Yi‐Chun C. Liu
- Department of Otolaryngology—Head and Neck SurgeryBaylor College of MedicineHoustonTexasUSA
- Department of Surgery ‐ Division of Pediatric OtolaryngologyTexas Children's HospitalHoustonTexasUSA
| | - Emily Brennan
- Department of Research and Education ServicesMedical University of South Carolina LibraryCharlestonSouth CarolinaUSA
| | - Mariam I. Nguyen
- Charleston County School of the ArtsNorth CharlestonSouth CarolinaUSA
| | - Clarice S. Clemmens
- Department of Otolaryngology—Head and Neck SurgeryMedical University of South CarolinaCharlestonSouth CarolinaUSA
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Blumberger D, Knyahnytska Y, Kaster T, Voineskos D, Trevizol A, Zomorrodi R. Safety, clinical and neurophysiological effects of intranasal ketamine in ECT non-responders: an open-label clinical trial. Pilot Study. Research Protocol. JMIR Res Protoc 2021; 11:e30163. [PMID: 34882570 PMCID: PMC8804953 DOI: 10.2196/30163] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2021] [Revised: 12/03/2021] [Accepted: 12/08/2021] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Major Depressive Disorder is among the four most disabling illnesses worldwide, with a lifetime prevalence estimated at 16.2%. Research suggests that 20-40% of patients with depression do not respond to pharmacotherapy, developing treatment-resistant depression (TRD). Electroconvulsive therapy (ECT) is the gold standard therapeutic approach for TRD, with remission rates reported 65-90%. A challenge with ECT remains in that 10-30% of patients do not respond to it, and many are unable to tolerate it due to ECT side effects. In this study, we operationalize both groups as ECT-non responders based on clinical management perspective, specifically as patients continue to exhibit symptoms of severe depression and a limited number of treatment options available for this sub-group. Thus, both groups remain at high risk and equally require treatment, which is robust and potentially can bring immediate clinical relief to depressive symptoms. Ketamine, an N-methyl-d-aspartate (NMDA) receptor antagonist, has been shown to exert rapid antidepressant effects in patients with TRD when administered in sub-anesthetic doses through 40-min intravenous (IV) infusions. Recently, a ketamine compound, esketamine (Spravato®), administered through the intranasal (IN) route, received regulatory approval by the FDA and Health Canada to treat depression. However, esketamine is challenging to access for most patients with severe depression due to high costs and limited availability. IN racemic ketamine (rketamine) is cheap and easy to access; however, the effects in ECT-non responders have yet to be understood and tested. This study will use noninvasive brain stimulation neurophysiological tools, such as transcranial magnetic stimulation (TMS), to study mechanisms of human brain cortical physiology at the systemic level. The combination of TMS with a central nervous system (CNS) pharmacological agent, such as ketamine, will provide a platform to explore the neurophysiological basis of the impact of ketamine on brain physiology, an essential piece of work towards identifying neurobiomarkers of treatment response. Until present, only several studies have attempted to examine the excitatory and inhibitory circuits by using a range of TMS protocols during infusion of incremental doses of ketamine, primarily using very low ketamine doses or single doses in healthy volunteers. Currently, the prediction of the therapeutic response in those with mood disorders as measured by changes in cortical excitability continues to be in very early stages and has not been systematically tested, making this proposal uniquely positioned amongst other neurophysiological studies on ketamine and TMS. OBJECTIVE The objective of the current proof-of-concept clinical trial is to test the safety, tolerability and clinical effects of intranasal ketamine in those with unipolar depression who did not respond or were unable to tolerate an acute course of ECT. The primary outcome is to determine the feasibility of a larger randomized controlled trial to test the efficacy of IN ketamine for ECT-non responders for clinical indicators in unipolar depression. The secondary outcome is to determine the preliminary effects of an intervention on clinical outcomes, such as depressive symptoms (as measured by HRSD-24), suicidal ideation (as measured by SSI), and quality of living (as measured by WHODAS). The third outcome measure is to explore neurophysiological changes as measured by TMS-EMG and EEG to measure changes in cortical excitability as potential predictors of clinical response. METHODS A sterile solution of racemic ketamine hydrochloride (rketamine) will be administered twice per week for four weeks (8 sessions) intranasally (IN) to patients diagnosed with unipolar depressive disorders who did not respond or were unable to tolerate an acute course of ECT. We will recruit 25 adults (24-65 yr) for two years from an academic psychiatric hospital in Toronto, ON, Canada. RESULTS The research ethics board (REB) and Health Canada have fully approved this study, with funding secured. The study has been registered at clinicaltrials.gov, and we are currently in the process of recruiting patients. CONCLUSIONS This is the first study to test repeated doses of IN rketamine in patients with unipolar depressive disorder who did not respond or were unable to tolerate a course of acute ECT. Results from this study will (1) inform the development of a larger, adequately powered randomized controlled trial to test the efficacy of this intervention towards clinical symptoms definitely, and (2) to determine potential neurophysiological markers of clinical response. CLINICALTRIAL clinicaltrial.gov identifier # NCT05137938.
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Affiliation(s)
- Daniel Blumberger
- Centre for Addiction and Mental Health, 1025 Queen Str West. B1-2104, Toronto, CA
| | - Yuliya Knyahnytska
- Centre for Addiction and Mental Health, 1025 Queen Str West. B1-2104, Toronto, CA
| | - Tyler Kaster
- Centre for Addiction and Mental Health, 1025 Queen Str West. B1-2104, Toronto, CA
| | - Daphne Voineskos
- Centre for Addiction and Mental Health, 1025 Queen Str West. B1-2104, Toronto, CA
| | - Alisson Trevizol
- Centre for Addiction and Mental Health, 1025 Queen Str West. B1-2104, Toronto, CA
| | - Reza Zomorrodi
- Centre for Addiction and Mental Health, 1025 Queen Str West. B1-2104, Toronto, CA
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Zhao C, Zhang N, Shrestha N, Liu H, Ge M, Luo F. Dexamethasone as a ropivacaine adjuvant to pre-emptive incision-site infiltration analgesia in pediatric craniotomy patients: A prospective, multicenter, randomized, double-blind, controlled trial. Paediatr Anaesth 2021; 31:665-675. [PMID: 33713371 DOI: 10.1111/pan.14178] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2020] [Revised: 02/13/2021] [Accepted: 03/03/2021] [Indexed: 11/27/2022]
Abstract
BACKGROUND Dexamethasone added to incision-site infiltration has been routinely used to reduce pain after tonsillectomy in children. However, this has not been studied in pediatric craniotomy patients yet. We hypothesized that incision-site infiltration with a combination of ropivacaine and dexamethasone might provide superior analgesia to ropivacaine alone in pediatric craniotomy patients. METHODS In this multicenter, double-blind, randomized, controlled trial, children aged 2-12 years, scheduled for craniotomy, were prospectively enrolled at two study centers, from September 2, 2019, to July 5, 2020. Eighty children were randomly assigned (1:1) to either ropivacaine plus dexamethasone group who received pre-emptive incision-site infiltration with 0.2% ropivacaine plus 0.025% dexamethasone, or ropivacaine group who received 0.2% ropivacaine alone. Primary outcome was the modified Children's Hospital of Eastern Ontario Pain Scale (mCHEOPS) at 24 h postoperatively. Primary analysis was performed using the modified intention-to-treat principle. RESULTS Pre-emptive incision-site infiltration with ropivacaine plus dexamethasone had a reduced pain score of 2.0, compared with the pain score of 2.9 in the ropivacaine group, at 24 h postoperatively (mean difference -0.9, 95% confidence interval [CI], -1.7 to -0.2; p = .019). Estimated median of the time of first rescue analgesic demand was 24 h in the ropivacaine plus dexamethasone group and 8.5 h in the ropivacaine group [hazard ratio 0.43, 95% CI 0.24 to 0.08; Log-rank p = .0025]. No adverse events related to incision-site infiltration with dexamethasone were observed in this study. DISCUSSION Dexamethsone reduces the local production of pro-inflammatory factors after tissue damage and as a ropivacaine adjuvant for incision-site infiltration reduced the pain scores by 31% at 24 h postoperatively. The results were similar to several prior studies on to tonsillectomy patients. However, this changes on pain scores might has limited clinical significance. CONCLUSIONS The addition of dexamethasone to ropivacaine for preoperative incision-site infiltration has better postoperative analgesic effect than ropivacaine alone in pediatric craniotomy patients.
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Affiliation(s)
- Chunmei Zhao
- Department of Pain Management, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Nijia Zhang
- Department of Pediatric Neurosurgery, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China
| | - Niti Shrestha
- Department of Pain Management, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Hongbing Liu
- Department of Pain Management, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Ming Ge
- Department of Pediatric Neurosurgery, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China
| | - Fang Luo
- Department of Pain Management, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
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Benini F, Congedi S, Giacomelli L, Papa S, Shah A, Milani G. Refractory symptoms in paediatric palliative care: can ketamine help? Drugs Context 2021; 10:2021-2-5. [PMID: 34104198 PMCID: PMC8152774 DOI: 10.7573/dic.2021-2-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2021] [Accepted: 04/15/2021] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND One of the main challenges for paediatric palliative care (PPC) is the management of concomitant, different and severe symptoms that frequently affect the quality of life of PPC patients and are often refractory to commonly used pharmacological treatments. Consequently, many efforts are still needed to find the best therapeutic options to handle these refractory conditions. Since the first synthesis of ketamine in the 1960s, its pharmacokinetic and pharmacodynamic properties have been largely investigated and its potential wide range of clinical applications has become clear. However, this molecule still receives poor attention in some areas, including in children and PPC. This narrative review analyses the use of ketamine in children and the potential extension of its applications in PPC in order to provide new options for treatment in the PPC setting. METHODS Scientific papers published before October 2020 on MEDLINE, EMBASE and the Cochrane Library were considered. The cited references of the selected papers and the authors' personal collections of literature were reviewed. The terms "palliative care", "ketamine", "neuropathic pain", "procedural pain", "status epilepticus", "refractory pain" and "child", adding "age: birth-18 years" on a further filter were used for the search. DISCUSSION The use of ketamine in PPC should be more widely considered due to its overall favourable safety profile and its efficacy, which are supported by an increasing number of studies, although in settings different from PPC and of mixed quality. Ketamine should be proposed according to a case-by-case evaluation and the specific diagnosis and the dosage and route of administration should be tailored to the specific needs of patients. Furthermore, there is evidence to suggest that ketamine is safe and efficacious in acute pain. These findings can prompt further research on the use of ketamine for the treatment of acute pain in PPC. CONCLUSION Ketamine could be a suitable option after the failure of conventional drugs in the treatment of different refractory conditions in PPC.
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Affiliation(s)
- Franca Benini
- Centro Regionale Veneto di Terapia del Dolore and Cure Palliative Pediatriche, Hospice Pediatrico, Padua, Italy
| | - Sabrina Congedi
- Centro Regionale Veneto di Terapia del Dolore and Cure Palliative Pediatriche, Hospice Pediatrico, Padua, Italy
| | | | | | | | - Gregorio Milani
- Department of Clinical Sciences and Community Health, Università degli Studi di Milano, Milan, Italy
- Pediatric Unit, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
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Pansini V, Curatola A, Gatto A, Lazzareschi I, Ruggiero A, Chiaretti A. Intranasal drugs for analgesia and sedation in children admitted to pediatric emergency department: a narrative review. ANNALS OF TRANSLATIONAL MEDICINE 2021; 9:189. [PMID: 33569491 PMCID: PMC7867955 DOI: 10.21037/atm-20-5177] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Acute pain is one of the most common symptoms in children admitted to the Pediatric Emergency Department (PED) and its management represents a real clinical challenge for pediatricians. Different painful procedures can be very stressful for young children and their perception of pain can be enhanced by emotional factors, such as anxiety, distress, or anger. Adequate procedural sedation reduces anxiety and emotional trauma for the patient, but it reduces also stress for operators and the time for procedures. We have reviewed the literature on this topic and the drugs covered in these papers were: midazolam, fentanyl, ketamine, and dexmedetomidine. There are several routes of administering for these drugs to provide analgesia and anxiolysis to children: oral, parenteral, or intranasal (IN). Intravenous (IV) sedation, since it involves the use of needles, can be stressful; instead, IN route is a non-invasive procedure and generally well tolerated by children and it has become increasingly widespread. Some medications can be administered by a mucosal atomizer device (MAD) or by drops. The benefits of the atomized release include less drug loss in the oropharynx, higher cerebrospinal fluid levels, better patient acceptability, and better sedative effects. IN midazolam has a sedative, anxiolytic and amnesic effect, but without analgesic properties. Fentanyl and ketamine are mainly used for pain control. Dexmedetomidine has anxiolytic and analgesic properties. In conclusion, IN analgo-sedation is a simple, rapid and painless option to treat pain and anxiety in the PED requiring brief training on the administration process and experience in sedation.
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Affiliation(s)
- Valeria Pansini
- Dipartimento di Pediatria, Fondazione Policlinico Universitario "A. Gemelli" IRCCS, Roma, Italia
| | - Antonietta Curatola
- Dipartimento di Pediatria, Fondazione Policlinico Universitario "A. Gemelli" IRCCS, Università Cattolica del Sacro Cuore, Roma, Italy
| | - Antonio Gatto
- Dipartimento di Pediatria, Fondazione Policlinico Universitario "A. Gemelli" IRCCS, Roma, Italia
| | - Ilaria Lazzareschi
- Dipartimento di Pediatria, Fondazione Policlinico Universitario "A. Gemelli" IRCCS, Università Cattolica del Sacro Cuore, Roma, Italy
| | - Antonio Ruggiero
- Pediatric Oncology Unit, Fondazione Policlinico Universitario "A. Gemelli" IRCCS, Università Cattolica Sacro Cuore, Rome, Italy
| | - Antonio Chiaretti
- Dipartimento di Pediatria, Fondazione Policlinico Universitario "A. Gemelli" IRCCS, Università Cattolica del Sacro Cuore, Roma, Italy
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Aldamluji N, Burgess A, Pogatzki-Zahn E, Raeder J, Beloeil H. PROSPECT guideline for tonsillectomy: systematic review and procedure-specific postoperative pain management recommendations. Anaesthesia 2020; 76:947-961. [PMID: 33201518 PMCID: PMC8247026 DOI: 10.1111/anae.15299] [Citation(s) in RCA: 54] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/05/2020] [Indexed: 12/12/2022]
Abstract
Tonsillectomy is one of the most frequently performed surgical procedures; however, pain management remains challenging. Procedure‐specific efficacy as well as specific risks of treatment options should guide selection of pain management protocols based on evidence and should optimise analgesia without harm. The aims of this systematic review were to evaluate the available literature and develop recommendations for optimal pain management after tonsillectomy. A systematic review utilising preferred reporting items for systematic reviews and meta‐analysis guidelines with procedure‐specific postoperative pain management (PROSPECT) methodology was undertaken. Randomised controlled trials published in the English language up to November 2019 assessing postoperative pain using analgesic, anaesthetic or surgical interventions were identified. Out of the 719 potentially eligible studies identified, 226 randomised controlled trials met the inclusion criteria, excluding the studies examining surgical techniques. Pre‐operative and intra‐operative interventions that improved postoperative pain were paracetamol; non‐steroidal anti‐inflammatory drugs; intravenous dexamethasone; ketamine (only assessed in children); gabapentinoids; dexmedetomidine; honey; and acupuncture. Inconsistent evidence was found for local anaesthetic infiltration; antibiotics; and magnesium sulphate. Limited evidence was found for clonidine. The analgesic regimen for tonsillectomy should include paracetamol; non‐steroidal anti‐inflammatory drugs; and intravenous dexamethasone, with opioids as rescue analgesics. Analgesic adjuncts such as intra‐operative and postoperative acupuncture as well as postoperative honey are also recommended. Ketamine (only for children); dexmedetomidine; or gabapentinoids may be considered when some of the first‐line analgesics are contra‐indicated. Further randomised controlled trials are required to define risk and combination of drugs most effective for postoperative pain relief after tonsillectomy.
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Affiliation(s)
- N Aldamluji
- Department of Adult Anaesthesiology, Sidra Medicine, Qatar
| | - A Burgess
- Department of Otolaryngology Head and Neck Surgery, Com Maillot-Hartmann Private Hospital, Neuilly sur Seine, France
| | - E Pogatzki-Zahn
- Department of Anaesthesiology, Intensive Care and Pain Medicine, University Hospital Muenster, Muenster, Germany
| | - J Raeder
- Department of Anaesthesiology, Oslo University Hospital and Faculty of Medicine, University of Oslo, Oslo, Norway
| | - H Beloeil
- Department of Anaesthesiology and Critical Care, Université Rennes, Rennes, France
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Abstract
OBJECTIVES Intranasal ketamine has not been well studied in acute pain treatment and does not have a recognized place in therapy in current practice guidelines for pediatric patients. Ketamine has a unique mechanism of action with a favorable side effect profile that may provide benefit to the pediatric population for acute pain. The purpose of this review is to summarize the evidence evaluating intranasal ketamine versus any other comparator for children who require acute pain treatment. METHODS A systematic review was performed to include clinical studies of intranasal ketamine for acute pain that reported any pain-related outcome and adverse events in children 0 to 17 years old. Trials were identified through PubMed, Google Scholar, clinical trial registries, research registries, and key journals through April 2018. The Jadad scoring system was used to assess the methodological quality of the included randomized controlled trials. RESULTS Six studies consisting of 261 patients were reviewed. Intranasal ketamine demonstrated pain relief in all included clinical studies; however, there was inconsistency in dosing, comparators, scales, and indications. Two of the randomized controlled trials were rated as high quality, and 1 randomized controlled trial was rated as poor quality on the Jadad scale. CONCLUSIONS Intranasal ketamine was safe and effective in the 6 clinical studies included in this systematic review.
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Hu Y, Yang XY, Zhang JH. Etomidate plus fentanyl for anesthesia in pediatric strabotomy. Med Hypotheses 2020; 140:109666. [PMID: 32193044 DOI: 10.1016/j.mehy.2020.109666] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2019] [Revised: 02/29/2020] [Accepted: 03/05/2020] [Indexed: 12/25/2022]
Abstract
Considering the side effects of etomidate, it requires additional anesthetics to reduce the side effects and improve efficacy. Ketamine is often used as an adjunct anesthetic. We hypothesized that etomidate combined with fentanyl was more effective than etomidate combined with ketamine in the anesthesia of pediatric strabotomy. To prove our hypothesis, a prospective randomized controlled clinical study was performed, in which 35 children with strabotomy received etomidate plus ketamine (group A) for anesthesia induction and maintenance and 35 children with strabotomy received etomidate combined with fentanyl (group B). Mean arterial pressure (MAP), heart rate (HR), bispectral index (BIS), anesthesia effect, and emergence agitation and pain were observed before anesthesia induction (T1), after anesthesia induction (T2), at the beginning of the operation (T3), after 10-min operation (T4), and at the end of the operation (T5). Children in group B had significantly lower MAP and HR from T3 to T5, decreased BIS from T2 to T4, better anesthesia effect, and smaller emergence agitation and pain scores at 10 min after entering into postanesthesia care unit (PACU) compared with group A (p < 0.05). The mean emergence agitation score in group B was significantly lower than that in group A when the maximum emergence in group B was at 20 min after entering into PACU (p < 0.05). In conclusion, etomidate combined with fentanyl plays a good efficacy in anesthesia of pediatric strabotomy compared with etomidate plus ketamine.
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Affiliation(s)
- Y Hu
- Department of Outpatient, Maternal and Child Health Hospital of Panzhihua, Panzhihua, Sichuan Province, China.
| | - X Y Yang
- Department of Ophthalmology, The Affiliated Hospital of Panzhihua University, Panzhihua, Sichuan Province, China
| | - J H Zhang
- Department of Ophthalmology, The 19th Metallurgical Hospital of Panzhihua, Panzhihua, Sichuan Province, China
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