Anaesthesia and pain management in cerebral palsy

Efficacy of a Multimodal Surgical Site Injection for Postoperative Pain Control in Pediatric Patients With Cerebral Palsy Undergoing Hip Reconstruction: A Randomized Controlled Trial

BACKGROUND

One in 4 children with cerebral palsy (CP) will undergo orthopaedic surgery during their childhood. Despite its ubiquity, postoperative pain control has been poorly studied in this patient population. Moreover, poor pain management has been associated with adverse surgical outcomes. Multimodal analgesic injections have been well studied in the adult population, demonstrating safety and efficacy in reducing postoperative pain and narcotic consumption, but this modality has not been studied in pediatric patients undergoing similarly complex procedures. The objective of this study was to evaluate the efficacy of a multimodal surgical site injection for postoperative pain control following operative management of hip dysplasia in patients with CP.

METHODS

After obtaining IRB approval, a multicenter, randomized double-blind placebo control trial was completed. Patients below 18 years old with a diagnosis of CP who were scheduled for varus derotation osteotomy (VDRO) of the proximal femur were randomized to receive a surgical-site injection with either a combination of ropivacaine (3 mg/kg), epinephrine (0.5 mg), and ketorolac (0.5 mg/kg) (experimental group) or normal saline (control). All included patients had identical postoperative care, including immobilization, physical therapy, and standardized, multimodal postoperative pain control. Pain scores and narcotic consumption were recorded at regular intervals and compared between groups utilizing two-tailed t test or a nonparametric Mann-Whitney test for quantitative variables and a Fischer exact test for categorical variables.

RESULTS

Thirty-four patients were included, evenly divided between study arms. There were no significant differences in demographic variables, gross motor function classification system (GMFCS), comorbidities, preoperative radiographic parameters, or concomitant surgeries between groups. Patients in the experimental group required significantly lower narcotic medications at all postoperative time points from PACU until hospital discharge compared with controls (0.41 ± 0.42 vs. 1.87 ± 2.05 total morphine mEQ/kg, P=0.01). Similarly, patients in the experimental group were found to have significantly lower pain scores throughout their hospital stays compared with controls (1.0 ± 0.6 vs. 2.4 ± 1.1 mean pain score, P<0.001). There were no significant differences in operative time, OR time, blood transfusion requirements or hospital length of stay between groups. There were no adverse medication reactions or injection site complications in either group.

CONCLUSIONS

In patients with CP undergoing hip reconstruction, surgical-site injection with a multimodal analgesic combination improves pain control and reduces narcotic consumption in the early postoperative period with no observed adverse effects.

SIGNIFICANCE

Local multimodal analgesic injections should be adopted as part of standard multimodal pain control in this patient population for all osseous surgeries.

LEVEL OF EVIDENCE

Level I-therapeutic.

Preoperative gastric volume assessment using ultrasound in cerebral palsy pediatric patients: a prospective observational study

BACKGROUND

Although cerebral palsy is a risk factor for aspiration, there is insufficient research on residual gastric volume after preoperative fasting in children with cerebral palsy. We evaluated the incidence of a full stomach by ultrasound assessment of the gastric volume in children with cerebral palsy who underwent orthopedic surgery after preoperative fasting.

METHODS

The patients fasted for 8 h for solid foods and 2 h for clear liquids. We obtained the gastric antral cross-sectional area using ultrasound in the semi-recumbent and right lateral decubitus positions. A calculated stomach volume > 1.5 mL.kg-1 was considered as full, which poses a high aspiration risk. The primary outcome was the incidence of full stomach, and the secondary outcomes were the qualitative gastric volume, correlation of disease severity categorized according to the Gross Motor Function Classification System with the residual gastric volume, gastric volume per body weight, and qualitative gastric volume.

RESULTS

Thirty-seven pediatric patients with cerebral palsy, scheduled for elective orthopedic surgery, were included for analysis. Full-stomach status was observed in none, and the gastric volume per body weight was 0.5 (0.4-0.7) mL.kg-1. No significant differences were observed in the residual gastric volume (p = 0.114), gastric volume per body weight (p = 0.117), or qualitative grade of gastric volume (p = 0.642) in relation to disease severities.

CONCLUSION

Children with cerebral palsy who fasted preoperatively had empty or nearly empty stomachs. Further studies are required to determine the optimal fasting duration for such children.

Regional anesthesia and analgesia in patients with spastic cerebral palsy undergoing orthopedic surgery: a historical cohort study

PURPOSE

We sought to examine the incidence of severe postoperative pain in patients with cerebral palsy (CP) in the first 48 hr after surgery performed under combined regional and general anesthesia and its association with patient and surgical factors.

METHODS

In a historical cohort study, we reviewed the electronic records of 452 patients with spastic CP who underwent orthopedic surgeries of the upper and lower extremities from April 2016 to February 2020. Collected data included patient characteristics, American Society of Anesthesiologists Physical Status, details of anesthesia and surgery, types of regional anesthesia applied, success rate of anesthesia, incidence of severe pain, and adverse events.

RESULTS

We analyzed data from 440 patients; 404 patients underwent lower extremity surgery, 20 upper extremity surgery, and 15 both, and one patient required stem cell injection. All patients received general anesthesia before block performance. Single-injection neuraxial anesthesia was performed in 241 (54.8%) patients, brachial plexus block in 27 (6.1%) patients, and femoral/sciatic nerve blocks in 17 (3.9%) patients. Continuous neuraxial, brachial plexus, and femoral/sciatic nerve blocks were performed in 149 (33.9%), four (0.9%), and seven (1.6%) of the patients, respectively. Major and complex major surgeries were performed in 161 (36.6%) and 72 (16.4%) patients, respectively and continuous catheters were inserted in 50.3% of patients undergoing major surgery and in 91.7% of patients undergoing complex major surgery. Severe pain was reported by the caregivers of 68 (15.5%) patients who received nonopioid analgesic interventions.

CONCLUSION

Despite the use of regional anesthesia, approximately 15% of patients with spastic CP undergoing orthopedic surgery for spastic cerebral palsy experienced severe pain that responded to treatment adjustments.

STUDY REGISTRATION

CTRI.nic.in (027002); registered 5 August 2020.

The Perioperative Anesthetic Management of the Pediatric Patient with Special Needs: An Overview of Literature

The perioperative management of pediatric patients with psycho-physical disorders with related relational and cognitive problems must be carefully planned, in order to make the entire hospitalization process as comfortable and as less traumatic as possible. This article reports an overview of the anesthetic management of non-cooperative patients between 6 and 14 years old. The pathologies most frequently responsible for psycho-physical disorders can be summarized into three groups: (1) collaboration difficulties (autism spectrum disorders, intellectual impairment, phobia); (2) motor dysfunction (cerebral palsy, epilepsy, other brain pathologies, neuromuscular disorders), and (3) craniofacial anomalies (Down syndrome, other genetic syndromes). Anesthesia can be performed safely and successfully due to careful management of all specific problems of these patients, such as a difficult preoperative evaluation (medical history, physical examination, blood sampling, evaluation of vital parameters and predictive indices of difficult airway) and the inapplicability of a "standard" perioperative path (timing and length of the hospitalization, anesthetic premedication, postoperative management). It is necessary to ensure a dedicated perioperative process that is safe, comfortable, tailored to specific needs, and as less traumatic as possible. At the same time, all necessary precautions must be taken to minimize possible complications.

Epidural Analgesia Versus Lumbar Plexus Blockade After Hip Reconstruction Surgery in Children With Cerebral Palsy and Intrathecal Baclofen Pumps: A Comparison of Safety and Efficacy

BACKGROUND

Epidural analgesia is commonly used for pain control after reconstructive hip surgery, but its use is controversial in the presence of an intrathecal baclofen pump (ITB). The purpose of this retrospective study was to investigate the rate of serious anesthetic and postoperative complications as well as the efficacy of epidural analgesia compared with lumbar plexus blocks (LPBs) for pain management after neuromuscular hip reconstruction in children with cerebral palsy (CP) and ITB.

METHODS

Pediatric patients with CP and ITB undergoing hip reconstructive surgery from 2010 to 2019 were retrospectively identified. Patients receiving epidural analgesia were compared with those receiving LPB. Morphine milligram equivalents per kilogram were used as a surrogate measure for pain-related outcomes, as pain scores were reported with wide ranges (eg, 0 to 5/10), making it unfeasible to compare them across the cohort. Postoperative complications were graded using the modified Clavien-Dindo classification.

RESULTS

Forty-four patients (26/44, 59% male) underwent surgery at an average age of 10.3 years (SD=3.4 y, range: 4 to 17 y). The majority utilized LPB (28/44, 64%) while the remaining utilized epidural (16/44, 36%). There were no differences in rates of serious complications, including no cases of ITB malfunction, damage, or infection. During the immediate postoperative course, patients who received LPB had higher morphine milligram equivalents per kilogram requirements than patients who received epidural analgesia.

CONCLUSIONS

In patients with CP undergoing hip reconstruction surgery with an ITB in situ, epidural anesthesia was associated with improved analgesia compared with LPB analgesia, with a similar risk for adverse outcomes. Epidural catheters placed using image-guided insertion techniques can avoid damage to the ITB catheter while providing effective postoperative pain control without increasing rates of complications in this complex patient population.

LEVEL OF EVIDENCE

Level III.

Fascia Iliaca Pain Block Results in Lower Overall Opioid Usage and Shorter Hospital Stays than Epidural Anesthesia After Hip Reconstruction in Children With Cerebral Palsy

INTRODUCTION AND OBJECTIVE

Epidural anesthesia (EA) is often used for pain control in children with cerebral palsy (CP) who undergo hip reconstructions. The purpose of this study is to determine if preoperative fascia iliaca (FI) pain blocks would improve pain scores, decrease opioid use, and result in shorter hospital stays in comparison to the use of EA.

METHODS

This is a nonrandomized retrospective cohort study examining 60 consecutive patients with CP who underwent hip reconstruction utilizing either a fascia iliac compartment nerve block (FICNB) (N=37) or continuous lumbar epidural (N=22) from January 2017 to March 2019. Age at surgery was 8.5±4.6 years. We recorded age, weight, operating room (OR) time, FLACC (Face, Legs, Activity, Cry, Consolability scale) scores on postoperative days (PODs) 0, 1, 2, and 3, opioid doses, overall opioid (mg) used, and length of stay. We compared pain scores, opioid usage, OR time, and lengths of stay between our 2 patient groups.

RESULTS

Pain scores were similar between groups on POD #0, 2, and 3 but were statistically improved on POD #1 (1.8±1.3 vs. 3.1±1.4, P<0.001). Total number of opiod doses (7.9±4.4 vs. 10.7±2.3, P=0.004), total milligram given (18.3±11.8 vs. 24.7±12.3, P<0.05), and milligram per kilogram given (0.77±0.42 vs. 1.11 mg/kg±0.36 mg/kg, P=0.001) were less for the FI group versus the epidural group. The OR time (which includes time for blocks/epidurals) was lower in the FI group (4.6±1.2 vs. 5.7±1.1 h, P=0.0002). Overall hospital stays were lower in the FI group (3.4±1.5 vs. 4.1±1.0 d, P<0.05).

CONCLUSIONS

This study demonstrates that in the setting of hip reconstruction, patients that received preoperative FI blocks used a lower amount of opioids, required fewer rescue doses and ultimately had a shorter hospital length of stay than those undergoing EA.

Genetic Pattern, Orthodontic and Surgical Management of Multiple Supplementary Impacted Teeth in a Rare, Cleidocranial Dysplasia Patient: A Case Report

Background: Cleidocranial dysplasia (CCD) is a rare, autosomal dominant skeletal dysplasia with a prevalence of one per million births. The main causes of CCD are mutations in the core-binding factor alpha-1 (CBFA1) or runt-related transcription factor-2 (RUNX2), located at the 6p21 chromosomal region. RUNX2 plays important roles in osteoblast differentiation, chondrocyte proliferation and differentiation, and tooth formation. The disease is characterized by clavicular aplasia or hypoplasia, Wormian bones, delayed closure of cranial suture, brachycephalic head, maxillary deficiency, retention of primary teeth, inclusion of permanent teeth, and multiple supernumerary teeth. Materials and Methods: A 22-year-old girl suffering from cleidocranial dysplasia with short stature, narrow shoulders, craniofacial manifestations (short face, broad forehead, etc.) and dental anomalies (different lower dental elements under eruption, supernumerary and impacted multiple teeth, etc.) was examined at our service (Complex Operative Unit of Odontostomatology of Policlinico of Bari). RX Orthopantomography (OPG) and cone beam computed tomography (CBCT) were requested to better assess the position of the supernumerary teeth and their relationships with others and to evaluate the bone tissue. Results: Under eruption was probably caused by dental interferences with supernumerary teeth; hence, extractions of supernumerary upper canines and lower premolars were performed under general anaesthesia. Surgery outcome was excellent with good tissue healing and improvements in the therapeutic possibilities with future orthodontics. Conclusions: The objective of this article is to give an update about radiological, clinical, and molecular features of CCD and to alert the health team about the importance of establishing an early diagnosis and an appropriate treatment in these patients to prevent impacted teeth complications and to offer them a better quality of life.

Dental treatment under general anesthesia for patients with severe disabilities

Patients with disabilities have difficulties tolerating in-office dental treatment due to limitations relating to cooperation and/or physical problems. Therefore, they often require general anesthesia or sedation to facilitate safe treatment. When deciding on dental treatment under general anesthesia, the plan should be carefully determined because compared to general patients, patients with disabilities are more likely to experience anesthetic complications because of their underlying medical conditions and potential drug interactions. Clinicians prefer simpler and more aggressive dental treatment procedures, such as extraction, since patients with impairment have difficulty maintaining oral hygiene, resulting in a high incidence of recurrent caries or restorative failures. This study aimed to review the available literature and discuss what dentists and anesthesiologists should consider when providing dental treatment to patients with severe disability under general anesthesia.

Epidural catheter placement in children with baclofen pumps

BACKGROUND

Children with cerebral palsy often suffer from increased tone, which can be treated with intrathecal baclofen via implanted pump. Additionally, they often require major orthopedic surgery for hip reconstruction; however, the presence of an intrathecal baclofen pump is a relative contraindication to regional anesthesia due to concerns about damaging the intrathecal baclofen pump system.

AIMS

(a) To evaluate adverse events related to placing epidural catheters in children with intrathecal baclofen pumps and (b) describe our multidisciplinary approach to the care of these complex patients.

METHODS

Children with cerebral palsy and intrathecal baclofen pump in situ who underwent hip reconstruction between 2010 and 2019 and had a perioperative epidural placed were reviewed retrospectively. Charts were assessed for adverse events or intrathecal baclofen complications. Fluoroscopic images were reviewed to evaluate the proximity between epidural and intrathecal baclofen catheters. The process of coordinating multiple services was examined.

RESULTS

Sixteen children met the inclusion criteria. There were no major complications following epidural placement. Postoperative pump interrogation was normal for all patients. Fluoroscopy was utilized for 9/16 (56%) epidural procedures. Epidurogram was used to confirm 11/16 catheters (68%). Children with an intrathecal baclofen pump were identified by orthopedic surgeons at the time of surgical booking and referred to the regional anesthesia team for review. The neurosurgical, pain, and regional anesthesia teams determined the appropriateness and safety of approaching the neuraxis. Pain and/or regional anesthesiologists with competency in spine fluoroscopy were scheduled on the day of surgery for fluoroscopically guided epidural placement. Postoperatively, catheters were managed by the acute pain team. Intrathecal baclofen pumps were interrogated by the baclofen pump team prior to patient discharge.

DISCUSSION

In this case series, not only was epidural placement feasible but also there were no observed complications. This work highlights the importance of a multidisciplinary approach to complex regional anesthetic techniques, as well as the importance of basic competency in spine fluoroscopy for regional anesthesiologists.

Application of Extrusion-Based 3D Printed Dosage Forms in the Treatment of Chronic Diseases

Chronic disease management has been a significant burden in many countries. As most treatment options involve long-term pharmacotherapy, patient compliance has been a challenge, as patients have to remember taking medications on time at the prescribed dose for each disease state. Patients are often required to split the dosage unit, which may lead to under- or over-dose and dose-related adverse effects. However, 3D printing technologies have been used for fabricating personalized medications and multiple drugs in a single dose unit (polypills), which might greatly reduce treatment monitoring, dosing errors, and follow-ups with the health care providers. Extrusion-based 3D printing is the most used technology to fabricate polypills and to customize the dose, dosage form, and release kinetics, which might potentially reduce the risk of patient non-compliance. Although extrusion-based 3D printing has existed for some time, interest in its potential to fabricate dosage forms for treating chronic diseases is still in its infancy. This review focuses on the various extrusion-based 3D printing technologies such as fused deposition modeling, pressure-assisted microsyringe, and direct powder extrusion 3D printing in the preparation of customizable, multi-drug dosage forms for treating chronic diseases.

The effects of an eight-week multi-model sport activity home programme on function of children with cerebral palsy

Study aim: This study was performed to investigate the effects of an eight-week multi-model sport activity home programme on function of children with cerebral palsy.

Material and methods: The study included 44 patients (11 girls, and 33 boys) aged between 4 and 11 years, having spastic diplegic and hemiplegic cerebral palsy, and receiving physical treatment from the rehabilitation centre. The 44 patients were divided into two groups each consisting of 22 children as the experimental group and control group. The mean age, height and weight were 8.27 ± 2.10 years, 123.36 ± 17.33 cm and 25.45 ± 8.87 kg in the experimental group, while the same parameters were 7.27 ± 2.80 years, 109.36 ± 16.99 cm and 20.20 ± 7.16 kg in the control group. Before taking measurements, the consent forms were signed by the families of patients with CP. The physical therapy programme based on the Bobath NDT method which took forty minutes was applied to both groups two days per week. Also, the multi-model sport activity home programme which took 50 minutes was applied regularly during eight weeks and five days a week in the Experimental Group. The Impact on Family Scale, the Gross Motor Function Classification System, the Gross Motor Function Measure, One Minute Walk Test, the time standing on the left and right foot, and Visual Pain Analog Scale were evaluated before and after the eight-week multi-model sport activity home programme.

Results: There were no significant differences in some measurements including the Gross Motor Function Classification System, the Gross Motor Function Measure, One Minute Walk Test, and the time standing on the left and right foot. A significant difference was found only in the Visual Pain Analog Scale (p = 0.003).

Conclusion: The effects of the eight-week multi-model sport activity home programme can contribute to a decrease in pain level of children with cerebral palsy.

Epidural bolus versus continuous epidural infusion analgesia on optic nerve sheath diameter in paediatric patients: A prospective, double-blind, randomised trial

The use of programmed intermittent epidural bolus for postoperative analgesia may have greater analgesic efficacy than continuous epidural infusion. However, the rapid delivery speed used with an epidural bolus is more likely to increase intracranial pressure. We compared the effects of lumbar epidural bolus versus continuous infusion epidural analgesia on intracranial pressure in children using optic nerve sheath diameter as a marker. We randomly assigned 40 paediatric patients to bolus or infusion groups. Epidural analgesia (0.15% ropivacaine 0.3 ml·kg⁻¹) was administered via bolus or infusion. Ultrasonography was used to measure the optic nerve sheath diameter before (T0), at 3 min (T1), 10 min (T2), and 70 min (T3) after starting the pump. There were statistically significant between-group differences in optic nerve sheath diameter over time (P_{Group x Time} = 0.045). From T0–T3, the area under the curve values were similar between the two groups. Although there were differences in the patterns of optic nerve sheath diameter change according to the delivery mode, the use of lumbar epidural bolus did not increase the risk of intracranial pressure increase over that of continuous infusion. Further research is needed to investigate intracranial pressure changes after continuous application of each delivery mode.

Sedation and analgesia in children with cerebral palsy: a narrative review

BACKGROUND

Patients with cognitive impairment due to cerebral palsy experience pain more often than healthy peers and frequently require diagnostic and therapeutic painful procedures. Analgesia and procedural sedation outside the operating room are often required, but they may not adequately be provided because of the inability to accurately recognize and classify the state of pain and for the perceived higher risk of complications.

DATA SOURCES

We reviewed the available literature to highlight the specific risk factors and area of criticism, that should be further improved. We searched the Cochrane Library, Medline, Pubmed from 1987 to September 2018 using key words such as 'cerebral palsy and children and pain' or 'sedation and cerebral palsy and children'.

RESULTS

While different pain scales are useful in recognizing pain expressions, anxiety scales are not available. Moreover, studies on non-pharmacological techniques do not always have comparable results. Several risk factors, from anatomic abnormalities to liver and kidney functioning, should be kept in mind before proceeding with sedation.

CONCLUSIONS

Large trials are needed to assess the impact of non-pharmacological techniques and to evaluate which pain control strategy (pharmacological and non-pharmacological) should be used in different settings.

Preoperative botulinum neurotoxin A for children with bilateral cerebral palsy undergoing major hip surgery: a randomized double-blind placebo-controlled trial

AIM

To assess whether preoperative botulinum neurotoxin A (BoNT-A) affects pain after major hip surgery for children with bilateral cerebral palsy (CP).

METHOD

This was a randomized, parallel arms, placebo-contolled trial. Children with hypertonic CP aged 2 to 15 years awaiting bony hip surgery at a tertiary hospital were randomized to receive either BoNT-A or placebo injections into the muscles of the hip on a single occasion immediately before surgery. The primary outcome was the paediatric pain profile (PPP), which was assessed at baseline and weekly for 6 weeks. Treatment allocation was by minimization. Participants, clinicians, and outcome assessors were masked to group assignment.

RESULTS

Twenty-seven participants (17 males, 10 females; mean 8y 8mo [SD 3y 9mo], range 3y 4mo-15y 10mo) were allocated to BoNT-A and 27 participants (14 males, 13 females; mean 8y 11mo [SD 3y 5mo], range 4y 1mo-15y 2mo) to placebo. Mean (SD) PPP at 6 weeks for the BoNT-A group (n=24 followed up) was 10.96 (7.22) and for the placebo group (n=26) was 10.04 (8.54) (p=0.69; 95% confidence interval [CI] -4.82, 3.18). There were 16 serious adverse events in total during 6 months of follow-up (n=6 in BoNT-A group).

INTERPRETATION

Use of BoNT-A immediately before bony hip surgery for reducing postoperative pain for children with CP was not supported.

WHAT THIS PAPER ADDS

Botulinum neurotoxin A (BoNT-A) does not reduce postoperative pain following bony hip surgery. BoNT-A also does not affect postoperative quality of life.

The use of opioids in children receiving intrathecal baclofen therapy

PURPOSE

We hypothesized that children on chronic intrathecal baclofen therapy (ITB) may require less analgesics for postoperative pain control and are at higher risk of developing opioid-induced respiratory depression postoperatively. The aims of this study are to review children on chronic intrathecal baclofen therapy receiving opioids after major surgery and to determine the incidence complications in this population.

METHOD

We conducted a retrospective cohort study comparing 13 children on ITB, who underwent posterior spinal fusion surgery, to 17 children with spina bifida that received the same surgery.

RESULTS

On postoperative day 0 (POD 0), four children (40%) had respiratory depression in the baclofen group compared to none in the control group. Desaturation was significantly more frequent in children in the ITB group compared to those of the control group on POD 0; oversedation was recorded in 8 (80%) children in the baclofen group vs. 3 (17.6%) in the control group. Desaturation, respiratory depression, and oversedation were significantly more frequent on POD 0 in children in the baclofen group compared with children in the control group.

CONCLUSIONS

The findings of the current study suggest that children on chronic intrathecal baclofen therapy require lesser amounts of opioids for postoperative pain control and are at a greater risk of developing postoperative respiratory depression and excessive sedation compared to patients without baclofen therapy.

A Comparison of Bispectral Index and Entropy During Sevoflurane Anesthesia Induction in Children with and without Diplegic Cerebral Palsy

Background: This study compared the correlation of bispectral index (BIS) or entropy with different sevoflurane concentrations between children with and without cerebral palsy (CP) during induction. Methods: For eighty-two children (40 CP and 42 non-CP children), anesthesia was induced with sevoflurane. BIS and entropy (response entropy and state entropy (RE and SE)) were recorded before and after the induction of anesthesia at end-tidal sevoflurane concentrations of 1–3 vol%. The sedation status was assessed using an Observer’s Assessment of Alertness/Sedation scale. The ability to predict awareness was estimated using the area under the receiver-operator characteristic curve (AUC) analysis. Results: RE, SE and BIS values decreased continuously over the observed concentration range of sevoflurane in both groups. The SE values while awake and the RE, SE, BIS values at 3 vol% sevoflurane were lower in children with CP than in those without CP. The AUC of the BIS was significantly better than RE or SE in children without CP. The AUC of the BIS was not significantly higher than that of the RE or SE in children with CP. Conclusion: BIS seems better correlated than entropy with the clinical state of loss of response in children without CP, but not in those with CP.

Post-Operative Pain Assessment and Management in Cerebral Palsy (CP): A Two-Pronged Comparative Study on the Experience of Surgical Patients

INTRODUCTION

This study compares the current practice patterns of pain assessment and management between children with and without CP following either posterior spinal instrumentation and fusion (PSIF) or hip osteotomy (HO).

METHODS

Two cohorts of CP patients were retrospectively identified and matched with non-CP patients based on age, surgical procedure, and approach to post-operative pain management. Sixteen CP patients undergoing PSIF and twenty-two undergoing HO were respectively matched with the same numbers of non-CP patients receiving the same procedures. The frequency of assessments conducted, highest pain scores recorded on each post-operative day (POD), and the amount of adjuvant analgesics administered were collected for POD 0-4.

RESULTS

Patients with CP were significantly more frequently evaluated for pain post-operatively, tended to have lower pain scores as measured by current scales, and received slightly fewer analgesics. Patients with CP differed from their non-CP counterparts in both frequency and method of post-operative pain assessment.

CONCLUSIONS

The purpose of this study is to elucidate the current state of post-operative pain assessment and management in children with CP undergoing major orthopaedic surgeries, to improve CP patient/caregiver understanding and expectation of the post-operative experience regarding pain, and to provide recommendations for improving the post-operative care for these patients.

Interventions in pain management for persons with an intellectual disability

Pain is a multidimensional and subjective experience, and an ideal pain management regime needs to be comprehensive, integrative and involve all relevant persons. Multimodal interventions may include pharmacological, physical, social, psychological and spiritual approaches in order to address pain management at a molecular, functional, behavioural, cognitive and affective levels. Pain management interventions will vary according to pain aetiology, patient characteristics and preferences. In keeping with best practice guidelines for effective pain management, a structured approach incorporating an effective assessment of pain by the healthcare professional, identification of the source and type of pain and accurate documentation is essential. This article focuses on pharmacological and non-pharmacological pain management for individuals with intellectual disability.

Management of pain in children and adolescents with cerebral palsy: a systematic review

AIM

To determine the efficacy of interventions for the management of pain in children and adolescents with cerebral palsy (CP).

METHOD

Electronic databases were searched from the earliest date possible to April 2018 using a mixture of subject headings and free text. Inclusion criteria comprised of studies with (1) diagnosis of CP, (2) under the age of 18 years, (3) intervention for the management of pain, (4) outcome measure of pain, and (5) studies published in English-language peer-reviewed journals.

RESULTS

Fifty-seven studies met the eligibility criteria. Pain related to (n=number of studies): hypertonia (n=17), spastic hip disease (n=13), procedures for the management of CP (n=7), postoperative (n=18), and other (n=2). Most of the studies were of level III to level V evidence.

INTERPRETATION

There is level II evidence to support intrathecal baclofen therapy for pain secondary to hypertonia in spastic and spastic-dyskinetic CP, and non-pharmacological interventions for procedural pain and pharmacological interventions for postoperative pain. Most studies were restricted by retrospective design and limited use of validated outcome measures. Future research is needed to explore multidisciplinary interventions for chronic pain and pain secondary to dystonia. Clinicians and researchers would benefit from a standardized approach to pain assessment.

WHAT THIS PAPER ADDS

The strongest evidence exists for pharmacological treatments for postoperative pain in children and adolescents with cerebral palsy (CP). There is moderate evidence for the efficacy of intrathecal baclofen for pain related to hypertonia in predominately spastic CP. There is a lack of standardization in the assessment of pain. There is limited evidence for multimodal and non-pharmacological strategies in paediatric CP.

Optimal Management of Undescended Testis in Boys with Cerebral Palsy. A Debate

Cerebral palsy is a rare condition following injury of the developing brain and including nonprogressive neurological disorders, spasticity, intellectual impairment and others. Boys with cerebral palsy have a high incidence of undescended testis. Although the motives for treatment (infertility, cancer prevention, psychological aspects, testicular torsion) are not different in boys without neurological impairment, the decision-making process in boys with cerebral palsy is very difficult. Besides medical and surgical arguments the discussion involves challenging ethical issues.

Application of 3D printing technology and quality by design approach for development of age-appropriate pediatric formulation of baclofen

Pediatric population is a sensitive sector of the healthcare and pharmaceutical field with additional needs compared to the adult population. Extemporaneous formulations for children are generally prepared by manipulating adult formulations, but medication errors can result in suboptimal efficacy and with significant safety concerns. The aim of proposed project was to explore a 3D printing technology for the development of customized minicaplets of baclofen for the pediatric population. Based on results of 3-point bend test, polyvinyl alcohol (PVA) with sorbitol (10% w/w) were selected for preparation of baclofen loaded filaments using hot melt extrusion (HME). Effect of dimension, infill percentage and infill pattern on dose, disintegration time and release profile were investigated. Characteristic crystalline peaks of baclofen were absent in DSC thermograms and XRD pattern of filament and minicaplets. Minicaplets printed in diamond (fast) infill pattern with 100% infill showed higher disintegration time (38 mins) compared to linear, sharkfill and hexagonal pattern. 3² full factorial orthogonal design suggested that baclofen release (D50 and D85) was marginally affected by infill percentage but significantly affected by caplet dimension (p < 0.05). Thus, low cost FDM 3D printing technique can be a promising alternative for preparation of dose and release customized pediatric dosage forms.

Higher risk of opioid-induced respiratory depression in children with neurodevelopmental disability: a retrospective cohort study of 12 904 patients

BACKGROUND

Children with neurodevelopmental disabilities may be at risk of opioid-induced respiratory depression. We aimed to quantify the risks and effectiveness of morphine nurse-controlled analgesia (morphine-NCA) for postoperative pain in children with neurodevelopmental disabilities.

METHODS

We carried out a retrospective cohort study of 12 904 children who received postoperative i.v. morphine-NCA. Subjects were divided into a neurodevelopmental disability group and a control group. Rates of clinical satisfaction, respiratory depression, and serious adverse events were obtained, and statistical analysis, including multilevel logistic regression using Bayesian inference, was performed.

RESULTS

Of 12 904 patients, 2390 (19%) had neurodevelopmental disabilities. There were 88 instances of respiratory depression and 52 serious adverse events; there were no opioid-related deaths. The cumulative incidence of respiratory depression in the neurodevelopmental disability group was 1.09% vs 0.59% in the control group [odds ratio 1.8 (98% chance that the true odds ratio was >1)]. A significant interaction between postoperative morphine dose and neurodevelopmental disabilities was observed, with higher risk of respiratory depression with increasing dose. Satisfaction with morphine-NCA was very high overall, although children with neurodevelopmental disabilities were 1% more likely to have infusions rated as fair or poor (3.3 vs 2.1%, χ²P<0.001).

CONCLUSIONS

Children with neurodevelopmental disabilities were 1.8 times more likely to suffer respiratory depression, absolute risk difference 0.5%; opioid-induced respiratory depression in this group may relate to increased sensitivity to dose-relate respiratory effects of morphine. Morphine-NCA as described was an acceptable technique for children with and without neurodevelopmental disabilities.

Efficacy of preemptive analgesia on acute postoperative pain in children undergoing major orthopedic surgery of the lower extremities

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.

Quantitative sensory testing profiles in children, adolescents and young adults (6-20 years) with cerebral palsy: Hints for a neuropathic genesis of pain syndromes

INTRODUCTION

Many patients with cerebral palsy (CP) suffer chronic pain as one of the most limiting factors in their quality of life. In CP patients, pain mechanisms are not well understood, and pain therapy remains a challenge. Quantitative sensory testing (QST) might provide unique information about the functional status of the somatosensory system and therefore better guide pain treatment.

OBJECTIVES

To understand better the underlying pain mechanisms in pediatric CP patients, we aimed to assess clinical and pain parameters, as well as QST profiles, which were matched to the patients' cerebral imaging pathology.

PATIENTS AND METHODS

Thirty CP patients aged 6-20 years old (mean age 12 years) without intellectual impairment underwent standardized assessments of QST. Cerebral imaging was reassessed. QST results were compared to age- and sex-matched controls (multiple linear regression; Fisher's exact test; linear correlation analysis).

RESULTS

CP patients were less sensitive to all mechanical and thermal stimuli than healthy controls but more sensitive to all mechanical pain stimuli (each p < 0.001). Fifty percent of CP patients showed a combination of mechanical hypoesthesia, thermal hypoesthesia and mechanical hyperalgesia; 67% of CP patients had periventricular leukomalacia (PVL), which was correlated with mechanic (r = 0.661; p < 0.001) and thermal (r = 0.624; p = 0.001) hypoesthesia.

CONCLUSION

The combination of mechanical hypoesthesia, thermal hypoesthesia and mechanical hyperalgesia in our CP patients implicates lemniscal and extralemniscal neuron dysfunction in the thalamus region, likely due to PVL. We suspect that extralemniscal tracts are involved in the original of pain in our CP patients, as in adults.

Usefulness of dexmedetomidine to prevent emergence agitation in a patient with Krabbe disease: a case report

Background

We report the case of a child with Krabbe disease who underwent three repeated surgeries and anesthetic management, and we discuss the major concerns about Krabbe disease and the usefulness of a perioperative administration of dexmedetomidine to prevent emergence agitation and hypertension. The patient was scheduled to undergo bilateral orchiopexy, adenotonsillectomy, and knee flexor tendon lengthening under general anesthesia during a 2-year period.

Case presentation

Adenotonsillectomy was scheduled as the second operation when the patient was 4 years old. His height and body weight were 93 cm and 10.3 kg, respectively. Anesthesia was induced with 8% sevoflurane mixed with 6 L/min of O₂ and maintained with N₂O (3.5 L/min), O₂ (1.5 L/min), and sevoflurane (1.5–2.0%). Upon completion of the right tonsillectomy, 1 h before the end of the surgery, a continuous infusion of dexmedetomidine (0.2 μg/kg/h) was started to prevent emergence agitation, irritability, resultant hypertension, and postoperative bleeding. Fentanyl (25 μg) was administered intravenously to reduce postoperative pain. The surgery was uneventful, and the patient’s emergence from general anesthesia was prompt. He exhibited no symptoms of emergence agitation or irritability. During his stay in the intensive care unit, 0.2–0.7 μg/kg/h of dexmedetomidine and 6.25 μg/h of fentanyl were continuously administered. The patient was discharged to the ward the following morning without complications.

Conclusions

The perioperative administration of dexmedetomidine was useful to prevent emergence agitation, hypertension, and resultant postoperative bleeding in a pediatric patient with Krabbe disease. Three repeated anesthetic management using inhalation anesthesia were completed uneventfully without muscle relaxants.

Anesthesia for intellectually disabled

Anesthetizing an intellectually disabled patient is a challenge due to lack of cognition and communication which makes perioperative evaluation difficult. The presence of associated medical problems and lack of cooperation further complicates the anesthetic technique. An online literature search was performed using keywords anesthesia, intellectually disabled, and mentally retarded and relevant articles were included for review. There is scarcity of literature dealing with intellectually disabled patients. The present review highlights the anesthetic challenges, their relevant evidence-based management, and the role of caretakers in the perioperative period. Proper understanding of the associated problems along with a considerate and unhurried approach are the essentials of anesthetic management of these patients.

Regional anesthesia for a total knee arthroplasty on an adult patient with spastic diplegia and an intrathecal baclofen pump

We describe the clinical presentation of a patient with spastic diplegia, and its unique perioperative challenges. Opioids and antispasmodic medications are the primary therapy for managing pain and spasticity in the perioperative setting. However, such combination results in several side-effects and their sedative properties are synergistic. A 64-year-old woman with a history of spastic diplegia and an intrathecal baclofen pump for the treatment of her lower extremity spasticity was scheduled for a third elective left knee arthroplasty. She requested a regional anesthetic for the anticipated surgery and an opioid sparing postoperative analgesic regiment. We describe the successful use of a lumbar plexus and a sciatic nerve block as the primary anesthetic for the surgery and the use of a continuous lumbar plexus catheter for the postoperative course. Based on our patient's past anesthetic history, a regional anesthetic/analgesic technique is the ideal strategy in controlling perioperative pain and spasticity.

Prognosis after treatment with multiple dental implants under general anesthesia and sedation in a cerebral palsy patient with mental retardation: A case report

Cerebral palsy is a non-progressive disorder resulting from central nervous system damage caused by multiple factors. Almost all cerebral palsy patients have a movement disorder that makes dental treatment difficult. Oral hygiene management is difficult and the risks for periodontitis, dental caries and loss of multiple teeth are high. Placement of dental implants for multiple missing teeth in cerebral palsy patients needs multiple rounds of general anesthesia, and the prognosis is poor despite the expense. Therefore, making the decision to perform multiple dental implant treatments on cerebral palsy patients is difficult. A 33-year-old female patient with cerebral palsy and mental retardation was scheduled for multiple implant treatments. She underwent computed tomography (CT) under sedation and the operation of nine dental implants under general anesthesia. Implant-supported fixed prosthesis treatment was completed. During follow-up, she had the anterior incisors extracted and underwent the surgery of 3 additional dental implants, completing the prosthetic treatment. Although oral parafunctions existed due to cerebral palsy, no implant failure was observed 9 years after the first implant surgery.

Pain Assessment and Treatment in Children With Significant Impairment of the Central Nervous System

Pain is a frequent and significant problem for children with impairment of the central nervous system, with the highest frequency and severity occurring in children with the greatest impairment. Despite the significance of the problem, this population remains vulnerable to underrecognition and undertreatment of pain. Barriers to treatment may include uncertainty in identifying pain along with limited experience and fear with the use of medications for pain treatment. Behavioral pain-assessment tools are reviewed in this clinical report, along with other strategies for monitoring pain after an intervention. Sources of pain in this population include acute-onset pain attributable to tissue injury or inflammation resulting in nociceptive pain, with pain then expected to resolve after treatment directed at the source. Other sources can result in chronic intermittent pain that, for many, occurs on a weekly to daily basis, commonly attributed to gastroesophageal reflux, spasticity, and hip subluxation. Most challenging are pain sources attributable to the impaired central nervous system, requiring empirical medication trials directed at causes that cannot be identified by diagnostic tests, such as central neuropathic pain. Interventions reviewed include integrative therapies and medications, such as gabapentinoids, tricyclic antidepressants, α-agonists, and opioids. This clinical report aims to address, with evidence-based guidance, the inherent challenges with the goal to improve comfort throughout life in this vulnerable group of children.

Comparison of Dexmedetomidine and Fentanyl as an Adjuvant to Ropivacaine for Postoperative Epidural Analgesia in Pediatric Orthopedic Surgery

PURPOSE

Opioids are commonly used as an epidural adjuvant to local anesthetics, but are associated with potentially serious side effects, such as respiratory depression. The aim of this study was to compare the efficacy and safety of dexmedetomidine with that of fentanyl as an adjuvant to epidural ropivacaine in pediatric orthopedic surgery.

MATERIALS AND METHODS

This study enrolled 60 children (3-12 years old) scheduled for orthopedic surgery of the lower extremities and lumbar epidural patient-controlled analgesia (PCA). Children received either dexmedetomidine (1 μg/kg) or fentanyl (1 μg/kg) along with 0.2% ropivacaine (0.2 mL/kg) via an epidural catheter at 30 minutes before the end of surgery. Postoperatively, the children were observed for ropivacaine consumption via epidural PCA, postoperative pain intensity, need for rescue analgesics, emergence agitation, and other adverse effects.

RESULTS

The mean dose of bolus epidural ropivacaine was significantly lower within the first 6 h after surgery in the dexmedetomidine group, compared with the fentanyl group (0.029±0.030 mg/kg/h vs. 0.053±0.039 mg/kg/h, p=0.012). The median pain score at postoperative 6 h was also lower in the dexmedetomidine group, compared to the fentanyl group [0 (0-1.0) vs. 1.0 (0-3.0), p=0.039]. However, there was no difference in the need for rescue analgesia throughout the study period between groups.

CONCLUSION

The use of dexmedetomidine as an epidural adjuvant had a significantly greater analgesic and local anesthetic-sparing effect, compared to fentanyl, in the early postoperative period in children undergoing major orthopedic lower extremity surgery.

Role of Anesthesiologist in the Management of a Child with Cerebral Palsy

Cerebral palsy (CP) refers to a spectrum of nonprogressive neurological disorders with disturbances in posture and movement, resulting from perinatal intrauterine insult to developing infant brain. Many conditions associated with CP require surgery. Such cases pose important gastrointestinal, respiratory, and other perioperative considerations. Anesthetic management in these cases is delicate. Intraoperative complications including hypovolemia, hypothermia, muscle spasms, seizures, and delayed recovery might complicate the anesthetic management. A thorough preanesthetic evaluation allows for a better intra- and post-operative care. Postoperative analgesia is important, particularly in orthopedic surgeries one for pain relief. This review highlights the clinical manifestations in CP and anesthetic considerations in such child presenting for various surgeries.

Epidural insertion height for ureteric reimplant surgery; does location matter?

BACKGROUND

Surgical correction of vesicoureteric reflux through ureteric reimplantation is a common, highly successful treatment. Postoperative pain can be severe and may relate to somatic wound pain from the lower abdominal incision or from visceral bladder spasm pain.

AIM

To conduct a prospective quality improvement audit to compare four perioperative analgesic techniques.

METHODS

Observational data were collected on 217 patients following open ureteroneocystostomy over 5 days. The patients were split into four groups: (i) 'morphine' infusion; (ii) 'caudal'-single-shot caudal; (iii) 'epidural'-epidural catheter inserted at T10-L2 given a bolus, followed by an infusion of 0.125% bupivacaine with fentanyl 2 μg·ml(-1) ; (iv) 'caudal catheter'-caudal placed epidural catheter was treated similar to the epidural catheter. Data regarding postoperative analgesic interventions were recorded. Intravesical pethidine was used for bladder spasm pain and i.v. morphine for wound pain.

RESULTS

Over the study period, the caudal catheter technique (mean interventions/patient = 1.8 ± 2.6) and the single-shot caudal (6.1 ± 4) needed significantly less bladder spasm interventions than morphine (9.2 ± 4) and epidural (8.0 ± 4.4) patients. For wound pain, the caudal catheter (8.8 ± 3.3) and epidural groups (11.4 ± 3.2) needed significantly less interventions than morphine (16.1 ± 3) and caudal (15.3 ± 3.3) patients. Overall, caudal catheter patients on average required about half the number of pain interventions and were associated with less high nursing workload.

CONCLUSIONS

Despite some limitations in data collection and study design, the caudal catheter technique was superior at reducing pain interventions, particularly bladder spasm interventions. Overall epidural analgesia was not superior to a single-shot caudal followed by opioid infusion. The issue of bladder spasm may be similar to the phenomenon of sacral sparing in obstetric epidural anesthesia. Thus, regional techniques, such as caudal epidural, targeting a better balance between sacral and lumber nerves are required.

Epidural analgesia is superior to local infiltration analgesia in children with cerebral palsy undergoing unilateral hip reconstruction

BACKGROUND AND PURPOSE

Treatment of postoperative pain in children with cerebral palsy (CP) is a major challenge. We investigated the effect of epidural analgesia, high-volume local infiltration analgesia (LIA), and an approximated placebo control on early postoperative pain in children with CP who were undergoing unilateral hip reconstruction.

PATIENTS AND METHODS

Between 2009 and 2014, we included 18 children with CP. The first part of the study was a randomized double-blind trial with allocation to either LIA or placebo for postoperative pain management, in addition to intravenous or oral analgesia. In the second part of the study, the children were consecutively included for postoperative pain management with epidural analgesia in addition to intravenous or oral analgesia. The primary outcome was postoperative pain 4 h postoperatively using 2 pain assessment tools (r-FLACC and VAS-OBS) ranging from 0 to 10. The secondary outcome was opioid consumption over the 21-h study period.

RESULTS

The mean level of pain 4 h postoperatively was lower in the epidural group (r-FLACC: 0.7; VAS-OBS: 0.6) than in both the LIA group (r-FLACC: 4.8, p = 0.01; VAS-OBS: 5.2, p = 0.02) and the placebo group (r-FLACC: 5.2, p = 0.01; VAS-OBS: 6.5, p < 0.001). Corrected for body weight, the mean opioid consumption was lower in the epidural group than in the LIA group and the placebo group (both p < 0.001).

INTERPRETATION

Epidural analgesia is superior to local infiltration analgesia for early postoperative pain management in children with cerebral palsy who undergo unilateral hip reconstruction.

Comparison of lumbar epidural bupivacaine with fentanyl or clonidine for postoperative analgesia in children with cerebral palsy after single-event multilevel surgery

AIM

To compare diazepam use, muscle spasm, analgesia, and side effects when clonidine or fentanyl are added to epidural bupivacaine in children with cerebral palsy after multilevel orthopaedic surgery.

METHOD

Fifty children were prospectively randomized to receive clonidine (n=24, mean age 10y 10mo [SD 2y 11mo]) or fentanyl (n=26, mean age 10y 11mo [SD 2y 10mo]).

RESULTS

There was no difference in primary outcome measures: median diazepam use (fentanyl 0, interquartile range [IQR] 0-0; clonidine 0, IQR 0-0; p=0.46), any muscle spasm (no muscle spasms in: fentanyl, 36%; clonidine, 62%; p=0.11), painful muscle spasm (fentanyl 40%; clonidine 25%; p=0.46), or pain score ≥6 (none: fentanyl 44%; clonidine 42%; p=0.29). There were differences in secondary outcome measures: no vomiting (clonidine 63%; fentanyl 20%); vomiting occurred more frequently with fentanyl (32% vomited more than three times; clonidine none; p=0.001). Fentanyl resulted in more oxygen desaturation (at least two episodes: fentanyl 20%; clonidine 0; p<0.001). Clonidine resulted in lower mean (SD) area under the curve for systolic blood pressure (fentanyl 106.5 [11.0]; clonidine 95.7mmHg [7.9]) and heart rate (fentanyl 104.9 beats per minute [13.6]; clonidine 85.3 [11.5]; p<0.001).

INTERPRETATION

Clonidine and fentanyl provide adequate analgesia with low rates of muscle spasm, resulting in low diazepam use. The choice of epidural additive should be based upon the most tolerable side-effect profile.

Epidural Baclofen for the Management of Postoperative Pain in Children With Cerebral Palsy

INTRODUCTION

Children with cerebral palsy undergoing soft tissue and bony procedures often experience pain and spasticity postoperatively. Differentiation of pain from spasticity complicates management, so controlling spasticity with a continuous infusion of baclofen, an antispasmodic, through an already present indwelling epidural catheter holds interest.

METHODS

A retrospective chart review was performed of patients with cerebral palsy undergoing single event, multilevel lower extremity surgery at a single institution who received epidural analgesia with or without continuous baclofen infusion. Primary outcomes included need for supplemental narcotic analgesics and benzodiazepines postoperatively. Duration of hospitalization, pain scores, and complications were also evaluated.

RESULTS

Forty-four patients were identified, ranging in age from 3 to 17 years, 19 of whom received epidural baclofen. No differences were found in use of supplemental narcotic analgesia, benzodiazepines, or duration of hospitalization. Differences in pain scores were not statistically significant (0.82±0.95 for baclofen vs. 1.48±0.99 for controls) (P=0.391). Mean arterial pressure was lower in patients receiving baclofen (P=0.004). No potential side effects attributable to baclofen were noted.

CONCLUSIONS

Continuous epidural baclofen infusion seems unlikely to alter the pain-spasm cycle experienced by patients with cerebral palsy following orthopaedic surgery to a clinically significant degree. More effective, and cost-effective, measures at assessing and controlling pain and muscle spasm should be explored to benefit cerebral palsy patients postoperatively.

LEVEL OF EVIDENCE

Level III-therapeutic study.

Hip reconstruction is more painful than spine fusion in children with cerebral palsy

PURPOSE

Concerns about pain control in patients with cerebral palsy (CP) are especially anxiety provoking for parents, given the fact that spasticity, communication issues, and postoperative muscle spasms are significant problems that make pain control difficult in these patients. A better understanding of the magnitude and quality of the pain these patients experience after our surgical procedures would better prepare the patients and their families. The purpose of this study is to quantify the amount of postoperative pain in children with CP undergoing hip reconstruction and spinal fusion. Specifically, the study will compare pain scores and the amount of narcotics used between the two groups.

MATERIALS AND METHODS

This is a retrospective chart review of a consecutive series of children with CP (GMFCS levels IV and V) over a 5-year period undergoing hip reconstruction (femoral osteotomy, pelvic osteotomy, or both) and posterior spinal fusion (PSF) at a tertiary-care pediatric hospital. The primary end point was the total opioid used by the patient during the hospitalization, by converting all forms of narcotics to morphine equivalents. The secondary end point was the documentation of pain with standard pain scores at standard time points postoperatively. Adverse effects related to pain management were documented for both groups. Student's t-tests were utilized to statistically compare differences between the groups, with significance determined at p < 0.05.

RESULTS

Forty-two patients with CP who underwent hip reconstruction (mean age 8.8 years) were compared to 26 patients who underwent PSF (mean age 15.4 years). The total opioid used, normalized by body weight and by days length of stay (DLOS), in the hip group was 0.49 mg morphine/kg/DLOS, compared to 0.24 for the spine group (p = 0.014). The mean pain score for the hip group was 1.52, compared to 0.72 for the spine group (p = 0.013). There were no significant differences in the occurrence of adverse effects related to pain management between the two groups.

CONCLUSION

Patients with CP undergoing hip reconstruction surgery had significantly more pain, as exhibited by requiring more narcotics and having higher pain scores, than those patients undergoing PSF. The knowledge that hip reconstruction is more painful than PSF for patients with CP will better prepare families about what to expect in the postoperative period and will alert providers to supply better postoperative pain control in these patients.

LEVEL OF EVIDENCE

III (case control series).

Spinal anaesthesia for orthopaedic surgery in children with cerebral palsy: Analysis of 36 patients

BACKGROUND AND OBJECTIVE

Cerebral palsy is one of the most common childhood neuromuscular diseases in the world. Spinal anaesthesia in children is an evolving technique with many advantages in perioperative management. The aim of this retrospective study was to provide first-hand reports of children with cerebral palsy who underwent orthopaedic surgery under spinal anaesthesia.

METHODS

Records of the children with cerebral palsy who underwent orthopaedic surgery under spinal anaesthesia between May 2012 and June 2013 at Selcuk University Hospital were investigated. In all patients, lumbar puncture was performed in lateral decubitus position with mask sevoflurane-nitrous oxide anaesthesia. In patients who were calm prior the spinal block, inhalation anaesthesia was terminated. In patients who were restless before the spinal block, anaesthesia was combined with light sevoflurane anaesthesia and a laryngeal mask. From anaesthesia records, the number of attempts required to complete the lumbar puncture, and the success rates of spinal anaesthesia and perioperative complications were noted. Data were expressed as numbers and percentages.

RESULTS

The study included 36 patients (20 girls and 16 boys). The mean age was 71 months. The rate of reaching subarachnoid space on first attempt was 86%. In all patients, spinal anaesthesia was considered successful. In 26 patients, laryngeal mask and light sevoflurane anaesthesia were required to maintain ideal surgical conditions. No major perioperative complications were observed.

CONCLUSION

Spinal anaesthesia alone or combined with light sevoflurane anaesthesia is a reliable technique with high success rates in children with cerebral palsy undergoing orthopaedic surgery.

Are We Undermedicating Patients With Neuromuscular Scoliosis After Posterior Spinal Fusion?

STUDY DESIGN

Retrospective, matched study of patients with adolescent idiopathic scoliosis (AIS) and patients with cerebral palsy (CP) undergoing (PSF).

OBJECTIVES

To compare pain management, through measurement of the amount of narcotic used and pain scores, for patients with neuromuscular (NM) scoliosis undergoing PSF to a cohort of patients with AIS.

SUMMARY OF BACKGROUND DATA

Posterior spinal fusion for children with severe NM scoliosis carries a high risk of complications. Appropriate assessment of pain is crucial; undertreatment of pain leads to anxiety whereas overtreatment can lead to respiratory depression and additional complications.

METHODS

A series of patients with NM scoliosis was matched for age, gender, and weight with a group of patients with AIS. Data collection included age, curve type and magnitude, and instrumentation type and levels fused. The total opioid used (TOU) was determined by summing all narcotics given during the hospital stay and converting them to morphine equivalent units. The data were then analyzed to determine differences in TOU.

RESULTS

A total of 25 patients with NM scoliosis were included in the study. This group was matched with 25 patients with AIS scoliosis. The TOU for the NM group was 1.2 mg morphine/kg (range, 0.28-4.21 mg morphine/kg) whereas the TOU for the AIS group was 3.52 mg morphine/kg (range, 0.71-15.51 mg morphine/kg) (p < .0000001).

CONCLUSIONS

In this case-control analysis, patients with AIS undergoing PSF received more than twice the amount of narcotic compared with a matched group of patients with NM scoliosis. These data suggest that NM patients' pain may be undertreated compared with AIS patients. More study is indicated to investigate pain assessment and pain control in this vulnerable patient population to improve care.

[Organization of pediatric pain management: Austrian interdisciplinary recommendations for pediatric perioperative pain management]

BACKGROUND

Postoperative pain management is still in need of vast improvement, especially for children. The aim of this article is to demonstrate which structures and processes must be optimized to ultimately improve patient satisfaction and safety.

RESPONSIBILITIES

Basic prerequisites are among others personnel continuity and good cooperation in a multiprofessional team. A clear assignment of responsibilities is also of essential importance.

PATIENT HISTORY AND INFORMED CONSENT

On admission every patient should be questioned on the currently existing pain. Patients or the parents must be informed about the pain therapy in a comprehensible manner. Possible complications, chances of success, advantages and disadvantages of the planned procedure and alternative forms of treatment must be discussed.

IMPLEMENTATION

The implementation needs a great deal of consideration. The introduction of clearly defined pathways and thorough schooling contribute more to successful pain management than the establishment of pain measurement or the use of special techniques alone.

EVALUATION AND DOCUMENTATION

Because pain intensity can only be described indirectly it is difficult to assess in children. Assessment is made by another person until children are 5 years old. The gold standard in pain measurement is, however, self-estimation using appropriate scales which is possible for older children. The routinely carried out representation of pain values and prompt documentation of all pain therapeutic measures are indispensible for the control and optimization of pain therapy.

QUALITY OF RESULTS

Whether improvements in acute pediatric pain therapy will actually be achieved can only be realized by standardized compilation and analysis of the quality of therapy. For this purpose QUIPSInfant was developed.

The Effect of Different End-tidal Desflurane Concentrations on Bispectral Index Values in Normal Children and Children with Cerebral Palsy

OBJECTIVE

In this study, we aimed to compare the effects of different intraoperative end-tidal desflurane concentrations on bispectral index (BIS) values in normal children and children with cerebral palsy.

METHODS

Twenty normal children (Group N) and 20 children with non-communicative/nonverbal cerebral palsy (Group CP), between 2 and 15 years of age, undergoing elective orthopaedic surgery were included in the study. Following premedication with midazolam, anaesthesia was induced by infusing 1% propofol at a rate of 200 mL hr(-1) until BIS reached 50. Heart rate, blood pressure and BIS values were recorded before and after the induction of anaesthesia, at steady-state end-tidal concentrations of 4% and 6% desflurane, and after emergence from anaesthesia. A p value <0.05 was considered significant in the statistical analyses, including Kolmogorov-Smirnov, t-test, paired samples t-test and chi-square test.

RESULTS

The time to extubation and eye opening after discontinuation of anaesthesia was longer in Group CP. BIS values before the induction of anaesthesia, at a steady-state end-tidal desflurane concentration of 4% and after emergence from the anaesthetic were significantly lower in Group CP. At a steady-state end-tidal desflurane concentration of 6%, BIS values were slightly lower in Group CP but this difference was not statistically significant.

CONCLUSION

Based on the data obtained, we concluded that BIS monitoring in children with cerebral palsy can be useful in terms of decreasing adverse effects and drug interactions due to multiple drug usage by reducing the use of anaesthetic agents and improving emergence from the anaesthetic.

Peri-operative pain management in children with cerebral palsy: comparative efficacy of epidural vs systemic analgesia protocols

INTRODUCTION

Selective Dorsal Rhizotomy (SDR) is the only surgical intervention with class I evidence supporting permanent reduction in spasticity for children with cerebral palsy (Paediatr Anaesth, 12, 2002, 296; Neurosurg Focus, 21, 2006, e2). Postoperatively, adequate analgesia can be difficult to achieve (J Neurosurg, 105, 2006, 8; Childs Nerv Syst, 17, 2001, 556; Pediatr Neurosurg, 43, 2007, 107; Anesth Analg, 79, 1994, 340; Reg Anesth Pain Med, 24, 1999, 438; Pediatr Anesth, 19, 2009, 1213). This study examines a novel regimen utilizing the combination of epidurally infused ropivacaine - hydromorphone and scheduled ketorolac. This regimen was compared to a protocol utilizing systemic fentanyl and diazepam.

METHODS

Following IRB approval, 31 patients receiving epidural analgesia were compared with 41 patients who received systemic analgesia. All surgeries were performed by one surgeon with standardized anesthetic and nursing care. Studied outcomes included: pain scores; episodes of severe pain; nausea, itching; oxygen desaturation; and ICU admission. Data were analyzed using Mann-Whitney U-test, CHI square, and Fisher exact test where indicated with P < 0.05 considered significant.

RESULTS

Studied groups had similar demographics, biometrics and disease burdens. Patients in the epidural group had statistically and clinically significant reductions in peak recorded pain scores for each 4-h period in the first 24 postoperative hours. Severe pain (score >5) was markedly reduced in the epidural group with 9% of epidural patients vs. 68% of systemic patients experiencing at least one episode. Fewer epidural patients experienced oxygen desaturation during the first two postoperative days (6.5% vs. 41%, 6.5% vs. 39%).

CONCLUSION

Epidural analgesia resulted in substantial improvements in pain control and safety. The data supports the superiority of a multimodal analgesia approach centered on epidural analgesia. A similar protocol should be considered following simple laminectomies or procedures associated with lower-extremity muscle spasm.

The use of botulinum toxin and epidural analgesia for the treatment of spasticity and pain in a patient with maple syrup urine disease

A 7-year-old boy, weighing 18 kg, was diagnosed with maple syrup urine disease (MSUD). He suffered from spasticity of the lower limbs and pain that did not respond to oral medications. Injections of botulinum toxin A (BTX-A) at 10 sites and epidural analgesia with 0.125% bupivacaine were used to treat spasticity with good results. We conclude that BTX-A combined with epidural analgesia may be a useful treatment option for incapacitating, painful spasticity related to MSUD. This treatment modality allowed a comprehensive rehabilitation program to be completed and it lasted longer than 9 months.