Analgesic efficacy of ketorolac 0.5% ophthalmic solution (Accular) in paediatric strabismus surgery

Comparison of topical oxybuprocaine and intravenous fentanyl in pediatric strabismus surgery

PURPOSE

To compare the outcomes such as postoperative nausea/vomiting, analgesic requirements, and hospital stay following the use of topical oxybuprocaine hydrochloride 0.4% or intravenous (IV) fentanyl in children undergoing strabismus surgery.

METHODS

This was a prospective cohort study. Children operated under general anesthesia for strabismus were given topical oxybuprocaine hydrochloride 0.4% (Group T) and IV fentanyl (Group F) before surgery. The episodes of nausea/vomiting, pain score, requirement of additional analgesia during postoperative period, and duration of hospital stay were compared in two groups.

RESULTS

There were 47 children in Group T and 59 children in Group F. The median pain score in two groups were 2.38 (25% quartile; 2.0) and 3.00 (25% quartile; 3.00), respectively. The difference was significant (K W P < 0.03). The episodes of nausea/vomiting in two groups were in 2 and 6 children in Group T and Group F, respectively. The median hospital stay of children of Group T and Group F were 242 and 285 min, respectively. The difference was not statistically significant (P = 0.22).

CONCLUSIONS

Using intraoperative topical oxybuprocaine drops, one can achieve better analgesic outcomes and reduce risk of nausea and vomiting compared to intravenous opioid analgesics and therefore, the hospital stay could also be marginally reduced.

Immediate rescue designs in pediatric analgesic trials: a systematic review and meta-analysis

BACKGROUND

Designing analgesic clinical trials in pediatrics requires a balance between scientific, ethical, and practical concerns. A previous consensus group recommended immediate rescue designs using opioid sparing as a surrogate measure of analgesic efficacy. The authors summarize the performance of rescue analgesic designs in pediatric trials of four commonly used classes of analgesics: opioids, nonsteroidal antiinflammatory drugs, acetaminophen, and local anesthetics.

METHODS

MEDLINE, Embase, CINAHL, The Cochrane Library, and Web of science were searched in April 2013. The 85 studies selected were randomized or controlled clinical trials using immediate rescue paradigms in postoperative pain settings. A random-effects meta-analysis was used to synthesize predefined outcomes using Hedges' g. Difference between the means of the treatment arms were also expressed as a percentage of the corresponding value in the placebo group (placebo-treatment/placebo). Distributions of pain scores in study and control groups and relationships between opioid sparing and pain scores were examined.

RESULTS

For each of the four study drug classes, significant opioid sparing was demonstrated in a majority of studies by one or more of the following endpoints: (1) total dose (milligram per kilogram per hour), (2) percentage of children requiring rescue medication, and (3) time to first rescue medication (minutes). Pain scores averaged 2.4/10 in study groups, 3.4/10 in control groups.

CONCLUSIONS

Opioid sparing is a feasible pragmatic endpoint for pediatric pain analgesic trials. This review serves to guide future research in pediatric analgesia trials, which could test whether some specific design features may improve assay sensitivity while minimizing the risk of unrelieved pain.

Effectiveness of ketorolac tromethamine in prevention of severe retinopathy of prematurity

PURPOSE

This study assessed the effectiveness of the use of ketorolac tromethamine to reduce retinopathy of prematurity (ROP) incidence and its progression to more severe forms.

METHODS

Forty-seven preterm newborn infants with a birth weight (BW) of 1,000 grams or less and/or a gestational age (GA) of 29 weeks or less were enrolled in the study when avascular retina zone I or ROP any stage were diagnosed at screening. Studied infants were randomized to receive ketorolac tromethamine ophthalmic solution in one eye and a drop of placebo in the other eye, until ROP requiring treatment or full retinal vascularization was diagnosed.

RESULTS

Only 2 newborn infants did not develop ROP. Among 45 newborn infants who developed ROP, 6 showed different ROP staging between the two eyes, 4 of which had a better outcome in the eye receiving ketorolac tromethamine. The differences between ROP stagings were not significant even when analyzed by GA and BW subgroups. No significant treatment-related side effects occurred.

CONCLUSION

This report suggests that ketorolac tromethamine ophthalmic solution cannot reduce the risk of developing severe ROP in preterm infants.

A systematic review of faces scales for the self-report of pain intensity in children

CONTEXT

Numerous faces scales have been developed for the measurement of pain intensity in children. It remains unclear whether any one of the faces scales is better for a particular purpose with regard to validity, reliability, feasibility, and preference.

OBJECTIVES

To summarize and systematically review faces pain scales most commonly used to obtain self-report of pain intensity in children for evaluation of reliability and validity and to compare the scales for preference and utility.

METHODS

Five major electronic databases were systematically searched for studies that used a faces scale for the self-report measurement of pain intensity in children. Fourteen faces pain scales were identified, of which 4 have undergone extensive psychometric testing: Faces Pain Scale (FPS) (scored 0-6); Faces Pain Scale-Revised (FPS-R) (0-10); Oucher pain scale (0-10); and Wong-Baker Faces Pain Rating Scale (WBFPRS) (0-10). These 4 scales were included in the review. Studies were classified by using psychometric criteria, including construct validity, reliability, and responsiveness, that were established a priori.

RESULTS

From a total of 276 articles retrieved, 182 were screened for psychometric evaluation, and 127 were included. All 4 faces pain scales were found to be adequately supported by psychometric data. When given a choice between faces scales, children preferred the WBFPRS. Confounding of pain intensity with affect caused by use of smiling and crying anchor faces is a disadvantage of the WBFPRS.

CONCLUSIONS

For clinical use, we found no grounds to switch from 1 faces scale to another when 1 of the scales is in use. For research use, the FPS-R has been recommended on the basis of utility and psychometric features. Data are sparse for children below the age of 5 years, and future research should focus on simplified measures, instructions, and anchors for these younger children.

Sub-Tenon's ropivacaine block for pain relief after primary strabismus surgery

PURPOSE

Pain is the main cause of patient distress/dissatisfaction after strabismus surgery. The aim of the study was to evaluate the effect of sub-Tenon's block with ropivacaine at the end of strabismus surgery on post-operative pain.

METHODS

A prospective trial was conducted in 79 patients (age 1.0-65 years) scheduled for outpatient primary strabismus surgery with fixed sutures under general anesthesia (GA) at a major tertiary hospital. Half the patients were randomly allocated to receive sub-Tenon's block with ropivacaine 0.2% at conclusion of the operation. Primary outcome measures were visual analog scale (VAS) scores at arrival to the post-anesthesia care unit (PACU), at discharge 3 hr later, 12-16 hr post-operatively, and 24 hr post-operatively. Supplemental analgesia requirements and patient satisfaction were recorded as well. Data were presented as median (range). Mann-Whitney test, Pearson chi(2)-test or Fisher's exact test was used for statistical analysis; p <or= 0.05 was considered significant.

RESULTS

There were no between-group differences in median VAS scores at arrival to the PACU and at discharge, with a borderline difference at 24 hr post-operatively (p = 0.06). At 12-16 hr post-operatively, the median score was 0.0 (range 0-5) in the study group and 4.0 (range 0-6) in the controls (p < 0.001). The lower VAS score in the study group was associated with a lower rate of supplemental analgesia use (21.9% versus 57.9%, p = 0.001), fewer doses of supplemental analgesia (10 doses versus 35, p = 0.03), and higher patient satisfaction (p < 0.001).

CONCLUSIONS

Sub-Tenon's block with ropivacaine 0.2% at the completion of outpatient primary strabismus surgery with fixed sutures under GA reduces pain 12-16 hr post-operatively and analgesia requirements 4-23 hr post-operatively.

Subtenon lidocaine vs topical proparacaine in adult strabismus surgery

Intraoperative subtenon 2% lidocaine and topical 0.5% proparacaine in patients undergoing strabismus surgery were compared. No additional systemic analgesics and sedatives were used. Mean and total pain scores intraoperatively and postoperatively were not different. Each anesthetic agent provides good intraoperative anesthesia and postoperative analgesia. Topical 0.5% proparacaine may be preferred because of its easy administration and fewer side effects, lack of hospital admission, and immediate and predictable alignment of the eyes.

Validity and reliability of the Behavioural Observational Pain Scale for postoperative pain measurement in children 1-7 years of age

OBJECTIVE

Pain measurement is a necessity in pain treatment but can be difficult in young children. The aim of this study was to evaluate the validity and reliability of the Behavioural Observational Pain Scale (BOPS) as a postoperative pain measurement scale for children aged 1-7 yrs. The scale assesses three elements of pain behaviors: facial expression, verbalization, and body position.

DESIGN

A prospective study.

SETTING

A day surgery care unit for children and a neurosurgical postoperative care unit.

PATIENTS

Seventy-six children aged 1-7 yrs (4.5 +/- 1.8) undergoing elective surgical procedures were observed.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

The study was divided into interrater reliability, concurrent validity, and construct validity. The interrater reliabilities of the observers were very good with a high agreement between the different nurses' BOPS scores. Each item of the BOPS scale ranged from kappa(w) 0.86 to 0.95. In the concurrent validity, BOPS and Children's Hospital of Eastern Ontario Pain Scale scores had a positive correlation indicating that both tools described similar behaviors (r(s) = .871, p < .001). In construct validity, the effect of analgesic was tested before analgesic administration and at 15, 30, and 60 mins after analgesic administration. The differences in BOPS score between the time intervals were significant (p < .01) before administration of analgesia and at 15, 30, and 60 mins. There was also statistical significance in the BOPS score (p < .01) between 15 and 60 mins after administration of analgesia.

CONCLUSIONS

With BOPS, the caretaker can evaluate and document pain with high reliability and validity and thereby improve postoperative pain treatment in preschool children. The simple scoring system makes BOPS easy to incorporate in a postoperative unit.

Treatment of retinopathy of prematurity with topical ketorolac tromethamine: a preliminary study

BACKGROUND

Retinopathy of Prematurity (ROP) is a common retinal neovascular disorder of premature infants. It is of variable severity, usually heals with mild or no sequelae, but may progress to blindness from retinal detachments or severe retinal scar formation. This is a preliminary report of the effectiveness and safety of a new and original use of topical ketorolac in preterm newborn to prevent the progression of ROP to the more severe forms of this disease.

METHODS

From January 2001 to December 2002, all fifty nine preterm newborns with birthweight less than 1250 grams or gestational age less than 30 weeks of gestational age admitted to neonatal intensive care were eligible for treatment with topical ketorolac (0.25 milligrams every 8 hours in each eye). The historical comparison group included all 53 preterm newborns, with the same inclusion criteria, admitted between January 1999 and December 2000.

RESULTS

Groups were comparable in terms of weight distribution, Apgar score at 5 minutes, incidence of sepsis, intraventricular hemorrhage and necrotizing enterocolitis. The duration of oxygen therapy was significantly longer in the control group. In the ketorolac group, among 43 children that were alive at discharge, one (2.3%) developed threshold ROP and cryotherapy was necessary. In the comparison group 35 children survived, and six child (17%) needed cryotherapy (Relative Risk 0.14, 95%CI 0.00 to 0.80, p = 0.041). Adjusting by duration of oxygen therapy did not significantly change these results. Adverse effects attributable to ketorolac were not detected.

CONCLUSIONS

This preliminary report suggests that ketorolac in the form of an ophthalmic solution can reduce the risk of developing severe ROP in very preterm newborns, without producing significant adverse side effects. These results, although promising, should be interpreted with caution because of the weakness of the study design. This is an inexpensive and simple intervention that might ameliorate the progression of a disease with devastating consequences for children and their families. We believe that next logical step would be to assess the effectiveness of this intervention in a randomized controlled trial of adequate sample size.

Amethocaine or ketorolac eyedrops provide inadequate analgesia in pediatric strabismus surgery

PURPOSE

Corrective strabismus surgery is associated with moderate pain after surgery. Postoperative analgesia for these patients may include topical local anesthetic agents and topical non-steroidal anti-inflammatory drugs. In this prospective randomized, double-blind placebo controlled clinical trial we compared the effect of placebo to intraoperative 0.5% topical amethocaine or 0.5% topical ketorolac on pain control after strabismus surgery in children.

METHODS

Following Institutional Ethics Committee approval and parental consent, we prospectively studied 51 healthy children between the ages of two and seven years who were undergoing elective bilateral recession surgery in a randomized, double-blind controlled clinical trial. Children were randomized to receive either placebo (normal saline), 0.5% amethocaine or 0.5% ketorolac eye drops at the start and end of strabismus repair surgery. Pain was assessed with a modified Children's Hospital of Eastern Ontario Pain Score in the recovery room. If the pain score was greater than 6, the patient was administered a single oral dose of acetaminophen (20 mg x kg(-1)).

RESULTS

The groups had similar demographic data. Duration of surgery and anesthesia, time spent in recovery room and length of hospital stay between the three groups were similar. Pain scores and analgesic requirements while in the hospital were also similar between the groups as was the time to first analgesic administration. There were no side effects observed in any of the three treatment arms.

CONCLUSION

We conclude that there is no improvement in postoperative pain control after the intraoperative administration of topical 0.5% ketorolac or 0.5% amethocaine when compared to placebo in children undergoing strabismus surgery.

Nonsteroidal anti-inflammatory drugs for postoperative pain: a focus on children

Pain is a common symptom after surgery in children, and the need for effective pain management is obvious. For example, after myringotomy, despite the brief nature of the procedure, at least one-half of children have significant pain. After more extended surgery, such as tonsillectomy, almost all children have considerable pain longer than 7 days. Nonsteroidal anti-inflammatory drugs (NSAIDs) are useful for postoperative pain management because surgery causes both pain and inflammation. Several pediatric studies indicate NSAIDs are effective analgesics in the management of mild and moderate pain. In the treatment of severe pain, NSAIDs should be given with acetaminophen (paracetamol) or opioids, and the use of an appropriate regional analgesic technique should be considered. NSAIDs are more effective in preventing pain than in the relief of established pain. Pain following surgery is best managed by providing medication on a regular basis, preventing the pain from recurring. This proactive approach should be implemented for any procedure where postoperative pain is the likely outcome. In children, the choice of formulation can be more important than the choice of drug. Intravenous administration is preferred for children with an intravenous line in place; thereafter mixtures and small tablets are feasible options. Children dislike suppositories, and intramuscular administration should not be used in nonsedated children. Ibuprofen, diclofenac, ketoprofen and ketorolac are the most extensively evaluated NSAIDs in children. Only a few trials have compared different NSAIDs, but no major differences in the analgesic action are expected when appropriate doses of each drug are used. Whether NSAIDs differ in the incidence and severity of adverse effects is open to discussion. Because NSAIDs prevent platelet aggregation they may increase bleeding. A few studies indicate that ketorolac may increase bleeding more so than other NSAIDs, but the evidence is conflicting. Severe adverse effects of NSAIDs in children are very rare, but it is important to know about adverse effects in order to recognize and treat them when they do occur. NSAIDs are contraindicated in patients in whom sensitivity reactions are precipitated by aspirin (acetylsalicylic acid) or other NSAIDs. They should be used with caution in children with liver dysfunction, impaired renal function, hypovolemia or hypotension, coagulation disorders, thrombocytopenia, or active bleeding from any cause. In contrast, it seems that most children with mild asthma may use NSAIDs.