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Ziesenitz VC, Welzel T, van Dyk M, Saur P, Gorenflo M, van den Anker JN. Efficacy and Safety of NSAIDs in Infants: A Comprehensive Review of the Literature of the Past 20 Years. Paediatr Drugs 2022; 24:603-655. [PMID: 36053397 PMCID: PMC9592650 DOI: 10.1007/s40272-022-00514-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/25/2022] [Indexed: 11/29/2022]
Abstract
Non-steroidal anti-inflammatory drugs (NSAIDs) are commonly used in infants, children, and adolescents worldwide; however, despite sufficient evidence of the beneficial effects of NSAIDs in children and adolescents, there is a lack of comprehensive data in infants. The present review summarizes the current knowledge on the safety and efficacy of various NSAIDs used in infants for which data are available, and includes ibuprofen, dexibuprofen, ketoprofen, flurbiprofen, naproxen, diclofenac, ketorolac, indomethacin, niflumic acid, meloxicam, celecoxib, parecoxib, rofecoxib, acetylsalicylic acid, and nimesulide. The efficacy of NSAIDs has been documented for a variety of conditions, such as fever and pain. NSAIDs are also the main pillars of anti-inflammatory treatment, such as in pediatric inflammatory rheumatic diseases. Limited data are available on the safety of most NSAIDs in infants. Adverse drug reactions may be renal, gastrointestinal, hematological, or immunologic. Since NSAIDs are among the most frequently used drugs in the pediatric population, safety and efficacy studies can be performed as part of normal clinical routine, even in young infants. Available data sources, such as (electronic) medical records, should be used for safety and efficacy analyses. On a larger scale, existing data sources, e.g. adverse drug reaction programs/networks, spontaneous national reporting systems, and electronic medical records should be assessed with child-specific methods in order to detect safety signals pertinent to certain pediatric age groups or disease entities. To improve the safety of NSAIDs in infants, treatment needs to be initiated with the lowest age-appropriate or weight-based dose. Duration of treatment and amount of drug used should be regularly evaluated and maximum dose limits and other recommendations by the manufacturer or expert committees should be followed. Treatment for non-chronic conditions such as fever and acute (postoperative) pain should be kept as short as possible. Patients with chronic conditions should be regularly monitored for possible adverse effects of NSAIDs.
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Affiliation(s)
- Victoria C. Ziesenitz
- grid.5253.10000 0001 0328 4908Pediatric Cardiology and Congenital Heart Diseases, Centre for Child and Adolescent Medicine, University Hospital Heidelberg, Im Neuenheimer Feld 430, 69120 Heidelberg, Germany ,grid.6612.30000 0004 1937 0642Pediatric Pharmacology and Pharmacometrics, University Children’s Hospital Basel, University of Basel, Basel, Switzerland
| | - Tatjana Welzel
- grid.6612.30000 0004 1937 0642Pediatric Pharmacology and Pharmacometrics, University Children’s Hospital Basel, University of Basel, Basel, Switzerland ,grid.411544.10000 0001 0196 8249Pediatric Rheumatology and Autoinflammatory Reference Center, University Hospital Tuebingen, Tuebingen, Germany
| | - Madelé van Dyk
- grid.1014.40000 0004 0367 2697Flinders Centre for Innovation in Cancer, College of Medicine and Public Health, Flinders University, Adelaide, SA Australia
| | - Patrick Saur
- grid.5253.10000 0001 0328 4908Pediatric Cardiology and Congenital Heart Diseases, Centre for Child and Adolescent Medicine, University Hospital Heidelberg, Im Neuenheimer Feld 430, 69120 Heidelberg, Germany
| | - Matthias Gorenflo
- grid.5253.10000 0001 0328 4908Pediatric Cardiology and Congenital Heart Diseases, Centre for Child and Adolescent Medicine, University Hospital Heidelberg, Im Neuenheimer Feld 430, 69120 Heidelberg, Germany
| | - Johannes N. van den Anker
- grid.6612.30000 0004 1937 0642Pediatric Pharmacology and Pharmacometrics, University Children’s Hospital Basel, University of Basel, Basel, Switzerland ,grid.239560.b0000 0004 0482 1586Division of Clinical Pharmacology, Children’s National Hospital, Washington DC, USA ,grid.416135.40000 0004 0649 0805Intensive Care and Department of Pediatric Surgery, Sophia Children’s Hospital, Rotterdam, The Netherlands
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Chen F, Wang CY, Zhang J, Wang F, Zhang M, Gu H, Song X, Chen J, Li Y, Cai YH, Li J, Lian QQ, Wu J, Liu HC. Comparison of Postoperative Analgesic Effects Between Nalbuphine and Fentanyl in Children Undergoing Adenotonsillectomy: A Prospective, Randomized, Double-Blind, Multicenter Study. Front Pharmacol 2020; 11:597550. [PMID: 33536911 PMCID: PMC7849154 DOI: 10.3389/fphar.2020.597550] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2020] [Accepted: 10/16/2020] [Indexed: 12/19/2022] Open
Abstract
Objective: There is no universal agreement on optimal pharmacological regimens for pain management during surgeries. The aim of this study to compare the postoperative analgesic effects of nalbuphine with fentanyl in children undergoing adenotonsillectomy. Design, Setting, Participants: We conducted a prospective, randomized, double-blind, non-inferiority and multicenter trial in 311 patients admitted to four different medical facilities in China from October 2017 to November 2018. Main Outcome Measure: The primary outcome was postoperative pain score. The secondary outcomes were as follows: the numbers of patients who developed moderate or severe pain (FLACC ≥4 points); time to first rescue analgesic top up and the actual number of rescue pain medicine given in pain control in post-anesthesia care unit (PACU), and additional analgesics requirement (received ≥2 rescue analgesics or/and other analgesics except study medications administered in PACU and ward); emergence and extubation time; Waking up time; time of PACU stay, and other side effects (desaturation, nausea/vomiting etc.). Results: A total of 356 children were screened and 322 patients were randomized. The mean age was 5.8 (5.5, 6.1) in the nalbuphine group and 5.6 (5.3, 5.8) in the fentanyl group (p = 0.2132). FLACC score of nalbuphine group was lower than that of fentanyl group upon patients' arrival at PACU (p < 0.05). The time to first required rescue dose of pain drug for nalbuphine group was longer than for the fentanyl group (2.5 vs 1.2 h, p < 0.0001). Only one patient (0.6%) in nalbuphine group presented a slow respiratory rate (RR) at 9/min while 29 patients (18.5%) in fentanyl group developed slow RR ≤10/min in PACU. Meanwhile, SpO2 was lower in the fentanyl group at 10 min after patients’ arrival in PACU (p < 0.05). The other profiles observed from these two drug groups were similar. Conclusion: Nalbuphine provided better pain relief with minimal respiration depression than fentanyl in children undergoing Adenotonsillectomy.
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Affiliation(s)
- Fang Chen
- Key Laboratory of Anesthesiology of Zhejiang Province, Department of Anesthesiology, Perioperative and Pain Medicine, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Zhejiang, China
| | - Cheng-Yu Wang
- Key Laboratory of Anesthesiology of Zhejiang Province, Department of Anesthesiology, Perioperative and Pain Medicine, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Zhejiang, China
| | - Jianmin Zhang
- Department of Anesthesiology, Beijing Children's Hospital, Capital Medical University, Beijing, China
| | - Fang Wang
- Department of Anesthesiology, Beijing Children's Hospital, Capital Medical University, Beijing, China
| | - Mazhong Zhang
- Department of Anesthesiology, Shanghai Children's Medical Center, Shanghai, China
| | - Hongbin Gu
- Department of Anesthesiology, Shanghai Children's Medical Center, Shanghai, China
| | - Xingrong Song
- Department of Anesthesiology, Guangzhou Women and Children's Medical Center, Guangzhou, China
| | - Jia Chen
- Key Laboratory of Anesthesiology of Zhejiang Province, Department of Anesthesiology, Perioperative and Pain Medicine, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Zhejiang, China
| | - Yang Li
- Key Laboratory of Anesthesiology of Zhejiang Province, Department of Anesthesiology, Perioperative and Pain Medicine, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Zhejiang, China
| | - Yu-Hang Cai
- Key Laboratory of Anesthesiology of Zhejiang Province, Department of Anesthesiology, Perioperative and Pain Medicine, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Zhejiang, China
| | - Jun Li
- Key Laboratory of Anesthesiology of Zhejiang Province, Department of Anesthesiology, Perioperative and Pain Medicine, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Zhejiang, China
| | - Qing-Quan Lian
- Key Laboratory of Anesthesiology of Zhejiang Province, Department of Anesthesiology, Perioperative and Pain Medicine, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Zhejiang, China
| | - Junzheng Wu
- Department of Anesthesiology, Cincinnati Children's Hospital, Cincinnati, OH, United States
| | - Hua-Cheng Liu
- Key Laboratory of Anesthesiology of Zhejiang Province, Department of Anesthesiology, Perioperative and Pain Medicine, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Zhejiang, China
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Postoperative Ketorolac Administration Is Not Associated with Hemorrhage in Cranial Vault Remodeling for Craniosynostosis. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2019; 7:e2401. [PMID: 31592008 PMCID: PMC6756670 DOI: 10.1097/gox.0000000000002401] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2019] [Accepted: 06/28/2019] [Indexed: 11/25/2022]
Abstract
Nonsteroidal anti-inflammatory drugs have been used as part of multimodal postoperative analgesic regimens to reduce the necessity of opioids. However, due to its effect on platelet function, there is a hesitation to utilize ketorolac postoperatively. The goal of this study is to analyze our experience utilizing ketorolac in patients who underwent major cranial vault remodeling (CVR) for craniosynostosis with an emphasis on postoperative hemorrhage and complications.
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Abstract
BACKGROUND Children who undergo surgical procedures in ambulatory and inpatient settings are at risk of experiencing acute pain. Nonsteroidal anti-inflammatory drugs (NSAIDs) can reduce moderate to severe pain without many of the side effects associated with opioids. However, NSAIDs may cause bleeding, renal and gastrointestinal toxicity, and potentially delay wound and bone healing. Intravenous administration of ketorolac for postoperative pain in children has not been approved in many countries, but is routinely administered in clinical practise. OBJECTIVES To assess the efficacy and safety of ketorolac for postoperative pain in children. SEARCH METHODS We searched the following databases, without language restrictions, to November 2017: CENTRAL (The Cochrane Library 2017, Issue 10); MEDLINE, Embase, and LILACS. We also checked clinical trials registers and reference lists of reviews, and retrieved articles for additional studies. SELECTION CRITERIA We included randomised controlled trials that compared the analgesic efficacy of ketorolac (in any dose, administered via any route) with placebo or another active treatment, in treating postoperative pain in participants zero to 18 years of age following any type of surgery. DATA COLLECTION AND ANALYSIS We used standard methodological procedures expected by Cochrane. Two review authors independently considered trials for inclusion in the review, assessed risk of bias, and extracted data. We analyzed trials in two groups; ketorolac versus placebo, and ketorolac versus opioid. However, we performed limited pooled analyses. We assessed the overall quality of the evidence for each outcome using GRADE, and created a 'Summary of findings' table. MAIN RESULTS We included 13 studies, involving 920 randomised participants. There was considerable heterogeneity among study designs, including the comparator arms (placebo, opioid, another NSAID, or a different regimen of ketorolac), dosing regimens (routes and timing of administration, single versus multiple dose), outcome assessment methods, and types of surgery. Mean study population ages ranged from 356 days to 13.9 years. The majority of studies chose a dose of either 0.5 mg/kg (as a single or multiple dose regimen) or 1 mg/kg (single dose with 0.5 mg/kg for any subsequent doses). One study administered interventions intraoperatively; the remainder administered interventions postoperatively, often after the participant reported moderate to severe pain.There were insufficient data to perform meta-analysis for either of our primary outcomes: participants with at least 50% pain relief; or mean postoperative pain intensity. Four studies individually reported statistically significant reductions in pain intensity when comparing ketorolac with placebo, but the studies were small and had various risks of bias, primarily due to incomplete outcome data and small sample sizes.We found limited data available for the secondary outcomes of participants requiring rescue medication and opioid consumption. For the former, we saw no clear difference between ketorolac and placebo; 74 of 135 (55%) participants receiving ketorolac required rescue analgesia in the post-anaesthesia care unit (PACU) versus 81 of 127 (64%) receiving placebo (relative risk (RR) 0.85, 95% confidence interval (CI) 0.71 to 1.00, P = 0.05; 4 studies, 262 participants). For opioid consumption in the PACU, we saw no clear difference between ketorolac and placebo (P = 0.61). For the time period zero to four hours after administration of the interventions, participants receiving ketorolac received 1.58 mg less intravenous morphine equivalents than those receiving placebo (95% CI -2.58 mg to -0.57 mg, P = 0.002; 2 studies, 129 participants). However, we are uncertain whether ketorolac has an important effect on opioid consumption, as the data were sparse and the results were inconsistent. Only one study reported data for opioid consumption when comparing ketorolac with an opioid. There were no clear differences between the ketorolac and opioid group at any time point. There were no data assessing this outcome for the comparison of ketorolac with another NSAID.There were insufficient data to allow us to analyze overall adverse event or serious adverse event rates. Although the majority of serious adverse events reported in those receiving ketorolac involved bleeding, the number of events was too low to conclude that bleeding risk was increased in those receiving ketorolac perioperatively. There was not a statistically significant increase in event rates for any specific adverse event, either in pooled analysis or in single studies, when comparing ketorolac and placebo. When comparing ketorolac with opioids or other NSAIDs, there were too few data to make any conclusions regarding event rates. Lastly, withdrawals due to adverse events were vary rare in all groups, reflecting the acute nature of such studies.We assessed the quality of evidence for all outcomes for each comparison (placebo or active) as very low, due to issues with risk of bias in individual studies, imprecision, heterogeneity between studies, and low overall numbers of participants and events. AUTHORS' CONCLUSIONS Due to the lack of data for our primary outcomes, and the very low-quality evidence for secondary outcomes, the efficacy and safety of ketorolac in treating postoperative pain in children were both uncertain. The evidence was insufficient to support or reject its use.
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Affiliation(s)
- Ewan D McNicol
- Department of Anesthesiology and Perioperative Medicine, Tufts Medical Center, Boston, Massachusetts, USA
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Gao B, Remondini T, Dhaliwal N, Frusescu A, Patel P, Cook A, Fermin-Risso C, Weber B. Incidence of bleeding in children undergoing circumcision with ketorolac administration. Can Urol Assoc J 2017; 12:E6-E9. [PMID: 29173273 DOI: 10.5489/cuaj.4632] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Circumcision is the most common surgical procedure performed by pediatric urologists. Ketorolac has been shown to have an efficacy similar to morphine in multimodal analgesic regimens without the commonly associated adverse effects. Concerns with perioperative bleeding limit the use of ketorolac as an adjunct for pain control in surgical patients. As such, we sought to evaluate our institutional outcomes with respect to ketorolac and postoperative bleeding. METHODS We retrospectively reviewed all pediatric patients undergoing circumcision from January 1, 2014 to December 31, 2015 at the Alberta Children's Hospital. Demographics, perioperative analgesic regimens, and return to emergency department or clinic for bleeding were gathered through chart review. RESULTS A total of 475 patients undergoing circumcisions were studied, including 150 (32%) who received perioperative ketorolac and 325 (68%) who received standard analgesia. Patients receiving ketorolac were more likely to return to the emergency department or clinic for bleeding (ketorolac group 19/150 [13%], non-ketorolac group 16/325 [5.0%]; p=0.005). Patients receiving ketorolac were more likely to have postoperative sanguineous drainage (ketorolac group 96/150 [64%], non-ketorolac group 150/325 [46%]; p<0.001). There was no significant difference in the number of patients requiring postoperative admission or further medical intervention. CONCLUSIONS Although a promising analgesic, ketorolac requires additional investigation for safe usage in circumcisions due to possible increased risk of bleeding.
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Affiliation(s)
- Bruce Gao
- Undergraduate Medicine, University of Calgary, Calgary, AB; Canada
| | - Taylor Remondini
- Undergraduate Medicine, University of Calgary, Calgary, AB; Canada
| | - Navraj Dhaliwal
- Undergraduate Medicine, University of Calgary, Calgary, AB; Canada
| | - Adrian Frusescu
- Undergraduate Nursing, University of Calgary, University of Calgary, Calgary, AB; Canada
| | - Premal Patel
- Department of Surgery, University of Manitoba, Winnipeg, MB; Canada
| | - Anthony Cook
- Department of Surgery, Alberta Children's Hospital, Calgary, AB; Canada
| | | | - Bryce Weber
- Department of Surgery, Alberta Children's Hospital, Calgary, AB; Canada
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Lewis SR, Nicholson A, Cardwell ME, Siviter G, Smith AF. Nonsteroidal anti-inflammatory drugs and perioperative bleeding in paediatric tonsillectomy. Cochrane Database Syst Rev 2013; 2013:CD003591. [PMID: 23881651 PMCID: PMC7154573 DOI: 10.1002/14651858.cd003591.pub3] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND Nonsteroidal anti-inflammatory drugs (NSAIDs) are used for pain relief following tonsillectomy in children. However, as they inhibit platelet aggregation and prolong bleeding time they could cause increased perioperative bleeding. The overall risk remains unclear. This review was originally published in 2005 and was updated in 2010 and in 2012. OBJECTIVES The primary objective of this review was to assess the effects of NSAIDs on bleeding with paediatric tonsillectomy. Our secondary outcome was to establish whether NSAIDs affect the incidence of other postoperative complications when compared to other forms of analgesia. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2012, Issue 10); MEDLINE (inception until October 2012); EMBASE (inception until October 2012); Current Problems (produced by the UK Medicines Control Agency), MedWatch (produced by the US Food and Drug Administration) and the Australian Adverse Drug Reactions Bulletins (to May 2010). The original search was performed in August 2004. We also contacted manufacturers and researchers in the field. SELECTION CRITERIA We included randomized controlled trials assessing NSAIDs in children, up to and including 16 years of age, undergoing elective tonsillectomy or adenotonsillectomy. DATA COLLECTION AND ANALYSIS Two authors independently assessed trial quality and extracted the data. We contacted study authors for additional information, where necessary. MAIN RESULTS We included 15 studies that involved 1101 children in this updated review. One study was added as a result of our 2012 search, another previously included study was removed due to lack of randomization. Fourteen included studies compared NSAIDs with other analgesics or placebo and reported on bleeding requiring surgical intervention. The use of NSAIDs was associated with a non-significant increase in the risk of bleeding requiring surgical intervention: Peto odds ratio (OR) 1.69 (95% confidence interval (CI) 0.71 to 4.01). Ten studies involving 365 children reported perioperative bleeding requiring non-surgical intervention. NSAIDs did not significantly alter the number of perioperative bleeding events requiring non-surgical intervention: Peto OR 0.99 (95% CI 0.41 to 2.40) but the confidence intervals did not exclude an increased risk. Thirteen studies involving 1021 children reported postoperative vomiting. There was less vomiting when NSAIDs were used as part of the analgesic regime than when NSAIDs were not used: Mantel Haenszel (M-H) risk ratio (RR) 0.72 (95% CI 0.61 to 0.85). AUTHORS' CONCLUSIONS There is insufficient evidence to exclude an increased risk of bleeding when NSAIDs are used in paediatric tonsillectomy. They do however confer the benefit of a reduction in vomiting.
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Affiliation(s)
- Sharon R Lewis
- Patient Safety Research, Royal Lancaster Infirmary, Lancaster, UK.
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[Therapy of perioperative pain in pediatric urology]. Urologe A 2009; 48:1158-69. [PMID: 19774357 DOI: 10.1007/s00120-009-2036-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Difficulties in estimating the kind and intensity of pain as well as uncertainty in drug selection and dosing are often responsible for a suboptimal treatment of pain therapy in the various age groups in childhood. The following article will help to minimize these deficits by contributing full details of safe and effective concepts for perioperative pain therapy in childhood.
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Inoue M, Caldarone CA, Frndova H, Cox PN, Ito S, Taddio A, Guerguerian AM. Safety and efficacy of ketorolac in children after cardiac surgery. Intensive Care Med 2009; 35:1584-92. [PMID: 19562323 DOI: 10.1007/s00134-009-1541-1] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2008] [Accepted: 05/11/2009] [Indexed: 02/08/2023]
Abstract
OBJECTIVE To evaluate the nephrotoxic and opioid-sparing effects of ketorolac in children after cardiac surgery. DESIGN A retrospective cohort study. SETTING A Cardiac Critical Care Unit in a university-affiliated children's hospital. SUBJECTS Children less than 18 years of age who underwent low-risk cardiac surgery from July 2002 to December 2005. RESULTS Among 248 children studied, 108 received ketorolac and 140 did not. The ketorolac group was older, included a larger proportion of atrial septum defect repairs and a smaller proportion of ventricular septum defect repairs compared to the control group. The median change in serum creatinine did not differ between the ketorolac group and the control group (% change [IQR]); 12% [1-25] increase versus 12% [-3 to 31] increase, P = 0.86. On postoperative day 0 or 1, the ketorolac group received less opioids than control group. There was no difference in duration of mechanical ventilation or in length of stay between groups. CONCLUSION Ketorolac started in the first 12 h after a low-risk cardiac surgery in children is not associated with a measurable difference in renal function. The data suggest that ketorolac may be effective in reducing the exposure to opioids. Further studies are required to define subsets of children after cardiac surgery who could safely benefit from ketorolac therapy to reduce pain.
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Affiliation(s)
- Miho Inoue
- Division of Clinical Pharmacology and Toxicology, Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
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Barcelona SL, Thompson AA, Coté CJ. Intraoperative pediatric blood transfusion therapy: a review of common issues. Part II: transfusion therapy, special considerations, and reduction of allogenic blood transfusions. Paediatr Anaesth 2005; 15:814-30. [PMID: 16176309 DOI: 10.1111/j.1460-9592.2004.01549.x] [Citation(s) in RCA: 63] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Affiliation(s)
- Sandra L Barcelona
- Department of Anesthesiology, The Feinberg School of Medicine, Northwestern University, Chicago, IL, USA.
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Schuster R, Stewart D, Schuster L, Greaney G, Waxman K. Preoperative Oral Rofecoxib and Postoperative Pain in Patients after Laparoscopic Cholecystectomy: A Prospective, Randomized, Double-Blinded, Placebo-Controlled Trial. Am Surg 2005. [DOI: 10.1177/000313480507101006] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Cyclooxygenase-2 (COX-2) inhibitors are a class of drugs that may avoid some of the side effects of narcotics and nonsteroidal anti-inflammatory drugs (NSAIDs). We performed a randomized, double-blinded, placebo-controlled trial giving a single oral dose of the COX-2 inhibitor rofecoxib 25 mg or placebo preoperatively to determine the impact upon postoperative pain, complications, narcotic use, and hospital stay after laparoscopic cholecystectomy. Investigators and patients were blinded. Pain was measured on a 10-point visual analogue scale. Eighty patients were randomized: 40 to the rofecoxib group and 40 to the placebo group. The amount of pain between the two groups postoperatively was equivalent. Pain was recorded at 1 hour, 4.03 ± 1.93 in the rofecoxib group versus 4.38 ± 1.34 in the placebo group ( P = 0.36); at 6 hours, 3.00 ± 1.12 in the rofecoxib group versus 2.78 ± 0.78 in the placebo group ( P = 0.42); and at 24 hours, 1.64 ± 0.67 in the rofecoxib group versus 2.68 ± 1.90 in the placebo group ( P = 0.17). The amount of pain medication received and lengths of hospital stay was not significantly different between the two groups. Our data demonstrate no significant benefit of preoperative oral rofecoxib in patients undergoing laparoscopic cholecystectomy.
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Affiliation(s)
- Rob Schuster
- Department of Surgery, Santa Barbara Cottage Hospital, Santa Barbara, California
| | - David Stewart
- Department of Surgery, Santa Barbara Cottage Hospital, Santa Barbara, California
| | - Lynn Schuster
- Department of Surgery, Santa Barbara Cottage Hospital, Santa Barbara, California
| | - Gregory Greaney
- Department of Surgery, Santa Barbara Cottage Hospital, Santa Barbara, California
| | - Kenneth Waxman
- Department of Surgery, Santa Barbara Cottage Hospital, Santa Barbara, California
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White MC, Nolan JA. An evaluation of pain and postoperative nausea and vomiting following the introduction of guidelines for tonsillectomy. Paediatr Anaesth 2005; 15:683-8. [PMID: 16029404 DOI: 10.1111/j.1460-9592.2004.01516.x] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND Tonsillectomy and adenotonsillectomy have a high incidence of postoperative pain, and postoperative nausea and vomiting (PONV). Pain is traditionally controlled with morphine but this increases the risk of PONV and may cause respiratory depression. Antiemetics reduce PONV but their routine use has been questioned on safety grounds. METHOD After determining the current anesthetic management of elective tonsillectomy and adenotonsillectomy patients in our hospital, guidelines were developed to avoid the routine use of morphine and antiemetics. The effect on pain and PONV was then evaluated over a 3 month period. Postoperative pain was scored using the Oucher visual analog scale and nausea scored using a five point scale. RESULTS We analysed 34 cases to determine our current practice and 37 cases to evaluate the effect of introducing guidelines. Postguidelines, the median Oucher pain score at 4 h was 10, and at 8, 12, 16 h was zero. Despite receiving no antiemetics, only two children vomited (5%) after introduction of guidelines. CONCLUSION Guidelines which use a combination of paracetamol, nonsteroidal anti-inflammatory drugs and fentanyl, provide excellent analgesia with minimal PONV after elective tonsillectomy and adenotonsillectomy. As a result the routine use of morphine and antiemetics can be avoided.
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Affiliation(s)
- Michelle C White
- Department of Anaesthesia, Bristol Royal Hospital for Children, Bristol, UK
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Abstract
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.
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Affiliation(s)
- Hannu Kokki
- Department of Anaesthesiology and Intensive Care, Kuopio University Hospital, Kuopio, Finland.
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Affiliation(s)
- Charles B Berde
- Department of Anesthesia, Children's Hospital, Boston, MA 02115, USA
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Stewart PCH, Baines DB, Dalton C. Paediatric day stay tonsillectomy service: development and audit. Anaesth Intensive Care 2002; 30:641-6. [PMID: 12413267 DOI: 10.1177/0310057x0203000517] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Day stay paediatric tonsillectomy is well established in many parts of the world but not in Australia. This audit presents the protocol and results of the first one hundred and twenty-five patients managed this way at our hospital. Patients assessed as being at low risk of postoperative complications were offered the procedure as a day patient. All patients had a standardized relaxant anaesthetic technique with an intraoperative opioid and antiemetics. The patients were observed for six hours postoperatively in the Day Stay Unit and contacted the day following surgery to assess any problems. The overall incidence of postoperative vomiting was 15.6%. Two patients required overnight admission. One child was re-admitted on day four for delayed postoperative haemorrhage. Forty-four of the first forty-nine patients' parents were contacted four to six weeks later to assess their experiences of the process. Although approximately three-quarters of the parents rated their child's pain as moderate or severe at some stage, all but one felt the analgesic regimen was good or adequate. Eighty per cent were satisfied with having the surgery as a day stay procedure.
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Affiliation(s)
- P C H Stewart
- Department of Anaesthesia, The New Children's Hospital, Sydney, New South Wales
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Russell MW, Jobes D. What should we do with aspirin, NSAIDs, and glycoprotein-receptor inhibitors? Int Anesthesiol Clin 2002; 40:63-76. [PMID: 11897936 DOI: 10.1097/00004311-200204000-00007] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- Michael W Russell
- Department of Anesthesia, University of Pennsylvania, Philadelphia 19104, USA
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Abstract
OBJECTIVE This technical report describes the procedures involved in developing the recommendations of the Subcommittee on Obstructive Sleep Apnea Syndrome in children. The group of primary interest for this report was otherwise healthy children older than 1 year who might have adenotonsillar hypertrophy or obesity as underlying risk factors of obstructive sleep apnea syndrome (OSAS). The goals of the committee were to enhance the primary care clinician's ability to recognize OSAS, identify the most appropriate procedure for diagnosis of OSAS, identify risks associated with pediatric OSAS, and evaluate management options for OSAS. METHODS A literature search was initially conducted for the years 1966-1999 and then updated to include 2000. The search was limited to English language literature concerning children older than 2 and younger than 18 years. Titles and abstracts were reviewed for relevance, and committee members reviewed in detail any possibly appropriate articles to determine eligibility for inclusion. Additional articles were obtained by a review of literature and committee members' files. Committee members compiled evidence tables and met to review and discuss the literature that was collected. RESULTS A total of 2115 titles were reviewed, of which 113 provided relevant original data for analysis. These articles were mainly case series and cross-sectional studies; overall, very few methodologically strong cohort studies or randomized, controlled trials concerning OSAS have been published. In addition, a minority of studies satisfactorily differentiated primary snoring from true OSAS. Reports of the prevalence of habitual snoring in children ranged from 3.2% to 12.1%, and estimates of OSAS ranged from 0.7% to 10.3%; these studies were too heterogeneous for data pooling. Children with sleep-disordered breathing are at increased risk for hyperactivity and learning problems. The combined odds ratio for neurobehavioral abnormalities in snoring children compared with controls is 2.93 (95% confidence interval: 2.23-3.83). A number of case series have documented decreased somatic growth in children with OSAS; right ventricular dysfunction and systemic hypertension also have been reported in children with OSAS. However, the risk growth and cardiovascular problems cannot be quantified from the published literature. Overnight polysomnography (PSG) is recognized as the gold standard for diagnosis of OSAS, and there are currently no satisfactory alternatives. The diagnostic accuracy of symptom questionnaires and other purely clinical approaches is low. Pulse oximetry appears to be specific but insensitive. Other methods, including audiotaping or videotaping and nap or home overnight PSG, remain investigational. Adenotonsillectomy is curative in 75% to 100% of children with OSAS, including those who are obese. Up to 27% of children undergoing adenotonsillectomy for OSAS have postoperative respiratory complications, but estimates are varied. Risk factors for persistent OSAS after adenotonsillectomy include continued snoring and a high apnea-hypopnea index on the preoperative PSG. CONCLUSIONS OSAS is common in children and is associated with significant sequelae. Overnight PSG is currently the only reliable diagnostic modality that can differentiate OSAS from primary snoring. However, the PSG criteria for OSAS have not been definitively validated, and it is not clear that primary snoring without PSG-defined OSAS is benign. Adenotonsillectomy is the first-line treatment for OSAS but requires careful postoperative monitoring because of the high risk of respiratory complications. Adenotonsillectomy is usually curative, but children with persistent snoring (and perhaps with severely abnormal preoperative PSG results) should have PSG repeated postoperatively.
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Litalien C, Jacqz-Aigrain E. Risks and benefits of nonsteroidal anti-inflammatory drugs in children: a comparison with paracetamol. Paediatr Drugs 2002; 3:817-58. [PMID: 11735667 DOI: 10.2165/00128072-200103110-00004] [Citation(s) in RCA: 112] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
Nonsteroidal anti-inflammatory drugs (NSAIDs) possess antipyretic, analgesic and anti-inflammatory effects. They are frequently used in children and have numerous therapeutic indications, the most common ones being fever, postoperative pain and inflammatory disorders, such as juvenile idiopathic arthritis (JIA) and Kawasaki disease. Their major mechanism of action is through inhibition of prostaglandin biosynthesis by blockade of cyclo-oxygenase (COX). The disposition of most NSAIDs has been mainly studied in infants > or = 2 years of age. Compared with adults, the volume of distribution and clearance of NSAIDs such as diclofenac, ibuprofen (infants aged between 3 months and 2.5 years), ketorolac and nimesulide were increased in children. The elimination half-life was similar in children to that in adults. These pharmacokinetic differences might be clinically significant with the need for higher loading and/or maintenance doses in children. Ibuprofen, acetylsalicylic acid (ASA) and acetaminophen are the most frequently used agents for fever reduction in children. Over the past 20 years, because of the association between ASA use and Reye's syndrome, most of the interest has been directed toward ibuprofen and acetaminophen. In view of its comparable antipyretic efficacy, but superior tolerability profile, acetaminophen, when used appropriately with age-adapted formulations, should remain the first-line therapy in the treatment of childhood fever. At the moment, there is no scientific evidence to recommend simultaneous use of these two antipyretic drugs. Most NSAIDs provide mild to moderate analgesia, with the exception of ketorolac which has a strong analgesic activity. The analgesic efficacy of ketorolac, ketoprofen, diclofenac and ibuprofen in the treatment of postoperative pain has been mainly studied following a single dose, in children of > or = 1 year of age undergoing minor surgeries. In this setting, when used either alone or in adjunct to caudal or epidural anaesthesia, they were associated with an opioid-sparing effect and were well tolerated. With the exception of ketorolac use in children undergoing tonsillectomy, where controversy exists regarding the risk of postoperative haemorrhage, NSAIDs have not been associated with an increased risk of perioperative bleeding. NSAIDs are the first-line therapy in JIA. They appear to be equally effective and tolerated, with the exception of ASA which is associated with more adverse effects. ASA has been used for many years in the treatment of Kawasaki disease and is part of the standard modality of treatment in combination with intravenous gammaglobulins. More recently, lung inflammation associated with cystic fibrosis (CF) has become a new target for NSAIDs. Despite promising preliminary results with ibuprofen, numerous questions need to be answered before this new strategy becomes part of the conventional treatment of patients with CF. In summary, NSAIDs are effective in reducing fever, alleviating pain and reducing inflammation in children, with a good tolerance profile. Pharmacokinetic studies are needed to characterise the disposition of NSAIDs in very young infants in order to use them rationally. To date, no studies have been published on the disposition, tolerability and efficacy of specific COX-2 inhibitors in children. Further clinical experience with these agents in adults is warranted before undergoing trials with specific COX-2 inhibitors in children.
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Affiliation(s)
- C Litalien
- Service of Pharmacology, Pediatrics and Pharmacogenetics, Hospital Robert Debré, Paris, France
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Rainer TH, Jacobs P, Ng YC, Cheung NK, Tam M, Lam PK, Wong R, Cocks RA. Cost effectiveness analysis of intravenous ketorolac and morphine for treating pain after limb injury: double blind randomised controlled trial. BMJ (CLINICAL RESEARCH ED.) 2000; 321:1247-51. [PMID: 11082083 PMCID: PMC27526 DOI: 10.1136/bmj.321.7271.1247] [Citation(s) in RCA: 52] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
OBJECTIVES To investigate the cost effectiveness of intravenous ketorolac compared with intravenous morphine in relieving pain after blunt limb injury in an accident and emergency department. DESIGN Double blind, randomised, controlled study and cost consequences analysis. SETTING Emergency department of a university hospital in the New Territories of Hong Kong. PARTICIPANTS 148 adult patients with painful isolated limb injuries (limb injuries without other injuries). MAIN OUTCOME MEASURES Primary outcome measure was a cost consequences analysis comparing the use of ketorolac with morphine; secondary outcome measures were pain relief at rest and with limb movement, adverse events, patients' satisfaction, and time spent in the emergency department. RESULTS No difference was found in the median time taken to achieve pain relief at rest between the group receiving ketorolac and the group receiving morphine, but with movement the median reduction in pain score in the ketorolac group was 1.09 per hour (95% confidence interval 1.05 to 2.02) compared with 0.87 (0.84 to 1.06) in the morphine group (P=0.003). The odds of experiencing adverse events was 144.2 (41.5 to 501.6) times more likely with morphine than with ketorolac. The median time from the initial delivery of analgesia to the participant leaving the department was 20 (4.0 to 39.0) minutes shorter in the ketorolac group than in the morphine group (P=0.02). The mean cost per person was $HK44 ( pound4; $5.6) in the ketorolac group and $HK229 in the morphine group (P<0.0001). The median score for patients' satisfaction was 6.0 for ketorolac and 5.0 for morphine (P<0.0001). CONCLUSION Intravenous ketorolac is a more cost effective analgesic than intravenous morphine in the management of isolated limb injury in an emergency department in Hong Kong, and its use may be considered as the dominant strategy.
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Affiliation(s)
- T H Rainer
- Accident and Emergency Medicine Academic Unit, Chinese University of Hong Kong, Rooms G05/06, Cancer Center, Prince of Wales Hospital, Shatin, NT, Hong Kong
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Gillis JC, Brogden RN. Ketorolac. A reappraisal of its pharmacodynamic and pharmacokinetic properties and therapeutic use in pain management. Drugs 1997; 53:139-88. [PMID: 9010653 DOI: 10.2165/00003495-199753010-00012] [Citation(s) in RCA: 217] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Ketorolac is a nonsteroidal anti-inflammatory drug (NSAID) with strong analgesic activity. The analgesic efficacy of ketorolac has been extensively evaluated in the postoperative setting, in both hospital inpatients and outpatients, and in patients with various other acute pain states. After major abdominal, orthopaedic or gynaecological surgery or ambulatory laparoscopic or gynaecological procedures, ketorolac provides relief from mild to severe pain in the majority of patients and has similar analgesic efficacy to that of standard dosages of morphine and pethidine (meperidine) as well as less frequently used opioids and other NSAIDs. The analgesic effect of ketorolac may be slightly delayed but often persists for longer than that of opioids. Combined therapy with ketorolac and an opioid results in a 25 to 50% reduction in opioid requirements, and in some patients this is accompanied by a concomitant decrease in opioid-induced adverse events, more rapid return to normal gastrointestinal function and shorter stay in hospital. In children undergoing myringotomy, hernia repair, tonsillectomy, or other surgery associated with mild to moderate pain, ketorolac provides comparable analgesia to morphine, pethidine or paracetamol (acetaminophen). In the emergency department, ketorolac attenuates moderate to severe pain in patients with renal colic, migraine headache, musculoskeletal pain or sickle cell crisis and is usually as effective as frequently used opioids, such as morphine and pethidine, and other NSAIDs and analgesics. Subcutaneous administration of ketorolac reduces pain in patients with cancer and seems particularly beneficial in pain resulting from bone metastases. The acquisition cost of ketorolac is greater than that of morphine or pethidine; however, in a small number of studies, the higher cost of ketorolac was offset when treatment with ketorolac resulted in a reduced hospital stay compared with alternative opioid therapy. The tolerability profile of ketorolac parallels that of other NSAIDs; most clinically important adverse events affect the gastrointestinal tract and/or renal or haematological function. The incidence of serious or fatal adverse events reported with ketorolac has decreased since revision of dosage guidelines. Results from a large retrospective postmarketing surveillance study in more than 20,000 patients demonstrated that the overall risk of gastrointestinal or operative site bleeding related to parenteral ketorolac therapy was only slightly higher than with opioids. However, the risk increased markedly when high dosages were used for more than 5 days, especially in the elderly. Acute renal failure may occur after treatment with ketorolac but is usually reversible on drug discontinuation. In common with other NSAIDs, ketorolac has also been implicated in allergic or hypersensitivity reactions. In summary, ketorolac is a strong analgesic with a tolerability profile which resembles that of other NSAIDs. When used in accordance with current dosage guidelines, this drug provides a useful alternative, or adjuvant, to opioids in patients with moderate to severe pain.
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Affiliation(s)
- J C Gillis
- Adis International Limited, Auckland, New Zealand.
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