Paediatric day-case anaesthesia and pain control

Adherence to Swedish guidelines for pain treatment in relation to pediatric tonsil surgery: A survey of the multidisciplinary team

BACKGROUND

Pain management in children after tonsil surgery is essential, and optimal pain treatment has been discussed for many years. Data from the National Tonsil Register in Sweden (NTRS) and a national mapping have demonstrated the need for national pain treatment guidelines for pediatric tonsil surgery. As a result, Swedish national guidelines, together with updated patient information on the website tonsilloperation.se, were developed and implemented in 2013.

OBJECTIVES

The objective of this study was to evaluate the professionals' opinions of and adherence to pain treatment guidelines for pediatric tonsil surgery patients in a two-year follow-up.

METHOD

This descriptive cross-sectional study was based on data from an inter-professional questionnaire, which was validated by an expert group using a content validity index (S-CVI 0.93). The questionnaire was sent to all Swedish ear, nose and throat (ENT) departments (n = 49) that the NTRS identified as performing tonsil surgery on children younger than 18 years of age. In each clinic, we asked for responses from staff in each of the following professions: ENT physicians, anesthesia physicians, registered nurse anesthetists, and registered nurses in the ENT departments.

RESULTS

Respondents from 48 ENT departments participated, and 139/163 (85%) completed questionnaires were returned. The guidelines were reported as being clear, ensuring patient safety and providing optimal pharmacological treatment. Treatment was given according to the guidelines: Half of the departments gave pre- or intraoperative treatment with clonidine, betamethasone and high-dose paracetamol (acetaminophen). A multimodal pain approach (paracetamol and COX-inhibitors) after hospital discharge was prescribed by all departments after tonsillectomy and, extensively, after tonsillotomy. One-third of the departments prescribed paracetamol with a higher normal dose for the first three postoperative days. Half of the departments prescribed rescue analgesics, clonidine or opioids after tonsillectomy. None of the departments prescribed codeine or tramadol, drugs that are discouraged in the guidelines. The majority of the departments used the website tonsilloperation.se to provide information to the patients and their caregivers.

CONCLUSION

The respondents' opinions of and the ENT departments adherence to the Swedish national guidelines were considered to be good. The national implementation process in Sweden has impacted the manner in which ENT departments treat pain after tonsil surgery.

The analgesic effects of rectal diclofenac versus rectal paracetamol following caudal-bupivacaine for pediatric day-case inguinal herniotomies: a randomized controlled prospective trial

BACKGROUND

Postoperative pain is a common complaint in day-case inguinal herniotomy, thus there is a need to provide effective analgesia. This study compared the postoperative analgesic effects of the combinations of caudal-bupivacaine and rectal diclofenac with caudal-bupivacaine and rectal-paracetamol in children scheduled for daycase inguinal-herniotomy.

METHODS

Ninety children of ASA I scheduled for elective day-case inguinal-herniotomy were randomly assigned into Group A (1ml/kg of 0.25% caudal-bupivacaine and 1mg/kg rectal-diclofenac), Group B (1ml/kg of 0.25% caudal-bupivacaine and 30mg/kg rectal paracetamol) and Group C (1ml/kg of 0.25% caudal-bupivacaine). The duration of analgesia, pain scores, postoperative analgesic consumption and side effects were assessed and recorded. Data collected was analyzed with the statistical package for social sciences 17 for windows.

RESULTS

Eighty-seven children completed the study, and it was found that the duration of analgesia was prolonged in Group A compared to Groups B and C (p<0.01).

CONCLUSION

Caudal-bupivacaine and rectal-diclofenac combination provides a more prolonged postoperative analgesia, and lower pain score compared to caudal-bupivacaine and rectal-paracetamol combination or caudal-bupivacaine alone.

LEVEL OF EVIDENCE

Level 1 evidence treatment study. Randomized controlled trials with adequate statistical power to detect differences (narrow confidence intervals) and follow up >80%.

Swedish guidelines for the treatment of pain in tonsil surgery in pediatric patients up to 18 years

BACKGROUND

Surgery of the tonsils often causes severe pain lasting for many days as been shown by data from the National Tonsil Surgery Register in Sweden. Tonsillotomy is associated with fewer readmissions due to bleeding, number of days requiring analgesics and health care contacts due to pain compared to tonsillectomy. The register data demonstrate the necessity of better-evidenced based pain treatment guidelines for tonsil-surgery.

OBJECTIVES

To develop evidenced based pain treatment guidelines for tonsil-surgery in Sweden.

METHODS

The evidence based guidelines were designed by an updated literature review and from the clinical expertise in the pediatric pain field, which thereafter were reviewed by ENT-doctors and anesthetists from each ENT-clinic in Sweden.

RESULTS

A multimodal pain treatment approach is advocated, including premedication and administration during anesthesia, with paracetamol (acetaminophen), clonidine and betamethasone. If not given as a premedication the combination can be administered intravenously in the initial phase of anesthesia. At the end of surgery, if no bleeding problems, cox-inhibitors can be given. After discharge from hospital, the recommendations for pain relief are paracetamol combined with cox-inhibitors (ibuprofen, diclofenac) and if needed oral clonidine in favor of opioids. When pain intensity decreases, discontinue the analgesic treatment in the following order: opioid, clonidine, paracetamol and at last ibuprofen. The need for analgesic treatment after tonsillectomy is usually 5-8 days, after tonsillotomy only 3-5 days. Parents are recommended to contact the hospital if the child has difficulties in drinking or eating adequately and/or suffers from pain despite taking the recommended medication regularly.

CONCLUSIONS

Swedish guidelines for tonsil-surgery provide practical evidence-based pain treatment recommendations.

Pain in children--are we accomplishing the optimal pain treatment?

Morphine, paracetamol and local anesthetics have for a long time been the foremost used analgesics in the pediatric patient by tradition but not always enough effective and associated with side effects. The purpose with this article is to propose alternative approaches in pain management, not always supported up by substantial scientific work but from a combination of science and clinical experience in the field. The scientific literature has been reviewed in parts regarding different aspects of pain assessment and analgesics used for treatment of diverse pain conditions with focus on procedural and acute pain. Clinical experience has been added to form the suggested improvements in accomplishing an improved pain management in pediatric patients. The aim with pain management in children should be a tailored analgesic medication with an individual acceptable pain level and optimal degree of mobilization with as little side effects as possible. Simple techniques of pain control are as effective as and complex techniques in pediatrics but the technique used is not of the highest importance in achieving a good pain management. Increased interest and improved education of the doctors prescribing analgesics is important in accomplishing a better pain management. The optimal treatment with analgesics is depending on the analysis of pain origin and analgesics used should be adjusted thereafter. A multimodal treatment regime is advocated for optimal analgesic effect.

Intravenous versus inhalational anaesthesia for paediatric outpatient surgery

BACKGROUND

Ambulatory or outpatient anaesthesia is performed in patients who are discharged on the same day as their surgery. Perioperative complications such as postoperative nausea and vomiting (PONV), postoperative behavioural disturbances and cardiorespiratory complications should be minimized in ambulatory anaesthesia. The choice of anaesthetic agents and techniques can influence the occurrence of these complications and thus delay in discharge.

OBJECTIVES

The objective of this review was to evaluate the risk of complications (the risk of postoperative nausea and vomiting (PONV), admission or readmission to hospital, postoperative behavioural disturbances and perioperative respiratory and cardiovascular complications) and recovery times (time to discharge from recovery ward and time to discharge from hospital) comparing the use of intravenous to inhalational anaesthesia for paediatric outpatient surgery.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library (2013, Issue 8); MEDLINE (1948 to 1 October 2013); EMBASE (1974 to 1 October 2013); Literatura Latino-Americana e do Caribe em Ciências da Saúde (LILACS) (1982 to 1 October 2013). We also handsearched relevant journals and searched the reference lists of the articles identified.

SELECTION CRITERIA

We included randomized controlled trials comparing paediatric outpatient surgery using intravenous versus inhalational anaesthesia.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trial quality and extracted the data. When necessary, we requested additional information and clarification of published data from the authors of individual trials.

MAIN RESULTS

We included 16 trials that involved 900 children in this review. Half of all the studies did not describe the generation of randomized sequence and most studies did not describe adequate allocation sequence concealment. The included studies showed variability in the types and combinations of drugs and the duration of anaesthesia, limiting the meta-analysis and interpretation of the results.For the induction and maintenance of anaesthesia there was a significant difference favouring intravenous anaesthesia with propofol; the incidence of PONV was 32.6% for sevoflurane and 16.1% for propofol (odds ratio (OR) 2.96; 95% confidence interval (CI) 1.35 to 6.49, four studies, 176 children, low quality evidence). The risk of postoperative behavioural disturbances also favoured intravenous anaesthesiaas the incidence was 24.7% for sevoflurane and 11.5% for propofol (OR 2.67; 95% CI 1.14 to 6.23, four studies, 176 children, very low quality evidence). There were no differences between groups in the risk of intraoperative and postoperative respiratory and cardiovascular complications (OR 0.75; 95% CI 0.27 to 2.13, three studies,130 children, very low quality evidence) and there was no difference in the time to recovery from anaesthesia and discharge from hospital. These results should be interpreted with caution due to heterogeneity between studies in the type and duration of operations, types of reported complications and the high risk of bias in almost all studies. Two studies (105 participants) compared halothane to propofol and showed heterogeneity in duration of anaesthesia and in the type of ambulatory procedure. For the risk of PONV the results of the studies were conflicting, and for the risks of intraoperative and postoperative complications there were no significant differences between the groups.For the maintenance of anaesthesia there was a significant difference favouring anaesthesia with propofol, with or without nitrous oxide (N2O), when compared to thiopentone and halothane + N2O (OR 3.23; 95% CI 1.49 to 7.02, four studies, 176 children, low quality evidence; and OR 7.44; 95% CI 2.60 to 21.26, two studies, 87 children, low quality evidence), respectively. For the time to discharge from the recovery room, there were no significant differences between groups. The studies were performed with different ambulatory surgeries and a high risk of bias.Four studies (250 participants) compared the induction of anaesthesia by the inhalational or intravenous route, with inhalational anaesthesia for maintenance, and found no significant differences between groups in all outcomes (the risk of PONV, behavioural disturbances, respiratory and cardiovascular complications and time to discharge from recovery room). Meta-analysis was not done in this comparison because of significant clinical heterogeneity.Readmission to hospital was not reported in any of the included studies. No other adverse effects were reported.

AUTHORS' CONCLUSIONS

There is insufficient evidence to determine whether intravenous anaesthesia with propofol for induction and maintenance of anaesthesia in paediatric outpatients undergoing surgery reduces the risk of postoperative nausea and vomiting and the risk of behavioural disturbances compared with inhaled anaesthesia. This evidence is of poor quality. More high-quality studies are needed to compare the different types of anaesthesia in different subsets of children undergoing ambulatory surgery.

Efficacy and safety of intraoperative dexmedetomidine for acute postoperative pain in children: a meta-analysis of randomized controlled trials

BACKGROUND

Aim of the current meta-analysis was to assess the effects of intraoperative dexmedetomidine on postoperative pain, analgesic consumption, and adverse events in comparison with placebo or opioids in children undergoing surgery.

METHODS

This meta-analysis was performed according to the recommendations of the PRISMA statement and the Cochrane collaboration. For dichotomous and continuous outcomes of efficacy and adverse events, the Revman(®) (The Nordic Cochrane Centre, Copenhagen, Denmark) statistical software was used to calculate relative risk (RR), mean difference (MD), and 95% confidence intervals (CI).

RESULTS

We included 11 randomized controlled trials - 434 children received dexmedetomidine, 440 received control. In comparison with placebo, children receiving dexmedetomidine showed a reduced RR for postoperative opioids (0.4; 95% CI: 0.26-0.62; P < 0.00001) and postoperative pain (0.51; 95% CI: 0.32-0.81; P = 0.004). Similar results were obtained for the comparison with intraoperative opioids: reduced RR for postoperative pain (0.49; 95% CI: 0.25-0.94; P = 0.03) and the need for postoperative opioids (0.77; 95% CI: 0.60-1.09; P = 0.05).

CONCLUSIONS

This meta-analysis revealed a lower risk for postoperative pain and the need for postoperative opioids following intraoperative dexmedetomidine in comparison with placebo or opioids in children undergoing surgery; however, the influence of dexmedetomidine on postoperative opioid consumption is less clear. Although there were only a limited number of adverse events, further studies focusing on procedure specific dexmedetomidine dosing and adverse events are urgently needed.

Day surgery for major paediatric foot and ankle procedures

PURPOSE

To review outcomes in 19 children who underwent major foot and ankle procedures as day cases.

METHODS

A consecutive series of 24 major foot and ankle procedures in 19 children performed as day cases by a single surgeon were reviewed in terms of the immediate postoperative pain relief, severe swelling (necessitating cast removal), and complications. Parental satisfaction was assessed using a telephone survey with respect to pain relief of the patients, and their views on management as day cases.

RESULTS

The 24 procedures comprised tendon transfers (n=18), posterior releases (n=3), and excisions of a tarsal coalition (n=3). During the post-discharge 24 hours, no patient developed complications that entailed hospital services. All parents of the patients were satisfied with the overall service provided. The analgesia prescribed at discharge was sufficient to control pain in 20 out of the 22 procedures. In the remaining 2 procedures (under caudal and general anaesthesia), the parents considered the analgesia insufficient, but did not contact the helpline for advice. One child bled through the bandages to a minor extent.

CONCLUSION

Some major paediatric foot and ankle procedures can be safely performed as day cases and achieved adequate analgesia with appropriate advice. More such procedures can be added to the day case list, even on an afternoon list.

Anesthesia and perioperative medical management of children with spinal muscular atrophy

OBJECTIVE

To describe the perioperative medical care, anesthetic considerations, and the risk of postanesthetic respiratory failure in patients with pediatric spinal muscular atrophy (SMA).

METHODS

There is a retrospective chart review carried out at an urban, tertiary care pediatric hospital. All patients with ICD-9 codes corresponding to SMA diagnoses were identified, and records screened for anesthetic and perioperative medical management. Medical records were reviewed for demographic, clinical, and outcome data.

MAIN RESULTS

Twenty-five children with SMA (10 type I, 8 type II, 7 type III) accounted for 56 general and regional anesthetic cases. Twenty-one (38%) cases had preexisting ventilator dependence. Total intravenous anesthesia with nitrous oxide was provided in 14 (25%) cases, balanced anesthesia with inhalational agents and epidural or systemic opioids were used in 41 (84%) cases, and one infant received a spinal anesthesia. Intraoperative and postoperative complications occurred in 2 (4%) and 2 (4%) cases respectively. One case required an unplanned postanesthetic intensive care unit admission, and there were two late deaths with redirection of care.

CONCLUSIONS

Perioperative care can be provided for children with SMA safely and effectively with total intravenous or inhaled anesthetics along with the judicious use of opioids to improve patient comfort without increased morbidity. Further prospective studies of standardized anesthetic and perioperative respiratory medical management in this population are required to minimize the decompensation of tenuous preoperative respiratory function.

[Therapy of perioperative pain in pediatric urology]

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.

Intra-operative local anaesthesia to reduce postoperative pain or distress in children after exodontia under general anaesthesia

DESIGN

A randomised controlled trial (RCT).

INTERVENTION

The appropriate drugs and dosage, namely 2 ml of 2% lidocaine with 1:200 000 epinephrine (adrenaline), or placebo of 2 ml of 0.9% sodium chloride, were administered by buccal infiltration injection adjacent to the teeth to be removed, after induction of general anaesthesia (GA).

OUTCOME MEASURE

Pain scores were recorded pre-operatively and after treatment upon waking, after 30 min and after 24 h; distress scores were recorded pre-operatively, upon waking and after 30 min following treatment. Lip and cheek biting injuries were also recorded.

RESULTS

One hundred and forty-two children were recruited to the study and randomly allocated to one of the two groups. Data were incomplete for three children. There were no statistically significant differences between the mean pain scores for the local anaesthetic and placebo group pre-operatively, on waking from the GA, at 30 min postoperatively or after 24 h. There were statistically significant increases in pain in both groups from pre-operative levels, with 13% of treatment and 12% of control patients recording severe pain and 13% of treatment and 10% of control patients recording very severe pain. These rates were similar at 30 min but reduced at 24 h following treatment. Lip or cheek biting injuries occurred in one control and three treatment patients.

CONCLUSIONS

Intra-operative local anaesthesia has been found to be effective for pain control following a range of other surgical procedures, but we did not find it to be effective in reducing postoperative pain or distress in children after oral surgery.