Analgesia review

Analgesic use and favourable patient-reported outcome measures after paediatric surgery: an analysis of registry data

BACKGROUND

Pain after paediatric appendectomy and tonsillectomy is often undertreated. Benchmarking of hospitals could reveal which measures are associated with improved patient- or parent-reported pain-related outcomes.

METHODS

A total of 898 anonymised cases from 11 European hospitals participating in PAIN OUT infant were analysed. The children completed a questionnaire on patient-reported outcomes (PROs) 24 h after surgery. According to a composite PRO measure, including pain intensity and pain-related interference, hospitals were allocated to Group I (favourable results), II (average results), and III (unfavourable results). Benchmarking of hospital groups was performed investigating process variables (dosing of non-opioid analgesics, opioids, and dexamethasone) associated with PROs, side-effects, and children's perception of care. Variables associated with PROs were analysed using multinomial regression analysis with the PRO score-related hospital group as a dependent variable (estimated odds ratios [OR], 95% confidence interval [CI]).

RESULTS

During the first 24 h after surgery, 1.2 (1.1-1.3) full daily doses of non-opioid analgesics (non-steroidal anti-inflammatory drug [NSAID], paracetamol, metamizole) were administered in group I and 0.7 (0.6-0.8) in group III (P<0.001). Intraoperative dexamethasone was administered to 70.1 and 52.6% of the children in Group I and Group III, respectively (P<0.001). A lower number of full daily doses of non-opioid analgesics: 0.22 [0.15-0.31]), less dexamethasone (0.49 [0.33-0.71]), fewer non-opioid analgesics before the end of surgery (0.37 [0.22-0.62]) and higher opioid doses were associated with hospital allocation to group III vs group I (Nagelkerke's R²=0.433).

CONCLUSIONS

The results indicated substantial deficits in the concept, application, and dosing of analgesics in paediatric patients after surgery. Timely administration of adequate analgesic doses can easily be introduced into daily clinical practice.

CLINICAL TRIAL REGISTRATION

clinicaltrials.gov NCT02083835.

In vivo drug delivery applications of nanogels: a review

In recent years, nanogels have emerged as promising drug delivery vehicles; their ability in holding active molecules, macromolecules and drugs, together with the capability to respond to external stimuli, makes them a suitable tool for a wide range of applications. These features allow nanogels to be exploited against many challenges of nanomedicine associated with different kinds of pathologies which require the use of specific drug delivery systems. In this review our aim is to give the reader an overview of the diseases that can be treated with nanogels as drug delivery systems, such as cancer, CNS disorders, cardiovascular diseases, wound healing and other diseases of human body. For all of these pathologies, biological in vivo assays can be found in the literature and in this work. We focus on the peculiarities of these nanogels, highlighting their features and their advantages in respect to conventional treatments.

Effect of Scalp Nerve Block with Ropivacaine on Postoperative Pain in Patients Undergoing Craniotomy: A Randomized, Double Blinded Study

Scalp nerve block with ropivacaine has been shown to provide perioperative analgesia. However, the best concentration of ropivacaine is still unknown for optimal analgesic effects. We performed a prospective study to evaluate the effects of scalp nerve block with varied concentration of ropivacaine on postoperative pain and intraoperative hemodynamic variables in patients undergoing craniotomy under general anesthesia. Eighty-five patients were randomly assigned to receive scalp block with either 0.2% ropivacaine, 0.33% ropivacaine, 0.5% ropivacaine, or normal saline. Intraoperative hemodynamics and post-operative pain scores at 2, 4, 6, 24 hours postoperatively were recorded. We found that scalp blockage with 0.2% and 0.33% ropivacaine provided adequate postoperative pain relief up to 2 h, while administration of 0.5% ropivacaine had a longer duration of action (up to 4 hour after craniotomy). Scalp nerve block with varied concentration of ropivacaine blunted the increase of mean arterial pressure in response to noxious stimuli during incision, drilling, and sawing skull bone. 0.2% and 0.5% ropivacaine decreased heart rate response to incision and drilling. We concluded that scalp block using 0.5% ropivacaine obtain preferable postoperative analgesia compared to lower concentrations. And scalp block with ropivacaine also reduced hemodynamic fluctuations in craniotomy operations.

Perioperative management of the child on long-term opioids

The strategies used to manage children exposed to long-term opioids are extrapolated from adult literature. Opioid consumption during the perioperative period is more than three times that observed in patients not taking chronic opioids. A sparing use of opioids in the perioperative period results in both poor pain management and withdrawal phenomena. The child's pre-existing opioid requirement should be maintained, and acute pain associated with operative procedures should be managed with additional analgesia. This usually comprises short-acting opioids, regional or local anesthesia, and adjuvant therapies. Long-acting opioids, transdermal opioid patches, and implantable pumps can be used to maintain the regular opioid requirement. Intravenous infusion, nurse controlled analgesia, patient-controlled analgesia, or oral formulations are invaluable for supplemental requirements postoperatively. Effective management requires more than simply increasing opioid dose during this time. Collaboration of the child, family, and all teams involved is necessary. While chronic pain or palliative care teams and other staff experienced with the care of children suffering chronic pain may have helpful input, many pediatric hospitals do not have chronic pain teams, and many patients receiving long-term opioids are not palliative. Acute pain services are appropriate to deal with those on long-term opioids in the perioperative setting and do so successfully in many centers. Staff caring for such children in the perioperative period should be aware of the challenges these children face and be educated before surgery about strategies for postoperative management and discharge planning.

Anesthesia in children with asthma and rhinitis

The incidence of asthma is increasing worldwide, but morbidity and mortality are decreasing, because of improvements in medical care. Although the incidence of severe perioperative bronchospasm is relatively low in asthmatics undergoing anaesthesia, when it does occur it may be life-threatening. Preoperative assessment of asthma should include a specialized medical hystory and physical examination as well as pulmonary function testing. Potential trigger agents should be identified and avoided. In many asthmatic patients treatment with systemic corticosteroids and bronchodilators is indicated to prevent the inflammation and bronchocostriction associated with endotracheal intubation. Nonetheless, acute bronchospasm can still occur, especially at induction and emergence, and should be promptly and methodically managed.

Clinical modifications induced by drugs during the perioperative period

Total intravenous anesthesia (TIVA) can be defined as a technique in which general anesthesia is induced and maintained using only intravenous agents. TIVA has become more popular in recent times because of the pharmacokinetic and pharmacodynamic properties of propofol, the availability of short acting synthetic opioids, and the development of delivery systems. Significant differences in anatomy and physiology in adults and children and special needs of younger patients have important consequences on many aspects of anesthesia. Airway and respiratory complications are the most common causes of morbidity during general anesthesia in children. Knowledge of the functional anatomy of airways in children forms the basis in the understanding of the pathological conditions that may occur.

Pharmacotherapy for acute pain in children: current practice and recent advances

INTRODUCTION

Acute pain in children may be undertreated. Improved understanding of developmental neurobiology and paediatric pharmacokinetics should facilitate better management of pharmacotherapy. The objective of this review is to discuss current paediatric practice and recent advances with these analgesic agents by using an evidence-based approach.

AREAS COVERED

Using PubMed an extensive literature review was conducted on the commonly used analgesic agents in children from 2000 to April 2010.

EXPERT OPINION

A multimodal analgesic regimen provides better pain control and functional outcome in children. The choice of pharmacological treatment is determined by the severity and type of pain. However, more research and evidence is required to determine the optimal drug combinations.

[Paediatric anaesthesia]

BACKGROUND

Paediatric anaesthesia comprises newborn, infants and children, necessitating a variety of techniques and approaches.

MATERIAL AND METHODS

This review is based on textbooks in paediatric anaesthesia, papers from major anaesthetic journals and many years of clinical experience.

RESULTS

Only a few Norwegian university hospitals have full-time paediatric anaesthesiologists. Anaesthesia in infants is associated with a higher frequency of morbidity and mortality than in adults; laryngospasm and emergency delirium are more common. Calculation of the amount of intravenous fluid and medication doses must be based on weight. Techniques such as mask inhalation for induction and caudal regional anaesthesia are used more frequently in children. Disease and congenital malformations can lead to anaesthetic problems. It is therefore important for the anaesthesiologist to have all available information preoperatively.

INTERPRETATION

Paediatric anaesthesia presents special challenges. Safe practice requires experience and knowledge of age-related anatomy, physiology and pathology.