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Batool M, Cai CL, Aranda JV, Hand I, Beharry KD. Early versus late caffeine and/or non-steroidal anti-inflammatory drugs (NSAIDS) for prevention of intermittent hypoxia-induced neuroinflammation in the neonatal rat. Int J Dev Neurosci 2024; 84:227-250. [PMID: 38459740 DOI: 10.1002/jdn.10321] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2023] [Revised: 01/17/2024] [Accepted: 02/13/2024] [Indexed: 03/10/2024] Open
Abstract
Preterm infants often experience frequent intermittent hypoxia (IH) episodes which are associated with neuroinflammation. We tested the hypotheses that early caffeine and/or non-steroidal inflammatory drugs (NSAIDs) confer superior therapeutic benefits for protection against IH-induced neuroinflammation than late treatment. Newborn rats were exposed to IH or hyperoxia (50% O2) from birth (P0) to P14. For early treatment, the pups were administered: 1) daily caffeine (Caff) citrate (Cafcit, 20 mg/kg IP loading on P0, followed by 5 mg/kg from P1-P14); 2) ketorolac (Keto) topical ocular solution in both eyes from P0 to P14; 3) ibuprofen (Ibu, Neoprofen, 10 mg/kg loading dose on P0 followed by 5 mg/kg/day on P1 and P2); 4) Caff+Keto co-treatment; 5) Caff+Ibu co-treatment; or 6) equivalent volume saline (Sal). On P14, animals were placed in room air (RA) with no further treatment until P21. For late treatment, pups were exposed from P0 to P14, then placed in RA during which they received similar treatments from P15-P21 (Sal, Caff, and/or Keto), or P15-P17 (Ibu). RA controls were similarly treated. At P21, whole brains were assessed for histopathology, apoptosis, myelination, and biomarkers of inflammation. IH caused significant brain injury and hemorrhage, inflammation, reduced myelination, and apoptosis. Early treatment with Caff alone or in combination with NSAIDs conferred better neuroprotection against IH-induced damage than late treatment. Early postnatal treatment during a critical time of brain development, may be preferable for the prevention of IH-induced brain injury in preterm infants.
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Affiliation(s)
- Myra Batool
- Department of Pediatrics, Division of Neonatal-Perinatal Medicine, State University of New York, Downstate Health Sciences University, Brooklyn, NY, USA
| | - Charles L Cai
- Department of Pediatrics, Division of Neonatal-Perinatal Medicine, State University of New York, Downstate Health Sciences University, Brooklyn, NY, USA
| | - Jacob V Aranda
- Department of Pediatrics, Division of Neonatal-Perinatal Medicine, State University of New York, Downstate Health Sciences University, Brooklyn, NY, USA
- Department of Ophthalmology, State University of New York, Downstate Health Sciences University, Brooklyn, NY, USA
| | - Ivan Hand
- Department of Pediatrics, Division of Neonatal-Perinatal Medicine, New York City Health & Hospitals/Kings County, Brooklyn, NY, USA
| | - Kay D Beharry
- Department of Pediatrics, Division of Neonatal-Perinatal Medicine, State University of New York, Downstate Health Sciences University, Brooklyn, NY, USA
- Department of Ophthalmology, State University of New York, Downstate Health Sciences University, Brooklyn, NY, USA
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Kiskaddon AL, Goldenberg NA, Abel T, Fierstein JL, Khayat D, Quintessenza JA, Stock AC. Ketorolac Dosing and Outcomes in Neonates Following Congenital Heart Surgery: A Retrospective Analysis. Crit Care Explor 2024; 6:e1078. [PMID: 38633134 PMCID: PMC11023609 DOI: 10.1097/cce.0000000000001078] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/19/2024] Open
Abstract
BACKGROUND Pain management is essential for postoperative surgery. Given the association of opioids with adverse outcomes, interest in the use of nonopioid analgesics, such as ketorolac, has increased. Published data on use in neonates are limited. OBJECTIVES To describe ketorolac dosing and safety and efficacy outcomes in the first 48 hours postcardiac surgery in neonates. DESIGN We performed a single-center retrospective cohort study of neonates (ages < 28 d) who received ketorolac following cardiac surgery from November 2020 to July 2023 (inclusive). The primary safety outcome was a clinically significant decline in renal function, as defined by the composite of an increase in serum creatinine by greater than or equal to 0.3 mg/dL from baseline within 96 hours of ketorolac initiation and urine output less than or equal to 0.5 mL/kg/hr for 6 hours. The secondary safety outcome was clinically significant bleeding, defined as the composite of major bleeding by the International Society on Thrombosis and Hemostasis pediatric criteria and severe/fatal bleeding by the criteria of Nellis et al (2019). Efficacy was measured by opioid utilization based on a standardized pain score-driven analgesia protocol. INTERVENTIONS Ketorolac was administered at 0.5 mg/kg every 6 hours as per an institutional clinical management algorithm. MEASUREMENTS AND MAIN RESULTS Thirty-nine patients met the eligibility criteria. The median ketorolac dose was 0.5 mg/kg/dose, and median (interquartile range [IQR]) duration of therapy was 48 hours (6-48 hr). No patients experienced a significant decline in renal function, and there were no clinically significant bleeding events. The median (IQR) IV morphine milligram equivalents (MMEs)/kg/d of opioid administration was 0.2 MME/kg/d (0.1-0.25 MME/kg/d) at the time of ketorolac initiation and 0.1 MME/kg/d (0.1-0.2 MME/kg/d) at 48 hours post-ketorolac initiation. CONCLUSIONS If validated prospectively, these findings suggest that a ketorolac regimen of 0.5 mg/kg/dose every 6 hours in neonates postcardiac surgery may be safe with regard to renal function and bleeding risk. Additional randomized studies would be needed to determine efficacy with regard to opioid-sparing capacity.
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Affiliation(s)
- Amy L Kiskaddon
- Department of Pharmacy, Johns Hopkins All Children's Hospital, St. Petersburg, FL
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD
- Institute for Clinical and Translational Research, Johns Hopkins All Children's Hospital, St. Petersburg, FL
- Heart Institute, Johns Hopkins All Children's Hospital, St. Petersburg, FL
| | - Neil A Goldenberg
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD
- Institute for Clinical and Translational Research, Johns Hopkins All Children's Hospital, St. Petersburg, FL
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
- Cancer and Blood Disorders Institute, Johns Hopkins All Children's Hospital, St. Petersburg, FL
| | - Trent Abel
- Department of Pharmacy, Johns Hopkins All Children's Hospital, St. Petersburg, FL
| | - Jamie L Fierstein
- Epidemiology and Biostatistics Shared Resource, Institute for Clinical and Translational Research, Johns Hopkins All Children's Hospital, St. Petersburg, FL
| | - Delia Khayat
- University of Florida College of Pharmacy, Gainesville, FL
| | | | - Arabela C Stock
- Heart Institute, Johns Hopkins All Children's Hospital, St. Petersburg, FL
- Division of Cardiac Critical Care, Heart Institute, Johns Hopkins All Children's Hospital, St. Petersburg, FL
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Persad E, Pizarro AB, Bruschettini M. Non-opioid analgesics for procedural pain in neonates. Cochrane Database Syst Rev 2023; 4:CD015179. [PMID: 37014033 PMCID: PMC10083513 DOI: 10.1002/14651858.cd015179.pub2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/05/2023]
Abstract
BACKGROUND Neonates are an extremely vulnerable patient population, with 6% to 9% admitted to the neonatal intensive care unit (NICU) following birth. Neonates admitted to the NICU will undergo multiple painful procedures per day throughout their stay. There is increasing evidence that frequent and repetitive exposure to painful stimuli is associated with poorer outcomes later in life. To date, a wide variety of pain control mechanisms have been developed and implemented to address procedural pain in neonates. This review focused on non-opioid analgesics, specifically non-steroidal anti-inflammatory drugs (NSAIDs) and N-methyl-D-aspartate (NMDA) receptor antagonists, which alleviate pain through inhibiting cellular pathways to achieve analgesia. The analgesics considered in this review show potential for pain relief in clinical practice; however, an evidence summation compiling the individual drugs they comprise and outlining the benefits and harms of their administration is lacking. We therefore sought to summarize the evidence on the level of pain experienced by neonates both during and following procedures; relevant drug-related adverse events, namely episodes of apnea, desaturation, bradycardia, and hypotension; and the effects of combinations of drugs. As the field of neonatal procedural pain management is constantly evolving, this review aimed to ascertain the scope of non-opioid analgesics for neonatal procedural pain to provide an overview of the options available to better inform evidence-based clinical practice. OBJECTIVES: To determine the effects of non-opioid analgesics in neonates (term or preterm) exposed to procedural pain compared to placebo or no drug, non-pharmacological intervention, other analgesics, or different routes of administration. SEARCH METHODS We searched the Cochrane Library (CENTRAL), PubMed, Embase, and two trial registries in June 2022. We screened the reference lists of included studies for studies not identified by the database searches. SELECTION CRITERIA We included all randomized controlled trials (RCTs), quasi-RCTs, and cluster-RCTs in neonates (term or preterm) undergoing painful procedures comparing NSAIDs and NMDA receptor antagonists to placebo or no drug, non-pharmacological intervention, other analgesics, or different routes of administration. DATA COLLECTION AND ANALYSIS: We used standard Cochrane methods. Our main outcomes were pain assessed during the procedure and up to 10 minutes after the procedure with a validated scale; episodes of bradycardia; episodes of apnea; and hypotension requiring medical therapy. MAIN RESULTS We included two RCTs involving a total of 269 neonates conducted in Nigeria and India. NMDA receptor antagonists versus no treatment, placebo, oral sweet solution, or non-pharmacological intervention One RCT evaluated using oral ketamine (10 mg/kg body weight) versus sugar syrup (66.7% w/w at 1 mL/kg body weight) for neonatal circumcision. The evidence is very uncertain about the effect of ketamine on pain score during the procedure, assessed with the Neonatal Infant Pain Scale (NIPS), compared with placebo (mean difference (MD) -0.95, 95% confidence interval (CI) -1.32 to -0.58; 1 RCT; 145 participants; very low-certainty evidence). No other outcomes of interest were reported on. Head-to-head comparison of different analgesics One RCT evaluated using intravenous fentanyl versus intravenous ketamine during laser photocoagulation for retinopathy of prematurity. Neonates receiving ketamine followed an initial regimen (0.5 mg/kg bolus 1 minute before procedure) or a revised regimen (additional intermittent bolus doses of 0.5 mg/kg every 10 minutes up to a maximum of 2 mg/kg), while those receiving fentanyl followed either an initial regimen (2 μg/kg over 5 minutes, 15 minutes before the procedure, followed by 1 μg/kg/hour as a continuous infusion) or a revised regimen (titration of 0.5 μg/kg/hour every 15 minutes to a maximum of 3 μg/kg/hour). The evidence is very uncertain about the effect of ketamine compared with fentanyl on pain score assessed with the Premature Infant Pain Profile-Revised (PIPP-R) scores during the procedure (MD 0.98, 95% CI 0.75 to 1.20; 1 RCT; 124 participants; very low-certainty evidence); on episodes of apnea occurring during the procedure (risk ratio (RR) 0.31, 95% CI 0.08 to 1.18; risk difference (RD) -0.09, 95% CI -0.19 to 0.00; 1 study; 124 infants; very low-certainty evidence); and on hypotension requiring medical therapy occurring during the procedure (RR 5.53, 95% CI 0.27 to 112.30; RD 0.03, 95% CI -0.03 to 0.10; 1 study; 124 infants; very low-certainty evidence). The included study did not report pain score assessed up to 10 minutes after the procedure or episodes of bradycardia occurring during the procedure. We did not identify any studies comparing NSAIDs versus no treatment, placebo, oral sweet solution, or non-pharmacological intervention or different routes of administration of the same analgesics. We identified three studies awaiting classification. AUTHORS' CONCLUSIONS: The two small included studies comparing ketamine versus either placebo or fentanyl, with very low-certainty evidence, rendered us unable to draw meaningful conclusions. The evidence is very uncertain about the effect of ketamine on pain score during the procedure compared with placebo or fentanyl. We found no evidence on NSAIDs or studies comparing different routes of administration. Future research should prioritize large studies evaluating non-opioid analgesics in this population. As the studies included in this review suggest potential positive effects of ketamine administration, studies evaluating ketamine are of interest. Furthermore, as we identified no studies on NSAIDs, which are widely used in older infants, or comparing different routes of administration, such studies should be a priority going forward.
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Affiliation(s)
- Emma Persad
- Cochrane Austria, Department for Evidence-based Medicine and Evaluation, Danube University Krems, Krems, Austria
| | | | - Matteo Bruschettini
- Paediatrics, Department of Clinical Sciences Lund, Lund University, Skåne University Hospital, Lund, Sweden
- Cochrane Sweden, Department of Research and Education, Lund University, Skåne University Hospital, Lund, Sweden
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Persad E, Pizarro AB, Alarcon-Ruiz C, Bruschettini M. Non-opioid analgesics for procedural pain in neonates. Hippokratia 2022. [DOI: 10.1002/14651858.cd015179] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Emma Persad
- Cochrane Austria, Department for Evidence-based Medicine and Evaluation; Danube University Krems; Krems Austria
| | | | - Christoper Alarcon-Ruiz
- Unidad de Investigación para la Generación y Síntesis de Evidencias en Salud; Universidad San Ignacio de Loyola; Lima Peru
| | - Matteo Bruschettini
- Department of Clinical Sciences Lund, Paediatrics; Lund University, Skåne University Hospital; Lund Sweden
- Cochrane Sweden; Lund University, Skåne University Hospital; Lund Sweden
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Continuous epidural chloroprocaine after abdominal surgery is associated with lower postoperative opioid exposure in NICU infants. J Pediatr Surg 2022; 57:683-689. [PMID: 34154813 DOI: 10.1016/j.jpedsurg.2021.05.015] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2021] [Revised: 04/27/2021] [Accepted: 05/17/2021] [Indexed: 11/20/2022]
Abstract
BACKGROUND Epidural anesthesia in infants undergoing open abdominal surgery has the potential to reduce opioid consumption, lower pain scores, and expedite tracheal extubation. We evaluated associations between use of continuous epidural chloroprocaine and improved intra- and post-operative outcomes. METHODS This matched retrospective cohort study first identified 24 patients who between April 2018 through December 2019 were treated with a caudal catheter and epidural chloroprocaine infusion for a laparotomy at postnatal age of 6 months or less. A matched comparator group of 24 patients was derived based on age and type of surgery. Exclusion criteria were the presence of a preoperative opioid infusion, comorbidities that would preclude appropriate pain assessment, or a recent surgical procedure. Primary outcomes included opioid consumption and pain scores; we secondarily analyzed intraoperative anesthetic requirements, other systemic analgesic use, vital signs, tracheal extubation time, and procedural times. RESULTS Treatment with epidural anesthesia was associated with lower 5-day total postoperative opioid consumption (3.2 mg/kg vs. 19.7 mg/kg in the respective epidural vs. systemic groups, p = 0.001) and time to tracheal extubation (1.3 days vs. 3.2 days, p = 0.005). Any statistically significant differences in pain scores were not clinically meaningful. There were no differences in mean arterial pressure or intraoperative inhaled anesthetic doses. CONCLUSION Continuous infusion of epidural chloroprocaine in infants following open abdominal surgery may limit exposure to systemic opioid medications while providing adequate postoperative analgesia and shortening time to tracheal extubation.
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Kaur B, Singh P. Inflammation: Biochemistry, Cellular Targets, Anti-inflammatory Agents and Challenges with Special Emphasis on Cyclooxygenase-2. Bioorg Chem 2022; 121:105663. [DOI: 10.1016/j.bioorg.2022.105663] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2021] [Revised: 01/17/2022] [Accepted: 02/05/2022] [Indexed: 12/13/2022]
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Stone SB. Ketorolac in Postoperative Neonates and Infants: A Systematic Review. J Pediatr Pharmacol Ther 2021; 26:240-247. [PMID: 33833624 DOI: 10.5863/1551-6776-26.3.240] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2020] [Accepted: 09/22/2020] [Indexed: 11/11/2022]
Abstract
OBJECTIVE To evaluate the pharmacokinetics and pharmacodynamics, dosing, efficacy, and safety of ketorolac in postoperative patients younger than 6 months of age. METHODS PubMed (1988-July 2020), Medline (1946-July 2020), and EBSCO Discovery Service (1988-July 2020) were searched to identify relevant published articles using the following search terms: ketorolac, neonate, infant. English-language articles evaluating the use of ketorolac in infants younger than 6 months of age were included. RESULTS Eight reports that included 239 infants receiving ketorolac were included. Of the included patients, 237 were younger than 6 months of age. Ketorolac exhibits rapid elimination of the analgesia-producing S (-) isomer, elimination half-life of 0.83 hours. Most patients received 0.5 mg/kg/dose every 6 hours for 48 to 72 hours. Analgesia was demonstrated by reduced use of open-label morphine and significant lowering of Neonatal/Infant Pain Scale scores. Adverse effects were minimal when ketorolac was used in term neonates and infants without baseline renal dysfunction. CONCLUSIONS Randomized placebo-controlled trials of ketorolac use in this population are lacking; however, most published reports noted efficacy and safety with ketorolac in properly selected infants.
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Donato J, Rao K, Lewis T. Pharmacology of Common Analgesic and Sedative Drugs Used in the Neonatal Intensive Care Unit. Clin Perinatol 2019; 46:673-692. [PMID: 31653302 DOI: 10.1016/j.clp.2019.08.004] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
In this review of analgesic and sedation medication in neonates, important classes of old and newer medications commonly used in the neonatal intensive care unit setting are discussed. In addition to drug metabolism, efficacy, and safety for individual drugs, new insights into multimodal analgesic approaches suggest ways in which multiple analgesic drug classes can be combined to maximize efficacy and minimize toxicity. Opiate pharmacogenetics and the potential for a precision therapeutics approach is explored, with a final description of gaps in knowledge and a call for future research of pain and sedation control in the neonatal population.
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Affiliation(s)
- Jamesia Donato
- Department of Pediatrics, Division of Neonatology, UMKC School of Medicine, Children's Mercy Hospital, 2401 Gillham Road, Kansas City, MO 64108, USA
| | - Karishma Rao
- Department of Pediatrics, Division of Neonatology, UMKC School of Medicine, Children's Mercy Hospital, 2401 Gillham Road, Kansas City, MO 64108, USA
| | - Tamorah Lewis
- Department of Pediatrics, Division of Neonatology, UMKC School of Medicine, Children's Mercy Hospital, 2401 Gillham Road, Kansas City, MO 64108, USA; Division of Clinical Pharmacology, Toxicology and Therapeutic Innovation, Department of Pediatrics, Division of Pediatric Clinical Pharmacology, UMKC School of Medicine, Children's Mercy Hospital, Kansas City, MO, USA.
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Squillaro A, Mahdi EM, Tran N, Lakshmanan A, Kim E, Kelley-Quon LI. Managing Procedural Pain in the Neonate Using an Opioid-sparing Approach. Clin Ther 2019; 41:1701-1713. [PMID: 31431300 PMCID: PMC6790974 DOI: 10.1016/j.clinthera.2019.07.014] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2019] [Revised: 07/15/2019] [Accepted: 07/16/2019] [Indexed: 12/20/2022]
Abstract
PURPOSE Pain in the neonate is often challenging to assess but important to control. Physicians often must balance the need for optimal pain control with the need to minimize oversedation and prolonged opioid use. Both inadequate pain control and overuse of opioids can have long-term consequences, including poor developmental outcomes. The aim of this review is to introduce a comprehensive approach to pain management for physicians, nurses, and surgeons caring for critically ill neonates, focusing on nonopioid alternatives to manage procedural pain. FINDINGS After review, categories of opioid-sparing interventions identified included (1) nonopioid pharmacologic agents, (2) local and regional anesthesia, and (3) nonpharmacologic alternatives. Nonopioid pharmacologic agents identified for neonatal use included acetaminophen, NSAIDs, dexmedetomidine, and gabapentin. Local and regional anesthesia included neuraxial blockade (spinals and epidurals), subcutaneous injections, and topical anesthesia. Nonpharmacologic agents uniquely available in the neonatal setting included skin-to-skin care, facilitated tucking, sucrose, breastfeeding, and nonnutritive sucking. IMPLICATIONS The use of various pharmacologic and interventional treatments for neonatal pain management allows for the incorporation of opioid-sparing techniques in neonates who are already at risk for poor neurodevelopmental outcomes. A multifactorial approach to pain control is paramount to optimize periprocedural comfort and to minimize the negative sequelae of uncontrolled pain in the neonate.
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Affiliation(s)
- Anthony Squillaro
- Division of Pediatric Surgery, Children's Hospital Los Angeles, Los Angeles, CA, USA; Department of Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, CA, USA
| | - Elaa M Mahdi
- Division of Pediatric Surgery, Children's Hospital Los Angeles, Los Angeles, CA, USA; Department of Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, CA, USA
| | - Nhu Tran
- Division of Pediatric Surgery, Children's Hospital Los Angeles, Los Angeles, CA, USA; Department of Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, CA, USA
| | - Ashwini Lakshmanan
- Fetal and Neonatal Medicine Institute, Division of Neonatology, Department of Pediatrics, Children's Hospital Los Angeles, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA; Department of Preventive Medicine, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA; Leonard D. Schaeffer Center for Health Policy and Economics, University of Southern California, Los Angeles, CA, USA
| | - Eugene Kim
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital Los Angeles, Los Angeles, CA, USA
| | - Lorraine I Kelley-Quon
- Division of Pediatric Surgery, Children's Hospital Los Angeles, Los Angeles, CA, USA; Department of Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, CA, USA; Department of Preventive Medicine, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA.
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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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Marzuillo P, Calligaris L, Amoroso S, Barbi E. Narrative review shows that the short-term use of ketorolac is safe and effective in the management of moderate-to-severe pain in children. Acta Paediatr 2018; 107:560-567. [PMID: 29247538 DOI: 10.1111/apa.14189] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2017] [Revised: 10/30/2017] [Accepted: 12/07/2017] [Indexed: 11/26/2022]
Abstract
In June 2013, the European Medicine Agency recommended limiting codeine use in paediatric patients, creating a void in managing moderate pain. We reviewed the literature published in English (1985-June 2017) on the pharmacokinetic, pharmacodynamic and safety profile of ketorolac, a possible substitute for codeine and opioids, for treating moderate-to-severe pain. We found that gastrointestinal side effects were mainly reported with prolonged use, significant bleeding was reported in adenotonsillectomy, and adverse renal effects appeared to be limited to patients with specific coexisting risk factors. CONCLUSION The short-term use of ketorolac appears to be safe for children in many situations.
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Affiliation(s)
- Pierluigi Marzuillo
- M.D. Department of Women and Children and General and Specialized Surgery; Università degli studi della Campania “Luigi Vanvitelli”; Naples Italy
| | - Lorenzo Calligaris
- M.D. Institute for Maternal and Child Health IRCCS “Burlo Garofolo”; Trieste Italy
| | | | - Egidio Barbi
- M.D. Institute for Maternal and Child Health IRCCS “Burlo Garofolo”; Trieste Italy
- University of Trieste; Trieste Italy
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Affiliation(s)
- Emily Rowe
- Tufts Medical Center; Department of Pharmacy; 800 Washington St, Box 420 Boston USA
| | - Tess E Cooper
- Cochrane; Cochrane Pain, Palliative and Supportive Care Review Group; Oxford Pain Research Churchill Hospital Oxford Oxfordshire UK OX3 7LE
| | - Ewan D McNicol
- Tufts Medical Center; Department of Pharmacy; 800 Washington St, Box 420 Boston USA
- Tufts Medical Center; Department of Anesthesiology; Boston Massachusetts USA
- Tufts University School of Medicine; Pain Research, Education and Policy (PREP) Program, Department of Public Health and Community Medicine; Boston Massachusetts USA
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Franklin AD, Hughes EM. Fluoroscopically guided tunneled trans-caudal epidural catheter technique for opioid-free neonatal epidural analgesia. J Anesth 2016; 30:493-7. [PMID: 26896945 DOI: 10.1007/s00540-016-2147-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2015] [Accepted: 01/30/2016] [Indexed: 11/29/2022]
Abstract
Epidural analgesia confers significant perioperative advantages to neonates undergoing surgical procedures but may be very technically challenging to place using a standard interlaminar loss-of-resistance to saline technique given the shallow depth of the epidural space. Thoracic epidural catheters placed via the caudal route may reduce the risk of direct neural injury from needle placement, but often pose higher risks of infection and/or improper positioning if placed without radiographic guidance. We present a detailed method of placing a fluoroscopically guided, tunneled transcaudal epidural catheter, which may reduce both of these risks. The accuracy and precision of this technique often provides adequate analgesia to allow for opioid-free epidural infusions as well as significant reductions in systemic opioids through the perioperative period. Opioid-free analgesia using a regional anesthetic technique allows for earlier extubation and reduced perioperative sedation, which may have a less deleterious neurocognitive effect on the developing brain of the neonate.
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Affiliation(s)
- Andrew D Franklin
- Monroe Carell Jr. Children's Hospital at Vanderbilt, Vanderbilt University Medical Center, 2200 Children's Way, Suite 3115, Nashville, TN, 37232, USA.
| | - Elisabeth M Hughes
- Monroe Carell Jr. Children's Hospital at Vanderbilt, Vanderbilt University Medical Center, 2200 Children's Way, Suite 3115, Nashville, TN, 37232, USA
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Kamata M, Cartabuke RS, Tobias JD. Perioperative care of infants with pyloric stenosis. Paediatr Anaesth 2015; 25:1193-206. [PMID: 26490352 DOI: 10.1111/pan.12792] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/07/2015] [Indexed: 11/28/2022]
Abstract
Pyloric stenosis (PS) is one of the most common surgical conditions affecting neonates and young infants. The definitive treatment for PS is surgical pyloromyotomy, either open or laparoscopic. However, surgical intervention should never be considered urgent or emergent. More importantly, emergent medical intervention may be required to correct intravascular volume depletion and electrolyte disturbances. Given advancements in surgical and perioperative care, morbidity and mortality from PS should be limited. However, either may occur related to poor preoperative resuscitation, anesthetic management difficulties, or postoperative complications. The following manuscript reviews the current evidence-based medicine regarding the perioperative care of infants with PS with focus on the preoperative assessment and correction of metabolic abnormalities, intraoperative care including airway management (particularly debate related to rapid sequence intubation), maintenance anesthetic techniques, and techniques for postoperative pain management. Additionally, reports of applications of regional anesthesia for either postoperative pain control or as an alternative to general anesthesia are discussed. Management recommendations are provided whenever possible.
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Affiliation(s)
- Mineto Kamata
- Department of Anesthesiology & Pain Medicine, Nationwide Children's Hospital, Columbus, OH, USA
| | - Richard S Cartabuke
- Department of Anesthesiology & Pain Medicine, Nationwide Children's Hospital, Columbus, OH, USA.,Department of Anesthesiology & Pain Medicine, The Ohio State University College of Medicine, Columbus, OH, USA
| | - Joseph D Tobias
- Department of Anesthesiology & Pain Medicine, Nationwide Children's Hospital, Columbus, OH, USA.,Department of Anesthesiology & Pain Medicine, The Ohio State University College of Medicine, Columbus, OH, USA.,Department of Pediatrics, The Ohio State University College of Medicine, Columbus, OH, USA
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Muhly WT, Gurnaney HG, Kraemer FW, Ganesh A, Maxwell LG. A retrospective comparison of ropivacaine and 2-chloroprocaine continuous thoracic epidural analgesia for management of postthoracotomy pain in infants. Paediatr Anaesth 2015; 25:1162-7. [PMID: 26306545 DOI: 10.1111/pan.12745] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/23/2015] [Indexed: 11/29/2022]
Abstract
INTRODUCTION Continuous thoracic epidural analgesia is useful in the management of infants following thoracotomy. Concerns about drug accumulation and toxicity limit the amount of amide local anesthetics that can be delivered. Continuous epidural infusions of the ester local anesthetic chloroprocaine result in little drug accumulation allowing for higher infusion rates. We retrospectively compared patients managed with 1.5% 2- chloroprocaine or 0.1% ropivacaine epidural infusions to determine if the increased infusion rate resulted in similar or improved analgesia. METHODS This retrospective cohort comparison consisted of full term infants 6 months or younger who underwent thoracotomy for congenital lung lesion resection. Patients were included if they were managed with either a 1.5% 2-chloroprocaine (Group C) (n = 26) or 0.1% ropivacaine (Group R) (n = 28) infusion administered through a caudally placed thoracic epidural catheter. The primary outcome was morphine administration at 0-24 h. RESULTS Patients were similar in age, weight, length of stay, epidural location and duration. There was weak evidence for a difference in morphine use in the first 24 h in Group C compared to Group R (P = 0.08) but no difference 24-48 h. Group C was more commonly managed with ketorolac at 0-24 h (P = 0.03) and 24-48 h (P =< 0.01). DISCUSSION The use of 2-chloroprocaine for continuous epidural infusion in infants following thoracotomy was not inferior to ropivacaine and there was weak evidence for a reduction in opioid consumption in the first 24 h postoperatively. However, the 2-chloroprocaine group was more likely to receive ketorolac.
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Affiliation(s)
- Wallis T Muhly
- Department of Anesthesiology and Critical Care, The Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Harshad G Gurnaney
- Department of Anesthesiology and Critical Care, The Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Francis W Kraemer
- Department of Anesthesiology and Critical Care, The Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Arjunan Ganesh
- Department of Anesthesiology and Critical Care, The Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Lynne G Maxwell
- Department of Anesthesiology and Critical Care, The Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
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Brasher C, Gafsous B, Dugue S, Thiollier A, Kinderf J, Nivoche Y, Grace R, Dahmani S. Postoperative pain management in children and infants: an update. Paediatr Drugs 2014; 16:129-40. [PMID: 24407716 DOI: 10.1007/s40272-013-0062-0] [Citation(s) in RCA: 54] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Many factors contribute to suboptimal pain management in children. Current evidence suggests that severe pain in children has significant long-lasting effects, even more so than in adults. In particular, recent evidence suggests a lack of optimal postoperative pain management in children, especially following ambulatory surgery. This review provides simple guidelines for the management of postoperative pain in children. It discusses the long-term effects of severe pain and how to evaluate pain in both healthy and neurologically impaired children, including neonates. Currently available treatment options are discussed with reference to the efficacy and side effects of opioid and non-opioid and regional analgesic techniques. The impact of preoperative anxiety on postoperative pain, and the efficacy of some nonpharmacological techniques such as hypnosis or distraction, are also discussed. Finally, basic organizational strategies are described, aiming to promote safer and more efficient postoperative pain management in children.
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Affiliation(s)
- Christopher Brasher
- Department of Anesthesiology, Intensive Care, Robert Debré Hospital, 48 Bd Sérurier, 75019, Paris, France
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17
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Maitra S, Baidya DK, Khanna P, Ray BR, Panda SS, Bajpai M. Acute perioperative pain in neonates: An evidence-based review of neurophysiology and management. ACTA ACUST UNITED AC 2014; 52:30-7. [DOI: 10.1016/j.aat.2014.02.004] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2013] [Accepted: 02/10/2014] [Indexed: 10/25/2022]
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18
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Abstract
We aimed to identify the risk factors for acute kidney injury in infants who have received ketorolac after a cardiac surgical procedure by identifying patients with a > or = 50% increase in serum creatinine from baseline and matching them by age with three controls that had < 50% increase in serum creatinine. Significant differences in primary surgical procedure, baseline serum creatinine, and concomitant aspirin use were noted. We conclude that the concomitant use of aspirin with ketorolac is associated with increased renal morbidity in young post-cardiac surgical infants.
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Giannantonio C, Papacci P, Purcaro V, Cota F, Tesfagabir MG, Molle F, Lepore D, Baldascino A, Romagnoli C. Effectiveness of ketorolac tromethamine in prevention of severe retinopathy of prematurity. J Pediatr Ophthalmol Strabismus 2011; 48:247-51. [PMID: 20873697 DOI: 10.3928/01913913-20100920-01] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2009] [Accepted: 08/16/2010] [Indexed: 11/20/2022]
Abstract
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.
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Affiliation(s)
- Carmen Giannantonio
- Department of Pediatrics, Catholic University Sacred Heart, 00168 Rome, Italy.
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20
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Aldrink JH, Ma M, Wang W, Caniano DA, Wispe J, Puthoff T. Safety of ketorolac in surgical neonates and infants 0 to 3 months old. J Pediatr Surg 2011; 46:1081-5. [PMID: 21683202 DOI: 10.1016/j.jpedsurg.2011.03.031] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2011] [Accepted: 03/26/2011] [Indexed: 10/18/2022]
Abstract
BACKGROUND Ketorolac is a nonsteroidal antiinflammatory drug widely used as an adjunct to postoperative pain control in adult and pediatric patients. Minimal safety data exist regarding the use of ketorolac in neonates. METHODS The charts of 57 postsurgical neonates between 0 and 3 months of age were retrospectively reviewed for bleeding events associated with ketorolac. Data included gestational age (GA), corrected gestational age (CGA) at the time of ketorolac, serum creatinine, platelet count, urine output (in milliliters per kilogram per hour), concomitant medications, enteral feeds, number of ketorolac doses, and surgical procedure performed. RESULTS Of 57 patients, 10 (17.2%) demonstrated a bleeding event. Mean CGA and serum creatinine for those with bleeding events was 39.4 weeks (P = .69) and 0.64 mg/dL (P = .03), respectively. Patients with a bleeding event received ketorolac at a mean of 20.7 days of life with 70% receiving the drug at less than 14 days of age, whereas those without a bleeding event received ketorolac at a mean of 31.9 days (P = .04). Bleeding events correlated with glomerular filtration rate of less than 30 mL/min/1.73 m(2) or concomitant medications in all but 1 patient. CONCLUSIONS Infants younger than 21 days and less than 37 weeks CGA are at significantly increased risk for bleeding events and should not be candidates for ketorolac therapy.
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Affiliation(s)
- Jennifer H Aldrink
- Division of Pediatric Surgery, Department of Surgery, Nationwide Children's Hospital, The Ohio State University College of Medicine, OH 43205, USA.
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Lynn AM, Bradford H, Kantor ED, Andrew M, Vicini P, Anderson GD. Ketorolac tromethamine: stereo-specific pharmacokinetics and single-dose use in postoperative infants aged 2-6 months. Paediatr Anaesth 2011; 21:325-34. [PMID: 21199130 PMCID: PMC3078765 DOI: 10.1111/j.1460-9592.2010.03484.x] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVE We determined the postoperative pharmacokinetics (PK), safety, and analgesic effects of ketorolac in 14 infants (aged <6 months) receiving a single intravenous (IV) administration of racemic ketorolac or placebo. BACKGROUND Information on the PK of ketorolac in infants is limited. Unblinded studies suggest ketorolac may be useful in infants. METHODS This double-blinded, placebo-controlled study enrolled 14 infants (aged <6 months) postoperatively. At 6-18 h after surgery, infants were randomized to receive placebo, 0.5 mg·kg(-1), or 1 mg·kg(-1) ketorolac IV. All infants received morphine sulfate as needed for pain control. Blood was collected up to 12-h postdosing. Analysis used noncompartmental and compartmental population modeling methods. RESULTS In addition to noncompartmental and empirical Bayes PK modeling, data were integrated with a previously studied data set comprising 25 infants and toddlers (aged 6-18 months). A two-compartmental model described the comprehensive data set. The population estimates of the R (+) isomer were (%CV): central volume of distribution 1130 (10%) ml, peripheral volume of distribution 626 (25%) ml, and clearance from the central compartment 7.40 (8%) ml·min(-1). Those of the S (-) isomer were 1930 (15%) ml, 319 (58%) ml, and 39.5 (13%) ml·min(-1). Typical elimination half-lives were 191 and 33 min, respectively. There was a trend for increased clearance and central volume with increasing age and weight. The base model suggested that clearance of the S (-) isomer was weakly related to age; however, when body size adjustment was added to the model, no covariates were significant. Safety assessment showed no changes in renal or hepatic function tests, surgical drain output, or continuous oximetry between groups. Cumulative morphine administration showed large inter-patient variability and was not different between groups. CONCLUSION Stereo-isomer-specific clearance of ketorolac in infants (aged 2-6 months) shows rapid elimination of the analgesic S (-) isomer as reported in infants aged 6-18 months. No adverse effects were seen after a single IV ketorolac dose.
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Affiliation(s)
- Anne M. Lynn
- Departments of Anesthesia & Pain Management, Seattle Children’s Hospital and University of Washington School of Medicine
| | - Heidi Bradford
- Departments of Anesthesia & Pain Management, Seattle Children’s Hospital and University of Washington School of Medicine
| | - Eric D. Kantor
- Department of Pharmacy, University of Washington School of Pharmacy
| | - Marilee Andrew
- Department of Bioengineering, University of Washington Schools of Engineering and Medicine Seattle, Washington,Applied Physics Laboratory, University of Washington, Seattle, Washington
| | - Paolo Vicini
- Department of Bioengineering, University of Washington Schools of Engineering and Medicine Seattle, Washington
| | - Gail D. Anderson
- Department of Pharmacy, University of Washington School of Pharmacy
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De Lima J, Carmo KB. Practical pain management in the neonate. Best Pract Res Clin Anaesthesiol 2010; 24:291-307. [DOI: 10.1016/j.bpa.2010.04.001] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
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Durrmeyer X, Vutskits L, Anand KJS, Rimensberger PC. Use of analgesic and sedative drugs in the NICU: integrating clinical trials and laboratory data. Pediatr Res 2010; 67:117-27. [PMID: 20091937 DOI: 10.1203/pdr.0b013e3181c8eef3] [Citation(s) in RCA: 108] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Recent advances in neonatal intensive care include and are partly attributable to growing attention for comfort and pain control in the term and preterm infant requiring intensive care.Limitation of painful procedures is certainly possible, but most critically ill infants require unavoidable painful or stressful procedures such as intubation, mechanical ventilation, or catheterization.Many analgesics (opioids and nonsteroidal anti-inflammatory drugs)and sedatives (benzodiazepines and other anesthetic agents) are available but their use varies considerably among units. This review summarizes current experimental knowledge on the effects of sedative and analgesic drugs on brain development and reviews clinical evidence that speaks for or against the use of common analgesic and sedative drugs in the NICU but avoids any discussion of anesthesia during surgery. Risk/benefit ratios of intermittent boluses or continuous infusions for the commonly used sedative and analgesic agents are discussed in the light of clinical and experimental studies. The limitations of extrapolating experimental results from animals to humans must be considered while making practical recommendations based on the currently available evidence.
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Affiliation(s)
- Xavier Durrmeyer
- Neonatal Intensive Care Unit, Centre Hospitalier Intercommunal de Créteil, Créteil 94000, France
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24
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Sinha VR, Kumar RV, Singh G. Ketorolac tromethamine formulations: an overview. Expert Opin Drug Deliv 2009; 6:961-75. [DOI: 10.1517/17425240903116006] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Abstract
The accurate assessment and effective treatment of acute pain in children in the hospital setting is a high priority. During the past 2 to 3 decades, pediatric pain management has gained tremendous knowledge with respect to the understanding of developmental neurobiology, developmental pharmacology the use of analgesics in children, the use of regional techniques in children, and of the psychological needs of children in pain. A wide range of medications is available to treat a variety of pain types. This article provides an overview of the most common analgesic medications and techniques used to treat acute pain in children.
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Affiliation(s)
- F Wickham Kraemer
- University of Pennsylvania, School of Medicine, Department of Anesthesiology and Critical Care, Philadelphia, PA 19104, USA.
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Aranda JV, Beharry KD, Valencia GB. Nonsteroidal anti-inflammatory drugs (NSAIDs) in the newborn – which ones? J Matern Fetal Neonatal Med 2009; 22 Suppl 3:21-2. [DOI: 10.1080/14767050903194461] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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27
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Lynn AM, Bradford H, Kantor ED, Seng KY, Salinger DH, Chen J, Ellenbogen RG, Vicini P, Anderson GD. Postoperative Ketorolac Tromethamine Use in Infants Aged 6–18 Months: The Effect on Morphine Usage, Safety Assessment, and Stereo-Specific Pharmacokinetics. Anesth Analg 2007; 104:1040-51, tables of contents. [PMID: 17456651 DOI: 10.1213/01.ane.0000260320.60867.6c] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Nonsteroidal antiinflammatory drugs have been useful for treating postoperative pain in children. The only parenteral nonsteroidal antiinflammatory drug currently available in the United States is ketorolac tromethamine with cyclooxygenase-1 and cyclooxygenase-2 effects. Information on the pharmacokinetics of ketorolac in infants is sparse, making dosing difficult. Ketorolac is administered as a racemic mixture with the S(-) isomer responsible for the analgesic effect. In this study, we describe the population pharmacokinetics of ketorolac in a group of 25 infants and toddlers who received a single IV administration of racemic ketorolac and evaluate the potential influence of patient covariates on ketorolac disposition. METHODS In this double-blind, placebo-controlled study, ketorolac pharmacokinetic, safety, and analgesic effects were studied in 37 infants and toddlers (aged 6-18 mo) postoperatively. On postoperative day 1, infants were randomized to receive placebo, 0.5, or 1 mg/kg ketorolac as a 10-min IV infusion. Blood samples were collected up to 12-h after dosing. The data were analyzed using noncompartmental and compartmental (nonlinear mixed-effects model) means. The patient covariates, including body weight, age, and surgical procedure, were analyzed in a stepwise fashion to identify their potential influence on ketorolac pharmacokinetics. RESULTS The data were best described by a two-compartmental model. Inclusion of covariates did not significantly decrease the nonlinear mixed-effects model objective function values and between-subject variability in the pharmacokinetic parameters of nested models. The mean and standard error of the estimates of the R(+) isomer were central volume of distribution 1200 +/- 163 mL (coefficient of variation of interindividual variability, 13.6%), peripheral volume of distribution 828 +/- 108 mL (13.0%), clearance from the central compartment 7.52 +/- 0.7 mL/min (9.3%), and extrapolated elimination half-life 238 +/- 48 min. Those of the S(-) isomer were 2320 +/- 34 (14.6%), 224 +/- 193 mL (86.2%), 45.3 +/- 5.5 mL/min (12.1%), and 50 +/- 42 min respectively. Dosing simulations, using population pharmacokinetic parameters, showed no accumulation of S(-) ketorolac but steady increases in R(+) ketorolac. Safety assessment showed no adverse effects on renal or hepatic function tests, surgical drain output, or continuous oximetry between placebo and ketorolac groups. Cumulative morphine administration showed large interpatient variability and was not different between groups. CONCLUSION The stereo-isomer-specific clearance of ketorolac in infants and toddlers (aged 6-18 mo) shows rapid elimination of the analgesic S(-) isomer. No adverse effects on surgical drain output, oximetry measured saturations, renal or hepatic function tests were seen. Simulation of single dosing at 0.5 or 1 mg/kg every 4 or 6 h does not lead to accumulation of S(-) ketorolac, the analgesic isomer, but does result in increases in R(+) ketorolac. Shorter dose intervals may be needed in infants older than 6 mo.
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Affiliation(s)
- Anne M Lynn
- Department of Anesthesia and Pain Management, Children's Hospital and Regional Medical Center, University of Washington School of Medicine, Seattle, Washington 98105, USA.
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Abstract
BACKGROUND Ketorolac is an injectable nonsteroidal anti-inflammatory drug that is often used as a transitional short-term analgesic to treat moderate pain and to decrease opioid use. There is a paucity of literature documenting the safety of using ketorolac in neonates and infants after cardiac surgery. METHODS A retrospective chart review was performed which identified all patients <6 months of age who received ketorolac after cardiac surgery. Patients' demographic, surgical, and dosing data were collected. A Student's t-test was used to identify significant differences in renal and hematologic laboratory values at baseline and at 48 h of treatment. RESULTS A total of 53 children <6 months of age received at least one dose of ketorolac after cardiac surgery. Eleven of 53 children (21%) were <1 month of age. The blood urea nitrogen/serum creatinine (SCr) levels increased from baseline at 48 h of therapy in all infants, but stayed within normal limits. The largest increase in SCr level from baseline on any day of ketorolac therapy was 26 micromol x l(-1) (0.3 mg x dl(-1)) which occurred in two neonates. Four patients (three infants and one neonate) had minor episodes of bleeding while being treated with ketorolac. There were no clinically significant changes in hemoglobin, hematocrit or platelet count. None of these episodes caused hemodynamic instability nor required transfusion of blood products. CONCLUSIONS Ketorolac was used safely in neonates and infants who have had cardiac surgery at our institution. Ketorolac was not associated with any adverse hematologic or renal effects. Prospective investigation is warranted to further assess the safety and effectiveness of ketorolac in this patient population.
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Affiliation(s)
- Brady S Moffett
- Department of Pharmacy, Texas Children's Hospital, Houston, TX 77030, USA.
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Abstract
PURPOSE OF REVIEW Pain management after thoracic surgery in children presents the challenge of providing adequate analgesia without excessive sedation, and maintaining adequate respiratory function in the face of compromise resulting from existing pathology, surgical trauma, single-lung ventilation and postoperative ventilation-perfusion abnormalities. In the pediatric population, pain assessment and reporting present additional challenges. The number and complexity of surgical procedures, including video-assisted thoracoscopic procedures, is increasing in the pediatric population. There is a need to explore pain management for these types of patients. RECENT FINDINGS There are effective and safe strategies whereby analgesia can be provided to this pediatric population. This review will outline the progress that has been made in this field, including the use of regional techniques. The routine use of caudal catheters in neonates and infants for thoracic surgical procedures and the use of electrical guidance of epidural catheters, the 'Tsui' technique, are reviewed. SUMMARY These techniques, applied within a comprehensive pain management strategy, can be extremely beneficial in the care of the pediatric thoracic patient.
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Affiliation(s)
- Brenda Golianu
- Stanford University School of Medicine, Stanford, California 94305, USA.
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