Remifentanil in children

The effect of remimazolam-based total intravenous anesthesia versus sevoflurane-based inhalation anesthesia on emergence delirium in children undergoing tonsillectomy and adenoidectomy: study protocol for a prospective randomized controlled trial

Background: Remimazolam, a new ultrashort-acting benzodiazepine, is becoming increasingly applied in general anesthesia. This study is designed to investigate the effect of remimazolam-based total intravenous anesthesia and sevoflurane-based inhalation anesthesia on emergence delirium in pediatric tonsillectomy and adenoidectomy. Methods and analysis: This is a monocentric, prospective, randomized, double-blind clinical trial. A total of 90 pediatric patients will be randomized to receive remimazolam-based total intravenous anesthesia (remimazolam group, n = 45) or sevoflurane-based inhalation anesthesia (sevoflurane group, n = 45). The primary outcome will be the incidence of emergence delirium, which will be evaluated using the Pediatric Anesthesia Emergence Delirium (PAED) scale. The secondary outcomes include the extubation time, recovery time, behavior change using the post-hospitalization behavior questionnaire for ambulatory surgery (PHBQ-AS), and adverse events. Ethics and dissemination: This study has been approved by the Institutional Review Board (IRB) of the Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University (2023-K-262-02). Clinical trial registration: ClinicalTrials.gov, identifier NCT06214117.

Effects of single-injection intercostal nerve block as a component of multimodal analgesia for pediatrics undergoing autologous auricular reconstruction: A double-blinded, prospective, and randomized study

Background

ː Pain management is essential in postoperative settings, especially with pediatric patients. Donor site pain after rib cartilage harvest is severe, particularly during the early postoperative period. This study aimed to explore the effectiveness of ultrasound guided single-injection intercostal nerve block (ICNB) as a component of multimodal analgesia for pediatrics undergoing autologous auricular reconstruction.

Methods

ː Fifty pediatric patients aged 6-16 years and scheduled for 2 rib cartilages harvest surgery were enrolled in this double-blind, prospective and randomized study. Pediatrics were randomly assigned into two groups: the intercostal nerve block group (group B) and the control group (group C). The nerve block was performed with 2 ml 0.25% ropivacaine each intercostal nerve in group B. Patients from group C received Tramadol 2 mg/kg by the end of the surgery as control. Tramadol-based patient-controlled intravenous analgesia and rescue analgesia were given in both groups. The primary outcome was pain scores at early postoperative period (VAS and FLACC scale, 4 h, and 8 h). The secondary outcome was the postoperative Tramadol consumption and time point of first rescue analgesic demand.

Results

ː VAS score was significantly lower in group B than group C at 4 h and 8 h postoperatively [2.5(2-5) vs. 4(2.5-5.5), p = 0.041 at 4 h; 3(2.5-4.5) vs. 4(3-5), p = 0.047 at 8 h]. Total Tramadol consumption in group B decreased significantly in contrast with group C at 8 h (p < 0.01), 12 h, 24 h and 48 h (p < 0.05, respectively). The first rescue analgesia demand and number of rescue Tramadol in block group was considerably delayed or reduced than control group (p < 0.01, p < 0.05, respectively).

Conclusions

ː Our findings indicated that ultrasound guided ICNB slightly but significantly reduced pain scores, and Tramadol consumption in pediatric patients after rib cartilage harvest as compared to who didn't receive nerve block at 4 h and 8 h postoperatively. Unified ICNB ropivacaine dosage might detrimental to providing superior analgesia.

Pharmacokinetics of Fentanyl and Its Derivatives in Children: A Comprehensive Review

Fentanyl and its derivatives sufentanil, alfentanil, and remifentanil are potent opioids. A comprehensive review of the use of fentanyl and its derivatives in the pediatric population was performed using the National Library of Medicine PubMed. Studies were included if they contained original pharmacokinetic parameters or models using established routes of administration in patients younger than 18 years of age. Of 372 retrieved articles, 44 eligible pharmacokinetic studies contained data of 821 patients younger than 18 years of age, including more than 46 preterm infants, 64 full-term neonates, 115 infants/toddlers, 188 children, and 28 adolescents. Underlying diagnoses included congenital heart and pulmonary disease and abdominal disorders. Routes of drug administration were intravenous, epidural, oral-transmucosal, intranasal, and transdermal. Despite extensive use in daily clinical practice, few studies have been performed. Preterm and term infants have lower clearance and protein binding. Pharmacokinetics was not altered by chronic renal or hepatic disease. Analyses of the pooled individual patients' data revealed that clearance maturation relating to body weight could be best described by the Hill function for sufentanil (R ² = 0.71, B _max 876 mL/min, K ₅₀ 16.3 kg) and alfentanil (R ² = 0.70, B _{max (fixed)} 420 mL/min, K ₅₀ 28 kg). The allometric exponent for estimation of clearance of sufentanil was 0.99 and 0.75 for alfentanil clearance. Maturation of remifentanil clearance was described by linear regression to bodyweight (R ² = 0.69). The allometric exponent for estimation of remifentanil clearance was 0.76. For fentanyl, linear regression showed only a weak correlation between clearance and bodyweight in preterm and term neonates (R ² = 0.22) owing to a lack of data in older age groups. A large heterogeneity regarding study design, clinical setting, drug administration, laboratory assays, and pharmacokinetic estimation was observed between studies introducing bias into the analyses performed in this review. A limitation of this review is that pharmacokinetic data, based on different modes of administration, dosing schemes, and parameter estimation methods, were combined.

Non-operating room anaesthesia in children

Administration of sedation and/or anaesthesia to patients undergoing painful or uncomfortable procedures at off-site locations is referred to as non-operating room anaesthesia (NORA). Sedating/anaesthetising children in an unfamiliar environment, with the lack of support staff, nonavailability of choice of medication and equipment is often challenging. Studies have shown an increased risk of airway-related adverse events, complications, and even death outside the operating room locations. It is crucial to be familiar with the anatomical and physiological variations in children, well versed with the difficult airway algorithm and call for help early. The most common event in NORA claims was inadequate oxygenation/ventilation, which are preventable with vigilant monitoring. English language articles were searched in Pubmed, Google Scholar, and Academic using 'sedation in children', 'remote location anaesthesia', 'peadiatric sedation', and 'nonoperating room anaesthesia' as the mesh words. Full text of the relevant articles was obtained and this review article was synthesised. The article outlines various safety guidelines, sedation techniques, drugs used for sedation, environmental concerns, procedure-specific risks, and complications associated with NORA in children.

Population Pharmacokinetic Modeling of Remifentanil in Infants with Unrepaired Tetralogy of Fallot

BACKGROUND

Although there is literature suggesting that pathophysiologic changes in children with congenital heart disease alter the pharmacokinetics of anesthetics and may result in dosage adjustment, limited information exists regarding the pharmacokinetics of remifentanil in infants with unrepaired tetralogy of Fallot (TOF). The objectives of the current analysis were to characterize the population pharmacokinetics of remifentanil in infants, and to evaluate the effects of TOF on remifentanil's pharmacokinetics.

METHODS

Twenty-seven infants (16 with TOF and 11 with normal cardiac anatomy; aged 114-360 days) scheduled to undergo elective surgery under general anesthesia were recruited in the study. All children received remifentanil 1 μg/kg/min intravenously for anesthesia induction and early maintenance [until ~ 20 min before cardiopulmonary bypass (CPB) for patients with TOF]. Serial arterial blood samples were drawn and analyzed. Population pharmacokinetics of remifentanil was characterized using NONMEM software. The estimates were standardized to a 70-kg adult using a per-kilogram model.

RESULTS

A two-compartment disposition model adequately described the pharmacokinetics of remifentanil. Besides body weight, the introduction of any other covariates, including TOF status, did not improve the model significantly (P > 0.05). The population parameter estimates for systemic clearance (Cl₁) and inter-compartment clearances (Cl₂) were 6.03 × (WT/70 kg) and 1.23 × (WT/70 kg) L/min, respectively, and central volume of distribution (V₁) and peripheral volumes of distribution (V₂) were 19.6 × (WT/70 kg) and 21.7 × (WT/70 kg) L, respectively.

CONCLUSIONS

Unrepaired TOF does not change the pharmacokinetics of remifentanil, suggesting a similar dosage for infants with TOF compared to normal cardiac anatomy infants.

CLINICAL TRIAL REGISTRATION

The patient enrollment in this study started at 2012, so we do not have clinic trial number, but we still think this is a valuable research and hope it could be considered for publication.

Postoperative pain management in children: Guidance from the pain committee of the European Society for Paediatric Anaesthesiology (ESPA Pain Management Ladder Initiative)

The main remit of the European Society for Paediatric Anaesthesiology (ESPA) Pain Committee is to improve the quality of pain management in children. The ESPA Pain Management Ladder is a clinical practice advisory based upon expert consensus to help to ensure a basic standard of perioperative pain management for all children. Further steps are suggested to improve pain management once a basic standard has been achieved. The guidance is grouped by the type of surgical procedure and layered to suggest basic, intermediate, and advanced pain management methods. The committee members are aware that there are marked differences in financial and personal resources in different institutions and countries and also considerable variations in the availability of analgesic drugs across Europe. We recommend that the guidance should be used as a framework to guide best practice.

Correction to: Pharmacokinetics of Fentanyl and Its Derivatives in Children: A Comprehensive Review

Fentanyl and its derivatives sufentanil, alfentanil, and remifentanil are potent opioids. A comprehensive review of the use of fentanyl and its derivatives in the pediatric population was performed using the National Library of Medicine PubMed. Studies were included if they contained original pharmacokinetic parameters or models using established routes of administration in patients younger than 18 years of age. Of 372 retrieved articles, 44 eligible pharmacokinetic studies contained data of 821 patients younger than 18 years of age, including more than 46 preterm infants, 64 full-term neonates, 115 infants/toddlers, 188 children, and 28 adolescents. Underlying diagnoses included congenital heart and pulmonary disease and abdominal disorders. Routes of drug administration were intravenous, epidural, oral-transmucosal, intranasal, and transdermal. Despite extensive use in daily clinical practice, few studies have been performed. Preterm and term infants have lower clearance and protein binding. Pharmacokinetics was not altered by chronic renal or hepatic disease. Analyses of the pooled individual patients' data revealed that clearance maturation relating to body weight could be best described by the Hill function for sufentanil (R ² = 0.71, B _max 876 mL/min, K ₅₀ 16.3 kg) and alfentanil (R ² = 0.70, B _{max (fixed)} 420 mL/min, K ₅₀ 28 kg). The allometric exponent for estimation of clearance of sufentanil was 0.99 and 0.75 for alfentanil clearance. Maturation of remifentanil clearance was described by linear regression to bodyweight (R ² = 0.69). The allometric exponent for estimation of remifentanil clearance was 0.76. For fentanyl, linear regression showed only a weak correlation between clearance and bodyweight in preterm and term neonates (R ² = 0.22) owing to a lack of data in older age groups. A large heterogeneity regarding study design, clinical setting, drug administration, laboratory assays, and pharmacokinetic estimation was observed between studies introducing bias into the analyses performed in this review. A limitation of this review is that pharmacokinetic data, based on different modes of administration, dosing schemes, and parameter estimation methods, were combined.

Effects of remifentanil and remifentanil-alfentanil administration on emergence agitation after brief ophthalmic surgery in children

Background

Sevoflurane is commonly usedin pediatric anesthesia due to its non-irritating airway properties, and rapid induction and emergence. However, it is associated with emergence agitation (EA) in children. EA may cause injury to the child or damage to the surgical site and is a cause of stress to both caregivers and families. The efficacy of remifentanil and additional alfentanil on EA in the pediatric patients underwent ophthalmic surgery with sevofluraneanesthesiawas not well evaluated to date. This study was designed to compare the effects of remifentanil and remifentanil plus alfentanil on EA in children undergoing ophthalmic surgery with sevofluraneanesthesia.

Methods

Children (aged 3–9 years) undergoing ophthalmic surgery undersevoflurane anesthesia were randomly assigned to group S (sevoflurane alone), group R (sevofluraneandremifentanil infusion, 0.1 μg/kg/min), or group RA (sevoflurane withremifentanil infusion and intravenous injection of alfentanil 5 μg/kg 10 min before the end of surgery). Mean arterial pressure (MAP), heart rate (HR), and sevoflurane concentration were checked every 15 min after induction of anesthesia. The incidence of EA, time to extubation from discontinuation of sevoflurane inhalation, and time to discharge from the postanesthesia care unit was assessed.

Results

The incidence of EA was significantly lower in groups R (32 %, 11/34; P = 0.01) and RA (31 %, 11/35; P = 0.008) than group S (64 %, 21/33). The time to extubation was prolonged in group RA (11.2 ± 2.3 min; P = 0.004 and P = 0.016) compared with groups S (9.2 ± 2.3 min) andR (9.5 ± 2.4 min). MAP and HR were similar in all three groups, apart from a reduction in HR at 45 min in groups R and RA. However, the sevoflurane concentration was lower in groups R and RA than group S (P < 0.001).

Conclusions

The administration of remifentanil to children undergoing ophthalmic surgery undersevoflurane anesthesia reduced the incidence of EA without clinically significant hemodynamic changes. However, the addition of alfentanil(5 μg/kg)10 min before the end of surgery provided no additional benefit compared withremifentanil alone.

Trial registration

Clinical trial number: NCT02486926, June.29.2015.

Intrathecal morphine attenuates acute opioid tolerance secondary to remifentanil infusions during spinal surgery in adolescents

Introduction

The unique pharmacokinetic properties of remifentanil with a context-sensitive half-life unaffected by length of infusion contribute to its frequent use during anesthetic management during posterior spinal fusion in children and adolescents. However, its intraoperative administration can lead to increased postoperative analgesic requirements, which is postulated to be the result of acute opioid tolerance with enhancement of spinal N-methyl-D-aspartate receptor function. Although strategies to prevent or reduce tolerance have included the coadministration of longer acting opioids or ketamine, the majority of these studies have demonstrated little to no benefit. The current study retrospectively evaluates the efficacy of intrathecal morphine (ITM) in preventing hyperalgesia following a remifentanil infusion.

Methods

We retrospectively analyzed 54 patients undergoing posterior spinal fusion with segmental spinal instrumentation, to evaluate the effects of ITM on hyperalgesia from remifentanil. Patients were divided into two groups based on whether they did or did not receive remifentanil during the surgery: no remifentanil (control group) (n=27) and remifentanil (study group) (n=27). Data included demographics, remifentanil dose and duration, Wong–Baker visual analog scale postoperative pain scores, and postoperative intravenous morphine consumption in the first 48 postoperative hours.

Results

The demographics of the two study groups were similar. There were no differences in the Wong–Baker visual analog scale pain scores in the postanesthesia care unit and on postoperative days 1 and 3. Pain scores were higher in the remifentanil group on postoperative day 2 (2.9 vs 3.8). Postoperative morphine requirements were similar between the two groups (0.029 vs 0.017 mg/kg/48 h for the control group and the study group, respectively).

Conclusion

In patients receiving preincisional ITM during spinal surgery, intraoperative remifentanil does not increase postoperative analgesic requirements.

Remifentanil versus morphine-midazolam premedication on the quality of endotracheal intubation in neonates: a noninferiority randomized trial

OBJECTIVE

To compare remifentanil and morphine-midazolam for use in nonurgent endotracheal intubation in neonates.

STUDY DESIGN

In this prospective noninferiority randomized trial, newborns of gestational age ≥28 weeks admitted in the neonatal intensive care unit requiring an elective or semielective endotracheal intubation were divided into 2 groups. One group (n = 36) received remifentanil (1 μg/kg), and the other group (n = 35) received morphine (100 μg/kg) and midazolam (50 μg/kg) at a predefined time before intubation (different in each group), to optimize the peak effect of each drug. Both groups also received atropine (20 μg/kg). The primary outcome was to compare the conditions of intubation, and the secondary outcome was to compare the duration of successful intubation, physiological variables, and pain scores between groups for first and second intubation attempts. Adverse events and neurologic test data were reported.

RESULTS

Intubation with remifentanil was not inferior to that with morphine-midazolam. At the first attempted intubation, intubation conditions were poor in 25% of the remifentanil group and in 28.6% of the morphine-midazolam group (P = .471). For the second attempt, conditions were poor in 28.6% of the remifentanil group, compared with 10% of the morphine-midazolam group (P = .360). The median time to successful intubation was 33 seconds (IQR, 24-45 seconds) for the remifentanil group versus 36 seconds (IQR, 25-59 seconds) for the morphine-medazolam group (P = .359) at the first attempt and 45 seconds (IQR, 35-64 seconds) versus 56 seconds (IQR, 44-68 seconds), respectively, for the second attempt (P = .302). No significant between-group difference was reported for hypotension, bradycardia, or adverse events.

CONCLUSION

In our cohort, remifentanil was at least as effective as the morphine-midazolam regimen for endotracheal intubation. Thus, premedication using this very-short-acting opioid can be considered in urgent intubations and is advantageous in rapid extubation.

Intraoperative Infusion of 0.6–0.9 µg · kg−1 · min−1 Remifentanil Induces Acute Tolerance in Young Children after Laparoscopic Ureteroneocystostomy

Background:

Intraoperative infusion of opioids has been associated with increased postoperative pain and analgesic requirements, but the development of tolerance in young children is less clear. This prospective, randomized, double-blinded study was designed to test the hypothesis that the intraoperative administration of remifentanil results in postoperative opioid tolerance in a dose-related manner in young children.

Methods:

We enrolled 60 children (aged 1–5 yr) who were undergoing elective laparoscopic ureteroneocystostomy. Patients were randomized and received an intraoperative infusion of 0, 0.3, 0.6, or 0.9 µg·kg−1·min−1 remifentanil. Postoperative pain was managed by a parent/nurse-controlled analgesia pump using fentanyl. The primary outcome included the total fentanyl consumptions at 24 and 48 h postsurgery. Secondary outcomes were the postoperative pain scores and adverse effects.

Results:

The children who received 0.6 and 0.9 µg·kg−1·min−1 remifentanil required more postoperative fentanyl than the children who received saline or 0.3 µg·kg−1·min−1 remifentanil (all P &lt; 0.001) for 24 h after surgery. The children who received 0.3–0.9 µg·kg−1·min−1 intraoperative remifentanil reported higher pain scores at 1 h after surgery than the children who received saline (P = 0.002, P = 0.023, and P = 0.006, respectively). No significant intergroup differences in recovery variables were observed, but vomiting was more frequent in the 0.9 µg·kg−1·min−1 remifentanil group than in the other groups (P = 0.027).

Conclusions:

The intraoperative use of 0.3 µg·kg−1·min−1 remifentanil for approximately 3 h (range: 140–265 min) did not induce acute tolerance, but the administration of 0.6 and 0.9 µg·kg−1·min−1 remifentanil to young children resulted in acute tolerance for 24 h after surgery in an apparently dose-related manner.

Emergence agitation in children undergoing adenotonsillectomy: a comparison of sevoflurane vs. sevoflurane-remifentanil administration

BACKGROUND

Sevoflurane is widely used in paediatric anaesthesia but frequently causes emergence agitation (EA). This study evaluated whether limiting the sevoflurane concentration by combining remifentanil with sevoflurane reduced the incidence of EA.

METHODS

Eighty-four preschool children scheduled for adenotonsillectomy were randomly assigned to either the remifentanil or sevoflurane group. In the remifentanil group, anaesthesia was induced with thiopental, rocuronium, and 1% sevoflurane. It was maintained with 1% sevoflurane, 60% nitrous oxide in oxygen, and a continuous infusion of remifentanil. For the sevoflurane group, anaesthesia was induced with thiopental, rocuronium, and 8% sevoflurane, and was maintained with 2-3% sevoflurane. Both groups received ketorolac 1 mg/kg and dexamethasone 0.15 mg/kg. EA was measured using the paediatric anaesthesia emergence delirium (PAED) scale and a four-point EA scale in the post-anaesthesia care unit.

RESULTS

The scores on the PAED scales were significantly lower in the remifentanil group than in the sevoflurane group [median (interquartile range); 6 (4.25-10.25) vs. 11 (7.75-14.0), P = 0.007], and the proportion of patients with PAED scores ≥ 10 was significantly lower in the remifentanil group than in the sevoflurane group [15 (35.7%) vs. 27 (64.2%), P = 0.009]. The incidence of EA evaluated using the four-point scale was also lower in the remifentanil group [11 (26.1%) vs. 21 (50%), respectively, P = 0.025].

CONCLUSION

The incidence of EA was lower in children undergoing adenotonsillectomy who received a lower concentration of sevoflurane combined with remifentanil than in those given a higher concentration of sevoflurane without remifentanil.

Remifentanil-induced tolerance, withdrawal or hyperalgesia in infants: a randomized controlled trial. RAPIP trial: remifentanil-based analgesia and sedation of paediatric intensive care patients

BACKGROUND

Short-acting opioids like remifentanil are suspected of an increased risk for tolerance, withdrawal and opioid-induced hyperalgesia (OIH). These potential adverse effects have never been investigated in neonates.

OBJECTIVES

To compare remifentanil and fentanyl concerning the incidence of tolerance, withdrawal and OIH.

METHODS

23 mechanically ventilated infants received up to 96 h either a remifentanil- or fentanyl-based analgesia and sedation regimen with low-dose midazolam. We compared the required opioid doses and the number of opioid dose adjustments. Following extubation, withdrawal symptoms were assessed by a modification of the Finnegan score. OIH was evaluated by the CHIPPS scale and by testing the threshold of the flexion withdrawal reflex with calibrated von Frey filaments.

RESULTS

Remifentanil had to be increased by 24% and fentanyl by 47% to keep the infants adequately sedated during mechanical ventilation. Following extubation, infants revealed no pronounced opioid withdrawal and low average Finnegan scores in both groups. Only 1 infant of the fentanyl group and 1 infant of the remifentanil group required methadone for treatment of withdrawal symptoms. Infants also revealed no signs of OIH and low CHIPPS scores in both groups. The median threshold of the flexion withdrawal reflex was 4.5 g (IQR = 2.3) in the fentanyl group and 2.7 g (IQR = 3.3) in the remifentanil group (p = 0.312), which is within the physiologic range of healthy infants.

CONCLUSIONS

Remifentanil does not seem to be associated with an increased risk for tolerance, withdrawal or OIH.

Update on perioperative management of the child with asthma

Asthma represents the leading cause of morbidity from a chronic disease among children. Dealing with this disease during the perioperative period of pediatric surgical procedures is, therefore, quite common for the anesthesiologist and other professionalities involved. Preoperative assessment has a key role in detecting children at increased risk of perioperative respiratory complications. For children without an optimal control of symptoms or with a recent respiratory tract infection elective surgery should be postponed, if possible, after the optimization of therapy. According to clinical setting, loco-regional anesthesia represents the desirable option since it allows to avoid airway instrumentation. Airway management goals are preventing the increase of airflow resistance during general anesthesia along with avoiding triggers of bronchospasm. When their use is possible, face mask ventilation and laringeal mask are considered more reliable than tracheal intubation for children with asthma. Sevoflurane is the most commonly used anesthetic for induction and manteinance. Salbutamol seems to be useful in preventing airflow resistance rise after endotracheal intubation. Mechanical ventilation should be tailored according to pathophysiology of asthma: an adequate expiratory time should be setted in order to avoid a positive end-expiratory pressure due to expiratory airflow obstruction. Pain should be prevented and promptly controlled with a loco-regional anesthesia technique when it is possible. Potential allergic reactions to drugs or latex should always be considered during the whole perioperative period. Creating a serene atmosphere should be adopted as an important component of interventions in order to guarantee the best care to the asthmatic child.

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.

The Effect of Ketamine with Remifentanil for Improving the Quality of Anaesthesia and Recovery in Paediatric Patients Undergoing Middle-Ear Ventilation Tube Insertion

This prospective randomized study evaluated the effects of ketamine with remifentanil to improve the quality of anaesthesia and postoperative recovery, following brief procedures, in 60 paediatric patients undergoing middle-ear ventilation tube insertion (MEVTI). Patients were randomly assigned to either ketamine 2 mg/kg intravenous [i.v.] bolus plus normal saline by i.v. infusion (K group, n = 30) or ketamine 2 mg/kg i.v. bolus, plus remifentanil 0.15 μg/kg per min i.v. infusion (KR group, n = 30). Parameters that were assessed included intraoperative patient movement, surgeon satisfaction, anaesthesia time, total ketamine dose, postoperative recovery time, agitation and side-effects. Intraoperative patient movement scores were significantly lower, and surgeon satisfaction scores were significantly higher, in the KR group than in the K group. Time to recovery was significantly shorter in the KR group than in the K group. In conclusion, remifentanil was a good adjuvant to ketamine, improving the quality of anaesthesia and postoperative recovery in children undergoing MEVTI.

A meta-analysis of the use of nonsteroidal antiinflammatory drugs for pediatric postoperative pain

BACKGROUND

Opioid side effects are a great concern during the postoperative period in children. Nonsteroidal antiinflammatory drugs (NSAIDs) have been shown to effectively decrease postoperative pain, but their opioid-sparing effect is still controversial. In this present meta-analysis, we investigated the postoperative opioid-sparing effect of NSAIDs in children.

METHODS

A comprehensive literature search was conducted to identify clinical trials using NSAIDs and opioids as perioperative analgesic compounds in children and infants. Outcomes measured were opioid consumption, pain intensity, postoperative nausea and vomiting (PONV), and urinary retention. All outcomes were studied during postanesthesia care unit (PACU) stay and the first 24 postoperative hours. Data from each trial were combined to calculate the pooled odds ratios (ORs) or standardized mean difference (SMD) and their 95% confidence interval.

RESULTS

Twenty-seven randomized controlled studies were analyzed. Perioperative administration of NSAIDs decreased postoperative opioid requirement (both in the PACU and during the first 24 postoperative hours; SMD = -0.66 [-0.84, -0.48] and -0.83 [-1.11, -0.55], respectively), pain intensity in the PACU (SMD = -0.85 [-1.24, -0.47]), and PONV during the first 24 postoperative hours (OR = 0.75 [0.57-0.99]). NSAIDs did not decrease pain intensity during the first 24 postoperative hours (OR = 0.56 [0.26-1.2]) and PONV during PACU stay (OR = 1.02 [0.73-1.44]). Subgroup analysis according to the timing of NSAID administration (intraoperative versus postoperative), type of surgery, or coadministration of paracetamol did not show any influence of these factors on the studied outcomes except the reduction of pain intensity and the incidence of PONV during the first 24 postoperative hours, which were influenced by the coadministration of paracetamol and the type of surgery, respectively.

CONCLUSION

This meta-analysis shows that perioperative NSAID administration reduces opioid consumption and PONV during the postoperative period in children.

The effect of remifentanil versus N(2)O on postoperative pain and emergence agitation after pediatric tonsillectomy/adenoidectomy

Background

Remifentanil can be an alternative to N₂O in general anesthesia. Intraoperative remifentanil may lead to acute opioid tolerance. This study aims to assess the effect of remifentanil substituted for 70% N₂O on postoperative pain in children undergoing tonsillectomy/adenoidectomy. In addition, we evaluated the effect of remifentanil infusion on incidence of emergence agitation in these patients.

Methods

Eighty children, aged 2-12 years, undergoing tonsillectomy/adenoidectomy were randomly allocated to the N₂O group (Group N; n = 40, sevoflurane and 70% N₂O) or remifentanil group (Group R; n = 40, sevoflurane with remifentanil infusion at the rate of 0.17 µg/kg/min). In the recovery room, severity of pain and agitation were assessed by an investigator blinded to the assigned group. Time to eye opening and incidence of severe pain and agitation were compared between groups. Logistic regression was used to identify factors related to occurrence of severe pain and agitation.

Results

Number of patients with severe postoperative pain was 6 and 16 in groups N and R, respectively (P = 0.012). Incidence of emergence agitation was not significantly different between groups. Remifentanil infusion was a significant factor related to the occurrence of severe postoperative pain (P = 0.015), and age was inversely related to occurrence of emergence agitation (P = 0.001).

Conclusions

In children undergoing tonsillectomy/adenoidectomy, intraoperative remifentanil infusion may increase incidence of severe postoperative pain compared to N₂O, but it may not affect incidence of emergence agitation.

Experience of remifentanil in extremely low-birth-weight babies undergoing laparotomy

Premature babies experience pain and require adequate analgesia for any painful procedure. Fentanyl and morphine resulted in safe and effective anesthesia in the past; however, their pharmacokinetics may be impaired in preterm babies with multiorgan failure. Remifentanil, despite the absence of available pharmacokinetic data in preterm infants and few reports in newborns, demonstrated its advantages in children undergoing either major surgery or minor painful procedures and has been shown to be useful even in neonates, because its elimination is independent of organ function. We report two cases of babies born at 26 weeks' and 27 weeks' gestation, weighing 580 g and 400 g, respectively, undergoing laparotomy for necrotizing enterocolitis. Both received midazolam bolus and remifentanil infusion at high doses. This technique seems to be an advantageous alternative even in extremely low-birth-weight prematures. Furthermore, it becomes a technique of choice in these babies because the available ventilators are often not equipped with halogenated vaporizers. Particularly in intensive care, where there are no scavenger systems, it could allow to operate without moving out the preterm babies and avoiding stress and hypothermia.

Total intravenous anesthesia (TIVA) in pediatric cardiac anesthesia

Although inhalational anesthesia with moderate- to high-dose opioid analgesia has been the mainstay of pediatric cardiac anesthesia, the availability of new short-acting drugs, new concepts in pharmacokinetic modeling and computer technology, and advances in surgery and perfusion have made total intravenous anesthesia (TIVA) an attractive option. In this article, we review some of the TIVA techniques used in pediatric cardiac anesthesia.

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.

Sedation and analgesia in children with developmental disabilities and neurologic disorders

Sedation and analgesia performed by the pediatrician and pediatric subspecialists are becoming increasingly common for diagnostic and therapeutic purposes in children with developmental disabilities and neurologic disorders (autism, epilepsy, stroke, obstructive hydrocephalus, traumatic brain injury, intracranial hemorrhage, and hypoxic-ischemic encephalopathy). The overall objectives of this paper are (1) to provide an overview on recent studies that highlight the increased risk for respiratory complications following sedation and analgesia in children with developmental disabilities and neurologic disorders, (2) to provide a better understanding of sedatives and analgesic medications which are commonly used in children with developmental disabilities and neurologic disorders on the central nervous system.

World SIVA: the pediatric initiative

Total intravenous anesthesia and targeted controlled infusions are emerging and developing techniques that can have a broad range of important clinical applications in future pediatric care.