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Cravero JP, Agarwal R, Berde C, Birmingham P, Coté CJ, Galinkin J, Isaac L, Kost‐Byerly S, Krodel D, Maxwell L, Voepel‐Lewis T, Sethna N, Wilder R. The Society for Pediatric Anesthesia recommendations for the use of opioids in children during the perioperative period. Paediatr Anaesth 2019; 29:547-571. [PMID: 30929307 PMCID: PMC6851566 DOI: 10.1111/pan.13639] [Citation(s) in RCA: 86] [Impact Index Per Article: 17.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2019] [Revised: 03/25/2019] [Accepted: 03/27/2019] [Indexed: 12/13/2022]
Abstract
Opioids have long held a prominent role in the management of perioperative pain in adults and children. Published reports concerning the appropriate, and inappropriate, use of these medications in pediatric patients have appeared in various publications over the last 50 years. For this document, the Society for Pediatric Anesthesia appointed a taskforce to evaluate the available literature and formulate recommendations with respect to the most salient aspects of perioperative opioid administration in children. The recommendations are graded based on the strength of the available evidence, with consensus of the experts applied for those issues where evidence is not available. The goal of the recommendations was to address the most important issues concerning opioid administration to children after surgery, including appropriate assessment of pain, monitoring of patients on opioid therapy, opioid dosing considerations, side effects of opioid treatment, strategies for opioid delivery, and assessment of analgesic efficacy. Regular updates are planned with a re-release of guidelines every 2 years.
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Affiliation(s)
- Joseph P. Cravero
- Department of Anesthesiology, Critical Care, and Pain MedicineBoston Children's Hospital, Harvard Medical SchoolBostonMassachusetts
| | - Rita Agarwal
- Pediatric Anesthesiology DepartmentLucille Packard Children's Hospital, Stanford University Medical SchoolStanfordCalifornia
| | - Charles Berde
- Department of Anesthesiology, Critical Care, and Pain MedicineBoston Children's Hospital, Harvard Medical SchoolBostonMassachusetts
| | - Patrick Birmingham
- Department of AnesthesiologyAnn and Robert H. Lurie Children's Hospital Northwestern University Feinberg School of MedicineEvanstonIllinois
| | - Charles J. Coté
- Department of AnesthesiologyMass General Hospital for Children, Harvard UniversityBostonMassachusetts
| | - Jeffrey Galinkin
- Anesthesiology DepartmentChildren's Hospital of Colorado, University of ColoradoAuroraColorado
| | - Lisa Isaac
- Department of Anesthesia and Pain MedicineHospital for Sick Children, University of TorontoTorontoOntarioCanada
| | - Sabine Kost‐Byerly
- Pediatric Anesthesiology and Critical Care MedicineJohns Hopkins University HospitalBaltimoreMaryland
| | - David Krodel
- Department of AnesthesiologyAnn and Robert H. Lurie Children's Hospital Northwestern University Feinberg School of MedicineEvanstonIllinois
| | - Lynne Maxwell
- Department of Aneshtesiology and Critical Care MedicineChildren's Hospital of Philadelphia, Perelman School of Medicine at the University of PennsylvaniaPhiladelphia
| | - Terri Voepel‐Lewis
- Department of AneshteiologyC. S. Mott Children's Hospital, University of Michigan Medical SchoolAnn ArborMichigan
| | - Navil Sethna
- Department of Anesthesiology, Critical Care, and Pain MedicineBoston Children's Hospital, Harvard Medical SchoolBostonMassachusetts
| | - Robert Wilder
- Department of Anesthesiology and Perioperative MedicineMayo ClinicRochesterMinnesota
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Abstract
This paper is the thirty-eighth consecutive installment of the annual review of research concerning the endogenous opioid system. It summarizes papers published during 2015 that studied the behavioral effects of molecular, pharmacological and genetic manipulation of opioid peptides, opioid receptors, opioid agonists and opioid antagonists. The particular topics that continue to be covered include the molecular-biochemical effects and neurochemical localization studies of endogenous opioids and their receptors related to behavior, and the roles of these opioid peptides and receptors in pain and analgesia, stress and social status, tolerance and dependence, learning and memory, eating and drinking, drug abuse and alcohol, sexual activity and hormones, pregnancy, development and endocrinology, mental illness and mood, seizures and neurologic disorders, electrical-related activity and neurophysiology, general activity and locomotion, gastrointestinal, renal and hepatic functions, cardiovascular responses, respiration and thermoregulation, and immunological responses.
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Affiliation(s)
- Richard J Bodnar
- Department of Psychology and Neuropsychology Doctoral Sub-Program, Queens College, City University of New York, Flushing, NY 11367, United States.
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Gall O, Champigneulle B, Schweitzer B, Deram T, Maupain O, Montmayeur Verchere J, Orliaguet G. Postoperative pain assessment in children: a pilot study of the usefulness of the analgesia nociception index. Br J Anaesth 2016; 115:890-5. [PMID: 26582849 DOI: 10.1093/bja/aev361] [Citation(s) in RCA: 44] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND The ability to perform objective pain assessment is very important in paediatric patients. The goal of this study was to investigate the relationship between the analgesia nociception index (ANI), which is based on the heart rate variability, and objective measurements of pain intensity in young or cognitively impaired children, after surgical or imaging procedures (control group) under general anaesthesia. METHODS On arrival in the recovery room and subsequently at 5-10 min intervals, the level of pain was rated using the FLACC pain scale (0-10). The ANI values (0-100; 0 indicating the worst pain) were recorded simultaneously. The area under the receiver operating characteristic curve (AUC) and grey zone approach were used to evaluate the performance of the ANI to detect patients with FLACC >4. Instantaneous ANI values were compared with ANI values averaged over 256 s periods of time. RESULTS All children in the surgical group (n=32) developed moderate-to-severe pain (FLACC >4). Children in the control group (n=30) exhibited minimal pain. Instantaneous ANI values were lower in children of the surgical group than in the control group [52 (sd16) vs 69 (16), P<0.001]. The AUC for the 256 s ANI recording period [0.94 (95% confidence interval 0.85-0.99)] was significantly higher than for instantaneous ANI (P<0.05). When measured for a period of 256 s, an ANI cut-off value of 56 (grey zone [58-60]) was most predictive of a FLACC ≥4. CONCLUSIONS The ANI may provide an objective measurement of acute postoperative pain, which is correlated with that measured on a FLACC scale in young or cognitively impaired children.
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Affiliation(s)
- O Gall
- Service d'Anesthésie Réanimation. Hôpital Universitaire Necker - Enfants Malades, Université Paris Descartes, Assistance Publique Hôpitaux de Paris, 149 rue de Sèvres, Paris 75743, France
| | - B Champigneulle
- Service d'Anesthésie Réanimation. Hôpital Universitaire Necker - Enfants Malades, Université Paris Descartes, Assistance Publique Hôpitaux de Paris, 149 rue de Sèvres, Paris 75743, France
| | - B Schweitzer
- Service d'Anesthésie Réanimation. Hôpital Universitaire Necker - Enfants Malades, Université Paris Descartes, Assistance Publique Hôpitaux de Paris, 149 rue de Sèvres, Paris 75743, France
| | - T Deram
- Service d'Anesthésie Réanimation. Hôpital Universitaire Necker - Enfants Malades, Université Paris Descartes, Assistance Publique Hôpitaux de Paris, 149 rue de Sèvres, Paris 75743, France
| | - O Maupain
- Service d'Anesthésie Réanimation. Hôpital Universitaire Necker - Enfants Malades, Université Paris Descartes, Assistance Publique Hôpitaux de Paris, 149 rue de Sèvres, Paris 75743, France
| | - J Montmayeur Verchere
- Service d'Anesthésie Réanimation. Hôpital Universitaire Necker - Enfants Malades, Université Paris Descartes, Assistance Publique Hôpitaux de Paris, 149 rue de Sèvres, Paris 75743, France
| | - G Orliaguet
- Service d'Anesthésie Réanimation. Hôpital Universitaire Necker - Enfants Malades, Université Paris Descartes, Assistance Publique Hôpitaux de Paris, 149 rue de Sèvres, Paris 75743, France
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Lukosiene L, Macas A, Trepenaitis D, Kalibatiene L, Malcius D, Barauskas V. Single shot intercostal block for pain management in pediatric patients undergoing the Nuss procedure: a double-blind, randomized, controlled study. J Pediatr Surg 2014; 49:1753-7. [PMID: 25487477 DOI: 10.1016/j.jpedsurg.2014.09.014] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2014] [Accepted: 09/05/2014] [Indexed: 11/18/2022]
Abstract
PURPOSE The aim of this study was to investigate the efficacy of a single shot intercostal block for pain control in pediatric patients undergoing the Nuss procedure. METHODS A double-blind, randomized, controlled study was performed. Thirty patients received a single shot bilateral intercostal block with levobupivacaine (L group) and 30 patients with 0.9 % saline (S group). Standardized baseline analgesia was applied for all patients. Morphine consumption, pain scores, respiratory depression, nausea and vomiting, and urinary retention were recorded every 3h for 48h after surgery. RESULTS The loading dose of morphine was lower (p<0.00001) in the L group. There were significantly lower morphine doses up to 6h after surgery and VAS scores up to 3h after surgery in the L group (p<0.001 and p=0.0003, respectively). The incidence of nausea and vomiting was lower in the L group (<0.00001). The incidence of urinary retention was lower in the L group (p=0.019). CONCLUSIONS A single shot IB is an effective additional treatment for pediatric patients undergoing the Nuss procedure and results in the reduced consumption of morphine, less postoperative pain, and fewer opioid-related adverse effects.
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Affiliation(s)
- Laura Lukosiene
- Lithuanian University of Health Sciences, Medical Academy, Lithuania.
| | - Andrius Macas
- Lithuanian University of Health Sciences, Medical Academy, Lithuania.
| | | | - Lina Kalibatiene
- Lithuanian University of Health Sciences, Medical Academy, Lithuania.
| | - Dalius Malcius
- Lithuanian University of Health Sciences, Medical Academy, Lithuania.
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Modulatory effects of TAOK3 variants on morphine requirement in acute postoperative pain: an early genome wide association study contribution to the field of pediatric pain. Pain 2014; 155:2435-2437. [PMID: 25456570 DOI: 10.1016/j.pain.2014.09.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2014] [Accepted: 09/05/2014] [Indexed: 11/23/2022]
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Confronting the challenges of effective pain management in children following tonsillectomy. Int J Pediatr Otorhinolaryngol 2014; 78:1813-27. [PMID: 25241379 DOI: 10.1016/j.ijporl.2014.08.011] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2014] [Accepted: 08/11/2014] [Indexed: 12/29/2022]
Abstract
Tonsillectomy is an extremely common surgical procedure associated with significant morbidity and mortality. The post-operative challenges include: respiratory complications, post-tonsillectomy hemorrhage, nausea, vomiting and significant pain. The present model of care demands that most of these children are managed in an ambulatory setting. The recent Federal Drug Agency (FDA) warning contraindicating the use of codeine after tonsillectomy in children represents a significant change of practice for many pediatric otolaryngological surgeons. This introduces a number of other safety concerns when deciding on a safe alternative to codeine, especially since most tonsillectomy patients are managed by lay primary caregiver's at home. This review outlines the safety issues and proposes, based on currently available evidence, a preventative multi-modal strategy to manage pain, nausea and vomiting without increasing the risk of post-tonsillectomy bleeding.
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Sadhasivam S, Zhang X, Prows CA, Kaufman KM, Martin LJ. Challenges and cautions with small and retrospective postoperative pain genome-wide association studies with TAOK3. Pain 2014; 155:2434-2435. [PMID: 25139587 DOI: 10.1016/j.pain.2014.08.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2014] [Revised: 08/08/2014] [Accepted: 08/11/2014] [Indexed: 10/24/2022]
Affiliation(s)
- Senthilkumar Sadhasivam
- Departments of Anesthesia and Pediatrics, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, MLC 2001, Cincinnati, Ohio 45229, USA Department of Pediatrics and Division of Human Genetics, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA Department of Pediatrics and Division of Rheumatology, Cincinnati Children's Hospital Medical Center, and Cincinnati VA Medical Center, Cincinnati, Ohio, USA
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Anderson BJ, van den Anker J. Why is there no morphine concentration-response curve for acute pain? Paediatr Anaesth 2014; 24:233-8. [PMID: 24467568 DOI: 10.1111/pan.12361] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Affiliation(s)
- Brian J Anderson
- Department of Anaesthesiology, University of Auckland, Auckland, New Zealand.
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