The postoperative management of pain from intracranial surgery in pediatric neurosurgical patients

TLR4 inhibitors through inhibiting (MYD88-TRIF) pathway, protect against experimentally-induced intestinal (I/R) injury

Intestinal ischemia/reperfusion (I/R) injury is a serious condition that causes intestinal dysfunction and can be fatal. Previous research has shown that toll-like receptor 4 (TLR4) inhibitors have a protective effect against this injury. This study aimed to investigate the protective effects of TLR4 inhibitors, specifically cyclobenzaprine, ketotifen, amitriptyline, and naltrexone, in rats with intestinal (I/R) injury. Albino rats were divided into seven groups: vehicle control, sham-operated, I/R injury, I/R-cyclobenzaprine (10 mg/kg body weight), I/R-ketotifen (1 mg/kg body weight), I/R-amitriptyline (10 mg/kg body weight), and I/R-naltrexone (4 mg/kg body weight) groups. Anesthetized rats (urethane 1.8 g/kg) underwent 30 min of intestinal ischemia by occluding the superior mesenteric artery (SMA), followed by 2 h of reperfusion. Intestinal tissue samples were collected to measure various parameters, including malondialdehyde (MDA), nitric oxide synthase (NO), myeloperoxidase (MPO), superoxide dismutase (SOD), TLR4, intercellular adhesion molecule-1 (ICAM-1), nuclear factor kappa bp65 (NF-ĸBP65), monocyte chemoattractant protein-1 (MCP-1), tumor necrosis factor-α (TNF-α), macrophages CD68, myeloid differentiation factor 88 (MYD88), and toll interleukin receptor-domain-containing adaptor-inducing interferon β (TRIF). The use of TLR4 inhibitors significantly reduced MDA, MPO, and NO levels, while increasing SOD activity. Furthermore, it significantly decreased TLR4, ICAM-1, TNF-α, MCP-1, MYD88, and TRIF levels. These drugs also showed partial restoration of normal cellular structure with reduced inflammation. Additionally, there was a decrease in NF-ĸBP65 and macrophages CD68 staining compared to rats in the I/R groups. This study focuses on how TLR4 inhibitors enhance intestinal function and protect against intestinal (I/R) injury by influencing macrophages CD86 through (MYD88-TRIF) pathway, as well as their effects on oxidation and inflammation.

Effect of scalp nerve block with ropivacaine on postoperative pain in pediatric patients undergoing craniotomy: A randomized controlled trial

Background

Scalp nerve block (SNB) is widely used for postoperative pain control, intraoperative hemodynamic control, and opioid-sparing in adult craniotomies. However, there are few studies of SNB in pediatric patients undergoing craniotomy. In the present study, we aimed to investigate the effect of SNB on postoperative pain, intraoperative hemodynamic stability, and narcotic consumption in pediatric craniotomy under general anesthesia.

Methods

This trial is a single-center, prospective, randomized, and double-blind study. A total of 50 children aged between 2 and 12 years who are undergoing elective brain tumor surgery will be randomly allocated in a 1:1 ratio to receive either 0.2% ropivacaine for SNB (group SNB, intervention group, n = 25) or the same volume of saline (group Ctrl, control group, n = 25). The primary outcome was to assess the score of postoperative pain intensity at time 1, 4, 8, 12, 24, and 48 h postoperatively using the FLACC score method. Secondary outcomes were to record intraoperative hemodynamic variables (MAP and HR) during skull-pin fixation, skin incision and end of skin closure, intraoperative total consumption of remifentanil and propofol, postoperative opioid consumption, and the incidence of postoperative nausea and vomiting.

Results

Fifty patients were analyzed (n = 25 in SNB group; n = 25 in control group). Compared to the control group, postoperative pain intensity was significantly relieved in the SNB group up to 8 h post-operatively. In addition, SNB provided good intraoperative hemodynamic stability, reduced intraoperative overall propofol and remifentanil consumption rate, and postoperative fentanyl consumption compared to the control group. However, the incidence of postoperative nausea and vomiting was not different between SNB and the control group.

Conclusions

In pediatric craniotomies, SNB with 0.2% ropivacaine provides adequate postoperative pain control and good intraoperative hemodynamic stability during noxious events compared to the control group.

Clinical trial registration

Chinese Clinical Trial Registry [No: ChiCTR2100050594], Prospective registration.

Analgesia in the Neurosurgical Intensive Care Unit

Acute pain in neurosurgical patients is an important issue. Opioids are the most used for pain treatment in the neurosurgical ICU. Potential side effects of opioid use such as oversedation, respiratory depression, hypercapnia, worsening intracranial pressure, nausea, and vomiting may be problems and could interfere with neurologic assessment. Consequently, reducing opioids and use of non-opioid analgesics and adjuvants (N-methyl-D-aspartate antagonists, α2 -adrenergic agonists, anticonvulsants, corticosteroids), as well as non-pharmacological therapies were introduced as a part of a multimodal regimen. Local and regional anesthesia is effective in opioid reduction during the early postoperative period. Among non-opioid agents, acetaminophen and non-steroidal anti-inflammatory drugs are used frequently. Adverse events associated with opioid use in neurosurgical patients are discussed. Larger controlled studies are needed to find optimal pain management tailored to neurologically impaired neurosurgical patients.

Dexamethasone as a ropivacaine adjuvant to pre-emptive incision-site infiltration analgesia in pediatric craniotomy patients: A prospective, multicenter, randomized, double-blind, controlled trial

BACKGROUND

Dexamethasone added to incision-site infiltration has been routinely used to reduce pain after tonsillectomy in children. However, this has not been studied in pediatric craniotomy patients yet. We hypothesized that incision-site infiltration with a combination of ropivacaine and dexamethasone might provide superior analgesia to ropivacaine alone in pediatric craniotomy patients.

METHODS

In this multicenter, double-blind, randomized, controlled trial, children aged 2-12 years, scheduled for craniotomy, were prospectively enrolled at two study centers, from September 2, 2019, to July 5, 2020. Eighty children were randomly assigned (1:1) to either ropivacaine plus dexamethasone group who received pre-emptive incision-site infiltration with 0.2% ropivacaine plus 0.025% dexamethasone, or ropivacaine group who received 0.2% ropivacaine alone. Primary outcome was the modified Children's Hospital of Eastern Ontario Pain Scale (mCHEOPS) at 24 h postoperatively. Primary analysis was performed using the modified intention-to-treat principle.

RESULTS

Pre-emptive incision-site infiltration with ropivacaine plus dexamethasone had a reduced pain score of 2.0, compared with the pain score of 2.9 in the ropivacaine group, at 24 h postoperatively (mean difference -0.9, 95% confidence interval [CI], -1.7 to -0.2; p = .019). Estimated median of the time of first rescue analgesic demand was 24 h in the ropivacaine plus dexamethasone group and 8.5 h in the ropivacaine group [hazard ratio 0.43, 95% CI 0.24 to 0.08; Log-rank p = .0025]. No adverse events related to incision-site infiltration with dexamethasone were observed in this study.

DISCUSSION

Dexamethsone reduces the local production of pro-inflammatory factors after tissue damage and as a ropivacaine adjuvant for incision-site infiltration reduced the pain scores by 31% at 24 h postoperatively. The results were similar to several prior studies on to tonsillectomy patients. However, this changes on pain scores might has limited clinical significance.

CONCLUSIONS

The addition of dexamethasone to ropivacaine for preoperative incision-site infiltration has better postoperative analgesic effect than ropivacaine alone in pediatric craniotomy patients.

Prevention and treatment of postoperative pain in pediatric patients undergone craniotomy: Systematic review of clinical evidence

BACKGROUND

Prevention and treatment of postoperative pain after craniotomy in pediatric patients is an open and challenging clinical problem due to limited epidemiological data and significant concerns on safety of the most common analgesics in neurosurgical patients. We reviewed the literature to evaluate the possible available strategies in pain management in pediatric patients.

METHODS

The systematic review was performed in accordance with PRISMA statement recommendations. PUBMED, EMBASE and Scopus databases were queried. Inclusion criteria were: randomized controlled trials, prospective and retrospective observational studies published before 2020 and reported postoperative pain management after craniotomy (i.e. including studies accomplished after craniotomy, craniectomy and reconstructive surgery) in children population (neonates to 18 years old).

RESULTS

A total of 11 studies - 4 randomized controlled, 5 prospective observational and 2 retrospective met criteria for inclusion. The selected studies reported data from a total of 1077 patients, with age ranging between neonates to 18 years, 52% male and 48% female. Opioids are still the most commonly used drugs. Paracetamol and NSAIDs are frequently used as adjuvants to reduce postoperative opioid requirements. Data on potential hypocoagulation due to the antiplatelet effect of NSAIDs are lacking. Selective scalp block provides lower pain scores in early postoperative period.

CONCLUSION

Clinical evidence on prevention and treatment of postoperative pain in pediatric patients undergone craniotomy is still sparse. Available data prove that a multimodal approach, realized as the use a combination of opioids, paracetamol/NSAIDs and regional anesthesia, is effective and rarely associate with complications.

Opioids in the Management of Acute Pediatric Pain: An Update in a Time of Crisis

Management of acute pain in children is fundamental to our practice. Its myriad benefits include reduced suffering, improved patient satisfaction, more rapid recovery, and a reduced risk of developing postsurgical chronic pain. Although a multimodal analgesic approach is now routinely used, informed and judicious use of opioid receptor agonists remains crucial in this treatment paradigm, as long as the benefits and risks are fully understood. Further, an ongoing public health response to the current opioid crisis is required to help prevent new cases of opioid addiction, identify opioid-addicted individuals, and ensure access to effective opioid addiction treatment, while at the same time continuing to safely meet the needs of patients experiencing pain.

Utility of a Team-Based Multimodal Opioid Reduction Protocol for the Pediatric Plastic Surgery Population

Opioid use can cause significant adverse side effects with increased propensity toward both short- and long-term complications in the pediatric population. We present a multifaceted opioid reduction protocol based on physician and care team member education. The strategy was designed to alter prescribing practices, improve preoperative and postoperative patient education, increase the use of nonnarcotic pain control modalities, and improve coordination of opiate reduction strategies for all team members participating in patient care. We present the utility of this strategy in limiting postoperative narcotic use in the pediatric plastic surgery population.A prospective study with historical controls was conducted to evaluate pediatric patients undergoing elective pediatric plastic surgery procedures at 3-month intervals in 2016, 2017, and 2018. In the final year, the dedicated opiate reduction protocol was implemented before the data collection period, and results were compared with the prior 2 collection periods. The primary outcomes were total days and doses of outpatient narcotics prescribed after surgery.The median days (quartiles) of opioids prescribed in 2016, 2017, and 2018 cohorts were 1.5 (1.1, 2.5) days, 1.5 (1.4, 2.5) days, and 0.8 (0, 1.6) days, respectively. The median doses (quartiles) of opioids prescribed in 2016, 2017, and 2018 cohorts were 6.3 (6, 10), 6.0 (5.7, 15.0), and 4.2 (0, 6.2) doses, respectively. There were statistically significantly less days and doses of opioids prescribed in the 2018 cohort when compared with the 2016 (P < 0.0001) and 2017 (P < 0.0001) cohorts.A multimodal opioid reduction protocol was successfully implemented for the pediatric plastic surgery population. Patients were able to shorten the duration of narcotic prescription upon discharge with the use of a multidisciplinary team approach.

Analgesia, sedation, and delirium in pediatric surgical critical care

The alleviation of discomfort and distress is an essential component of the management of critically ill surgical patients. Pain and anxiety have multifocal etiologies that may be related to an underlying disease or surgical procedure, ongoing medical therapy, invasive monitors, an unfamiliar, complex and chaotic environment, as well as fear. Pharmacologic and non-pharmacologic therapies have complex risk benefit profiles. A fundamental understanding of analgesia, sedation, and delirium is essential for optimizing important outcomes in critically ill pediatric surgical patients. There has been a recent emphasis on goal directed, evidence based, and patient-centered management of the physical and psychological needs of these children. The purpose of this article is to review and summarize recent advances and describe current practice of these important subjects in the pediatric surgical intensive care environment.

Pharmacokinetic considerations for pediatric patients receiving analgesia in the intensive care unit; targeting postoperative, ECMO and hypothermia patients

INTRODUCTION

Adequate postoperative analgesia in pediatric patients in the intensive care unit (ICU) matters, since untreated pain is associated with negative outcomes. Compared to routine postoperative patients, children undergoing hypothermia (HT) or extracorporeal membrane oxygenation (ECMO), or recovering after cardiac surgery likely display non-maturational differences in pharmacokinetics (PK) and pharmacodynamics (PD). These differences warrant additional dosing recommendations to optimize pain treatment. Areas covered: Specific populations within the ICU will be discussed with respect to expected variations in PK and PD for various analgesics. We hereby move beyond maturational changes and focus on why PK/PD may be different in children undergoing HT, ECMO or cardiac surgery. We provide a stepwise manner to develop PK-based dosing regimens using population PK approaches in these populations. Expert opinion: A one-dose to size-fits-all for analgesia is suboptimal, but for several commonly used analgesics the impact of HT, ECMO or cardiac surgery on average PK parameters in children is not yet sufficiently known. Parameters considering both maturational and non-maturational covariates are important to develop population PK-based dosing advices as part of a strategy to optimize pain treatment.

Review of the enhanced recovery pathway for children: perioperative anesthetic considerations

PURPOSE

Enhanced recovery after surgery (ERAS) pathways have been used for two decades to improve perioperative recovery in adults. Nevertheless, little is known about their effectiveness in children. The purpose of this review was to consider pediatric ERAS pathways, review the literature concerned with their potential benefit, and compare them with adult ERAS pathways.

SOURCE

A PubMed literature search was performed for articles that included the terms enhanced recovery and/or fast track in the pediatric perioperative period. Pediatric patients included those from the neonatal period through teenagers and/or youths.

PRINCIPAL FINDINGS

The literature search revealed a paucity of articles about pediatric ERAS. This lack of academic investigation is likely due in part to the delayed acceptance of ERAS in the pediatric surgical arena. Several pediatric studies examined individual components of adult-based ERAS pathways, but the overall study of a comprehensive multidisciplinary ERAS protocol in pediatric patients is lacking.

CONCLUSION

Although adult ERAS pathways have been successful at reducing patient morbidity, the translation, creation, and utility of instituting pediatric ERAS pathways have yet to be realized.

An Analysis of 34,218 Pediatric Outpatient Controlled Substance Prescriptions

BACKGROUND

Prescription errors are among the most common types of iatrogenic errors. Because of a previously reported 82% error rate in handwritten discharge narcotic prescriptions, we developed a computerized, web-based, controlled substance prescription writer that includes weight-based dosing logic and alerts to reduce the error rate to (virtually) zero. Over the past 7 years, >34,000 prescriptions have been created by hospital providers using this platform. We sought to determine the ongoing efficacy of the program in prescription error reduction and the patterns with which providers prescribe controlled substances for children and young adults (ages 0-21 years) at hospital discharge.

METHODS

We examined a database of 34,218 controlled substance discharge prescriptions written by our institutional providers from January 1, 2007 to February 14, 2014, for demographic information, including age and weight, type of medication prescribed based on patient age, formulation of dispensed medication, and amount of drug to be dispensed at hospital discharge. In addition, we randomly regenerated 2% (700) of prescriptions based on stored data and analyzed them for errors using previously established error criteria. Weights that were manually entered into the prescription writer by the prescriber were compared with the patient's weight in the hospital's electronic medical record.

RESULTS

Patients in the database averaged 9 ± 6.1 (range, 0-21) years of age and 36.7 ± 24.9 (1-195) kg. Regardless of age, the most commonly prescribed opioid was oxycodone (73%), which was prescribed as a single agent uncombined with acetaminophen. Codeine was prescribed to 7% of patients and always in a formulation containing acetaminophen. Liquid formulations were prescribed to 98% of children <6 years of age and to 16% of children >12 years of age (the remaining 84% received tablet formulations). Regardless of opioid prescribed, the amount of liquid dispensed averaged 106 ± 125 (range, 2-3240) mL, and the number of tablets dispensed averaged 51 ± 51 (range, 1-1080). Of the subset of 700 regenerated prescriptions, all were legible (drug, amount dispensed, dose, patient demographics, and provider name) and used best prescribing practice (e.g., no trailing zero after a decimal point, leading zero for doses <1). Twenty-five of the 700 (3.6%) had incorrectly entered weights compared with the most recent weight in the chart. Of these, 14 varied by 10% or less and only 2 varied by >15%. Of these, 1 resulted in underdosing (true weight 80 kg prescribed for a weight of 50 kg) and the other in overdosing (true weight 10 kg prescribed for a weight of 30 kg).

CONCLUSIONS

A computerized prescription writer eliminated most but not all the errors common to handwritten prescriptions. Oxycodone has supplanted codeine as the most commonly prescribed oral opioid in current pediatric pain practice and, independent of formulation, is dispensed in large quantities. This study underscores the need for liquid opioid formulations in the pediatric population and, because of their abuse potential, the urgent need to determine how much of the prescribed medication is actually used by patients.

Options for perioperative pain management in neurosurgery

Moderate-to-severe pain following neurosurgery is common but often does not get attention and is therefore underdiagnosed and undertreated. Compounding this problem is the traditional belief that neurosurgical pain is inconsequential and even dangerous to treat. Concerns about problematic effects associated with opioid analgesics such as nausea, vomiting, oversedation, and increased intracranial pressure secondary to elevated carbon dioxide tension from respiratory depression have often led to suboptimal postoperative analgesic strategies in caring for neurosurgical patients. Neurosurgical patients may have difficulty or be incapable of communicating their need for analgesics due to neurologic deficits, which poses an additional challenge. Postoperative pain control should be a priority, because pain adversely affects recovery and patient outcomes. Inconsistent practices and the quality of current analgesic strategies for neurosurgical patients still leave room for improvement. Given the complexity of postoperative pain management for these patients, multimodal strategies are often required to optimize pain control and at the same time limit undesired side effects.

The Role of NMDARs Ligands on Antinociceptive Effects of Pregabalin in the Tail Flick Test

Background:

Pregabalin as a new anticonvulsant has been used in different pain treatments.

Objectives:

The aim of this study was to investigate the role of N-methyl-D-aspartate (NMDA) ligands in antinociceptive effect of pregabalin in mice using tail flick.

Materials and Methods:

NMDA (15 and 30 mg/kg) as an agonist or MK801 (0.02 and 0.05 mg/kg) as an antagonist were injected intraperitoneally either alone or 15 minutes before antinociceptive dose of pregabalin (100 mg/kg). Then the latency times and %MPE were measured in the tail flick assay during 75 minutes.

Results:

NMDA and MK801 had no effects alone. NMDA pretreatment significantly decreased the latency times of pregabalin till 75^th minutes. In NMDA pretreated groups, %MPE₃₀ unlike %MPE₇₅ decreased significantly compared to those of pregabalin. MK801 delayed the latency times in pretreated groups, but %MPE₃₀ and %MPE₇₅ did not change significantly compared to pregabalin alone.

Conclusions:

Our findings support the role of NMDARs in pregabalin antinociception, because the NMDAR agonist, unlike the antagonist, decreased the antinociceptive effect of pregabalin, even if tail flick is not an adequate pain assessment method in this regard.