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Joe YE, Lee JH, Eum D, Kim JH, Lee JR. Intravenous dexamethasone does not prolong the duration of pudendal nerve block in infants and children undergoing hypospadias surgery: A randomized clinical trial. Paediatr Anaesth 2024; 34:259-266. [PMID: 38037830 DOI: 10.1111/pan.14805] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2023] [Revised: 10/27/2023] [Accepted: 11/19/2023] [Indexed: 12/02/2023]
Abstract
BACKGROUND The administration of intravenous dexamethasone increases the duration of neuraxial block and improves the quality of analgesia. However, little is known about these effects of dexamethasone on peripheral nerve blocks in children. AIMS In this study, we aimed to investigate the benefit of intravenous dexamethasone for enhancing the effect of pudendal block on postoperative analgesia in children who underwent hypospadias surgery. METHODS In total, 46 children aged 6-36 months who underwent hypospadias surgery were randomly allocated to either a control group (normal saline, group C) or dexamethasone group (0.5 mg/kg, group D). Pudendal block was performed before the surgery using 0.3 mL/kg of 0.225% ropivacaine on both sides. Parents were instructed to press the patient-controlled analgesia bolus button when their children's pain score was >4 points. The primary outcome measure was the time at which the first patient-controlled analgesia by proxy bolus dose was administered. The secondary outcome measures were pain score, number of patient-controlled analgesia administration by proxy bolus attempts, number of rescue analgesics required, total amount of fentanyl administered, and overall parental satisfaction. RESULTS The time of first patient-controlled analgesia bolus administration by proxy was not different between the control and dexamethasone groups (5.6 [5.2, 8.8] h versus 6.5 [5.4, 8.1] h, hazard ratio 0.8, 95% confidence intervals 0.43 to 1.47, p = .46). There were no statistically significant differences among the secondary outcomes. CONCLUSIONS Administration of intravenous dexamethasone did not enhance the duration of pudendal nerve block in infants and children aged 6-36 months who underwent hypospadias surgery.
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Affiliation(s)
- Young-Eun Joe
- Department of Anesthesiology and Pain Medicine, Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Seoul, South Korea
| | - Jae-Hoon Lee
- Department of Anesthesiology and Pain Medicine, Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Seoul, South Korea
| | - Darhae Eum
- Department of Anesthesiology and Pain Medicine, Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Seoul, South Korea
| | - Ji-Ho Kim
- Department of Anesthesiology and Pain Medicine, Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Seoul, South Korea
| | - Jeong-Rim Lee
- Department of Anesthesiology and Pain Medicine, Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Seoul, South Korea
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Guan J, Liu L, Yang Y, Zheng Z, Li J, Zheng Z. Erector spinae plane block versus caudal block for postoperative analgesia in pediatric patients undergoing inguinal hernia repair: a randomized controlled trial. Ann Med 2023; 55:2298868. [PMID: 38154039 PMCID: PMC10763821 DOI: 10.1080/07853890.2023.2298868] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2023] [Accepted: 12/19/2023] [Indexed: 12/30/2023] Open
Abstract
BACKGROUND Erector spinae plane block is a promising strategy for pain management in some settings. However, the effectiveness of erector spinae plane block versus caudal block in pediatric inguinal hernia repair has yet to be formally investigated. METHODS One hundred and two patients aged 2-5 years undergoing unilateral open inguinal hernia repair randomly received unilateral erector spinae plane block (0.2% ropivacaine 0.5 mL kg-1), caudal block (0.2% ropivacaine 1 mL kg-1), or no block. The primary outcome was time to the first rescue analgesia, defined as the interval from the end of surgery to the Face, Legs, Activity, Cry, and Consolability scale greater than three. Secondary outcomes included the number of patients requiring rescue analgesia, the area under the curve of pain scores over time, satisfaction of guardians, and adverse events. RESULTS The median time to the first rescue analgesia was longer in the erector spinae plane block group than in the caudal block group [10.0 h (interquartile range, 6.6-24.0 h) vs. 5.0 h (interquartile range, 2.9-7.3 h); p < .001]. The Cox regression model demonstrated that the risk of postoperative rescue analgesia requirement was 0.38 in children receiving erector spinae plane block compared with caudal block (95% confidence interval 0.23-0.64; p < .001). Additionally, the area under the curve of the pain scores over time was lower in the erector spinae plane block group than in the caudal block group (44.3 [36.6-50.7] vs. 59.0 [47.1-64.5]; p < .001). CONCLUSIONS Erector spinae plane block provided superior postoperative analgesia compared to caudal block in children undergoing inguinal hernia repair.Trial registration: Chinese Clinical Trial Registry; ChiCTR2100048303.
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Affiliation(s)
- Jinsheng Guan
- Department of Anesthesiology, Fujian Maternity and Child Health Hospital, College of Clinical Medicine for Obstetrics & Gynecology and Pediatrics, Fujian Medical University, Fuzhou, Fujian, People’s Republic of China
| | - Linwei Liu
- Department of Anesthesiology, Shengli Clinical Medical College of Fujian Medical University, Fujian Provincial Hospital, Fuzhou, Fujian, People’s Republic of China
| | - Ying Yang
- Department of Anesthesiology, Shengli Clinical Medical College of Fujian Medical University, Fujian Provincial Hospital, Fuzhou, Fujian, People’s Republic of China
| | - Zongli Zheng
- Department of Anesthesiology, Shengli Clinical Medical College of Fujian Medical University, Fujian Provincial Hospital, Fuzhou, Fujian, People’s Republic of China
| | - Junyu Li
- Department of Anesthesiology, Shengli Clinical Medical College of Fujian Medical University, Fujian Provincial Hospital, Fuzhou, Fujian, People’s Republic of China
| | - Zheng Zheng
- Department of Neurology, Shengli Clinical Medical College of Fujian Medical University, Fuzhou, Fujian, People’s Republic of China
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Ringsten M, Kredo T, Ebrahim S, Hohlfeld A, Bruschettini M. Diclofenac for acute postoperative pain in children. Cochrane Database Syst Rev 2023; 12:CD015087. [PMID: 38078559 PMCID: PMC10712214 DOI: 10.1002/14651858.cd015087.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: 12/18/2023]
Abstract
BACKGROUND Many children undergo various surgeries, which often lead to acute postoperative pain. This pain influences recovery and quality of life. Non-steroidal anti-inflammatory drugs (NSAIDs), specifically cyclo-oxygenase (COX) inhibitors such as diclofenac, can be used to treat pain and reduce inflammation. There is uncertainty regarding diclofenac's benefits and harms compared to placebo or other drugs for postoperative pain. OBJECTIVES To assess the efficacy and safety of diclofenac (any dose) for acute postoperative pain management in children compared with placebo, other active comparators, or diclofenac administered by different routes (e.g. oral, rectal, etc.) or strategies (e.g. 'as needed' versus 'as scheduled'). SEARCH METHODS We used standard, extensive Cochrane search methods. We searched CENTRAL, MEDLINE, and trial registries on 11 April 2022. SELECTION CRITERIA We included randomised controlled trials (RCTs) in children under 18 years of age undergoing surgery that compared diclofenac (delivered in any dose and route) to placebo or any active pharmacological intervention. We included RCTs comparing different administration routes of diclofenac and different strategies. DATA COLLECTION AND ANALYSIS We used standard methodological procedures expected by Cochrane. Our primary outcomes were: pain relief (PR) reported by the child, defined as the proportion of children reporting 50% or better postoperative pain relief; pain intensity (PI) reported by the child; adverse events (AEs); and serious adverse events (SAEs). We presented results using risk ratios (RR), mean differences (MD), and standardised mean differences (SMD), with the associated confidence intervals (CI). MAIN RESULTS We included 32 RCTs with 2250 children. All surgeries were done using general anaesthesia. Most studies (27) included children above age three. Only two studies had an overall low risk of bias; 30 had an unclear or high risk of bias in one or several domains. Diclofenac versus placebo (three studies) None of the included studies reported on PR or PI. We are very uncertain about the benefits and harms of diclofenac versus placebo on nausea/vomiting (RR 0.83, 95% CI 0.38 to 1.80; 2 studies, 100 children) and any reported bleeding (RR 3.00, 95% CI 0.34 to 26.45; 2 studies, 100 children), both very low-certainty evidence. None of the included studies reported SAEs. Diclofenac versus opioids (seven studies) We are very uncertain if diclofenac reduces PI at 2 to 24 hours postoperatively compared to opioids (median pain intensity 0.3 (interquartile range (IQR) 0.0 to 2.5) for diclofenac versus median 0.7 (IQR 0.1 to 2.4) in the opioid group; 1 study, 50 children; very low-certainty evidence). None of the included studies reported on PR or PI for other time points. Diclofenac probably results in less nausea/vomiting compared to opioids (41.0% in opioids, 31.0% in diclofenac; RR 0.75, 95% CI 0.58 to 0.96; 7 studies, 463 participants), and probably increases any reported bleeding (5.4% in opioids, 16.5% in diclofenac; RR 3.06, 95% CI 1.31 to 7.13; 2 studies, 222 participants), both moderate-certainty evidence. None of the included studies reported SAEs. Diclofenac versus paracetamol (10 studies) None of the included studies assessed child-reported PR. Compared to paracetamol, we are very uncertain if diclofenac: reduces PI at 0 to 2 hours postoperatively (SMD -0.45, 95% CI -0.74 to -0.15; 2 studies, 180 children); reduces PI at 2 to 24 hours postoperatively (SMD -0.64, 95% CI -0.89 to -0.39; 3 studies, 300 children); reduces nausea/vomiting (RR 0.47, 95% CI 0.25 to 0.87; 5 studies, 348 children); reduces bleeding events (RR 0.57, 95% CI 0.12 to 2.62; 5 studies, 332 participants); or reduces SAEs (RR 0.50, 95% CI 0.05 to 5.22; 1 study, 60 children). The evidence certainty was very low for all outcomes. Diclofenac versus bupivacaine (five studies) None of the included studies reported on PR or PI. Compared to bupivacaine, we are very uncertain about the effect of diclofenac on nausea/vomiting (RR 1.28, 95% CI 0.58 to 2.78; 3 studies, 128 children) and SAEs (RR 4.52, 95% CI 0.23 to 88.38; 1 study, 38 children), both very low-certainty evidence. Diclofenac versus active pharmacological comparator (10 studies) We are very uncertain about the benefits and harms of diclofenac versus any other active pharmacological comparator (dexamethasone, pranoprofen, fluorometholone, oxybuprocaine, flurbiprofen, lignocaine), and for different routes and delivery of diclofenac, due to few and small studies, no reporting of key outcomes, and very low-certainty evidence for the reported outcomes. We are unable to draw any meaningful conclusions from the numerical results. AUTHORS' CONCLUSIONS We remain uncertain about the efficacy of diclofenac compared to placebo, active comparators, or by different routes of administration, for postoperative pain management in children. This is largely due to authors not reporting on clinically important outcomes; unclear reporting of the trials; or poor trial conduct reducing our confidence in the results. We remain uncertain about diclofenac's safety compared to placebo or active comparators, except for the comparison of diclofenac with opioids: diclofenac probably results in less nausea and vomiting compared with opioids, but more bleeding events. For healthcare providers managing postoperative pain, diclofenac is a COX inhibitor option, along with other pharmacological and non-pharmacological approaches. Healthcare providers should weigh the benefits and risks based on what is known of their respective pharmacological effects, rather than known efficacy. For surgical interventions in which bleeding or nausea and vomiting are a concern postoperatively, the risks of adverse events using opioids or diclofenac for managing pain should be considered.
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Affiliation(s)
- Martin Ringsten
- Department of Health Sciences, Lund University, Skåne University Hospital, Lund, Sweden
- Cochrane Sweden, Lund University, Skåne University Hospital, Lund, Sweden
| | - Tamara Kredo
- Health Systems Research Unit, South African Medical Research Council, Cape Town, South Africa
| | - Sumayyah Ebrahim
- Health Systems Research Unit, South African Medical Research Council, Cape Town, South Africa
- Department of Surgery, School of Clinical Medicine, University of KwaZulu-Natal, Durban, South Africa
| | - Ameer Hohlfeld
- Health Systems Research Unit, South African Medical Research Council, Cape Town, South Africa
| | - Matteo Bruschettini
- Cochrane Sweden, Lund University, Skåne University Hospital, Lund, Sweden
- Department of Clinical Sciences Lund, Paediatrics, Lund University, Skåne University Hospital, Lund, Sweden
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Archer VA, Samiee-Zafarghandy S, Farrokyhar F, Briatico D, Braga LH, Walton JM. Intravenous acetaminophen for postoperative pain in the neonatal intensive care unit: A protocol for a pilot randomized controlled trial (IVA POP). PLoS One 2023; 18:e0294519. [PMID: 37983228 PMCID: PMC10659208 DOI: 10.1371/journal.pone.0294519] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2023] [Accepted: 10/20/2023] [Indexed: 11/22/2023] Open
Abstract
BACKGROUND In neonates, uncontrolled pain and opioid exposure are both correlated with short- and long-term adverse events. Therefore, managing pain using opioid-sparing approaches is critical in neonatal populations. Multimodal pain control offers the opportunity to manage pain while reducing short- and long-term opioid-related adverse events. Intravenous (IV) acetaminophen may represent an appropriate adjunct to opioid-based postoperative pain control regimes. However, no trials assess this drug in patients less than 36 weeks post-conceptual age or weighing less than 1500 g. OBJECTIVE The proposed study aims to determine the feasibility of conducting a randomized control trial to compare IV acetaminophen and fentanyl to a saline placebo and fentanyl for patients admitted to the neonatal intensive care unit (NICU) undergoing major abdominal or thoracic surgery. METHODS AND DESIGN This protocol is for a single-centre, external pilot randomized controlled trial (RCT). Infants in the NICU who have undergone major thoracic or abdominal surgery will be enrolled. Sixty participants will undergo 1:1 randomization to receive intravenous acetaminophen and fentanyl or saline placebo and fentanyl. After surgery, IV acetaminophen or placebo will be given routinely for eight days (192 hours). Appropriate dosing will be determined based on the participant's gestational age. Patients will be followed for eight days after surgery and will undergo a chart review at 90 days. Primarily feasibility outcomes include recruitment rate, follow-up rate, compliance, and blinding index. Secondary clinical outcomes will be collected as well. CONCLUSION This external pilot RCT will assess the feasibility of performing a multicenter RCT comparing IV acetaminophen and fentanyl to a saline placebo and fentanyl in NICU patients following major abdominal and thoracic surgery. The results will inform the design of a multicenter RCT, which will have the appropriate power to determine the efficacy of this treatment. TRIAL REGISTRATION ClinicalTrials.gov NCT05678244, Registered December 6, 2022.
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Affiliation(s)
- Victoria Anne Archer
- Division of General Surgery, Department of Surgery, McMaster University, Hamilton, ON, Canada
| | | | | | - Daniel Briatico
- Department of Surgery, McMaster University, Hamilton, ON, Canada
| | - Luis H. Braga
- Division of Urology, McMaster University, Hamilton, ON, Canada
| | - J. Mark Walton
- Division of Pediatric General Surgery, Department of Surgery, McMaster University, Hamilton, ON, Canada
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5
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Koo JM, Park HJ, Rim GM, Hyun K, Huh J, Choi H, Kim Y, Hwang W. Analysis of Factors Affecting Postoperative Opioid Requirement in Pediatric Patients Undergoing Pectus Excavatum Repair with Multimodal Analgesic Management. J Clin Med 2023; 12:5240. [PMID: 37629283 PMCID: PMC10455545 DOI: 10.3390/jcm12165240] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2023] [Revised: 08/04/2023] [Accepted: 08/10/2023] [Indexed: 08/27/2023] Open
Abstract
Children with pectus excavatum are treated with surgical repair in a procedure known as minimally invasive repair of pectus excavatum (MIRPE). MIRPE causes considerable postoperative pain, resulting in the administration of a substantial dose of opioids. This study aimed to identify perioperative factors that influence the requirement for opioids in children undergoing MIRPE. Retrospective data from children who underwent MIRPE were analyzed. A multimodal analgesic protocol was implemented with a continuous wound infiltration system and administration of non-opioid analgesics. Intravenous opioid analgesics were administered if the pain score was greater than 4. The cumulative opioid use was assessed by calculating the morphine equivalent dose at 6, 24, and 48 h after surgery. Perioperative factors affecting the postoperative opioid use were identified with multiple linear regression analyses. This study included 527 children aged 3-6 years, with a mean age of 3.9 years. Symmetrically depressed chest walls, a lower Haller index, and a lower revised depression index were found to be associated with decreased postoperative opioids. Boys required higher opioid doses than girls. Longer pectus bars (10 inches versus 9 inches) were associated with increased opioid use. Severity indices, gender, and the length of pectus bars influence postoperative opioid requirement in children undergoing MIRPE surgery with multimodal analgesia.
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Affiliation(s)
- Jung Min Koo
- Department of Anesthesiology and Pain Medicine, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul 02706, Republic of Korea; (J.M.K.); (J.H.); (H.C.)
| | - Hyung Joo Park
- Department of Thoracic and Cardiovascular Surgery, Nanoori Hospitals, Seoul 06048, Republic of Korea; (H.J.P.); (G.M.R.)
| | - Gong Min Rim
- Department of Thoracic and Cardiovascular Surgery, Nanoori Hospitals, Seoul 06048, Republic of Korea; (H.J.P.); (G.M.R.)
| | - Kwanyong Hyun
- Department of Thoracic and Cardiovascular Surgery, St. Vincent’s Hospital, College of Medicine, The Catholic University of Korea, Suwon 16247, Republic of Korea;
| | - Jaewon Huh
- Department of Anesthesiology and Pain Medicine, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul 02706, Republic of Korea; (J.M.K.); (J.H.); (H.C.)
| | - Hoon Choi
- Department of Anesthesiology and Pain Medicine, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul 02706, Republic of Korea; (J.M.K.); (J.H.); (H.C.)
| | - Yunji Kim
- Department of Anesthesiology and Pain Medicine, Uijeongbu St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Bucheon-si 11765, Republic of Korea;
| | - Wonjung Hwang
- Department of Anesthesiology and Pain Medicine, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul 02706, Republic of Korea; (J.M.K.); (J.H.); (H.C.)
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Gao L, Mu H, Lin Y, Wen Q, Gao P. Review of the Current Situation of Postoperative Pain and Causes of Inadequate Pain Management in Africa. J Pain Res 2023; 16:1767-1778. [PMID: 37273275 PMCID: PMC10237197 DOI: 10.2147/jpr.s405574] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2023] [Accepted: 05/16/2023] [Indexed: 06/06/2023] Open
Abstract
Postoperative pain is one of the most prevalent complications following surgery, and more than 47% of surgical patients endure postoperative discomfort worldwide. In Africa, due to resource shortages and other issues, postoperative pain is substantially more common when compared to developed countries. Severe postoperative pain has many negative effects, including possibly death, which can burden both individuals and society as a whole. Therefore, effectively controlling postoperative pain is becoming increasingly important. To enhance the effectiveness of future pain management, a thorough analysis of the current reasons for inadequate postoperative pain management is necessary. In this article, the present situations of occurring postoperative pain, children's postoperative pain, and pain management in Africa are reviewed, based on relevant and recent literature. In particular, the reasons for inadequate postoperative pain management in Africa are detailed in this article from five perspectives: the inadequate assessment of postoperative pain, the knowledge gap among medical professionals, the patients' misconceptions, the scarcity of resources, and the lack of medications. Additionally, we offer appropriate solutions following various factors.
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Affiliation(s)
- Lejun Gao
- Department of Anesthesiology, First Affiliated Hospital of Dalian Medical University, Dalian, People’s Republic of China
| | - Huaixin Mu
- Emergency Department, Shenyang Children’s Hospital, Shenyang, People’s Republic of China
| | - Yun Lin
- Department of Anesthesiology, First Affiliated Hospital of Dalian Medical University, Dalian, People’s Republic of China
| | - Qingping Wen
- Department of Anesthesiology, First Affiliated Hospital of Dalian Medical University, Dalian, People’s Republic of China
- Department of Anesthesiology, Dalian Medical University, Dalian, People’s Republic of China
| | - Peng Gao
- Department of Anesthesiology, First Affiliated Hospital of Dalian Medical University, Dalian, People’s Republic of China
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Hamed M, Asoglu H, Lampmann T, Winkelmann LM, Salemdawod A, Müller M, Vatter H, Banat M, Eichhorn L. Pain management with epidural catheter and epidural analgesia after spinal dorsal instrumentation of lumbar spine. Medicine (Baltimore) 2023; 102:e32902. [PMID: 36800634 PMCID: PMC9936043 DOI: 10.1097/md.0000000000032902] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/19/2023] Open
Abstract
Spinal dorsal instrumentation (SDI) is an established treatment for degenerative spinal diseases. Adequate and immediate postoperative pain control is important for patient recovery and may be compromised by uncertainty about its efficacy and concern about early postoperative surgical complications or adverse events. The aim of the current study was to compare the use of epidural analgesia (EA) with systemic analgesia (SA) as regards pain reduction and early postoperative complications after SDI. Pain management with epidural or systemic analgesia in patients undergoing SDI by posterior approach between January 2019 and July 2020 was evaluated by clinical functional testing, measuring total opioid amounts used, and evaluating numerical rating scale values 24 and 96 hours postoperatively. The following were also monitored: demographic data, number of affected segments, length of hospital stay, inflammatory markers (leukocytes and serum C-reactive protein), early postoperative surgical complication rates, and adverse events. In total 79 patients were included (33 in the EA and 46 in the SA group). The SA group had significantly lower numerical rating scale values at days 1 to 4 after surgery (P ≤ .001) and lower cumulative opioid use than the EA group (P < .001). We found no difference in infection parameters, length of hospital stay or surgery-related complication rates. Our data demonstrate that epidural anesthesia was inferior to an opioid-based SA regime in reducing postoperative pain in patients undergoing spinal surgery. There is no benefit to the use of epidural catheters.
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Affiliation(s)
- Motaz Hamed
- Department of Neurosurgery, University Hospital Bonn, Bonn, Germany
| | - Harun Asoglu
- Department of Neurosurgery, University Hospital Bonn, Bonn, Germany
| | - Tim Lampmann
- Department of Neurosurgery, University Hospital Bonn, Bonn, Germany
| | - Lena Marie Winkelmann
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Bonn, Bonn, Germany
| | - Abdallah Salemdawod
- Department of Neurosurgery, University Hospital Bonn, Bonn, Germany
- Center for Advanced Imaging Research, Department of Diagnostic Radiology and Nuclear Medicine, University of Maryland Marlene and Stewart Greenebaum, Comprehensive Cancer Center, University of Maryland, Baltimore, MD
| | - Martin Müller
- Department of Emergency Medicine, Inselspital, Bern University Hospital, Bern University, Bern, Switzerland
| | - Hartmut Vatter
- Department of Neurosurgery, University Hospital Bonn, Bonn, Germany
| | - Mohammed Banat
- Department of Neurosurgery, University Hospital Bonn, Bonn, Germany
- * Correspondence: Mohammed Banat, Department of Neurosurgery, University Hospital Bonn, Bonn, Germany (e-mail: )
| | - Lars Eichhorn
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Bonn, Bonn, Germany
- Clinic for Anesthesiology and Intensive Care Medicine, Helios Klinikum Bonn/Rhein-Sieg, Bonn, Germany
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8
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Wolfson PE, Andries J, Ahlers D, Whippo M. Ketamine-assisted psychotherapy in adolescents with multiple psychiatric diagnoses. Front Psychiatry 2023; 14:1141988. [PMID: 37065886 PMCID: PMC10098148 DOI: 10.3389/fpsyt.2023.1141988] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2023] [Accepted: 02/28/2023] [Indexed: 04/18/2023] Open
Abstract
Ketamine-assisted psychotherapy is a promising new treatment for a variety of mental disorders of adolescence. There is currently an adolescent mental health crisis, with a high prevalence of disorders, diagnostic complexity, and many adolescents failing to respond to conventional treatments. While there is strong evidence for the use of ketamine in adults for a variety of treatment-refractory mental illnesses, research in adolescents is in its early stages. Ketamine-assisted psychotherapy (KAP) has been described in adults with promising results and here we present the first published cases of the use of KAP in adolescents. The four cases include adolescents aged 14-19 at the initiation of treatment, each with a variety of comorbid diagnoses including treatment-resistant depression, bipolar disorder, eating disorders, anxiety, panic, and trauma-related symptoms. They each initially received sublingual ketamine, followed by sessions with intramuscular ketamine. Their courses varied, but each had symptomatic and functional improvements, and the treatment was well-tolerated. Subjective patient reports are included. Rapid resolution of symptomatology and suffering often occurs within months as the result of the application of KAP to adolescent psychiatric care but is not inevitable. Family involvement in the treatment process appears to be essential to success. The development of this modality may have a singularly positive impact that will expand the psychiatric toolbox and its healing potency.
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Affiliation(s)
- Philip E. Wolfson
- The Center for Transformational Psychotherapy, San Anselmo, CA, United States
- Ketamine Research Foundation, San Anselmo, CA, United States
- *Correspondence: Philip E. Wolfson
| | - Julane Andries
- The Center for Transformational Psychotherapy, San Anselmo, CA, United States
- Ketamine Research Foundation, San Anselmo, CA, United States
| | - Daniel Ahlers
- The Center for Transformational Psychotherapy, San Anselmo, CA, United States
- Ketamine Research Foundation, San Anselmo, CA, United States
| | - Melissa Whippo
- The Center for Transformational Psychotherapy, San Anselmo, CA, United States
- Ketamine Research Foundation, San Anselmo, CA, United States
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9
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Zhang Y, Wang YP, Wang HT, Xu YC, Lv HM, Yu Y, Wang P, Pei XD, Zhao JW, Nan ZH, Yang JJ. Ultrasound-guided quadratus lumborum block provided more effective analgesia for children undergoing lower abdominal laparoscopic surgery: a randomized clinical trial. Surg Endosc 2022; 36:9046-9053. [PMID: 35764836 DOI: 10.1007/s00464-022-09370-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Accepted: 05/28/2022] [Indexed: 01/06/2023]
Abstract
BACKGROUND Postoperative pain treatment for pediatrics is often inadequate and the evidence of pediatric postoperative analgesia is scarce. To our knowledge, no report regarding the comparison among caudal block, transversus abdominis plane (TAP) block and quadratus lumborum (QL) block for children undergoing lower abdominal laparoscopic surgery was found at present. Thus this trial aimed to compare the efficacies of them for children undergoing lower abdominal laparoscopic surgery. METHODS One hundred and eighty children aged from 1 to 12 years undergoing lower abdominal laparoscopic surgery were included and randomized to receive caudal block, TAP block or QL block. The primary outcome was the Face, Legs, Activity, Cry, and Consolability (FLACC) score at 30 min, 1 h, 4 h, 8 h, 12 h, and 24 h and tramadol consumption during first 24 h postoperatively. Secondary outcomes included the number of children received tramadol, time to first tramadol request, parents' satisfaction and postoperative adverse reactions. RESULTS The QLB group had lower postoperative FLACC scores at 8 h (median difference - 0.43, P = 0.03) than the Caudal group and at 4 h (median difference - 0.6, P = 0.001) and 8 h (median difference - 0.43, P = 0.03) than the TAPB group. The tramadol consumption was lower in the QLB group (28.43 ± 6.55) than the TAPB group (37.17 ± 6.12, P = 0.023). Although the number of children received tramadol did not differ among the three groups, the time to first tramadol request was longer in the QLB group (7.20 ± 0.79) than the caudal group (8.42 ± 0.61, P = 0.008). No statistical difference was observed concerning other secondary outcomes. CONCLUSIONS QLB produced more effective postoperative analgesia for children undergoing laparoscopic abdominal surgery compared with the TAPB and caudal block.
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Affiliation(s)
- Yue Zhang
- Department of Anesthesiology, Pain and Perioperative Medicine, The First Affiliated Hospital of Zhengzhou University, No. 1 East Jianshe Road, Zhengzhou, 450052, China
| | - Yan-Ping Wang
- Department of Anesthesiology, Pain and Perioperative Medicine, The First Affiliated Hospital of Zhengzhou University, No. 1 East Jianshe Road, Zhengzhou, 450052, China
| | - Hai-Tao Wang
- Department of Anesthesiology, Pain and Perioperative Medicine, The First Affiliated Hospital of Zhengzhou University, No. 1 East Jianshe Road, Zhengzhou, 450052, China
| | - Yu-Can Xu
- Department of Anesthesiology, Pain and Perioperative Medicine, The First Affiliated Hospital of Zhengzhou University, No. 1 East Jianshe Road, Zhengzhou, 450052, China
| | - Hui-Min Lv
- Department of Anesthesiology, Pain and Perioperative Medicine, The First Affiliated Hospital of Zhengzhou University, No. 1 East Jianshe Road, Zhengzhou, 450052, China
| | - Yang Yu
- Department of Anesthesiology, Pain and Perioperative Medicine, The First Affiliated Hospital of Zhengzhou University, No. 1 East Jianshe Road, Zhengzhou, 450052, China
| | - Peng Wang
- Department of Anesthesiology, Pain and Perioperative Medicine, The First Affiliated Hospital of Zhengzhou University, No. 1 East Jianshe Road, Zhengzhou, 450052, China
| | - Xiang-Dong Pei
- Department of Anesthesiology, Pain and Perioperative Medicine, The First Affiliated Hospital of Zhengzhou University, No. 1 East Jianshe Road, Zhengzhou, 450052, China
| | - Jing-Wei Zhao
- Department of Anesthesiology, Pain and Perioperative Medicine, The First Affiliated Hospital of Zhengzhou University, No. 1 East Jianshe Road, Zhengzhou, 450052, China
| | - Zhen-Hua Nan
- Department of Anesthesiology, Pain and Perioperative Medicine, The First Affiliated Hospital of Zhengzhou University, No. 1 East Jianshe Road, Zhengzhou, 450052, China
| | - Jian-Jun Yang
- Department of Anesthesiology, Pain and Perioperative Medicine, The First Affiliated Hospital of Zhengzhou University, No. 1 East Jianshe Road, Zhengzhou, 450052, China.
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10
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Unglert AK, Lehnick D, Szavay PO, Zundel S. A Novel Tool to Predict Postoperative Opioid Need after Laparoscopic Appendectomy in Children: A Step toward Evidence-Based Pain Management. Eur J Pediatr Surg 2022; 32:529-535. [PMID: 35263775 DOI: 10.1055/s-0042-1744148] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
BACKGROUND Optimizing postoperative pain treatment is essential to minimize morbidity, lower costs, and ensure patient and parent satisfaction. This study aims at identifying pre- and intraoperative parameters predicting opioid needs after laparoscopic appendectomy to enable timely and adequate postoperative pain control. MATERIALS AND METHODS A retrospective analysis of patients treated with laparoscopic appendectomy for appendicitis between January 2018 and March 2019 was performed. Multiple logistic regression was applied to identify predictors of opioid demand. RESULTS Based on our analysis, we developed a prediction tool for opioid requirements after laparoscopic appendectomies in children. The integrated parameters are: presence of turbid fluid, age, white-blood-cell count, symptom duration, and body temperature. CONCLUSION We developed an algorithm-based predictor tool that has the potential to better anticipate postoperative pain and, thereby, optimize pain management following laparoscopic appendectomies in children. The proposed predictor tool will need validation through further prospective studies.
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Affiliation(s)
- Ann-Katrin Unglert
- Department of Anesthesiology, University Hospital Zurich, Zurich, Switzerland
| | - Dirk Lehnick
- Department of Health Sciences and Health Policy, Universitat Luzern Kultur- und Sozialwissenschaftliche Fakultat, Luzern, Switzerland
| | - Philipp O Szavay
- Department of Pediatric Surgery, Luzerner Kantonsspital Kinderspital, Spitalstrasse, Lucerne, Switzerland
| | - Sabine Zundel
- Department of Pediatric Surgery, Luzerner Kantonsspital Kinderspital, Spitalstrasse, Lucerne, Switzerland
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11
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Mencía S, Alonso C, Pallás-Alonso C, López-Herce J. Evaluation and Treatment of Pain in Fetuses, Neonates and Children. CHILDREN (BASEL, SWITZERLAND) 2022; 9:1688. [PMID: 36360416 PMCID: PMC9689143 DOI: 10.3390/children9111688] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/08/2022] [Revised: 10/25/2022] [Accepted: 10/28/2022] [Indexed: 08/03/2023]
Abstract
The perception of pain is individual and differs between children and adults. The structures required to feel pain are developed at 24 weeks of gestation. However, pain assessment is complicated, especially in neonates, infants and preschool-age children. Clinical scales adapted to age are the most used methods for assessing and monitoring the degree of pain in children. They evaluate several behavioral and/or physiological parameters related to pain. Some monitors detect the physiological changes that occur in association with painful stimuli, but they do not yet have a clear clinical use. Multimodal analgesia is recommended for pain treatment with non-pharmacological and pharmacological interventions. It is necessary to establish pharmacotherapeutic protocols for analgesia adjusted to the acute or chronic, type and intensity of pain, as well as age. The most used analgesics in children are paracetamol, ibuprofen, dipyrone, opioids (morphine and fentanyl) and local anesthetics. Patient-controlled analgesia is an adequate alternative for adolescent and older children in specific situations, such as after surgery. In patients with severe or persistent pain, it is very important to consult with specific pain services.
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Affiliation(s)
- Santiago Mencía
- Pediatric Intensive Care Service, Gregorio Marañón General University Hospital, Health Research Institute of Gregorio Marañón Madrid, 28029 Madrid, Spain
- Departamento de Salud Pública y Maternoinfantil, Facultad de Medicina, Universidad Complutense de Madrid, 28040 Madrid, Spain
- Carlos III Institute, 28029 Madrid, Spain
| | - Clara Alonso
- Carlos III Institute, 28029 Madrid, Spain
- Department of Neonatology, 12 de Octubre University Hospital, 28041 Madrid, Spain
| | - Carmen Pallás-Alonso
- Departamento de Salud Pública y Maternoinfantil, Facultad de Medicina, Universidad Complutense de Madrid, 28040 Madrid, Spain
- Carlos III Institute, 28029 Madrid, Spain
- Department of Neonatology, 12 de Octubre University Hospital, 28041 Madrid, Spain
| | - Jesús López-Herce
- Pediatric Intensive Care Service, Gregorio Marañón General University Hospital, Health Research Institute of Gregorio Marañón Madrid, 28029 Madrid, Spain
- Departamento de Salud Pública y Maternoinfantil, Facultad de Medicina, Universidad Complutense de Madrid, 28040 Madrid, Spain
- Carlos III Institute, 28029 Madrid, Spain
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12
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Abstract
This is a protocol for a Cochrane Review (intervention). The objectives are as follows: To assess the efficacy and safety of diclofenac (any dose) for acute postoperative pain management in children compared with placebo, other active comparators, or diclofenac administered by either different routes (e.g. oral, rectal, etc.) or strategies (e.g. as needed versus as scheduled).
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13
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Fattah Kamel AA, Abdel Naby SM, Elmesallamy WARA, Salem DAE. Opioid sparing analgesia: Continuous intraoperative infusion of dexmedetomidine versus lidocaine for intracranial surgeries in children: A double-blind randomized clinical trial. EGYPTIAN JOURNAL OF ANAESTHESIA 2022. [DOI: 10.1080/11101849.2022.2048580] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
Affiliation(s)
- Alshaimaa Abdel Fattah Kamel
- Anesthesia, Intensive Care and Pain Management Department, Faculty of Human Medicine, Zagazig University, Alsharkia, Egypt
| | - Sara Mohamed Abdel Naby
- Anesthesia, Intensive Care and Pain Management Department, Faculty of Human Medicine, Zagazig University, Alsharkia, Egypt
| | | | - Dina Abdelhameed Elsadek Salem
- Anesthesia, Intensive Care and Pain Management Department, Faculty of Human Medicine, Zagazig University, Alsharkia, Egypt
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14
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Sykes AG, Oviedo P, Rooney AS, Gollin G. An assessment of dexmedetomidine as an opioid-sparing agent after neonatal open thoracic and abdominal operations. J Perinatol 2022; 42:307-312. [PMID: 34312472 DOI: 10.1038/s41372-021-01175-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2021] [Revised: 07/12/2021] [Accepted: 07/16/2021] [Indexed: 11/09/2022]
Abstract
OBJECTIVE To evaluate the efficacy of dexmedetomidine as an opioid-sparing agent in infants following open thoracic or abdominal operations. METHODS Retrospective review of postoperative neonates who received IV acetaminophen with or without dexmedetomidine. The primary outcome was opioid dosage within the first ten postoperative days. Secondary outcomes included times to extubation, full feedings and discharge. RESULTS 112 infants met inclusion criteria. Those managed with dexmedetomidine received 1.8-4.3 times more opioid on postoperative days 1-3, had longer times to extubation and trended towards longer lengths of hospital stay than infants who were not. Opioid was dosed >0.2 ME/kg on only 23% of days when the acetaminophen dose was >40 mg/kg/day and 10% of days when the acetaminophen dose was >45 mg/kg. CONCLUSION Dexmedetomidine may not be opioid sparing after major operations in neonates and its use delays recovery. IV acetaminophen dosed at 40 mg/kg/day or greater may yield the most substantial opioid-sparing effect.
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Affiliation(s)
| | - Parisa Oviedo
- University of California San Diego School of Medicine, San Diego, CA, USA
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15
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Stake CE, Manworren RCB, Rizeq YK, Minhas S, Quan H, Barsness KA. Use of Opioids and Nonopioid Analgesics to Treat Pediatric Postoperative Pain in the Emergency Department. Pediatr Emerg Care 2022; 38:e234-e239. [PMID: 32941362 DOI: 10.1097/pec.0000000000002227] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES The incidence, demographic characteristics, and treatment approaches for pediatric patients who present to the ED with a primary complaint of postoperative pain have not been well described. The purpose of this study was to describe opioid and nonopioid prescribing patterns for pediatric patients evaluated for postoperative pain in the Emergency Department (ED). METHODS Pediatric Health Information System is an administrative database of encounter-level data from 48 children's hospitals. Emergency department visits for postoperative pain from January 2014 to September 2017 were analyzed. Visits were matched by the Pediatric Health Information System identifier to associate corresponding same site surgery encounters directly preceding ED visits. RESULTS There were 7365 ED visits for acute postoperative pain, for which 4044 could be linked to corresponding surgical procedure. Eight-one percent of ED visits were within 7 days of surgery. Opioids were given at 1979 (49%) of visits, and nonopioids at 678 (17%) of visits. The most common surgeries preceding a postoperative pain ED visit were for tonsils and adenoids (48.5%). Age, sex, length of stay for both procedure and ED visits, procedure specialty, and the number of days between procedure discharge and admission to ED were associated with opioid administration during ED visits (P < 0.05). CONCLUSIONS Pediatric patients treated in the ED for postoperative pain were often treated with opioid and nonopioid analgesics, with wide prescriber variability. Further research is warranted to help balance optimal pain management and safe prescribing practices.
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Affiliation(s)
| | | | - Yazan K Rizeq
- From the Ann & Robert H. Lurie Children's Hospital of Chicago
| | - Sana Minhas
- From the Ann & Robert H. Lurie Children's Hospital of Chicago
| | - Hehui Quan
- From the Ann & Robert H. Lurie Children's Hospital of Chicago
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16
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Aurilio C, Pace MC, Sansone P, Giaccari LG, Coppolino F, Pota V, Barbarisi M. Multimodal analgesia in neurosurgery: a narrative review. Postgrad Med 2021; 134:267-276. [PMID: 34872428 DOI: 10.1080/00325481.2021.2015221] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Pain following brain surgery can compromise the result of surgery. Several pharmacological interventions have been used to prevent postoperative pain in adults undergoing brain surgery. Pain following craniotomy is considered to be moderate to severe during the first two post-operative days. Opioids have been historically the mainstay and are the current prominent strategy for pain treatment. They produce analgesia but may alter respiratory, cardiovascular, gastrointestinal, and neuroendocrine functions. All these side effects may affect the normal postoperative course of craniotomy by affecting neurological function and increasing intracranial pressure. Therefore, their use in neurosurgery is limited, and opioids are used in case of strict necessity or as rescue medication. In addition to opioids, drugs with differing mechanisms of actions target pain pathways, resulting in additive and/or synergistic effects. Some of these agents include acetaminophen/non-steroidal anti-inflammatory drugs (NSAIDs), alpha-2 agonists, NMDA receptor antagonists, gabapentinoids, and local anesthesia techniques. Multimodal analgesia should be a balance between adequate analgesia and less drug-induced sedation, respiratory depression, hypercapnia, nausea, and vomiting, which may increase intracranial pressure. Non-opioid analgesics can be an useful pharmacological alternative in multimodal regimes to manage post-craniotomy pain. This narrative review aims to outline the current clinical evidence of multimodal analgesia for post craniotomy pain control.
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Affiliation(s)
- Caterina Aurilio
- Department of Women, Child and General and Specialized Surgery, University of Campania Luigi Vanvitelli, Naples, Italy
| | - Maria Caterina Pace
- Department of Women, Child and General and Specialized Surgery, University of Campania Luigi Vanvitelli, Naples, Italy
| | - Pasquale Sansone
- Department of Women, Child and General and Specialized Surgery, University of Campania Luigi Vanvitelli, Naples, Italy
| | - Luca Gregorio Giaccari
- Department of Women, Child and General and Specialized Surgery, University of Campania Luigi Vanvitelli, Naples, Italy
| | - Francesco Coppolino
- Department of Women, Child and General and Specialized Surgery, University of Campania Luigi Vanvitelli, Naples, Italy
| | - Vincenzo Pota
- Department of Women, Child and General and Specialized Surgery, University of Campania Luigi Vanvitelli, Naples, Italy
| | - Manlio Barbarisi
- Department of Medical, Surgical, Neurological, Metabolic and Aging Sciences, University of Campania "Luigi Vanvitelli", Naples, Italy
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17
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Abstract
Adequate pain management is important for successful postoperative recovery after any surgical procedure. Unfortunately, the USA and many other parts of the world are in the midst of an opioid epidemic, and healthcare providers are thus tasked with balancing the comfort and recovery of their patients after an operation against the individual and societal harms of the over-prescription of opioids. The goal of this article is to discuss the range of opioid formulations currently in use, examine why this may be problematic, and explore alternatives that provide similar efficacy and may improve overall safety in the pediatric population after urologic surgery. Improving the way opioids are prescribed through clinical practice guidelines as well as considering alternatives to opioids can ensure patients have access to safer and more effective pain treatments and potentially reduce opioid misuse.
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18
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Farahmand Rad R, Imani F, Emami A, Salehi R, Ghavamy AR, Shariat AN. Postoperative Pain Management: Efficacy of Caudal Tramadol in Pediatric Lower Abdominal Surgery: A Randomized Clinical Study. Anesth Pain Med 2021; 11:e119346. [PMID: 34692449 PMCID: PMC8520683 DOI: 10.5812/aapm.119346] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2021] [Accepted: 09/12/2021] [Indexed: 01/02/2023] Open
Abstract
BACKGROUND One of the methods of pain control after pediatric surgical procedures is regional techniques, including caudal block, despite their limitations. OBJECTIVES In this study, the pain score and complications of caudal tramadol were evaluated in pediatrics following lower abdominal surgery. METHODS In this study, 46 children aged 3 to 10 years were allocated into two equal groups (R and TR) for performing caudal analgesia after lower abdominal surgery. The injectate contained 0.2% ropivacaine 1 mL/kg in the R group (control group) and tramadol (2 mg/kg) and ropivacaine in the TR group. The pain score, duration of pain relief, amount of paracetamol consumption, hemodynamic alterations, and possible complications at specific times (1, 2, and 6 hours) were evaluated in both groups. RESULTS No considerable difference was observed in the pain score between the groups in the first and second hours (P > 0.05). However, in the sixth hour, the TR group had a significantly lower pain score than the R group (P < 0.05). Compared to the R group, the TR group had a longer period of analgesia and lower consumption of analgesic drugs (P < 0.05). Heart rate and blood pressure differences were not significant between the two groups (P > 0.05). Similarly, the duration of operation and recovery time were not remarkably different between the two groups (P > 0.05). Complications had no apparent differences between these two groups, as well (P > 0.05). CONCLUSIONS In this study, the addition of tramadol to caudal ropivacaine in pediatric lower abdominal surgery promoted pain relief without complications.
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Affiliation(s)
- Reza Farahmand Rad
- Pain Research Center, Department of Anesthesiology and Pain Medicine, Iran University of Medical Sciences, Tehran, Iran
| | - Farnad Imani
- Pain Research Center, Department of Anesthesiology and Pain Medicine, Iran University of Medical Sciences, Tehran, Iran
| | - Azadeh Emami
- Pain Research Center, Department of Anesthesiology and Pain Medicine, Iran University of Medical Sciences, Tehran, Iran
| | - Reza Salehi
- Pain Research Center, Department of Anesthesiology and Pain Medicine, Iran University of Medical Sciences, Tehran, Iran
| | - Ali Reza Ghavamy
- Pain Research Center, Department of Anesthesiology and Pain Medicine, Iran University of Medical Sciences, Tehran, Iran
| | - Ali Nima Shariat
- Icahn School of Medicine of Mount Sinai, Mount Sinai Morningside Hospital Center, New York, USA
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19
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Pan Y, Wang Y, Lie D, Liu D, Chen X, Wu Z, Chen L, Wang H, Peng L, Liang H, Song X, Zhao B. Effectiveness of analgesia with hydromorphone hydrochloride for postoperative pain following surgical repair of structural congenital malformations in children: a randomized controlled trial. BMC Anesthesiol 2021; 21:192. [PMID: 34271853 PMCID: PMC8284015 DOI: 10.1186/s12871-021-01412-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2020] [Accepted: 06/28/2021] [Indexed: 12/14/2022] Open
Abstract
Background Effective postoperative analgesia is needed to prevent the negative effects of postoperative pain on patient outcomes. To compare the effectiveness of hydromorphone hydrochloride and sufentanil, combined with flurbiprofen axetil, for postoperative analgesia in pediatric patients. Methods This prospective randomized controlled trial included 222 pediatric patients scheduled for repair of a structural congenital malformation under general anesthesia. Patients were randomized into 3 groups: hydromorphone hydrochloride 0.1 mg/kg (H1), hydromorphone hydrochloride 0.2 mg/kg; (H2) or sufentanil 1.5 µg/kg (S). Analgesics were diluted in 0.9% saline to 100 ml and infused continuously at a basic flow rate of 2 mL per h. The primary outcome measure was the Face, Legs, Activity, Cry, and Consolability (FLACC) pain score. Secondary outcomes included heart rate (HR), respiration rate (RR), SpO2, Ramsay sedation scores, scores on the Paediatric Anaesthesia Emergence Delirium (PAED) scale, adverse reactions, parent satisfaction with analgesia. Results The FLACC score was significantly lower in H1 and H2 groups compared to S. The Ramsay sedation score was significantly higher in H1 and H2 groups compared to S. Recovery time was shorter in H1 group compared to patients H2 group or S group. There were no significant differences in the PAED scale, HR, RR, SpO2, adverse reactions, satisfaction of parents with analgesia, or length and cost of hospital stay. Conclusions Hydromorphone hydrochloride is a more effective analgesic than sufentanil for postoperative pain in pediatric patients following surgical repair of a structural congenital malformation, however, hydromorphone hydrochloride and sufentanil had similar safety profiles in this patient population. Trial registration Chinese Clinical Trial Register ChiCTR-INR-17013935). Clinical trial registry URL: Date of registration: December 14, 2017. Supplementary Information The online version contains supplementary material available at 10.1186/s12871-021-01412-8.
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Affiliation(s)
- Yongying Pan
- Department of Anesthesiology, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, No. 9 Jinsui Road, Tianhe District, Guangdong, 510623, Guangzhou, China
| | - Yimin Wang
- Department of Anesthesiology, Guangdong Second Provincial General Hospital, Guangzhou, 510000, China
| | - Dongxu Lie
- Department of Anesthesiology, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, No. 9 Jinsui Road, Tianhe District, Guangdong, 510623, Guangzhou, China
| | - Di Liu
- Department of Anesthesiology, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, No. 9 Jinsui Road, Tianhe District, Guangdong, 510623, Guangzhou, China
| | - Xi Chen
- Department of Anesthesiology, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, No. 9 Jinsui Road, Tianhe District, Guangdong, 510623, Guangzhou, China
| | - Zeyan Wu
- Department of Anesthesiology, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, No. 9 Jinsui Road, Tianhe District, Guangdong, 510623, Guangzhou, China
| | - Liumei Chen
- Department of Anesthesiology, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, No. 9 Jinsui Road, Tianhe District, Guangdong, 510623, Guangzhou, China
| | - Huaizhen Wang
- Department of Anesthesiology, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, No. 9 Jinsui Road, Tianhe District, Guangdong, 510623, Guangzhou, China
| | - Liangming Peng
- Department of Anesthesiology, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, No. 9 Jinsui Road, Tianhe District, Guangdong, 510623, Guangzhou, China
| | - Huiying Liang
- Institute of Pediatrics, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, No. 9 Jinsui Road, Tianhe District, Guangdong, 510623, Guangzhou, China.
| | - Xingrong Song
- Department of Anesthesiology, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, No. 9 Jinsui Road, Tianhe District, Guangdong, 510623, Guangzhou, China.
| | - Baisong Zhao
- Department of Anesthesiology, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, No. 9 Jinsui Road, Tianhe District, Guangdong, 510623, Guangzhou, China.
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20
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Anne S, Mims JW, Tunkel DE, Rosenfeld RM, Boisoneau DS, Brenner MJ, Cramer JD, Dickerson D, Finestone SA, Folbe AJ, Galaiya DJ, Messner AH, Paisley A, Sedaghat AR, Stenson KM, Sturm AK, Lambie EM, Dhepyasuwan N, Monjur TM. Clinical Practice Guideline: Opioid Prescribing for Analgesia After Common Otolaryngology Operations. Otolaryngol Head Neck Surg 2021; 164:S1-S42. [PMID: 33822668 DOI: 10.1177/0194599821996297] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVE Opioid use disorder (OUD), which includes the morbidity of dependence and mortality of overdose, has reached epidemic proportions in the United States. Overprescription of opioids can lead to chronic use and misuse, and unused narcotics after surgery can lead to their diversion. Research supports that most patients do not take all the prescribed opioids after surgery and that surgeons are the second largest prescribers of opioids in the United States. The introduction of opioids in those with OUD often begins with prescription opioids. Reducing the number of extra opioids available after surgery through smaller prescriptions, safe storage, and disposal should reduce the risk of opioid use disorder in otolaryngology patients and their families. PURPOSE The purpose of this specialty-specific guideline is to identify quality improvement opportunities in postoperative pain management of common otolaryngologic surgical procedures. These opportunities are communicated through clear actionable statements with explanation of the support in the literature, evaluation of the quality of the evidence, and recommendations on implementation. Employing these action statements should reduce the variation in care across the specialty and improve postoperative pain control while reducing risk of OUD. The target patients for the guideline are any patients treated for anticipated or reported pain within the first 30 days after undergoing common otolaryngologic procedures. The target audience of the guideline is otolaryngologists who perform surgery and clinicians who manage pain after surgical procedures. Outcomes to be considered include whether the patient has stopped using opioids, has disposed of unused opioids, and was satisfied with the pain management plan.The guideline addresses assessment of the patient for OUD risk factors, counseling on pain expectations, and identifying factors that can affect pain duration and/or severity. It also discusses the use of multimodal analgesia as first-line treatment and the responsible use of opioids. Last, safe disposal of unused opioids is discussed.This guideline is intended to focus on evidence-based quality improvement opportunities judged most important by the guideline development group. It is not a comprehensive guide on pain management in otolaryngologic procedures. The statements in this guideline are not intended to limit or restrict care provided by clinicians based on their experiences and assessments of individual patients. ACTION STATEMENTS The guideline development group made strong recommendations for the following key action statements: (3A) prior to surgery, clinicians should identify risk factors for opioid use disorder when analgesia using opioids is anticipated; (6) clinicians should advocate for nonopioid medications as first-line management of pain after otolaryngologic surgery; (9) clinicians should recommend that patients (or their caregivers) store prescribed opioids securely and dispose of unused opioids through take-back programs or another accepted method.The guideline development group made recommendations for the following key action statements: (1) prior to surgery, clinicians should advise patients and others involved in the postoperative care about the expected duration and severity of pain; (2) prior to surgery, clinicians should gather information specific to the patient that modifies severity and/or duration of pain; (3B) in patients at risk for OUD, clinicians should evaluate the need to modify the analgesia plan; (4) clinicians should promote shared decision making by informing patients of the benefits and risks of postoperative pain treatments that include nonopioid analgesics, opioid analgesics, and nonpharmacologic interventions; (5) clinicians should develop a multimodal treatment plan for managing postoperative pain; (7) when treating postoperative pain with opioids, clinicians should limit therapy to the lowest effective dose and the shortest duration; (8A) clinicians should instruct patients and caregivers how to communicate if pain is not controlled or if medication side effects occur; (8B) clinicians should educate patients to stop opioids when pain is controlled with nonopioids and stop all analgesics when pain has resolved; (10) clinicians should inquire, within 30 days of surgery, whether the patient has stopped using opioids, has disposed of unused opioids, and was satisfied with the pain management plan.
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Affiliation(s)
| | - James Whit Mims
- Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - David E Tunkel
- Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | | | | | | | - John D Cramer
- Wayne State University School of Medicine, Detroit, Michigan, USA
| | - David Dickerson
- NorthShore University Health System, Evanston, Illinois, USA.,University of Chicago Medicine, Chicago, Illinois, USA
| | | | - Adam J Folbe
- Oakland University William Beaumont School of Medicine, Royal Oak, Michigan, USA
| | - Deepa J Galaiya
- Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Anna H Messner
- Baylor College of Medicine/Texas Children's Hospital, Houston, Texas, USA
| | - Allison Paisley
- University of Pennsylvania Otorhinolaryngology, Philadelphia, Pennsylvania, USA
| | - Ahmad R Sedaghat
- University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | | | - Angela K Sturm
- Angela Sturm, MD, PLLC, Houston, Texas, USA.,University of Texas Medical Branch, Galveston, Texas, USA
| | - Erin M Lambie
- American Academy of Otolaryngology-Head and Neck Surgery Foundation, Alexandria, Virginia, USA
| | - Nui Dhepyasuwan
- American Academy of Otolaryngology-Head and Neck Surgery Foundation, Alexandria, Virginia, USA
| | - Taskin M Monjur
- American Academy of Otolaryngology-Head and Neck Surgery Foundation, Alexandria, Virginia, USA
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21
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Tirotta CF, Lin JH, Tran MH. Effectiveness of Liposomal Bupivacaine Compared With Standard- of-Care Measures in Pediatric Cardiothoracic Surgery: A Retrospective Cohort Study. J Cardiothorac Vasc Anesth 2021; 35:3681-3687. [PMID: 33975790 DOI: 10.1053/j.jvca.2021.04.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2020] [Revised: 03/22/2021] [Accepted: 04/02/2021] [Indexed: 11/11/2022]
Abstract
OBJECTIVE Effective postsurgical pain management is important for pediatric patients to improve outcomes while reducing resource use and waste. The authors examined opioid consumption and economic outcomes associated with liposomal bupivacaine (LB) or non-LB analgesia use in pediatric patients undergoing cardiothoracic surgery. DESIGN The authors retrospectively analyzed Premier Healthcare Database records. SETTING The data extracted from the database included patient records from hospitals across the United States in both rural and urban locations. PARTICIPANTS The records included data from patients aged 12-to-<18 years. INTERVENTIONS The records belonged to patients undergoing video-assisted thoracoscopic procedures (VATS) who received LB or non-LB analgesia after surgery. MEASUREMENTS AND MAIN RESULTS Outcomes included in-hospital postsurgical opioid consumption in morphine milligram equivalents (MMEs), hospital length of stay (LOS), and total hospital costs; the LB and non-LB cohorts were compared using a generalized linear model with inverse probability of treatment weighting to balance the cohorts. For VATS procedures, pediatric patients receiving LB had significant reductions in in-hospital opioid consumption (632 v 991 MMEs; p < 0.0001), shorter LOS (5.1 v 5.6 days; p = 0.0023), and lower total hospital costs ($18,084 v $21,962; p < 0.0001) compared with those receiving non-LB analgesia. CONCLUSIONS These results support use of LB in multimodal analgesia regimens for managing pain in pediatric patients after cardiothoracic surgery.
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Khalid GM, Musazzi UM, Selmin F, Franzè S, Minghetti P, Cilurzo F. Extemporaneous printing of diclofenac orodispersible films for pediatrics. Drug Dev Ind Pharm 2021; 47:636-644. [PMID: 33826438 DOI: 10.1080/03639045.2021.1908335] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
OBJECTIVE The possible application of a hot-melt ram extrusion printing to the preparation of diclofenac orodispersible films (ODF) made of maltodextrin was studied focusing the attention on the effects of taste-masking agents (i.e. namely mint, licorice-mint, and sucralose) and an opacifier (titanium dioxide [TiO2]). SIGNIFICANCE This is a proof-of-concept of the feasibility to print ODF loaded with a thermosensitive drug substance by hot-melt technologies. METHODS Diclofenac sodium (DNa) ODF made of maltodextrin (dextrose equivalent (DE) = 6 ) plasticized with glycerol were prepared by hot-melt extrusion printing. ODF were characterized for disintegration time, drug content, and solid state, in vitro dissolution in deionized water and simulated salivary fluid at pH 5.7, tensile, and adhesive properties. Moreover, the stability of ODF was assessed in accelerated conditions over six months. RESULTS After the preparation, no variation in drug solid state was evident and the formation of impurity A of DNa was detected, even if it remained below the Pharmacopoeia (Ph. Eur.) limits (< 0.2%). Only the addition of DNa significantly improved the ODF tensile properties: the tensile strength increased from 0.17 ± 0.03 MPa (placebo ODF) to 2.21 ± 0.54 MPa (p ≤ 0.03). All ODF disintegrated in about 1 min, and the t80% was lower than 3 min. TiO2 reduced the static and dynamic peel forces (p ≤ 0.006) favoring the ODF detachment from the primary packaging material. During the accelerated stability study, ODF were easy to handle without fracture; the drug content, impurity A, and dissolution profiles remained superimposable. CONCLUSION Hot-melt printing can be suitable to prepare palatable ODF loaded with bitter thermosensitive drugs.
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Affiliation(s)
- Garba M Khalid
- Department of Pharmaceutical Sciences, Università degli Studi di Milano, Milan, Italy
| | - Umberto M Musazzi
- Department of Pharmaceutical Sciences, Università degli Studi di Milano, Milan, Italy
| | - Francesca Selmin
- Department of Pharmaceutical Sciences, Università degli Studi di Milano, Milan, Italy
| | - Silvia Franzè
- Department of Pharmaceutical Sciences, Università degli Studi di Milano, Milan, Italy
| | - Paola Minghetti
- Department of Pharmaceutical Sciences, Università degli Studi di Milano, Milan, Italy
| | - Francesco Cilurzo
- Department of Pharmaceutical Sciences, Università degli Studi di Milano, Milan, Italy
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Moon TS, Smith KM. Ketamine Use in the Surgical Patient: a Literature Review. Curr Pain Headache Rep 2021; 25:17. [PMID: 33630190 DOI: 10.1007/s11916-020-00930-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/29/2020] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW While ketamine is an established anesthetic, its role in the management of acute surgical pain is less certain. Therefore, a literature review is warranted to examine the role of ketamine in acute pain management. RECENT FINDINGS The use of ketamine appears to be most efficacious in larger procedures that lead to increased systemic inflammation or extensive tissue damage. In addition, ketamine seems to be most successful when administered consistently throughout a procedure, such as by an infusion instead of a single bolus, in order to have adequate dosing for an analgesic effect. Therefore, the focus of research should be on procedures that lead to moderate to severe pain using frequent dosing to determine the most effective role of ketamine. Most importantly, the current literature shows that ketamine can be used as a successful part of multimodal anesthesia with few side effects in patients undergoing major procedures associated with moderate to severe pain.
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Affiliation(s)
- Tiffany S Moon
- University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX, 75390-9068, USA.
| | - Katelynn M Smith
- University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX, 75390-9068, USA
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Stangler MIS, Lubianca JPN, Lubianca JN, Lubianca Neto JF. Dipyrone as pre-emptive measure in postoperative analgesia after tonsillectomy in children: a systematic review. Braz J Otorhinolaryngol 2021; 87:227-236. [PMID: 33485779 PMCID: PMC9422646 DOI: 10.1016/j.bjorl.2020.12.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2020] [Revised: 12/03/2020] [Accepted: 12/03/2020] [Indexed: 11/25/2022] Open
Abstract
Introduction Tonsillectomy is the 2nd most common outpatient surgery performed on children in the United States of America. Its main complication is pain, which varies in intensity from moderate to severe. Dipyrone is one of the most widely used painkillers in the postoperative period in children. Its use, however, is controversial in the literature, to the point that it is banned in many countries due to its potential severe adverse effects. Because of this controversy, reviewing the analgesic use of dipyrone in the postoperative period of tonsillectomy in children is essential. Objective The aim of this study was to review the analgesic use of dipyrone in the postoperative period of tonsillectomy in children. Methods Systematic review of the literature, involving an evaluation of the quality of articles in the databases MEDLINE/Pubmed, EMBASE and Virtual Health Library, selected with a preestablished search strategy. Only studies with a randomised clinical trial design evaluating the use of dipyrone in the postoperative period of tonsillectomy in children were included. Results and conclusion Only 2 randomised clinical trials were found. Both compared dipyrone, paracetamol, and placebo. We were unable to carry out a metanalysis because the studies were too heterogenous (dipyrone was used as pre-emptive analgesic in one and only postoperatively in another). The analgesic effect of dipyrone, measured by validated pain scales in childhood, was shown to be superior to placebo and similar to paracetamol. It appears that dipyrone exhibits a profile suitable for use in children. However, the scarcity of randomised clinical trials evaluating its analgesic effect in this age group leads to the conclusion that more well-designed studies are still needed to establish the role of dipyrone in the postoperative period of tonsillectomy in children.
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Affiliation(s)
- Maira Isis S Stangler
- Universidade Federal de Ciências da Saúde de Porto Alegre (UFCSPA), Programa de Pós-Graduação em Pediatria, Porto Alegre, RS, Brazil; Santa Casa de Misericórdia de Porto Alegre, Hospital da Criança Santo Antônio, Porto Alegre, RS, Brazil.
| | | | - Jaqueline Neves Lubianca
- Universidade Federal do Rio Grande do Sul (UFRGS), Faculdade de Medicina, Hospital de Clínicas de Porto Alegre, Departamento de Ginecologia e Obstetrícia, Porto Alegre, RS, Brazil
| | - José Faibes Lubianca Neto
- Universidade Federal de Ciências da Saúde de Porto Alegre (UFCSPA), Faculdade de Medicina, Departamento de Clínica Cirúrgica, Programa de Pós-Graduação em Pediatria, Porto Alegre, RS, Brazil; Santa Casa de Misericórdia de Porto Alegre, Hospital da Criança Santo Antônio, Serviço de Otorrinolaringologia, Porto Alegre, RS, Brazil
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Páramo-Cano T, Ortiz MI, Gómez-Busto FJ, Espinoza-Ramírez AL. Management of Procedural Pain in Children. Curr Pediatr Rev 2021; 17:288-328. [PMID: 33820520 DOI: 10.2174/1573396317666210405150526] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2020] [Revised: 11/02/2020] [Accepted: 01/25/2021] [Indexed: 11/22/2022]
Abstract
In recent years, there has been increased interest in the study of pain in children and its treatment. It is known that when facing diagnostic and therapeutic procedures similar to those performed on adults, children either do not receive specific pain treatment or receive it on a significantly lower scale. However, recent research suggests a change in attitude and an improvement in the current treatment of children's pain. Although current knowledge demonstrates the falsity of many preconceived ideas about pain and its management, our results suggest that attitudinal change towards childhood pain remains slow and that real improvement in the training and practical application of the pediatrician who has to treat childhood pain is urgently needed. In this context, this manuscript has prepared standards and guidelines to improve pain management practices in a large number of national and international professional settings.
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Affiliation(s)
- Tatjana Páramo-Cano
- Academic Area of Medicine, Institute of Health Sciences, Universidad Autónoma del Estado de Hidalgo, Pachuca, Hidalgo, Mexico., Dr. Eliseo Ramírez Ulloa 400, Col. Doctores, 42090, Pachuca, Hidalgo,Mexico
| | - Mario I Ortiz
- Academic Area of Medicine, Institute of Health Sciences, Universidad Autónoma del Estado de Hidalgo, Pachuca, Hidalgo, Mexico., Dr. Eliseo Ramírez Ulloa 400, Col. Doctores, 42090, Pachuca, Hidalgo,Mexico
| | - Federico J Gómez-Busto
- Academic Area of Medicine, Institute of Health Sciences, Universidad Autónoma del Estado de Hidalgo, Pachuca, Hidalgo, Mexico., Dr. Eliseo Ramírez Ulloa 400, Col. Doctores, 42090, Pachuca, Hidalgo,Mexico
| | - Ana L Espinoza-Ramírez
- Academic Area of Medicine, Institute of Health Sciences, Universidad Autónoma del Estado de Hidalgo, Pachuca, Hidalgo, Mexico., Dr. Eliseo Ramírez Ulloa 400, Col. Doctores, 42090, Pachuca, Hidalgo,Mexico
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Abstract
Trends in pediatric pain management are moving toward thinking beyond opioids. Regional anesthetic techniques, such as quadratus lumborum and erector spinae plane blocks, demonstrate efficacy and safety in pediatric populations. Extremity blocks with motor-sparing characteristics also are used. Adjuvants may be added to pediatric peripheral nerve blocks to increase duration of action and improve block efficacy. For medical management, pediatric pain management frequently uses nonopioid medications. These opioid-sparing medications and regional techniques are used to facilitate enhanced recovery after surgery in pediatric surgical patients. Virtual reality is a field where technology can aid in managing acute pain in pediatric patients.
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Affiliation(s)
- Charlotte M Walter
- Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, MLC 2001, Cincinnati, OH 45229-3026, USA.
| | - Niekoo Abbasian
- Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, MLC 2001, Cincinnati, OH 45229-3026, USA
| | - Vanessa A Olbrecht
- Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, MLC 2001, Cincinnati, OH 45229-3026, USA
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Nguyen BK, Svider PF, Hsueh WD, Folbe AJ. Perioperative Analgesia for Sinus and Skull-Base Surgery. Otolaryngol Clin North Am 2020; 53:789-802. [PMID: 32771245 DOI: 10.1016/j.otc.2020.05.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Perioperative analgesic management is multifaceted, and an individualized approach should be taken with each patient. Preoperative discussion of the plan for pain control and the patient's postoperative expectations is a necessary facet for optimal outcomes of analgesia. There is the potential for significant abuse and development of dependence on opioids. Nonopioids, such as nonsteroidal anti-inflammatory drugs, acetaminophen, and gabapentinoids, provide reliable alternatives for analgesic management following sinus and skull-base surgery. There is a paucity of literature regarding perioperative pain regimens for sinus and skull-base surgery, and the authors hope that this review serves as a valuable tool for otolaryngologists.
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Affiliation(s)
- Brandon K Nguyen
- Department of Otolaryngology-Head and Neck Surgery, Rutgers New Jersey Medical School, Newark, NJ, USA
| | - Peter F Svider
- Hackensack Meridian Health, Hackensack University Medical Center, Hackensack, NJ, USA
| | - Wayne D Hsueh
- Department of Otolaryngology-Head and Neck Surgery, Rutgers New Jersey Medical School, Newark, NJ, USA
| | - Adam J Folbe
- Department of Otolaryngology, William Beaumont Hospital, Royal Oak, MI, USA; Barbara Ann Karmanos Cancer Institute, Detroit, MI, USA.
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Reddy SK, Jones JJ, Gordish-Dressman H, Pestieau SR. Dexmedetomidine as an Opioid-Sparing Agent in Pediatric Craniofacial Surgery. CHILDREN-BASEL 2020; 7:children7070068. [PMID: 32630167 PMCID: PMC7401866 DOI: 10.3390/children7070068] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 05/22/2020] [Revised: 06/18/2020] [Accepted: 06/23/2020] [Indexed: 11/16/2022]
Abstract
Pediatric craniofacial reconstruction surgery is associated with significant perioperative analgesic requirements. As dexmedetomidine mediates central nervous system sympathetic activity and pain modulation, its intraoperative use could be beneficial in craniofacial surgery. We hypothesized that intraoperative administration of dexmedetomidine in children undergoing craniofacial reconstructive surgery would result in reduced opioid requirements, pain, sedation scores, and opioid-induced side effects compared to patients who did not receive dexmedetomidine. All patients who underwent craniofacial reconstructive surgery at our institution from July 2013 to June 2017 were retrospectively evaluated. The primary outcome measure was mean postoperative morphine equivalent requirements. Secondary outcome measures included incidence of opioid-related side effects, pain scores, and hospital length of stay. Thirty-nine patients received dexmedetomidine intraoperatively while 41 patients did not. There was no difference in postoperative opioid requirements or pain scores between the two cohorts. However, patients who received higher doses of dexmedetomidine (4.7 mcg/kg) intraoperatively exhibited significantly lower rescue medication requirements for nausea and vomiting postoperatively. Contrary to the hypothesis, dexmedetomidine was not associated with reduced postoperative opioid requirements or pain scores in children undergoing craniofacial reconstructive surgery. However, our findings do suggest that dexmedetomidine may be beneficial in reducing side effects such as postoperative nausea and vomiting. A randomized controlled trial would be necessary to verify these findings.
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Affiliation(s)
- Srijaya K. Reddy
- Department of Anesthesiology, Division of Pediatric Anesthesiology—Monroe Carell Jr. Children’s Hospital, Vanderbilt University Medical Center, 2200 Children’s Way Suite 3116, Nashville, TN 37232, USA
- Correspondence:
| | - Jacob J. Jones
- Division of Anesthesiology, Pain and Perioperative Medicine—Children’s National Hospital, The George Washington University School of Medicine and Health Sciences, 111 Michigan Avenue NW, Washington, DC 20010, USA; (J.J.J.); (S.R.P.)
| | - Heather Gordish-Dressman
- Center for Translational Research—Children’s National Hospital, The George Washington University School of Medicine and Health Sciences, 111 Michigan Avenue NW, Washington, DC 20010, USA;
| | - Sophie R. Pestieau
- Division of Anesthesiology, Pain and Perioperative Medicine—Children’s National Hospital, The George Washington University School of Medicine and Health Sciences, 111 Michigan Avenue NW, Washington, DC 20010, USA; (J.J.J.); (S.R.P.)
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Kościelniak-Merak B, Batko I, Kobylarz K, Sztefko K, Tomasik PJ. Intravenous, Perioperatively Administered Lidocaine Regulates Serum Pain Modulators’ Concentrations in Children Undergoing Spinal Surgery. PAIN MEDICINE 2020; 21:1464-1473. [DOI: 10.1093/pm/pnz212] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 08/30/2023]
Abstract
AbstractObjectivesWe analyzed the influence of perioperative, intravenous (i.v.) lidocaine infusion as a part of multimodal anesthesia on concentrations of selected pain modulators.DesignAn observational study.SettingUniversity Children’s Hospital in Cracow, Poland, from May 2015 to May 2018.SubjectsForty-four children undergoing extensive spinal surgery, divided into two groups after surgery: the study group (N = 23), anesthetized generally with lidocaine as a co-analgesic, and the control group (N = 22), anesthetized generally without lidocaine.MethodsWe assessed proinflammatory mediators like neuron growth factor (NGF), high mobility group box 1 (HMGB1), interleukin 6 (IL-6), and FOS protein before, immediately after, six hours and 12–15 hours after surgery. We evaluated pain intensity at corresponding time points using a 10-point numerical/graphical scale.ResultsWe observed that children in the lidocaine group had reduced pain intensity in the resting state and during movement until six hours after surgery when compared with controls. We found lower NGF concentrations in the lidocaine group vs controls only at six hours after surgery. Mean HMGB1 concentrations during the postoperative period in the study group were relatively stable, whereas we observed significant increases at six hours after surgery and a slight decrease at 12–15 hours after surgery in the control group. IL-6 concentrations at six hours were lower in lidocaine patients when compared with controls. We noted a negative correlation between HMGB1, NGF, Il-6, and lidocaine concentrations after surgery. We did not find any differences in FOS protein concentrations between the groups.ConclusionsOur findings suggest that intraoperative and postoperative i.v. lidocaine administration as a part of multimodal anesthesia may reduce inflammatory-dependent postoperative pain intensity.
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Affiliation(s)
- Barbara Kościelniak-Merak
- Department of Clinical Biochemistry, Pediatrics Institute, Jagiellonian University Medical College, Cracow, Poland
| | - Ilona Batko
- Intensive Care Unit, University Children’s Hospital, Cracow, Poland
| | - Krzysztof Kobylarz
- Intensive Care Unit, University Children’s Hospital, Cracow, Poland
- Department of Anesthesiology and Intensive Care, Jagiellonian University Medical College, Cracow, Poland
| | - Krystyna Sztefko
- Department of Clinical Biochemistry, Pediatrics Institute, Jagiellonian University Medical College, Cracow, Poland
| | - Przemysław J Tomasik
- Department of Clinical Biochemistry, Pediatrics Institute, Jagiellonian University Medical College, Cracow, Poland
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Sobey JH, Menser CC, Reddy SK, Hughes EM. Successful utilisation of epidural analgesia for perioperative pain management in a child with sodium voltage-gated channel alpha subunit (SCN1A) gene mutation. BMJ Case Rep 2020; 13:13/6/e234314. [PMID: 32532910 DOI: 10.1136/bcr-2020-234314] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Sodium voltage-gated channel alpha subunit (SCN1A) gene mutation is a rare disorder with a large spectrum of clinical presentations. Little is known regarding anaesthetic and analgesic management of these patients. We present a case of a child with SCN1A gene mutation that was successfully managed with an epidural for perioperative analgesia for an abdominal surgery.
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Affiliation(s)
- Jenna H Sobey
- Department of Anesthesiology, Division of Pediatric Anesthesiology, Monroe Carell Junior Children's Hospital at Vanderbilt, Nashville, Tennessee, USA
| | - Carrie C Menser
- Department of Anesthesiology, Division of Pediatric Anesthesiology, Monroe Carell Junior Children's Hospital at Vanderbilt, Nashville, Tennessee, USA
| | - Srijaya K Reddy
- Department of Anesthesiology, Division of Pediatric Anesthesiology, Monroe Carell Junior Children's Hospital at Vanderbilt, Nashville, Tennessee, USA
| | - Elisabeth M Hughes
- Department of Anesthesiology, Division of Pediatric Anesthesiology, Monroe Carell Junior Children's Hospital at Vanderbilt, Nashville, Tennessee, USA
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Andersen MZ, Gülen S, Fonnes S, Andresen K, Rosenberg J. Half of Cochrane reviews were published more than 2 years after the protocol. J Clin Epidemiol 2020; 124:85-93. [PMID: 32413390 DOI: 10.1016/j.jclinepi.2020.05.011] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2020] [Revised: 05/03/2020] [Accepted: 05/06/2020] [Indexed: 01/03/2023]
Abstract
OBJECTIVES The objective of the study is to examine the time from publication of the protocol for a Cochrane review to publication of the Cochrane review for the entire Cochrane Database of Systematic Reviews (CDSR). STUDY DESIGN AND SETTINGS Cochrane reviews from the CDSR published between 1995 and 2019 were assessed. Characteristics of the reviews were extracted, and time from publication of protocol to publication of review was calculated. These times were grouped for relevant characteristics and visualized through charts and tables to illustrate trends. RESULTS Of the total 8,201 reviews in the CDSR, 6,764 were included. The median publication time was 2 years (range 0 days to 21.7 years). Reviews that were published more than 5 years after the protocol made up 11% of all included reviews, whereas 19% of reviews were published within a year. The median publication time for the individual Cochrane Review Groups ranged from 15 to 39 months. CONCLUSION Half of Cochrane reviews were published later than Cochrane's aim of 2 years. Furthermore, the Cochrane Review Groups' median times from publication of protocol to publication of review varied widely.
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Affiliation(s)
- Mikkel Zola Andersen
- Center for Perioperative Optimization, Department of Surgery, Herlev and Gentofte Hospitals, University of Copenhagen, Borgmester Ib Juuls Vej 1, DK-2730 Herlev, Denmark; Cochrane Colorectal Group, Herlev Hospital, Borgmester Ib Juuls Vej 1, DK-2730 Herlev, Denmark.
| | - Sengül Gülen
- Center for Perioperative Optimization, Department of Surgery, Herlev and Gentofte Hospitals, University of Copenhagen, Borgmester Ib Juuls Vej 1, DK-2730 Herlev, Denmark; Cochrane Colorectal Group, Herlev Hospital, Borgmester Ib Juuls Vej 1, DK-2730 Herlev, Denmark
| | - Siv Fonnes
- Center for Perioperative Optimization, Department of Surgery, Herlev and Gentofte Hospitals, University of Copenhagen, Borgmester Ib Juuls Vej 1, DK-2730 Herlev, Denmark; Cochrane Colorectal Group, Herlev Hospital, Borgmester Ib Juuls Vej 1, DK-2730 Herlev, Denmark
| | - Kristoffer Andresen
- Center for Perioperative Optimization, Department of Surgery, Herlev and Gentofte Hospitals, University of Copenhagen, Borgmester Ib Juuls Vej 1, DK-2730 Herlev, Denmark; Cochrane Colorectal Group, Herlev Hospital, Borgmester Ib Juuls Vej 1, DK-2730 Herlev, Denmark
| | - Jacob Rosenberg
- Center for Perioperative Optimization, Department of Surgery, Herlev and Gentofte Hospitals, University of Copenhagen, Borgmester Ib Juuls Vej 1, DK-2730 Herlev, Denmark; Cochrane Colorectal Group, Herlev Hospital, Borgmester Ib Juuls Vej 1, DK-2730 Herlev, Denmark
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Nielsen BN, Anderson BJ, Falcon L, Henneberg SW, Lauritsen T, Lomstein E, Ydemann M, Afshari A. Pharmacokinetics of an intravenous bolus dose of clonidine in children undergoing surgery. Paediatr Anaesth 2020; 30:607-613. [PMID: 32166831 DOI: 10.1111/pan.13856] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2019] [Revised: 02/17/2020] [Accepted: 03/10/2020] [Indexed: 11/27/2022]
Abstract
BACKGROUND Clonidine is used off-label in children but only limited pediatric pharmacokinetic data are available for intravenously administered clonidine. OBJECTIVES To determine pharmacokinetic parameter estimates of clonidine in healthy children undergoing surgery and to investigate age-related differences. Furthermore, to investigate possible pharmacokinetic differences of clonidine between this group of children and a cohort with cardiac diseases. METHODS In a randomized placebo-controlled trial (The PREVENT AGITATION trial), blood samples for clonidine pharmacokinetic analysis were collected in a proportion of the enrolled patients. Healthy children with ASA score 1-2 in the age-groups 1 to <2 years and 2-5 years were randomized for blood sampling. Clonidine was administered as a single intravenous bolus of 3 µg/kg intraoperatively. Blood samples were drawn at baseline, 5, 10, 15, 30, 60 minutes after dosing and additionally every hour until discharge from the PACU. Clonidine analysis was performed on liquid chromatography-mass spectrometry. RESULTS Data form eighteen children were available for pharmacokinetic analysis (ASA I; male/female: 17/1; age: 1-5 years; weight 8.7-24 kg). Population parameter estimates for the 2-compartment model were similar to previous published data for children who underwent cardiac surgery. A pooled analysis including data from 59 children indicated clearance of 14.4 L h-1 70 kg-1 and volume of distribution of 192.6 L 70 kg-1 . No age-related pharmacokinetic differences and no difference in time from administration of study medication to awakening were found. Children 1 to <2 years had a shorter PACU stay than children 2-5 years (mean difference 17% 95% CI:3%-34%, P = .02). CONCLUSION Pharmacokinetic parameter estimates were similar for children undergoing general surgery and cardiac surgery given a single dose of intravenous clonidine. These results indicated that no dose reduction is needed in children aged 1 to <2 years compared with those 2-5 years, which was supported by pharmacodynamic observations.
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Affiliation(s)
- Bettina N Nielsen
- Department of Anaesthesia, The Juliane Marie Centre, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Brian J Anderson
- Department of Anaesthesiology, University of Auckland, Auckland, New Zealand
| | - Lars Falcon
- Department of Anaesthesia, The Juliane Marie Centre, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Steen W Henneberg
- Department of Anaesthesia, The Juliane Marie Centre, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Torsten Lauritsen
- Department of Anaesthesia, The Juliane Marie Centre, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Erik Lomstein
- Center for Laboratory, Food and Environmental Technology, The Business Academy Aarhus, Aarhus, Denmark
| | - Mogens Ydemann
- Department of Neuroanaethestesiology, Copenhagen University Hospital, Copenhagen, Denmark
| | - Arash Afshari
- Department of Anaesthesia, The Juliane Marie Centre, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
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Kühlmann AYR, van Rosmalen J, Staals LM, Keyzer-Dekker CMG, Dogger J, de Leeuw TG, van der Toorn F, Jeekel J, Wijnen RMH, van Dijk M. Music Interventions in Pediatric Surgery (The Music Under Surgery In Children Study). Anesth Analg 2020; 130:991-1001. [DOI: 10.1213/ane.0000000000003983] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
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Abstract
PURPOSE OF REVIEW Ambulatory surgery is the standard for the majority of pediatric surgery in 2019 and adenotonsillectomy is the second most common ambulatory surgery in children so it is an apt paradigm. Preparing and managing these children as ambulatory patients requires a thorough understanding of the current literature. RECENT FINDINGS The criteria for undertaking pediatric adenotonsillectomy on an ambulatory basis, fasting after clear fluids, postoperative nausea and vomiting (PONV), perioperative pain management and discharge criteria comprise the themes addressed in this review. SUMMARY Three criteria determine suitability of adenotonsillectomy surgery on an ambulatory basis: the child's age, comorbidities and the severity of the obstructive sleep apnea syndrome (OSAS). Diagnosing OSAS in children has proven to be a challenge resulting in alternate, noninvasive techniques, which show promise. Abbreviating the 2 h clear fluid fasting guideline has garnered attention, although the primary issue is that parents do not follow the current clear fluid fasting regimen and until that is resolved, consistent fasting after clear fluids will remain elusive. PONV requires aggressive prophylactic measures that fail in too many children. The importance of unrecognized genetic polymorphisms in PONV despite prophylactic treatment is understated as are the future roles of palonosetron and Neurokinin-1 receptor antagonists that may completely eradicate PONV when combined with dexamethasone. Pain management requires test doses of opioids intraoperatively in children with OSAS and nocturnal desaturation to identify those with reduced opioid dosing thresholds, an uncommon practice as yet. Furthermore, postdischarge nonsteroidal anti-inflammatory agents as well as other pain management strategies should replace oral opioids to prevent respiratory arrests in those who are ultra-rapid CYP2D6 metabolizers. Finally, discharge criteria are evolving and physiological-based criteria should replace time-based, reducing the risk of readmission.
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Simić D, Vlajković A, Stević M. Postoperative analgesia in children. ABC: ČASOPIS URGENTNE MEDICINE 2020. [DOI: 10.5937/abc2001001s] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
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Tomaszek L, Fenikowski D, Gawron D, Komotajtys H. Comparative efficacy of continuous infusion of bupivacaine/fentanyl and ropivacaine/fentanyl for paediatric pain control after the Ravitch procedure and thoracotomy. A prospective randomized study. Biomed Pap Med Fac Univ Palacky Olomouc Czech Repub 2019; 163:366-373. [DOI: 10.5507/bp.2018.072] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2018] [Accepted: 11/05/2018] [Indexed: 02/08/2023] Open
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Martin LD, Adams TL, Duling LC, Grigg EB, Bosenberg A, Onchiri F, Jimenez N. Comparison between epidural and opioid analgesia for infants undergoing major abdominal surgery. Paediatr Anaesth 2019; 29:835-842. [PMID: 31140664 DOI: 10.1111/pan.13672] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2018] [Revised: 05/21/2019] [Accepted: 05/24/2019] [Indexed: 11/27/2022]
Abstract
BACKGROUND Epidural analgesia is considered optimal for postoperative pain management after major abdominal surgery. The potential to decrease anesthetic and opioid exposure is particularly desirable for infants, given their vulnerability to respiratory depression and concern for anesthetic neurotoxicity. We reviewed our experience with infants undergoing major abdominal surgery to determine if epidural catheter use decreased anesthetic and opioid exposure and improved postoperative analgesia. METHODS This retrospective cohort study included infants (<12 months) who underwent exploratory laparotomy, ureteral reimplantation, or bladder exstrophy repair between November 2011 and November 2014. Primary outcomes of anesthetic exposure (mean endtidal sevoflurane) and intraoperative opioid administration were compared between infants who received epidural catheters and those who did not. Secondary outcomes included postoperative pain and sedation scores and morphine equivalents administered 0-24 and 24-48 hours after surgery. RESULTS Of 158 eligible infants, 82 were included and 47 received epidurals. Patients with epidurals underwent bladder exstrophy repair (N = 9), ureteral reimplantation (N = 8), and exploratory laparotomy (N = 30). Infants with epidurals received less intraoperative fentanyl (2.6 mcg/kg (0,4.5) vs 3.3 mcg/kg (2.4,5.8), P = 0.019) and morphine (6% (3/47) vs 26% (9/35), P = 0.014) in univariate analysis. After controlling for age and emergency surgery, differences in long-acting opioid administration persisted, with significantly less morphine given in the epidural group (OR 0.181; 95% CI 0.035-0.925; P = 0.040). Mean endtidal sevoflurane concentrations were similar between groups. There was no significant difference in postoperative median morphine equivalents. CONCLUSION Placement of epidural catheters in infants undergoing major abdominal surgery is associated with decreased long-acting opioid requirements intraoperatively. Epidural placement does not preclude opioid exposure however, as opioids may be administered for indications other than nociceptive pain in the difficult-to-assess postoperative infant. Further prospective studies are warranted to better quantify the effect of epidural analgesia on intraoperative anesthetic exposure in infants.
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Affiliation(s)
- Lizabeth D Martin
- Department of Anesthesiology and Pain Management, University Washington Medical School, Seattle Children's Hospital, Seattle, Washington
| | - Trevor L Adams
- Department of Anesthesiology and Pain Management, University Washington Medical School, Seattle Children's Hospital, Seattle, Washington
| | - Laura C Duling
- Department of Anesthesiology and Pain Management, University Washington Medical School, Seattle Children's Hospital, Seattle, Washington
| | - Eliot B Grigg
- Department of Anesthesiology and Pain Management, University Washington Medical School, Seattle Children's Hospital, Seattle, Washington
| | - Adrian Bosenberg
- Department of Anesthesiology and Pain Management, University Washington Medical School, Seattle Children's Hospital, Seattle, Washington
| | - Frankline Onchiri
- Core for Biomedical Statistics, Center for Clinical and Translational Research, Seattle Children's Research Institute, Seattle, Washington
| | - Nathalia Jimenez
- Department of Anesthesiology and Pain Management, University Washington Medical School, Seattle Children's Hospital, Seattle, Washington
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Metamizole for Postoperative Pain in Pediatric Patients Undergoing Subarachnoid Anesthesia. Am J Ther 2019; 27:e338-e345. [PMID: 31356348 DOI: 10.1097/mjt.0000000000000951] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Efficient postoperative pain management, which is aimed at decreasing the risk of complications and drug-induced side effects, without affecting the quality of analgesia, is part of today's concept of enhanced recovery after surgery, that is, fast-track surgery. STUDY QUESTION The objective of this study was to determine whether effective management of acute postoperative pain was possible without opioids, while avoiding complications, drug-induced side effects, and suboptimal treatment. Introduction of metamizole, which has regained popularity, into a multimodal analgesia regimen was used, as opioids are not routinely administered. STUDY DESIGN The study was prospective, observational, unrandomized, and without the control group. MEASURES AND OUTCOMES This study was performed in a pediatric hospital with 300 beds and an average of 1700 annual surgical interventions. The study group comprised 378 patients aged 1-17 years, undergoing lower abdominal or limb surgery between June 2016 and June 2017. Children underwent subarachnoid anesthesia combined with intravenous sedation and received not routinely but on demand postoperative opioid analgesia. The pain was self-assessed by the pediatric patient or was assessed by the nurse using pain scores. RESULTS Metamizole proved to be safe, efficient, and very well tolerated by children. Multimodal analgesia using acetaminophen, nonsteroidal anti-inflammatory drug with metamizole for the treatment of moderate to severe pain in children undergoing surgery, required a single opioid dose in 292 patients (77.24%) of the 378 in this study. CONCLUSIONS In pediatric patients undergoing surgery, subarachnoid anesthesia combined with intravenous sedation, multimodal analgesia that includes metamizole, and nonpharmacological complementary therapies in pain management enable avoidance or reduction of opioids to a single dose, without undertreatment. There is also a minimum of anesthesia, accelerated children's recovery and a rapid return to presurgical levels of function.
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Nahum E, Friedman M, Kaplan E, Weissbach A, Kadmon G. The Hemodynamic Effect of Intravenous Paracetamol in Children: A Retrospective Chart Review. Paediatr Drugs 2019; 21:177-183. [PMID: 31155693 DOI: 10.1007/s40272-019-00336-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
AIM Studies in adults have reported frequent episodes of blood pressure drops following intravenous paracetamol administration. We aimed to investigate the hemodynamic effects of intravenous paracetamol in critically ill children. METHODS The charts of 100 pediatric intensive care patients (age range 0.1-18 years) who were treated with intravenous paracetamol between March and September 2017 were retrospectively reviewed. A hemodynamic event was defined as a drop of > 15% in systolic or mean arterial blood pressure within 120 min after drug administration. Hypotension was defined as either a drop in systolic blood pressure (SBP) below the 5th percentile for age or a hemodynamic event associated with tachycardia, increased lactate level, or treatment with a fluid bolus or vasopressors. RESULTS A hemodynamic event was observed in 39 patients (39%). In these patients, SBP was in the pre-hypertension or hypertension values in 36/39 patients before paracetamol administration, median (IQR) SBP decreased from the 99th (95-99) percentile for age before to the 50th (50-95) percentile after paracetamol (p < 0.001) and mean heart rate was 137 bpm before treatment and 115 bpm after (p = 0.002). SBP values did not drop below the 5th percentile in any patient. In 15 patients diagnosed with shock on admission, paracetamol treatment did not cause an increase in vasopressor treatment after drug administration. CONCLUSIONS In the present study of critically ill pediatric patients, intravenous paracetamol administration was associated with a drop in SBP from high to normal values for age, possibly due to pain relief, with no evidence for a negative hemodynamic event.
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Affiliation(s)
- Elhanan Nahum
- Pediatric Intensive Care Unit, Schneider Children's Medical Center in Israel, 14 Kaplan Street, 4920235, Petach Tikva, Israel
| | - Matan Friedman
- Sackler Faculty of Medicine, Tel Aviv University, PC 39040, 69978, Tel Aviv, Israel
| | - Eytan Kaplan
- Pediatric Intensive Care Unit, Schneider Children's Medical Center in Israel, 14 Kaplan Street, 4920235, Petach Tikva, Israel
| | - Avichai Weissbach
- Pediatric Intensive Care Unit, Schneider Children's Medical Center in Israel, 14 Kaplan Street, 4920235, Petach Tikva, Israel
| | - Gili Kadmon
- Pediatric Intensive Care Unit, Schneider Children's Medical Center in Israel, 14 Kaplan Street, 4920235, Petach Tikva, Israel.
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Eerdekens M, Beuter C, Lefeber C, van den Anker J. The challenge of developing pain medications for children: therapeutic needs and future perspectives. J Pain Res 2019; 12:1649-1664. [PMID: 31213880 PMCID: PMC6536714 DOI: 10.2147/jpr.s195788] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2018] [Accepted: 02/27/2019] [Indexed: 12/11/2022] Open
Abstract
It is broadly accepted that children of all age groups including (preterm) neonates and young infants can perceive pain and that there is an absolute need to treat their pain safely and effectively. The approved treatment options for children, particularly (preterm) neonates and young infants, are very limited with only a few medications specifically labelled for this population. This article presents the challenges of developing pain medications for children. A short overview gives information on pain in children, including pain perception, prevalence of pain and the long-term consequences of leaving pain untreated in this vulnerable population. Current pain management practices are briefly discussed. The challenges of conducting pediatric clinical trials in general and trials involving analgesic medications in particular within the regulatory framework available to develop these medications for children are presented. Emphasis is given to the operational hurdles faced in conducting a pediatric clinical trial program. Some suggestions to overcome these hurdles are provided based on our experience during the pediatric trial program for the strong analgesic tapentadol used for the treatment of moderate to severe acute pain.
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Affiliation(s)
| | | | | | - John van den Anker
- Division of Paediatric Pharmacology and Pharmacometrics, University of Basel Children’s Hospital, Basel, Switzerland
- Division of Clinical Pharmacology, Children’s National Medical Center, Washington, DC, USA
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Following Cochrane review protocols to completion 10 years later: a retrospective cohort study and author survey. J Clin Epidemiol 2019; 111:41-48. [PMID: 30928507 DOI: 10.1016/j.jclinepi.2019.03.006] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2018] [Revised: 02/07/2019] [Accepted: 03/01/2019] [Indexed: 01/19/2023]
Abstract
OBJECTIVE We analyzed patterns of publication of Cochrane review protocols (CRPs). STUDY DESIGN AND SETTING We analyzed CRPs published in 2010, extracted their characteristics, and analyzed whether they were published by February 2018. We surveyed corresponding authors and Cochrane review groups to analyze reasons for nonpublication of protocols and analyzed factors predicting the time to publication. RESULTS Of 576 CRPs, 446 (77.4%) were published as a full review and 130 (22.6%) were still unpublished in February 2018; among unpublished, 37 (28.5%) were withdrawn and 93 (71.5%) were still active. The most common authors' reason for abandoning a protocol was a lack of time to work on the review. The median time to publication was 2.78 years (range 0.96 to 8.05). Multivariate analysis showed that factors with the strongest association with shorter time to publication were review being an update and new authors added. Analysis only on methodological variables indicated that the strongest association for a shorter time until publication was found for including only published data. CONCLUSIONS Almost a quarter of CRPs remains unpublished after 8 years. This figure is slightly higher than in a previous analysis 10 years ago. Strategies for enhancing completion of Cochrane reviews should be considered.
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Ogunyinka IA, Oshikoya KA, Olowo-okere A, Lukong CS, Adamaigbo C, Adebayo AA. Appropriateness of postoperative analgesic doses among pediatric surgical patients in a teaching hospital in Northwest Nigeria. DRUGS & THERAPY PERSPECTIVES 2019. [DOI: 10.1007/s40267-019-00604-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Boric K, Jelicic Kadic A, Boric M, Zarandi-Nowroozi M, Jakus D, Cavar M, Dosenovic S, Jeric M, Batinic M, Vukovic I, Puljak L. Outcome domains and pain outcome measures in randomized controlled trials of interventions for postoperative pain in children and adolescents. Eur J Pain 2018; 23:389-396. [DOI: 10.1002/ejp.1313] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2017] [Revised: 08/20/2018] [Accepted: 08/24/2018] [Indexed: 12/18/2022]
Affiliation(s)
- Krste Boric
- Department of Traumatology and Orthopaedics; University Hospital Split; Split Croatia
| | | | - Matija Boric
- Department of Abdominal Surgery; University Hospital Split; Split Croatia
| | | | - Dora Jakus
- Laboratory for Pain Research; School of Medicine; University of Split; Split Croatia
| | - Marija Cavar
- Department of Radiology; University Hospital Center Split; Split Croatia
| | - Svjetlana Dosenovic
- Department of Anesthesiology and Intensive Care; University Hospital Split; Split Croatia
| | - Milka Jeric
- Department of Dermatovenerology; General Hospital Zadar; Zadar Croatia
| | - Marijan Batinic
- Laboratory for Pain Research; School of Medicine; University of Split; Split Croatia
| | - Igor Vukovic
- Department of Anesthesiology and Intensive Care; University Hospital Split; Split Croatia
| | - Livia Puljak
- Laboratory for Pain Research; School of Medicine; University of Split; Split Croatia
- Department for Development, Research and Health Technology Assessment; Agency for Medicinal Products and Medical Devices; Zagreb Croatia
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Puljak L, Dosenovic S, Boric K. Importance of consistent outcomes in randomized controlled trials and systematic reviews about anesthesiology and pain. Pain Manag 2018; 8:251-253. [DOI: 10.2217/pmt-2018-0023] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Affiliation(s)
- Livia Puljak
- Laboratory for Pain Research, University of Split School of Medicine, Split, Croatia
- Agency for Quality & Accreditation in Health Care & Social Welfare, Zagreb, Croatia
| | - Svjetlana Dosenovic
- Department of Anesthesiology & Intensive Care Medicine, University Hospital Split, Split, Croatia
| | - Krste Boric
- Department of Surgery, University Hospital Split, Split, Croatia
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Boric K, Boric M, Dosenovic S, Jelicic Kadic A, Batinic M, Cavar M, Jeric M, Puljak L. Authors' lack of awareness and use of core outcome set on postoperative pain in children is hindering comparative effectiveness research. J Comp Eff Res 2018; 7:463-470. [PMID: 29775075 DOI: 10.2217/cer-2017-0079] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
AIM To analyze awareness about and acceptability of core outcome set (COS) for pediatric pain recommended by the PedIMMPACT. METHODS We invited authors of systematic reviews and randomized controlled trials about interventions for postoperative pain in children to participate in a survey. RESULTS Only a third of surveyed authors of systematic reviews and randomized controlled trials about postoperative pain in children had heard about the PedIMMPACT COS for acute pediatric pain. Problems indicated as preventing them from using the COS were lack of awareness, difficulties with implementation, and lack of resources. CONCLUSION Further discussions about the adequacy of COS for acute pediatric pain, as well as interventions to increase the uptake of COS may be warranted.
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Affiliation(s)
- Krste Boric
- Department of Traumatology & Orthopaedics, University Hospital Split, Split, Croatia
| | - Matija Boric
- Department of Abdominal Surgery, University Hospital Split, Split, Croatia
| | - Svjetlana Dosenovic
- Department of Anesthesiology & Intensive Care, University Hospital Split, Split, Croatia
| | | | - Marijan Batinic
- Laboratory for Pain Research, University of Split School of Medicine, Split, Croatia
| | - Marija Cavar
- Department of Radiology, University Hospital Center Split, Split, Croatia
| | - Milka Jeric
- Department of Dermatovenerology, General Hospital Zadar, Zadar, Croatia
| | - Livia Puljak
- Laboratory for Pain Research, University of Split School of Medicine, Split, Croatia.,Department for Development, Research & Health Technology Assessment, Agency for Medicinal Products & Medical Devices, Zagreb, Croatia
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Puljak L. If there is only one author or only one database was searched, a study should not be called a systematic review. J Clin Epidemiol 2017; 91:4-5. [PMID: 28823649 DOI: 10.1016/j.jclinepi.2017.08.002] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2017] [Accepted: 08/09/2017] [Indexed: 01/08/2023]
Affiliation(s)
- Livia Puljak
- Cochrane Croatia, University of Split School of Medicine, Soltanska 2, 21000 Split, Croatia; Department for Development, Research and Health Technology Assessment, Agency for Quality and Accreditation in Health Care and Social Welfare, Planinska 13, Zagreb 10000, Croatia.
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