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Ren Y, Gao J, Nie X, Hua L, Zheng T, Guo D, Zhang J. Bilateral ultrasound-guided erector spinae plane block for postoperative analgesia in paediatric idiopathic scoliosis patients undergoing posterior spine fusion surgery: a randomized controlled trial. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2024; 33:3823-3832. [PMID: 39174796 DOI: 10.1007/s00586-024-08457-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/27/2024] [Revised: 06/23/2024] [Accepted: 08/15/2024] [Indexed: 08/24/2024]
Abstract
PURPOSE Major spinal surgery causes severe pain. We examined the ability of erector spinae plane block (ESPB) to alleviate pain after posterior spinal fusion (PSF) in paediatric scoliosis patients. METHODS Seventy-two patients who underwent PSF were randomized into a preoperative ultrasound-guided ESPB group or a no-block control group. The composite primary outcome was the area under the curve (AUC) of the numerical rating scale (NRS) score in the first 24 h after surgery and the number of parent-controlled intravenous analgesia (PCIA) boluses administered 24 h after surgery. The secondary outcomes included the NRS score, opioid consumption, rescue analgesia, adverse events, and quality of recovery. RESULTS The AUC-NRS at rest was 62 (13) in the ESPB group and 89 (13) in the control group (P < 0.001). There were 15 (5) 24-h PCIA boluses administered in the ESPB group and 30 (7) in the control group (P < 0.001). Compared with those in the control group, the NRS scores at rest were lower in the ESPB group at 0, 3, 6, and 9 h postoperatively, and the NRS scores during movement were lower in the ESPB group at 0, 3, 6, 9 and 12 h postoperatively. The ESPB group showed a lower need for PCIA than did the control group at 0-6, 6-12, 12-18 and 1-24 h postoperatively. In the ESPB group, fewer patients required rescue analgesics, and patients exhibited a higher quality of recovery. CONCLUSION Preoperative ESPB improves postoperative analgesia in paediatric scoliosis patients who underwent PSF. TRIAL REGISTRATION NUMBER ChiCTR2300074505. DATE OF REGISTRATION August 8, 2023.
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Affiliation(s)
- Yi Ren
- Department of Anaesthesiology, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, No. 56, South Lishi Road, Beijing, 100045, China
| | - Jingchun Gao
- Department of Orthopaedics, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China
| | - Xiaolu Nie
- Center for Clinical Epidemiology and Evidence-Based Medicine, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China
| | - Lei Hua
- Department of Anaesthesiology, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, No. 56, South Lishi Road, Beijing, 100045, China
| | - Tiehua Zheng
- Department of Anaesthesiology, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, No. 56, South Lishi Road, Beijing, 100045, China
| | - Dong Guo
- Department of Orthopaedics, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China
| | - Jianmin Zhang
- Department of Anaesthesiology, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, No. 56, South Lishi Road, Beijing, 100045, China.
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Mogahed MM, Abd El-Ghaffar MS, Elkahwagy MS. Bilateral Ultrasound-Guided Erector Spinae Plane Block for Management of Acute Postoperative Surgical Pain After Pediatric Cardiac Surgeries Through a Midline Sternotomy. Ann Card Anaesth 2024; 27:316-323. [PMID: 39365129 DOI: 10.4103/aca.aca_210_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2023] [Accepted: 05/11/2024] [Indexed: 10/05/2024] Open
Abstract
BACKGROUND Ultrasound (US) guided erector spinae plane block (ESPB) is a safe and effective technique in providing perioperative pain management in pediatrics with a high success rate. THE AIM OF THIS STUDY Was to compare the efficacy of bilateral ultrasound-guided erector spinae plane block for management of acute postoperative surgical pain after pediatric cardiac surgeries through a midline sternotomy. METHODS One hundred patients aged 4-12 years were randomly assigned into two groups, both groups received general anesthesia followed by bilateral sham erector spinae plane block at the level of T6 transverse process using 0.4 ml/kg normal saline on each side in the control group (group C) or bilateral ultrasound-guided erector spinae plane block at the level of T6 transverse process using 0.4 ml/kg ropivacaine 0.2% with a maximum dose of 2 mg/kg mixed with adrenaline 2 mcg/ml in erector spinae plane block group (group E). The postoperative pain scores were evaluated immediately post-extubation, at 1 hour, 2, 4, 6, 8, 10, 12, 14, 16, 18, 20, 22, and 24 hours after extubation, total consumption of intraoperative fentanyl and time to first rescue analgesic administration were also recorded. RESULTS There was a statistically high significant delay in the group E (314.72 ± 45.94) compared with the group C (36.7 ± 7.22) as regards to the mean (SD) of the time of the rescue analgesia (P < 0.001) (with 95% CI), moreover; the number of rescue analgesic was significantly higher in the group C compared with the group E (P < 0.001) (with 95% CI) and the mean (SD) of total intraoperative and postoperative levels fentanyl requirements in the group C were significantly higher compared with the group E (6.47 ± 0.98 and 5.09 ± 0.83) (with 95% CI) in group C versus (4.69 ± 0.71 and 2.31 ± 0.66) (with 95% CI) in group E respectively (P < 0.001) (with 95% CI). CONCLUSION Ultrasound-guided bilateral ESPB with ropivacaine and adrenaline delays the postoperative need of analgesia and reduces postoperative fentanyl consumption at 24 h in pediatric patients undergoing cardiac surgery through midline sternotomy.
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Affiliation(s)
- Mona M Mogahed
- Department of Anesthesiology, Faculty of Medicine, Tanta University, Egypt
| | | | - Mohamed S Elkahwagy
- Department of Cardiothoracic Surgery, Faculty of Medicine, Tanta University, Egypt
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Hadland SE, Agarwal R, Raman SR, Smith MJ, Bryl A, Michel J, Kelley-Quon LI, Raval MV, Renny MH, Larson-Steckler B, Wexelblatt S, Wilder RT, Flinn SK. Opioid Prescribing for Acute Pain Management in Children and Adolescents in Outpatient Settings: Clinical Practice Guideline. Pediatrics 2024:e2024068752. [PMID: 39344439 DOI: 10.1542/peds.2024-068752] [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: 10/01/2024] Open
Abstract
This is the first clinical practice guideline (CPG) from the American Academy of Pediatrics outlining evidence-based approaches to safely prescribing opioids for acute pain in outpatient settings. The central goal is to aid clinicians in understanding when opioids may be indicated to treat acute pain in children and adolescents and how to minimize risks (including opioid use disorder, poisoning, and overdose). The document also seeks to alleviate disparate pain treatment of Black, Hispanic, and American Indian/Alaska Native children and adolescents, who receive pain management that is less adequate and less timely than that provided to white individuals. There may also be disparities in pain treatment based on language, socioeconomic status, geographic location, and other factors, which are discussed. The document recommends that clinicians treat acute pain using a multimodal approach that includes the appropriate use of nonpharmacologic therapies, nonopioid medications, and, when needed, opioid medications. Opioids should not be prescribed as monotherapy for children or adolescents who have acute pain. When using opioids for acute pain management, clinicians should prescribe immediate-release opioid formulations, start with the lowest age- and weight-appropriate doses, and provide an initial supply of 5 or fewer days, unless the pain is related to trauma or surgery with expected duration of pain longer than 5 days. Clinicians should not prescribe codeine or tramadol for patients younger than 12 years; adolescents 12 to 18 years of age who have obesity, obstructive sleep apnea, or severe lung disease; to treat postsurgical pain after tonsillectomy or adenoidectomy in patients younger than 18 years; or for any breastfeeding patient. The CPG recommends providing opioids when appropriate for treating acutely worsened pain in children and adolescents who have a history of chronic pain; clinicians should partner with other opioid-prescribing clinicians involved in the patient's care and/or a specialist in chronic pain or palliative care to determine an appropriate treatment plan. Caution should be used when treating acute pain in those who are taking sedating medications. The CPG describes potential harms of discontinuing or rapidly tapering opioids in individuals who have been on stable, long-term opioids to treat chronic pain. The guideline also recommends providing naloxone and information on naloxone, safe storage and disposal of opioids, and direct observation of medication administration. Clinicians are encouraged to help caregivers develop a plan for safe disposal. The CPG contains 12 key action statements based on evidence from randomized controlled trials, high-quality observational studies, and, when studies are lacking or could not feasibly or ethically be conducted, from expert opinion. Each key action statement includes a level of evidence, the benefit-harm relationship, and the strength of recommendation.
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Affiliation(s)
- Scott E Hadland
- Mass General for Children; Harvard Medical School, Boston, Massachusetts
| | - Rita Agarwal
- Stanford University School of Medicine, Stanford, California
| | | | - Michael J Smith
- Pediatrics, Duke University School of Medicine, Durham, North Carolina
| | - Amy Bryl
- Division of Emergency Medicine, Rady Children's Hospital San Diego and Department of Pediatrics, University of California San Diego, San Diego, California
| | - Jeremy Michel
- Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania and Department of Biomedical Informatics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Lorraine I Kelley-Quon
- Division of Pediatric Surgery, Children's Hospital Los Angeles and Departments of Surgery and Population and Public Health Sciences, Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Mehul V Raval
- Division of Pediatric Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
| | - Madeline H Renny
- Departments of Emergency Medicine, Pediatrics, and Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, New York
| | | | - Scott Wexelblatt
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati Children's Hospital Medical Center Perinatal Institute, Cincinnati, Ohio
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Orgil Z, Karthic A, Bell NF, Heisterberg LM, Williams SE, Ding L, Kashikar-Zuck S, King CD, Olbrecht VA. Use of Biofeedback-Based Virtual Reality in Pediatric Perioperative and Postoperative Settings: Observational Study. JMIR Perioper Med 2024; 7:e48959. [PMID: 38742940 PMCID: PMC11444093 DOI: 10.2196/48959] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2023] [Revised: 02/08/2024] [Accepted: 04/01/2024] [Indexed: 05/16/2024] Open
Abstract
BACKGROUND Biofeedback-based virtual reality (VR-BF) is a novel, nonpharmacologic method for teaching patients how to control their breathing, which in turn increases heart rate variability (HRV) and may reduce pain. Unlike traditional forms of biofeedback, VR-BF is delivered through a gamified virtual reality environment, increasing the accessibility of biofeedback. This is the first study to systematically integrate VR-BF use in the pediatric perioperative setting, with the ultimate goal of evaluating the efficacy of VR-BF to reduce pain, anxiety, and opioid consumption once feasibility and acceptability have been established. OBJECTIVES The primary objective was to develop a clinical trial protocol for VR-BF use in the pediatric perioperative setting, including preoperative education and training, and postoperative application of VR-BF in children undergoing surgery. A secondary objective was to evaluate the patient and parent experience with VR-BF. METHODS A total of 23 patients (12-18 years of age) scheduled for surgery at Nationwide Children's Hospital were recruited using purposive sampling. Following training, participants independently completed a daily, 10-minute VR-BF session for 7 days before surgery and during their inpatient stay. Participants could use VR-BF up to 2 weeks after hospital discharge. Patient- and session-level data of VR-BF usage and achievement of target HRV parameters were measured to identify the optimal frequency and duration of sessions before and after surgery for this population. Standardized questionnaires and semistructured interviews were conducted to obtain qualitative information about patients' experiences with VR-BF. RESULTS Patient-level data indicated that the highest odds of achieving 1 session under target HRV parameters was after 4 sessions (odds ratio [OR] 5.1 for 4 vs 3 sessions, 95% CI 1.3-20.6; OR 16.6 for 3 vs 2 sessions, 95% CI 1.2-217.0). Session-level data showed that a session duration of 9 to 10 minutes provided the greatest odds of achieving 1 session under target HRV parameters (OR 1.3 for 9 vs 8 min, 95% CI 1.1-1.7; OR 1.4 for 8 vs 7 min, 95% CI 1.1-1.8; OR 1 for 10 vs 9 min, 95% CI 0.9-1.2). Qualitative data revealed patient satisfaction with the VR-BF technology, particularly in managing perioperative stress (17/20, 85%). Few patients reported VR-BF as beneficial for pain (8/20, 40%). CONCLUSIONS Children and adolescents undergoing surgery successfully learned behavioral strategies with VR-BF with 10-minute sessions once daily for 5 days. To integrate VR-BF as a therapeutic intervention in a subsequent clinical trial, patients will be instructed to complete three 10-minute sessions a day for 7 days after surgery. TRIAL REGISTRATION ClinicalTrials NCT04943874; https://clinicaltrials.gov/ct2/show/NCT04943874.
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Affiliation(s)
- Zandantsetseg Orgil
- Abigail Wexner Research Institute, Nationwide Children's Hospital, Columbus, OH, United States
| | - Anitra Karthic
- Department of Anesthesiology, The Ohio State University College of Medicine, Columbus, OH, United States
- Department of Anesthesiology & Pain Medicine, Nationwide Children's Hospital, Columbus, OH, United States
| | - Nora F Bell
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, United States
| | - Lisa M Heisterberg
- Department of Anesthesiology, The Ohio State University College of Medicine, Columbus, OH, United States
| | - Sara E Williams
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Palo Alto, CA, United States
| | - Lili Ding
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, United States
- Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, United States
| | - Susmita Kashikar-Zuck
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, United States
- Pediatric Pain Research Center, Division of Behavioral Medicine and Clinical Psychology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, United States
| | - Christopher D King
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, United States
- Pediatric Pain Research Center, Division of Behavioral Medicine and Clinical Psychology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, United States
| | - Vanessa A Olbrecht
- Department of Anesthesiology and Perioperative Medicine, Nemours Children's Health, Delaware Valley, Wilmington, DE, United States
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Azamfirei R, Procaccini D, Lobner K, Kudchadkar SR. The Effects of Intraoperative Methadone on Postoperative Pain Control in Pediatric Patients: A Scoping Review. Anesth Analg 2024; 139:263-271. [PMID: 37285308 DOI: 10.1213/ane.0000000000006548] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
Inadequate perioperative pain control has deleterious effects on children's development and can lead to heightened pain experiences and the avoidance of future medical procedures. Reports of perioperative use of methadone in children are increasing, as it has a favorable pharmacodynamic profile; however, the effectiveness of methadone in reducing postoperative pain has not been established. We, therefore, aimed to provide a scoping review of the literature comparing the effect of intraoperative methadone versus other opioids on postoperative opioid consumption, pain scores, and adverse events in pediatric patients. We identified studies in PubMed, Scopus, Embase, and Cumulative Index to Nursing and Allied Health Literature (CINAHL) databases from inception to January 2023. Postoperative opioid consumption, pain scores, and adverse events were extracted for analysis. We screened 1864 studies, of which 83 studies were selected for full-text review. Five studies were included in the final analysis. Postoperative opioid consumption was decreased overall in children who received methadone compared to those who did not. The majority of studies indicated that methadone was superior to other opioids in reported pain scores, while the frequency of adverse events was similar between the groups. Although the data reviewed highlight a potential benefit of intraoperative methadone in pediatric patients, 4 of the 5 studies had serious methodological concerns. Thus, we cannot make strong recommendations for the regular use of methadone in the perioperative setting at this time. Our results highlight the need for large, well-designed randomized trials to fully evaluate the safety and efficacy of intraoperative methadone in diverse pediatric surgical populations.
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Affiliation(s)
- Razvan Azamfirei
- From the Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
- "George Emil Palade" University of Medicine, Pharmacy, Science and Technology, Targu Mures, Romania
| | - Dave Procaccini
- Department of Pharmacy, The Johns Hopkins Hospital, Baltimore, Maryland
| | - Katie Lobner
- Welch Medical Library, Johns Hopkins University School of Medicin, Baltimore, Maryland
| | - Sapna R Kudchadkar
- From the Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
- Department of Physical Medicine and Rehabilitation, Johns Hopkins University School of Medicine, Baltimore, Maryland
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland
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Herbinger LA. Children and the Opioid Crisis: We Can Make a Difference. J Perianesth Nurs 2024:S1089-9472(24)00049-2. [PMID: 38703178 DOI: 10.1016/j.jopan.2024.02.003] [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: 11/09/2023] [Revised: 02/09/2024] [Accepted: 02/12/2024] [Indexed: 05/06/2024]
Abstract
The use of opioid-sparing and opioid-free strategies in children can provide adequate analgesia while decreasing the risk of adverse events and contributing to the ongoing battle against the opioid crisis. However, every child must be evaluated individually so that a safe and efficacious perioperative pain management plan can be created. A working knowledge of the risks and benefits of opioids, nonopioid adjuncts, and regional anesthesia along with the ethical considerations for balancing stewardship and beneficent care is essential to the success of these strategies. As perioperative practitioners caring for children, we have an obligation to consider opioid-sparing and opioid-free strategies to promote overall best outcomes. We can make a difference, one child at a time.
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Affiliation(s)
- Lisa Allison Herbinger
- Department of Nurse Anesthesia, Samford University, Birmingham, AL; Department of Anesthesia, Children's of Alabama, Birmingham, AL.
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Richtrová M, Košková O, Janků M, Bönischová T, Fabián D, Štourač P. Regional anesthesia in neonates with cleft lip and palate: Retrospective study. Int J Pediatr Otorhinolaryngol 2024; 180:111965. [PMID: 38718430 DOI: 10.1016/j.ijporl.2024.111965] [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: 03/19/2024] [Revised: 04/22/2024] [Accepted: 05/03/2024] [Indexed: 05/15/2024]
Abstract
BACKGROUND Orofacial clefts are the most common congenital abnormalities. Cleft lip reconstruction is performed mostly in 3 months of life including the neonatal period. The consumption of opioids during anesthesia is one of the monitored parameters of anesthesia safety. We investigated the effect of using an infraorbital nerve block for reducing opioid consumption during cleft lip surgery in neonates. PATIENTS/METHODS Overall, 100 patients who underwent primary cleft lip surgery in neonatal age between 2018 and 2021 were included in the study. The primary outcome was to compare opioid requirements during cleft lip surgery with and without using regional anesthesia. Secondary outcomes included a first oral intake from surgery between neonates with and without regional anesthesia and complications rate of infraorbital nerve block. RESULTS Data from 100 patients (46 patients with and 64 without regional anesthesia) were retrospectively analyzed and classified into two groups according to whether regional anesthesia during neonatal cleft lip surgery had been performed or not. The use of infraorbital block was found to be positively correlated with lower doses of opioids used during the general anesthesia for the surgery (mean 0.48 μg/kg vs 0.29 μg/kg, p < 0.05). The postoperative course was evaluated based on the interval from surgery to first oral intake which was statistically insignificant shorter (p = 0.16) in the group of patients using regional anesthesia. No complications were recorded in the group of patients with regional anesthesia. CONCLUSIONS Regional anesthesia is associated with reduced opioid consumption during anesthesia thereby increasing the safety of anesthesia in neonates. CLINICALTRIALS GOV IDENTIFIER NCT06067854https://clinicaltrials.gov/study/NCT06067854?cond=NCT06067854&rank=1.
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Affiliation(s)
- Michaela Richtrová
- University Hospital Brno, Department of Paediatric Anaesthesiology and Intensive Care Medicine (Cernopolni 9, Brno) Masaryk University, Faculty of Medicine (Kamenice 5, Brno), Brno, Czech Republic
| | - Olga Košková
- University Hospital Brno, Department of Burns and Plastic Surgery (Jihlavska 20, Brno), Masaryk University, Faculty of Medicine (Kamenice 5, Brno), Brno, Czech Republic
| | - Martin Janků
- University Hospital Brno, Department of Paediatric Anaesthesiology and Intensive Care Medicine (Cernopolni 9, Brno) Masaryk University, Faculty of Medicine (Kamenice 5, Brno), Brno, Czech Republic
| | - Tereza Bönischová
- University Hospital Brno, Department of Paediatric Anaesthesiology and Intensive Care Medicine (Cernopolni 9, Brno) Masaryk University, Faculty of Medicine (Kamenice 5, Brno), Brno, Czech Republic.
| | - Dominik Fabián
- University Hospital Brno, Department of Paediatric Anaesthesiology and Intensive Care Medicine (Cernopolni 9, Brno) Masaryk University, Faculty of Medicine (Kamenice 5, Brno), Brno, Czech Republic
| | - Petr Štourač
- University Hospital Brno, Department of Paediatric Anaesthesiology and Intensive Care Medicine (Cernopolni 9, Brno) Masaryk University, Faculty of Medicine (Kamenice 5, Brno), Brno, Czech Republic
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Odegard M, Ourshalimian S, Hijaz D, Goldstein RY, Ignacio RC, Chen SY, Kim E, Kim ES, Kelley-Quon LI. Factors Associated with Postoperative Opioid Use in Adolescents. J Pediatr Surg 2024; 59:709-717. [PMID: 38097461 DOI: 10.1016/j.jpedsurg.2023.11.010] [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: 05/29/2023] [Revised: 10/15/2023] [Accepted: 11/20/2023] [Indexed: 04/08/2024]
Abstract
BACKGROUND We aimed to identify factors associated with postoperative prescription opioid use in adolescents. METHODS Adolescents aged 13-20 years undergoing surgery were prospectively recruited from a children's hospital. Adolescent-parent dyads completed a preoperative survey, measuring clinical and sociodemographic factors, and two postoperative surveys evaluating self-reported opioid use at 30- and 90-days. Poisson regression analysis identified factors associated with the number of pills used within 90-days, adjusting for age, gender, race/ethnicity, surgery type, and pain at discharge. RESULTS We enrolled 119 adolescents who reported postoperative opioid use following posterior spinal fusion (PSF) (50 %), arthroscopy (23 %), pectus excavatum repair (11 %), tonsillectomy (8 %), and hip reconstruction (7 %). Overall, 81 % of adolescents reported unused opioids. The median pain score at discharge was 7 (IQR:5-8). Adolescents reported using a median of 7 (IQR:2-15) opioid pills, with 20 (IQR:7-30) pills left unused. Compared to all other surgeries, adolescents undergoing PSF reported the highest median pill use (10, IQR:5-29; p = 0.004). Adolescents undergoing tonsillectomy reported the lowest median pill use (1, IQR:0-7; p = 0.03). On regression analysis, older patient age was associated with a 12 % increase in pill use (95 % CI:3%-23 %). Undergoing PSF was associated with a 63 % increase in pill use (95 % CI:15%-31 %). Each additional pain scale point reported at discharge was associated with a 13 % increase in pill use (95 % CI:5%-22 %). CONCLUSIONS Older age, surgery type, and patient-reported pain at discharge are associated with postoperative prescription opioid use in adolescents. Understanding patient and surgery-specific factors associated with opioid use may guide surgeons to minimize excess opioid prescribing. LEVEL OF EVIDENCE II.
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Affiliation(s)
- Marjorie Odegard
- Division of Pediatric Surgery, Children's Hospital Los Angeles, Los Angeles, CA, USA; Department of Surgery, Keck School of Medicine, University of Southern California, 4650 Sunset Blvd, Los Angeles, CA, 90027, USA.
| | - Shadassa Ourshalimian
- Division of Pediatric Surgery, Children's Hospital Los Angeles, Los Angeles, CA, USA; Department of Surgery, Keck School of Medicine, University of Southern California, 4650 Sunset Blvd, Los Angeles, CA, 90027, USA
| | - Donia Hijaz
- Division of Pediatric Surgery, Children's Hospital Los Angeles, Los Angeles, CA, USA; Department of Surgery, Keck School of Medicine, University of Southern California, 4650 Sunset Blvd, Los Angeles, CA, 90027, USA
| | - Rachel Y Goldstein
- Division of Pediatric Surgery, Children's Hospital Los Angeles, Los Angeles, CA, USA; Department of Surgery, Keck School of Medicine, University of Southern California, 4650 Sunset Blvd, Los Angeles, CA, 90027, USA
| | - Romeo C Ignacio
- Rady Children's Hospital San Diego, 3020 Children's Way, San Diego, CA, 92123, USA
| | - Stephanie Y Chen
- Cedars-Sinai Medical Center, 8700 Beverly Boulevard, Los Angeles, CA, 90048, USA
| | - Eugene Kim
- Division of Pediatric Surgery, Children's Hospital Los Angeles, Los Angeles, CA, USA; Department of Surgery, Keck School of Medicine, University of Southern California, 4650 Sunset Blvd, Los Angeles, CA, 90027, USA
| | - Eugene S Kim
- Division of Pediatric Surgery, Children's Hospital Los Angeles, Los Angeles, CA, USA; Department of Surgery, Keck School of Medicine, University of Southern California, 4650 Sunset Blvd, Los Angeles, CA, 90027, USA; Cedars-Sinai Medical Center, 8700 Beverly Boulevard, Los Angeles, CA, 90048, USA
| | - Lorraine I Kelley-Quon
- Division of Pediatric Surgery, Children's Hospital Los Angeles, Los Angeles, CA, USA; Department of Surgery, Keck School of Medicine, University of Southern California, 4650 Sunset Blvd, Los Angeles, CA, 90027, USA; Department of Population and Public Health Sciences, University of Southern California, 1845 N. Soto Dr., Los Angeles, CA, 90032, USA
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Chakravartula S, Thrasher B, Mann J, Chaturbedi A, Han X, Dahan A, Florian J, Strauss D, Li Z. Physiologically based modeling reveals different risk of respiratory depression after fentanyl overdose between adults and children. Clin Transl Sci 2024; 17:e13780. [PMID: 38618722 PMCID: PMC11017203 DOI: 10.1111/cts.13780] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2024] [Revised: 03/01/2024] [Accepted: 03/14/2024] [Indexed: 04/16/2024] Open
Abstract
Despite a rapid increase in pediatric mortality rate from prescription and illicit opioids, there is limited research on the dose-dependent impact of opioids on respiratory depression in children, the leading cause of opioid-associated death. In this article, we extend a previously developed translational model to cover pediatric populations by incorporating age-dependent pharmacokinetic, pharmacodynamic, and physiological changes compared to adults. Our model reproduced previous perioperative clinical findings that adults and children have similar risk of respiratory depression at the same plasma fentanyl concentration when specific endpoints (minute ventilation, CO2 tension in the blood) were used. However, our model points to a potential caveat that, in a perioperative setting, routine use of mechanical ventilation and supplemental oxygen maintained the blood and tissue oxygen partial pressures in patients and prevented the use of oxygen-related endpoints to evaluate the consequences of respiratory depression. In a community setting when such oxygenation procedures are not immediately available, our model suggests that the higher oxygen demand and reduced cerebrovascular reactivity could make children more susceptible to severe hypoxemia and brain hypoxia, even with the same plasma fentanyl concentration as adults. Our work indicates that when developing intervention strategies to protect children from opioid overdose in a community setting, these pediatric-specific factors may need to be considered.
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Affiliation(s)
- Shilpa Chakravartula
- Division of Applied Regulatory Science, Office of Clinical Pharmacology, Office of Translational SciencesCenter for Drug Evaluation and Research, Food and Drug AdministrationSilver SpringMarylandUSA
| | - Bradlee Thrasher
- Division of Applied Regulatory Science, Office of Clinical Pharmacology, Office of Translational SciencesCenter for Drug Evaluation and Research, Food and Drug AdministrationSilver SpringMarylandUSA
| | - John Mann
- Division of Applied Regulatory Science, Office of Clinical Pharmacology, Office of Translational SciencesCenter for Drug Evaluation and Research, Food and Drug AdministrationSilver SpringMarylandUSA
| | - Anik Chaturbedi
- Division of Applied Regulatory Science, Office of Clinical Pharmacology, Office of Translational SciencesCenter for Drug Evaluation and Research, Food and Drug AdministrationSilver SpringMarylandUSA
| | - Xiaomei Han
- Division of Applied Regulatory Science, Office of Clinical Pharmacology, Office of Translational SciencesCenter for Drug Evaluation and Research, Food and Drug AdministrationSilver SpringMarylandUSA
| | - Albert Dahan
- Leiden University Medical CenterLeidenThe Netherlands
| | - Jeffry Florian
- Division of Applied Regulatory Science, Office of Clinical Pharmacology, Office of Translational SciencesCenter for Drug Evaluation and Research, Food and Drug AdministrationSilver SpringMarylandUSA
| | - David Strauss
- Division of Applied Regulatory Science, Office of Clinical Pharmacology, Office of Translational SciencesCenter for Drug Evaluation and Research, Food and Drug AdministrationSilver SpringMarylandUSA
| | - Zhihua Li
- Division of Applied Regulatory Science, Office of Clinical Pharmacology, Office of Translational SciencesCenter for Drug Evaluation and Research, Food and Drug AdministrationSilver SpringMarylandUSA
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Kiskaddon AL, Goldenberg NA, Abel T, Fierstein JL, Khayat D, Quintessenza JA, Stock AC. Ketorolac Dosing and Outcomes in Neonates Following Congenital Heart Surgery: A Retrospective Analysis. Crit Care Explor 2024; 6:e1078. [PMID: 38633134 PMCID: PMC11023609 DOI: 10.1097/cce.0000000000001078] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/19/2024] Open
Abstract
BACKGROUND Pain management is essential for postoperative surgery. Given the association of opioids with adverse outcomes, interest in the use of nonopioid analgesics, such as ketorolac, has increased. Published data on use in neonates are limited. OBJECTIVES To describe ketorolac dosing and safety and efficacy outcomes in the first 48 hours postcardiac surgery in neonates. DESIGN We performed a single-center retrospective cohort study of neonates (ages < 28 d) who received ketorolac following cardiac surgery from November 2020 to July 2023 (inclusive). The primary safety outcome was a clinically significant decline in renal function, as defined by the composite of an increase in serum creatinine by greater than or equal to 0.3 mg/dL from baseline within 96 hours of ketorolac initiation and urine output less than or equal to 0.5 mL/kg/hr for 6 hours. The secondary safety outcome was clinically significant bleeding, defined as the composite of major bleeding by the International Society on Thrombosis and Hemostasis pediatric criteria and severe/fatal bleeding by the criteria of Nellis et al (2019). Efficacy was measured by opioid utilization based on a standardized pain score-driven analgesia protocol. INTERVENTIONS Ketorolac was administered at 0.5 mg/kg every 6 hours as per an institutional clinical management algorithm. MEASUREMENTS AND MAIN RESULTS Thirty-nine patients met the eligibility criteria. The median ketorolac dose was 0.5 mg/kg/dose, and median (interquartile range [IQR]) duration of therapy was 48 hours (6-48 hr). No patients experienced a significant decline in renal function, and there were no clinically significant bleeding events. The median (IQR) IV morphine milligram equivalents (MMEs)/kg/d of opioid administration was 0.2 MME/kg/d (0.1-0.25 MME/kg/d) at the time of ketorolac initiation and 0.1 MME/kg/d (0.1-0.2 MME/kg/d) at 48 hours post-ketorolac initiation. CONCLUSIONS If validated prospectively, these findings suggest that a ketorolac regimen of 0.5 mg/kg/dose every 6 hours in neonates postcardiac surgery may be safe with regard to renal function and bleeding risk. Additional randomized studies would be needed to determine efficacy with regard to opioid-sparing capacity.
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Affiliation(s)
- Amy L Kiskaddon
- Department of Pharmacy, Johns Hopkins All Children's Hospital, St. Petersburg, FL
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD
- Institute for Clinical and Translational Research, Johns Hopkins All Children's Hospital, St. Petersburg, FL
- Heart Institute, Johns Hopkins All Children's Hospital, St. Petersburg, FL
| | - Neil A Goldenberg
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD
- Institute for Clinical and Translational Research, Johns Hopkins All Children's Hospital, St. Petersburg, FL
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
- Cancer and Blood Disorders Institute, Johns Hopkins All Children's Hospital, St. Petersburg, FL
| | - Trent Abel
- Department of Pharmacy, Johns Hopkins All Children's Hospital, St. Petersburg, FL
| | - Jamie L Fierstein
- Epidemiology and Biostatistics Shared Resource, Institute for Clinical and Translational Research, Johns Hopkins All Children's Hospital, St. Petersburg, FL
| | - Delia Khayat
- University of Florida College of Pharmacy, Gainesville, FL
| | | | - Arabela C Stock
- Heart Institute, Johns Hopkins All Children's Hospital, St. Petersburg, FL
- Division of Cardiac Critical Care, Heart Institute, Johns Hopkins All Children's Hospital, St. Petersburg, FL
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11
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Chen J, Wang CY, Zhong JW, Cai YH, Zhang J, Wang F, Zhang M, Gu H, Ma HY, Wang Z, Wu J, Liu HC. Comparison of postoperative analgesia and side effects in pediatric laparoscopic surgery with morphine and nalbuphine. iScience 2024; 27:109287. [PMID: 38496295 PMCID: PMC10943434 DOI: 10.1016/j.isci.2024.109287] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2023] [Revised: 12/31/2023] [Accepted: 02/16/2024] [Indexed: 03/19/2024] Open
Abstract
There is currently no consensus on the optimal perioperative pain management strategy involving specific opioids. This study aims to compare the postoperative analgesia, the associated side effects between nalbuphine and morphine in children undergoing laparoscopic surgery. One hundred ninety children were randomly assigned to nalbuphine (0.2 mg/kg) or morphine (0.2 mg/kg). Nalbuphine's analgesic effect was non-inferior to morphine, with similar total rescue analgesic consumption during PACU stay (0.03 ± 0.05mg vs. 0.04 ± 0.06 mg, p > 0.05). Nalbuphine group had a lower incidence of respiratory depression (RR ≤ 10/min) (4.8% vs. 38.6%, p < 0.001), PONV (2.4% vs. 18.1%, p = 0.002), and pruritus (0% vs. 16.9%, p < 0.001) than morphine. Additionally, nalbuphine showed a shorter laryngeal mask airway removal time (13.9 [12.7, 15.1]) compared with morphine (17.0 [15.1, 18.9], p = 0.011). Nalbuphine provides equipotent analgesia with significantly lower incidences of respiratory depression, PONV, and pruritus compared with morphine in pediatric laparoscopic surgery.
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Affiliation(s)
- Jia Chen
- Department of Anaesthesiology and Perioperative Medicine, The Second Affiliated Hospital and Yuying Children’s Hospital of Wenzhou Medical University; Key Laboratory of Paediatric Anaesthesiology, Ministry of Education, Wenzhou Medical University; Key Laboratory of Anaesthesiology of Zhejiang Province, Wenzhou Medical University, Wenzhou, Zhejiang, China
| | - Cheng-Yu Wang
- Department of Anaesthesiology and Perioperative Medicine, The Second Affiliated Hospital and Yuying Children’s Hospital of Wenzhou Medical University; Key Laboratory of Paediatric Anaesthesiology, Ministry of Education, Wenzhou Medical University; Key Laboratory of Anaesthesiology of Zhejiang Province, Wenzhou Medical University, Wenzhou, Zhejiang, China
| | - John Wei Zhong
- Department of Anaesthesiology and Pain Management, University of Texas Southwestern Medical Centre, Dallas, TX, USA
| | - Yu-Hang Cai
- Department of Anaesthesiology and Perioperative Medicine, The Second Affiliated Hospital and Yuying Children’s Hospital of Wenzhou Medical University; Key Laboratory of Paediatric Anaesthesiology, Ministry of Education, Wenzhou Medical University; Key Laboratory of Anaesthesiology of Zhejiang Province, Wenzhou Medical University, Wenzhou, Zhejiang, China
| | - Jianmin Zhang
- Department of Anesthesiology, Beijing Children’s Hospital, Capital Medical University, Beijing 100045, China
| | - Fang Wang
- Department of Anesthesiology, Beijing Children’s Hospital, Capital Medical University, Beijing 100045, China
| | - Mazhong Zhang
- Department of Anesthesiology, Shanghai Children’s Medical Center, Shanghai 200127, China
| | - Hongbin Gu
- Department of Anesthesiology, Shanghai Children’s Medical Center, Shanghai 200127, China
| | - Hong-Yu Ma
- Department of Anaesthesiology and Perioperative Medicine, The Second Affiliated Hospital and Yuying Children’s Hospital of Wenzhou Medical University; Key Laboratory of Paediatric Anaesthesiology, Ministry of Education, Wenzhou Medical University; Key Laboratory of Anaesthesiology of Zhejiang Province, Wenzhou Medical University, Wenzhou, Zhejiang, China
| | - Zhen Wang
- Laboratory Medicine Center, Allergy Center, Department of Transfusion Medicine, Zhejiang Provincial People’s Hospital, Affiliated People’s Hospital, Hangzhou Medical College, Hangzhou, Zhejiang, China
| | - Junzheng Wu
- Department of Anesthesia and Pediatrics, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH 45229, USA
| | - Hua-Cheng Liu
- Department of Anaesthesiology and Perioperative Medicine, The Second Affiliated Hospital and Yuying Children’s Hospital of Wenzhou Medical University; Key Laboratory of Paediatric Anaesthesiology, Ministry of Education, Wenzhou Medical University; Key Laboratory of Anaesthesiology of Zhejiang Province, Wenzhou Medical University, Wenzhou, Zhejiang, China
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12
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Stanek K, Alrayashi W, Nussbaum L, Ganske IM, Rogers-Vizena CR. Suprazygomatic Maxillary Nerve Block in Palatoplasty: A Retrospective Cohort Study of Perioperative Outcomes in Syndromic and Non-Syndromic Children. Cleft Palate Craniofac J 2024:10556656241234595. [PMID: 38426799 DOI: 10.1177/10556656241234595] [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: 03/02/2024] Open
Abstract
OBJECTIVE This study compares the impact of surgical site infiltration of local anesthesia alone to surgical site infiltration plus suprazygomatic maxillary nerve block (SMB) in non-syndromic and syndromic children undergoing primary palatoplasty. DESIGN Retrospective cohort study of intra- and post-operative outcomes and opioid utilization in children undergoing palatoplasty by a single surgeon. SETTING Urban, academic, tertiary care children's hospital. PATIENTS, PARTICIPANTS Children 24 months or younger undergoing primary palatoplasty were included (n = 102). Exclusion criteria were concurrent painful procedures, history of neonatal abstinence syndrome, and nurse-controlled analgesia (n = 30). INTERVENTIONS All patients received epinephrine-containing local anesthetic infiltrated at the surgical site. Fifty-seven also underwent placement of ultrasound-guided SMB. MAIN OUTCOME MEASURE(S) Intra-operative opioid requirement, duration of anesthesia, time to wake up, post-operative opioid requirement, hypoxemic episodes, need for respiratory support, FLACC scores, and length of stay. RESULTS When controlling for syndromic status and cleft phenotype, SMB was associated with a 57% reduction in intraoperative opioid requirements (95% CI = 15-81%, p = 0.024) but also with a 29% (∼5-min) increase in wake-up time post-surgery (95% CI = 3-50%, p = 0.048). Postoperatively, SMB was linked to a 18% reduction in hospital stay length (95% CI = 2-31%, p = 0.027) and a 88% reduction in opioid requirements within 24 h after surgery (p = 0.006). Desaturations and new respiratory support requirements were unaffected by SMB. CONCLUSIONS Compared to surgical site infiltration of local anesthetic alone, adding SMB reduces intra- and postoperative narcotic requirements and decreases length of stay. These benefits apply to both syndromic and non-syndromic children. SMB does not meaningfully affect respiratory outcomes.
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Affiliation(s)
- Krystof Stanek
- Department of Plastic and Oral Surgery, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Walid Alrayashi
- Harvard Medical School, Boston, MA, USA
- Department of Anesthesiology, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA, USA
| | - Lisa Nussbaum
- Department of Plastic and Oral Surgery, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA, USA
| | - Ingrid M Ganske
- Department of Plastic and Oral Surgery, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Carolyn R Rogers-Vizena
- Department of Plastic and Oral Surgery, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
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13
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Xie Y, Liang Z, Chen S, Liu J, Lv H, Xing F, Mao Y, Ren Y, Wei X, Wang Z, Xing N, Yang J, Gu X, Yuan J. Effectiveness of perioperative low-dose esketamine infusion for postoperative pain management in pediatric urological surgery: a prospective clinical trial. BMC Anesthesiol 2024; 24:65. [PMID: 38360531 PMCID: PMC10868074 DOI: 10.1186/s12871-024-02450-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2023] [Accepted: 02/08/2024] [Indexed: 02/17/2024] Open
Abstract
BACKGROUND Postoperative pain is common in pediatric urological surgery. The study assess the impact of perioperative intravenous infusion of low-dose esketamine on postoperative pain in pediatric urological surgery. METHODS Pediatric patients (n = 80) undergoing urological surgery were randomized into four groups. Patients in the control group were administered an analgesic pump containing only hydromorphone at a dose of 0.1 mg/kg (Hydromorphone Group 1, H1) or 0.15 mg/kg (Hydromorphone Group 2, H2). Patients in the experimental group were injected intravenously with 0.3 mg/kg of esketamine (Esketamine group 1, ES1) or equal volume of saline (Esketamine Group 2, ES2) during anesthesia induction. Esketamine 1.0 mg/kg and hydromorphone 0.1 mg/kg were added to the analgesic pump. Face, Leg, Activity, Crying, and Comfort (FLACC) scale or the Numerical Rating Scale (NRS) and adverse effects were recorded at 2, 6, 24, and 48 h postoperatively. Additionally, total and effective PCA button presses were recorded. RESULTS In comparison to the H1 group, the pain scores were notably reduced at all postoperative time points in both the ES1 and H2 groups. The ES2 group exhibited lower pain scores only at 24 and 48 h postoperatively. When compared to the H2 group, there were no significant differences in pain scores at various postoperative time points in the ES2 group. However, the ES1 group demonstrated significantly lower pain scores at 6, 24 and 48 h postoperatively, and these scores were also significantly lower than those observed in the ES2 group. The total and effective number of PCA button presses in the ES1, ES2 and H2 group were lower than that in the H1 group (P < 0.001). The incidence of adverse effects within 48 h after surgery was 15% in ES1, 22% in ES2, 58% in H1, and 42% in H2, respectively (P = 0.021). CONCLUSIONS The use of low-dose esketamine infusion in analgesia pump can effectively alleviates postoperative pain in pediatric urological patients, leading to a significant reduction in the number of analgesic pump button press. The combined approach of perioperative anesthesia induction and analgesia pump administration is recommended for optimal pain management in these patients. TRIAL REGISTRATION Chinese Clinical Trial Registry- ChiCTR2300073879 (24/07/2023).
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Affiliation(s)
- Yanle Xie
- Department of Anesthesiology, Pain and Perioperative Medicine, the First Affiliated Hospital of Zhengzhou University, No. 1 Jianshe East Road, Erqi District, Zhengzhou City, Henan Province, China
- Henan Province International Joint Laboratory of Pain, Cognition and Emotion, Zhengzhou, Henan Province, China
| | - Zenghui Liang
- Department of Anesthesiology, Pain and Perioperative Medicine, the First Affiliated Hospital of Zhengzhou University, No. 1 Jianshe East Road, Erqi District, Zhengzhou City, Henan Province, China
- Henan Province International Joint Laboratory of Pain, Cognition and Emotion, Zhengzhou, Henan Province, China
| | - Shuhan Chen
- Department of Anesthesiology, Pain and Perioperative Medicine, the First Affiliated Hospital of Zhengzhou University, No. 1 Jianshe East Road, Erqi District, Zhengzhou City, Henan Province, China
- Henan Province International Joint Laboratory of Pain, Cognition and Emotion, Zhengzhou, Henan Province, China
| | - Jing Liu
- Department of Anesthesiology, Pain and Perioperative Medicine, the First Affiliated Hospital of Zhengzhou University, No. 1 Jianshe East Road, Erqi District, Zhengzhou City, Henan Province, China
| | - Huimin Lv
- Department of Anesthesiology, Pain and Perioperative Medicine, the First Affiliated Hospital of Zhengzhou University, No. 1 Jianshe East Road, Erqi District, Zhengzhou City, Henan Province, China
- Henan Province International Joint Laboratory of Pain, Cognition and Emotion, Zhengzhou, Henan Province, China
| | - Fei Xing
- Department of Anesthesiology, Pain and Perioperative Medicine, the First Affiliated Hospital of Zhengzhou University, No. 1 Jianshe East Road, Erqi District, Zhengzhou City, Henan Province, China
- Henan Province International Joint Laboratory of Pain, Cognition and Emotion, Zhengzhou, Henan Province, China
| | - Yuanyuan Mao
- Department of Anesthesiology, Pain and Perioperative Medicine, the First Affiliated Hospital of Zhengzhou University, No. 1 Jianshe East Road, Erqi District, Zhengzhou City, Henan Province, China
- Henan Province International Joint Laboratory of Pain, Cognition and Emotion, Zhengzhou, Henan Province, China
| | - Yanling Ren
- Department of Anesthesiology, Pain and Perioperative Medicine, the First Affiliated Hospital of Zhengzhou University, No. 1 Jianshe East Road, Erqi District, Zhengzhou City, Henan Province, China
- Henan Province International Joint Laboratory of Pain, Cognition and Emotion, Zhengzhou, Henan Province, China
| | - Xin Wei
- Department of Anesthesiology, Pain and Perioperative Medicine, the First Affiliated Hospital of Zhengzhou University, No. 1 Jianshe East Road, Erqi District, Zhengzhou City, Henan Province, China
- Henan Province International Joint Laboratory of Pain, Cognition and Emotion, Zhengzhou, Henan Province, China
| | - Zhongyu Wang
- Department of Anesthesiology, Pain and Perioperative Medicine, the First Affiliated Hospital of Zhengzhou University, No. 1 Jianshe East Road, Erqi District, Zhengzhou City, Henan Province, China
| | - Na Xing
- Department of Anesthesiology, Pain and Perioperative Medicine, the First Affiliated Hospital of Zhengzhou University, No. 1 Jianshe East Road, Erqi District, Zhengzhou City, Henan Province, China
- Henan Province International Joint Laboratory of Pain, Cognition and Emotion, Zhengzhou, Henan Province, China
| | - Jianjun Yang
- Department of Anesthesiology, Pain and Perioperative Medicine, the First Affiliated Hospital of Zhengzhou University, No. 1 Jianshe East Road, Erqi District, Zhengzhou City, Henan Province, China
- Henan Province International Joint Laboratory of Pain, Cognition and Emotion, Zhengzhou, Henan Province, China
| | - Xiyao Gu
- Department of Anesthesiology, Renji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China.
- Key Laboratory of Anesthesiology, Ministry of Education, Shanghai Jiao Tong University, Shanghai, China.
| | - Jingjing Yuan
- Department of Anesthesiology, Pain and Perioperative Medicine, the First Affiliated Hospital of Zhengzhou University, No. 1 Jianshe East Road, Erqi District, Zhengzhou City, Henan Province, China.
- Henan Province International Joint Laboratory of Pain, Cognition and Emotion, Zhengzhou, Henan Province, China.
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Elhamrawy A, Aepli S, Heydinger G, Tobias JD, Beltran RJ. Epidural Abscess Complicating Tunneled Caudal Epidural Catheter in an Infant for Postoperative Pain Management of Open Abdominal Surgery. J Med Cases 2024; 15:7-14. [PMID: 38328807 PMCID: PMC10846496 DOI: 10.14740/jmc4180] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2023] [Accepted: 01/10/2024] [Indexed: 02/09/2024] Open
Abstract
Regional anesthesia is being used more frequently in pediatric anesthesia practice, including the perioperative care of neonates and infants. Adverse effects may be encountered during epidural needle placement, with catheter advancement, or subsequently during infusion of local anesthetic agents. Despite applying standard practice of care regarding placement of epidural catheter, epidural catheter-related infections may still occur. We present the rare occurrence of an epidural abscess in a 4-month-old infant after placement and subsequent use of a tunneled caudal epidural catheter for postoperative pain management following abdominal surgery. Magnetic resonance imaging (MRI) was the gold standard diagnostic imaging modality and was used to identify the abscess. Management included intravenous antibiotic therapy as well as hemilaminectomy with evacuation of the epidural abscess and hematoma. The patient continued to progress well with no deficits noted on neurological examination. There were no other postoperative concerns. When there is a concern for epidural catheter-related infection, the catheter should be removed immediately. The epidural catheter tip as well as any purulent discharge from the insertion site should be sent for culture and sensitivity. Urgent neurosurgical and infectious disease consultation is suggested to provide opinions regarding surgical intervention and antibiotic therapy.
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Affiliation(s)
- Amr Elhamrawy
- Department of Anesthesiology & Pain Medicine, Nationwide Children’s Hospital, Columbus, OH, USA
| | - Savannah Aepli
- Department of Anesthesiology & Pain Medicine, Nationwide Children’s Hospital, Columbus, OH, USA
| | - Grant Heydinger
- Department of Anesthesiology & Pain Medicine, Nationwide Children’s Hospital, Columbus, OH, USA
- Department of Anesthesiology & Pain Medicine, The Ohio State University College of Medicine, Columbus, OH, USA
| | - Joseph D. Tobias
- Department of Anesthesiology & Pain Medicine, Nationwide Children’s Hospital, Columbus, OH, USA
- Department of Anesthesiology & Pain Medicine, The Ohio State University College of Medicine, Columbus, OH, USA
| | - Ralph J. Beltran
- Department of Anesthesiology & Pain Medicine, Nationwide Children’s Hospital, Columbus, OH, USA
- Department of Anesthesiology & Pain Medicine, The Ohio State University College of Medicine, Columbus, OH, USA
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15
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Kiskaddon AL, Stock AC, Fierstein JL, Miller A, Quintessenza JA, Goldenberg N. Ketorolac in neonates and infants following congenital heart surgery: a retrospective review. Cardiol Young 2023:1-7. [PMID: 38131146 DOI: 10.1017/s1047951123004262] [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] [Indexed: 12/23/2023]
Abstract
INTRODUCTION Pain management is essential in the immediate post-surgical period. We sought to describe the ketorolac dose regimen in neonates and infants following cardiac surgery. Secondary outcomes included renal dysfunction, bleeding, and pain management. METHODS We performed a single-centre retrospective cohort study of neonates and infants (aged < 12 months) who received ketorolac following cardiac surgery, from November 2020 through November 2021 (inclusive). Ketorolac was administered at 0.5 mg/kg every 6 hours. Safety was defined by absence of a clinically significant decline in renal function (i.e., increase in serum creatinine [SCr] by ≥ 0.3 mg/dL from baseline within 48 hours and/or urine output ≤ 0.5 mL/kg/hour for 6 hours) and absence of clinically significant bleeding defined as major by International Society on Thrombosis and Hemostasis paediatric criteria or Severe/Fatal Bleeding Events by Nellis et al. Efficacy measures included pain scores and opioid utilisation. RESULTS Fifty-five patients met eligibility criteria. The median (range) dose and duration of ketorolac administration was 0.5 mg/kg/dose for 48 (6-90) hours. Among all patients, there was not a statistically significant difference observed in median SCr within 48 hours of baseline (p > .9). There were no major or severe bleeding events. The median (range) opioid requirements (morphine intravenous equivalents per kg per day) at 48 hours post-ketorolac initiation was 0.1 (0-0.8) mg/kg/day. CONCLUSIONS If validated prospectively, these findings suggest that a ketorolac regimen 0.5 mg/kg/dose every 6 hours in neonates and infants post-cardiac surgery may be safe with regard to renal function and bleeding risk, and effective regarding opioid-sparing capacity.
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Affiliation(s)
- Amy L Kiskaddon
- Department of Pharmacy, Johns Hopkins All Children's Hospital, St. Petersburg, FL, USA
- Division of Cardiology, Department of Pediatrics, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Arabela C Stock
- Division of Cardiac Critical Care, Heart Institute, Johns Hopkins All Children's Hospital, St. Petersburg, FL, USA
- Heart Institute, Johns Hopkins All Children's Hospital, St. Petersburg, FL, USA
| | - Jamie L Fierstein
- Institute for Clinical and Translational Research, Epidemiology and Biostatistics Shared Resource, Johns Hopkins All Children's Hospital, St. Petersburg, FL, USA
| | - Alexandra Miller
- Institute for Clinical and Translational Research, Epidemiology and Biostatistics Shared Resource, Johns Hopkins All Children's Hospital, St. Petersburg, FL, USA
| | | | - Neil Goldenberg
- Institute for Clinical and Translational Research, Epidemiology and Biostatistics Shared Resource, Johns Hopkins All Children's Hospital, St. Petersburg, FL, USA
- Division of Hematology, Departments of Medicine and Pediatrics, Johns Hopkins School of Medicine, Baltimore, MD, USA
- Cancer and Blood Disorders Institute, Johns Hopkins All Children's Hospital, St. Petersburg, FL, USA
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16
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Sofia JT, Kim A, Jones I, Rabbitts JA, Groenewald CB. Opioid prescription rates associated with surgery among adolescents in the United States from 2015 to 2020. Paediatr Anaesth 2023; 33:1083-1090. [PMID: 37789737 PMCID: PMC10872763 DOI: 10.1111/pan.14753] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2023] [Revised: 08/07/2023] [Accepted: 08/23/2023] [Indexed: 10/05/2023]
Abstract
INTRODUCTION The United States currently faces an epidemic of opioid misuse which extends to adolescent surgical populations. Opioid prescriptions after surgery are associated with persistent opioid use and serve as a reservoir for diversion. However, it is unclear what proportion of opioid prescriptions are surgical, and little is known about trends in opioid prescription rates associated with surgery in adolescents in the United States. This study aims to describe national trends in postsurgical opioid prescription rates over time among adolescents in the United States. METHODS We conducted a population-based cross-sectional analysis of data captured in the Medical Expenditure Panel Survey (MEPS) from 2015 to 2020. MEPS classified adolescents 10-19 years of age (n = 26 909) as having a surgical procedure if they had any inpatient, outpatient, or emergency department visit during which a surgical procedure was performed. RESULTS Mean age (SD) of the sample was 14.4 (0.01) years. Sociodemographic characteristics were representative of the USA adolescent population. In total, 4.7% of adolescents underwent a surgical procedure. The surgery rate remained stable between 2015 (4.3%): and 2020 (4.4%) and was lower among minority populations. The combined rate of opioid prescribing for surgical and nonsurgical indications significantly decreased from 4.1% in 2015 to 1.4% in 2020 among all adolescents, an estimated difference of 2.7% (95% confidence interval (CI): 1.7%-3.7%, p < .0001). However, opioid prescribing for surgery remained relatively stable (1% in 2015 vs. 0.8% in 2020). DISCUSSION Opioid prescription rates associated with surgery remained stable between 2015 and 2020 in the United States, despite significant decreases in prescribing among nonsurgical populations. Surgery is now a leading source of medical prescribed opioids among adolescents. Secondary findings included a stable trend in surgery utilization between 2015 and 2020, as well as continued racial disparities, both in terms of surgery utilization and opioid prescribing. CONCLUSION The large number of adolescents being prescribed opioids for surgery in the USA each year, suggests there is a need for national guidelines aimed at adolescent opioid use, similar to the recent CDC guidelines aimed at adult opioid use.
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Affiliation(s)
- Joseph T. Sofia
- Department of Anesthesiology and Pain Medicine, University of Washington School of Medicine, Seattle, Washington
| | - Agnes Kim
- Medical College of Georgia at Augusta University, Augusta University/University of Georgia Medical Partnership, Athens, Georgia
| | - Ian Jones
- Department of Anesthesiology and Pain Medicine, University of Washington School of Medicine, Seattle, Washington
| | - Jennifer A. Rabbitts
- Department of Anesthesiology and Pain Medicine, University of Washington School of Medicine, Seattle, Washington
- Center for Clinical and Translation Research, Seattle Children’s Hospital, Seattle Washington
| | - Cornelius B. Groenewald
- Department of Anesthesiology and Pain Medicine, University of Washington School of Medicine, Seattle, Washington
- Center for Child Health, Behavior, and Development, Seattle Children’s Hospital, Seattle Washington
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Abstract
PURPOSE OF REVIEW The aim of this article is to briefly review the pediatric ambulatory surgery landscape, identify two of the most common comorbidities affecting this population, examine the influence of pediatric obesity and sleep disordered breathing (SDB)/obstructive sleep apnea (OSA) on perioperative care, and provide information that can be used when formulating site specific criteria for ambulatory surgical centers. RECENT FINDINGS Most pediatric surgeries performed are now ambulatory, a majority of which take place outside of academic centers. Children with comorbidities such as obesity and SDB/OSA are undergoing surgical or diagnostic procedures which were previously deemed unacceptable for ambulatory surgery. The increase in pediatric ambulatory surgery coupled with a recent shortage of pediatric anesthesiologists means many children will receive anesthesia care from general clinicians who care for children intermittently and may be unfamiliar with the perioperative risks these comorbidities can present. SUMMARY Our pediatric ambulatory surgical population is anticipated to demonstrate increasing rates of obesity and SDB/OSA. Bringing attention to potential perioperative complications associated with these comorbidities provides a stronger foundation upon which to formulate criteria for individual ambulatory centers. It allows for targeted anesthetic management, influences provider assignments and/or staffing ratios, and informs scheduling times. For anesthesiologists who do not practice pediatric anesthesia daily, knowing what to anticipate plays a significant role in the ability to eliminate surprises and care for these patients safely.
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Affiliation(s)
- Audra M Webber
- Department of Anesthesiology and Perioperative Medicine, University of Rochester School of Medicine and Dentistry, Rochester, New York
| | - Marjorie Brennan
- Department of Anesthesiology, Pain and Perioperative Medicine, The George Washington University School of Medicine, Children's National Hospital, Washington, District of Columbia, USA
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Wolter NE, Scheffler P, Li C, End C, McKinnon NK, Narang I, Amin R, Chiang J, Matava C, Propst EJ. Adenotonsillectomy for obstructive sleep apnea in children with cerebral palsy: Risks and benefits. Int J Pediatr Otorhinolaryngol 2023; 174:111743. [PMID: 37748322 DOI: 10.1016/j.ijporl.2023.111743] [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: 05/27/2023] [Revised: 07/24/2023] [Accepted: 09/20/2023] [Indexed: 09/27/2023]
Abstract
OBJECTIVES To determine outcomes following adenotonsillectomy for obstructive sleep apnea (OSA) and the impact of motor and swallowing impairment on respiratory complications in children with Cerebral Palsy (CP). METHODS A retrospective review of children with CP and sleep disordered breathing (SDB) who underwent adenotonsillectomy (2003-2021) was performed. Children with CP were age-matched to children without CP. Motor and swallowing function was assessed using the Gross Motor Functional Classification System (GMFCS) and the Eating and Drinking Ability Classification System (EDACS). The primary outcome was postoperative obstructive apnea-hypopnea index (OAHI). Secondary outcomes were cure rate, complications, and need for additional interventions. RESULTS Ninety-seven children with CP were assessed for SDB, and 74 underwent polysomnography. Moderate or severe OSA was found in 49% (36/74). Adenotonsillectomy was performed in 30% (29/97). All children who underwent adenotonsillectomy experienced an initial reduction in OAHI (31.7/h to 2.9/h, p < 0.0001). Children with CP were less likely to achieve an OAHI<1 compared with children without CP (62.5% vs 81.8%, p = 0.23). Children with CP had more postoperative complications (43.5% vs. 8.7%) and greater odds of respiratory complications compared with children without CP (OR 8.9 95% CI 2.1-37.9). Children with CP and a GMFCS score of 5 and EDACS score between 3 and 5 had more respiratory complications post-adenotonsillectomy compared to those with GMFCS<5 (p = 0.002) and EDACS<3 (p = 0.031). CONCLUSION Children with CP had an improved OAHI initially following adenotonsillectomy but had higher rates of post-adenotonsillectomy complications. Respiratory complications after adenotonsillectomy were more common in children with motor and swallowing impairment. Findings may provide better preoperative planning for caregivers.
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Affiliation(s)
- Nikolaus E Wolter
- Department of Otolaryngology - Head and Neck Surgery, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada.
| | - Patrick Scheffler
- Phoenix Children's Hospital, Division of Otolaryngology - Head and Neck Surgery, Phoenix, AZ, USA
| | - Chantal Li
- Department of Otolaryngology - Head and Neck Surgery, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Christopher End
- Department of Otolaryngology - Head and Neck Surgery, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Nicole K McKinnon
- Department of Critical Care Medicine, The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | - Indra Narang
- Division of Respiratory Medicine, Department of Paediatrics, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Reshma Amin
- Division of Respiratory Medicine, Department of Paediatrics, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Jackie Chiang
- Division of Respiratory Medicine, Department of Paediatrics, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Clyde Matava
- Department of Anesthesia and Pain Medicine, Department of Anesthesia, The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | - Evan J Propst
- Department of Otolaryngology - Head and Neck Surgery, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
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Messerer B, Stijic M, Sandner-Kiesling A, Brillinger JM, Helm J, Scheer J, Strohmeier CS, Avian A. Is PONV still a problem in pediatric surgery: a prospective study of what children tell us. Front Pediatr 2023; 11:1241304. [PMID: 37964809 PMCID: PMC10642485 DOI: 10.3389/fped.2023.1241304] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2023] [Accepted: 10/09/2023] [Indexed: 11/16/2023] Open
Abstract
Background Postoperative nausea and vomiting (PONV) is an unpleasant complication after surgery that commonly co-occurs with pain. Considering the high prevalence among pediatric patients, it is important to explore the main risk factors leading to PONV in order to optimize treatment strategies. The objectives of this study are as follows: (1) to determine the prevalence of PONV on the day of surgery by conducting interviews with pediatric patients, (2) to assess PONV prevalence in the recovery room and on the ward by analyzing nursing records, and (3) to collect information on PONV risk factors on the day of surgery and the following postoperative days. We wanted to investigate real-life scenarios rather than relying on artificially designed studies. Methods A prospective analysis [according to STrengthening the Reporting of OBservational studies in Epidemiology (STROBE) guidelines] of PONV on the day of surgery and the following postoperative days was conducted by evaluating demographic and procedural parameters, as well as conducting interviews with the children under study. A total of 626 children and adolescents, ranging in age from 4 to 18 years, were interviewed on the ward following their surgery. The interviews were conducted using a questionnaire, as children aged 4 and above can participate in an outcome-based survey. Results On the day of surgery, several multivariable independent predictors were identified for PONV. The type of surgery was found to be a significant factor (p = 0.040) with the highest odds ratio (OR) in patients with procedural investigations [OR 5.9, 95% confidence interval (CI): 1.8-19.2], followed by abdominal surgery (OR 3.1, 95% CI: 0.9-11.1) when inguinal surgery was used as the reference category. In addition, the study identified several predictors, including the amount of fentanyl administered during anesthesia (µg/kg body weight) (OR 1.4, 95% CI: 1.1-1.8), intraoperative use of piritramide (OR 2.6, 95% CI: 1.5-4.4) and diclofenac (OR 2.0, 95% CI: 1. 3-3.1), opioid administration in the recovery room (OR 3.0, 95% CI: 1.9-4.7), and piritramide use on the ward (OR 4.5, 95% CI: 1.7-11.6). Conclusions The main risk factors for PONV include the intraoperative administration of opioids during the recovery room stay and at the ward, the intraoperative use of non-opioids (diclofenac), and the specific type of surgical procedure. Real-life data demonstrated that in clinical praxis, there is a gap between the adherence to established guidelines and the use of antiemetic prophylaxis in surgeries that are generally not associated with a high PONV prevalence. Further efforts are needed to improve the existing procedures and thus improve the overall outcome.
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Affiliation(s)
- Brigitte Messerer
- Department of Anesthesiology and Intensive Care Medicine, Medical University of Graz, Graz, Austria
| | - Marko Stijic
- Institute for Medical Informatics, Statistics and Documentation, Medical University of Graz, Graz, Austria
- University Clinic for Neurology, Clinical Department for Neurogeriatrics, Medical University of Graz, Graz, Austria
| | - Andreas Sandner-Kiesling
- Department of Anesthesiology and Intensive Care Medicine, Medical University of Graz, Graz, Austria
| | - Johanna M. Brillinger
- Institute for Medical Informatics, Statistics and Documentation, Medical University of Graz, Graz, Austria
| | - Jasmin Helm
- Institute for Medical Informatics, Statistics and Documentation, Medical University of Graz, Graz, Austria
| | - Jacqueline Scheer
- Institute for Medical Informatics, Statistics and Documentation, Medical University of Graz, Graz, Austria
| | - Christof Stefan Strohmeier
- Institute for Medical Informatics, Statistics and Documentation, Medical University of Graz, Graz, Austria
| | - Alexander Avian
- Institute for Medical Informatics, Statistics and Documentation, Medical University of Graz, Graz, Austria
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Dourson AJ, Jankowski MP. Developmental impact of peripheral injury on neuroimmune signaling. Brain Behav Immun 2023; 113:156-165. [PMID: 37442302 PMCID: PMC10530254 DOI: 10.1016/j.bbi.2023.07.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Revised: 06/01/2023] [Accepted: 07/05/2023] [Indexed: 07/15/2023] Open
Abstract
A peripheral injury drives neuroimmune interactions at the level of the injury and throughout the neuraxis. Understanding these systems will be beneficial in the pursuit to target persistent pain that involves both neural and immune components. In this review, we discuss the impact of injury on the development of neuroimmune signaling, along with data that suggest a possible cellular immune memory. We also discuss the parallel effects of injury in the nervous system and immune related areas including bone marrow, lymph node and central nervous system-related cells. Finally, we relate these findings to patient populations and current research that evaluates human tissue.
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Affiliation(s)
- Adam J Dourson
- Department of Anesthesia, Division of Pain Management, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, United States; Department of Anesthesiology, Washington University School of Medicine, St. Louis, MO, United States
| | - Michael P Jankowski
- Department of Anesthesia, Division of Pain Management, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, United States; Department of Pediatrics, University of Cincinnati, College of Medicine, Cincinnati, OH, United States; Pediatric Pain Research Center, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, United States.
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21
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Ramsey LB, Prows CA, Tang Girdwood S, Van Driest S. Current Practices in Pharmacogenomics. Pediatr Clin North Am 2023; 70:995-1011. [PMID: 37704356 PMCID: PMC10865383 DOI: 10.1016/j.pcl.2023.05.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/15/2023]
Abstract
Pharmacogenomics, where genomic information is used to tailor medication management, is a strategy to maximize drug efficacy and minimize toxicity. Although pediatric evidence is less robust than for adults, medications influenced by pharmacogenomics are prescribed to children and adolescents. Evidence-based guidelines and drug label annotations are available from the Clinical Pharmacogenetics Implementation Consortium (CPIC) and the Pharmacogenomics Knowledgebase (PharmGKB). Some pediatric health care facilities use pharmacogenomics to provide dosing recommendations to pediatricians. Herein, we use a case-based approach to illustrate the use of pharmacogenomic data in pediatric clinical care and provide resources for finding and using pharmacogenomic guidelines.
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Affiliation(s)
- Laura B Ramsey
- Division of Clinical Pharmacology, Cincinnati Children's Hospital Medical Center, College of Medicine, University of Cincinnati, 3333 Burnet Avenue, MLC 6018, Cincinnati, OH 45229, USA; Division of Research in Patient Services, Cincinnati Children's Hospital Medical Center, College of Medicine, University of Cincinnati, 3333 Burnet Avenue, MLC 6018, Cincinnati, OH 45229, USA; Department of Pediatrics, University of Cincinnati College of Medicine, 3333 Burnet Avenue, MLC 9016, Cincinnati, OH 45529, USA.
| | - Cynthia A Prows
- Division of Human Genetics, Department of Pediatrics and Center for Professional Excellence, Patient Services, Cincinnati Children's Hospital Medical Center, College of Medicine, University of Cincinnati, 3333 Burnet Avenue, MLC 6018, Cincinnati, OH 45229, USA
| | - Sonya Tang Girdwood
- Department of Pediatrics, University of Cincinnati College of Medicine, 3333 Burnet Avenue, MLC 9016, Cincinnati, OH 45529, USA; Division of Hospital Medicine, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, MLC 9016, Cincinnati, OH 45529, USA; Division of Clinical Pharmacology, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, MLC 9016, Cincinnati, OH 45529, USA
| | - Sara Van Driest
- Department of Pediatrics, Vanderbilt University Medical Center, 2200 Children's Way, 8232 DOT, Nashville, TN 37205, USA
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22
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Bardol M, Pan S, Walker SM, Standing JF, Dawes JM. Pharmacokinetic pharmacodynamic modeling of analgesics and sedatives in children. Paediatr Anaesth 2023; 33:781-792. [PMID: 37341161 PMCID: PMC10947261 DOI: 10.1111/pan.14712] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2023] [Revised: 05/18/2023] [Accepted: 05/21/2023] [Indexed: 06/22/2023]
Abstract
Pharmacokinetic pharmacodynamic modeling is an important tool which uses statistical methodology to provide a better understanding of the relationship between concentration and effect of drugs such as analgesics and sedatives. Pharmacokinetic pharmacodynamic models also describe between-subject variability that allows identification of subgroups and dose adjustment for optimal pain management in individual patients. This approach is particularly useful in the pediatric population, where most drugs have received limited evaluation and dosing is extrapolated from adult practice. In children, the covariates of weight and age are used to describe size- and maturation-related changes in pharmacokinetics. It is important to consider both size and maturation in order to develop an accurate model and determine the optimal dose for different age groups. An adequate assessment of analgesic and sedative effect using pain scales or brain activity measures is essential to build reliable pharmacokinetic pharmacodynamic models. This is often challenging in children due to the multidimensional nature of pain and the limited sensitivity and specificity of some measurement tools. This review provides a summary of the pharmacokinetic and pharmacodynamic methodology used to describe the dose-concentration-effect relationship of analgesics and sedation in children, with a focus on the different pharmacodynamic endpoints and the challenges of pharmacodynamic modeling.
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Affiliation(s)
- Maddlie Bardol
- Infection, Immunity and Inflammation, Great Ormond Street Institute of Child HealthUniversity College LondonLondonUK
| | - Shan Pan
- Infection, Immunity and Inflammation, Great Ormond Street Institute of Child HealthUniversity College LondonLondonUK
| | - Suellen M. Walker
- Department of Anaesthesia and Pain MedicineGreat Ormond St Hospital NHS Foundation TrustLondonUK
- Developmental Neurosciences Program, UCL Great Ormond St Institute of Child HealthUniversity College LondonLondonUK
| | - Joseph F. Standing
- Infection, Immunity and Inflammation, Great Ormond Street Institute of Child HealthUniversity College LondonLondonUK
- Department of PharmacyGreat Ormond St Hospital NHS Foundation TrustLondonUK
| | - Joy M. Dawes
- Infection, Immunity and Inflammation, Great Ormond Street Institute of Child HealthUniversity College LondonLondonUK
- Department of Anaesthesia and Pain MedicineGreat Ormond St Hospital NHS Foundation TrustLondonUK
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23
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Cepeda A, Johnson ML, Kelagere K, Obinero CG, Nguyen PD, Greives MR. The Limit Is Zero: A Prospective Evaluation of Ketorolac in Patients Undergoing Primary Palatoplasty to Reduce Narcotic Utilization. J Craniofac Surg 2023; 34:1713-1716. [PMID: 37381130 DOI: 10.1097/scs.0000000000009503] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Accepted: 05/16/2023] [Indexed: 06/30/2023] Open
Abstract
BACKGROUND Patients undergoing primary palatoplasty rely on narcotics for pain control, but narcotics can lead to sedation and respiratory depression. Recent research into Enhanced Recovery After Surgery (ERAS) pathways utilizing multimodal pain therapy has yielded promising results for patients undergoing palatoplasty in terms of decreased hospital length of stay (LOS), increased oral intake, and decreased narcotic usage. Despite the potential benefit of ketorolac after palatoplasty, there is a paucity of data regarding its use. METHODS A single-center cohort study of patients undergoing primary palatoplasty was performed using 2 cohorts: a retrospective cohort treated with our institution's prior ERAS protocol from 2016 to 2018 and a prospective group of patients who also received ketorolac (ERAS+K) postoperatively from 2020 to 2022. RESULTS A total of 85 patients (57 ERAS and 28 ERAS+K) were included. Compared with the ERAS group, the ERAS+K cohort had significantly decreased LOS (31.8 versus 55 h, P =0.02), decreased morphine milligram equivalents administered at 24 hours (1.5 versus 2.5, P =0.003), 48 hours (0 versus 1.5, P <0.001), and total inpatient morphine milligram equivalents (1.9 versus 3.8, P =0.001). The ERAS+K group also had a significant decrease in the prescribed narcotic rate (32.1% versus 61.4%, P =0.006). No bleeding issues, blood transfusions, or reoperations were noted in either cohort. CONCLUSIONS This study illustrates many potential benefits of using ketorolac as a pain management adjunct in combination with a multimodal pain regimen. Our results demonstrated favorable outcomes, including decreased narcotic usage and LOS as well as increased hourly oral intake, without increasing bleeding complications.
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Affiliation(s)
- Alfredo Cepeda
- Division of Plastic and Reconstructive Surgery, Department of Surgery, McGovern Medical School at the University of Texas Health Science Center at Houston and Children's Memorial Hermann Hospital, Houston, TX
| | - Madysen L Johnson
- Division of Plastic and Reconstructive Surgery, Department of Surgery, McGovern Medical School at the University of Texas Health Science Center at Houston and Children's Memorial Hermann Hospital, Houston, TX
| | - Kavya Kelagere
- Department of Internal Medicine, McGovern Medical School at the University of Texas Health Science Center at Houston, Houston, TX
| | - Chioma G Obinero
- Division of Plastic and Reconstructive Surgery, Department of Surgery, McGovern Medical School at the University of Texas Health Science Center at Houston and Children's Memorial Hermann Hospital, Houston, TX
| | - Phuong D Nguyen
- Division of Plastic and Reconstructive Surgery, Department of Surgery, McGovern Medical School at the University of Texas Health Science Center at Houston and Children's Memorial Hermann Hospital, Houston, TX
| | - Matthew R Greives
- Division of Plastic and Reconstructive Surgery, Department of Surgery, McGovern Medical School at the University of Texas Health Science Center at Houston and Children's Memorial Hermann Hospital, Houston, TX
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Kodvavi MS, Asghar MA, Ghaffar RA, Nadeem I, Bhimani S, Kumari V, Rabbani A, Iqbal M, Naeem R, Nasir AM, Hassan SS, Ghazni MS. Effectiveness of virtual reality in managing pain and anxiety in adults during periprocedural period: a systematic review and meta-analysis. Langenbecks Arch Surg 2023; 408:301. [PMID: 37556082 DOI: 10.1007/s00423-023-03046-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2022] [Accepted: 08/03/2023] [Indexed: 08/10/2023]
Abstract
PURPOSE Patients undergoing medical procedures often experience pain and anxiety. These periprocedural outcomes can be overcome by providing a distraction using virtual reality (VR), decreasing their perception. VR has proved effective in reducing pediatric pain and anxiety; however, limited studies have confirmed its effectiveness in adults. We performed a systematic review and meta-analysis on the effectiveness of VR, as opposed to standard care, in reducing periprocedural pain and anxiety in adults. METHODS A systematic search of randomized controlled trials was conducted using the databases of MEDLINE, Cochrane CENTRAL, and Scopus. Trials involving patients (> 18 years) undergoing elective medical procedures conducted with or without local anesthesia and participating in VR therapy were included. Primary outcomes were pre-procedural anxiety, post-procedural anxiety, and intra-procedural pain. Pre-procedural pain, post-procedural pain, and intra-procedural anxiety were secondary outcomes. RESULTS Data from 10 studies shortlisted for inclusion revealed no significant association between the use of VR and lower pre-procedural anxiety compared to standard care (p > 0.05) (SMD = -0.02, 95% CI = -0.18 - 0.14, P = 0.81) but demonstrated that the use of VR was significantly associated with a reduction in post-procedural anxiety (SMD = -0.73, 95% CI = -1.08 - -0.39, P < 0.0001), intra-procedural pain (SMD = -0.61, 95% CI = -1.18 - -0.04, P = 0.04), and post-procedural pain (SMD = -0.25, 95% CI = -0.44 - -0.05, P = 0.01). CONCLUSION The use of VR caused a significant reduction in post-procedural anxiety, intra-procedural pain, and post-procedural pain in adults undergoing medical procedures, although the findings were insignificant concerning pre-procedural anxiety.
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Affiliation(s)
| | - Mustafa Ali Asghar
- Department of Internal Medicine, Dow University of Health Sciences, Karachi, Pakistan.
| | - Rimmel Abdul Ghaffar
- Department of Internal Medicine, Dow University of Health Sciences, Karachi, Pakistan
| | - Ilsa Nadeem
- Department of Internal Medicine, Dow University of Health Sciences, Karachi, Pakistan
| | - Sunaina Bhimani
- Department of Internal Medicine, Dow University of Health Sciences, Karachi, Pakistan
| | - Varsha Kumari
- Department of Internal Medicine, Dow University of Health Sciences, Karachi, Pakistan
| | - Azkah Rabbani
- Department of Internal Medicine, Dow University of Health Sciences, Karachi, Pakistan
| | - Maham Iqbal
- Department of Internal Medicine, Dow University of Health Sciences, Karachi, Pakistan
| | - Raahim Naeem
- Department of Internal Medicine, Dow University of Health Sciences, Karachi, Pakistan
| | - Aqsa Muhammad Nasir
- Department of Internal Medicine, Dow University of Health Sciences, Karachi, Pakistan
| | - Syed Shayaan Hassan
- Department of Internal Medicine, Dow University of Health Sciences, Karachi, Pakistan
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Jiang M, Huang W, Yang Y, Liang Y, Li C, Wang L, Liu T, Xu C. Paravertebral Block Under Direct Vision Versus Local Anesthetic Infiltration for Pediatric Thoracoscopic Surgery. J Laparoendosc Adv Surg Tech A 2023; 33:814-820. [PMID: 37163293 DOI: 10.1089/lap.2022.0431] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/11/2023] Open
Abstract
Background: For children with congenital lung malformations (CLMs), there is insufficient evidence of the efficacy of direct visual paravertebral block (PVB). We aimed to evaluate its effectiveness and safety by comparing it with local anesthetic infiltration (LAI). Materials and Methods: This was a nonrandomized control study of CLMs in children younger than 3 years of age who underwent thoracoscopic surgery in our hospital from January to December 2020. The children were divided into group A (PVB analgesia group) and group B (LAI group). The primary outcome was the incidence of rebound pain within 72 hours. Secondary outcomes included the Face, Legs, Activity, Crying, Consolability (FLACC) pain scores at 0, 6, 12, 24, 36, 48, and 72 hours, side effects, adverse events, the number of rebound pains, and the postoperative family observation scores. Results: The incidence of rebound pain was 10% in group A and 60.5% in group B within 72 hours (P < .001). The PVB was associated with decreased FLACC pain scores at 12, 24, 36, 48, and 72 hours, family observation scores, and the number of rebound pains (P < .001, P = .01, P = .028, P = .005, P = .006, P = .026, and P < .001, respectively). Group B was also associated with a higher rate of side effects and adverse events. There was no difference in the length of hospital stay. Conclusion: The PVB under direct vision analgesia technique is effective and safe for postoperative pain control in pediatric patients with CLMs. It may be an attractive alternative to LAI for pediatric thoracoscopic surgical procedures.
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Affiliation(s)
- Meiling Jiang
- Department of Pediatric Surgery, West China Hospital, Sichuan University/West China School of Nursing, Sichuan University, Chengdu, China
| | - Wenjiao Huang
- Department of Pediatric Surgery, West China Hospital, Sichuan University/West China School of Nursing, Sichuan University, Chengdu, China
| | - Yang Yang
- Department of Pediatric Surgery, West China Hospital, Sichuan University/West China School of Nursing, Sichuan University, Chengdu, China
| | - Yuanyuan Liang
- Department of Pediatric Surgery, West China Hospital, Sichuan University/West China School of Nursing, Sichuan University, Chengdu, China
| | - Changqin Li
- Department of Pediatric Surgery, West China Hospital, Sichuan University/West China School of Nursing, Sichuan University, Chengdu, China
| | - Lisi Wang
- Department of Pediatric Surgery, West China Hospital, Sichuan University/West China School of Nursing, Sichuan University, Chengdu, China
| | - Tian Liu
- Department of Pediatric Surgery, West China Hospital, Sichuan University/West China School of Nursing, Sichuan University, Chengdu, China
| | - Chang Xu
- Department of Pediatric Surgery, West China Hospital, Sichuan University, Chengdu, China
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Kitzman JM, Mesheriakova VV, Borucki AN, Agarwal R. Substance Use Disorders in Adolescents and Young Adults: History and Perioperative Considerations From the Society for Pediatric Pain Medicine. Anesth Analg 2023:00000539-990000000-00608. [PMID: 37450650 DOI: 10.1213/ane.0000000000006623] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/18/2023]
Abstract
Substance use disorders (SUDs) are on the rise in children and young adults in the United States. According to reports, over 40 million people aged 12 and older had a diagnosed SUD in 2020.1 A recent report from the Centers for Disease Control and Prevention (CDC) found that overdose death in children aged 10 to 19 years old increased 109% from 2019 to 2021.2 Given the rapidly increasing prevalence of SUD, anesthesiologists will almost certainly encounter children, adolescents, and young adults with a history of recreational drug use or nonmedical use of prescription opioids in the perioperative period. Since the perioperative period can be a particularly challenging time for patients with SUD, anesthesiologists can tailor their perioperative care to reduce rates of relapse and can serve as both advocates and educators for this vulnerable patient population. This article examines the history of SUD and physiology of substance use in children, adolescents, and young adults, including reasons why young people are more susceptible to the addictive effects of many substances. The coronavirus disease 2019 (COVID-19) pandemic impacted many aspects of life, including increased social isolation and shifted dynamics at home, both thought to impact substance use.3 Substance use patterns in the wake of the COVID-19 pandemic are explored. Although current literature is mostly on adults, the evidence-based medical treatments for patients with SUD are reviewed, and recommendations for perioperative considerations are suggested. The emphasis of this review is on opioid use disorder, cannabis, and vaping particularly because these have disproportionately affected the younger population. The article provides recommendations and resources for recognizing and treating adolescents and young adults at risk for SUD in the perioperative period. It also provides suggestions to reduce new persistent postoperative opioid use.
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Affiliation(s)
- Jamie M Kitzman
- From the Department of Anesthesiology, Division of Pediatric Anesthesiology, Emory University School of Medicine, Atlanta, Georgia
| | - Veronika V Mesheriakova
- Department of Pediatrics, Division of Adolescent and Young Adult Medicine, University of California San Francisco, San Francisco, California
| | - Amber N Borucki
- Department of Anesthesiology, University of California San Francisco, San Francisco, California
| | - Rita Agarwal
- Department of Anesthesiology, Perioperative Medicine, and Pain Management, Stanford University School of Medicine, Stanford, California
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Ewing MA, Livesay LN, Cook JL, Leary EV, Hoernschemeyer DG, Gupta SK. Household Income and Parental Educational Level Affect Post-Operative Opioid Usage in Pediatric Orthopaedic Patients. MISSOURI MEDICINE 2023; 120:306-313. [PMID: 37609472 PMCID: PMC10441272] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 08/24/2023]
Abstract
Opioid medications are commonly prescribed after pediatric orthopaedic surgery, but there is a critical need to optimize prescribing practice. This study identifies socio-economic characteristics, surgical characteristics, and patient reported psychological factors influencing postoperative opioid use in this population and found that post-operative opioid use in this pediatric orthopaedic population is multifactorial. Physicians should consider implementing protocols for initial opioid prescriptions to cover two to three days following common orthopaedic surgeries for most pediatric patients.
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Affiliation(s)
- Michael A Ewing
- Department of Orthopaedic Surgery, University of Missouri - Columbia, Columbia, Missouri
| | - Lauren N Livesay
- Department of Orthopaedic Surgery, University of Missouri - Columbia, Columbia, Missouri
| | - James L Cook
- Department of Orthopaedic Surgery and the Thompson Laboratory for Regenerative Orthopaedics, University of Missouri - Columbia, Columbia, Missouri
| | - Emily V Leary
- Department of Orthopaedic Surgery and the Thompson Laboratory for Regenerative Orthopaedics, University of Missouri - Columbia, Columbia, Missouri
| | - Daniel G Hoernschemeyer
- Department of Orthopaedic Surgery and Women's and Children's Hospital, University of Missouri - Columbia, Columbia, Missouri
| | - Sumit K Gupta
- Department of Orthopaedic Surgery and Women's and Children's Hospital, University of Missouri - Columbia, Columbia, Missouri
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28
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Chen YH, Sadhasivam S, DeMedal S, Visoiu M. Short-acting versus long-acting opioids for pediatric postoperative pain management. Expert Rev Clin Pharmacol 2023; 16:813-823. [PMID: 37531096 PMCID: PMC10529420 DOI: 10.1080/17512433.2023.2244417] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2023] [Accepted: 08/01/2023] [Indexed: 08/03/2023]
Abstract
INTRODUCTION Opioids are potent analgesics commonly used to manage children's moderate to severe perioperative pain in children. A wide range of short and long-acting opioids are used to treat surgical pain and will be reviewed in this article. AREAS COVERED Both short- and long-acting opioids contain unique therapeutic benefits and adverse effects; however, due to the side effect profile and safety concerns, lack of familiarity, and evidence with long-acting opioids to treat surgical pain, shorter-acting opioids have traditionally been used in children. Almost all opioids work by binding to the mu receptor. Methadone, a long-acting opioid, is an exception because it also has beneficial N-methyl-D-aspartate antagonist properties. Clinically methadone's properties could translate to improved analgesic outcomes, reduced risk of adverse events, less risk for acute hyperalgesia, tolerance and abuse potential, faster recovery, and reduced risk for chronic persistent surgical pain. This review article summarizes and compares the evidence of commonly used short and long-acting opioids for perioperative pain control in the pediatric population. EXPERT OPINION Individualized methadone therapy using pharmacogenomics has the potential to transform opioid use in pain management by improving patient safety and analgesic outcomes, thereby addressing the gaps in current standardized ERAS protocols.
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Affiliation(s)
- Yun Han Chen
- Department of Anesthesiology and Pain Medicine, UPMC Children’s Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Senthilkumar Sadhasivam
- Department of Anesthesiology and Pain Medicine, UPMC Children’s Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Spencer DeMedal
- Department of Anesthesiology and Pain Medicine, UPMC Children’s Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Mihaela Visoiu
- Department of Anesthesiology and Pain Medicine, UPMC Children’s Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, Pennsylvania
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Heydinger G, Karthic A, Olbrecht VA. Paediatric pain management: from regional to virtual. Curr Opin Anaesthesiol 2023; 36:347-353. [PMID: 36745092 DOI: 10.1097/aco.0000000000001247] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
PURPOSE OF REVIEW Due to increased interest in opioid-sparing multimodal analgesic strategies both inside and outside of the operating room, anaesthesiologists have started to look towards regional anaesthesia as well as nonpharmacological pain-reducing techniques. The purpose of this article is to discuss current trends and recent developments in regional anaesthesia and virtual reality for paediatric pain management. RECENT FINDINGS The development of novel fascial plane blocks has expanded regional options for anaesthesiologists, especially when neuraxial anaesthesia is not a viable or straightforward option. Other regional techniques, such as spinal anaesthesia and continuous epidural analgesia for infants and neonates, are becoming more popular, as more paediatric anaesthesiologists become familiar with these techniques. Virtual reality for paediatric pain management is a relatively new area of study that has shown promise, but more research needs to be done before widespread adoption of this practice becomes a reality. Various preexisting pain-reducing strategies such as distraction and biofeedback are being integrated with virtual reality to help optimize its effect on pain and anxiety for paediatric patients. SUMMARY Regional anaesthesia and virtual reality are valuable tools that serve to alleviate pain in paediatric patients. Advances are being made within both fields in various healthcare settings for different types of pain. Over the next few years, they will likely both play an increasing role in paediatric pain management.
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Affiliation(s)
- Grant Heydinger
- Department of Anesthesiology and Pain Medicine, Nationwide Children's Hospital and the Department of Anesthesiology and Pain Medicine, The Ohio State University College of Medicine
| | - Anitra Karthic
- The Ohio State University College of Medicine, Columbus, Ohio, USA
| | - Vanessa A Olbrecht
- Department of Anesthesiology and Pain Medicine, Nationwide Children's Hospital and the Department of Anesthesiology and Pain Medicine, The Ohio State University College of Medicine
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Ozdemir C, Isik B, Kurtipek O. Analgesic Efficacy of Erector Spinae Plane Block in Pediatric Abdominal Surgery: Guidance with Conventional Method and NOL: Case Series. Niger J Clin Pract 2023; 26:779-786. [PMID: 37470653 DOI: 10.4103/njcp.njcp_754_22] [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: 07/21/2023]
Abstract
Background Erector spinae plane (ESP) block is a regional anesthesia technique that blocks both somatic and visceral nerve fibers. Despite its high analgesic potential, its mechanism of action is not yet fully understood. The ultrasound-guided ESP block, which can be easily performed, makes important contributions to the control of intraoperative pain in pediatric patients undergoing abdominal surgery. The follow-up of pain in the intraoperative period is usually done by evaluating the changes in hemodynamic parameters. Due to physiological differences in pediatric patients, it is more difficult to do this with only hemodynamic changes than in adult patients. Aim: The NOL® (Nociception Level) monitor calculates the nociception/pain score by evaluating many parameters through a proprietary algorithm. Our primary aim was to demonstrate the effectiveness of ESP block with an advanced pain monitor in this patient group; our secondary aim was to investigate the necessity of pain monitors in the pediatric patient group. Methods In this case series, we applied intraoperative NOL® monitoring in addition to standard monitoring (ECG, SpO2, heart rate, EtCO2) in pediatric patients (16 cases) who were scheduled for abdominal surgery and underwent ESP block. Results Considering the hemodynamic data, NOL values, postoperative pain scores, side effects, and complications, it was concluded that ESP block can be used safely in this patient group. Although the hemodynamic data and the NOL® index were compatible with each other after a nociceptive stimulus, the NOL index was less affected by other variables and gave the clinician clearer information about pain.
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Affiliation(s)
- C Ozdemir
- Department of Anesthesiology and Reanimation, Mamak State Hospital, Ankara, Turkey
| | - B Isik
- Department of Anesthesiology and Reanimation, Faculty of Medicine, Gazi University, Ankara, Turkey
| | - O Kurtipek
- Department of Anesthesiology and Reanimation, Faculty of Medicine, Gazi University, Ankara, Turkey
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Boisvert-Plante V, Poulin-Harnois C, Ingelmo P, Einhorn LM. What we know and what we don't know about the perioperative use of methadone in children and adolescents. Paediatr Anaesth 2023; 33:185-192. [PMID: 36281540 PMCID: PMC10416808 DOI: 10.1111/pan.14584] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2022] [Revised: 09/07/2022] [Accepted: 10/18/2022] [Indexed: 02/05/2023]
Abstract
Postoperative pain control is essential to optimizing patient outcomes, improving satisfaction, and allowing patients to resume their baseline functional activities. Methadone, a synthetic mu-opioid agonist, has multiple pharmacologic properties that may be optimal for perioperative use. Compared to other opioids, methadone has a longer duration of action, rapid onset, extended dosing intervals, high oral bioavailability, low cost, lack of active metabolites, and action on multiple receptors. The current literature examining the use of methadone in the perioperative care of children and adolescents is limited and most often reported within the context of spine or cardiothoracic surgery. Overall, these studies support the hypothesis that perioperative methadone in pediatric patients may decrease postoperative pain, opioid consumption, length-of-stay, and the incidence of some opioid-related side effects, like constipation and urinary retention. A variety of protocols for the perioperative use of methadone have been described, including a single intraoperative dose as well as multiple small doses within multimodal pain protocols. The superiority of these protocols has not been established. Like all opioids, methadone has a side effect profile which includes nausea, vomiting, reduced GI motility, sedation, and respiratory depression at high doses. There is also a concern that it can cause QTc prolongation in patients. The primary aim of this educational review is to examine the pharmacologic data, published perioperative protocols, dosing considerations, and risks and benefits associated with inclusion of methadone in analgesic regimens for surgical patients. A secondary aim is to introduce opportunities for research around the perioperative use of methadone in children and adolescents. Based on our review, we would prioritize establishing optimal procedure-specific methadone protocols, determining generalizability for use in routine pediatric surgeries, and investigating methadone safety and efficacy prospectively as the primary opioid for pain management in the postanesthesia care unit or postsurgical floors.
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Affiliation(s)
| | - Christelle Poulin-Harnois
- Department of Pediatric Anesthesia, Montreal Children’s Hospital, McGill University Health Center, Montréal, Quebec, Canada
| | - Pablo Ingelmo
- Department of Pediatric Anesthesia, Montreal Children’s Hospital, McGill University Health Center, Montréal, Quebec, Canada
- Alan Edwards Centre for Pain Research, McGill University, Montreal, Quebec, Canada
- Edwards Family Interdisciplinary Complex Pain Centre, Montreal Children’s Hospital, McGill University Health Center, Montreal, Quebec, Canada
- Research Institute of the McGill University Health Center, Montreal, Quebec, Canada
| | - Lisa M. Einhorn
- Department of Anesthesiology, Pediatric Division, Duke University School of Medicine, Durham, North Carolina, United States
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[Evidence-based guideline for neonatal pain management in China (2023)]. ZHONGGUO DANG DAI ER KE ZA ZHI = CHINESE JOURNAL OF CONTEMPORARY PEDIATRICS 2023; 25:109-127. [PMID: 36854686 PMCID: PMC9979385 DOI: 10.7499/j.issn.1008-8830.2210052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 10/12/2022] [Accepted: 12/06/2022] [Indexed: 03/02/2023]
Abstract
Pain disrupts neonatal vital signs and internal environment homeostasis and affects the recovery process, and recurrent pain stimulation is one of the important risk factors for neurodevelopmental disorders and some chronic diseases. In order to standardize pain management practice in neonatal wards in China and effectively prevent and reduce the adverse effects of pain on the physical and mental development of neonates, National Clinical Research Center for Child Health and Diseases (Children's Hospital of Chongqing Medical University) convened a multidisciplinary panel to formulate the evidence-based guideline for neonatal pain management in China (2023 edition) following the principles and methods for the guideline development issued by the World Health Organization. Based on the best evidence and expert consensus, this guideline gives 26 recommendations for nine clinical issues, i.e., the classification and definition of neonatal pain, common sources of pain, pain assessment principles, pain assessment methods, analgesic principle, non-pharmaceutical analgesic methods, pharmaceutical analgesic methods, parental participation in pain management, and recording methods for pain management, so as to provide medical staff with guidance and a decision-making basis for neonatal pain assessment and analgesia management.
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Orgil Z, Johnson L, Karthic A, Williams SE, Ding L, Kashikar-Zuck S, King CD, Olbrecht VA. Feasibility and acceptability of perioperative application of biofeedback-based virtual reality versus active control for pain and anxiety in children and adolescents undergoing surgery: protocol for a pilot randomised controlled trial. BMJ Open 2023; 13:e071274. [PMID: 36697053 PMCID: PMC9884985 DOI: 10.1136/bmjopen-2022-071274] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
Abstract
INTRODUCTION Current clinical applications of virtual reality (VR) provide patients with transient pain relief during acutely painful events by redirecting attention. Biofeedback (BF) is a mind-body therapy that effectively produces sustained pain reduction, but there are obstacles to its routine use. Combined, BF-based VR (VR-BF) may increase accessibility while enhancing the benefits of BF. VR-BF has yet to be employed in perioperative care, and as such, no defined treatment protocol for VR-BF exists. The primary aim of this study is to assess the feasibility of the perioperative use of VR-BF in children and adolescents. The secondary aims are to assess the acceptability of VR-BF and to collect pilot efficacy data. METHODS AND ANALYSIS This is a single-centre, randomised controlled pilot clinical trial. A total of 70 patients (12-18 years) scheduled for surgery anticipated to cause moderate to severe pain with ≥1 night of hospital admission will be randomised to one of two study arms (VR-BF or control). Participants randomised to VR-BF (n=35) will use the ForeVR VR platform to engage their breathing in gamified VR applications. Participants randomised to control (n=35) will interact with a pain reflection app, Manage My Pain. The primary outcome is feasibility of VR-BF use in adolescents undergoing surgery as assessed through recruitment, enrolment, retention and adherence to the protocol. Secondary outcomes are acceptability of VR-BF and pilot efficacy measures, including pain, anxiety and opioid consumption. ETHICS AND DISSEMINATION The protocol was approved by the Nationwide Children's Hospital Institutional Review Board (IRB #STUDY00002080). Patient recruitment begins in March 2023. Written informed consent is obtained for all participants. All information acquired will be disseminated via scientific meetings and published in peer-reviewed journals. Data will be available per request and results will be posted on ClinicalTrials.gov. TRIAL REGISTRATION NUMBER ClinicalTrials.gov Registry (NCT04943874).
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Affiliation(s)
- Zandantsetseg Orgil
- Department of Clinical Research Services, Nationwide Children's Hospital, Columbus, Ohio, USA
- Department of Anesthesiology & Pain Medicine, Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Leah Johnson
- Department of Clinical Research Services, Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Anitra Karthic
- Department of Anesthesiology & Pain Medicine, Nationwide Children's Hospital, Columbus, Ohio, USA
- Ohio State University College of Medicine, Columbus, Ohio, USA
| | - Sara E Williams
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
- Pediatric Pain Research Center, Division of Behavioral Medicine and Clinical Psychology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Lili Ding
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
- Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Susmita Kashikar-Zuck
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
- Pediatric Pain Research Center, Division of Behavioral Medicine and Clinical Psychology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Christopher D King
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
- Pediatric Pain Research Center, Division of Behavioral Medicine and Clinical Psychology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Vanessa A Olbrecht
- Department of Anesthesiology & Pain Medicine, Nationwide Children's Hospital, Columbus, Ohio, USA
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Analgesic use and favourable patient-reported outcome measures after paediatric surgery: an analysis of registry data. Br J Anaesth 2023; 130:74-82. [PMID: 36470745 DOI: 10.1016/j.bja.2022.09.028] [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: 07/04/2022] [Revised: 08/30/2022] [Accepted: 09/26/2022] [Indexed: 12/09/2022] Open
Abstract
BACKGROUND Pain after paediatric appendectomy and tonsillectomy is often undertreated. Benchmarking of hospitals could reveal which measures are associated with improved patient- or parent-reported pain-related outcomes. METHODS A total of 898 anonymised cases from 11 European hospitals participating in PAIN OUT infant were analysed. The children completed a questionnaire on patient-reported outcomes (PROs) 24 h after surgery. According to a composite PRO measure, including pain intensity and pain-related interference, hospitals were allocated to Group I (favourable results), II (average results), and III (unfavourable results). Benchmarking of hospital groups was performed investigating process variables (dosing of non-opioid analgesics, opioids, and dexamethasone) associated with PROs, side-effects, and children's perception of care. Variables associated with PROs were analysed using multinomial regression analysis with the PRO score-related hospital group as a dependent variable (estimated odds ratios [OR], 95% confidence interval [CI]). RESULTS During the first 24 h after surgery, 1.2 (1.1-1.3) full daily doses of non-opioid analgesics (non-steroidal anti-inflammatory drug [NSAID], paracetamol, metamizole) were administered in group I and 0.7 (0.6-0.8) in group III (P<0.001). Intraoperative dexamethasone was administered to 70.1 and 52.6% of the children in Group I and Group III, respectively (P<0.001). A lower number of full daily doses of non-opioid analgesics: 0.22 [0.15-0.31]), less dexamethasone (0.49 [0.33-0.71]), fewer non-opioid analgesics before the end of surgery (0.37 [0.22-0.62]) and higher opioid doses were associated with hospital allocation to group III vs group I (Nagelkerke's R2=0.433). CONCLUSIONS The results indicated substantial deficits in the concept, application, and dosing of analgesics in paediatric patients after surgery. Timely administration of adequate analgesic doses can easily be introduced into daily clinical practice. CLINICAL TRIAL REGISTRATION clinicaltrials.gov NCT02083835.
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Haynes N, Mclean C, Collins J, de Lima J. "Persistent Post-Operative Pain in Children - An Argument for a Transitional Pain Service in Pediatrics". Pain Manag Nurs 2022; 23:784-790. [PMID: 35931646 DOI: 10.1016/j.pmn.2022.06.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2021] [Revised: 05/15/2022] [Accepted: 06/11/2022] [Indexed: 12/24/2022]
Abstract
BACKGROUND Persistent post-operative pain continues to occur in pediatric patients. Despite the growing amount of literature on causes, there is little discussion on treatment and prevention with a majority of studies focusing on specific surgeries. AIM The aim of this retrospective chart study is to identify risk factors and clinical features of persistent post-operative pain after any surgery in a pediatric quaternary complex pain service, describe the pharmacologic and non-pharmacologic management in children, and explore options to improve outcomes, in particular, the introduction of a transitional pain service. METHODS A retrospective chart review recorded demographics, gender, age, pain location and surgery type, treatment, and outcomes of 31 children identified through relevant registers over a 2-year period. RESULTS A total of 31 children were positively identified as having persistent post-operative pain and were seen in the complex pain clinic. Consistent with the literature, most cases represented neuropathic pain and persistent post-operative pain was most commonly seen after orthopedic surgery. All but four children had resolution of their pain after implementing the pain management plan. Management was characterized by early intervention, emphasis on non-pharmacologic strategies, and conservative use of opioids. CONCLUSIONS Identifying risk factors is useful, however putting strategies into place for prevention is necessary. Early intervention and the implementation of strategies before and immediately after are best provided by a transitional pain service.
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Affiliation(s)
- Natasha Haynes
- Department of Pain Medicine, The Children's Hospital at Westmead, Sydney, Australia.
| | - Catriona Mclean
- Department of Pain Medicine, The Children's Hospital at Westmead, Sydney, Australia
| | - John Collins
- Department of Pain Medicine, The Children's Hospital at Westmead, Sydney, Australia; Department of Paediatrics & Child Health, Sydney Medical School, Sydney, Australia
| | - Jonathan de Lima
- Department of Pain Medicine, The Children's Hospital at Westmead, Sydney, Australia
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Aguado La Iglesia I, Granacher PP, Manzano Lorefice MF, López Arias JF, Yang Xia F, Muñoz Alameda LE. Erector spinae plane block for thoracoscopy in a paediatric patient. REVISTA ESPANOLA DE ANESTESIOLOGIA Y REANIMACION 2022; 69:693-696. [PMID: 36347756 DOI: 10.1016/j.redare.2021.10.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/26/2021] [Accepted: 10/01/2021] [Indexed: 11/07/2022]
Abstract
We present the case of a 9 year old patient with a clinical history of epilepsy and various hospitalizations due to aspirative broncopneumonia among others, who was admitted to our hospital because of septic shock secondary to pneumonia of the lower left lobule associated with a parapneumonic pleural effusion and a complicated clinical course. During her stay, the patient undergoes surgical debridement using video assisted thoracoscopic surgery (VATS) under general anaesthesia and the hydropneumothorax is drained. For the procedure an ecoguided erector spinae plane block is performed and combined with general anaesthesia. On one hand this block permitted reduction of perioperative opioid administration and improved the patient's respiration, on the other hand it permitted avoiding the use of drugs, which can lower seizure threshold and increase the risk of convulsions. This case illustrates the importance of locoregional anaesthesia, a technique on the rise in the field of paediatric anaesthesia.
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Affiliation(s)
- I Aguado La Iglesia
- Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, Hospital Universitario Fundación Jiménez Díaz, Madrid, Spain.
| | - P P Granacher
- Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, Hospital Universitario Fundación Jiménez Díaz, Madrid, Spain
| | - M F Manzano Lorefice
- Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, Hospital Universitario Fundación Jiménez Díaz, Madrid, Spain
| | - J F López Arias
- Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, Hospital Universitario Fundación Jiménez Díaz, Madrid, Spain
| | - F Yang Xia
- Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, Hospital Universitario Fundación Jiménez Díaz, Madrid, Spain
| | - L E Muñoz Alameda
- Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, Hospital Universitario Fundación Jiménez Díaz, Madrid, Spain
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Dixit AA, Ho N, Inglis-Arkell C, Chen CL, Ferschl M, Manuel SP. Unused opioid prescription prevalence after pediatric ambulatory surgery: a survey study. ANNALS OF PEDIATRIC SURGERY 2022. [DOI: 10.1186/s43159-022-00219-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Abstract
Background
Surgery is a risk factor for opioid initiation, persistent use, and subsequent misuse in pediatric patients. The objective of this study was to assess the rate of postoperative opioid prescribing and extent of unused opioid prescriptions on the first postoperative day after pediatric ambulatory surgery.
Methods
A telephone survey was administered on postoperative day 1 (POD1) to guardians of all pediatric patients who underwent ambulatory surgery at a single medical center. Participants were asked whether postoperative opioids were prescribed, and, if yes, whether they were currently taking them. Multivariable logistic regression was used to assess factors associated with postoperative opioid prescribing and unused opioids on POD1.
Results
Of 1344 pediatric patients who underwent ambulatory surgical procedures, 849 (63.1%) guardians responded to the survey. 275 (32.4%) were prescribed postoperative opioids, and 164 (59.6%) reported not taking opioids on POD1. The highest rates of unused opioid prescriptions were from orthopedic and plastic surgery services (28% and 29%, respectively). Governmental insurance status predicted having unused opioids (OR 0.59, CI 0.35–0.97).
Conclusions
Unused opioid prescriptions were prevalent in this pediatric ambulatory surgical population. Opportunities remain to streamline opioid prescribing in pediatric patients undergoing ambulatory surgical procedures.
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Fenikowski D, Tomaszek L. Intravenous Morphine Infusion versus Thoracic Epidural Infusion of Ropivacaine with Fentanyl after the Ravitch Procedure-A Single-Center Cohort Study. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:11291. [PMID: 36141560 PMCID: PMC9517208 DOI: 10.3390/ijerph191811291] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 08/14/2022] [Revised: 09/05/2022] [Accepted: 09/06/2022] [Indexed: 06/16/2023]
Abstract
OBJECTIVE To compare the efficacy of analgesia with intravenous infusion of morphine and thoracic epidural infusion of ropivacaine with fentanyl in pediatric patients after the Ravitch procedure. METHODS Postoperative analgesia was achieved by intravenous morphine infusion with a dose of 0.02-0.06 mg/kg per hour (intravenous group, n = 56) or thoracic epidural infusion of 0.2% ropivacaine and fentanyl 5 µg/mL with a flow rate of 0.1 mL/kg per hour (epidural group, n = 40). Furthermore, the multimodal pain management protocol included paracetamol, non-steroidal anti-inflammatory drugs, and metamizole as a rescue drug. The primary outcomes included pain scores (according to the Numerical Rating Scale, range 0-10), while the secondary outcomes included consumption of the rescue drug, anxiety, postoperative side effects, and patient satisfaction. The observation period lasted from postoperative day 0 to postoperative day 3. RESULTS Median average and maximal pain scores at rest, during deep breathing, and coughing were significantly lower in the intravenous group compared to the epidural group (p < 0.05). The effect size was medium (Cohen's d ranged from 0.5 to 0.7). Patients receiving morphine required significantly lower numbers of metamizole doses than in the epidural group (median 1 vs. 3; p = 0.003; Cohen's d = 0.6). Anxiety, postoperative side effects, and patient satisfaction were similar in both groups (p > 0.05). CONCLUSIONS An intravenous infusion of morphine may offer better postoperative analgesia than a thoracic epidural infusion of ropivacaine with fentanyl.
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Affiliation(s)
- Dariusz Fenikowski
- Department of Thoracic Surgery, Institute of Tuberculosis and Lung Diseases, Rabka-Zdrój Branch, 34-700 Rabka-Zdrój, Poland
| | - Lucyna Tomaszek
- Department of Thoracic Surgery, Institute of Tuberculosis and Lung Diseases, Rabka-Zdrój Branch, 34-700 Rabka-Zdrój, Poland
- Faculty of Medicine and Health Sciences, Andrzej Frycz Modrzewski Krakow University, 30-705 Kraków, Poland
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Oppitz F, Hindriks-Keegstra A, Kaufmann J. [Perioperative Pain Management in Children]. Anasthesiol Intensivmed Notfallmed Schmerzther 2022; 57:536-549. [PMID: 36049738 DOI: 10.1055/a-1690-5637] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
Abstract
Acute pain therapy in children is highly complex. Already preoperatively, the course for a successful therapy is set in the interaction with the child and parents. The goal of the treatment is a satisfied child. This means the use of empathy and therapy planning aimed at a balance between effect and side effect and functionality. Modern concepts are opioid-sparing and procedure-specific. Regional anaesthesia plays a major role, among other things due to excellent safety data. Knowledge of age- and block-specific local anaesthetic dosages is essential. Little is known about pharmacodynamic data of analgesics in children. Although knowledge about pharmacokinetic characteristics is increasing, off-label use of analgesics is inevitable. International databases such as the Kinderformularium provide up-to-date information. When using opioids, rules for safe handling must be followed both in terms of use and prescribing. Non-opioids and adjuvants - individually or in combination - have an established place in perioperative pain management. Non-pharmacological interventions can reduce anxiety and pain. Anxiety is one of the risk factors for chronic postsurgical pain.
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Odegard M, Kelley-Quon LI. Postoperative Opioid Prescribing, Use, and Disposal in Children. Adv Pediatr 2022; 69:259-271. [PMID: 35985715 DOI: 10.1016/j.yapd.2022.03.003] [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: 11/26/2022]
Abstract
This article provides an overview of postoperative opioid prescribing, use, and disposal patterns in children and also identifies gaps in knowledge and areas for improvement. We present evidence that there is a need to tailor prescriptions to specific procedures to reduce the number of excess, unused prescription opioid pills in the home. We also explain the need to provide culturally competent care when managing a child's pain after surgery. Finally, we discuss the need for widespread provider and caregiver education about safe prescription opioid use, storage, and disposal.
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Affiliation(s)
- Marjorie Odegard
- Division of Pediatric Surgery, Children's Hospital Los Angeles, 4650 Sunset Boulevard, Mailstop #100, Los Angeles, CA 90027, USA.
| | - Lorraine I Kelley-Quon
- Division of Pediatric Surgery, Children's Hospital Los Angeles, 4650 Sunset Boulevard, Mailstop #100, Los Angeles, CA 90027, USA; Department of Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, CA 90033, USA; Department of Population and Public Health Sciences, University of Southern California, Los Angeles, CA 90033, USA
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Mazurenko O, Mills CA, Bandali E, Ballard JH, Bell TM. Using prescription opioids throughout a traumatic injury recovery: A qualitative exploratory study of adolescents in a Midwestern state. Drug Alcohol Depend 2022; 236:109480. [PMID: 35525239 DOI: 10.1016/j.drugalcdep.2022.109480] [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: 01/27/2022] [Revised: 04/25/2022] [Accepted: 04/26/2022] [Indexed: 11/25/2022]
Abstract
BACKGROUND Injury is one of the most common reasons adolescents are prescribed opioids. Little is known about adolescent experiences who used prescription opioids throughout their recovery from traumatic injury. METHODS We used a qualitative exploratory study design nested within a longitudinal cohort study conducted at two trauma hospitals in the United States. We conducted semi-structured telephone interviews with adolescents (n = 28) aged from 12 to 20 years at the time of their hospital admission for injury. We used purposive sampling to gather a broad range of experiences from the longitudinal patient cohort. We conducted a modified thematic analysis of transcribed interviews. RESULTS Adolescents reported a wide range of efficacy with which prescription opioids controlled their pain during the injury recovery and numerous opioid-related side effects. A desire for relief from acute pain caused by the injury was the most common driver for using opioids in the hospital. At home, adolescents' decisions to use opioids were influenced by family history of addiction, awareness of harms associated with opioids, and desire to challenge themselves. Adolescents reported closely adhering to a prescribed regimen or using fewer opioids than prescribed while recovering at home. Finally, adolescents reported considerable variability in parental involvement in prescription opioid use, ranging from giving adolescents unrestricted access to prescription opioids to complete parental discretion and administration upon request. CONCLUSIONS Adolescents had diverse experiences with prescription opioids during recovery from traumatic injury. Educational interventions that focus on the appropriate use of opioids to address pain care needs among adolescents with traumatic injuries are urgently needed.
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Affiliation(s)
- Olena Mazurenko
- Department of Health Policy and Management, Indiana University Richard M. Fairbanks School of Public Health, 1050 Wishard Blvd, RG 6140, Indianapolis, IN 46202, United States.
| | - Carol A Mills
- Department of Health Policy and Management, Indiana University Richard M. Fairbanks School of Public Health, United States.
| | - Elhaam Bandali
- Program Management Specialist, Center for Health Policy, Indiana University Richard M. Fairbanks School of Public Health, United States.
| | - Joseph H Ballard
- Medical Student, Indiana University School of Medicine, United States.
| | - Teresa M Bell
- Trauma Research Director, Intermountain Primary Children's Hospital, United States; Depts of Surgery and Population Health Sciences at University of Utah School of Medicine, Intermountain Primary Children's Hospital, United States.
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Beckman EJ, Hovey S, Bondi DS, Patel G, Parrish RH. Pediatric Perioperative Clinical Pharmacy Practice: Clinical Considerations and Management: An Opinion of the Pediatrics and Perioperative Care Practice and Research Networks of the American College of Clinical Pharmacy. J Pediatr Pharmacol Ther 2022; 27:490-505. [DOI: 10.5863/1551-6776-27.6.490] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2021] [Accepted: 11/24/2021] [Indexed: 11/11/2022]
Abstract
Pediatric perioperative clinical pharmacists are uniquely positioned to provide therapeutic and medication management expertise at a particularly vulnerable transition of care from the preoperative space, through surgery, and postoperative setting. There are many direct-patient care activities that are included in the role of the pediatric perioperative pharmacist, as well as many opportunities to develop effective, optimized, and safe medication use processes. This article outlines many of the areas in which a pediatric perioperative clinical pharmacist may intervene.
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Affiliation(s)
- Elizabeth J. Beckman
- Department of Pharmacy Services, University of Kentucky HealthCare, Lexington, KY (EJB)
| | - Sara Hovey
- Department of Pharmacy Practice, University of Illinois at Chicago, College of Pharmacy, University of Illinois Hospital, Chicago, IL (SH)
| | - Deborah S. Bondi
- Department of Pharmacy Services, University of Chicago Medicine, Chicago, IL (DSB, GP)
| | - Gourang Patel
- Department of Pharmacy Services, University of Chicago Medicine, Chicago, IL (DSB, GP)
| | - Richard H. Parrish
- Department of Biomedical Sciences, Mercer University School of Medicine, Columbus, GA (RHP)
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Hageman IC, Tien MY, Trajanovska M, Palmer GM, Corlette SJ, King SK. Perioperative opioid use in paediatric inguinal hernia patients: A systematic review and retrospective audit of practice. J Pediatr Surg 2022; 57:1249-1257. [PMID: 35397872 DOI: 10.1016/j.jpedsurg.2022.02.039] [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: 02/08/2022] [Accepted: 02/23/2022] [Indexed: 11/18/2022]
Abstract
BACKGROUND Opioids play a major role in postoperative pain management in children, but their administration remains an under investigated topic. This study aimed to describe perioperative opioid prescribing practices for paediatric inguinal hernia patients in the literature and at The Royal Children's Hospital (RCH) in Melbourne, Australia. MATERIAL/METHOD A systematic review of English articles (published from 2009 to 2019) was conducted on paediatric (0-18y) inguinal hernia patients who received a postoperative or discharge opioid prescription, or both. The review was combined with a retrospective audit of RCH patients. Demographic, surgical, and analgesic details were collected from the electronic medical records. RESULTS Fifteen studies (n = 1166; combined mean age 4.93y) met the systematic review criteria. The percentage of patients receiving opioids postoperatively overall ranged from 3.33-100%, and doses ranged from 0.07 to 0.35 mg/kg oMEDD. At the RCH, perioperative opioid use was analyzed from 150 inguinal hernia patients (male - 113, median age - 3 months old). Postoperatively, 26 (17.3%) patients received opioids. The most commonly administered opioids were fentanyl (0.04-0.60 mg/kg oMEDD) in the post anaesthesia care unit and oxycodone (0.14-0.40 mg/kg oMEDD) in the first 24 h postoperatively. Older age at surgery, female sex and absence of regional anaesthesia were significantly associated with higher risk of total opioid use. No patients received an opioid prescription at discharge. CONCLUSION There is demonstratable variability in opioid prescribing practices for paediatric inguinal hernia patients as described in the literature. At our institution opioids were not used frequently in postoperative period.
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Affiliation(s)
- Isabel C Hageman
- Murdoch Children's Research Institute, 50 Flemington Road, Parkville, Victoria 3052, Australia; Faculty of Medicine, Utrecht University, Utrecht, the Netherland.
| | - Melissa Y Tien
- Murdoch Children's Research Institute, 50 Flemington Road, Parkville, Victoria 3052, Australia
| | - Misel Trajanovska
- Murdoch Children's Research Institute, 50 Flemington Road, Parkville, Victoria 3052, Australia; Department of Paediatrics, University of Melbourne, Parkville, Victoria, Australia
| | - Greta M Palmer
- Murdoch Children's Research Institute, 50 Flemington Road, Parkville, Victoria 3052, Australia; Department of Paediatrics, University of Melbourne, Parkville, Victoria, Australia; Department of Anaesthesia and Pain Management, The Royal Children's Hospital, Parkville, Victoria, Australia
| | - Sebastian J Corlette
- Murdoch Children's Research Institute, 50 Flemington Road, Parkville, Victoria 3052, Australia; Department of Paediatrics, University of Melbourne, Parkville, Victoria, Australia; Department of Anaesthesia and Pain Management, The Royal Children's Hospital, Parkville, Victoria, Australia
| | - Sebastian K King
- Murdoch Children's Research Institute, 50 Flemington Road, Parkville, Victoria 3052, Australia; Department of Paediatrics, University of Melbourne, Parkville, Victoria, Australia; Department of Paediatric Surgery, The Royal Children's Hospital, Parkville, Victoria, Australia
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Efficacy of Dexmedetomidine Anesthesia plus Dorsal Penile Nerve Block in Pediatric Circumcision. EVIDENCE-BASED COMPLEMENTARY AND ALTERNATIVE MEDICINE 2022; 2022:1974131. [PMID: 35677376 PMCID: PMC9170400 DOI: 10.1155/2022/1974131] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 04/07/2022] [Revised: 04/29/2022] [Accepted: 05/09/2022] [Indexed: 11/18/2022]
Abstract
Objective To assess the efficacy of dexmedetomidine anesthesia plus dorsal penile nerve block in pediatric circumcision. Methods In this retrospective study, 80 children receiving circumcision in our hospital from February 2020 to February 2021 were recruited and assigned via different anesthesia methods at a ratio of 1 : 1 to receive dorsal penile nerve block plus dexmedetomidine anesthesia (combined anesthesia group) or only sevoflurane for total inhalational anesthesia (total anesthesia group). Traditional Chinese medicine (TCM) care was introduced to both groups of patients. Outcome measures included vital signs, operative indices, anesthesia effect, adverse reactions, parent satisfaction, and nursing satisfaction. Results There were no significant differences in the heart rate, oxygen saturation, and mean arterial pressure between the two groups of children before anesthesia, after anesthesia, and during the awakening period (P > 0.05). Patients receiving combined anesthesia showed a shorter time lapse before the disappearance of eyelash reflex, longer time lapse before postoperative analgesic use, faster awakening, and shorter operation time and hospital stay versus those receiving total inhalational anesthesia alone (P > 0.05). The combined anesthesia resulted in a lower Induction Compliance Checklist (ICC) score, McGill score, and Richmond Agitation-Sedation Scale (RASS) score and a higher Ramsay score versus total anesthesia (P > 0.05). Patients receiving combined anesthesia showed a significantly lower incidence of adverse events (5.00% (2/40)) versus total inhalational anesthesia (62.50% (25/40)) (X2 = 29.574, P > 0.05). The combined anesthesia group had a higher parent satisfaction (92.50% (37/40)) versus the total anesthesia group (75.00% (30/40)) (X2 = 4.501, P > 0.05). A total of 80 questionnaires were distributed, with a 100% return rate and a 100% validity rate, and all 80 questionnaires scored 90 points or above. The families of children in both groups were satisfied with the quality of TCM care. Conclusion The efficacy of dorsal penile nerve block plus dexmedetomidine anesthesia in pediatric circumcision is better than total inhalational anesthesia with sevoflurane.
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"Systematic Review and Guidelines for Perioperative Management of Pediatric Patients Undergoing Major Plastic Surgery Procedures, With a Focus on Free Tissue Transfer.". Plast Reconstr Surg 2022; 150:406e-415e. [PMID: 35674517 DOI: 10.1097/prs.0000000000009325] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Microsurgical free tissue transfer has been successfully implemented for various reconstructive applications in children. The goal of this study was to identify the best available evidence on perioperative management of pediatric patients undergoing free tissue transfer, and use it to develop evidence-based care guidelines. METHODS A systematic review was conducted in Pubmed, Embase, Scopus, and Cochrane Library databases. Since a preliminary search of the pediatric microsurgical literature yielded scant data with low level of evidence (LOE), pediatric anesthesia guidelines for healthy children undergoing major surgeries were also included. Exclusion criteria included: vague descriptions of perioperative care, case reports, and studies of syndromic or chronically ill children. RESULTS 204 articles were identified, and 53 met inclusion criteria. Management approaches specific to the pediatric population were used to formulate recommendations. High quality data was found for anesthesia, analgesia, fluid administration / blood transfusion, and anticoagulation (LOE 1). Lower quality evidence was identified for patient temperature (LOE 3) and vasodilator use (LOE 4). Key recommendations include: administering sevoflurane for general anesthesia, implementing a multimodal analgesia strategy, limiting preoperative fasting, restricting blood transfusions until hemoglobin < 7 g/dl unless patient is symptomatic, and reserving chemical venous thromboembolism prophylaxis for high risk patients. CONCLUSIONS Pediatric-specific guidelines are important as they acknowledge physiologic differences in children, which may be overlooked when extrapolating from adult studies. These evidence-based recommendations are a key first step toward standardization of perioperative care of pediatric patients undergoing plastic surgical procedures, including free tissue transfer, to improve outcomes and minimize complications.
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Risk factors associated with recent opioid-related hospitalizations in children: a nationwide analysis. Pediatr Surg Int 2022; 38:843-851. [PMID: 35239012 DOI: 10.1007/s00383-022-05088-0] [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] [Accepted: 02/16/2022] [Indexed: 10/18/2022]
Abstract
PURPOSE Identifying at-risk children can provide a crucial opportunity for preventative measures to avoid opioid addiction. This study sought to determine at-risk pediatric patients that were previously hospitalized due to other causes prior to their opioid-related admission. METHODS The Nationwide Readmissions Database (2010-2014) was queried for children 1-18 years old with an opioid-related hospitalization. Previous admissions (up to 1 year prior) and associated diagnoses were compared. Results were weighted for national estimates. RESULTS 51,349 opioid-related hospitalizations were identified with an overall in-hospital mortality of 0.8%. Seventeen percent had a previous admission during the same calendar year of which 44% had > 1 and 11% had ≥ 5 prior admissions. Only 4% of prior admissions occurred at a different hospital. Males and females were equally represented, and 82% were ≥ 13 years old. Only 16% of previously admitted patients underwent a major surgical procedure during a previous hospitalization. The most common concomitant diagnoses for patients with prior hospitalizations were drug abuse (37%), chronic pulmonary disease (18%), and depression (10%). CONCLUSION Opioid-related hospitalizations often occur among children with multiple recent admissions, usually to the same hospital. Most patients do not have a history of cancer or recent surgery to account for their opioid use.
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Rosenbloom JM, De Souza E, Perez FD, Xie J, Suarez-Nieto MV, Wang E, Anderson TA. Association of Race and Ethnicity with Pediatric Postoperative Pain Outcomes. J Racial Ethn Health Disparities 2022; 10:1414-1422. [PMID: 35622316 DOI: 10.1007/s40615-022-01327-1] [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: 11/15/2021] [Revised: 05/04/2022] [Accepted: 05/05/2022] [Indexed: 11/24/2022]
Abstract
INTRODUCTION Inequitable variability in healthcare practice negatively affects patient outcomes. Children of color may receive different analgesic medications in the perioperative period, resulting in different outcomes. METHODS Medical records of children 0 to ≤ 18 years old from May 2014 to August 2019 were reviewed. The exposure was racial or ethnic groups: Asian, Black, Hispanic, Pacific Islander, and White non-Hispanic (reference). PRIMARY OUTCOME post-anesthesia care unit mean pain score. SECONDARY OUTCOMES inpatient mean pain score; opioid, antiemetic, and antipruritic administration in the post-anesthesia care unit and inpatient ward. The association of race or ethnicity with outcomes was modeled using multilevel logistic regression, adjusting for confounders and covariates. RESULTS Twenty-nine thousand six hundred fourteen cases are included. In the post-anesthesia care unit, Black, Hispanic, and Pacific Islander children had no significant difference in the odds of receiving opioids or having moderate-severe pain as compared to White non-Hispanic patients; Asian children had lower odds of receiving opioids and lower odds of having a moderate-severe mean pain score. In the inpatient setting, Black, Hispanic, and Pacific Islander children had no significant difference in the odds of receiving opioids or having moderate severe-pain as compared to White non-Hispanic children, but Asian children had lower odds of receiving opioids and of having a moderate-severe mean pain score. CONCLUSIONS Asian children had lower odds of receiving opioids and having moderate-severe pain postoperatively compared to the White non-Hispanic children. These differences may be a function of variation in patient/caregivers culture or healthcare provider care and warrant further investigation.
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Affiliation(s)
- Julia M Rosenbloom
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Elizabeth De Souza
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Felipe D Perez
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - James Xie
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Maria V Suarez-Nieto
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Ellen Wang
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - T Anthony Anderson
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.
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Chung W. Another new kid on the BLOCK for pain control in pediatric cardiac surgery. Korean J Anesthesiol 2022; 75:200-201. [PMID: 35656697 PMCID: PMC9171550 DOI: 10.4097/kja.22223] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2022] [Accepted: 04/21/2022] [Indexed: 11/25/2022] Open
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McElroy NA, Bustin A, Gattoline S. Evaluation of the Safety of Ketorolac in Postsurgical Infants Less Than Six Months of Age. J Pediatr Pharmacol Ther 2022; 27:347-351. [DOI: 10.5863/1551-6776-27.4.347] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2021] [Accepted: 10/22/2021] [Indexed: 11/11/2022]
Abstract
OBJECTIVE
Ketorolac-related adverse events are not yet elucidated in neonates and infants given paucity of data. The objective of this research is to determine the incidence of major bleed in postsurgical neonates and infants treated with ketorolac, and to describe characteristics of ketorolac therapy and its effect on renal function.
METHODS
This retrospective review assessed postsurgical patients younger than 6 months of age, without renal and/or coagulation dysfunction, who received ketorolac for postoperative pain during the study period. Major bleed was defined as a decrease in hemoglobin by ≥ 2 g/dL in a 24-hour period and/or intracranial, intraventricular, gastrointestinal, or pulmonary hemorrhage. Renal injury was identified per pediatric-modified RIFLE (risk, injury, failure, loss, end stage renal disease) criteria.
RESULTS
One hundred twenty-five patients were analyzed, having a mean dosing weight of 5.6 kg, gestational age of 37.2 weeks, and postnatal age of 3.8 months. Ketorolac therapy was most frequently 0.5 mg/kg intravenously every 6 hours with a mean of 6.7 doses administered. The primary endpoint of major bleed occurred in 2 (1.6%) 2-month-old patients of 39 weeks' gestation. Both bleeds were characterized by decrease in hemoglobin without evidence of clinically significant bleeding. One (0.8%) and 3 (2.4%) patients experienced a decrease in glomerular filtration rate and urine output, respectively. Sixty-two (49.6%) patients received a concomitant medication associated with decreased bleeding risk.
CONCLUSIONS
Ketorolac appears to have low incidence of major bleeds in postsurgical patients younger than 6 months of age without renal and/or coagulation dysfunction. Larger, prospective studies are needed to confirm safety of ketorolac use in this population.
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Affiliation(s)
- Nicole A. McElroy
- Department of Pharmacy, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Anna Bustin
- Department of Pharmacy, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Sarah Gattoline
- Department of Pharmacy, Children's Hospital of Philadelphia, Philadelphia, PA
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Li MMJ, Larche CL, Vickers K, Vigouroux M, Ingelmo PM, Hovey R, Ferland CE. Experience and Management of the Adverse Effects of Analgesics After Surgery: A Pediatric Patient Perspective. J Patient Exp 2022; 9:23743735221092632. [PMID: 35450091 PMCID: PMC9016538 DOI: 10.1177/23743735221092632] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
After surgery, the adverse effects (AEs) of analgesics are common and critical
factors influencing the postoperative experience of pediatric patients.
Inadequate management of AEs has been found to prolong hospital stay, increase
readmission rates and decrease satisfaction with care. The aim of this
qualitative descriptive study was to better understand the AEs of analgesics
from the perspective of adolescent patients with idiopathic scoliosis after
spinal surgery. A total of 7 patients participated in the study. Semistructured
interviews were conducted at discharge and 1 week after discharge. Transcribed
data were analyzed using qualitative content analysis and themes were
identified. Overall, participants most frequently reported gastrointestinal and
cognitive AEs, with constipation being the most persistent and bothersome. The
pediatric participants used a combination of 3 strategies to mitigate analgesic
AEs, namely pharmacologic, nonpharmacologic, and reduction of analgesic intake.
Participants demonstrated a lack of understanding of AEs and involvement in
their own care. Future studies should be conducted to evaluate the efficacy of
nonpharmacological strategies in managing analgesic AEs for pediatric patients
after surgery.
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Affiliation(s)
- Mandy M. J. Li
- McGill University, Montreal, Canada
- Shriners Hospitals for Children-Canada, Montreal, Canada
| | | | - Kelsey Vickers
- Shriners Hospitals for Children-Canada, Montreal, Canada
| | - Marie Vigouroux
- McGill University, Montreal, Canada
- Chronic Pain Services, Montreal Children’s Hospital, Montreal, Canada
| | - Pablo M. Ingelmo
- McGill University, Montreal, Canada
- Chronic Pain Services, Montreal Children’s Hospital, Montreal, Canada
| | | | - Catherine E. Ferland
- McGill University, Montreal, Canada
- Shriners Hospitals for Children-Canada, Montreal, Canada
- Chronic Pain Services, Montreal Children’s Hospital, Montreal, Canada
- Integrated Program in Neurosciences, McGill University, Montreal, Canada
- Research Institute-McGill University Health Centre, Montreal, Canada
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