Single-Dose Ondansetron Prevents Postoperative Vomiting in Pediatric Outpatients

Drowsiness following ondansetron given the day after general anesthesia for postoperative nausea: a pediatric case report

BACKGROUND

Ondansetron is an antiemetic drug that is useful not only for prevention but also for the treatment of postoperative nausea and vomiting (PONV). We report a rare case of drowsiness in a child after using ondansetron for nausea on the day after general anesthesia.

CASE PRESENTATION

A 5-year-old boy underwent circumcision under general anesthesia and suffered from postoperative nausea and vomiting. He was administered 0.1mg/kg of ondansetron in the PACU and 23 h later on the day after surgery. After the second dose, he acutely exhibited drowsiness which resolved in 3 h. He was discharged to home later on the same day. He was not given any other drugs at the time, and the drowsiness was thought to be directly attributable to ondansetron, though the exact mechanism was unknown.

CONCLUSIONS

When drowsiness or other cognitive symptoms are observed after administration of ondansetron, it must be considered and managed as a possible side effect.

Ondansetron treatment reduces rotavirus symptoms-A randomized double-blinded placebo-controlled trial

Background

Rotavirus and norovirus cause acute gastroenteritis with severe diarrhoea and vomiting, symptoms that may lead to severe dehydration and death. The objective of this randomized double-blinded placebo-controlled study was to investigate whether ondansetron, a serotonin receptor antagonist could attenuate rotavirus- and norovirus-induced vomiting and diarrhoea, which would facilitate oral rehydration and possibly accelerate recovery and reduce need for hospitalization.

Methods

Children with acute gastroenteritis, aged 6 months to 16 years where enrolled (n = 104) and randomized to one single oral dose (0.15mg/kg) of ondansetron (n = 52) or placebo (n = 52). The number of diarrhoea and vomiting episodes during the 24 hours following treatment was reported as well as the number of days with symptoms. Pathogens in faeces were diagnosed by real-time PCR. Outcome parameters were analyzed for rotavirus- and norovirus-positive children.

Results

One dose of oral ondansetron reduced duration of rotavirus clinical symptoms (p = 0.014), with a median of two days. Furthermore, ondansetron reduced diarrhea episodes, most pronounced in children that had been sick for more than 3 days before treatment (p = 0.028).

Conclusion

Ondansetron may be a beneficial treatment for children with rotavirus gastroenteritis.

Trial registration

European Clinical Trial Database EudraCT 2011-005700-15.

WITHDRAWN: Drugs for preventing postoperative nausea and vomiting

BACKGROUND

Drugs can prevent postoperative nausea and vomiting, but their relative efficacies and side effects have not been compared within one systematic review.

OBJECTIVES

The objective of this review was to assess the prevention of postoperative nausea and vomiting by drugs and the development of any side effects.

SEARCH METHODS

We searched The Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library, Issue 2, 2004), MEDLINE (January 1966 to May 2004), EMBASE (January 1985 to May 2004), CINAHL (1982 to May 2004), AMED (1985 to May 2004), SIGLE (to May 2004), ISI WOS (to May 2004), LILAC (to May 2004) and INGENTA bibliographies.

SELECTION CRITERIA

We included randomized controlled trials that compared a drug with placebo or another drug, or compared doses or timing of administration, that reported postoperative nausea or vomiting as an outcome.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed trial quality and extracted outcome data.

MAIN RESULTS

We included 737 studies involving 103,237 people. Compared to placebo, eight drugs prevented postoperative nausea and vomiting: droperidol, metoclopramide, ondansetron, tropisetron, dolasetron, dexamethasone, cyclizine and granisetron. Publication bias makes evidence for differences among these drugs unreliable. The relative risks (RR) versus placebo varied between 0.60 and 0.80, depending upon the drug and outcome. Evidence for side effects was sparse: droperidol was sedative (RR 1.32) and headache was more common after ondansetron (RR 1.16).

AUTHORS' CONCLUSIONS

Either nausea or vomiting is reported to affect, at most, 80 out of 100 people after surgery. If all 100 of these people are given one of the listed drugs, about 28 would benefit and 72 would not. Nausea and vomiting are usually less common and, therefore, drugs are less useful. For 100 people, of whom 30 would vomit or feel sick after surgery if given placebo, 10 people would benefit from a drug and 90 would not. Between one to five patients out of every 100 people may experience a mild side effect, such as sedation or headache, when given an antiemetic drug. Collaborative research should focus on determining whether antiemetic drugs cause more severe, probably rare, side effects. Further comparison of the antiemetic effect of one drug versus another is not a research priority.

Comparative safety of serotonin (5-HT3) receptor antagonists in patients undergoing surgery: a systematic review and network meta-analysis

BACKGROUND

Serotonin (5-HT3) receptor antagonists are commonly used to decrease nausea and vomiting for surgery patients, but these agents may be harmful. We conducted a systematic review on the comparative safety of 5-HT3 receptor antagonists.

METHODS

Searches were done in MEDLINE, Embase, and the Cochrane Central Register of Controlled Trials to identify studies comparing 5-HT3 receptor antagonists with each other, placebo, and/or other antiemetic agents for patients undergoing surgical procedures. Screening search results, data abstraction, and risk of bias assessment were conducted by two reviewers independently. Random-effects pairwise meta-analysis and network meta-analysis (NMA) were conducted. PROSPERO registry number: CRD42013003564.

RESULTS

Overall, 120 studies and 27,787 patients were included after screening of 7,608 citations and 1,014 full-text articles. Significantly more patients receiving granisetron plus dexamethasone experienced an arrhythmia relative to placebo (odds ratio (OR) 2.96, 95 % confidence interval (CI) 1.11-7.94), ondansetron (OR 3.23, 95 % CI 1.17-8.95), dolasetron (OR 4.37, 95 % CI 1.51-12.62), tropisetron (OR 3.27, 95 % CI 1.02-10.43), and ondansetron plus dexamethasone (OR 5.75, 95 % CI 1.71-19.34) in a NMA including 31 randomized clinical trials (RCTs) and 6,623 patients of all ages. No statistically significant differences in delirium frequency were observed across all treatment comparisons in a NMA including 18 RCTs and 3,652 patients.

CONCLUSION

Granisetron plus dexamethasone increases the risk of arrhythmia.

Dexamethasone versus ondansetron in combination with dexamethasone for the prophylaxis of postoperative vomiting in pediatric outpatients: a double-blind, randomized, placebo-controlled clinical trial

OBJECTIVES

To determine the frequency of postoperative vomiting (POV) in children submitted to outpatient surgery and to compare the efficacy of antiemetic drugs in preventing this complication.

BACKGROUND

Nausea and vomiting are common in the immediate postoperative period following anesthetic and surgical procedures. Compared to adults, pediatric patients are more likely to develop postoperative nausea and vomiting, the incidence of which ranges from 8.9% to 42%.

METHODS

This double-blind, randomized, placebo-controlled clinical trial included 129 children. The participants were randomized into three prophylactic treatment groups: dexamethasone (n = 43), ondansetron in combination with dexamethasone (n = 44), and placebo (n = 42). The variables studied were the frequency of POV and the incidence of vomiting after the patient had been discharged from hospital, the need for antiemetic rescue therapy in the postanesthesia care unit (PACU), need for hospitalization, and the time the patient remained in the PACU. A significance level of 5% was adopted.

RESULTS

Postoperative vomiting occurred in 12.4% of the children, with no statistically significant difference between the groups: 6.8% in the group receiving ondansetron combined with dexamethasone, 14.3% in the placebo group, and 14% in the group that received dexamethasone alone (P = 0.47). Furthermore, no significant difference was found between the groups with respect to the time the children remained in the PACU, and only five patients reported having vomited following discharge from hospital.

CONCLUSIONS

The prophylactic use of antiemetic drugs failed to reduce the incidence of POV in pediatric outpatient surgery with a low emetic potential; therefore, routine prophylaxis may be unnecessary.

The management of children with gastroenteritis and dehydration in the emergency department

BACKGROUND

Acute gastroenteritis is characterized by diarrhea, which may be accompanied by nausea, vomiting, fever, and abdominal pain.

OBJECTIVE

To review the evidence on the assessment of dehydration, methods of rehydration, and the utility of antiemetics in the child presenting with acute gastroenteritis.

DISCUSSION

The evidence suggests that the three most useful predictors of 5% or more dehydration are abnormal capillary refill, abnormal skin turgor, and abnormal respiratory pattern. Studies are conflicting on whether blood urea nitrogen (BUN) or BUN/creatinine ratio correlates with dehydration, but several studies found that low serum bicarbonate combined with certain clinical parameters predicts dehydration. In most studies, oral or nasogastric rehydration with an oral rehydration solution was equally efficacious as intravenous (i.v.) rehydration. Many experts discourage the routine use of antiemetics in young children. However, children receiving ondensetron are less likely to vomit, have greater oral intake, and are less likely to be treated by intravenous rehydration. Mean length of Emergency Department (ED) stay is also less, and very few serious side effects have been reported.

CONCLUSIONS

In the ED, dehydration is evaluated by synthesizing the historical and physical examination, and obtaining laboratory data points in select patients. No single laboratory value has been found to be accurate in predicting the degree of dehydration and this is not routinely recommended. The evidence suggests that the majority of children with mild to moderate dehydration can be treated successfully with oral rehydration therapy. Ondansetron (orally or intravenously) may be effective in decreasing the rate of vomiting, improving the success rate of oral hydration, preventing the need for i.v. hydration, and preventing the need for hospital admission in those receiving i.v. hydration.

Acute gastroenteritis in children: role of anti-emetic medication for gastroenteritis-related vomiting

Acute gastroenteritis is associated with significant morbidity in developed countries and each year is the cause of death of several million children in developing countries. Acute gastroenteritis is usually self-limiting. Oral rehydration therapy (ORT) is effective and successful in the majority of patients. Vomiting is common at the outset of viral gastroenteritis and can limit the effectiveness of ORT. Treatment with newer anti-emetic medications has been reported to facilitate ORT and to minimize the risk of dehydration and the need for intravenous hydration and hospitalization. The role of anti-emetic medications in the treatment of gastroenteritis-related vomiting is not clear. Some physicians agree with the use of anti-emetic medications because vomiting is unpleasant and distressing for the child and parents alike, and because vomiting can increase the likelihood of dehydration, electrolyte imbalance, and the need for intravenous hydration or hospitalization. Several surveys have shown that anti-emetic medications are commonly prescribed in the treatment of pediatric gastroenteritis and that adverse events are uncommon. Efficacy studies of the newer anti-emetic medications are now available and reveal that some are effective and help facilitate ORT. Other physicians disagree with the use of anti-emetic medications because acute gastroenteritis is a self-limiting condition, vomiting might help rid the body of toxic substances, there was previously a relative lack of published evidence of clinical benefit, and there are potential adverse events associated with the use of an anti-emetic medication. Anti-emetic medications that are currently available include ondansetron, granisetron, tropisetron, dolasetron, ramosetron, promethazine, dimenhydrinate, metoclopramide, domperidone, droperidol, prochlorperazine, and trimethobenzamide. Randomized, placebo-controlled trials suggest that ondansetron is efficacious and superior to other anti-emetic medications in the treatment of gastroenteritis-related vomiting. A recent double-blind clinical trial showed that a single oral dose of ondansetron reduces gastroenteritis-related vomiting and facilitates ORT without significant adverse events. Ondansetron shows promise as a first-line anti-emetic, and judicious use of this agent might increase the success of ORT, minimize the need for intravenous therapy and hospitalization, and reduce healthcare costs. Ondansetron should be considered in situations where vomiting hinders ORT, but a larger randomized, placebo-controlled trial is necessary before the medication can be routinely recommended for the treatment of gastroenteritis-related vomiting in children.

Management of postoperative nausea and vomiting in children

Postoperative nausea and vomiting (PONV) continues to be a frequent and important cause of morbidity in children. Postoperative vomiting (POV) is more commonly studied in children than postoperative nausea because of a child's inability to effectively express distress after experiencing nausea. POV is problematic in children and is one of the leading postoperative complaints from parents and the leading cause of readmission to the hospital. POV occurs twice as frequently in children as in adults, increasing until puberty and then decreasing to adult incidence rates. Gender differences are not seen before puberty. POV remains a main cause of morbidity in children because severe vomiting can be associated with dehydration, postoperative bleeding, pulmonary aspiration, and wound dehiscence. While children have an increased potential for dehydration and the resulting physiologic impairments, other associated results such as a delay in hospital discharge or an overnight or longer hospital admission also must be considered. The two most common emetogenic surgical procedures evaluated in children are strabismus repair and adenotonsillectomy. The approach to the management of PONV and POV in children is similar to that in adults. However, as the rate of POV is more frequent in children than in adults, more children are candidates for antiemetic prophylaxis. The management approach is multifactorial and involves proper preoperative preparation, risk stratification, rational selection of antiemetic prophylaxis, choice of anesthesia technique, and a plan for postoperative antiemetic therapy. It is important to identify children at moderate-to-high risk for POV as prophylactic antiemetic therapy is useful in these children. Antiemetics of choice for POV in children include dexamethasone, dimenhydrinate, perphenazine, ondansetron, dolasetron, granisetron, and tropisetron. The serotonin (5-hydroxytryptamine; 5-HT(3)) antagonists are the antiemetic drugs of first choice for POV prophylaxis in children because as a group they have greater efficacy for preventing vomiting than nausea. The 5-HT(3) antagonists can be effectively combined with dexamethasone with an increase in efficacy. If possible, regional anesthesia should be considered. For those undergoing general anesthesia, the baseline POV risk should be reduced. Children at moderate-to-high PONV risk should receive combination therapy with two or three prophylactic antiemetics from different antiemetic drug classes. Reference to and the use of PONV guidelines and management algorithms help improve cost-effective postoperative care.

Emergency department treatment of viral gastritis using intravenous ondansetron or dexamethasone in children

OBJECTIVES

To compare the efficacy of intravenous ondansetron or dexamethasone compared with intravenous fluid therapy alone in children presenting to the emergency department with refractory vomiting from viral gastritis who had failed attempts at oral hydration.

METHODS

This double-blind, randomized, controlled trial was performed in a tertiary care pediatric emergency department. Children aged 6 months to 12 years presenting with more than three episodes of vomiting in the past 24 hours, mild/moderate dehydration, and failed oral hydration were included. Patients with other medical causes were excluded. Subjects were randomized to dexamethasone 1 mg/kg (15 mg maximum), ondansetron 0.15 mg/kg, or placebo (normal saline [NS], 10 mL). All subjects also received intravenous NS at 10-20 mL/kg/hr. Oral fluid tolerance was evaluated at two and four hours. Those not tolerating oral fluids at four hours were admitted. Discharged patients were evaluated at 24 and 72 hours for vomiting and repeat health care visits. The primary study outcome was hospitalization rates between the groups. Data were analyzed using chi-square test, Kruskal-Wallis test, Mantel-Haenszel test, and analysis of variance, with p < 0.05 considered significant.

RESULTS

A total of 166 subjects were enrolled; data for analysis were available for 44 NS-treated patients, 46 ondansetron-treated patients, and 47 dexamethasone-treated patients. Hospital admission occurred in nine patients (20.5%) receiving placebo (NS alone), two patients (4.4%) receiving ondansetron, and seven patients (14.9%) receiving dexamethasone, with ondansetron significantly different from placebo (p = 0.02). Similarly, at two hours, more ondansetron-treated patients (39 [86.6%]) tolerated oral hydration than NS-treated patients (29 [67.4%]; relative risk, 1.28; 95% confidence interval = 1.02 to 1.68). There were no differences in number of mean episodes of vomiting or repeat visits to health care at 24 and 72 hours in the ondansetron, dexamethasone, or NS groups.

CONCLUSIONS

In children with dehydration secondary to vomiting from acute viral gastritis, ondansetron with intravenous rehydration improves tolerance of oral fluids after two hours and reduces the hospital admission rate when compared with intravenous rehydration with or without dexamethasone.

Drugs for preventing postoperative nausea and vomiting

BACKGROUND

Drugs can prevent postoperative nausea and vomiting, but their relative efficacies and side effects have not been compared within one systematic review.

OBJECTIVES

The objective of this review was to assess the prevention of postoperative nausea and vomiting by drugs and the development of any side effects.

SEARCH STRATEGY

We searched The Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library, Issue 2, 2004), MEDLINE (January 1966 to May 2004), EMBASE (January 1985 to May 2004), CINAHL (1982 to May 2004), AMED (1985 to May 2004), SIGLE (to May 2004), ISI WOS (to May 2004), LILAC (to May 2004) and INGENTA bibliographies.

SELECTION CRITERIA

We included randomized controlled trials that compared a drug with placebo or another drug, or compared doses or timing of administration, that reported postoperative nausea or vomiting as an outcome.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed trial quality and extracted outcome data.

MAIN RESULTS

We included 737 studies involving 103,237 people. Compared to placebo, eight drugs prevented postoperative nausea and vomiting: droperidol, metoclopramide, ondansetron, tropisetron, dolasetron, dexamethasone, cyclizine and granisetron. Publication bias makes evidence for differences among these drugs unreliable. The relative risks (RR) versus placebo varied between 0.60 and 0.80, depending upon the drug and outcome. Evidence for side effects was sparse: droperidol was sedative (RR 1.32) and headache was more common after ondansetron (RR 1.16).

AUTHORS' CONCLUSIONS

Either nausea or vomiting is reported to affect, at most, 80 out of 100 people after surgery. If all 100 of these people are given one of the listed drugs, about 28 would benefit and 72 would not. Nausea and vomiting are usually less common and, therefore, drugs are less useful. For 100 people, of whom 30 would vomit or feel sick after surgery if given placebo, 10 people would benefit from a drug and 90 would not. Between one to five patients out of every 100 people may experience a mild side effect, such as sedation or headache, when given an antiemetic drug. Collaborative research should focus on determining whether antiemetic drugs cause more severe, probably rare, side effects. Further comparison of the antiemetic effect of one drug versus another is not a research priority.

A Double-Blind Comparison of Intravenous Ondansetron and Placebo for Preventing Postoperative Emesis in 1- to 24-Month-Old Pediatric Patients After Surgery Under General Anesthesia

We assessed the efficacy and safety of ondansetron (0.1 mg/kg IV) prophylactically administered before surgery for prevention of postoperative vomiting (POV) in a double-blind, placebo-controlled study of 670 pediatric patients, 1- to 24-mo-old, undergoing elective surgery under general anesthesia. The study enrolled 335 children in each treatment group (ondansetron versus placebo). Significantly fewer children treated with ondansetron exhibited emesis or discontinued the study prematurely after surgery (ondansetron, 11%; placebo, 28%; odds ratio = 0.33; P < 0.0001). The number required to treat prophylactically with ondansetron to prevent POV was approximately six. Ondansetron treatment also resulted in fewer patients requiring rescue medication or assumed to have had rescue upon early discontinuation from the study during the postoperative period (ondansetron, 5%; placebo, 10%) and less emesis (0 of 6) after rescue medication when compared with placebo (7 of 21). The incidence of POV and other antiemetic effects of ondansetron were similar in children aged 1-12 mo and 13-24 mo and in children prospectively expected or not expected to require opioids as part of their anesthetic or analgesic management. Ondansetron was well tolerated; the incidence of adverse events considered possibly related to study drug was similar between treatment groups (ondansetron, 1.8%; placebo, 1.5%).

IMPLICATIONS

This prospective, randomized, double-blind, placebo-controlled study establishes the efficacy and tolerability of IV ondansetron (0.1 mg/kg) in the prevention of postoperative emesis in 1- to 24-mo-old pediatric patients undergoing elective surgery under general anesthesia.

Ondansetron Oral Disintegrating Tablets: Acceptability and Efficacy in Children Undergoing Adenotonsillectomy

Postoperative nausea and vomiting (PONV), a major complication in children, is responsive to IV and oral ondansetron. Because these routes are not always available, we studied the acceptability and efficacy of ondansetron oral disintegrating tablets (ODT). In this double-blind, randomized, placebo-controlled study, 62 patients undergoing adenotonsillectomy, aged 5 to 11 years, preoperatively received ODT (4 mg) or placebo. Patients assessed the medication for taste and sensation. Anesthesia was induced with sevoflurane, maintained with desflurane, and supplemented with fentanyl 2.5 microg/kg and dexamethasone 0.5 mg/kg (maximum dose, 12 mg). An observer blinded to treatment evaluated patients for pain, agitation, and PONV. Postoperative treatment consisted of fentanyl 1 microg/kg for pain and agitation and metoclopramide 0.15 mg/kg (maximum dose, 10 mg) for PONV. There were no significant differences between study groups with regard to age, weight, recovery time, agitation, or pain. Approximately 90% of the subjects found the ODT to taste good. No subject rejected the study medication, but the ondansetron-containing tablets were found to be less palatable than the placebo. The incidence of vomiting was significantly less in the ondansetron-medicated group.

The development and validation of a risk score to predict the probability of postoperative vomiting in pediatric patients

Risk scores to predict the occurrence of postoperative vomiting (PV) or nausea and vomiting that were developed for adult patients do not fit for children, because several risk factors are difficult to assess or are usually not applicable in pediatric patients (e.g., smoking status). Thus, in the present study, we sought to develop and to validate a simple score to predict PV in children (POVOC-score). Development and validation of the new score was based on data from 4 independent institutions of 1257 children (aged 0-14 yr) undergoing various types of surgery under general anesthesia without antiemetic prophylaxis. Preoperatively, several potential risk factors were recorded. Postoperatively, the occurrence of PV was observed for up to 24 h. The dataset was randomly split into an evaluation set (n = 657) that was analyzed using a forward logistic regression technique and a validation set (n = 600) that was used to confirm the accuracy of prediction by means of the area under a receiver operating characteristic curve. Four independent risk factors for PV were identified in the final analysis: duration of surgery >/=30 min, age >/=3 yr, strabismus surgery, and a positive history of PV in the children or PV/postoperative nausea and vomiting in relatives (mother, father, or siblings). The incidence of PV was 9%, 10%, 30%, 55%, and 70% for 0, 1, 2, 3, and 4 risk factors observed. Using these incidences as cut-off values in the validation dataset, the area under the receiver operating characteristic curve was 0.72 (95% confidence interval: 0.68-0.77). Our data suggest that PV can be predicted with an acceptable accuracy using a four-item simplified risk score.

Applicability of risk scores for postoperative nausea and vomiting in adults to paediatric patients

BACKGROUND

Scores to predict the occurrence of postoperative vomiting (PV) or nausea and vomiting (PONV) are well established in adult patients. The aim of this survey was to evaluate the applicability of risk scores developed and tested in adult patients in 983 paediatric patients (0-12 yr) undergoing various surgical procedures.

METHOD

The predictive properties of five models were compared with respect to discriminating power (measured by the area under a receiver operating characteristic curve) and calibration (comparison of the predicted and the actual incidences of the disease by weighed linear regression analysis).

RESULTS

The cumulative incidence of PV was 33.2% within 24 h. The discriminating power was low and insufficient in all models tested (0.56-0.65). Furthermore, the predicted incidences of the scores correlated only vaguely with the actual incidences observed.

CONCLUSION

Specialized scores for children are required. These might use the history of PV, strabismus surgery, duration of anaesthesia > or =45 min, age > or =5 yr and administration of postoperative opioids as independent risk factors.

Management of postoperative nausea and vomiting in children

In spite of improvements in anesthesia techniques, the 'big little problem' of postoperative nausea and vomiting (PONV) still exists. PONV can prolong recovery room stay and hospitalization, and is one of the most common causes of hospital readmission after day surgery. While there is little evidence to support prophylactic administration of antiemetics in patients at low risk of PONV, the higher risk population could benefit from the use of adequate antiemetic drugs. A wide variety of pharmacological approaches have been reported to be effective, as well as some nonpharmacological approaches. Antiemetic drugs available to treat or prevent PONV include phenothiazines, antihistamines, anticholinergics, benzamides, butyrophenones and 5-HT(3) antagonists. Since available drugs still present undesired adverse effects and are not completely able to control PONV, clinical investigations are ongoing for more effective and better tolerated agents; indeed, the ideal antiemetic drug might be cost-effective for routine use.

Long-acting morphine for pain control in paediatric oncology

BACKGROUND

Guidelines for treatment of paediatric cancer pain recommend the usage of long-acting morphine. However, published paediatric experience with this drug is restricted to 147 children not systematically evaluated, and thus insufficient. We aimed to systematically analyse the age-dependent effects and adverse effects of long-acting morphine in paediatric cancer patients.

PROCEDURE

Ninety-five children aged 1 to 19 years were enrolled in a collaborative retrospective study conducted over seven-and-a-half years. Pain was scored according to a numeric rating scale (NRS, range 0 to 5), and the corresponding medication was recorded.

RESULTS

In 83 children documentation period started during morphine treatment (71, oral long-acting; 1, rectal; 11, IV). Mean oral/equivalent morphine starting dose was 1.3 mg/kgbw/d (SD 0.9). Mean end dose was 2.8 mg/kgbw/d (SD 2.7). Infants aged < 7 years received the highest average dose (2.6 mg/kgbw/d, SD 2.8), while patients > 12 years received the lowest dose (1.4 mg/kgbw/d, SD 1.1). Median pain intensity decreased from score 1.0 (mean 1.2) NRS at the beginning to 0 (mean 0.6) NRS at the end. The proportion of patients scoring > 2 NRS (severe or most severe pain) under morphine treatment decreased from 26 to 12% (P = 0.08). In children > 12 years pruritus was frequently observed (23% of patients). In all age groups, there were no severe adverse effects during the study period.

CONCLUSIONS

In paediatric haematology/oncology, pain control by oral long-acting morphine proved to be safe and effective even in the very young patients. The pharmacological properties of long-acting morphine are ideally suited for paediatric use, combining efficacy and compatibility.

Perioperative management issues in pediatric patients

Recent developments in perioperative practice, emphasizing issues that are of greatest concern in pediatric patients, are reviewed in this article. Many areas bear further evaluation in the evolving field of perioperative medicine: Effective techniques of psychologic preparation for children and their parents in an era in which the family rarely encounters the hospital environment before the day of surgery Application of newer intraoperative anesthetics, such as new narcotics and muscle relaxants, to shorten PACU and pediatric ICU stay while maintaining safety and comfort Critical evaluation of current methods of pain management to optimize comfort, while minimizing cost of such management in an increasingly cost-conscious health care environment The recent advent of a process for credentialing pediatric anesthesia fellowship programs, which requires a research component, bodes well for the prospect of finding answers to some of these questions.