Low-Dose Intrathecal Morphine for Postoperative Analgesia in Children

A Randomized Controlled Trial of Intrathecal versus Caudal Morphine-Bupivacaine on Postoperative Analgesia and Cortisol Levels in Pediatric Patients

BACKGROUND

Morphine is commonly used in pediatric caudal blocks. We compared the analgesic efficacy and effect on cortisol levels of intrathecal morphine and bupivacaine with caudal morphine and bupivacaine in children undergoing lower abdominal surgeries.

METHODS

Forty children undergoing lower abdominal surgeries were randomized to receive 4 μg/kg of intrathecal morphine and 0.5% hyperbaric bupivacaine (n = 20), or caudal morphine 40 μg/kg and 0.25% bupivacaine (n = 20). Postoperative analgesia was provided with intravenous (IV) paracetamol (PCM). The primary outcome was time to reach Face, Legs, Activity, Cry, and Consolability (FLACC) score ≥4 postoperatively. Secondary outcomes were perioperative serum cortisol levels, analgesic requirement, and parent satisfaction.

RESULTS

Since seventy 5% of patients receiving intrathecal morphine and bupivacaine did not reach a FLACC score ≥4 within 24 hours, the primary outcome was presented as the Kaplan-Meier curve. The probability of FLACC score <4 was significantly higher with intrathecal morphine and bupivacaine than with caudal morphine and bupivacaine (P < .001). The unadjusted and adjusted (for gender) hazard ratio (95% confidence interval [CI]) of occurrence of pain (FLACC score ≥4) was 0.07 (0.03-0.15, P < .001) and 0.06 (0.03-0.14, P < .001), respectively. The difference in means (95% CI) of cortisol levels between caudal morphine (with bupivacaine) and intrathecal morphine (with bupivacaine) groups were after intubation -0.667 (-4.99 to 3.65, P = .76), at 2 hours intraoperatively 7.88 (3.55-12.2, P < .001), 6 hours postoperatively 16.8 (12.5-21.1, P < .001), and 24 hours postoperatively 15.4 (11.1-19.7, P < .001) μg/dL. Intraoperatively, rescue fentanyl was required by 60% of patients on caudal morphine and bupivacaine against 20% of patients receiving intrathecal morphine and bupivacaine (absolute risk-reduction [95% CI] of 40% [12%-68%]; P = .010). Postoperative rescue fentanyl was required in 45% of patients on caudal morphine and bupivacaine and 5% of patients on intrathecal morphine and bupivacaine. All (100%) patients on caudal morphine and bupivacaine required postoperative PCM against 6 (30%) patients on intrathecal morphine and bupivacaine (absolute risk-reduction [95% CI] of 70% [50%-90%]; P < .001).The median (interquartile range [IQR]) parent satisfaction score for patients on caudal morphine (with bupivacaine) and intrathecal morphine (with bupivacaine) was 0(0-0) and 2(2-2) at 12 hours postoperatively (P < .001) and 0(0-1) and 2(1.5-2) at 24 hours postoperatively (P < .001). One patient in each group developed nausea and vomiting, and 1 patient in the intrathecal group developed pruritus. There was no incidence of respiratory depression.

CONCLUSIONS

Intrathecal morphine and bupivacaine results in longer duration of analgesia, lower analgesic consumption, prevents surgical-stress-related elevation of serum cortisol, and improves parent satisfaction compared to caudal morphine with bupivacaine in children undergoing lower abdominal surgeries.

Effectiveness and Safety of Intrathecal Morphine for Pediatric Patients Undergoing Scoliosis Surgery: A Systematic Review and Meta-Analysis

Adolescent idiopathic scoliosis (AIS) often necessitates spinal fusion surgery in pediatric patients, posing significant challenges in postoperative pain management. Standard care involves the administration of intravenous opioids perioperatively, often requiring high doses to achieve adequate analgesia following an operation. This increases the risk of adverse events, may delay recovery and prolong hospital stay, and increases the likelihood of future abuse and dependence. In this systematic review and meta-analysis, we assess the safety and effectiveness of intrathecal morphine (ITM) in pediatric patients undergoing posterior spinal fusion. Ovid Embase and MEDLINE were searched in October 2023 for articles that directly compared ITM use with standard pain management approaches for pediatric patients undergoing posterior spinal fusion. Our primary outcome was postoperative pain scores. Secondary outcomes included opioid usage details, adverse events, and blood loss. Of the 384 unique studies identified, nine studies (one randomized control trial, one prospective review, and seven retrospective reviews) met the inclusion criteria. The total number of patients within the ITM and control groups were 1384 and 676, respectively. Meta-analysis revealed significantly lower pain scores in the ITM group (standardized mean difference (SMD): -1.30 (-2.29, -0.31); p = 0.01). Similarly, ITM patients had significantly lower opioid usage, both intraoperatively (mean difference (MD): -0.71 mg/kg (-0.99, -0.44); p < 0.00001) as well as postoperatively (SMD: -2.10 (-3.48, -0.73); p = 0.003), and significantly lower blood loss (MD: -0.88 L (-1.34, -0.43); p = 0.0001). The occurrence of adverse events was similar across both groups. Our analysis of the available data demonstrates that a low to moderate dose of ITM is a safe and effective adjunct to improve standard postoperative care without increasing the risk of respiratory depression. When compared to control, ITM patients had superior analgesia while using fewer opioids had significantly reduced intraoperative blood loss when ITM was administered before spinal fusion, and had a similar complication profile. While further studies are warranted to establish optimal dosing, these findings underscore the potential of ITM as a valuable addition to multimodal pain management.

The effect of intraoperative intrathecal opioid administration on the length of stay and postoperative pain control for patients undergoing lumbar interbody fusion

PURPOSE

In an effort to control postoperative pain more effectively in spinal fusion patients, intraoperative intrathecal morphine (ITM) administration is gaining popularity and acceptance with clinicians. This study seeks to determine the impact of intraoperative intrathecal opioid (ITO) administration following lumbar fusion surgery on postoperative pain and length of hospitalization as primary outcomes. Secondary outcomes will investigate postoperative opioid intake and side effects.

METHODS

The retrospective analysis of collected data was performed. The study compared patients undergoing one- or two-level transforaminal interbody fusions between 2019 and 2021 who intraoperatively received two different ITO doses (n = 89) vs. the reference group (n = 48) that did not receive ITO. The patients in the ITO group received either 0.2 mg (n = 44) of duramorph or 0.2 mg duramorph + 50 mcg fentanyl (n = 45). The effect of ITO was evaluated for the first four postoperative days (POD) on pain scores (visual analog scale), length of stay (LOS, hours) and opioid requirement (MED, morphine equivalent dose).

RESULTS

In the ITO group, a significant reduction of postoperative pain scores (t(99) = 4.3, p < 0.001) and opioid intake (t(70) = 2.49, p = 0.015) was noted on POD1. Cohen's d effect sizes were 0.76 and 0.50, meaning that postoperative pain and MED intake were reduced by about ¾ to ½ standard deviations (SD) in the ITO group. Further, multivariate regression models revealed that ITO administration predicted lower postoperative pain scores for the two PODs (β =  - 0.83, p < 0.001; β =  - 0.63, p = 0.022) and MED intake for the first two PODs (β =  - 20.8, p = 0.047; β =  - 16.4, p = 0.030). Mean LOS was 15.4 h less in the ITO group (mean ± SD, 63.4 ± 37.1 vs. 78.8 ± 39.6, p = 0.10).

CONCLUSIONS

In conclusion, our study provides results in a large sample of patients undergoing transforaminal lumbar fusions. The results demonstrated that ITO administration is effective in reducing POD1 pain scores and POD1-2 opioid requirement while not increasing the risk of any opioid-related side effects.

Intravenous ondansetron reduced nausea but not pruritus following intrathecal morphine in children: Interim results of a randomized, double-blinded, placebo-control trial

STUDY OBJECTIVE

This study's purpose was to determine if ondansetron can prevent pruritus after administration of intrathecal morphine in children, as has been demonstrated in adults.

DESIGN

A double-blinded, randomized placebo-controlled trial.

SETTING

Operating room and first 24 h postoperative inpatient stay at an academic children's hospital.

PATIENTS

Forty-six children aged 3-17 years, who received 4-5 mcg/kg intrathecal morphine for urological or orthopedic procedures were included.

INTERVENTIONS

Children were randomized to receive intravenous ondansetron (treatment) or saline placebo (placebo), prior to intrathecal morphine administration, and q6H for 24 h thereafter. Intraoperative anti-emetics and postoperative rescue treatments for pruritus and nausea were standardized.

MEASUREMENTS

Patients were interviewed q6H for scored pruritus, nausea, and pain, using standardized scales.

MAIN RESULTS

The trial was terminated for futility after interim analysis. Forty-six children were recruited and 45 completed data collection. No significant difference was found between both groups for incidence of pruritus (requiring treatment) [relative risk (RR) 0.9, 95% CI: 0.7, 1.2], during the first postoperative 24 h. Notably, the incidence of pruritus was 84% overall, much higher than rates in previously published studies. Intravenous ondansetron significantly reduced the incidence of nausea, compared with the placebo group [RR 0.5, 95% CI: 0.3, 0.9].

CONCLUSIONS

This study found no evidence for intravenous ondansetron as an effective preventative for pruritus following intrathecal morphine in children. However, this RCT did find that the rate of pruritus following intrathecal morphine administration may be significantly higher than previously thought. Nausea and vomiting (a secondary outcome) were reduced significantly in the treatment group. The negative findings of this study reinforce the potential dangers of extrapolating the drug effects seen in adults onto pediatric patients.

Post-thoracotomy analgesia

Thoracotomy is considered one of the most painful operative procedures. Due to anatomical complexity, post-thoracotomy pain requires multimodal perioperative treatment to adequately manage to ensure proper postoperative recovery. There are several different strategies to control post-thoracotomy pain including interventional techniques, such as neuraxial and regional injections, and conservative treatments including medications, massage therapy, respiratory therapy, and physical therapy. This article describes different strategies and evidence base for their use.

Zero Patient-controlled Analgesia is an Achievable Target for Postoperative Rapid Recovery Management of Adolescent Idiopathic Scoliosis Patients

STUDY DESIGN

Retrospective review.

OBJECTIVE

The objective of this study was to report on one institution's use of single bolus micro-dose intrathecal morphine as part of a rapid recovery pathway during posterior spinal fusion (PSF) for adolescent idiopathic scoliosis (AIS) and its comparison to patients whose pain was controlled with patient-controlled analgesia (PCA).

SUMMARY OF BACKGROUND DATA

Narcotic substance addiction has risen across all patient populations, including pediatrics. Narcotics have been historically used in complex spine surgeries as a measure of pain control, predominantly provided as PCA and additional take-home medication.

METHODS

AIS patients undergoing PSF from 2015 to 2019 were reviewed. In 2018, we instituted a standardized rapid recovery pathway for scoliosis patients undergoing PSF utilizing micro-dose intrathecal morphine (ITM-RRP). Before this, traditional protocol with PCA was used for postoperative management. Perioperative data, morphine consumption and prescription refill requests were compared.

RESULTS

There were 373 AIS patients total in this study, of which 250 patients were in the PCA group and 123 in the ITM-RRP Group. Preoperative Cobb angles (P = 0.195), as well as levels fused (P = 0.481) and body mass index (P = 0.075) were similar. 69.4% of ITM-RRP patients had a length of stay ≤3 days, significantly >11.6% of PCA patients (P < 0.001). ITM-RRP patients began ambulating significantly earlier with 84.6% patients out of bed by postoperative day 1 versus 8% PCA patients (P < 0.001). Additionally, ITM-RRP patients had significantly lower VAS pain scores with activity and earlier initial bowel movements (P < 0.001).Postoperative emesis was similar (P = 0.11). No patients had pruritus, respiratory depression, or required supplemental oxygenation.

CONCLUSION

This is the first study to show that a rapid recovery protocol utilizing single micro-dose ITM with oral analgesics have adequate recovery, significantly better postoperative pain control and superior perioperative outcomes to traditional protocols using PCA in the AIS population following PSF.Level of Evidence: 3.

Effects of 5 µg/kg intrathecal morphine for postoperative analgesia in pediatric patients undergoing major surgery

BACKGROUND

The effects and analgesic adequacy of intrathecal morphine (ITM) administration have been studied less frequently than other regional analgesia techniques in pediatric surgical procedures.

OBJECTIVE

To evaluate the efficacy and adverse event rate of 5 µg/kg ITM administration for postoperative analgesia according to age group.

METHODS

We retrospectively evaluated the medical records of patients who underwent major pediatric surgery and were administered ITM for postoperative analgesia. Patients were divided into three age groups: ≤ 5 years (group I), 5.1-13 years (group II) and > 13 years (group III). All patients received ITM 5 µg/kg (max 300 μg) through the L_4-5 or L₅-S₁ interspace. Postoperative pain (modified pediatric objective pain score > 4), need for rescue analgesics, sleep interruption due to pain, sedation (Ramsay sedation scale score > 3), opioid-related postoperative adverse events (at 0, 4, 8, 12, and 24 h after intervention), hemodynamic data and nurse satisfaction with the analgesic method were compared between groups.

RESULTS

The analysis included 100 children (47 girls, 9 ± 5.4 years). Groups were similar regarding postoperative rescue analgesia consumption and sleep interruption (p = 0.238, p = 0.958), 96% of the children did not require rescue analgesia, and sleep interruption was not observed in 97%. Postoperative adverse events were pruritus in 14 and nausea/vomiting in 9 patients (p = 0.052). Overall, nurses were satisfied or very satisfied in 99% of the cases.

CONCLUSION

Administration of 5 µg/kg ITM can be used for postoperative analgesia in pediatric surgery in all age groups, with no severe adverse events and high nurse satisfaction with analgesic management.

Effects of opioid-reduced anesthesia during scoliosis surgery in children: a prospective observational study

Aims: Opioid-reduced anesthesia (ORA) was suggested to decrease morphine consumption after adolescent idiopathic scoliosis (AIS) surgery and incidence of chronic pain. Materials & methods: A prospective analysis using the ORA in AIS surgery was performed. Two cohorts were compared: a control group (opioid-based anesthesia) and the ORA group. The main outcome was morphine consumption at day 1. Results: 33 patients operated for AIS using ORA were compared with 36 with opioid-based anesthesia. Morphine consumption was decreased in the ORA group (1.1 mg.kg^-1 [0.2-2] vs 0.8 mg.kg^-1 [0.3-2]; p = 0.02) at day 1. Persistent neuropathic pain at 1 year was decreased in the ORA group (p = 0.02). Conclusion: The ORA protocol is efficient to reduce postoperative morphine consumption in AIS surgery and preventing neuropathic pain.

Persistent Hypothermia and Excessive Sweating Following Intrathecal Morphine Administration in a Teenage Boy: A Case Report

Introduction

Opioids are used intrathecally to manage surgical pain. There are few reports of hypothermia after spinal morphine injection, none in the pediatric population. We present a teenager's case of mild hypothermia.

Case Presentation

A 15-year-old boy was scheduled for elective abdominal laparotomy. General anesthesia was combined with spinal anesthesia, using levobupivacaine and morphine. In the recovery room, he presented a decreased tympanic temperature (34.4°C) associated with excessive sweating, hyperglycemia, and complained of feeling hot. All other vital signs were normal. It was decided to maintain clinical vigilance and hourly monitoring of temperature and glycaemia values. Despite active warming, he remained hypothermic for 16 hours, with gradual remission of symptoms and normalization of glycemic values. It is unknown how intrathecal morphine causes hypothermia. The most viable hypothesis is its effect on the hypothalamus. In our case the most probable causes of post anesthesia hypothermia were excluded; therefore, we can admit that the cause of hypothermia was the spinal administration of morphine. Some reports used naloxone and lorazepam successfully. In our report, they disappeared spontaneously 16 hours later, which corroborates our diagnosis.

Conclusions

Children undergoing subarachnoid block with with intrathecal morphine may develop a disruption on thermoregulation, leading to a resistant postoperative hypothermia associated with excessive sweating.

Pediatric Perioperative Pain Management

Effective perioperative pain control in pediatric patients undergoing orthopedic surgery remains a challenge. Developing a successful pain control regimen begins preoperatively with assessment of the patient and discussion with the patient and family regarding expectations. Perioperative pain control regimens are customized based on the type of surgery, patient characteristics, and anticipated severity and duration of the postoperative pain. Recent study focuses on multimodal strategies and regional anesthesia options, allowing for decreased opioid use. This article provides an evidence-based overview of preoperative, intraoperative, and postoperative pain control for the pediatric orthopedic patient.

A retrospective comparison of intrathecal morphine and epidural hydromorphone for analgesia following posterior spinal fusion in adolescents with idiopathic scoliosis

BACKGROUND

Posterior spinal fusion to correct idiopathic scoliosis is associated with severe postoperative pain. Intrathecal morphine is commonly used for analgesia after adolescent posterior spinal fusion; however, anticipating and managing the increase in pain scores after resolution of analgesic effect of intrathecal morphine analgesia is challenging. In 2014, we developed a clinical protocol detailing both the administration of intrathecal morphine intraoperatively and the transition to routine, scheduled oral analgesics at 18 h postoperatively. The goal of our study was to examine the efficacy of our intrathecal morphine protocol vs epidural hydromorphone for postoperative analgesia after posterior spinal fusion.

METHODS

Following IRB approval, we retrospectively identified developmentally intact children of ages 10-20 years in our electronic database with a diagnosis of idiopathic scoliosis who had undergone elective posterior spinal fusion surgery from June 2014 to April 2015. For the intrathecal morphine group, intrathecal morphine was administered in a dose of 12 μg·kg^-1 (max 1000 μg) prior to incision. Postoperatively, all children in the intrathecal morphine group had an order to receive oral oxycodone (0.1 mg·kg^-1 , max 5 mg) starting at 18 h postintrathecal morphine injection. For the epidural hydromorphone group, catheters were placed by the surgeon and bolused with 5 μg·kg^-1 hydromorphone (max 200 μg) and 1 μg·kg^-1 fentanyl (max 50 μg), followed by a continuous infusion of 40-60 μg·h^-1 , and patient-controlled bolus doses of 5 μg with a lockout interval of 30 min. All patients in both groups had postoperative orders for acetaminophen, diazepam, and ketorolac.

RESULTS

During the study time period, 20 patients received intrathecal morphine and were successfully matched with 20 patients who received epidural hydromorphone. All patients in the intrathecal morphine group were transitioned to oral analgesics on the first postoperative day, without need for intravenous opioids after discharge from the postanesthesia care unit. Compared to the epidural hydromorphone group, the intrathecal morphine group reported lower pain scores in the postanesthesia care unit (difference in means -4.26 [95% CI -6.56, -1.96], P = 0.001) and first 8 h after surgery (difference in means -1.88 [95% CI -3.84, 0.082, P = 0.060) and higher pain scores on the 2nd postoperative day (difference in means 1.60 [95% CI 0.10, 3.10], P = 0.037). The documented time to ambulation and time of Foley catheter removal were statistically earlier in the intrathecal morphine group, and the hospital length of stay was significantly shorter (3.0 ± 0.5 days vs 3.5 ± 0.7 days; P = 0.03). Adverse events did not significantly differ between the groups.

CONCLUSION

The efficacy of intraoperative intrathecal morphine for postoperative analgesia in the posterior spinal fusion patient population has been shown previously; however, the pain and analgesic trajectory, including transition to other analgesics, has not previously been studied. Our findings suggest that for many patients, use of intrathecal morphine in addition to routine administration of nonopioid medications facilitates direct transition to oral analgesics in the early postoperative period and earlier routine ambulation and discharge of posterior spinal fusion patients.

Efficacy of Intrathecal Morphine in a Model of Surgical Pain in Rats

Concerns over interactions between analgesics and experimental outcomes are a major reason for withholding opioids from rats undergoing surgical procedures. Only a fraction of morphine injected intravenously reaches receptors responsible for analgesia in the central nervous system. Intrathecal administration of morphine may represent a way to provide rats with analgesia while minimizing the amount of morphine injected. This study aimed to assess whether morphine injected intrathecally via direct lumbar puncture provides sufficient analgesia to rats exposed to acute surgical pain (caudal laparotomy).In an initial blinded, randomised study, pain-free rats received morphine subcutaneously (MSC, 3mg.kg-1, N = 6), intrathecally (MIT, 0.2mg.kg-1, N = 6); NaCl subcutaneously (NSC, N = 6) or intrathecally (NIT, N = 6). Previously validated pain behaviours, activity and Rat Grimace Scale (RGS) scores were recorded at baseline, 1, 2, 4 and 8h post-injection. Morphine-treated rats had similar behaviours to NaCl rats, but their RGS scores were significantly different over time and between treatments. In a second blinded study, rats (N = 28) were randomly allocated to one of the following four treatments (N = 7): MSC, 3mg.kg-1, surgery; MIT, 0.2mg.kg-1, surgery; NIT, surgery; NSC, sham surgery. Composite Pain Behaviours (CPB) and RGS were recorded as previously. CPB in MIT and MSC groups were not significantly different to NSC group. MSC and MIT rats displayed significantly lower RGS scores than NIT rats at 1 and 8h postoperatively. RGS scores for MIT and MSC rats were not significantly different at 1, 2, and 8h postoperatively. Intraclass correlation value amongst operators involved in RGS scoring (N = 9) was 0.913 for total RGS score. Intrathecal morphine was mostly indistinguishable from its subcutaneous counterpart, providing pain relief lasting up to 8 hours in a rat model of surgical pain. Further studies are warranted to clarify the relevance of the rat grimace scale for assessing pain in rats that have received opioid analgesics.

Port Site Local Anesthetic Infiltration Vs Single-dose Intrathecal Opioid Injection to Control Perioperative Pain in Children Undergoing Minimal Invasive Surgery: A Comparative Analysis

OBJECTIVE

To compare the efficacy of the intrathecal opiate vs wound site local anesthetic infiltration for perioperative pain control during and after surgery in patients undergoing minimally invasive pediatric urologic procedures.

METHODS

Using an Institutional Review Board-approved registry database, we identified patients who underwent minimally invasive urologic procedures at our institution between 2009 and 2013. We collected all relevant preoperative variables and postoperative outcomes. Patients in intrathecal injection of opioids (ITO) group were matched with patients who received local anesthetic infiltration (LAI) based on age, diagnosis, and procedure. Perioperative analgesic requirements were converted to morphine equivalents standardized to body weight. Statistical analysis was performed using SPSS, and parametric comparisons were completed to determine difference in morphine equivalents between the 2 groups.

RESULTS

One hundred thirty children (78 girls and 52 boys) were included in our study. Sixty-six patients underwent ITO and 66 received LAI. Sixty-six patients underwent ureteral reimplantation, 60 underwent pyeloplasty, and 4 underwent nephrectomy. Ages ranged from 0.5 to 19.9 years. There was no significant difference in cumulative morphine equivalents or weight administered between the ITO and LAI groups for the total period of hospitalization (0.76 units vs 0.79 units, P > .05). Multivariate regression analysis predicted that older age corresponds to higher analgesic requirements.

CONCLUSION

ITO does not impact total analgesic requirements during the hospital stay compared to LAI following minimally invasive surgery. Considering the potential complications of ITO, LAI may be the preferred modality for pain management for minimally invasive surgery in children.

Pain outcomes in children who received intrathecal vs intravenous opioids for pain control following major urologic surgery: a retrospective review

BACKGROUND

Intrathecal (IT) opioid administration has been associated with postoperative benefits including reduced pain and opioid use in children. However, the postoperative benefits and risks of IT opioid administration during major urologic surgery in children remain unclear.

AIM

The aim of this study was to compare postoperative pain and adverse event outcomes among children who received IT vs intravenous (IV) opioids during major urologic surgery.

METHODS

We reviewed the medical records of children 3-17 years of age who underwent ureteroneocystostomy or pyeloplasty between 2006 and 2012. Electronically captured anesthetic and surgical data, postanesthesia care recovery unit (PACU) and nursing flowsheets, and daily progress notes through hospital discharge were reviewed. Analgesic techniques (i.e., IT or IV patient/nurse controlled opioids), all analgesic drugs and doses were recorded. Outcome measures included pain scores, need for rescue analgesics, opioid-related adverse events, and their treatments.

RESULTS

Seventy-seven children received IT opioids and 51 received IV opioids. More children in the IV group required rescue analgesics and had higher pain scores at PACU discharge. Children in the IV group required rescue opioids more frequently than the IT group from 0 to 8 h and 8 to 16 h after PACU discharge, but rates were similar by 16-24 h 70% of children in IT group transitioned directly to oral opioids. Seven IT placements were considered as failed due to early need for rescue opioids. Four (8%) of the IV group and seven (9%) of the IT group experienced oxygen desaturation. Two of these, both in IT group required naloxone and one was admitted to ICU for observation. The IT group experienced a higher incidence of pruritus, constipation and hypotension.

CONCLUSION

We observed better postoperative pain control in children who received IT vs IV opioids for the first 16 h with no discernible difference thereafter. The intrathecal group experienced higher incidences of pruritus, constipation, and hypotension.

Intrathecal morphine analgesia after cervical and thoracic spinal cord tumor surgery

Object

The aim of this study was to provide evidence for the effect of intrathecal morphine application after spinal cord tumor resection.

Methods

Twenty patients participated in a prospective open proof-of-concept study. During dural closure, morphine (7 μg/kg) was injected into the subarachnoid space. All patients were monitored in an intensive care setting postoperatively. Pain, additional opioids given, and vital parameters were recorded.

Results

Six patients received a mean morphine dose of 365 μg between C-3 and C-7 and 14 patients received a mean dose of 436 μg between T-2 and T-12. In the cervical and thoracic groups, the mean Numeric Rating Scale score was highest upon intensive care unit admission (1.2 and 2.5, respectively) and declined at 12 hours (0.5 and 0.8, respectively). Minimal extra morphine was required. Minor side effects occurred without consequence.

Conclusions

Intrathecal morphine for postoperative analgesia after resection of cervical and thoracic spinal cord tumors is effective and safe. These preliminary results require confirmation by larger comparative studies and further clinical experience.

The robotic-assisted laparoscopic pyeloplasty: gateway to advanced reconstruction

Robotic pyeloplasty is now commonly performed for children with ureteropelvic junction obstruction. Because surgical robotics is a tool that facilitates pyeloplasty and other reconstructive urologic operations, the indications for robotic-assisted laparoscopic pyeloplasty are the same as those for an open pyeloplasty but offer distinct advantages with respect to visualization, range of motion, and ease of laparoscopic suturing. In this review, the authors discuss the operative approach for robotic pyeloplasty in children and the extensions of the basic techniques to challenging clinical scenarios.

Spinal anesthesia in children: A review

Even after a vast safety record, the role of spinal anesthesia (SA) as a primary anesthetic technique in children remains contentious and is mainly limited to specialized pediatric centers. It is usually practiced on moribund former preterm infants (<60 weeks post-conception) to reduce the incidence of post-operative apnea when compared to general anesthesia (GA). However, there is ample literature to suggest its safety and efficacy for suitable procedures in older children as well. SA in children has many advantages as in adults with an added advantage of minimal cardio-respiratory disturbance. Recently, several reports from animal studies have raised serious concerns regarding the harmful effects of GA on young developing brain. This may further increase the utility of SA in children as it provides all components of balanced anesthesia technique. Also, SA can be an economical option for countries with finite resources. Limited duration of surgical anesthesia in children is one of the major deterrents for its widespread use in them. To overcome this, several additives like epinephrine, clonidine, fentanyl, morphine, neostigmine etc. have been used and found to be effective even in neonates. But, the developing spinal cord may also be vulnerable to drug-related toxicity, though this has not been systematically evaluated in children. So, adjuvants and drugs with widest therapeutic index should be preferred in children. Despite its widespread use, incidence of side-effects is low and permanent neurological sequalae have not been reported with SA. Literature yields encouraging results regarding its safety and efficacy. Technical skills and constant vigilance of experienced anesthesia providers is indispensable to achieve good results with this technique.

Pain status and sedation level in Chinese children after cardiac surgery: an observational study

AIMS AND OBJECTIVES

This study explored current pain status, sedation level and their trajectories in Chinese children after cardiac surgery. Background.  Pain and sedation management are fundamental care practices in the critical care setting, yet they both are frequently under-implemented for children after major surgery.

DESIGN

Repeated observational design.

METHODS

This study was conducted in a paediatric medical centre in Shanghai, China where 170 children who underwent cardiac surgery were recruited. Pain was measured with the face, legs, activity, cry, consolability scale and sedation levels with the COMFORT Behaviour Scale at 18 fixed time-points for three consecutive postoperative days. Results.  The study indicated that 95 children (55·9%) received continuous opioids for pain relief, and 61 children (35·9%) received no analgesics. Multiple sedatives were used for these children, including bolus phenobarbital for 117 children (68·8%), phenergan for 81 children (47·6%) and midazolam for three children (1·8%). The mean pain scores significantly decreased throughout the operation day (POD-0) to the 2nd postoperative day (POD-2) with the lowest score on POD-2. Less than 5% of pain assessments were identified as moderate to severe across all 2815 observations. The sedation scores significantly increased through POD-0 to POD-2 with the highest score on POD-2. The rate of over-sedation was 50·3% with <1% under-sedation occurring among all the observations. Results also suggested that the length of stay in the cardiac intensive care unit was a predictor of increased analgesic usage in the critical care setting (odds ratio: 1·72).

CONCLUSIONS

Usage of analgesic and sedative agents in cardiac intensive care unit was variable and children experienced low pain scores but a high rate of over-sedation, indicating that healthcare providers should address ways to improve postoperative pain and sedation management in this population.

RELEVANCE TO CLINICAL PRACTICE

The pain and sedation status for children after cardiac surgery changed across the postoperative days. Healthcare providers should be trained in the use of reliable tools to accurately monitor children's pain and sedation levels.

Neuraxial analgesia in neonates and infants: a review of clinical and preclinical strategies for the development of safety and efficacy data

Neuraxial drugs provide robust pain control, have the potential to improve outcomes, and are an important component of the perioperative care of children. Opioids or clonidine improves analgesia when added to perioperative epidural infusions; analgesia is significantly prolonged by the addition of clonidine, ketamine, neostigmine, or tramadol to single-shot caudal injections of local anesthetic; and neonatal intrathecal anesthesia/analgesia is increasing in some centers. However, it is difficult to determine the relative risk-benefit of different techniques and drugs without detailed and sensitive data related to analgesia requirements, side effects, and follow-up. Current data related to benefits and complications in neonates and infants are summarized, but variability in current neuraxial drug use reflects the relative lack of high-quality evidence. Recent preclinical reports of adverse effects of general anesthetics on the developing brain have increased awareness of the potential benefit of neuraxial anesthesia/analgesia to avoid or reduce general anesthetic dose requirements. However, the developing spinal cord is also vulnerable to drug-related toxicity, and although there are well-established preclinical models and criteria for assessing spinal cord toxicity in adult animals, until recently there had been no systematic evaluation during early life. Therefore, in the second half of this review, we present preclinical data evaluating age-dependent changes in the pharmacodynamic response to different spinal analgesics, and recent studies evaluating spinal toxicity in specific developmental models. Finally, we advocate use of neuraxial drugs with the widest demonstrable safety margin and suggest minimum standards for preclinical evaluation before adoption of new analgesics or preparations into routine clinical practice.

[Intrathecal opioid medication for perioperative analgesia in severely handicapped children undergoing spinal operations]

PURPOSE OF THE STUDY

Intrathecal opioids have been shown to be safe and effective for postoperative analgesia in healthy children for spinal surgery. The aim of this study was to evaluate the applicability of intrathecal opioids in severely handicapped children scheduled for spinal surgery.

METHODS

With hospital ethical committee approval, patients with physical states III and IV of the ASA classification requiring spinal surgery were retrospectively studied. In addition to inhalational anesthesia with sevoflurane or intravenous anesthesia using propofol, morphine 20 microg/kgBW and sufentanil 1.5 microg/kgBW were administered intrathecally before surgery. After surgery an infusion of nalbuphine was started. Need for additional intraoperative and postoperative analgesics, time of extubation, postoperative pain scores and p(a)CO2 values as well as adverse effects were recorded.

RESULTS

A total of 28 patients aged from 2.8 to 18.5 years (median 11.6 years) were studied. Immediate tracheal extubation in the operating room was possible in 17 patients and for 11 patients delayed extubation was elected. All patients were extubated within 24 h except for 1 patient who received massive postoperative transfusions. In 26 out of 28 patients (93%) the combination of intrathecal opioids with postoperative nalbuphine provided adequate analgesia. Observed side effects were post-operative nausea and vomiting (PONV), pruritus and moderate hypoventilation. In two patients a change to intravenous morphine therapy was necessary.

CONCLUSION

The use of intrathecal opioids for perioperative pain control from spinal fusion in severely handicapped children is feasible. Intrathecal opioids provide adequate postoperative analgesia and allow early extubation without persisting relevant respiratory compromise in most of these patients.

Validation of a preclinical spinal safety model: effects of intrathecal morphine in the neonatal rat

BACKGROUND

Preclinical studies demonstrate increased neuroapoptosis after general anesthesia in early life. Neuraxial techniques may minimize potential risks, but there has been no systematic evaluation of spinal analgesic safety in developmental models. We aimed to validate a preclinical model for evaluating dose-dependent efficacy, spinal cord toxicity, and long-term function after intrathecal morphine in the neonatal rat.

METHODS

Lumbar intrathecal injections were performed in anesthetized rats aged postnatal day (P) 3, 10, and 21. The relationship between injectate volume and segmental spread was assessed postmortem and by in vivo imaging. To determine the antinociceptive dose, mechanical withdrawal thresholds were measured at baseline and 30 min after intrathecal morphine. To evaluate toxicity, doses up to the maximum tolerated were administered, and spinal cord histopathology, apoptosis, and glial response were evaluated 1 and 7 days after P3 or P21 injection. Sensory thresholds and gait analysis were evaluated at P35.

RESULTS

Intrathecal injection can be reliably performed at all postnatal ages and injectate volume influences segmental spread. Intrathecal morphine produced spinally mediated analgesia at all ages with lower dose requirements in younger pups. High-dose intrathecal morphine did not produce signs of spinal cord toxicity or alter long-term function.

CONCLUSIONS

The therapeutic ratio for intrathecal morphine (toxic dose/antinociceptive dose) was at least 300 at P3 and at least 20 at P21 (latter doses limited by side effects). These data provide relative efficacy and safety for comparison with other analgesic preparations and contribute supporting evidence for the validity of this preclinical neonatal safety model.

Efficacy of a low-dose spinal morphine with bupivacaine for postoperative analgesia in children undergoing hypospadias repair

BACKGROUND

Children undergoing hypospadias repair need to be protected from highly unpleasant sensory and emotional experiences during and after surgery. We designed a double-blinded, randomized, and placebo-controlled study to compare the efficacy of a low-dose (2 microg x kg(-1)) of intrathecal morphine with placebo for postoperative pain control of children undergoing repair of hypospadias surgery with spinal anesthesia.

METHODS

Fifty-four children were randomly assigned to one of two spinal anesthesia groups. Group M (n = 27) received hyperbaric bupivacaine plus 2 microg x kg(-1) of preservative-free morphine and group P (n = 27) received hyperbaric bupivacaine plus 0.9% NaCl (placebo) under inhalation anesthesia. General anesthetics were discontinued subsequent to the block. The primary outcome was the presence of pain-requiring analgesics during the first 12 h after the spinal block. Side effects were also recorded. The analgesic effects were evaluated by using the Children's Hospital of Eastern Ontario Pain Scale.

RESULTS

Forty-nine patients completed the trial. Fifteen patients (60%) in group P received supplementary analgesics within the first 12 h compared to only four patients (16.7%) in group M (P = 0.005). Mean duration of analgesia was 480 +/- 209 and 720 +/- 190 min in group P and group M respectively (P = 0.009). The groups were similar in postoperative side effects.

CONCLUSION

Spinal anesthesia provided by hyperbaric bupivacaine is adequate for distal hypospadias repair in children, but adding 2 microg x kg(-1) intrathecal morphine provides better postoperative pain control when compared to placebo in these children.

Pharmacologic management of acute pediatric pain

The accurate assessment and effective treatment of acute pain in children in the hospital setting is a high priority. During the past 2 to 3 decades, pediatric pain management has gained tremendous knowledge with respect to the understanding of developmental neurobiology, developmental pharmacology the use of analgesics in children, the use of regional techniques in children, and of the psychological needs of children in pain. A wide range of medications is available to treat a variety of pain types. This article provides an overview of the most common analgesic medications and techniques used to treat acute pain in children.

Robotic-Assisted Laparoscopic Surgery in Pediatric Urology: An Update

Laparoscopic procedures for urological diseases in children, such as nephrectomy, pyeloplasty and orchiopexy, have proven to be safe and effective with outcome comparable to the open procedure. However, main drawback has been the relatively steep learning curve for this procedure because of technical difficulties of suturing and anastomosis. More recently, robotic-assisted laparoscopic surgery (RAS) has gained enormous popularity in adult urology and is increasingly being adopted around the world; however, few pediatric urology series have been reported. RAS has several advantages over conventional laparoscopic surgery, with the main advantage being simplification and precision of exposure and suturing because of allowing movements of the robotic arm in real time with increased degree of freedom and magnified 3-dimentional view. These features render RAS ideal for complex reconstructive surgery in a pediatric urological population. This review discusses the role of RAS in pediatric urology, and provides some technical aspects of RAS and a critical summary of current knowledge on its indications and out-come. Almost all operations that are classically performed as open or conventional laparoscopic reconstructive surgery for children with urological anomalies could be replaced by RAS, which may be established as an alternative minimally invasive surgery in the future.

Robotic pediatric urology

The number of current advances in robotic surgery for the pediatric population is growing every day: the different procedures range from extirpative to reconstructive, including pyeloplasty, reimplantation, catheterizable channels and augmentation. Despite its early success, robotic surgery still poses many challenges in pediatric patients. Robotics also allows the seasoned laparoscopist to become more proficient and refined, providing a greater armamentarium to expand minimally invasive surgery to more complex reconstructive procedures. The procedure most performed with the da Vinci Surgical System in pediatric urology is pyeloplasty for ureteropelvic junction obstruction. There are many other procedures that can be performed with the robot, such as ureteral reimplantation, and nephrectomy, both total and partial. The reconstructive aspect has been taken to the next level where more difficult procedures, such as appendicovesicostomy and bladder augmentation, can be performed in children.

Endogenous opiates and behavior: 2007

This paper is the thirtieth consecutive installment of the annual review of research concerning the endogenous opioid system. It summarizes papers published during 2007 that studied the behavioral effects of molecular, pharmacological and genetic manipulation of opioid peptides, opioid receptors, opioid agonists and opioid antagonists. The particular topics that continue to be covered include the molecular-biochemical effects and neurochemical localization studies of endogenous opioids and their receptors related to behavior, and the roles of these opioid peptides and receptors in pain and analgesia; stress and social status; tolerance and dependence; learning and memory; eating and drinking; alcohol and drugs of abuse; sexual activity and hormones, pregnancy, development and endocrinology; mental illness and mood; seizures and neurologic disorders; electrical-related activity and neurophysiology; general activity and locomotion; gastrointestinal, renal and hepatic functions; cardiovascular responses; respiration and thermoregulation; and immunological responses.

Dose-response study of intrathecal fentanyl added to bupivacaine in infants undergoing lower abdominal and urologic surgery

BACKGROUND

Intrathecal (IT) adjuncts often are used to enhance the duration of spinal bupivacaine. Fentanyl is a spinal analgesic that could be a useful adjunct, and enhances the duration and quality of sensory block in adult surgical and obstetric population. However, no data exist to assess the dose-response characteristics of IT fentanyl when added to bupivacaine in infants.

METHODS

Fifty-eight infants undergoing lower abdominal and urologic procedures were randomized into four groups to receive plain 0.5% hyperbaric bupivacaine F0 (<5 kg = 0.5 mg.kg(-1); 5-10 kg = 0.4 mg.kg(-1)). Groups F0.25, F0.5, and F1 groups received bupivacaine added with 0.25, 0.5, and 1 mug.kg(-1) of fentanyl, respectively. Duration of spinal anesthesia (SA) as assessed by the recovery of hip flexion in the postoperative period was the primary variable analyzed. In addition, the duration of analgesia in the postoperative period, rescue postoperative analgesic requirements and hemodynamic changes were recorded.

RESULTS

Fifty-six infants were studied. The four groups were similar for age, weight, duration of surgery, onset of sensory, motor block, and the highest level of analgesia attained. The addition of 1 mug.kg(-1) fentanyl (F1) significantly increased the duration of SA (74.27 +/- 6.1 min) compared to the control group (51.21 +/- 5.2 min) (P = 0.001). Postoperative pain-free interval was prolonged (P = 0.004) and significantly less rescue analgesics were required after 1 mug.kg(-1) IT fentanyl (P = 0.032). These parameters did not show any significant difference among groups F0, F0.25, and F0.5.

CONCLUSIONS

The addition of 1 mug.kg(-1) IT fentanyl to spinal bupivacaine prolonged the duration of spinal block in infants undergoing lower abdominal and urologic procedures.