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Li Y, Ma Y, Guo W, Ge W, Cheng Y, Jin C, Guo H. Effect of transcutaneous electrical acupoint stimulation on postoperative pain in pediatric orthopedic surgery with the enhanced recovery after surgery protocol: a prospective, randomized controlled trial. Anaesth Crit Care Pain Med 2023; 42:101273. [PMID: 37419321 DOI: 10.1016/j.accpm.2023.101273] [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] [Received: 04/15/2023] [Revised: 06/21/2023] [Accepted: 06/24/2023] [Indexed: 07/09/2023]
Abstract
STUDY OBJECTIVE To evaluate the safety and effectiveness of transcutaneous electrical acupoint stimulation (TEAS) in postoperative analgesia following pediatric orthopedic surgery with the enhanced recovery after surgery (ERAS) protocol. DESIGN Prospective randomized controlled trial. SETTING The Seventh Medical Center of the Chinese People's Liberation Army General Hospital. PARTICIPANTS Eligible participants were children aged 3-15 years who were scheduled to undergo orthopedic surgery of the lower extremities under general anesthesia. INTERVENTIONS A total of 58 children were randomly allocated into two groups: TEAS (n = 29) and sham-TEAS (n = 29). The ERAS protocol was used in both groups. In the TEAS group, the bilateral Hegu (LI4) and Neiguan (PC6) acupoints were stimulated starting from 10 min before anesthetic induction until the completion of surgery. In the sham-TEAS group, the electric stimulator was also connected to the participants; however, electrical stimulation was not applied. MEASURES The primary outcome was the severity of pain before leaving the post-anesthesia care unit (PACU) and at postoperative 2 h, 24 h, and 48 h. Pain intensity was measured with the Faces Pain Scale-Revised (FPS-R). RESULTS None of the participants had any TEAS-related adverse reactions. In comparison with the sham-TEAS group, FPS-R scores in the TEAS group were significantly decreased before leaving the PACU and at postoperative 2 h and 24 h (p < 0.05). The incidence of emergence agitation, intraoperative consumption of remifentanil, and time to extubation were significantly reduced in the TEAS group. Furthermore, the time to first press of the patient-controlled intravenous analgesia (PCIA) pump was significantly longer, the pressing times of the PCIA pump in 48 h after surgery was significantly decreased, and parental satisfaction was significantly improved (all p < 0.05). CONCLUSION TEAS may safely and effectively relieve postoperative pain and reduce the consumption of perioperative analgesia in children following orthopedic surgery with the ERAS protocol. TRIAL REGISTRATION Chinese Clinical Trial Registry (ChiCTR2200059577), registered on May 4, 2022.
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Affiliation(s)
- Yajun Li
- Department of Anesthesiology, Shanxi Medical University, Taiyuan 030001, China; Department of Anesthesiology, The Seventh Medical Center to Chinese PLA General Hospital, Beijing 100700, China.
| | - Yaqun Ma
- Department of Anesthesiology, The Seventh Medical Center to Chinese PLA General Hospital, Beijing 100700, China
| | - Wenzhi Guo
- Department of Anesthesiology, The Seventh Medical Center to Chinese PLA General Hospital, Beijing 100700, China
| | - Wenchao Ge
- Department of Anesthesiology, The Seventh Medical Center to Chinese PLA General Hospital, Beijing 100700, China
| | - Yafei Cheng
- Department of Anesthesiology, Shanxi Medical University, Taiyuan 030001, China; Department of Anesthesiology, The Seventh Medical Center to Chinese PLA General Hospital, Beijing 100700, China
| | - Chenyan Jin
- Department of Anesthesiology, Shanxi Medical University, Taiyuan 030001, China; Department of Anesthesiology, The Seventh Medical Center to Chinese PLA General Hospital, Beijing 100700, China
| | - Hang Guo
- Department of Anesthesiology, The Seventh Medical Center to Chinese PLA General Hospital, Beijing 100700, China.
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Dai F, Zhang R, Deng R, Wang G, Guo H, Guo C. Regular use of low-dose of opioids after gastrointestinal surgery may lead to postoperative gastrointestinal tract dysfunction in children: a Chinese national regional health center experience sharing. BMC Gastroenterol 2023; 23:369. [PMID: 37907841 PMCID: PMC10617101 DOI: 10.1186/s12876-023-02999-7] [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: 01/23/2023] [Accepted: 10/14/2023] [Indexed: 11/02/2023] Open
Abstract
BACKGROUND The need for pain management is increasing in pediatrics, but the side effects of overuse or abuse of analgesics can be harmful to children's health and even life-threatening in severe cases. METHODS Patients who underwent resection of Meckel's diverticulum at the Children's Hospital of Chongqing Medical University from July 1, 2019, to July 1, 2022, were included in this study. Opioids were administered through patient-controlled analgesia (PCA). Based on the preoperative choices made by the legal guardians, patients were stratified into two groups: PCA Group (PCAG) and Non-PCA Group (NPCAG). Data pertaining to the clinical characteristics and prognoses of these patients were subsequently collected and analyzed to assess the impact of opioid administration. RESULTS In the study, a total of 126 patients were enrolled, with 72 allocated to the Patient-Controlled Analgesia Group (PCAG) and 54 to the Non-Patient-Controlled Analgesia Group (NPCAG). When compared to the NPCAG, the PCAG exhibited a longer duration of postoperative fasting (median 72 vs. 62 h, p = 0.044) and increased utilization of laxatives (12[16.7%] vs. 2[3.7%], p = 0.022). However, the PCAG also experienced higher incidences of intestinal stasis and abnormal intestinal dilation (13[18.1%] vs. 3[5.6%], p = 0.037). No statistically significant differences were observed in pain assessments at the conclusion of the surgical procedure (0 vs. 1[1.9%], p = 0.429) or within the first 24 h postoperatively (16[22.2%] vs. 18[33.3%], p = 0.164). Additionally, NPCAG patients did not necessitate increased administration of rescue analgesics (2[2.8%] vs. 4[7.4%], p = 0.432). CONCLUSIONS The administration of opioids did not demonstrably ameliorate postoperative pain but was associated with a heightened incidence of postoperative gastrointestinal tract dysfunction. The retrospective nature of the current research should be considered and should be clarified further.
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Affiliation(s)
- Fangyu Dai
- Department of Pediatrics, Chongqing health center for women and children, Chongqing, P.R. China
- Anesthesiology Class 1, Chongqing Medical University, 2020, Chongqing, P.R. China
- Department of Pediatric General Surgery, Children's Hospital, Chongqing Medical University, Chongqing, P.R. China
| | - Rensen Zhang
- Department of Pediatrics, Chongqing health center for women and children, Chongqing, P.R. China
- Department of Pediatric General Surgery, Children's Hospital, Chongqing Medical University, Chongqing, P.R. China
- Department of Anesthesiology, Children's Hospital of Chongqing Medical University, Chongqing, P.R. China
| | - Ruyu Deng
- Department of Respiratory Medicine, National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing Key Laboratory of Pediatrics, Children's Hospital of Chongqing Medical University, Chongqing, P.R. China
| | - Guoyong Wang
- Department of Pediatrics, Chongqing health center for women and children, Chongqing, P.R. China
- Department of Pediatric General Surgery, Children's Hospital, Chongqing Medical University, Chongqing, P.R. China
| | - Hongjie Guo
- Department of Anesthesiology, Children's Hospital of Chongqing Medical University, Chongqing, P.R. China
| | - Chunbao Guo
- Anesthesiology Class 1, Chongqing Medical University, 2020, Chongqing, P.R. China.
- Department of Pediatrics, Women and Children's Hospital of Chongqing Medical University, Chongqing, P.R. China.
- Department of Pediatric General Surgery, Women and Children's Hospital of Chongqing Medical University, 120 Longshan Road, Yubei District, 401147, Chongqing, Chongqing, P.R. China.
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Harris EM, Vilk E, Donado C, Williams A, Heeney MM, Solodiuk J, Greco C, Archer NM. Ketamine use for management of vaso-occlusive pain in pediatric sickle cell disease. Pediatr Blood Cancer 2023; 70:e30254. [PMID: 36861789 DOI: 10.1002/pbc.30254] [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: 11/23/2022] [Revised: 01/08/2023] [Accepted: 01/26/2023] [Indexed: 03/03/2023]
Abstract
BACKGROUND Typical sickle cell disease (SCD) vaso-occlusive pain episode (VOE) management includes opioids, which are often inadequate and can be associated with significant side effects. Ketamine, a dissociative anesthetic, is a potentially effective adjunct to VOE management. OBJECTIVES This study aimed to characterize ketamine use for VOE management in pediatric SCD. METHOD This retrospective case series summarizes a single-center experience regarding the use of ketamine for inpatient management of pediatric VOE in 156 admissions from 2014 to 2020. RESULTS Continuous low-dose ketamine infusion was most commonly prescribed to adolescents and young adults as an adjunct to opioids (median starting dose 2.0 μg/kg/min; median maximum dose 3.0 μg/kg/min). Ketamine was started a median of 13.7 hours after admission. Median ketamine infusion duration was 3 days. In most encounters, ketamine infusion was discontinued prior to opioid patient-controlled analgesia (PCA) discontinuation. The majority of encounters (79.3%) had a reduction in either PCA dose, continuous opioid infusion, or both while receiving ketamine. Low-dose ketamine infusion was associated with side effects noted in 21.8% (n = 34) of encounters. The most common side effects included dizziness (5.6%), hallucinations (5.1%), dissociation (2.6%), and sedation (1.9%). There were no reports of ketamine withdrawal. Most patients who received ketamine went on to receive it again during a subsequent admission. CONCLUSION Further study is needed to determine the optimal timing of ketamine initiation and dosing. The variability of ketamine administration highlights the need for standardized protocols for ketamine use in VOE management.
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Affiliation(s)
- Emily M Harris
- Dana-Farber/Boston Children's Cancer and Blood Disorders Center, Boston, Massachusetts, USA
- Division of Hematology, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Emily Vilk
- Division of Hematology, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Carolina Donado
- Department of Anesthesiology, Critical Care, and Pain Medicine, Boston Children's Hospital, Boston, Massachusetts, USA
- Department of Anaesthesia, Harvard Medical School, Boston, Massachusetts, USA
| | - Alexis Williams
- Department of Pediatrics, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Matthew M Heeney
- Dana-Farber/Boston Children's Cancer and Blood Disorders Center, Boston, Massachusetts, USA
- Division of Hematology, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Jean Solodiuk
- Department of Anesthesiology, Critical Care, and Pain Medicine, Boston Children's Hospital, Boston, Massachusetts, USA
- Department of Anaesthesia, Harvard Medical School, Boston, Massachusetts, USA
| | - Christine Greco
- Department of Anesthesiology, Critical Care, and Pain Medicine, Boston Children's Hospital, Boston, Massachusetts, USA
- Department of Anaesthesia, Harvard Medical School, Boston, Massachusetts, USA
| | - Natasha M Archer
- Dana-Farber/Boston Children's Cancer and Blood Disorders Center, Boston, Massachusetts, USA
- Division of Hematology, Boston Children's Hospital, Boston, Massachusetts, USA
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Santana L, Driggers J, Carvalho NF. Pain management for the Nuss procedure: comparison between erector spinae plane block, thoracic epidural, and control. WORLD JOURNAL OF PEDIATRIC SURGERY 2022; 5:e000418. [DOI: 10.1136/wjps-2022-000418] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Accepted: 07/19/2022] [Indexed: 11/04/2022] Open
Abstract
ObjectivePectus excavatum is a congenital deformity characterized by a caved-in chest wall. Repair requires surgery. The less invasive Nuss procedure is very successful, but postoperative pain management is challenging and evolving. New pain management techniques to reduce opioid reliance include the erector spinae plane (ESP) block. We retrospectively examined opioid consumption after Nuss procedure comparing three pain management techniques: ESP block, thoracic epidural (TE), and patient-controlled analgesia (PCA).MethodsThis retrospective cohort study compared pain management outcomes of three patient groups. Seventy-eight subjects aged 10–18 years underwent Nuss procedure at our institution between January 2014 and January 2020. The primary outcome measure was opioid consumption measured in morphine milligram equivalents. Secondary measures included pain ratings and length of stay (LOS). Pain was quantified using the Numeric Pain Rating Scale. Analysis of variance was performed on all outcome measures.ResultsAverage cumulative opioid use was significantly lower in the ESP block (67 mg) than the TE (117 mg) (p=0.0002) or the PCA group (172 mg) (p=0.0002). The ESP block and PCA groups both had a significantly shorter average LOS (3.3 and 3.7 days, respectively) than the TE group (4.7 days). ESP block performed best for reducing opioid consumption and LOS. Reduced opioid consumption is key for limiting side effects. This study supports use of ESP block as a superior choice when choosing among the three postoperative pain management options that were evaluated.ConclusionESP resulted in reduced opioid consumption postoperatively and shorter LOS than TE or PCA for patients undergoing the Nuss procedure for surgical repair of pectus excavatum.
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Rodieux F, Ivanyuk A, Besson M, Desmeules J, Samer CF. Hydromorphone Prescription for Pain in Children-What Place in Clinical Practice? Front Pediatr 2022; 10:842454. [PMID: 35547539 PMCID: PMC9083226 DOI: 10.3389/fped.2022.842454] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2021] [Accepted: 03/25/2022] [Indexed: 11/13/2022] Open
Abstract
While morphine is the gold standard treatment for severe nociceptive pain in children, hydromorphone is increasingly prescribed in this population. This review aims to assess available knowledge about hydromorphone and explore the evidence for its safe and effective prescription in children. Hydromorphone is an opioid analgesic similar to morphine structurally and in its pharmacokinetic and pharmacodynamic properties but 5-7 times more potent. Pediatric pharmacokinetic and pharmacodynamic data on hydromorphone are sorely lacking; they are non-existent in children younger than 6 months of age and for oral administration. The current data do not support any advantage of hydromorphone over morphine, both in terms of efficacy and safety in children. Morphine should remain the treatment of choice for moderate and severe nociceptive pain in children and hydromorphone should be reserved as alternative treatment. Because of the important difference in potency, all strategies should be taken to avoid inadvertent administration of hydromorphone when morphine is intended.
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Affiliation(s)
- Frédérique Rodieux
- Division of Clinical Pharmacology and Toxicology, Department of Anesthesiology, Pharmacology and Intensive Care, Geneva University Hospitals, Geneva, Switzerland
| | - Anton Ivanyuk
- Division of Clinical Pharmacology and Toxicology, Department of Anesthesiology, Pharmacology and Intensive Care, Geneva University Hospitals, Geneva, Switzerland
| | - Marie Besson
- Division of Clinical Pharmacology and Toxicology, Department of Anesthesiology, Pharmacology and Intensive Care, Geneva University Hospitals, Geneva, Switzerland.,Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Jules Desmeules
- Division of Clinical Pharmacology and Toxicology, Department of Anesthesiology, Pharmacology and Intensive Care, Geneva University Hospitals, Geneva, Switzerland.,Faculty of Medicine, University of Geneva, Geneva, Switzerland.,Institute of Pharmaceutical Sciences of Western Switzerland (ISPSO), School of Pharmaceutical Sciences, University of Geneva, Geneva, Switzerland
| | - Caroline F Samer
- Division of Clinical Pharmacology and Toxicology, Department of Anesthesiology, Pharmacology and Intensive Care, Geneva University Hospitals, Geneva, Switzerland.,Faculty of Medicine, University of Geneva, Geneva, Switzerland
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Mansfield SA, Woodroof J, Murphy AJ, Davidoff AM, Morgan KJ. Does epidural analgesia really enhance recovery in pediatric surgery patients? Pediatr Surg Int 2021; 37:1201-1206. [PMID: 33830298 DOI: 10.1007/s00383-021-04897-z] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/23/2021] [Indexed: 11/25/2022]
Abstract
PURPOSE We sought to determine the benefits of epidural anesthesia (EA) in pediatric surgical patients. METHODS This study is a single-institution retrospective review of EA for pediatric patients undergoing thoracotomy or laparotomy from 2015 to 2020. Patients with recent or chronic opioid use were excluded. Urgent or emergent cases, patients with hemodynamic instability, or those with surgical complications that significantly impacted their post-operative course were also excluded. The primary objectives were comparison of pain scores and systemic opioid use between those patients with EA and those without EA. RESULTS Epidural anesthesia was used in 151 (81.6%) laparotomies and 58 (77.3%) thoracotomies. EA use was associated with lower mean systemic opioid administration during the early post-operative period for laparotomy (POD#0-0.33 ± 0.3 oral morphine equivalents per kilogram (OME/Kg) with EA vs 0.93 ± 1.53, p < 0.001, POD#1-1.34 ± 1.79 OME/Kg with EA vs 2.61 ± 2.60, p < 0.001) and thoracotomy (POD#0-0.40 ± 0.37 OME/Kg with EA vs 0.68 ± 0.41, p = 0.008, POD#1-0.89 ± 0.86 OME/Kg with EA vs 2.02 ± 1.92, p < 0.001). There were no differences seen by POD#2. Average pain scores were significantly lower in patients with EA following laparotomy (POD#0-1.22 ± 0.99 with EA vs 1.75 ± 1.33, p = 0.008) and thoracotomy (POD#0-1.71 ± 1.13 with EA vs 2.40 ± 1.52, p = 0.04). CONCLUSIONS The use of EA in pediatric surgery patients was associated with lower pain scores despite lower systemic opioid requirements in the early post-operative period.
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Affiliation(s)
- Sara A Mansfield
- Department of Surgery, St. Jude Children's Research Hospital, 262 Danny Thomas Place, Memphis, TN, 38105, USA.
| | - Jacob Woodroof
- Department of Surgery, St. Jude Children's Research Hospital, 262 Danny Thomas Place, Memphis, TN, 38105, USA
| | - Andrew J Murphy
- Department of Surgery, St. Jude Children's Research Hospital, 262 Danny Thomas Place, Memphis, TN, 38105, USA
- Division of Pediatric Surgery, Department of Surgery, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Andrew M Davidoff
- Department of Surgery, St. Jude Children's Research Hospital, 262 Danny Thomas Place, Memphis, TN, 38105, USA
- Division of Pediatric Surgery, Department of Surgery, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Kyle J Morgan
- Division of Anesthesiology, Department of Pediatric Medicine, St. Jude Children's Research Hospital, Memphis, TN, USA
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Minimum effective volume of 0.2% ropivacaine for ultrasound-guided axillary brachial plexus block in preschool-age children. Sci Rep 2021; 11:17002. [PMID: 34417524 PMCID: PMC8379224 DOI: 10.1038/s41598-021-96582-3] [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] [Received: 05/23/2021] [Accepted: 08/12/2021] [Indexed: 11/09/2022] Open
Abstract
Ultrasound-guided axillary brachial plexus block is increasingly used in preschool-age patients. However, the minimum effective volume of local anaesthetics has not been determined. With ethical committee approval and written informed consent from the guardians of all paediatric patients, we studied 27 consecutive patients aged 3 to 6 years who were scheduled for hand surgery. After general anaesthesia, eligible patients received a set volume of ultrasound-guided axillary brachial plexus block. We determined the volume of 0.2% ropivacaine for consecutive patients from the preceding patient's outcome. The initial volume was 0.4 ml/kg. The testing interval was set at 0.05 ml/kg, and the lowest volume was 0.1 ml/kg. The following conditions were defined as a successful block: no heart rate changes, body movement, or ventilatory disorders during the operation; no use of fentanyl in the PACU; and a postoperative sensory block score < 3. The sequences of positive and negative blocks in consecutive patients were recorded. Using probit regression analysis, the 50% effective volume was 0.185 ml/kg (95% CI 0.123-0.234), and the 95% effective volume was 0.280 ml/kg (95% CI 0.232-0.593). EV50 and EV95 values of 0.2% ropivacaine for ultrasound-guided axillary brachial plexus block were 0.185 ml/kg and 0.280 ml/kg, respectively.
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Muirhead R, Kynoch K, Peacock A, Lewis PA. Safety and effectiveness of parent- or nurse-controlled analgesia in neonates: a systematic review. JBI Evid Synth 2021; 20:3-36. [PMID: 34387281 DOI: 10.11124/jbies-20-00385] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
Abstract
OBJECTIVE The aim of this systematic review was to determine the safety and effectiveness of parent- or nurse-controlled analgesia on neonatal patient outcomes. More specifically, the objective was to determine the effect of parent- or nurse-controlled analgesia on neonatal pain scores, analgesic use, and incidence of iatrogenic withdrawal syndrome, as well as any opioid-associated adverse events. INTRODUCTION Despite recent innovations in neonatology leading to significant improvements in short- and long-term outcomes for newborns requiring intensive care, optimal management of pain and distress remains a challenge for the treating multidisciplinary team. The inability of neonates to communicate pain easily, inconsistent practice among health professionals, insufficient analgesic prescriptions, and delays in medical reviews all impact effective pain management. Exploring the effect of parent- or nurse-controlled analgesia may identify a modality that negates these concerns and improves the pharmacological management of pain in newborns. INCLUSION CRITERIA This review considered experimental and observational studies evaluating the safety and effectiveness of parent- or nurse-controlled analgesia that included babies born at 23 weeks' gestation to four weeks post-term. The interventions considered for inclusion were any type of analgesia delivered by an infusion pump that allowed bolus dosing or a continuous analgesic infusion with bolus dosing as required. Studies using algorithms and protocols to guide timing and dosage were eligible for inclusion. Comparators included the standard management of pain for neonates in the newborn intensive care unit. A modification to the a priori protocol was made to include all neonates nursed outside of a neonatal intensive care unit to ensure all studies that examined the use of parent- or nurse-controlled analgesia in the neonatal population were included in the review. METHODS An extensive search of six major databases was conducted (CINAHL, Cochrane Library, Embase, PubMed, PsycINFO, and Web of Science). Studies published from 1997 to 2020 in English were considered for inclusion in this review. Databases searched for unpublished studies included MedNar and ProQuest Dissertations and Theses. RESULTS Fourteen studies were included in this review: two randomized controlled trials, six quasi-experimental studies, one case-control study, and five case series. There was considerable heterogeneity in the interventions and study outcome measures within the studies, resulting in an inability to statistically pool results. The small sample sizes and inability to distinguish data specific to neonates in six of the studies resulted in low quality of evidence for the safety and effectiveness of parent- or nurse-controlled analgesia in neonates. However, studies reporting neonatal data demonstrated low pain scores and a trend in reduced opioid consumption when parent- or nurse-controlled analgesia was used. CONCLUSIONS The use of parent- or nurse-controlled analgesia in the neonatal population has shown some effect in reducing the amount of opioid analgesia required without compromising pain relief or increasing the risk of adverse events. Due to the paucity of evidence available, certainty of the results is compromised; therefore, larger trials exploring the use of parent- or nurse-controlled analgesia in neonates and the development of nurse-led models for analgesia delivery are needed. SYSTEMATIC REVIEW REGISTRATION NUMBER PROSPERO CRD42018114382.
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Affiliation(s)
- Renee Muirhead
- Neonatal Critical Care Unit, Mater Misericordiae Limited, Brisbane, QLD, Australia School of Nursing, Midwifery and Social Work, University of Queensland, Brisbane, QLD, Australia The Queensland Centre for Evidence Based Nursing and Midwifery: A JBI Centre of Excellence, Mater Misercordiae Limited, South Brisbane, QLD, Australia
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Abstract
Nonsteroidal anti-inflammatory drugs (NSAIDs) are often used for pediatric pain management in the emergency setting and postoperatively. This narrative literature review evaluates pain relief, opioid requirements, and adverse effects associated with NSAID use. A PubMed search was conducted to identify randomized controlled trials evaluating the use of conventional systemic NSAIDs as pain management for children in the perioperative or emergency department (traumatic injury) setting. Trials of cyclooxygenase-2 inhibitors ("coxibs") were excluded. Search results included studies of ibuprofen (n = 12), ketoprofen (n = 5), ketorolac (n = 6), and diclofenac (n = 4). NSAIDs reduced the opioid requirement in 10 of 13 studies in which this outcome was measured. NSAID use did not compromise pain relief; NSAIDs provided improved or similar pain scores compared with opioids (or other control) in 24 of 27 studies. Adverse event frequencies were reported in 26 studies; adverse event frequencies with NSAIDs were lower than with opioids (or other control) in three of 26 studies, similar in 21 of 26 studies, and more frequent in two of 26 studies. Perioperative and emergency department use of NSAIDs may reduce opioid requirements while maintaining pain control, with similar or reduced frequencies of opioid-associated adverse events.
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Affiliation(s)
- Maureen F Cooney
- Pain Management, Westchester Medical Center, Valhalla, NY, 10595, USA.
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Egbuta C, Mason KP. Current State of Analgesia and Sedation in the Pediatric Intensive Care Unit. J Clin Med 2021; 10:1847. [PMID: 33922824 PMCID: PMC8122992 DOI: 10.3390/jcm10091847] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2021] [Revised: 04/16/2021] [Accepted: 04/20/2021] [Indexed: 12/15/2022] Open
Abstract
Critically ill pediatric patients often require complex medical procedures as well as invasive testing and monitoring which tend to be painful and anxiety-provoking, necessitating the provision of analgesia and sedation to reduce stress response. Achieving the optimal combination of adequate analgesia and appropriate sedation can be quite challenging in a patient population with a wide spectrum of ages, sizes, and developmental stages. The added complexities of critical illness in the pediatric population such as evolving pathophysiology, impaired organ function, as well as altered pharmacodynamics and pharmacokinetics must be considered. Undersedation leaves patients at risk of physical and psychological stress which may have significant long term consequences. Oversedation, on the other hand, leaves the patient at risk of needing prolonged respiratory, specifically mechanical ventilator, support, prolonged ICU stay and hospital admission, and higher risk of untoward effects of analgosedative agents. Both undersedation and oversedation put critically ill pediatric patients at high risk of developing PICU-acquired complications (PACs) like delirium, withdrawal syndrome, neuromuscular atrophy and weakness, post-traumatic stress disorder, and poor rehabilitation. Optimal analgesia and sedation is dependent on continuous patient assessment with appropriately validated tools that help guide the titration of analgosedative agents to effect. Bundled interventions that emphasize minimizing benzodiazepines, screening for delirium frequently, avoiding physical and chemical restraints thereby allowing for greater mobility, and promoting adequate and proper sleep will disrupt the PICU culture of immobility and reduce the incidence of PACs.
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Affiliation(s)
| | - Keira P. Mason
- Department of Anesthesiology, Critical Care and Pain Medicine, Harvard Medical School, Boston Children’s Hospital, 300 Longwood Ave., Boston, MA 02115, USA;
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Mauritz MD, Hasan C, Dreier LA, Schmidt P, Zernikow B. Opioid-Induced Respiratory Depression in Pediatric Palliative Care Patients with Severe Neurological Impairment-A Scoping Literature Review and Case Reports. CHILDREN-BASEL 2020; 7:children7120312. [PMID: 33371493 PMCID: PMC7767476 DOI: 10.3390/children7120312] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/06/2020] [Revised: 12/18/2020] [Accepted: 12/18/2020] [Indexed: 11/16/2022]
Abstract
Pediatric Palliative Care (PPC) addresses children, adolescents, and young adults with a broad spectrum of underlying diseases. A substantial proportion of these patients have irreversible conditions accompanied by Severe Neurological Impairment (SNI). For the treatment of pain and dyspnea, strong opioids are widely used in PPC. Nonetheless, there is considerable uncertainty regarding the opioid-related side effects in pediatric patients with SNI, particularly concerning Opioid-Induced Respiratory Depression (OIRD). Research on pain and OIRD in pediatric patients with SNI is limited. Using scoping review methodology, we performed a systematic literature search for OIRD in pediatric patients with SNI. Out of n = 521 identified articles, n = 6 studies were included in the review. Most studies examined the effects of short-term intravenous opioid therapy. The incidence of OIRD varied between 0.13% and 4.6%; besides SNI, comorbidities, and polypharmacy were the most relevant risk factors. Additionally, three clinical cases of OIRD in PPC patients receiving oral or transdermal opioids are presented and discussed. The case reports indicate that the risk factors identified in the scoping review also apply to adolescents and young adults with SNI receiving low-dose oral or transdermal opioid therapy. However, the risk of OIRD should never be a barrier to adequate symptom relief. We recommend careful consideration and systematic observation of opioid therapy in this population of patients.
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Affiliation(s)
- Maximilian David Mauritz
- Paediatric Palliative Care Centre, Children’s and Adolescents’ Hospital, 45711 Datteln, Germany; (C.H.); (P.S.); (B.Z.)
- Correspondence: ; Tel.: +49-2363-9750
| | - Carola Hasan
- Paediatric Palliative Care Centre, Children’s and Adolescents’ Hospital, 45711 Datteln, Germany; (C.H.); (P.S.); (B.Z.)
- Department of Children’s Pain Therapy and Paediatric Palliative Care, Faculty of Health, School of Medicine, Witten/Herdecke University, 58448 Witten, Germany
| | | | - Pia Schmidt
- Paediatric Palliative Care Centre, Children’s and Adolescents’ Hospital, 45711 Datteln, Germany; (C.H.); (P.S.); (B.Z.)
- Department of Children’s Pain Therapy and Paediatric Palliative Care, Faculty of Health, School of Medicine, Witten/Herdecke University, 58448 Witten, Germany
| | - Boris Zernikow
- Paediatric Palliative Care Centre, Children’s and Adolescents’ Hospital, 45711 Datteln, Germany; (C.H.); (P.S.); (B.Z.)
- Department of Children’s Pain Therapy and Paediatric Palliative Care, Faculty of Health, School of Medicine, Witten/Herdecke University, 58448 Witten, Germany
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12
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Abstract
Management of acute pain in children is fundamental to our practice. Its myriad benefits include reduced suffering, improved patient satisfaction, more rapid recovery, and a reduced risk of developing postsurgical chronic pain. Although a multimodal analgesic approach is now routinely used, informed and judicious use of opioid receptor agonists remains crucial in this treatment paradigm, as long as the benefits and risks are fully understood. Further, an ongoing public health response to the current opioid crisis is required to help prevent new cases of opioid addiction, identify opioid-addicted individuals, and ensure access to effective opioid addiction treatment, while at the same time continuing to safely meet the needs of patients experiencing pain.
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13
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Farid IS, Lewis JM, Kendrick EJ. The safety and efficacy of hydromorphone via patient controlled analgesia or patient controlled analgesia by proxy for pediatric postoperative pain control. J Clin Anesth 2020; 60:65-66. [PMID: 31466034 DOI: 10.1016/j.jclinane.2019.08.033] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2019] [Revised: 08/12/2019] [Accepted: 08/17/2019] [Indexed: 11/18/2022]
Affiliation(s)
- Ibrahim S Farid
- Akron Children's Hospital, 215 W Bowery St, Akron, OH 44308, United States.
| | - Judith M Lewis
- Akron Children's Hospital, 215 W Bowery St, Akron, OH 44308, United States.
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14
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Czarnecki ML, Hainsworth K, Simpson PM, Arca MJ, Uhing MR, Zhang L, Grippe A, Varadarajan J, Rusy LM, Firary M, Weisman SJ. A Pilot Randomized Controlled Trial of Outcomes Associated with Parent-Nurse Controlled Analgesia vs. Continuous Opioid Infusion in the Neonatal Intensive Care Unit. Pain Manag Nurs 2019; 21:72-80. [PMID: 31494028 DOI: 10.1016/j.pmn.2019.08.002] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2019] [Revised: 07/15/2019] [Accepted: 08/03/2019] [Indexed: 12/28/2022]
Abstract
PURPOSE Prospectively compare parent/nurse controlled analgesia (PNCA) to continuous opioid infusion (COI) in the post-operative neonatal intensive care unit (NICU) population. DESIGN/METHODS A randomized controlled trial compared neonates treated with morphine PNCA to those treated with morphine COI. The primary outcome was average opioid consumption up to 3 post-operative days. Secondary outcomes included 1) pain intensity, 2) adverse events that may be directly related to opioid consumption, and 3) parent and nurse satisfaction. RESULTS The sample consisted of 25 post-operative neonates and young infants randomized to either morphine PNCA (n = 16) or COI (n = 9). Groups differed significantly on daily opioid consumption, with the PNCA group receiving significantly less opioid (P = .02). Groups did not differ on average pain score or frequency of adverse events (P values > .05). Parents in both groups were satisfied with their infant's pain management and parents in the PNCA group were slightly more satisfied with their level of involvement (P = .03). Groups did not differ in nursing satisfaction. CONCLUSIONS PNCA may be an effective alternative to COI for pain management in the NICU population. This method may also substantially reduce opioid consumption, provide more individualized care, and improve parent satisfaction with their level of participation. CLINICAL IMPLICATIONS Patients in the NICU represent one of our most vulnerable patient populations. As nurses strive to provide safe and effective pain management, results of this study suggest PNCA may allow nurses to maintain their patients' comfort while providing less opioid and potentially improving parental perception of involvement. STUDY TYPE Treatment study. LEVEL OF EVIDENCE I.
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Affiliation(s)
- Michelle L Czarnecki
- Jane B. Pettit Pain and Headache Center, Children's Hospital of Wisconsin, Milwaukee, Wisconsin.
| | - Keri Hainsworth
- Jane B. Pettit Pain and Headache Center, Children's Hospital of Wisconsin, Milwaukee, Wisconsin; Department of Anesthesiology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Pippa M Simpson
- Division of Quantitative Health Sciences, Medical College of Wisconsin, Milwaukee, Wisconsin; Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin; Department of Surgery, Section of Pediatric Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Marjorie J Arca
- Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin; Department of Surgery, Section of Pediatric Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Michael R Uhing
- Department of Surgery, Section of Pediatric Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin; Department of Pediatrics, Section of Neonatology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Liyun Zhang
- Division of Quantitative Health Sciences, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Ann Grippe
- Neonatal Intensive Care Unit, Children's Hospital of Wisconsin, Milwaukee, Wisconsin
| | - Jaya Varadarajan
- Department of Anesthesiology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Lynn M Rusy
- Jane B. Pettit Pain and Headache Center, Children's Hospital of Wisconsin, Milwaukee, Wisconsin; Department of Anesthesiology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Mary Firary
- Department of Pharmacy, Children's Hospital of Wisconsin, Milwaukee, Wisconsin
| | - Steven J Weisman
- Jane B. Pettit Pain and Headache Center, Children's Hospital of Wisconsin, Milwaukee, Wisconsin; Department of Anesthesiology, Medical College of Wisconsin, Milwaukee, Wisconsin; Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin
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15
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Cravero JP, Agarwal R, Berde C, Birmingham P, Coté CJ, Galinkin J, Isaac L, Kost‐Byerly S, Krodel D, Maxwell L, Voepel‐Lewis T, Sethna N, Wilder R. The Society for Pediatric Anesthesia recommendations for the use of opioids in children during the perioperative period. Paediatr Anaesth 2019; 29:547-571. [PMID: 30929307 PMCID: PMC6851566 DOI: 10.1111/pan.13639] [Citation(s) in RCA: 89] [Impact Index Per Article: 17.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2019] [Revised: 03/25/2019] [Accepted: 03/27/2019] [Indexed: 12/13/2022]
Abstract
Opioids have long held a prominent role in the management of perioperative pain in adults and children. Published reports concerning the appropriate, and inappropriate, use of these medications in pediatric patients have appeared in various publications over the last 50 years. For this document, the Society for Pediatric Anesthesia appointed a taskforce to evaluate the available literature and formulate recommendations with respect to the most salient aspects of perioperative opioid administration in children. The recommendations are graded based on the strength of the available evidence, with consensus of the experts applied for those issues where evidence is not available. The goal of the recommendations was to address the most important issues concerning opioid administration to children after surgery, including appropriate assessment of pain, monitoring of patients on opioid therapy, opioid dosing considerations, side effects of opioid treatment, strategies for opioid delivery, and assessment of analgesic efficacy. Regular updates are planned with a re-release of guidelines every 2 years.
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Affiliation(s)
- Joseph P. Cravero
- Department of Anesthesiology, Critical Care, and Pain MedicineBoston Children's Hospital, Harvard Medical SchoolBostonMassachusetts
| | - Rita Agarwal
- Pediatric Anesthesiology DepartmentLucille Packard Children's Hospital, Stanford University Medical SchoolStanfordCalifornia
| | - Charles Berde
- Department of Anesthesiology, Critical Care, and Pain MedicineBoston Children's Hospital, Harvard Medical SchoolBostonMassachusetts
| | - Patrick Birmingham
- Department of AnesthesiologyAnn and Robert H. Lurie Children's Hospital Northwestern University Feinberg School of MedicineEvanstonIllinois
| | - Charles J. Coté
- Department of AnesthesiologyMass General Hospital for Children, Harvard UniversityBostonMassachusetts
| | - Jeffrey Galinkin
- Anesthesiology DepartmentChildren's Hospital of Colorado, University of ColoradoAuroraColorado
| | - Lisa Isaac
- Department of Anesthesia and Pain MedicineHospital for Sick Children, University of TorontoTorontoOntarioCanada
| | - Sabine Kost‐Byerly
- Pediatric Anesthesiology and Critical Care MedicineJohns Hopkins University HospitalBaltimoreMaryland
| | - David Krodel
- Department of AnesthesiologyAnn and Robert H. Lurie Children's Hospital Northwestern University Feinberg School of MedicineEvanstonIllinois
| | - Lynne Maxwell
- Department of Aneshtesiology and Critical Care MedicineChildren's Hospital of Philadelphia, Perelman School of Medicine at the University of PennsylvaniaPhiladelphia
| | - Terri Voepel‐Lewis
- Department of AneshteiologyC. S. Mott Children's Hospital, University of Michigan Medical SchoolAnn ArborMichigan
| | - Navil Sethna
- Department of Anesthesiology, Critical Care, and Pain MedicineBoston Children's Hospital, Harvard Medical SchoolBostonMassachusetts
| | - Robert Wilder
- Department of Anesthesiology and Perioperative MedicineMayo ClinicRochesterMinnesota
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16
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Czarnecki ML, Hainsworth KR, Simpson PM, Weisman SJ. Parent/Nurse-Controlled Analgesia Compared with Intravenous PRN Opioids for Postsurgical Pain Management in Children with Developmental Delay: A Randomized Controlled Trial. PAIN MEDICINE 2019; 19:742-752. [PMID: 29099960 DOI: 10.1093/pm/pnx257] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Objectives The aim of this study was to conduct a randomized, controlled comparison of outcomes associated with parent/nurse-controlled analgesia (PNCA), with and without a basal (background) opioid infusion, with intravenous (IV) opioids intermittently administered by a nurse on an "as needed" basis (IV PRN) for postoperative pain management in children with developmental delay (DD). Methods Participants included children with DD expected to require IV opioids for at least 24 postoperative hours. Patients were randomized to one of three groups: PNCA with a basal infusion, PNCA without a basal infusion, or IV PRN opioids. Demographics, pain scores, opioid consumption, and frequency of side effects were collected beginning 12 hours after emerging from anesthesia to decrease the impact of anesthetic agents on outcomes. Results The 81 participants (median = 12.0, 9.0-15.0 years) were primarily Caucasian (74%) males (58%), with severe DD (69%) having spinal surgery (41%). The proportion of patients in each group with pain scores ≤3 vs ≥ 4 revealed no between-group differences in any epoch (P = 0.09-0.27). Patients in the PNCA with a basal group consumed significantly more opioid (median = 0.03 mg/kg/h morphine equivalents, 0.02-0.03 mg/kg/h) than the PNCA without a basal infusion. No difference was found between the PNCA without a basal (median = 0.01 mg/kg/h morphine equivalents, 0.00-0.02 mg/kg/h) and the PRN groups (median = 0.01 mg/kg/h morphine equivalents, 0.01-0.02 mg/kg/h). There were no statistically significant differences in side effects, with the exception that more children in the PNCA group required supplemental oxygen (P = 0.05). Conclusions Results suggest there may be no advantage to PNCA over PRN opioids in this patient population after the first 12 postoperative hours with regard to pain scores, opioid consumption, or side effects.
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Affiliation(s)
- Michelle L Czarnecki
- Jane B. Pettit Pain and Headache Center, Children's Hospital of Wisconsin, Milwaukee, Wisconsin
| | - Keri R Hainsworth
- Jane B. Pettit Pain and Headache Center, Children's Hospital of Wisconsin, Milwaukee, Wisconsin.,Department of Anesthesiology
| | - Pippa M Simpson
- Division of Quantitative Health Sciences.,Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Steven J Weisman
- Jane B. Pettit Pain and Headache Center, Children's Hospital of Wisconsin, Milwaukee, Wisconsin.,Department of Anesthesiology.,Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
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17
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Guay J, Suresh S, Kopp S. The use of ultrasound guidance for perioperative neuraxial and peripheral nerve blocks in children. Cochrane Database Syst Rev 2019; 2:CD011436. [PMID: 30820938 PMCID: PMC6395955 DOI: 10.1002/14651858.cd011436.pub3] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND The use of ultrasound guidance for regional anaesthesia has become popular over the past two decades. However, it is not recognized by all experts as an essential tool, perhaps because it is unclear whether ultrasound reduces the risk of severe neurological complications, and the cost of an ultrasound machine (USD 22,000) is substantially higher than the cost of other tools. This review was published in 2016 and updated in 2019. OBJECTIVES To determine whether ultrasound guidance offers any clinical advantage when neuraxial and peripheral nerve blocks are performed in children in terms of decreasing failure rate or the rate of complications. SEARCH METHODS We searched CENTRAL, MEDLINE, Embase, and two trial registers up to March 2018 together with reference checking to identify additional studies and contacted study authors to obtain additional trial information. SELECTION CRITERIA We included all parallel randomized controlled trials that evaluated the effects of ultrasound guidance used when a regional blockade technique was performed in children. We included studies performed in children (≤ 18 years of age) undergoing any type of surgical procedure (open or laparoscopic), for which a neuraxial (spinal, epidural, caudal, or combined spinal and epidural) or peripheral nerve block (any peripheral nerve block including fascial (fascia iliaca, transversus abdominis plane, rectus sheath blocks) or perivascular blocks), for surgical anaesthesia (alone or in combination with general anaesthesia) or for postoperative analgesia, was performed with ultrasound guidance. We excluded studies in which regional blockade was used to treat chronic pain.We included studies in which ultrasound guidance was used to perform the technique in real time (in-plane or out-of-plane), as pre-scanning before the procedure or to evaluate the spread of the local anaesthetic so the position of the needle could be adjusted or the block complemented. For control groups, any other technique used to perform the block including landmarks, loss of resistance (air or fluid), click, paraesthesia, nerve stimulator, transarterial, or infiltration was accepted. DATA COLLECTION AND ANALYSIS We used the standard methodological procedures expected by Cochrane. Our primary outcomes were failed blocks, pain scores at one hour after surgery, and block duration. Secondary outcomes included time to perform the block, number of needle passes, and minor and major complications. We used GRADE to assess the quality of evidence for each outcome. MAIN RESULTS We included 33 trials with a total of 2293 participants from 0.9 to 12 (mean or median) years of age. Most trials were at low risk of selection, detection, attrition, and reporting bias, however the lack of blinding of participants and personnel caring for participants resulted in 25 trials being judged as at high or unclear risk of bias. We identified five ongoing trials.Ultrasound guidance probably reduces the risk of failed block (risk difference (RD) -0.16, 95% confidence interval (CI) -0.25 to -0.07; 22 trials; 1789 participants; moderate-quality evidence). When ultrasound guidance was used, there was a small to moderate reduction in pain one hour after surgery, equivalent to a reduction of 1.3 points on the revised Bieri FACES pain scale (scale; 0 = no pain, 10 = maximal pain) (standardized mean difference (SMD) -0.41, 95% CI -0.74 to -0.07 (medium effect size); 15 trials; 982 participants; moderate-quality evidence). Ultrasound guidance increases block duration by the equivalent of 42 minutes (SMD 1.24, 95% CI 0.72 to 1.75; 10 trials; 460 participants; high-quality evidence).There is probably little or no difference in the time taken to perform the block (SMD -0.46, 95% CI -1.06 to 0.13; 9 trials; 680 participants; moderate-quality evidence). It is uncertain whether the number of needle passes required is reduced with the use of ultrasound guidance (SMD -0.63, 95% CI -1.08 to -0.18; 3 trials; 256 participants; very low-quality evidence).There were no occurrences of major complications in either the intervention or control arms of the trials (cardiac arrest from local anaesthetic toxicity (22 trials; 1576 participants; moderate-quality evidence); lasting neurological injury (19 trials; 1250 participants; low-quality evidence)).There may be little of no difference in the risk of bloody puncture (RD -0.02, 95% CI -0.05 to 0.00; 13 trials; 896 participants; low-quality evidence) or transient neurological injury (RD -0.00, 95% CI -0.01 to 0.01; 18 trials; 1230 participants; low-quality evidence). There were no occurrences of seizure from local anaesthetic toxicity (22 trials; 1576 participants; moderate-quality evidence) or block infections without neurological injury (18 trials; 1238 participants; low-quality evidence). AUTHORS' CONCLUSIONS Ultrasound guidance for regional blockade in children probably decreases the risk of failed block. It increases the duration of the block and probably decreases pain scores at one hour after surgery. There may be little or no difference in the risks of some minor complications. The five ongoing studies may alter the conclusions of the review once published and assessed.
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Affiliation(s)
- Joanne Guay
- University of SherbrookeDepartment of Anesthesiology, Faculty of MedicineSherbrookeQuebecCanada
- University of Quebec in Abitibi‐TemiscamingueTeaching and Research Unit, Health SciencesRouyn‐NorandaQCCanada
- Faculty of Medicine, Laval UniversityDepartment of Anesthesiology and Critical CareQuebec CityQCCanada
| | - Santhanam Suresh
- Ann & Robert H. Lurie Children's Hospital of Chicago Research CenterDepartment of Pediatric Anesthesiology225 E. Chicago AveChicagoILUSA60611
| | - Sandra Kopp
- Mayo Clinic College of MedicineDepartment of Anesthesiology and Perioperative Medicine200 1st St SWRochesterMNUSA55901
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18
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Donado C, Solodiuk J, Rangel SJ, Nelson CP, Heeney MM, Mahan ST, Ullrich C, Tsegaye B, Berde CB. Patient- and Nurse-Controlled Analgesia: 22-Year Experience in a Pediatric Hospital. Hosp Pediatr 2019; 9:129-133. [PMID: 30655310 DOI: 10.1542/hpeds.2018-0179] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
OBJECTIVES Pediatric pain management has rapidly changed over the last 2 decades. In this study, we describe the changing practices and adverse events (AEs) related to patient-controlled analgesia (PCA) and/or nurse-controlled analgesia (NCA) over a 22-year period. METHODS After institutional review board approval, retrospective data from a single tertiary-care pediatric hospital were collected between 1994 and 2016. Subgroup analyses were done for surgical and medical case patients. We reported the number of times that PCA and/or NCA was ordered annually, the median and interquartile ranges for age, PCA and/or NCA duration and length of stay, and AE frequencies. RESULTS Over 22 years, 32 338 PCAs and/or NCAs were ordered in this institution. Morphine and hydromorphone were used most commonly. Between 1994 and 2006, initial orders for PCA and/or NCA increased 2.5-fold. After 2007, initial orders for PCA and/or NCA rapidly decreased; after 2013, the decrease continued at a slower rate, with a total of 1007 orders in 2016. This decrease occurred despite increased hospital admissions and surgeries. Between 2007 and 2012, peripheral nerve blocks rapidly increased (10-fold). After 2002, 146 AEs were reported (1.0%). Of those, 50.5% were nonintercepted, and 20.6% were intercepted AEs; 5.5% and 6.2% were preventable and nonpreventable AEs, respectively. CONCLUSIONS PCA and/or NCA usage continues to be common in pediatric patients, although usage has declined and stabilized in the setting of other emerging methods of analgesia and increases in the number of minimally invasive surgical procedures. The overall rate of AEs was extremely low. However, improvements to eliminate all errors are needed, especially with medications with a great risk of harm (such as opioids).
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Affiliation(s)
- Carolina Donado
- Departments of Anesthesiology, Critical Care, Pain Medicine.,Departments of Anesthesia and
| | - Jean Solodiuk
- Departments of Anesthesiology, Critical Care, Pain Medicine.,Departments of Anesthesia and
| | | | | | - Matthew M Heeney
- Cancer and Blood Disorders Center and.,Cancer and Blood Disorders Center, and.,Department of Cancer and Blood Disorders Center, and
| | - Susan T Mahan
- Orthopedic Surgery.,Orthopedic Surgery, Harvard Medical School, Boston, Massachusetts; and
| | - Christina Ullrich
- Department of Cancer and Blood Disorders Center, and.,Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Binyam Tsegaye
- Anesthesiology Information Technology, Boston Children's Hospital, Boston, Massachusetts
| | - Charles B Berde
- Departments of Anesthesiology, Critical Care, Pain Medicine, .,Departments of Anesthesia and
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19
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Jay MA, Thomas BM, Nandi R, Howard RF. Higher risk of opioid-induced respiratory depression in children with neurodevelopmental disability: a retrospective cohort study of 12 904 patients. Br J Anaesth 2018; 118:239-246. [PMID: 28100528 DOI: 10.1093/bja/aew403] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/11/2016] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Children with neurodevelopmental disabilities may be at risk of opioid-induced respiratory depression. We aimed to quantify the risks and effectiveness of morphine nurse-controlled analgesia (morphine-NCA) for postoperative pain in children with neurodevelopmental disabilities. METHODS We carried out a retrospective cohort study of 12 904 children who received postoperative i.v. morphine-NCA. Subjects were divided into a neurodevelopmental disability group and a control group. Rates of clinical satisfaction, respiratory depression, and serious adverse events were obtained, and statistical analysis, including multilevel logistic regression using Bayesian inference, was performed. RESULTS Of 12 904 patients, 2390 (19%) had neurodevelopmental disabilities. There were 88 instances of respiratory depression and 52 serious adverse events; there were no opioid-related deaths. The cumulative incidence of respiratory depression in the neurodevelopmental disability group was 1.09% vs 0.59% in the control group [odds ratio 1.8 (98% chance that the true odds ratio was >1)]. A significant interaction between postoperative morphine dose and neurodevelopmental disabilities was observed, with higher risk of respiratory depression with increasing dose. Satisfaction with morphine-NCA was very high overall, although children with neurodevelopmental disabilities were 1% more likely to have infusions rated as fair or poor (3.3 vs 2.1%, χ2P<0.001). CONCLUSIONS Children with neurodevelopmental disabilities were 1.8 times more likely to suffer respiratory depression, absolute risk difference 0.5%; opioid-induced respiratory depression in this group may relate to increased sensitivity to dose-relate respiratory effects of morphine. Morphine-NCA as described was an acceptable technique for children with and without neurodevelopmental disabilities.
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Affiliation(s)
- M A Jay
- Department of Anaesthesia and Pain Medicine, Great Ormond Street Hospital for Children NHS Foundation Trust, Level 4, Old Building, Great Ormond Street, London WC1N 3JH, UK
| | - B M Thomas
- Magill Department of Anaesthesia, Critical Care and Pain Medicine, Chelsea and Westminster Hospital NHS Foundation Trust, 369 Fulham Road, London SW10 9NH, UK
| | - R Nandi
- Department of Anaesthesia and Pain Medicine, Great Ormond Street Hospital for Children NHS Foundation Trust, Level 4, Old Building, Great Ormond Street, London WC1N 3JH, UK
| | - R F Howard
- Department of Anaesthesia and Pain Medicine, Great Ormond Street Hospital for Children NHS Foundation Trust, Level 4, Old Building, Great Ormond Street, London WC1N 3JH, UK
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20
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Abstract
BACKGROUND Children who undergo surgical procedures in ambulatory and inpatient settings are at risk of experiencing acute pain. Nonsteroidal anti-inflammatory drugs (NSAIDs) can reduce moderate to severe pain without many of the side effects associated with opioids. However, NSAIDs may cause bleeding, renal and gastrointestinal toxicity, and potentially delay wound and bone healing. Intravenous administration of ketorolac for postoperative pain in children has not been approved in many countries, but is routinely administered in clinical practise. OBJECTIVES To assess the efficacy and safety of ketorolac for postoperative pain in children. SEARCH METHODS We searched the following databases, without language restrictions, to November 2017: CENTRAL (The Cochrane Library 2017, Issue 10); MEDLINE, Embase, and LILACS. We also checked clinical trials registers and reference lists of reviews, and retrieved articles for additional studies. SELECTION CRITERIA We included randomised controlled trials that compared the analgesic efficacy of ketorolac (in any dose, administered via any route) with placebo or another active treatment, in treating postoperative pain in participants zero to 18 years of age following any type of surgery. DATA COLLECTION AND ANALYSIS We used standard methodological procedures expected by Cochrane. Two review authors independently considered trials for inclusion in the review, assessed risk of bias, and extracted data. We analyzed trials in two groups; ketorolac versus placebo, and ketorolac versus opioid. However, we performed limited pooled analyses. We assessed the overall quality of the evidence for each outcome using GRADE, and created a 'Summary of findings' table. MAIN RESULTS We included 13 studies, involving 920 randomised participants. There was considerable heterogeneity among study designs, including the comparator arms (placebo, opioid, another NSAID, or a different regimen of ketorolac), dosing regimens (routes and timing of administration, single versus multiple dose), outcome assessment methods, and types of surgery. Mean study population ages ranged from 356 days to 13.9 years. The majority of studies chose a dose of either 0.5 mg/kg (as a single or multiple dose regimen) or 1 mg/kg (single dose with 0.5 mg/kg for any subsequent doses). One study administered interventions intraoperatively; the remainder administered interventions postoperatively, often after the participant reported moderate to severe pain.There were insufficient data to perform meta-analysis for either of our primary outcomes: participants with at least 50% pain relief; or mean postoperative pain intensity. Four studies individually reported statistically significant reductions in pain intensity when comparing ketorolac with placebo, but the studies were small and had various risks of bias, primarily due to incomplete outcome data and small sample sizes.We found limited data available for the secondary outcomes of participants requiring rescue medication and opioid consumption. For the former, we saw no clear difference between ketorolac and placebo; 74 of 135 (55%) participants receiving ketorolac required rescue analgesia in the post-anaesthesia care unit (PACU) versus 81 of 127 (64%) receiving placebo (relative risk (RR) 0.85, 95% confidence interval (CI) 0.71 to 1.00, P = 0.05; 4 studies, 262 participants). For opioid consumption in the PACU, we saw no clear difference between ketorolac and placebo (P = 0.61). For the time period zero to four hours after administration of the interventions, participants receiving ketorolac received 1.58 mg less intravenous morphine equivalents than those receiving placebo (95% CI -2.58 mg to -0.57 mg, P = 0.002; 2 studies, 129 participants). However, we are uncertain whether ketorolac has an important effect on opioid consumption, as the data were sparse and the results were inconsistent. Only one study reported data for opioid consumption when comparing ketorolac with an opioid. There were no clear differences between the ketorolac and opioid group at any time point. There were no data assessing this outcome for the comparison of ketorolac with another NSAID.There were insufficient data to allow us to analyze overall adverse event or serious adverse event rates. Although the majority of serious adverse events reported in those receiving ketorolac involved bleeding, the number of events was too low to conclude that bleeding risk was increased in those receiving ketorolac perioperatively. There was not a statistically significant increase in event rates for any specific adverse event, either in pooled analysis or in single studies, when comparing ketorolac and placebo. When comparing ketorolac with opioids or other NSAIDs, there were too few data to make any conclusions regarding event rates. Lastly, withdrawals due to adverse events were vary rare in all groups, reflecting the acute nature of such studies.We assessed the quality of evidence for all outcomes for each comparison (placebo or active) as very low, due to issues with risk of bias in individual studies, imprecision, heterogeneity between studies, and low overall numbers of participants and events. AUTHORS' CONCLUSIONS Due to the lack of data for our primary outcomes, and the very low-quality evidence for secondary outcomes, the efficacy and safety of ketorolac in treating postoperative pain in children were both uncertain. The evidence was insufficient to support or reject its use.
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Affiliation(s)
- Ewan D McNicol
- Department of Anesthesiology and Perioperative Medicine, Tufts Medical Center, Boston, Massachusetts, USA
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21
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22
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Vittinghoff M, Lönnqvist PA, Mossetti V, Heschl S, Simic D, Colovic V, Dmytriiev D, Hölzle M, Zielinska M, Kubica-Cielinska A, Lorraine-Lichtenstein E, Budić I, Karisik M, Maria BDJ, Smedile F, Morton NS. Postoperative pain management in children: Guidance from the pain committee of the European Society for Paediatric Anaesthesiology (ESPA Pain Management Ladder Initiative). Paediatr Anaesth 2018; 28:493-506. [PMID: 29635764 DOI: 10.1111/pan.13373] [Citation(s) in RCA: 67] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/14/2018] [Indexed: 12/21/2022]
Abstract
The main remit of the European Society for Paediatric Anaesthesiology (ESPA) Pain Committee is to improve the quality of pain management in children. The ESPA Pain Management Ladder is a clinical practice advisory based upon expert consensus to help to ensure a basic standard of perioperative pain management for all children. Further steps are suggested to improve pain management once a basic standard has been achieved. The guidance is grouped by the type of surgical procedure and layered to suggest basic, intermediate, and advanced pain management methods. The committee members are aware that there are marked differences in financial and personal resources in different institutions and countries and also considerable variations in the availability of analgesic drugs across Europe. We recommend that the guidance should be used as a framework to guide best practice.
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Affiliation(s)
- Maria Vittinghoff
- Department of Anesthesiology and Intensive Care Medicine, Medical University of Graz, Graz, Austria
| | - Per-Arne Lönnqvist
- Paediatric Anaesthesia & Intensive Care, Section of Anaesthesiology & Intensive Care, Department of Physiology & Pharmacology, Karolinska Institutet, Stockholm, Sweden
| | - Valeria Mossetti
- Department of Anesthesia and Intensive Care, Regina Margherita Children's Hospital, Torino, Italy
| | - Stefan Heschl
- Department of Anesthesiology and Intensive Care Medicine, Medical University of Graz, Graz, Austria
| | - Dusica Simic
- University Children's Hospital, Medical Faculty University of Belgrade, Serbia
| | - Vesna Colovic
- Royal Manchester Children's Hospital, Central Manchester University Hospitals, Manchester, UK
| | - Dmytro Dmytriiev
- Department of Anesthesiology and Intensive Care, Vinnitsa National Medical University, Vinnitsa, Ukraine
| | - Martin Hölzle
- Section of Paediatric Anaesthesia, Department of Anaesthesia, Luzerner Kantonsspital, Luzern, Switzerland
| | - Marzena Zielinska
- Department of Paediatric Anaesthesiology and Intensive Care, Wroclaw Medical University, Wroclaw, Poland
| | - Anna Kubica-Cielinska
- Department of Paediatric Anaesthesiology and Intensive Care, Wroclaw Medical University, Wroclaw, Poland
| | | | - Ivana Budić
- Centre for Anesthesiology and Resuscitation, Clinical Centre Nis Department of Anesthesiology, Medical Faculty, University of Nis, Nis, Serbia
| | - Marijana Karisik
- Institute for Children Diseases, Department of Anaesthesiology, Clinical Centre of Montenegro, Podgorica, Montenegro
| | - Belen De Josè Maria
- Department of Pediatric Anesthesia, Hospital Sant Joan de Deu, University of Barcelona, Barcelona, Spain
| | - Francesco Smedile
- Department of Pediatric Anesthesiology, Bambino Gesù Children's Hospital, Rome, Italy
| | - Neil S Morton
- Paediatric Anaesthesia and Pain Management, University of Glasgow, Glasgow, UK
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Codeine and opioid metabolism: implications and alternatives for pediatric pain management. Curr Opin Anaesthesiol 2018; 30:349-356. [PMID: 28323671 DOI: 10.1097/aco.0000000000000455] [Citation(s) in RCA: 44] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
PURPOSE OF REVIEW Use of perioperative opioids for surgical pain management of children presents clinical challenges because of concerns of serious adverse effects including life-threatening respiratory depression. This is especially true for children with history of obstructive sleep apnea. This review will explore current knowledge of clinically relevant factors and genetic polymorphisms that affect opioid metabolism and postoperative outcomes in children. RECENT FINDINGS Within the past several years, an increasing number of case reports have illustrated clinically important respiratory depression, anoxic brain injuries and even death among children receiving appropriate weight-based dosages of codeine and other opioids for analgesia at home setting particularly following tonsillectomy. Several national and international organizations have issued advisories on use of codeine in pediatrics, based on cytochrome P450 family 2 subfamily D type 6 (CYP2D6) pharmacogenetics. We have discussed the pros and cons of alternatives to codeine for pain management. SUMMARY Although routine preoperative genotyping to identify children at risk and personalized opioid use for pediatric perioperative pain management is still a distant reality, current known implications of CYP2D6 pharmacogenetics on codeine use shows that pharmacogenetics has the potential to guide anesthesia providers on perioperative opioid selection and dosing to maximize efficacy and safety.
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Faerber J, Zhong W, Dai D, Baehr A, Maxwell LG, Kraemer FW, Feudtner C. Comparative Safety of Morphine Delivered via Intravenous Route vs. Patient-Controlled Analgesia Device for Pediatric Inpatients. J Pain Symptom Manage 2017; 53:842-850. [PMID: 28062336 DOI: 10.1016/j.jpainsymman.2016.12.328] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2015] [Revised: 11/18/2016] [Accepted: 12/23/2016] [Indexed: 11/18/2022]
Abstract
CONTEXT Although patient-controlled analgesia (PCA) is an effective pain control modality, there is a lack of large studies on PCA safety in pediatric patients. OBJECTIVES This study compared the delivery of morphine either via intravenous route (morphine IV) or via PCA device (morphine PCA) on risk of cardiopulmonary resuscitation (CPR) and mechanical ventilation (MV) using a large administrative database. METHODS We assembled a retrospective cohort of pediatric inpatients between five and 21 years old in 42 children's hospitals between 2007 and 2011 from the Pediatric Health Information System database. After propensity score matching, we created matched cohorts of morphine PCA and morphine IV patients, in both surgical and nonsurgical samples, who were similar on demographic, clinical, and hospital-level factors. We examined if PCA administration was associated with greater likelihood of CPR or MV up to two days after drug administration. RESULTS Surgical and nonsurgical patients administered morphine PCA generally had lower odds of having MV on the baseline day and up to two days after PCA exposure, although these estimates were not statistically significant. Similarly, PCA exposure was associated with about 20%-44% lower odds of same day CPR in both surgical and nonsurgical patients, with a slightly greater reduction in the odds of CPR in the surgical patients. CONCLUSION In this large pediatric inpatient population, morphine administered via PCA device for surgical and nonsurgical pain was not associated with an increased risk of receiving CPR or MV, and was associated with slightly better safety outcomes than intravenous morphine.
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Affiliation(s)
- Jennifer Faerber
- Pediatric Advanced Care Team, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Wenjun Zhong
- Pediatric Advanced Care Team, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Dingwei Dai
- Pediatric Advanced Care Team, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Avi Baehr
- The Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Lynne G Maxwell
- Department of Anesthesiology and Critical Care, The Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Francis Wickham Kraemer
- Department of Anesthesiology and Critical Care, The Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Chris Feudtner
- Pediatric Advanced Care Team, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA; Department of Pediatrics, The Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA.
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Guay J, Suresh S, Kopp S. The Use of Ultrasound Guidance for Perioperative Neuraxial and Peripheral Nerve Blocks in Children. Anesth Analg 2017; 124:948-958. [DOI: 10.1213/ane.0000000000001363] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Chidambaran V, Pilipenko V, Spruance K, Venkatasubramanian R, Niu J, Fukuda T, Mizuno T, Zhang K, Kaufman K, Vinks AA, Martin LJ, Sadhasivam S. Fatty acid amide hydrolase-morphine interaction influences ventilatory response to hypercapnia and postoperative opioid outcomes in children. Pharmacogenomics 2016; 18:143-156. [PMID: 27977335 DOI: 10.2217/pgs-2016-0147] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
AIM Fatty acid amide hydrolase (FAAH) degrades anandamide, an endogenous cannabinoid. We hypothesized that FAAH variants will predict risk of morphine-related adverse outcomes due to opioid-endocannabinoid interactions. PATIENTS & METHODS In 101 postsurgical adolescents receiving morphine analgesia, we prospectively studied ventilatory response to 5% CO2 (HCVR), respiratory depression (RD) and vomiting. Blood was collected for genotyping and morphine pharmacokinetics. RESULTS We found significant FAAH-morphine interaction for missense (rs324420) and several regulatory variants, with HCVR (p < 0.0001) and vomiting (p = 0.0339). HCVR was more depressed in patients who developed RD compared with those who did not (p = 0.0034), thus FAAH-HCVR association predicts risk of impending RD from morphine use. CONCLUSION FAAH genotypes predict risk for morphine-related adverse outcomes.
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Affiliation(s)
- Vidya Chidambaran
- Department of Anesthesia, College of Medicine, University of Cincinnati, Cincinnati, OH 45229, USA.,Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, OH 45229, USA
| | - Valentina Pilipenko
- Division of Human Genetics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH 45229, USA
| | - Kristie Spruance
- Department of Anesthesia, College of Medicine, University of Cincinnati, Cincinnati, OH 45229, USA
| | - Raja Venkatasubramanian
- Department of Anesthesia, College of Medicine, University of Cincinnati, Cincinnati, OH 45229, USA
| | - Jing Niu
- Department of Anesthesia, College of Medicine, University of Cincinnati, Cincinnati, OH 45229, USA.,Division of Pharmacology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH 45229, USA
| | - Tsuyoshi Fukuda
- Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, OH 45229, USA.,Division of Pharmacology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH 45229, USA
| | - Tomoyuki Mizuno
- Division of Pharmacology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH 45229, USA
| | - Kejian Zhang
- Division of Human Genetics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH 45229, USA
| | - Kenneth Kaufman
- Center for Autoimmune Genomics and Etiology (CAGE), Cincinnati Children's Hospital Medical Center, Cincinnati, OH 45229, USA
| | - Alexander A Vinks
- Division of Pharmacology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH 45229, USA
| | - Lisa J Martin
- Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, OH 45229, USA.,Division of Human Genetics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH 45229, USA
| | - Senthilkumar Sadhasivam
- Department of Anesthesia, College of Medicine, University of Cincinnati, Cincinnati, OH 45229, USA.,Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, OH 45229, USA
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Langhan ML, Li FY, Lichtor JL. Respiratory depression detected by capnography among children in the postanesthesia care unit: a cross-sectional study. Paediatr Anaesth 2016; 26:1010-7. [PMID: 27396979 DOI: 10.1111/pan.12965] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/07/2016] [Indexed: 11/30/2022]
Abstract
BACKGROUND Children are at risk for respiratory depression while recovering from anesthesia. Currently, monitoring children in the postanesthesia care unit (PACU) with pulse oximetry is recommended. However, pulse oximetry does not reliably recognize hypoventilation or apnea, particularly in the presence of supplemental oxygen. Capnography is a sensitive monitor of ventilation that is not often used in the PACU. AIM To determine the frequency of hypoventilation and apnea as detected by capnography among children in the PACU. METHODS In a cross-sectional study, capnography monitoring was applied to healthy children of age 1-17 years in the PACU of a tertiary care hospital. Staff was blinded to the capnography monitor; alarms were disabled. Staff provided routine care and monitoring with pulse oximetry to all patients. Vital signs, patient interventions, and medication administration were recorded by a research assistant every 30 s until all monitoring was discontinued by staff. Outcome measures included frequency of hypoventilation and apnea as measured by capnography and oxygen desaturations as measured by pulse oximetry, as well as staff interventions for these events. RESULTS Data from 194 children were analyzed. Capnography detected hypoventilation or apnea in 45.5% (95% CI 38.5%, 52.5%) of patients. Oxygen desaturations occurred in 19% (95% CI 13%, 24%) of patients. Interventions occurred in 9% (95% CI 5%, 13%) of patients. Patients who received narcotic medications were more likely to experience hypoventilation (OR 2.3, 95% CI 1.02, 5.3) and apnea (OR 2.7, 95% CI 1.1, 7). Hypoventilation was seen more often among children who received supplemental oxygen (OR 3.1, 95% CI 1.1, 12). CONCLUSIONS Hypoventilation and apnea are common among children in the PACU; however, few interventions occur to address these events. Routine monitoring with capnography may improve recognition of respiratory depression and enhance patient safety in the PACU.
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Affiliation(s)
- Melissa L Langhan
- Department of Pediatrics and Emergency Medicine, Section of Pediatric Emergency Medicine, Yale University School of Medicine, New Haven, CT, USA
| | - Fang-Yong Li
- Yale Center for Analytical Sciences, Yale University School of Public Health, New Haven, CT, USA
| | - J Lance Lichtor
- Department of Anesthesiology and Pediatrics, Yale University School of Medicine, New Haven, CT, USA
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Affiliation(s)
- Emily Rowe
- Tufts Medical Center; Department of Pharmacy; 800 Washington St, Box 420 Boston USA
| | - Tess E Cooper
- Cochrane; Cochrane Pain, Palliative and Supportive Care Review Group; Oxford Pain Research Churchill Hospital Oxford Oxfordshire UK OX3 7LE
| | - Ewan D McNicol
- Tufts Medical Center; Department of Pharmacy; 800 Washington St, Box 420 Boston USA
- Tufts Medical Center; Department of Anesthesiology; Boston Massachusetts USA
- Tufts University School of Medicine; Pain Research, Education and Policy (PREP) Program, Department of Public Health and Community Medicine; Boston Massachusetts USA
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Le May S, Ali S, Khadra C, Drendel AL, Trottier ED, Gouin S, Poonai N. Pain Management of Pediatric Musculoskeletal Injury in the Emergency Department: A Systematic Review. Pain Res Manag 2016; 2016:4809394. [PMID: 27445614 PMCID: PMC4904632 DOI: 10.1155/2016/4809394] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2015] [Accepted: 12/03/2015] [Indexed: 12/21/2022]
Abstract
Background. Pain management for children with musculoskeletal injuries is suboptimal and, in the absence of clear evidence-based guidelines, varies significantly. Objective. To systematically review the most effective pain management for children presenting to the emergency department with musculoskeletal injuries. Methods. Electronic databases were searched systematically for randomized controlled trials of pharmacological and nonpharmacological interventions for children aged 0-18 years, with musculoskeletal injury, in the emergency department. The primary outcome was the risk ratio for successful reduction in pain scores. Results. Of 34 studies reviewed, 8 met inclusion criteria and provided data on 1169 children from 3 to 18 years old. Analgesics used greatly varied, making comparisons difficult. Only two studies compared the same analgesics with similar routes of administration. Two serious adverse events occurred without fatalities. All studies showed similar pain reduction between groups except one study that favoured ibuprofen when compared to acetaminophen. Conclusions. Due to heterogeneity of medications and routes of administration in the articles reviewed, an optimal analgesic cannot be recommended for all pain categories. Larger trials are required for further evaluation of analgesics, especially trials combining a nonopioid with an opioid agent or with a nonpharmacological intervention.
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Affiliation(s)
- Sylvie Le May
- Faculty of Nursing, University of Montreal, Montreal, QC, Canada H3T 1A8
- CHU Sainte-Justine Research Centre, Montreal, QC, Canada H3T 1C5
| | - Samina Ali
- Women and Children's Health Research Institute, Edmonton, AB, Canada T6G 1C9
- Department of Pediatrics, Faculty of Medicine & Dentistry, University of Alberta, Edmonton, Canada T6G 1C9
| | - Christelle Khadra
- Faculty of Nursing, University of Montreal, Montreal, QC, Canada H3T 1A8
- CHU Sainte-Justine Research Centre, Montreal, QC, Canada H3T 1C5
- McGill University Health Centre, Montreal, QC, Canada H4A 3J1
| | - Amy L. Drendel
- Department of Pediatrics, Section of Emergency Medicine, Medical College of Wisconsin, Milwaukee, WI 53226, USA
| | - Evelyne D. Trottier
- CHU Sainte-Justine Research Centre, Montreal, QC, Canada H3T 1C5
- Division of Emergency Medicine, Department of Pediatrics, Sainte-Justine Hospital (CHU Sainte-Justine), Montreal, QC, Canada H3T 1C5
| | - Serge Gouin
- CHU Sainte-Justine Research Centre, Montreal, QC, Canada H3T 1C5
- Division of Emergency Medicine, Department of Pediatrics, Sainte-Justine Hospital (CHU Sainte-Justine), Montreal, QC, Canada H3T 1C5
| | - Naveen Poonai
- Children's Hospital, London Health Sciences Centre, London, ON, Canada N6A 5W9
- Schulich School of Medicine and Dentistry, London, ON, Canada N6A 5C1
- Child Health Research Institute, London, ON, Canada N6C 2V5
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Guay J, Suresh S, Kopp S. The use of ultrasound guidance for perioperative neuraxial and peripheral nerve blocks in children. Cochrane Database Syst Rev 2016; 2:CD011436. [PMID: 26895372 PMCID: PMC6464776 DOI: 10.1002/14651858.cd011436.pub2] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
BACKGROUND The use of ultrasound guidance for regional anaesthesia has become popular over the past two decades. However, it is not recognized by all experts as an essential tool. The cost of an ultrasound machine is substantially higher than the cost of other tools such as a nerve stimulator. OBJECTIVES To determine whether ultrasound guidance offers any clinical advantage when neuraxial and peripheral nerve blocks are performed in children in terms of increasing the success rate or decreasing the rate of complications. SEARCH METHODS We searched the following databases to March 2015: Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE (OvidSP), EMBASE (OvidSP) and Scopus (from inception to 27 January 2015). SELECTION CRITERIA We included all parallel randomized controlled trials (RCTs) that evaluated the effects of ultrasound guidance used when a regional blockade technique was performed in children, and that included any of our selected outcomes. DATA COLLECTION AND ANALYSIS We assessed selected studies for risk of bias by using the assessment tool of The Cochrane Collaboration. Two review authors independently extracted data. We graded the level of evidence for each outcome according to the GRADE (Grades of Recommendation, Assessment, Development and Evaluation) Working Group scale. MAIN RESULTS We included 20 studies (1241 participants) for which the source of funding was a government organization (two studies), a charitable organization (one study), an institutional department (four studies) or an unspecified source (11 studies); two studies declared that they received help from the industry (equipment loan). In 14 studies (939 participants), ultrasound guidance increased the success rate by decreasing the occurrence of a failed block: risk difference (RD) -0.11 (95% confidence interval (CI) -0.17 to -0.05); I(2) = 64%; number needed for additional beneficial outcome for a peripheral nerve block (NNTB) 6 (95% CI 5 to 8). Blocks were performed under general anaesthesia (usual clinical practice in this population); therefore, haemodynamic changes to the surgical stimulus (rather than classic sensory/motor blockade evaluation) were used to define success. For peripheral nerve blocks, the younger the child, the greater was the benefit. In eight studies (414 participants), pain scores at one hour in the post-anaesthesia care unit were reduced when ultrasound guidance was used; however, the clinical relevance of the difference was unclear (equivalent to -0.2 on a scale from 0 to 10). In eight studies (358 participants), block duration was longer when ultrasound guidance was used: standardized mean difference (SMD) 1.21 (95% CI 0.76 to 1.65; I(2) = 73%; equivalent to 62 minutes). Here again, younger children benefited most from ultrasound guidance. Time to perform the procedure was reduced when ultrasound guidance was used for pre-scanning before a neuraxial block (SMD -1.97, 95% CI -2.41 to -1.54; I(2) = 0%; equivalent to 2.4 minutes; two studies with 122 participants) or as an out-of-plane technique (SMD -0.68, 95% CI -0.96 to -0.40; I(2) = 0%; equivalent to 94 seconds; two studies with 204 participants). In two studies (122 participants), ultrasound guidance reduced the number of needle passes required to perform the block (SMD -0.90, 95% CI -1.27 to -0.52; I(2) = 0%; equivalent to 0.6 needle pass per participant). For two studies (204 participants), we could not demonstrate a difference in the incidence of bloody puncture when ultrasound guidance was used for neuraxial blockade, but we found that the number of participants was well below the optimal information size (RD -0.07, 95% CI -0.19 to 0.04). No major complications were reported for any of the 1241 participants. We rated the quality of evidence as high for success, pain scores at one hour, block duration, time to perform the block and number of needle passes. We rated the quality of evidence as low for bloody punctures. AUTHORS' CONCLUSIONS Ultrasound guidance seems advantageous, particularly in young children, for whom it improves the success rate and increases the block duration. Additional data are required before conclusions can be drawn on the effect of ultrasound guidance in reducing the rate of bloody puncture.
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Affiliation(s)
- Joanne Guay
- University of SherbrookeDepartment of Anesthesiology, Faculty of MedicineSherbrookeCanada
| | - Santhanam Suresh
- Ann & Robert H. Lurie Children's Hospital of Chicago Research CenterDepartment of Pediatric Anesthesiology225 E. Chicago AveChicagoUSA60611
| | - Sandra Kopp
- Mayo Clinic College of MedicineDepartment of Anesthesiology and Perioperative Medicine200 1st St SWRochesterUSA55901
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Görges M, West NC, Christopher NA, Koch JL, Brodie SM, Lowlaavar N, Lauder GR, Ansermino JM. An Ethnographic Observational Study to Evaluate and Optimize the Use of Respiratory Acoustic Monitoring in Children Receiving Postoperative Opioid Infusions. Anesth Analg 2016; 122:1132-40. [PMID: 26745756 DOI: 10.1213/ane.0000000000001127] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Respiratory depression in children receiving postoperative opioid infusions is a significant risk because of the interindividual variability in analgesic requirement. Detection of respiratory depression (or apnea) in these children may be improved with the introduction of automated acoustic respiratory rate (RR) monitoring. However, early detection of adverse events must be balanced with the risk of alarm fatigue. Our objective was to evaluate the use of acoustic RR monitoring in children receiving opioid infusions on a postsurgical ward and identify the causes of false alarm and optimal alarm thresholds. METHODS A video ethnographic study was performed using an observational, mixed methods approach. After surgery, an acoustic RR sensor was placed on the participant's neck and attached to a Rad87 monitor. The monitor was networked with paging for alarms. Vital signs data and paging notification logs were obtained from the central monitoring system. Webcam videos of the participant, infusion pump, and Rad87 monitor were recorded, stored on a secure server, and subsequently analyzed by 2 research nurses to identify the cause of the alarm, response, and effectiveness. Alarms occurring within a 90-second window were grouped into a single-alarm response opportunity. RESULTS Data from 49 patients (30 females) with median age 14 (range, 4.4-18.8) years were analyzed. The 896 bedside vital sign threshold alarms resulted in 160 alarm response opportunities (44 low RR, 74 high RR, and 42 low SpO2). In 141 periods (88% of total), for which video was available, 65% of alarms were deemed effective (followed by an alarm-related action within 10 minutes). Nurses were the sole responders in 55% of effective alarms and the patient or parent in 20%. Episodes of desaturation (SpO2 < 90%) were observed in 9 patients: At the time of the SpO2 paging trigger, the RR was >10 bpm in 6 of 9 patients. Based on all RR samples observed, the default alarm thresholds, to serve as a starting point for each patient, would be a low RR of 6 (>10 years of age) and 10 (4-9 years of age). CONCLUSIONS In this study, the use of RR monitoring did not improve the detection of respiratory depression. An RR threshold, which would have been predictive of desaturations, would have resulted in an unacceptably high false alarm rate. Future research using a combination of variables (e.g., SpO2 and RR), or the measurement of tidal volumes, may be needed to improve patient safety in the postoperative ward.
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Affiliation(s)
- Matthias Görges
- From the Departments of *Electrical and Computer Engineering and †Anesthesiology, Pharmacology, and Therapeutics, University of British Columbia, Vancouver, British Columbia, Canada; and ‡Department of Neurosciences and Surgery, BC Children's Hospital, Vancouver, British Columbia, Canada
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Miller KM, Kim AY, Yaster M, Kudchadkar SR, White E, Fackler J, Monitto CL. Long-term tolerability of capnography and respiratory inductance plethysmography for respiratory monitoring in pediatric patients treated with patient-controlled analgesia. Paediatr Anaesth 2015; 25:1054-9. [PMID: 26040512 PMCID: PMC5080840 DOI: 10.1111/pan.12702] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/07/2015] [Indexed: 12/30/2022]
Abstract
BACKGROUND The Anesthesia Patient Safety Foundation has advocated the use of continuous electronic monitoring of oxygenation and ventilation to preemptively identify opioid-induced respiratory depression. In adults, capnography is the gold standard in respiratory monitoring. An alternative technique used in sleep laboratories is respiratory inductance plethysmography (RIP). However, it is not known if either monitor is well tolerated by pediatric patients for prolonged periods of time. AIM The goal of this study was to determine whether capnography or RIP is better tolerated in nonintubated, spontaneously breathing pediatric patients being treated with intravenous patient-controlled analgesia (IVPCA). METHODS Nasal cannula capnography with oral sampling and thoracic and abdominal inductance plethysmography bands were placed along with the routine monitors on pediatric patients being treated for acute pain with IVPCA. Study monitors were left in place for as long as they were tolerated by the patient, up to a maximum of 24 consecutive hours. If the patient did not wear a particular study monitor for any reason, but tolerated the remaining monitor, participation in the study continued. If the patient would not wear either monitor, participation was terminated. RESULTS Twenty-six patients (18 female, eight male, average age 10.1 ± 5.5 years) consented to participate, but only 14 patients attempted to wear one or both the devices. Among those who wore either device, median time to device removal was 8.33 h (range 0.3-23.6 h) for capnography and 23.5 h (range 0.7-24 h) for RIP bands. CONCLUSION Children did not tolerate wearing capnography cannulae for prolonged periods of time, limiting the usefulness of this device as a continuous monitor of ventilation in children. RIP bands were better tolerated; however, they require further assessment of their utility. Until more effective, child-friendly monitors are developed and their utility is validated, guidelines recommended for adult patients cannot be extended to children.
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Affiliation(s)
- Karen M. Miller
- Department of Anesthesiology and Critical Care Medicine, The Johns Hopkins School of Medicine, Baltimore, USA
| | - Andrew Y. Kim
- Department of Anesthesiology and Critical Care Medicine, The Johns Hopkins School of Medicine, Baltimore, USA
| | - Myron Yaster
- Departments of Anesthesiology and Critical Care Medicine and Pediatrics, The Johns Hopkins School of Medicine, Baltimore, USA
| | - Sapna R. Kudchadkar
- Departments of Anesthesiology and Critical Care Medicine and Pediatrics, The Johns Hopkins School of Medicine, Baltimore, USA
| | - Elizabeth White
- Department of Anesthesiology and Critical Care Medicine, The Johns Hopkins School of Medicine, Baltimore, USA
| | - James Fackler
- Departments of Anesthesiology and Critical Care Medicine and Pediatrics, The Johns Hopkins School of Medicine, Baltimore, USA
| | - Constance L. Monitto
- Department of Anesthesiology and Critical Care Medicine, The Johns Hopkins School of Medicine, Baltimore, USA
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Messerer B, Grögl G, Stromer W, Jaksch W. [Pediatric perioperative systemic pain therapy: Austrian interdisciplinary recommendations on pediatric perioperative pain management]. Schmerz 2015; 28:43-64. [PMID: 24550026 DOI: 10.1007/s00482-013-1384-0] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
BACKGROUND Many analgesics used in adult medicine are not licensed for pediatric use. Licensing limitations do not, however, justify that children are deprived of a sufficient pain therapy particularly in perioperative pain therapy. The treatment is principally oriented to the strength of the pain. Due to the degree of pain caused, intramuscular and subcutaneous injections should be avoided generally. NON-OPIOIDS The basis of systemic pain therapy for children are non-opioids and primarily non-steroidal anti-inflammatory drugs (NSAIDs). They should be used prophylactically. The NSAIDs are clearly more effective than paracetamol for acute posttraumatic and postoperative pain and additionally allow economization of opioids. Severe side effects are rare in children but administration should be carefully considered especially in cases of hepatic and renal dysfunction or coagulation disorders. Paracetamol should only be taken in pregnancy and by children when there are appropriate indications because a possible causal connection with bronchial asthma exists. To ensure a safe dosing the age, body weight, duration of therapy, maximum daily dose and dosing intervals must be taken into account. Dipyrone is used in children for treatment of visceral pain and cholic. According to the current state of knowledge the rare but severe side effect of agranulocytosis does not justify a general rejection for short-term perioperative administration. OPIOIDS In cases of insufficient analgesia with non-opioid analgesics, the complementary use of opioids is also appropriate for children of all age groups. They are the medication of choice for episodes of medium to strong pain and are administered in a titrated form oriented to effectiveness. If severe pain is expected to last for more than 24 h, patient-controlled anesthesia should be implemented but requires a comprehensive surveillance by nursing personnel. KETAMINE Ketamine is used as an adjuvant in postoperative pain therapy and is recommended for use in pediatric sedation and analgosedation.
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Affiliation(s)
- B Messerer
- Universitätsklinik für Anästhesiologie und Intensivmedizin, Medizinische Universität Graz, LKH-Universitätsklinikum Graz, Auenbruggerplatz 29, 8036, Graz, Österreich,
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Guay J, Suresh S. The use of ultrasound guidance for perioperative neuraxial and peripheral nerve blocks in children. Cochrane Database Syst Rev 2014. [DOI: 10.1002/14651858.cd011436] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
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Chidambaran V, Mavi J, Esslinger H, Pilipenko V, Martin LJ, Zhang K, Sadhasivam S. Association of OPRM1 A118G variant with risk of morphine-induced respiratory depression following spine fusion in adolescents. THE PHARMACOGENOMICS JOURNAL 2014; 15:255-62. [PMID: 25266679 DOI: 10.1038/tpj.2014.59] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/26/2014] [Revised: 08/21/2014] [Accepted: 08/25/2014] [Indexed: 01/28/2023]
Abstract
The μ1 opioid receptor (OPRM1) genetic variant A118G results in decreased μ-receptor binding potential in the brain and increases morphine requirement. We hypothesized that OPRM1 A118G polymorphism will affect morphine-induced respiratory depression (MIRD) risk in children receiving morphine. A prospective genotype-blinded study was conducted in 88 healthy adolescents (11-18 years; 67% female, 85% Caucasian) who underwent spine fusion for scoliosis. They were followed for 48 h postoperatively for MIRD, pain scores, morphine consumption and use of analgesic adjuvants. Patients were genotyped for OPRM1 A118G variant-76% were wild type (AA) and 24% heterozygous/homozygous for variant (AG/GG). Multivariable logistic regression showed that the risk of MIRD in patients with AA genotype was significantly higher (odds ratio 5.6, 95% CI: 1.4-37.2, P=0.030). Presence of G allele was associated with higher pain scores (effect size 0.73, P=0.045). This novel association is an important step toward predicting MIRD susceptibility and personalizing morphine use.
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Affiliation(s)
- V Chidambaran
- 1] Department of Anesthesia, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA [2] Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - J Mavi
- 1] Department of Anesthesia, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA [2] Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - H Esslinger
- Department of Anesthesia, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - V Pilipenko
- Division of Human Genetics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - L J Martin
- Division of Human Genetics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - K Zhang
- Division of Human Genetics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - S Sadhasivam
- 1] Department of Anesthesia, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA [2] Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
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Vasquenza K, Ruble K, Chen A, Billett C, Kozlowski L, Atwater S, Kost-Byerly S. Pain Management for Children during Bone Marrow and Stem Cell Transplantation. Pain Manag Nurs 2014; 16:156-62. [PMID: 25267531 DOI: 10.1016/j.pmn.2014.05.005] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2011] [Revised: 05/20/2014] [Accepted: 05/21/2014] [Indexed: 11/25/2022]
Abstract
Pain management for children during bone marrow and stem cell transplantation is a significant clinical challenge for the health care team. Pain management strategies vary by institution. This paper reports on the use of a pediatric pain management service and patient- and caregiver-controlled analgesia for children undergoing transplant. This 2-year retrospective chart review examined the pain management practices and outcomes of children undergoing bone marrow and stem cell transplants in a large urban teaching hospital during 2008 and 2009. We concluded that patient- and caregiver-controlled analgesia is a well-tolerated modality for pain control during hospitalization for transplantation at this institution.
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Affiliation(s)
- Kelly Vasquenza
- Department of Pediatric Pain Management, Johns Hopkins Hospital, Baltimore, Maryland
| | - Kathy Ruble
- Department of Pediatric Oncology, Baltimore, Maryland.
| | - Allen Chen
- Department of Oncology and Pediatrics Oncology, Baltimore, Maryland
| | - Carol Billett
- Department of Pediatric Pain Management, Johns Hopkins Hospital, Baltimore, Maryland
| | - Lori Kozlowski
- Department of Pediatric Pain Management, Johns Hopkins Hospital, Baltimore, Maryland
| | - Sara Atwater
- Department of Pediatric Pain Management, Johns Hopkins Hospital, Baltimore, Maryland
| | - Sabine Kost-Byerly
- Department of Pediatric Pain Management, Johns Hopkins Hospital, Baltimore, Maryland; Department of Anesthesiology and Critical Care Medicine, Baltimore, Maryland
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Hall Burton DM, Boretsky KR. A comparison of paravertebral nerve block catheters and thoracic epidural catheters for postoperative analgesia following the Nuss procedure for pectus excavatum repair. Paediatr Anaesth 2014; 24:516-20. [PMID: 24612096 DOI: 10.1111/pan.12369] [Citation(s) in RCA: 66] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/21/2014] [Indexed: 11/28/2022]
Abstract
INTRODUCTION Thoracic epidurals (TE) have been advocated as a superior method for controlling postoperative pain after repair of pectus excavatum with a Nuss procedure. However, three recent reports of permanent neurologic injury after the Nuss procedure with concurrent TE analgesia have raised concerns about the safety of this combination. Paravertebral nerve blocks (PVNB) are used successfully for analgesia of the chest, but no studies are available comparing TE and PVNB catheters for postoperative analgesia in this patient population. This study was conducted to compare the efficacy of PVNB catheters with TE catheters for postoperative analgesia in pediatric patients undergoing the Nuss procedure. METHODS We retrospectively reviewed the medical records of 20 adolescent males undergoing a thoracoscopic Nuss procedure with either bilateral PVNB catheters (n = 10) or TE catheter (n = 10) and compared postoperative opiate consumption and pain scores. RESULTS There were no statistically significant differences between the groups with respect to demographics, opiate consumption measured in morphine equivalents, and pain scores. DISCUSSION In this small series, bilateral PVNB catheters resulted in equivalent opioid consumption and pain scores when compared to TE for postoperative pain management in pediatric patients undergoing the Nuss procedure. Large prospective studies are needed to further compare the efficacy, incidence of side effects, and complications of TE and PVNB catheters for postoperative analgesia in this pediatric population.
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Affiliation(s)
- Denise M Hall Burton
- Department of Anesthesiology, Children's Hospital of Pittsburgh of UPMC, Pittsburgh, PA, USA
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Czarnecki ML, Hainsworth K, Simpson PM, Arca MJ, Uhing MR, Varadarajan J, Weisman SJ. Is there an alternative to continuous opioid infusion for neonatal pain control? A preliminary report of parent/nurse-controlled analgesia in the neonatal intensive care unit. Paediatr Anaesth 2014; 24:377-85. [PMID: 24417623 PMCID: PMC4331187 DOI: 10.1111/pan.12332] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/20/2013] [Indexed: 11/28/2022]
Abstract
BACKGROUND Continuous opioid infusion (COI) remains the mainstay of analgesic therapy in the neonatal intensive care unit (NICU). Parent/nurse-controlled analgesia (PNCA) has been accepted as safe and effective for pediatric patients, but few reports include use in neonates. This study sought to compare outcomes of PNCA and COI in postsurgical neonates and young infants. METHODS Twenty infants treated with morphine PNCA were retrospectively compared with 13 infants treated with fentanyl COI in a Midwestern pediatric hospital in the United States. Outcome measures included opioid consumption, pain scores, frequency of adverse events, and subsequent methadone use. RESULTS The PNCA group (median 6.4 μg · kg(-1) · h(-1) morphine equivalents, range 0.0-31.4) received significantly less opioid (P < 0.001) than the COI group (median 40.0 μg · kg(-1) · h(-1) morphine equivalents; range 20.0-153.3), across postoperative days 0-3. Average daily pain scores (based on 0-10 scale) were low for both groups, but median scores differed nonetheless (0.8 PNCA vs 0.3 COI, P < 0.05). There was no significant difference in the frequency of adverse events or methadone use. CONCLUSION Results suggest PNCA may be a feasible and effective alternative to COI for pain management in postsurgical infants in the NICU. Results also suggest PNCA may provide more individualized care for this vulnerable population and in doing so, may potentially reduce opioid consumption; however, more studies are needed.
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Affiliation(s)
- Michelle L. Czarnecki
- Jane B. Pettit Pain Management Center, Children’s Hospital of Wisconsin, Milwaukee, USA
| | - Keri Hainsworth
- Jane B. Pettit Pain Management Center, Children’s Hospital of Wisconsin, Milwaukee, USA,Department of Anesthesiology, Medical College of Wisconsin, Milwaukee, USA
| | - Pippa M. Simpson
- Department of Quantitative Health Sciences, Medical College of Wisconsin, Milwaukee, USA,Department of Pediatrics, Medical College of Wisconsin, Milwaukee, USA
| | - Marjorie J. Arca
- Department of Surgery, Medical College of Wisconsin, Milwaukee, USA,Department of Pediatrics, Medical College of Wisconsin, Milwaukee, USA
| | - Michael R. Uhing
- Department of Pediatrics, Medical College of Wisconsin, Milwaukee, USA,Department of neonatology, Medical College of Wisconsin, Milwaukee, USA
| | - Jaya Varadarajan
- Jane B. Pettit Pain Management Center, Children’s Hospital of Wisconsin, Milwaukee, USA,Department of Anesthesiology, Medical College of Wisconsin, Milwaukee, USA
| | - Steven J. Weisman
- Jane B. Pettit Pain Management Center, Children’s Hospital of Wisconsin, Milwaukee, USA,Department of Anesthesiology, Medical College of Wisconsin, Milwaukee, USA,Department of Pediatrics, Medical College of Wisconsin, Milwaukee, USA
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Martin DP, Bhalla T, Beltran R, Veneziano G, Tobias JD. The safety of prescribing opioids in pediatrics. Expert Opin Drug Saf 2013; 13:93-101. [PMID: 24073760 DOI: 10.1517/14740338.2013.834045] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
INTRODUCTION Pain management has become a widely discussed topic throughout all medical subspecialties. Although pediatric pain management has evolved significantly in its recent history, there is continued interest in the adequacy of pain treatment, both in the acute inpatient setting as well as the postoperative and chronic pain management setting. Although health care providers are becoming more aggressive concerning prompt and effective treatment of acute and chronic pain, safety data and adverse effects of narcotic analgesics may be overlooked. AREAS COVERED The authors review the current paradigm of acute pain management with an emphasis on oral narcotic medications, and the safety data available concerning prescribing these medications. EXPERT OPINION Further, the authors present their opinions concerning current and future practices regarding the prescribing practice of opiate analgesics, as well as a step-wise approach for acute oral pain management.
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Affiliation(s)
- David P Martin
- Ohio State University, Nationwide Children's Hospital, Department of Anesthesiology and Pain Medicine , 700 Children's Drive, Columbus, OH 43205 , USA +1 614 722 4200 ; +1 614 722 4203 ;
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Nursing surveillance moderates the relationship between staffing levels and pediatric postoperative serious adverse events: A nested case–control study. Int J Nurs Stud 2013; 50:905-13. [DOI: 10.1016/j.ijnurstu.2012.11.014] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2012] [Revised: 11/20/2012] [Accepted: 11/20/2012] [Indexed: 11/15/2022]
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Voepel-Lewis T, Wagner D, Burke C, Tait AR, Hemberg J, Pechlivanidis E, Malviya S, Talsma A. Early adjuvant use of nonopioids associated with reduced odds of serious postoperative opioid adverse events and need for rescue in children. Paediatr Anaesth 2013; 23:162-9. [PMID: 22978850 DOI: 10.1111/pan.12026] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/13/2012] [Indexed: 12/14/2022]
Abstract
OBJECTIVES Examine factors associated with opioid adverse drug events (ADE) in children. SPECIFIC AIMS Examine whether adjuvant nonopioid use is associated with a decreased probability of opioid-ADEs and need for rescue. BACKGROUND Opioid-ADEs contribute to serious preventable harm for hospitalized children. Adjuvant nonopioid use may mitigate opioid risk postoperatively, yet few studies support this notion. METHOD This nested case-control study included children who required intervention or rescue from opioid-ADEs and procedure-matched controls. Data were recorded from medical records and primary outcomes included serious opioid-ADEs (over-sedation and respiratory depression) and need for rescue (e.g., naloxone, rapid response team). Hierarchical logistic regression (HLR) models examined relationships between factors and opioid-ADEs. Early clinical signs and symptoms of deterioration were examined. RESULTS Twenty five children with opioid-ADEs and 98 children without events were included. ASA-PS remained an independent risk factor (odds ratio, 2.56 [1.09, 6.03]; P = 0.031), while adjuvant nonopioids a risk reduction factor for opioid-ADEs (OR, 0.16 [0.05, 0.47]; P = 0.001) and need for rescue (0.14 [0.04, 0.47]; P = 0.001). Supplemental oxygen use at PACU discharge was associated with an increased odds of opioid-ADEs (OR, 3.72 [1.35, 10.23]; P = 0.007) and need for rescue (5.5 [1.7, 17.82]; P = 0.002). CONCLUSIONS Findings from this study suggest that strategies such as early use of adjuvant nonopioids may reduce risk of opioid-ADEs postoperatively. Furthermore, children who require supplemental oxygen early postoperatively may be at heightened risk of later events.
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Affiliation(s)
- Terri Voepel-Lewis
- Department of Anesthesiology, University of Michigan Health Systems, Ann Arbor, MI, USA.
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Voepel-Lewis T, Piscotty RJ, Annis A, Kalisch B. Empirical review supporting the application of the "pain assessment as a social transaction" model in pediatrics. J Pain Symptom Manage 2012; 44:446-57. [PMID: 22658250 DOI: 10.1016/j.jpainsymman.2011.09.005] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2011] [Revised: 09/28/2011] [Accepted: 10/05/2011] [Indexed: 11/28/2022]
Abstract
Despite decades of research, national mandates, and widespread implementation of guidelines, recent reports suggest that the quality of pain assessment and management in hospitalized children remains suboptimal. The mismatch between what is advocated and what is done in practice has led experts to argue for a conceptual shift in thinking, where the pain assessment process is viewed from a complex social communication or transaction framework. This article examines the empirical evidence from the recent pediatric pain assessment and decision-making literature that supports adaptation of Schiavenato and Craig's "Pain Assessment as a Social Transaction" model in explaining pediatric acute pain management decisions. Multiple factors contributing to children's pain experiences and expressions are explored, and some of the difficulties interpreting their pain scores are exposed. Gaps in knowledge related to nurses' clinical pain management decisions are identified, and the importance of children's and parents' preferences and roles and the influence of risks and adverse events on decision making are identified. This review highlights the complexity of pediatric nurses' pain management decisions toward the clinical goal of improving comfort while minimizing risk. Further study evaluating the propositions related to nurses' decisions to intervene is needed in pediatric clinical settings to better synthesize this model for children.
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Abstract
Patient-controlled analgesia offers safe and effective pain control for children who can self-administer medication. Some children may not be candidates for patient-controlled analgesia (PCA) unless a proxy can administer doses. The safety of proxy-administered PCA has been studied, but the safety of parent-administered PCA in children with cancer has not been reported. In this study, we compare the rate of complications in PCA by parent proxy versus PCA by clinician (nurse) proxy and self-administered PCA. Our pediatric institution's quality improvement database was reviewed for adverse events associated with PCA from 2004 through 2010. Each PCA day was categorized according to patient or proxy authorization. Data from 6151 PCA observation days were included; 61.3% of these days were standard PCA, 23.5% were parent-proxy PCA, and 15.2% were clinician-proxy PCA days. The mean duration of PCA use was 12.1 days, and the mean patient age was 12.3 years. The mean patient age was lower in the clinician-proxy (9.4 y) and parent-proxy (5.1 y) groups, respectively. The complication rate was lowest in the parent-proxy group (0.62%). We found that proxy administration of PCA by authorized parents is as safe as clinician administered and standard PCA at our pediatric institution.
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Sohn VY, Zenger D, Steele SR. Pain Management in the Pediatric Surgical Patient. Surg Clin North Am 2012; 92:471-85, vii. [DOI: 10.1016/j.suc.2012.03.002] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Ineffective morphine treatment regimen for the control of Neonatal Abstinence Syndrome in buprenorphine- and methadone-exposed infants. J Dev Orig Health Dis 2012; 3:262-70. [DOI: 10.1017/s2040174412000190] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
This study aimed to determine if morphine is effective in ameliorating Neonatal Abstinence Syndrome (NAS) symptoms to non-opioid-exposed control levels in methadone- and buprenorphine-exposed infants. A prospective, non-randomized comparison study with flexible dosing was undertaken in a large teaching maternity hospital in Australia. Twenty-five infants in the groups of buprenorphine-, methadone- and control non-opioid-exposed infants were compared (totaln= 75 infants). Oral morphine sulphate (1 mg/ml) was administered every 4 h to opioid agonist-exposed infants. Modified Finnegan Withdrawal Scale (MFWS) scores determined dosing: score of 8–10: 0.5 mg/kg/day, 11–13: 0.7 mg/kg/day and 14+: 0.9 mg/kg/day. Withdrawal score, amount of morphine administered and length of hospital stay, were used to assess NAS over a 4-week follow-up period. No controls achieved a score higher than 7 on the MFWS. There was no significant difference in the percentage of infants requiring treatment between methadone (60%) and buprenorphine (48%) infants. For treated infants, significantly (P< 0.01) more morphine was administered to methadone (40.07 ± 3.95 mg) compared with buprenorphine infants (22.77 ± 4.29 mg) to attempt to control NAS. Following treatment initiation, significantly more (P< 0.01) methadone (87%) compared with buprenorphine infants (42%) continued to exceed scoring thresholds for morphine treatment requirement, and non-opioid-exposed control infant scores. For treated infants, there was no significant difference in length of hospital stay between methadone and buprenorphine infants. Morphine treatment was not entirely effective in ameliorating NAS to non-opioid-exposed control symptom levels in methadone or buprenorphine infants. The regimen may be less effective in methadone compared with buprenorphine infants.
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Herr K, Coyne PJ, McCaffery M, Manworren R, Merkel S. Pain Assessment in the Patient Unable to Self-Report: Position Statement with Clinical Practice Recommendations. Pain Manag Nurs 2011; 12:230-50. [DOI: 10.1016/j.pmn.2011.10.002] [Citation(s) in RCA: 333] [Impact Index Per Article: 25.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2011] [Accepted: 08/22/2011] [Indexed: 01/16/2023]
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Van Hulle Vincent C, Wilkie DJ, Wang E. Response to Voepel-Lewis’s Letter to the Editor, “Bridging the Gap Between Pain Assessment and Treatment: Time for a New Theoretical Approach?”. West J Nurs Res 2011. [DOI: 10.1177/0193945911408394] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Monitto CL, Kost-Byerly S, White E, Lee CKK, Rudek MA, Thompson C, Yaster M. The optimal dose of prophylactic intravenous naloxone in ameliorating opioid-induced side effects in children receiving intravenous patient-controlled analgesia morphine for moderate to severe pain: a dose finding study. Anesth Analg 2011; 113:834-42. [PMID: 21890885 DOI: 10.1213/ane.0b013e31822c9a44] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Opioid-induced side effects, such as pruritus, nausea, and vomiting are common and may be more debilitating than pain itself. A continuous low-dose naloxone infusion (0.25 μg/kg/h) ameliorates some of these side effects in many but not all patients without adversely affecting analgesia. We sought to determine the optimal dose of naloxone required to minimize opioid-induced side effects and to measure plasma morphine and naloxone levels in a dose escalation study. METHODS Fifty-nine pediatric patients (24 male/35 female; average age 14.2 ± 2.2 years) experiencing moderate to severe postoperative pain were started on IV patient-controlled analgesia morphine (basal infusion 20 μg/kg/h, demand dose 20 μg/kg, 5 doses/h) and a low-dose naloxone infusion (initial cohort: 0.05 μg/kg/h; subsequent cohorts: 0.10, 0.15, 0.25, 0.40, 0.65, 1, and 1.65 μg/kg/h). If 2 patients developed intolerable nausea, vomiting, or pruritus, the naloxone infusion was increased for subsequent patients. Dose/treatment success occurred when 10 patients had minimal side effects at a naloxone dose. Blood samples were obtained for measurement of plasma morphine and naloxone levels after initiation of the naloxone infusion, processed, stored, and measured by tandem mass spectrometry with electrospray positive ionization. RESULTS The minimum naloxone dose at which patients were successfully treated with a <10% side effect/failure rate was 1 μg/kg/h; cohort size varied between 4 and 11 patients. Naloxone was more effective in preventing pruritus than nausea and vomiting. Concomitant use of supplemental medicines to treat opioid-induced side effects was required at all naloxone infusion rates. Plasma naloxone levels were below the level of assay quantification (0.1 ng/mL) for infusion rates ≤0.15 μg/kg/h. At rates >0.25 μg/kg/h, plasma levels increased linearly with increasing infusion rate. In each dose cohort, patients who failed therapy had comparable or higher plasma naloxone levels than those levels measured in patients who did not fail treatment. Plasma morphine levels ranged between 3.52 and 172 ng/mL, and >90% of levels ranged between 10.2 and 61.6 ng/mL. Plasma morphine levels were comparable between patients who failed therapy and those patients who achieved symptom control. CONCLUSIONS Naloxone infusion rates ≥1 μg/kg/h significantly reduced, but did not eliminate, the incidence of opioid-induced side effects in postoperative pediatric patients receiving IV patient-controlled analgesia morphine. Patients who failed therapy generally had plasma naloxone and morphine levels that were comparable to those who had good symptom relief suggesting that success or failure to ameliorate opioid-induced side effects was unrelated to plasma levels.
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Affiliation(s)
- Constance L Monitto
- Department of Anesthesiology and Critical Care Medicine, Division of Pediatric Anesthesiology and Critical Care Medicine, The Johns Hopkins University School of Medicine, 600 North Wolfe St., Blalock 904, Baltimore, MD 21287, USA.
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Voepel-Lewis T. Bridging the Gap Between Pain Assessment and Treatment. West J Nurs Res 2011; 33:846-51; author reply 852-7. [DOI: 10.1177/0193945911403940] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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