1
|
Xu W, Wei H, Zhang T. Methods of prolonging the effect of caudal block in children. Front Pediatr 2024; 12:1406263. [PMID: 38887564 PMCID: PMC11180814 DOI: 10.3389/fped.2024.1406263] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2024] [Accepted: 05/22/2024] [Indexed: 06/20/2024] Open
Abstract
Caudal epidural blockade is one of the most frequently administered regional anesthesia techniques in children. It is a supplement during general anesthesia and for providing postoperative analgesia in pediatrics for sub-umbilical surgeries, especially for genitourinary surgeries. However, the duration of the analgesic effect is occasionally unsatisfactory. In this review, we discuss the main advantages and disadvantages of different techniques to prolong postoperative analgesia for single-injection caudal blockade in children. A literature search of the keywords "caudal", "analgesia", "pediatric", and "children" was performed using PubMed and Web of Science databases. We highlight that analgesic quality correlates substantially with the local anesthetic's type, dose, the timing relationship between caudal block and surgery, caudal catheterization, and administration of epidural opioids or other adjuvant drugs.
Collapse
Affiliation(s)
| | | | - Tao Zhang
- Department of Anesthesiology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China
| |
Collapse
|
2
|
Walker SM, Malkmus S, Eddinger K, Steinauer J, Roberts AJ, Shubayev VI, Grafe MR, Powell SB, Yaksh TL. Evaluation of neurotoxicity and long-term function and behavior following intrathecal 1 % 2-chloroprocaine in juvenile rats. Neurotoxicology 2021; 88:155-167. [PMID: 34801587 DOI: 10.1016/j.neuro.2021.11.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2021] [Revised: 11/08/2021] [Accepted: 11/16/2021] [Indexed: 01/20/2023]
Abstract
Spinally-administered local anesthetics provide effective perioperative anesthesia and/or analgesia for children of all ages. New preparations and drugs require preclinical safety testing in developmental models. We evaluated age-dependent efficacy and safety following 1 % preservative-free 2-chloroprocaine (2-CP) in juvenile Sprague-Dawley rats. Percutaneous lumbar intrathecal 2-CP was administered at postnatal day (P)7, 14 or 21. Mechanical withdrawal threshold pre- and post-injection evaluated the degree and duration of sensory block, compared to intrathecal saline and naive controls. Tissue analyses one- or seven-days following injection included histopathology of spinal cord, cauda equina and brain sections, and quantification of neuronal apoptosis and glial reactivity in lumbar spinal cord. Following intrathecal 2-CP or saline at P7, outcomes assessed between P30 and P72 included: spinal reflex sensitivity (hindlimb thermal latency, mechanical threshold); social approach (novel rat versus object); locomotor activity and anxiety (open field with brightly-lit center); exploratory behavior (rearings, holepoking); sensorimotor gating (acoustic startle, prepulse inhibition); and learning (Morris Water Maze). Maximum tolerated doses of intrathecal 2-CP varied with age (1.0 μL/g at P7, 0.75 μL/g at P14, 0.5 μL/g at P21) and produced motor and sensory block for 10-15 min. Tissue analyses found no significant differences across intrathecal 2-CP, saline or naïve groups. Adult behavioral measures showed expected sex-dependent differences, that did not differ between 2-CP and saline groups. Single maximum tolerated in vivo doses of intrathecal 2-CP produced reversible spinal anesthesia in juvenile rodents without detectable evidence of developmental neurotoxicity. Current results cannot be extrapolated to repeated dosing or prolonged infusion.
Collapse
Affiliation(s)
- Suellen M Walker
- Department of Anesthesiology, University of California San Diego, CA, USA; Developmental Neurosciences Department, UCL Great Ormond Street Institute of Child Health and Department of Anaesthesia and Pain Medicine, Great Ormond St Hospital Foundation Trust, London, United Kingdom.
| | - Shelle Malkmus
- Department of Anesthesiology, University of California San Diego, CA, USA
| | - Kelly Eddinger
- Department of Anesthesiology, University of California San Diego, CA, USA
| | - Joanne Steinauer
- Department of Anesthesiology, University of California San Diego, CA, USA
| | - Amanda J Roberts
- Animal Models Core, Scripps Research Institute, La Jolla, CA, USA
| | - Veronica I Shubayev
- Department of Anesthesiology, University of California San Diego, CA, USA; Veterans Affairs San Diego Healthcare System, La Jolla, CA, USA
| | - Marjorie R Grafe
- Department of Pathology, Oregon Health & Science University, Portland, OR, USA
| | - Susan B Powell
- Veterans Affairs San Diego Healthcare System, La Jolla, CA, USA; Department of Psychiatry, University of California San Diego, La Jolla, CA, USA
| | - Tony L Yaksh
- Department of Anesthesiology, University of California San Diego, CA, USA
| |
Collapse
|
3
|
Gibbs A, Kim SS, Heydinger G, Veneziano G, Tobias J. Postoperative Analgesia in Neonates and Infants Using Epidural Chloroprocaine and Clonidine. J Pain Res 2020; 13:2749-2755. [PMID: 33154665 PMCID: PMC7608143 DOI: 10.2147/jpr.s281484] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2020] [Accepted: 10/07/2020] [Indexed: 12/01/2022] Open
Abstract
INTRODUCTION In neonates and infants, epidural analgesia has gained popularity as a means of providing postoperative analgesia, limiting opioid-related adverse effects and improving the postoperative course. In addition to a local anesthetic agent, adjunctive agents may be added to further augment analgesia. Clonidine is an α2-adrenergic agonist that is frequently added to single-shot caudal analgesia, but there are limited data regarding its use in a continuous epidural infusion, especially in patients ≤12 months of age. METHODS We retrospectively reviewed the hospital records of neonates and infants who received postoperative epidural infusions with 2-chloroprocaine, and clonidine was identified over a 4-year period. RESULTS The study cohort included 52 neonates and infants ranging in age from 0 to 12 months and in weight from 2.1 to 10.1 kilograms. The catheters were dosed with either 1.5% 2-chloroprocaine (n=47) or 3% 2-chloroprocaine (n=5) with clonidine (median concentration 0.2 µg/mL) infused at a median rate of 0.72 mL/kg/hour. Pain scores were uniformly ≤3 at all evaluation points during the first 72 postoperative hours with a limited need for supplemental systemic opioids. No serious adverse effects were noted. CONCLUSION With the recognized limitations of a retrospective study, these preliminary data demonstrate the safety of adding clonidine to an epidural infusion of 2-chloroprocaine in neonates and infants less than 12 months of age. Future studies are needed to determine its analgesic efficacy compared to 2-chloroprocaine alone and the optimal clonidine concentration for postoperative epidural infusions.
Collapse
Affiliation(s)
- Anna Gibbs
- The Ohio State University College of Medicine, Columbus, OH, USA
| | - Stephani S Kim
- Department of Anesthesiology & Pain Medicine, Nationwide Children’s Hospital, Columbus, OH, USA
| | - Grant Heydinger
- Department of Anesthesiology & Pain Medicine, Nationwide Children’s Hospital, Columbus, OH, USA
- Department of Anesthesiology & Pain Medicine, The Ohio State University College of Medicine, Columbus, OH, USA
| | - Giorgio Veneziano
- Department of Anesthesiology & Pain Medicine, Nationwide Children’s Hospital, Columbus, OH, USA
- Department of Anesthesiology & Pain Medicine, The Ohio State University College of Medicine, Columbus, OH, USA
| | - Joseph Tobias
- Department of Anesthesiology & Pain Medicine, Nationwide Children’s Hospital, Columbus, OH, USA
- Department of Anesthesiology & Pain Medicine, The Ohio State University College of Medicine, Columbus, OH, USA
| |
Collapse
|
4
|
Alphonso N, Angelini A, Barron DJ, Bellsham-Revell H, Blom NA, Brown K, Davis D, Duncan D, Fedrigo M, Galletti L, Hehir D, Herberg U, Jacobs JP, Januszewska K, Karl TR, Malec E, Maruszewski B, Montgomerie J, Pizzaro C, Schranz D, Shillingford AJ, Simpson JM. Guidelines for the management of neonates and infants with hypoplastic left heart syndrome: The European Association for Cardio-Thoracic Surgery (EACTS) and the Association for European Paediatric and Congenital Cardiology (AEPC) Hypoplastic Left Heart Syndrome Guidelines Task Force. Eur J Cardiothorac Surg 2020; 58:416-499. [DOI: 10.1093/ejcts/ezaa188] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Affiliation(s)
- Nelson Alphonso
- Queensland Pediatric Cardiac Service, Queensland Children’s Hospital, University of Queensland, Brisbane, QLD, Australia
| | - Annalisa Angelini
- Department of Cardiac, Thoracic Vascular Sciences and Public health, University of Padua Medical School, Padua, Italy
| | - David J Barron
- Department of Cardiovascular Surgery, Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | | | - Nico A Blom
- Division of Pediatric Cardiology, Department of Pediatrics, Leiden University Medical Center, Leiden, Netherlands
| | - Katherine Brown
- Paediatric Intensive Care, Heart and Lung Division, Great Ormond Street Hospital NHS Foundation Trust, London, UK
| | - Deborah Davis
- Department of Anesthesiology, Thomas Jefferson University, Philadelphia, PA, USA
- Nemours Cardiac Center, A.I. Du Pont Hospital for Children, Wilmington, DE, USA
| | - Daniel Duncan
- Nemours Cardiac Center, A.I. Du Pont Hospital for Children, Wilmington, DE, USA
| | - Marny Fedrigo
- Department of Cardiac, Thoracic Vascular Sciences and Public Health, University of Padua Medical School, Padua, Italy
| | - Lorenzo Galletti
- Unit of Pediatric Cardiac Surgery, Bambino Gesù Children's Hospital, Rome, Italy
| | - David Hehir
- Division of Cardiology, Children’s Hospital of Philadelphia, Philadelphia, PA, USA
| | - Ulrike Herberg
- Department of Pediatric Cardiology, University Hospital Bonn, Bonn, Germany
| | | | - Katarzyna Januszewska
- Division of Pediatric Cardiac Surgery, University Hospital Muenster, Westphalian-Wilhelm’s-University, Muenster, Germany
| | | | - Edward Malec
- Division of Pediatric Cardiac Surgery, University Hospital Muenster, Westphalian-Wilhelm’s-University, Muenster, Germany
| | - Bohdan Maruszewski
- Department for Pediatric Cardiothoracic Surgery, Children's Memorial Health Institute, Warsaw, Poland
| | - James Montgomerie
- Department of Anesthesia, Birmingham Children’s Hospital, Birmingham, UK
| | - Christian Pizzaro
- Nemours Cardiac Center, A.I. Du Pont Hospital for Children, Wilmington, DE, USA
- Department of Surgery, Thomas Jefferson University, Philadelphia, PA, USA
| | - Dietmar Schranz
- Pediatric Heart Center, Justus-Liebig University, Giessen, Germany
| | - Amanda J Shillingford
- Division of Cardiology, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | | | | |
Collapse
|
5
|
Abstract
BACKGROUND Critically ill newborn infants undergo a variety of painful procedures or experience a variety of painful conditions during their early life in the neonatal unit. In the critically ill paediatric and neonatal population, clonidine is prescribed as an adjunct to opioids or benzodiazepines aiming to reduce the doses of these drugs that are required for analgesia or sedation, or to facilitate weaning from mechanical ventilation. It has been shown that clonidine premedication might have a positive effect on postoperative pain in children. OBJECTIVES To assess the benefit and harms of clonidine for the prevention or treatment of procedural pain; postoperative pain; or pain associated with clinical conditions in non-ventilated neonates. SEARCH METHODS We used the standard search strategy of Cochrane Neonatal to search the CENTRAL, MEDLINE via PubMed, Embase, and CINAHL to December 2018. We also searched clinical trials databases, conference proceedings, and the reference lists of retrieved articles for randomised controlled trials and quasi-randomised trials. We ran an updated search from 1 January 2018 to 11 March 2020 in CENTRAL via CRS Web, MEDLINE via Ovid, and CINAHL via EBSCOhost. SELECTION CRITERIA Randomised controlled trials, quasi-randomised controlled trials, and cluster trials comparing clonidine to placebo or no treatment, opioids, paracetamol, dexmedetomidine, or non-pharmacological pain-reducing interventions for the management of procedural pain, postoperative pain, and pain associated with clinical conditions in preterm and term newborns. DATA COLLECTION AND ANALYSIS Two review authors independently planned to extract data (e.g. number of participants, birth weight, gestational age, modality of administration, and dose of clonidine) and assess the risk of bias (e.g. adequacy of randomisation, blinding, completeness of follow-up). The primary outcome considered was pain: for procedural pain, the mean values of each analgesia scale assessed during the procedure and at one to two hours after the procedure; for postoperative pain and for pain associated with clinical conditions, the mean values of each analgesia scale assessed at 30 minutes, three hours, and 12 hours after the administration of the intervention. We planned to use the GRADE approach to assess the quality of evidence. MAIN RESULTS Our search strategy yielded 3383 references. Two review authors independently assessed all references for inclusion. We did not find any completed studies for inclusion. We excluded three trials where clonidine was administered for spinal anaesthesia. AUTHORS' CONCLUSIONS We did not find any studies that met our inclusion criteria and hence there is no evidence to recommend or refute the use of clonidine for the prevention or treatment of procedural or postoperative pain, or pain associated with clinical conditions in neonates.
Collapse
Affiliation(s)
- Olga Romantsik
- Lund University, Skåne University HospitalDepartment of Clinical Sciences Lund, PaediatricsLundSweden
| | - Maria Grazia Calevo
- Istituto Giannina GasliniEpidemiology, Biostatistics Unit, IRCCSGenoaItaly16147
| | - Elisabeth Norman
- Lund University, Skåne University HospitalDepartment of PaediatricsLundSweden
| | - Matteo Bruschettini
- Lund University, Skåne University HospitalDepartment of Clinical Sciences Lund, PaediatricsLundSweden
- Skåne University HospitalCochrane SwedenWigerthuset, Remissgatan 4, First FloorRoom 11‐221LundSweden22185
| | | |
Collapse
|
6
|
|
7
|
Wang K, Li C. Effects of dexmedetomidine on inflammatory factors, T lymphocyte subsets and expression of NF-κB in peripheral blood mononuclear cells in patients receiving radical surgery of colon carcinoma. Oncol Lett 2018; 15:7153-7157. [PMID: 29725437 PMCID: PMC5920235 DOI: 10.3892/ol.2018.8205] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2017] [Accepted: 02/16/2018] [Indexed: 01/16/2023] Open
Abstract
The effects of dexmedetomidine on inflammatory factors, T lymphocyte subsets and expression of nuclear factor-κB (NF-κB) in peripheral blood mononuclear cells in patients receiving radical surgery of colon carcinoma were investigated. A total of 141 patients receiving radical surgery of colon carcinoma from January 2014 to April 2017 were divided into two groups randomly. The patients in the treatment group were given dexmedetomidine, while the patients in the control group were treated with saline. Results showed that there were no significant differences in preoperative levels of NF-κB, sICAM-1 and IL-8 between the two groups. However, the above three indexes of the groups were all significantly increased at 0.5 and 24 h after operation, and the results showed that the control group had a higher degree of increase (P<0.05). It was also found that the changes in levels of IL-6 and CRP in patients were the same as those of the above three indexes; in other words, the degree of the increase in the control group was significantly higher than that in the treatment group after operation. Moreover, it was found that there was little difference in the preoperative Ramsay score of patients between the two groups. The scores at 0.5 and 12 h after operation in the treatment group were significantly higher than those in the control group (P<0.05). It was also found that the intraoperative and postoperative dosages of fentanyl in the treatment group were significantly less than those in the control group (P<0.05). We can conclude that the application of dexmedetomidine during anesthesia in patients receiving radical operation of colon carcinoma has a better clinical treatment effect, which can reduce the secretion of inflammatory factors, decrease the inhibition of immunity and reduce the use of fentanyl.
Collapse
Affiliation(s)
- Kun Wang
- Department of Anesthesiology, Jining No. 1 People's Hospital, Jining, Shandong 272011, P.R. China
| | - Chengwen Li
- Department of Anesthesiology, Jining No. 1 People's Hospital, Jining, Shandong 272011, P.R. China
| |
Collapse
|
8
|
Chetty DK, Ahmed F, Chatterjee R, Rathore M. Comparison of Intrathecal Nalbuphine Hydrochloride and Clonidine Hydrochloride as an Adjuvant to Hyperbaric Bupivacaine in Abdominal Hysterectomy. Anesth Essays Res 2018; 12:402-406. [PMID: 29962606 PMCID: PMC6020575 DOI: 10.4103/aer.aer_5_18] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Background Various adjuvants for prolongation of intraoperative and postoperative analgesia have been clinically studied in the literature. Aim This study was done to evaluate and compare the effects of nalbuphine and clonidine as an adjuvant to bupivacaine in spinal anesthesia. Methods In this prospective, randomized, placebo control, double-blind, and comparative study, a total of ninety patients of American Society of Anesthesiologists physical status Classes I and II undergoing abdominal hysterectomy under subarachnoid block were randomly divided into three groups. In addition to 15 mg of 0.5% hyperbaric bupivacaine administered, patients of groups BS, BN, and BC received 0.9% normal saline, 1.6 mg nalbuphine, and 30 μg clonidine, respectively. The total volume of drugs administered intrathecally was made up to 3.5 ml by addition of sterile isotonic normal saline in all. The onset time and duration of sensory and motor block, duration of analgesia, and total dose of postoperative analgesic requirement in the first 24 h were compared among groups. Hemodynamic changes and side effects were also recorded. Results Addition of study adjuvants brought significantly faster onset of sensory and motor block. Patients in clonidine group showed significantly longer mean time two segment sensory block regression (P < 0.05) lowest seen in control group. The regression time of motor block to modified Bromage Grade I was significantly longer in clonidine group and comparable in the other groups. Adjuvants have significantly increased the mean duration of analgesia, highest in clonidine group (P < 0.05). Conclusion Intrathecal clonidine is associated with prolonged motor and sensory block, better hemodynamic stability, and less postoperative analgesic requirement as compared to nalbuphine.
Collapse
Affiliation(s)
- Dikshitha K Chetty
- Department of Anaesthesiology and Critical Care, Sawai Man Singh Medical College and Attached Group of Hospitals, Jaipur, Rajasthan, India
| | - Fareed Ahmed
- Department of Anaesthesiology and Critical Care, Sawai Man Singh Medical College and Attached Group of Hospitals, Jaipur, Rajasthan, India
| | - Rama Chatterjee
- Department of Anaesthesiology and Critical Care, Sawai Man Singh Medical College and Attached Group of Hospitals, Jaipur, Rajasthan, India
| | - Monica Rathore
- Department of Preventive and Social Medicine, Sawai Man Singh Medical College and Attached Group of Hospitals, Jaipur, Rajasthan, India
| |
Collapse
|
9
|
The European society of regional anesthesia and pain therapy and the American society of regional anesthesia and pain medicine joint committee practice advisory on controversial topics in pediatric regional anesthesia I and II. Curr Opin Anaesthesiol 2017; 30:613-620. [DOI: 10.1097/aco.0000000000000508] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|
10
|
Ramachandran R, Bansal S, Yadav P, Rewari V. Transversus Abdominis Plane Block for Inguinal Hernia Repair in a Premature Infant: A Case Report. ACTA ACUST UNITED AC 2017; 8:31-32. [PMID: 27828783 DOI: 10.1213/xaa.0000000000000415] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
In this report, we describe the case of a premature infant (36 weeks' postgestational age) who underwent left inguinal hernia repair under general anesthesia without the use of any airway device. Anesthesia was induced and maintained with sevoflurane in oxygen and nitrous oxide. An ultrasound-guided transversus abdominis plane block was performed that provided effective analgesia, obviating the need for opioids in the intraoperative period. The infant's hemodynamics remained stable throughout the surgery. This report also briefly explains the advantages of using a transversus abdominis plane block, compared with neuraxial blockade, for hernia repair surgery.
Collapse
Affiliation(s)
- Rashmi Ramachandran
- From the Department of Anaesthesiology, Pain Medicine and Critical Care, All India Institute of Medical Sciences, Delhi, India
| | | | | | | |
Collapse
|
11
|
Yaksh TL, Fisher CJ, Hockman TM, Wiese AJ. Current and Future Issues in the Development of Spinal Agents for the Management of Pain. Curr Neuropharmacol 2017; 15:232-259. [PMID: 26861470 PMCID: PMC5412694 DOI: 10.2174/1570159x14666160307145542] [Citation(s) in RCA: 44] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2015] [Revised: 12/02/2015] [Accepted: 02/05/2016] [Indexed: 11/22/2022] Open
Abstract
Targeting analgesic drugs for spinal delivery reflects the fact that while the conscious experience of pain is mediated supraspinally, input initiated by high intensity stimuli, tissue injury and/or nerve injury is encoded at the level of the spinal dorsal horn and this output informs the brain as to the peripheral environment. This encoding process is subject to strong upregulation resulting in hyperesthetic states and downregulation reducing the ongoing processing of nociceptive stimuli reversing the hyperesthesia and pain processing. The present review addresses the biology of spinal nociceptive processing as relevant to the effects of intrathecally-delivered drugs in altering pain processing following acute stimulation, tissue inflammation/injury and nerve injury. The review covers i) the major classes of spinal agents currently employed as intrathecal analgesics (opioid agonists, alpha 2 agonists; sodium channel blockers; calcium channel blockers; NMDA blockers; GABA A/B agonists; COX inhibitors; ii) ongoing developments in the pharmacology of spinal therapeutics focusing on less studied agents/targets (cholinesterase inhibition; Adenosine agonists; iii) novel intrathecal targeting methodologies including gene-based approaches (viral vectors, plasmids, interfering RNAs); antisense, and toxins (botulinum toxins; resniferatoxin, substance P Saporin); and iv) issues relevant to intrathecal drug delivery (neuraxial drug distribution), infusate delivery profile, drug dosing, formulation and principals involved in the preclinical evaluation of intrathecal drug safety.
Collapse
Affiliation(s)
- Tony L. Yaksh
- University of California, San Diego, Anesthesia Research Lab 0818, 9500 Gilman Dr. LaJolla, CA 92093, USA
| | - Casey J. Fisher
- University of California, San Diego, Anesthesia Research Lab 0818, 9500 Gilman Dr. LaJolla, CA 92093, USA
| | - Tyler M. Hockman
- University of California, San Diego, Anesthesia Research Lab 0818, 9500 Gilman Dr. LaJolla, CA 92093, USA
| | - Ashley J. Wiese
- University of California, San Diego, Anesthesia Research Lab 0818, 9500 Gilman Dr. LaJolla, CA 92093, USA
| |
Collapse
|
12
|
Adjunct analgesic drugs to local anaesthetics for neuroaxial blocks in children. Curr Opin Anaesthesiol 2016; 29:626-31. [DOI: 10.1097/aco.0000000000000372] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
|
13
|
Bian Y, Deng C, Li W, Lei Z, Li Y, Li X. A Comparative Study on the Biological Characteristics of Human Adipose-Derived Stem Cells from Lipectomy and Liposuction. PLoS One 2016; 11:e0162343. [PMID: 27610618 PMCID: PMC5017729 DOI: 10.1371/journal.pone.0162343] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2016] [Accepted: 08/22/2016] [Indexed: 01/07/2023] Open
Abstract
PURPOSES To compare the biological behaviors of human adipose-derived stem cells (ADSCs) isolated from adipose tissue by lipectomy and liposuction, with the purpose of providing the basis for clinical application. METHODS The proliferation and apoptosis of ADSCs were analyzed by CCK-8 assay and flow cytometry. Cell migration was measured by a wound healing assay. An ELISA assay was used to evaluate paracrine functions. SOD and MDA were tested by xanthine oxidase and thiobarbituric acid reactions, respectively. In addition, we used a CCK-8, LDH assay and flow cytometry to analyze the proliferation and apoptosis of ADSCs treated with lidocaine or adrenaline. RESULTS The viable ADSCs yield from liposuction was significantly lower than that from lipectomy, while the apoptosis of cells from liposuction was significantly higher than from lipectomy. The paracrine secretion of the two sources of ADSCs was highest when treated with 10-7 mol/L insulin and 10 ng/mL TGF-α, but there were no significant differences in VEGF, IL-6, IL-8 or HGF levels. The ADSCs from lipectomy migrated faster than those from liposuction, and SOD in the lipectomy group was higher than in the liposuction group, whereas MDA of the lipectomy group was lower than that of the liposuction group. The proliferation ADSCs treated with lidocaine or adrenaline was greatly decreased, while apoptosis was significantly increased, and cytotoxicity of lidocaine or adrenaline to ADSCs was dose-dependent. CONCLUSIONS Compared with ADSCs from liposuction, the ADSCs from lipectomy have better biological characteristics. Lidocaine and adrenaline decreased the viability of ADSCs, and their cytotoxicity to ADSCs was dose-dependent.
Collapse
Affiliation(s)
- Yongqian Bian
- Department of Burn and Plastic Surgery, Tangdu Hospital, Fourth Military Medical University, Xi'an, Shannxi, China
| | - Chen Deng
- Department of Burn and Plastic Surgery, Tangdu Hospital, Fourth Military Medical University, Xi'an, Shannxi, China
| | - Wangzhou Li
- Department of Burn and Plastic Surgery, Tangdu Hospital, Fourth Military Medical University, Xi'an, Shannxi, China
| | - Zhanjun Lei
- Department of Burn and Plastic Surgery, Tangdu Hospital, Fourth Military Medical University, Xi'an, Shannxi, China
| | - Yuejun Li
- Department of Burn and Plastic Surgery, Tangdu Hospital, Fourth Military Medical University, Xi'an, Shannxi, China
- * E-mail: (XL); (YL)
| | - Xueyong Li
- Department of Burn and Plastic Surgery, Tangdu Hospital, Fourth Military Medical University, Xi'an, Shannxi, China
- * E-mail: (XL); (YL)
| |
Collapse
|
14
|
Zhang H, Sun XR, Wang J, Zhang ZZ, Zhao HT, Li HH, Ji MH, Li KY, Yang JJ. Reactive Oxygen Species-mediated Loss of Phenotype of Parvalbumin Interneurons Contributes to Long-term Cognitive Impairments After Repeated Neonatal Ketamine Exposures. Neurotox Res 2016; 30:593-605. [DOI: 10.1007/s12640-016-9653-1] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2016] [Revised: 07/08/2016] [Accepted: 07/13/2016] [Indexed: 01/29/2023]
|
15
|
Wolf A, McKay A, Spowart C, Granville H, Boland A, Petrou S, Sutherland A, Gamble C. Prospective multicentre randomised, double-blind, equivalence study comparing clonidine and midazolam as intravenous sedative agents in critically ill children: the SLEEPS (Safety profiLe, Efficacy and Equivalence in Paediatric intensive care Sedation) study. Health Technol Assess 2016; 18:1-212. [PMID: 26099138 DOI: 10.3310/hta18710] [Citation(s) in RCA: 44] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Children in paediatric intensive care units (PICUs) require analgesia and sedation but both undersedation and oversedation can be harmful. OBJECTIVE Evaluation of intravenous (i.v.) clonidine as an alternative to i.v. midazolam. DESIGN Multicentre, double-blind, randomised equivalence trial. SETTING Ten UK PICUs. PARTICIPANTS Children (30 days to 15 years inclusive) weighing ≤ 50 kg, expected to require ventilation on PICU for > 12 hours. INTERVENTIONS Clonidine (3 µg/kg loading then 0-3 µg/kg/hour) versus midazolam (200 µg/kg loading then 0-200 µg/kg/hour). Maintenance infusion rates adjusted according to behavioural assessment (COMFORT score). Both groups also received morphine. MAIN OUTCOME MEASURES Primary end point Adequate sedation defined by COMFORT score of 17-26 for ≥ 80% of the time with a ± 0.15 margin of equivalence. Secondary end points Percentage of time spent adequately sedated, increase in sedation/analgesia, recovery after sedation, side effects and safety data. RESULTS The study planned to recruit 1000 children. In total, 129 children were randomised, of whom 120 (93%) contributed data for the primary outcome. The proportion of children who were adequately sedated for ≥ 80% of the time was 21 of 61 (34.4%) - clonidine, and 18 of 59 (30.5%) - midazolam. The difference in proportions for clonidine-midazolam was 0.04 [95% confidence interval (CI) -0.13 to 0.21], and, with the 95% CI including values outside the range of equivalence (-0.15 to 0.15), equivalence was not demonstrated; however, the study was underpowered. Non-inferiority of clonidine to midazolam was established, with the only values outside the equivalence range favouring clonidine. Times to reach maximum sedation and analgesia were comparable hazard ratios: 0.99 (95% CI 0.53 to 1.82) and 1.18 (95% CI 0.49 to 2.86), respectively. Percentage time spent adequately sedated was similar [medians clonidine 73.8% vs. midazolam 72.8%: difference in medians 0.66 (95% CI -5.25 to 7.24)]. Treatment failure was 12 of 64 (18.8%) on clonidine and 7 of 61 (11.5%) on midazolam [risk ratio (RR) 1.63, 95% CI 0.69 to 3.88]. Proportions with withdrawal symptoms [28/60 (46.7%) vs. 30/58 (52.6%)] were similar (RR 0.89, 95% CI 0.62 to 1.28), but a greater proportion required clinical intervention in those receiving midazolam [11/60 (18.3%) vs. 16/58 (27.6%) (RR 0.66, 95% CI 0.34 to 1.31)]. Post treatment, one child on clonidine experienced mild rebound hypertension, not requiring intervention. A higher incidence of inotropic support during the first 12 hours was required for those on clonidine [clonidine 5/45 (11.1%) vs. midazolam 3/52 (5.8%)] (RR 1.93 95% CI 0.49 to 7.61). CONCLUSIONS Clonidine is an alternative to midazolam. Our trial-based economic evaluation suggests that clonidine is likely to be a cost-effective sedative agent in the PICU in comparison with midazolam (probability of cost-effectiveness exceeds 50%). Rebound hypertension did not appear to be a significant problem with clonidine but, owing to its effects on heart rate, specific cardiovascular attention needs to be taken during the loading and early infusion phase. Neither drug in combination with morphine provided ideal sedation, suggesting that in unparalysed patients a third background agent is necessary. The disappointing recruitment rates reflect a reluctance of parents to provide consent when established on a sedation regimen, and reluctance of clinicians to allow sedation to be studied in unstable critically ill children. Future studies will require less exacting protocols allowing enhanced recruitment. TRIAL REGISTRATION Current Controlled Trials ISRCTN02639863. FUNDING This project was funded by the NIHR Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 18, No. 71. See the NIHR Journals Library website for further project information.
Collapse
Affiliation(s)
- Andrew Wolf
- Bristol Royal Children's Hospital, Bristol, UK
| | - Andrew McKay
- Clinical Trials Research Centre, University of Liverpool, Liverpool, UK
| | - Catherine Spowart
- Clinical Trials Research Centre, University of Liverpool, Liverpool, UK
| | - Heather Granville
- Clinical Trials Research Centre, University of Liverpool, Liverpool, UK
| | - Angela Boland
- Liverpool Reviews and Implementation Group, University of Liverpool, Liverpool, UK
| | | | - Adam Sutherland
- Central Manchester University Hospitals NHS Trust, Manchester, UK
| | - Carrol Gamble
- Clinical Trials Research Centre, University of Liverpool, Liverpool, UK
| |
Collapse
|
16
|
Mazo I, Roza C, Zamanillo D, Merlos M, Vela JM, Lopez-Garcia JA. Effects of centrally acting analgesics on spinal segmental reflexes and wind-up. Eur J Pain 2015; 19:1012-20. [PMID: 25469831 DOI: 10.1002/ejp.629] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/15/2014] [Indexed: 12/30/2022]
Abstract
BACKGROUND The spinal cord is a prime site of action for analgesia. Here we characterize the effects of established analgesics on segmental spinal reflexes. The aim of the study was to look for the pattern of action or signature of analgesic effects on these reflexes. METHODS We used a spinal cord in vitro preparation of neonate mice to record ventral root responses to dorsal root stimulation. Pregabalin, clonidine, morphine and duloxetine and an experimental sigma-1 receptor antagonist (S1RA) were applied to the preparation in a cumulative concentration protocol. Drug effects on the wind-up produced by repetitive stimulation of C-fibres and on responses to single A- and C-fibre intensity stimuli were analysed. RESULTS All compounds produced a concentration-dependent inhibition of total spikes elicited by repetitive stimulation. Concentrations producing ∼50% reduction in this parameter were (in μM) clonidine (0.01), morphine (0.1), pregabalin (1), duloxetine (10) and S1RA (30). At these concentrations clonidine, pregabalin and S1RA had significant effects on the wind-up index and little depressant effects on responses to single stimuli. Morphine and duloxetine did not depress wind-up index and showed large effects on responses to single stimuli. None of the compounds had strong effects on the amplitude of the non-nociceptive monosynaptic reflex. CONCLUSIONS morphine and duloxetine had general depressant effects on spinal reflexes, whereas the effects of clonidine, pregabalin and S1RA appeared to be restricted to signals originated by strong repetitive activation of C-fibres. Results are discussed in the context of reported behavioural effects of the compounds studied.
Collapse
Affiliation(s)
- I Mazo
- Department of Systems Biology (Division Physiology), Edificio Medicina, Universidad de Alcala, Madrid, Spain
| | - C Roza
- Department of Systems Biology (Division Physiology), Edificio Medicina, Universidad de Alcala, Madrid, Spain
| | - D Zamanillo
- Esteve, Drug Discovery and Preclinical Development, Parc Científic de Barcelona, Spain
| | - M Merlos
- Esteve, Drug Discovery and Preclinical Development, Parc Científic de Barcelona, Spain
| | - J M Vela
- Esteve, Drug Discovery and Preclinical Development, Parc Científic de Barcelona, Spain
| | - J A Lopez-Garcia
- Department of Systems Biology (Division Physiology), Edificio Medicina, Universidad de Alcala, Madrid, Spain
| |
Collapse
|
17
|
Eizaga Rebollar R, García Palacios MV, Morales Guerrero J, Torres Morera LM. [Central blockades in Pediatrics: A review of current literature]. ACTA ACUST UNITED AC 2015; 63:91-100. [PMID: 25866132 DOI: 10.1016/j.redar.2015.03.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2014] [Revised: 02/28/2015] [Accepted: 03/02/2015] [Indexed: 10/23/2022]
Abstract
Pediatric neuraxial anesthesia is an effective tool that can be used as a supplement or alternative to general anesthesia. However, there have always been doubts about its usefulness and risk-benefit ratio. The purpose of this review is to describe the current role of central blockades in pediatric patients, upgrade practical and safety aspects, and review the latest technological advances applied to this procedure.
Collapse
Affiliation(s)
- R Eizaga Rebollar
- Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, Hospital Universitario Puerta del Mar, Cádiz, España.
| | - M V García Palacios
- Servicio de Medicina Preventiva y Salud Pública, Hospital Universitario Puerta del Mar, Cádiz, España
| | - J Morales Guerrero
- Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, Hospital Universitario Puerta del Mar, Cádiz, España
| | - L M Torres Morera
- Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, Hospital Universitario Puerta del Mar, Cádiz, España
| |
Collapse
|
18
|
Lönnqvist PA. Adjuncts should always be used in pediatric regional anesthesia. Paediatr Anaesth 2015; 25:100-6. [PMID: 25230242 DOI: 10.1111/pan.12526] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/15/2014] [Indexed: 02/03/2023]
Abstract
A number of different adjuncts to local anesthetics can be used to prolong and optimize postoperative pain relief following regional anesthesia in children. The present text provides a slightly opinionated but evidence-based argument in favor of this practice.
Collapse
Affiliation(s)
- Per-Arne Lönnqvist
- Paediatric Anaesthesia & Intensive Care, Section of Anaesthesiology & Intensive Care, Department of Physiology & Pharmacology, Karolinska Institutet, Stockholm, Sweden; Paediatric Anaesthesia, Inetsive Care & ECMO Services, Astrid Lindgrens Children's Hospital/Karolinska University Hospital-Solna, Stockholm, Sweden
| |
Collapse
|
19
|
Maitra S, Baidya DK, Pawar DK, Arora MK, Khanna P. Epidural anesthesia and analgesia in the neonate: a review of current evidences. J Anesth 2014; 28:768-79. [DOI: 10.1007/s00540-014-1796-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2013] [Accepted: 01/19/2014] [Indexed: 01/16/2023]
|
20
|
Abstract
Effective management of procedural and postoperative pain in neonates is required to minimize acute physiological and behavioral distress and may also improve acute and long-term outcomes. Painful stimuli activate nociceptive pathways, from the periphery to the cortex, in neonates and behavioral responses form the basis for validated pain assessment tools. However, there is an increasing awareness of the need to not only reduce acute behavioral responses to pain in neonates, but also to protect the developing nervous system from persistent sensitization of pain pathways and potential damaging effects of altered neural activity on central nervous system development. Analgesic requirements are influenced by age-related changes in both pharmacokinetic and pharmacodynamic response, and increasing data are available to guide safe and effective dosing with opioids and paracetamol. Regional analgesic techniques provide effective perioperative analgesia, but higher complication rates in neonates emphasize the importance of monitoring and choice of the most appropriate drug and dose. There have been significant improvements in the understanding and management of neonatal pain, but additional research evidence will further reduce the need to extrapolate data from older age groups. Translation into improved clinical care will continue to depend on an integrated approach to implementation that encompasses assessment and titration against individual response, education and training, and audit and feedback.
Collapse
Affiliation(s)
- Suellen M Walker
- Correspondence Suellen Walker, Portex Unit: Pain Research; 6th Floor Cardiac Wing, UCL Institute of Child Health, 30 Guilford St, London WC1N 1EH, UK,
| |
Collapse
|
21
|
Abstract
Even after a vast safety record, the role of spinal anesthesia (SA) as a primary anesthetic technique in children remains contentious and is mainly limited to specialized pediatric centers. It is usually practiced on moribund former preterm infants (<60 weeks post-conception) to reduce the incidence of post-operative apnea when compared to general anesthesia (GA). However, there is ample literature to suggest its safety and efficacy for suitable procedures in older children as well. SA in children has many advantages as in adults with an added advantage of minimal cardio-respiratory disturbance. Recently, several reports from animal studies have raised serious concerns regarding the harmful effects of GA on young developing brain. This may further increase the utility of SA in children as it provides all components of balanced anesthesia technique. Also, SA can be an economical option for countries with finite resources. Limited duration of surgical anesthesia in children is one of the major deterrents for its widespread use in them. To overcome this, several additives like epinephrine, clonidine, fentanyl, morphine, neostigmine etc. have been used and found to be effective even in neonates. But, the developing spinal cord may also be vulnerable to drug-related toxicity, though this has not been systematically evaluated in children. So, adjuvants and drugs with widest therapeutic index should be preferred in children. Despite its widespread use, incidence of side-effects is low and permanent neurological sequalae have not been reported with SA. Literature yields encouraging results regarding its safety and efficacy. Technical skills and constant vigilance of experienced anesthesia providers is indispensable to achieve good results with this technique.
Collapse
Affiliation(s)
- Anju Gupta
- Department of Anesthesiology and Intensive Care, Delhi State Cancer Hospital, Dilshad Garden, New Delhi, India
| | - Usha Saha
- LHMC and Associated Hospitals, New Delhi, India
| |
Collapse
|
22
|
Evaluation of spinal toxicity and long-term spinal reflex function after intrathecal levobupivaciane in the neonatal rat. Anesthesiology 2013; 119:142-55. [PMID: 23514721 DOI: 10.1097/aln.0b013e31828fc7e7] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Neuraxial anesthesia is utilized in children of all ages. Local anesthetics produce dose-dependent toxicity in certain adult models, but the developing spinal cord may also be susceptible to drug-induced apoptosis. In postnatal rodents, we examined the effects of intrathecal levobupivacaine on neuropathology and long-term sensorimotor outcomes. METHODS Postnatal day 3 (P3) or P7 rat pups received intrathecal levobupivacaine 2.5 mg/kg (0.5%) or saline. Mechanical withdrawal thresholds and motor block were assessed. Spinal cord tissue analysis included apoptosis counts (activated caspase-3, Fluoro-Jade C) at 24 h, glial reactivity at 7 days, and histopathology in cord and cauda equina at 24 h and 7 days. Long-term spinal function in young adults (P35) was assessed by hind limb withdrawal thresholds, electromyography responses to suprathreshold stimuli, and gait analysis. RESULTS Intrathecal levobupivacaine produced spinal anesthesia at P3 and P7. No increase in apoptosis or histopathological change was seen in the cord or cauda equina. In the P3 saline group, activated caspase-3 (mean±SEM per lumbar cord section 6.1±0.3) and Fluoro-Jade C (12.1±1.2) counts were higher than at P7, but were not altered by levobupivacaine (P=0.62 and P=0.11, two-tailed Mann-Whitney test). At P35, mechanical withdrawal thresholds, thermal withdrawal latency, and electromyographic reflex responses did not differ across P3 or P7 levobupivacaine or saline groups (one way ANOVA with Bonferroni comparisons). Intrathecal bupivacaine at P3 did not alter gait. CONCLUSION Single dose intrathecal levobupivacaine 0.5% did not increase apoptosis or produce spinal toxicity in neonatal rat pups. This study provides preclinical safety data relevant to neonatal use of neuraxial local anesthesia.
Collapse
|
23
|
Affiliation(s)
- A Machotta
- Department of Anesthesiology, Sophia Children's Hospital, Erasmus MC Rotterdam, Dr. Molewaterplein 60, P.O. Box 2040, 3000 CA, Rotterdam, Niederlande.
| | | |
Collapse
|
24
|
|
25
|
Sanders RD, Hassell J, Davidson AJ, Robertson NJ, Ma D. Impact of anaesthetics and surgery on neurodevelopment: an update. Br J Anaesth 2013; 110 Suppl 1:i53-72. [PMID: 23542078 DOI: 10.1093/bja/aet054] [Citation(s) in RCA: 146] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Accumulating preclinical and clinical evidence suggests the possibility of neurotoxicity from neonatal exposure to general anaesthetics. Here, we review the weight of the evidence from both human and animal studies and discuss the putative mechanisms of injury and options for protective strategies. Our review identified 55 rodent studies, seven primate studies, and nine clinical studies of interest. While the preclinical data consistently demonstrate robust apoptosis in the nervous system after anaesthetic exposure, only a few studies have performed cognitive follow-up. Nonetheless, the emerging evidence that the primate brain is vulnerable to anaesthetic-induced apoptosis is of concern. The impact of surgery on anaesthetic-induced brain injury has not been adequately addressed yet. The clinical data, comprising largely retrospective cohort database analyses, are inconclusive, in part due to confounding variables inherent in these observational epidemiological approaches. This places even greater emphasis on prospective approaches to this problem, such as the ongoing GAS trial and PANDA study.
Collapse
Affiliation(s)
- R D Sanders
- Wellcome Department of Imaging Neuroscience, Institute for Women's Health, University College London, London, UK.
| | | | | | | | | |
Collapse
|
26
|
The Myth of the Equiangular Triangle for Identification of Sacral Hiatus in Children Disproved by Ultrasonography. Reg Anesth Pain Med 2013; 38:243-7. [DOI: 10.1097/aap.0b013e31828e8a1a] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|
27
|
Lönnqvist PA, Walker SM. Ketamine as an adjunct to caudal block in neonates and infants: is it time to re-evaluate? Br J Anaesth 2012; 109:138-40. [PMID: 22782976 DOI: 10.1093/bja/aes228] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
|
28
|
Walker SM, Yaksh TL. Neuraxial analgesia in neonates and infants: a review of clinical and preclinical strategies for the development of safety and efficacy data. Anesth Analg 2012; 115:638-62. [PMID: 22798528 DOI: 10.1213/ane.0b013e31826253f2] [Citation(s) in RCA: 54] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
Neuraxial drugs provide robust pain control, have the potential to improve outcomes, and are an important component of the perioperative care of children. Opioids or clonidine improves analgesia when added to perioperative epidural infusions; analgesia is significantly prolonged by the addition of clonidine, ketamine, neostigmine, or tramadol to single-shot caudal injections of local anesthetic; and neonatal intrathecal anesthesia/analgesia is increasing in some centers. However, it is difficult to determine the relative risk-benefit of different techniques and drugs without detailed and sensitive data related to analgesia requirements, side effects, and follow-up. Current data related to benefits and complications in neonates and infants are summarized, but variability in current neuraxial drug use reflects the relative lack of high-quality evidence. Recent preclinical reports of adverse effects of general anesthetics on the developing brain have increased awareness of the potential benefit of neuraxial anesthesia/analgesia to avoid or reduce general anesthetic dose requirements. However, the developing spinal cord is also vulnerable to drug-related toxicity, and although there are well-established preclinical models and criteria for assessing spinal cord toxicity in adult animals, until recently there had been no systematic evaluation during early life. Therefore, in the second half of this review, we present preclinical data evaluating age-dependent changes in the pharmacodynamic response to different spinal analgesics, and recent studies evaluating spinal toxicity in specific developmental models. Finally, we advocate use of neuraxial drugs with the widest demonstrable safety margin and suggest minimum standards for preclinical evaluation before adoption of new analgesics or preparations into routine clinical practice.
Collapse
Affiliation(s)
- Suellen M Walker
- Portex Unit: Pain Research, UCL Institute of Child Health and Great Ormond Street Hospital NHS Trust, London, UK.
| | | |
Collapse
|