Postoperative pain control in children: a guide to drug choice

A Comprehensive Review on the Role of Melatonin's Anesthetic Applications in Pediatric Care

Anesthesia is critical to pediatric care, ensuring the safety and comfort of children undergoing medical procedures. With a growing interest in alternative anesthetic agents, melatonin has emerged as a promising candidate due to its sedative, analgesic, anti-inflammatory, and neuroprotective properties. This comprehensive review explores the potential applications of melatonin in pediatric anesthesia. We delve into the pharmacological characteristics of melatonin, its anesthetic properties, and its clinical applications in pediatric care, including preoperative sedation, adjunct to general anesthesia, postoperative pain management, and prevention of emergence delirium. Additionally, we discuss the safety profile of melatonin, potential adverse effects, and comparative analysis with traditional anesthetics. Finally, we highlight future research directions to provide insights into melatonin's role in pediatric anesthesia and its implications for clinical practice.

Comparative Analgesic Efficacies of Ropivacaine and Bupivacaine for Postoperative Rectus Sheath Block in Paediatric Abdominal Surgery: A Meta-Analysis of Randomized Controlled Trial and Retrospective Cohort Studies

Background

The optimal dose and concentration of analgesic efficacy of ropivacaine (RPV) and bupivacaine (BPV) for postoperative pain relief in paediatric abdominal surgery patients is still unclear. Therefore, this meta-analysis compared the efficacy of these analgesics, their administered modes (ultrasound-guided RSB versus LAI) for postoperative pain relief, and side effects.

Methods

Three databases, PubMed, Embase, and Cochrane Database of Systematic Reviews, were exhaustively searched with predefined keywords. Eight randomized clinical trials and retrospective studies were selected. Analgesic effect, postoperative pain score, level of side effect, applied dose, and concentration of drug were analysed.

Results

Drug dose ranged from 0.5–2.5 mL/kg of 0.2 to 0.5% concentrations. Male participant for RSB and LAI treatment groups varied from 40–62% and 25–83%, respectively. Mean age of RSB and LAI groups ranged from 3.8–11.65 years and 4.3–11.27 years, respectively. Our meta-analysis revealed that RSB could reduce total opioid use postoperatively (WMD = −0.02, 95% CI: −0.02, −0.02), with I² value of 15%. We found that the RPV (0.25%, 2.5 ml/kg) was optimal in suppressing the pain. Its lower concentration (0.2%) was ineffective, whereas higher one (0.375%) seems to increase risk of systemic toxicity. Similarly, BPV (0.25%, 2.5 mg/kg) efficaciously reduced the pain score, while its lower concentration was ineffective. The combined postoperative pain score in the RPV-treated group was found to be significantly reduced (p < 0.01) with I² value of 85% indicating high heterogeneity.

Conclusion

Both RPV and BPV were significantly effective in reducing postoperative pain score. It appears that RSB could be a preferred choice to deliver analgesia, due to reduced opiate dose requirement and improved clinical safety without significant postoperative adverse events.

Review of the enhanced recovery pathway for children: perioperative anesthetic considerations

PURPOSE

Enhanced recovery after surgery (ERAS) pathways have been used for two decades to improve perioperative recovery in adults. Nevertheless, little is known about their effectiveness in children. The purpose of this review was to consider pediatric ERAS pathways, review the literature concerned with their potential benefit, and compare them with adult ERAS pathways.

SOURCE

A PubMed literature search was performed for articles that included the terms enhanced recovery and/or fast track in the pediatric perioperative period. Pediatric patients included those from the neonatal period through teenagers and/or youths.

PRINCIPAL FINDINGS

The literature search revealed a paucity of articles about pediatric ERAS. This lack of academic investigation is likely due in part to the delayed acceptance of ERAS in the pediatric surgical arena. Several pediatric studies examined individual components of adult-based ERAS pathways, but the overall study of a comprehensive multidisciplinary ERAS protocol in pediatric patients is lacking.

CONCLUSION

Although adult ERAS pathways have been successful at reducing patient morbidity, the translation, creation, and utility of instituting pediatric ERAS pathways have yet to be realized.

Attitudes to and knowledge about pain and pain management, of nurses working with children with cancer: A comparative study between UK, South Africa and Sweden

Pain is among the most common effects of cancer and its treatment. Children and young people with cancer often consider pain from procedures and treatment to be the worst aspect of their illness.

This study aimed to i) identify and describe knowledge and attitudes to pain and pain management amongst nurses working with children with cancer and ii) compare the perspectives on pain and pain management of nurses from UK, South Africa and Sweden.

106 nurses working with children with cancer in UK, South Africa and Sweden completed Salanterä's (1999) questionnaire on nurses' attitudes to pain in children.

Nurses had good levels of knowledge and positive attitudes to pain management, with Swedish nurses' having higher levels of knowledge and a more positive attitude to pain management than nurses from UK or South Africa.

A high level of knowledge was correlated to a more positive attitude to pain management. Knowledge levels need to be improved to ensure more positive attitudes to pain management, especially for nurses in South Africa. Swedish nurses' level of knowledge about non-pharmacological pain management strategies has scope for improvement. British nurses may need to focus more on the sociology and psychology of pain.

Update on Analgesic Medication for Adult and Pediatric Dental Patients

This article is an update on pain management in the dental care setting for adult and pediatric patients. The 3 main categories of analgesic medications are examined: (1) opioids, (2) nonsteroidal antiinflammatory drugs (NSAIDs), and (3) nonopioid, non-NSAID medications. Pharmacology, side effects, patient selection, and treatment strategies and principles are examined. The information provided is aimed to facilitate the clinical perspective and update the oral health care clinician on providing safe and effective analgesia to adult and pediatric patients.

Attention to postoperative pain control in children

Even with the rapid development of pediatric postoperative pain management, pediatric patients have remained undertreated for postoperative pain because of difficulty in pain assessment and concerns regarding side effects of opioid analgesics. Although there are no perfect pain assessment techniques and no absolutely safe analgesics, proper monitoring and an individualized analgesic plan after due consideration of age, operative procedures, and underlying illness, using multimodal analgesics may improve the quality of pain control in children.

The validity of the Computer Face Scale for measuring pediatric pain and mood

OBJECTIVE

The aim was to assess the validity of the Computer Face Scale.

METHODS

Forty children (5-13 years old) rated pain and mood prior to and twice following tonsillectomy. The children used the Computer Face Scale to adjust a cartoon face to rate pain and mood. During sessions one and two, the children also chose an expression on the Wong-Baker Faces Scale to rate their pain, and they reported their mood verbally on a seven-point scale.

RESULTS

On average, the children reported no pain and a positive mood prior to surgery. Soon after surgery, they reported mild pain and a slightly negative mood. An hour later, they reported decreases in pain and return to a positive mood. The differences between presurgery and postsurgery ratings were statistically significant (P ≤ 0.001) for all measures. The correlation between the two mood measures was 0.88 before surgery and 0.78 afterward. The correlation between the two measures of pain was 0.83 after surgery (P's < 0.001).

CONCLUSIONS

The results support the validity of the Computer Face Scale. The mean ratings of pain and mood followed the expected pattern from pre- to postsurgery, and there was a significant association between ratings obtained by different methods. The Computer Face Scale provides a simple-to-use scale with more resolution and electronic capture, which may provide advantages in numerous clinical and research applications.

Pediatric Palliative Care, Costa Rica’s Experience

Background: This article describes the patients and activities of the Pediatric Palliative Care and Pain Control Clinic of the National Children’s Hospital (PPCPCC NCH) in San Jose, Costa Rica Central America, founded in 1990, is the first such clinic in the country. Methods: This study includes all the children and adolescents referred to the PPCPCC NCH from January 2000 to December 2008. This is a quantitative and descriptive study. We used a simple format that included variables such as age, sex, diagnostic, place of reference, pain, and other symptoms. Results: The database initially registered a total of 1470 patients; 25 of these were excluded from the study because of incomplete information, leaving a total of 1445 registered cases for the analysis. The average number of patients admitted was 156 per year. Malignant tumor was the principal diagnosis at the time of admission, followed by central nervous system abnormalities. Pain was the most frequent symptom. Most patients were visited or examined at home and/or the pediatric palliative care day center and died in their own home. Conclusion: The initial analysis enabled us to obtain information and feedback about the work of the PPCPCC. We are now able to understand more fully the needs of pediatric palliative care in Costa Rica such as increasing the coverage of pediatric patients who require palliative care, improving our resources, further defining the criteria for admission of patients to a palliative care program, and developing standards for measuring and recording symptoms besides pain.

Pre-surgical child behavior ratings and pain management after two different techniques of tonsil surgery

OBJECTIVE

The purpose of this investigation was to compare child behavior before surgery with experience of pain and anxiety in relation to two techniques of tonsil surgery, to relate previous experiences of surgery/tonsillitis with anxiety and pain, and to compare the children's, parent's and nurse's rating of pain.

METHOD

Ninety-two children (5-15 years) with sleep-disordered breathing (SDB) and with or without recurrent tonsillitis were randomized to partial tonsil resection/tonsillotomy (TT) or full tonsillectomy (TE).

MEASURES

Parents: Child Behavior Checklist (CBCL). Children: State-Trait-Anxiety Inventory for Children (STAIC) and seven-point Faces Pain Scale (FPS). Parents/staff: seven-point Verbal Pain Rating Scale (VPRS). Pain relievers were opoids, paracetamol and diclophenac.

RESULTS

These children with SDB scored significantly higher on CBCL than did normative groups, but no connection was observed between CBCL rating and experience of pain. There was no relation between pre-operative anxiety and pain. The post-operative anxiety level (STAIC) correlated with pain. The TE-group scored higher on STAIC after surgery. Previous experience of surgery or tonsillitis did not influence post-operative pain. The TE-group rated higher experience of pain despite more medication. The nurses scored pain lower than the parents/children and under-medicated.

CONCLUSION

SDB may influence children's behavior, but with no relation to post-operative pain. The surgical method predicts pain better than does the child's behavior rating. The nurses underestimated the pain experienced by the child.

Plasma concentrations following repeated rectal or intravenous administration of paracetamol after heart surgery

BACKGROUND

Paracetamol is commonly used for post-operative pain management in combination with more potent analgesics. The best route of paracetamol administration after major surgery, when oral intake may not be optimal, is not known. Our primary purpose was to study plasma concentrations after the 1st and 4th dose of 1 g of paracetamol given either rectally or intravenously (i.v.) after major surgery.

METHODS

In this prospective, randomized study, 48 patients undergoing heart surgery were randomized upon arrival to the intensive care unit (ICU) to receive paracetamol every 6th hour either as suppositories or intravenous injections. In half the patients (n = 24), blood samples for paracetamol concentration were obtained before and 20, 40 and 80 min after the first dose. In the other patients (n = 24), additional samples were taken prior to, and at 20, 40, 80 min and 4 and 6 h after, the 4th dose.

RESULTS

Plasma paracetamol concentration peaked (95 +/- 36 micromol/l) within 40 min after initial i.v. administration but did not increase within 80 min after the 1st suppository. Plasma concentration before the 4th dose was 74 +/- 51 and 50 +/- 27 in the rectal and i.v. groups, respectively. Paracetamol concentration peaked 20 min after the 4th dose for the i.v. patients (210 +/- 84 micromol/l) and declined to 99 +/- 27 micromol/l at 80 min as compared with the rectal patients 69 +/- 44 to 77 +/- 48 micromol/l.

CONCLUSION

Both time course and peak plasma concentrations of paracetamol given rectally differ from the one seen after intravenous administration. The clinical impact of these differences needs further investigation.

Safety of ketorolac in neonates and infants after cardiac surgery

BACKGROUND

Ketorolac is an injectable nonsteroidal anti-inflammatory drug that is often used as a transitional short-term analgesic to treat moderate pain and to decrease opioid use. There is a paucity of literature documenting the safety of using ketorolac in neonates and infants after cardiac surgery.

METHODS

A retrospective chart review was performed which identified all patients <6 months of age who received ketorolac after cardiac surgery. Patients' demographic, surgical, and dosing data were collected. A Student's t-test was used to identify significant differences in renal and hematologic laboratory values at baseline and at 48 h of treatment.

RESULTS

A total of 53 children <6 months of age received at least one dose of ketorolac after cardiac surgery. Eleven of 53 children (21%) were <1 month of age. The blood urea nitrogen/serum creatinine (SCr) levels increased from baseline at 48 h of therapy in all infants, but stayed within normal limits. The largest increase in SCr level from baseline on any day of ketorolac therapy was 26 micromol x l(-1) (0.3 mg x dl(-1)) which occurred in two neonates. Four patients (three infants and one neonate) had minor episodes of bleeding while being treated with ketorolac. There were no clinically significant changes in hemoglobin, hematocrit or platelet count. None of these episodes caused hemodynamic instability nor required transfusion of blood products.

CONCLUSIONS

Ketorolac was used safely in neonates and infants who have had cardiac surgery at our institution. Ketorolac was not associated with any adverse hematologic or renal effects. Prospective investigation is warranted to further assess the safety and effectiveness of ketorolac in this patient population.

Early bioavailability of paracetamol after oral or intravenous administration

BACKGROUND

Paracetamol is a peripherally acting analgesic commonly used in multimodal post-operative pain management to reduce the need for more potent analgesics with their unwanted side-effects. The dose and optimal galenical form for achieving analgesic concentrations is not well defined. The primary aim of this pilot project was to study the early bioavailability for two fixed doses of orally administrated paracetamol and one dose of intravenous propacetamol, all of which were given after minor surgery.

METHODS

Thirty-five patients undergoing day surgery were divided into five groups, seven patients each. Groups received either 1 g of an ordinary paracetamol tablet, 2 g of an ordinary paracetamol tablet, 1 g of a bicarbonate paracetamol tablet, 2 g of a bicarbonate paracetamol tablet or 2 g intravenously of prodrug propacetamol. We studied the plasma concentration of paracetamol during the first 80 min after administration.

RESULTS

Within 40 min, intravenous propacetamol gave a median plasma paracetamol concentration of 85 micromol/l (range 65-161) and decreased thereafter. After oral administration, median plasma paracetamol concentration increased with increasing dose and time, but there were huge inter-individual differences at all time points studied. At 80 min after oral paracetamol the median plasma concentrations were 36 and 129 micromol/l for the 1- and 2-g groups, respectively, with an overall range between 0 and 306 micromol/l.

CONCLUSION

Oral administration of paracetamol as part of multimodal pain management immediately post-operatively resulted in a huge and unpredictable variation in plasma concentration compared with the intravenous administration.