Effect of pre-operative rectal diclofenac suppository on post-operative analgesic requirement in cleft palate repair: A randomised clinical trial

Comparison of postoperative analgesia in children following ropivacaine and lidocaine surgical field infiltration with epinephrine for cleft palate repair: A double-blinded, randomized controlled trial

STUDY OBJECTIVE

The study aimed to evaluate the efficacy of ropivacaine in providing postoperative analgesia for children undergoing cleft palate repair.

METHODS

A double-blinded, randomized controlled trial was conducted on sixty-four children scheduled for cleft palate repair. The patients received either local infiltration with 1% lidocaine or 0.2% ropivacaine before incision. The primary outcome was the postoperative average pain score, and secondary outcomes included pain scores at various time points, consumption of flurbiprofen and hydromorphone, effectiveness of nurse-controlled analgesia pump, and incidence of bradycardia, vomiting, and respiratory depression.

MAIN RESULTS

The results showed that the postoperative average pain score was significantly lower in the ropivacaine group compared to the lidocaine group (1.27±0.28 vs. 1.75±0.29, P<0.001). Pain scores at multiple postoperative time points were also lower in the ropivac:aine group. Additionally, consumption of flurbiprofen and hydromorphone was lower, and ineffective compressions of the nurse-controlled analgesia pump were reduced in the ropivacaine group. The incidence of vomiting, bradycardia, and respiratory depression did not show significant differences between the two groups.

CONCLUSION

Local infiltration with ropivacaine effectively provided postoperative analgesia for children undergoing cleft palate repair without major side effects. It was found to be superior to lidocaine in reducing the need for additional rescue analgesia.

Diclofenac for acute postoperative pain in children

BACKGROUND

Many children undergo various surgeries, which often lead to acute postoperative pain. This pain influences recovery and quality of life. Non-steroidal anti-inflammatory drugs (NSAIDs), specifically cyclo-oxygenase (COX) inhibitors such as diclofenac, can be used to treat pain and reduce inflammation. There is uncertainty regarding diclofenac's benefits and harms compared to placebo or other drugs for postoperative pain.

OBJECTIVES

To assess the efficacy and safety of diclofenac (any dose) for acute postoperative pain management in children compared with placebo, other active comparators, or diclofenac administered by different routes (e.g. oral, rectal, etc.) or strategies (e.g. 'as needed' versus 'as scheduled').

SEARCH METHODS

We used standard, extensive Cochrane search methods. We searched CENTRAL, MEDLINE, and trial registries on 11 April 2022.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) in children under 18 years of age undergoing surgery that compared diclofenac (delivered in any dose and route) to placebo or any active pharmacological intervention. We included RCTs comparing different administration routes of diclofenac and different strategies.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane. Our primary outcomes were: pain relief (PR) reported by the child, defined as the proportion of children reporting 50% or better postoperative pain relief; pain intensity (PI) reported by the child; adverse events (AEs); and serious adverse events (SAEs). We presented results using risk ratios (RR), mean differences (MD), and standardised mean differences (SMD), with the associated confidence intervals (CI).

MAIN RESULTS

We included 32 RCTs with 2250 children. All surgeries were done using general anaesthesia. Most studies (27) included children above age three. Only two studies had an overall low risk of bias; 30 had an unclear or high risk of bias in one or several domains. Diclofenac versus placebo (three studies) None of the included studies reported on PR or PI. We are very uncertain about the benefits and harms of diclofenac versus placebo on nausea/vomiting (RR 0.83, 95% CI 0.38 to 1.80; 2 studies, 100 children) and any reported bleeding (RR 3.00, 95% CI 0.34 to 26.45; 2 studies, 100 children), both very low-certainty evidence. None of the included studies reported SAEs. Diclofenac versus opioids (seven studies) We are very uncertain if diclofenac reduces PI at 2 to 24 hours postoperatively compared to opioids (median pain intensity 0.3 (interquartile range (IQR) 0.0 to 2.5) for diclofenac versus median 0.7 (IQR 0.1 to 2.4) in the opioid group; 1 study, 50 children; very low-certainty evidence). None of the included studies reported on PR or PI for other time points. Diclofenac probably results in less nausea/vomiting compared to opioids (41.0% in opioids, 31.0% in diclofenac; RR 0.75, 95% CI 0.58 to 0.96; 7 studies, 463 participants), and probably increases any reported bleeding (5.4% in opioids, 16.5% in diclofenac; RR 3.06, 95% CI 1.31 to 7.13; 2 studies, 222 participants), both moderate-certainty evidence. None of the included studies reported SAEs. Diclofenac versus paracetamol (10 studies) None of the included studies assessed child-reported PR. Compared to paracetamol, we are very uncertain if diclofenac: reduces PI at 0 to 2 hours postoperatively (SMD -0.45, 95% CI -0.74 to -0.15; 2 studies, 180 children); reduces PI at 2 to 24 hours postoperatively (SMD -0.64, 95% CI -0.89 to -0.39; 3 studies, 300 children); reduces nausea/vomiting (RR 0.47, 95% CI 0.25 to 0.87; 5 studies, 348 children); reduces bleeding events (RR 0.57, 95% CI 0.12 to 2.62; 5 studies, 332 participants); or reduces SAEs (RR 0.50, 95% CI 0.05 to 5.22; 1 study, 60 children). The evidence certainty was very low for all outcomes. Diclofenac versus bupivacaine (five studies) None of the included studies reported on PR or PI. Compared to bupivacaine, we are very uncertain about the effect of diclofenac on nausea/vomiting (RR 1.28, 95% CI 0.58 to 2.78; 3 studies, 128 children) and SAEs (RR 4.52, 95% CI 0.23 to 88.38; 1 study, 38 children), both very low-certainty evidence. Diclofenac versus active pharmacological comparator (10 studies) We are very uncertain about the benefits and harms of diclofenac versus any other active pharmacological comparator (dexamethasone, pranoprofen, fluorometholone, oxybuprocaine, flurbiprofen, lignocaine), and for different routes and delivery of diclofenac, due to few and small studies, no reporting of key outcomes, and very low-certainty evidence for the reported outcomes. We are unable to draw any meaningful conclusions from the numerical results.

AUTHORS' CONCLUSIONS

We remain uncertain about the efficacy of diclofenac compared to placebo, active comparators, or by different routes of administration, for postoperative pain management in children. This is largely due to authors not reporting on clinically important outcomes; unclear reporting of the trials; or poor trial conduct reducing our confidence in the results. We remain uncertain about diclofenac's safety compared to placebo or active comparators, except for the comparison of diclofenac with opioids: diclofenac probably results in less nausea and vomiting compared with opioids, but more bleeding events. For healthcare providers managing postoperative pain, diclofenac is a COX inhibitor option, along with other pharmacological and non-pharmacological approaches. Healthcare providers should weigh the benefits and risks based on what is known of their respective pharmacological effects, rather than known efficacy. For surgical interventions in which bleeding or nausea and vomiting are a concern postoperatively, the risks of adverse events using opioids or diclofenac for managing pain should be considered.

Patient Safety and Quality Improvement Initiatives in Cleft Lip and Palate Surgery: A Systematic Review

BACKGROUND

Cleft lip and/or palate repair techniques require continued reevaluation of best practice through high-quality evidence. The objective of this systematic review was to highlight the existing evidence for patient safety and quality improvement (QI) initiatives in cleft lip and palate surgery.

METHODS

A systematic review of published literature evaluating patient safety and QI in patients with cleft lip and/or palate was conducted from database inception to June 9, 2022, using Preferred Reporting Items for Systematic Reviews guidelines. Quality appraisal of included studies was conducted using Methodological Index for Non-Randomized Studies, Cochrane, or a Measurement Tool to Assess Systematic Reviews (AMSTAR) 2 instruments, according to study type.

RESULTS

Sixty-one studies met inclusion criteria, with most published between 2010 and 2020 (63.9%). Randomized controlled trials represented the most common study design (37.7%). Half of all included studies were related to the topic of pain and analgesia, with many supporting the use of infraorbital nerve block using 0.25% bupivacaine. The second most common intervention examined was use of perioperative antibiotics in reducing fistula and infection (11.5%). Other studies examined optimal age and closure material for cleft lip repair, early recovery after surgery protocols, interventions to reduce blood loss, and safety of outpatient surgery.

CONCLUSIONS

Patient safety and QI studies in cleft surgery were of moderate quality overall and covered a wide range of interventions. To further enhance PS in cleft repair, more high-quality research in the areas of perioperative pharmaceutical usage, appropriate wound closure materials, and optimal surgical timing are needed.

Perioperative Pain Management in Cleft Lip and Palate Surgery: A Systematic Review and Meta-Analysis of Randomized Controlled Studies

BACKGROUND

Developing effective strategies to manage perioperative pain remains a focus of cleft care. The present study's purpose was to systematically review perioperative pain control strategies for cleft lip and palate repair.

METHODS

A systematic review and meta-analysis of randomized controlled trials was performed. Primary outcomes included pain scale scores and time to analgesia failure. Cohen d normalized effect size permitted comparison between studies, and a fixed-effects model was used for analysis. I2 and Q-statistic p values were calculated.

RESULTS

Twenty-three studies were included: eight of 23 studies provided data for meta-analytic comparison. Meta-analyses evaluated the efficacy of intraoperative nerve blocks on postoperative pain management. Meta-analysis included a total of 475 treatment and control patients. Cleft lip studies demonstrated significantly improved pain control with a nerve block versus placebo by means of pain scale scores ( p < 0.001) and time to analgesia failure ( p < 0.001). Measurement of effect size over time demonstrated statistically significant pain relief with local anesthetic. Palatoplasty studies showed significantly improved time to analgesia failure ( p < 0.005) with maxillary and palatal nerve blocks. Multiple studies demonstrated an opioid-sparing effect with the use of local anesthetics and other nonopioid medications. Techniques for nerve blocks in cleft lip and palate surgery are reviewed.

CONCLUSIONS

The present systematic review and meta-analysis of randomized controlled studies demonstrates that intraoperative nerve blocks for cleft lip and palate surgery provide effective pain control. Opioid-sparing effects were appreciated in multiple studies. Intraoperative nerve blocks should be considered in all cases of cleft lip and palate repair to improve postoperative pain management.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, II.

An Intervention Study on Children's Healthy Joint Attention Skills Based on a Mixed Instructional Approach of DTT and PRT

Joint attention is an important element that influences children's early development of communication and sociality, and joint attention is more often than not the earliest incipient of their prosocial behavior. Joint attention skills are one of the core deficits of children with autism, and identifying and remediating the core problems of autism is a popular area of interest, with joint attention being the focus of attention. The aim of this study was to investigate whether the combined orientation model of Discrete Trial Teaching (DTT) and Pivotal Response Training (PRT) could improve the joint attention skills of children with autism. This study used a cross-behavioral multitest design in a single-subject study with two preschool children with autism as subjects, with the independent variable being joint attention teaching and the dependent variable being the three joint attention skills (eye gaze, following directions, and active display). After the instructional intervention, children with autism showed a significant increase in the correctness of "eye alternation," "following directions," and "moving displays."

Guidelines for Opioid Prescribing in Children and Adolescents After Surgery: An Expert Panel Opinion

IMPORTANCE

Opioids are frequently prescribed to children and adolescents after surgery. Prescription opioid misuse is associated with high-risk behavior in youth. Evidence-based guidelines for opioid prescribing practices in children are lacking.

OBJECTIVE

To assemble a multidisciplinary team of health care experts and leaders in opioid stewardship, review current literature regarding opioid use and risks unique to pediatric populations, and develop a broad framework for evidence-based opioid prescribing guidelines for children who require surgery.

EVIDENCE REVIEW

Reviews of relevant literature were performed including all English-language articles published from January 1, 1988, to February 28, 2019, found via searches of the PubMed (MEDLINE), CINAHL, Embase, and Cochrane databases. Pediatric was defined as children younger than 18 years. Animal and experimental studies, case reports, review articles, and editorials were excluded. Selected articles were graded using tools from the Oxford Centre for Evidence-based Medicine 2011 levels of evidence. The Appraisal of Guidelines for Research & Evaluation (AGREE) II instrument was applied throughout guideline creation. Consensus was determined using a modified Delphi technique.

FINDINGS

Overall, 14 574 articles were screened for inclusion, with 217 unique articles included for qualitative synthesis. Twenty guideline statements were generated from a 2-day in-person meeting and subsequently reviewed, edited, and endorsed externally by pediatric surgical specialists, the American Pediatric Surgery Association Board of Governors, the American Academy of Pediatrics Section on Surgery Executive Committee, and the American College of Surgeons Board of Regents. Review of the literature and guideline statements underscored 3 primary themes: (1) health care professionals caring for children who require surgery must recognize the risks of opioid misuse associated with prescription opioids, (2) nonopioid analgesic use should be optimized in the perioperative period, and (3) patient and family education regarding perioperative pain management and safe opioid use practices must occur both before and after surgery.

CONCLUSIONS AND RELEVANCE

These are the first opioid-prescribing guidelines to address the unique needs of children who require surgery. Health care professionals caring for children and adolescents in the perioperative period should optimize pain management and minimize risks associated with opioid use by engaging patients and families in opioid stewardship efforts.

Reporting of Randomized Controlled Trials in Cleft Lip and Palate: A 10-Year Review

Objectives

Reviews of the quality of reporting of randomized controlled trials (RCTs) have recently been conducted in different surgical specialties. In this review of RCTs relating to cleft lip, cleft palate, and cleft lip and palate (CL/P), we investigate the quality of reporting against the Consolidated Standards of Reporting Trials (CONSORT) checklist.

Design

A systematic review of CL/P RCTs published from 2004 to 2013, with the included articles scored against the CONSORT checklist.

Patients, Participants

The literature search identified 174 articles. Studies were selected for participants with CL/P who were involved in an RCT with prospective data collection and reported in a full journal article. A total of 6352 participants were included from 65 CUP RCTs during the study period.

Main Outcome Measures

The methodological quality of RCTs was assessed using the CONSORT checklist and Jadad scale.

Results

The mean CONSORT score was 15.8, and the mean Jadad score was 3.3. There was a significant positive correlation between the CONSORT and Jadad score ( P < .0001, ρ = .47). The only significant correlation showed that with an increasing number of authors, both the CONSORT and the Jadad score increased.

Conclusion

This analysis has shown that that there are deficiencies in the transparent reporting of factors such as randomization implementation, blinding, and participant flow. Interventions, outcomes, and the interpretation of results are well presented. We would recommend that RCTs are conceived and undertaken using the CONSORT checklist and reported in a clear and reproducible manner.

Comparison of preoperative rectal paracetamol with paracetamol - diclofenac combination for postoperative analgesia in pediatric surgeries under general anesthesia

CONTEXT

Traditionally, pain in children is a topic that has received only minimal attention. However, in the recent times, considerable progress has been made in the field of neonatal and pediatric pharmacology. The concept of preemptive analgesia is important in combating postoperative pain in children. In this study, we sought to compare the effectiveness of preemptive analgesia provided by paracetamol alone and by its combination with diclofenac when administered per rectum.

AIMS

To compare the efficacy of preoperative rectal paracetamol with paracetamol - diclofenac combination for postoperative analgesia in pediatric surgeries under general anesthesia.

SETTINGS AND DESIGN

Prospective randomized double-blind study.

SUBJECTS AND METHODS

Sixty children scheduled for various surgeries under general anesthesia were randomly allocated into two Groups A and B, with 30 in each. Children in Group A received paracetamol suppository 20 mg/kg and those in Group B received paracetamol 20 mg/kg + diclofenac 2 mg/kg as suppository immediately after tracheal intubation. All the children were assessed for 24 h from the time of extubation. The pain was measured using numerical rating scale in children above 7 years and face-legs-activity-cry-consolability scale in children below 7 years. The time interval between extubation and the administration of the first dose of rescue analgesic was taken as the duration of postoperative analgesia.

STATISTICAL ANALYSIS USED

Descriptive and inferential statistical methods were used to analyze the data.

RESULTS

The duration of postoperative analgesia was significantly longer in paracetamol + diclofenac group (21.13 ± 2.68 h) as compared to paracetamol alone group (10.18 ± 2.39 h).

CONCLUSIONS

The combination of paracetamol and diclofenac administered per rectum preoperatively is more effective than paracetamol alone in providing postoperative analgesia in children.

Immediate rescue designs in pediatric analgesic trials: a systematic review and meta-analysis

BACKGROUND

Designing analgesic clinical trials in pediatrics requires a balance between scientific, ethical, and practical concerns. A previous consensus group recommended immediate rescue designs using opioid sparing as a surrogate measure of analgesic efficacy. The authors summarize the performance of rescue analgesic designs in pediatric trials of four commonly used classes of analgesics: opioids, nonsteroidal antiinflammatory drugs, acetaminophen, and local anesthetics.

METHODS

MEDLINE, Embase, CINAHL, The Cochrane Library, and Web of science were searched in April 2013. The 85 studies selected were randomized or controlled clinical trials using immediate rescue paradigms in postoperative pain settings. A random-effects meta-analysis was used to synthesize predefined outcomes using Hedges' g. Difference between the means of the treatment arms were also expressed as a percentage of the corresponding value in the placebo group (placebo-treatment/placebo). Distributions of pain scores in study and control groups and relationships between opioid sparing and pain scores were examined.

RESULTS

For each of the four study drug classes, significant opioid sparing was demonstrated in a majority of studies by one or more of the following endpoints: (1) total dose (milligram per kilogram per hour), (2) percentage of children requiring rescue medication, and (3) time to first rescue medication (minutes). Pain scores averaged 2.4/10 in study groups, 3.4/10 in control groups.

CONCLUSIONS

Opioid sparing is a feasible pragmatic endpoint for pediatric pain analgesic trials. This review serves to guide future research in pediatric analgesia trials, which could test whether some specific design features may improve assay sensitivity while minimizing the risk of unrelieved pain.

Rectal route in the 21st Century to treat children

The rectal route can be considered a good alternative to the oral route for the paediatric population because these dosage forms are neither to be swallowed nor need to be taste-masked. Rectal forms can also be administered in an emergency to unconscious or vomiting children. Their manufacturing cost is low with excipients generally regarded as safe. Some new formulation strategies, including mucoadhesive gels and suppositories, were introduced to increase patient acceptability. Even if recent paediatric clinical studies have demonstrated the equivalence of the rectal route with others, in order to enable the use of this promising route for the treatment of children in the 21st Century, some effort should be focused on informing and educating parents and care givers. This review is the first ever to address all the aforementioned items, and to list all drugs used in paediatric rectal forms in literature and marketed products in developed countries.