Neuropathic pain other than CRPS in children and adolescents: incidence, referral, clinical characteristics, management, and clinical outcomes

BACKGROUND AND OBJECTIVES

Chronic pain in children and adolescents is common, but proportion of neuropathic pain (NP), a heterogeneous group of diseases with major impact on health-related quality of life, significant economic burden, and limited treatment options, is unclear. Many studies have focused only on complex regional pain syndrome (CRPS). Our aim was to examine the incidence, clinical features, management, and outcome of non-CRPS NP in patients referred to a chronic pediatric pain clinic (CPPC) at a tertiary-care hospital.

METHODS

Retrospective analyses of the patient's files with non-CRPS NP from 2008 until 2012.

RESULTS

Twenty patients (9.9-22.0 years; 10.7% of new referrals) were treated with non-CRPS NP (postoperative 8/20, trauma-related 5/20, disease-related 7/20). The number of consultations performed and the number of medications used before CPPC were significantly higher than in CPPC (Z = 0.75, P = 0.005; Z = 1.68, P = 0.003; respectively, Wilcoxon test). The number of diagnostic procedures was not statistically significant. Invasive treatments were used in 50% of patients. Full/partial recovery was accomplished in 95%. anova with repeated measures yielded a highly significant difference between the initial and final visual analog scale (VAS) scores (8.2 ± 1.3; 1.19 ± 2.01, respectively; P < 0.001), and no effect of age, gender, time needed for referral to CPPC, and patient's categories on the change in VAS.

CONCLUSIONS

Better understanding of the medical profile of pediatric patients with non-CRPS NP is crucial to timely and correct diagnosis and effective management, but even children with delayed diagnosis still have a good outcome. The management of this condition by an experienced team is recommended.

Spinal anesthesia for noncardiac surgery in infants with congenital heart diseases

OBJECTIVE/AIM

To compare hemodynamic parameters in infants with congenital heart disease (CHD) undergoing noncardiac surgery (NCS) under awake spinal anesthesia (SA) with controls without CHD also undergoing SA.

BACKGROUND

NCS poses a twofold higher mortality risk in infants with CHD. SA might be a good alternative to general anesthesia (GA) in this setting.

METHODS

The files of 84 infants were reviewed; 42 had CHD and 42 were controls without CHD. Primary outcome measures were percent decrease in mean arterial pressure (%MAP decrease) and heart rate (%HR decrease)from baseline to the lowest intraoperative value. One-way analysis of variance(ANOVA), ANOVA with repeated measures, Pearson chi-square test, Fisher's exact test, and Pearson correlation were used for statistical analysis.Time to discharge was analyzed with the nonparametric Mann–Whitney U-test.

RESULTS

There were no significant between-group differences in %MAP decrease and %HR decrease; no significant associations and correlations between %MAP decrease or %HR decrease and other variables; and no correlation between %MAP decrease and %HR decrease. A %MAP decrease of >20% was documented in 11 patients with CHD (26.2%) and 10 controls (23.8%); a lowest intraoperative HR of <100 b.min)1 was recorded in two study patients (4.8%) and four controls (9.5%) (P = NS for both). There were no cases of high SA or conversion to GA and no need for mechanical ventilation or inotropic support intra/postoperatively.

CONCLUSIONS

These preliminary findings show that hemodynamic parameters in infants with CHD undergoing NCS under awake SA are not different from controls without CHD and that SA appears to be safe in infants with CHD.

Spinal anesthesia in neonates and infants - a single-center experience of 505 cases

BACKGROUND

Our aim was to assess the safety and efficacy of spinal anesthesia (SA) in newborns and infants undergoing surgery appropriate for this technique.

METHODS

The files of 505 patients who underwent surgery under spinal anesthesia since 1998 at a major tertiary hospital in Israel were analyzed retrospectively. SA was performed with bupivacaine 5 mgxml(-1) by attending pediatric anesthesiologists or an anesthesia resident. Demographic data, prematurity history, comorbidities, technical data, cardiovascular stability, complications and supplementary drugs were documented. The surgeon assessed the quality of anesthesia at the end of surgery.

RESULTS

Appropriate SA was achieved in 95.3% of cases; in 69.9% at the first attempt. The mean number of attempts per patient was 1.41 and mean dose of bupivacaine was 0.66 +/- 0.16 mgxkg(-1). Intravenous sedation, usually with midazolam (dose 0.1-0.2 mgxkg(-1)) was required in 28.1% of children because of crying/restlessness. Intraoperative conversion to general anesthesia was necessary in five patients (1.04%). The main side effect was bradycardia (<100 bxmin(-1)) without desaturation which occurred in nine patients (1.8%). In three patients (0.62%), high spinal block occurred without bradycardia and hypotension. None of the patients had postoperative meningitis.

CONCLUSIONS

SA is safe and effective in newborns and infants undergoing low abdominal, perineal and orthopedic surgery. In order to save time, our advice is to attempt SA after the surgeon is scrubbed, and minimize surgical teaching activity. The need to deal with a small and sometimes sick patient independent of the type of anesthesia requires the presence of an experienced pediatric anesthesiologist.