A Clinical Audit to Assess the Efficacy of the Coolsense® Pain Numbing Applicator for Intravenous Cannulation in Children

The Coolsense® device is a topical applicator that is used to anaesthetise the skin before a painful procedure. It is a handheld device with a temperature-controlled head that acts on application, without chemicals, to cool and anaesthetise the site of injection. This prospective observational audit of 100 children and adolescents aged six to 18 years studied the analgesic efficacy and patient and carer satisfaction rating of the device during intravenous cannulation and complications arising from its use. The audit demonstrated effective skin analgesia for intravenous cannulation in children and adolescents. Ninety-four percent of patients rated the pain during cannulation as less than or equal to three on a numerical pain rating scale of zero to ten. Patient and carer satisfaction with the device and cannulation success rates were high; 66% of patients and 82% of carers ‘really liked’ the device and 28% of patients and 12% of carers ‘liked’ it. Ninety-five percent of patients were cannulated on the first attempt. The incidence of complications using the device was low. The Coolsense device appears to be a useful tool that provides effective analgesia for intravenous cannulation in children with minimal complications. Comparative studies with topical local anaesthesia creams are warranted.

Intrathecal morphine provides effective and safe analgesia in children after cardiac surgery

BACKGROUND

The purpose of this prospective, randomized, blinded to observer study was to assess the analgesic effect and safety of intrathecal morphine (ITM) in post-operative pain control in children after heart surgery with a sternotomy incision.

METHODS

Eighty children, 3-55 kg in body weight, undergoing elective cardiac surgery with opioid-based anaesthesia were randomly divided into two treatment groups to receive either 20 micrograms/kg ITM at induction of anaesthesia or control. To standardize the protocol for administration of post-operative rescue intravenous morphine boluses and infusion (20-60 micrograms/kg/h), the Cardiac Analgesic Assessment Scale (CAAS) was used.

RESULTS

Nine patients were excluded from the study after randomization. Thirty-five patients were enrolled to the ITM group and 36 to the control group. The groups were similar for demographics and intra-operative clinical characteristics. The mean time for the first intravenous morphine dose from ITM administration or equivalent time zero in the control group was significantly longer (P = 0.003) in the ITM group compared with the control group (12.3 vs. 8.7 h). Time from Paediatric Intensive Care Unit (PICU) admission to the start of intravenous morphine was also significantly longer (P = 0.01) in the ITM group (6.0 vs. 3.4 h). The total intravenous morphine consumption over the mean 19 post-operative hours was significantly lower (P = 0.03) in the ITM group. However, the use of ITM did not result in earlier extubation or earlier discharge from the PICU. Of the 35 patients who received ITM at induction of anesthesia, 20% (n = 7) did not require any additional morphine in the PICU compared with three out of 36 control group patients. This did not reach statistical significance. The incidence of adverse events was low in both groups.

CONCLUSIONS

An ITM dose of 20 micrograms/kg had a significant (P = 0.03) intravenous morphine-sparing effect after cardiac surgery. Effective analgesia was observed for 12 h after administration of intrathecal morphine.

Bloodless open-heart surgery in infants and children

Between October 1984 and January 1993, seven children of Jehovah's Witnesses underwent corrective open-heart surgery for congenital defects, on cardiopulmonary bypass (CPB). Age at surgery ranged from three months to 6.5 years, and weight ranged from 4.2 kg to 23.2 kg, with two children weighing less than 10 kg. The principal cardiac anomalies were tetralogy of Fallot (two), double outlet right ventricle (one), subaortic stenosis (one), transposition of the great arteries and ventricular septal defect (one), atrial septal defect and congenital heart block (one), and congenital mitral regurgitation (one). Hypothermic CPB was used in all seven operations with crystalloid priming of the extracorporeal circuit. CPB was based on our standard perfusion protocols. All surgical procedures were done without the use of blood or blood products. The mean preoperative haematocrit (Hct) was 40.9% (range 31.0-47.8%). The mean lowest intraoperative Hct was 17.3% (range 15.0-24.3%), whereas the immediate post-CPB Hct was 19.6% (range 15.3-24.0%). The Hct progressively increased to 29.2% (range 21.0-34.2%) on the first postoperative day, and 32.3% (range 24.2-38.3%) at the time of discharge. There was no hospital mortality, and the mean hospital stay was 10 days (8-13 days). We report the safe repair of complex open-heart surgery in children, without blood transfusion, even in small infants. The successful management of these patients requires meticulous attention to surgical and perfusion technique, and sound postoperative management.