CHEOPS Score Research Articles

Analgesic Effect of Bilateral Sonography-Guided Ilioinguinal Iliohypogastric Block and Caudal Block in Children: A Randomized Trial

Background: Herniorrhaphy is the most common inguinal surgery in children. Several methods such as caudal block, ilioinguinal iliohypogastric block, and wound infiltration have been studied for postoperative pain management in these patients. Caudal block is common in pediatrics. However, ilioinguinal iliohypogastric block is effective and less invasive. Previous studies have shown different comparative results regarding these blocks. This study compares the analgesic effect of caudal and bilateral ilioinguinal iliohypogastric block with ropivacaine in children. Methods: This study is a randomized double-blind clinical trial. A total number of 66 patients aged between 1-7 years that volunteered for bilateral inguinal hernia repair were randomly assigned to two groups. After general anesthesia, caudal block with 1cc/kg ropivacaine 0.2% was performed for 33 patients and sonography-guided ilioinguinal iliohypogastric block with 0.1 cc/kg ropivacaine for each side was considered for another group. Hemodynamic parameters (systolic blood pressure, diastolic blood pressure, and heart rate) during anesthesia, pain score (CHEOPS), delirium score (PAED), nurses’ satisfaction score (RN), need for additional narcotic, recovery time, and complications were compared in these two groups. Results: There was no statistically significant difference between the two groups in terms of hemodynamic parameters during the anesthesia process. Furthermore, the two groups had no statistically significant difference in CHEOPS score (6.27 in ilioinguinal block and 5.70 in caudal block, P=0.061), PAED score (5.64 vs 5.30, P=0.144), and RN satisfaction score. However, the need for narcotics, mean recovery time, and block complications were comparable in two groups. Conclusion: Caudal block and ilioinguinal block are equally effective for post herniorrhaphy pain and emergence agitation management in pediatrics. Additionally, no differences were observed in complications. It is recommended that the study be performed with a larger sample size.

The Outcomes of Caudal or Intravenous Addition of Morphine and Clonidine into The Caudal Block Performed with Levobupivacaine In Children; A Retrospective Study

Ineffective post-operative pain management in children may be associated with chronic pain. 98 pediatric patients aged 6 months to 12 years who underwent caudal levobupivacaine for hypospadias surgery were evaluated retrospectively. The patients who received additional intravenous clonidine were added in group 1; the patients who received additional intravenous morphine were added in group 2, patients who received additional caudal clonidine was added in group 3, and patients who received additional caudal morphine was added in group 4. CHEOPS score was assessed 1, 6, 12 and 24 hours after the operation and patients with score 6 or higher were determined. At the 1st hour, there were 8 cases in the intravenous morphine group (40%), 5cases in the intravenous clonidine group (25%), and 3 cases in the caudal morphine group (15%). At the 12th hour, there were 5 cases in the intravenous morphine group (25%), 10 cases in the intravenous clonidine group (50%), and 4 cases in the caudal morphine group (20%). At the 24th hour, there were 10 cases in the intravenous morphine group (50%), 10 cases in the intravenous clonidine group (50%), 9 cases in the caudal morphine group (45%) and 2 cases in the caudal clonidine group (10%) (p<0.05). There was no difference between the groups in terms of sedation scores at all hours (p>0.05). The lowest pain scores at the 1st, 12th, and 24th hours were recorded in the caudal clonidine group. It had the lowest pain scores at 6 hours. By these methods, in favor of the clonidine group, we agreed that the analgesia lasts for approximately 12 hours postoperatively, so the postoperative stress that the children and their families have can be minimized.

Topical and systemic analgesia versus caudal epidural and dorsal penile nerve block in relieving pain after pediatric circumcision

Objective: There is no consensus on the use of optimal analgesic method after pediatric circumcision, although, caudal block (CB),dorsal penile nerve block (DPNB), topical local anesthetic application and systemic analgesic administration are frequently usedmethods. In this study, we aimed to compare the postoperative analgesic effects and side effects, as well as parental satisfactionconcerning these methods.Patients and Methods: Eighty children, aged 3-12 years, undergoing circumcision were randomized into four groups (n=20). GroupCaudal Anesthesia (CA), Group Dorsal Penile Blok (DP), Group Topical Analgesia (TA), Group Systemic Analgesics (SA). Theseverity of pain was measured with NRS or CHEOPS scores. Time to awakening, first analgesic requirement, hospital discharge, sideeffects and parental satisfaction were recorded.Results: In groups CA and DP, pain scores during the first postoperative hour were lower than the pain scores of other groups and ingroup CA, the first analgesic requirement time was significantly longer compared to other groups (p<0.05). In the early postoperativehour, parental satisfaction was higher in group CA compared to other groups.Conclusion: In the early postoperative period, CB and DPNB reduce pain more effectively and provide more parental satisfactionthan other applications, (in children who underwent) circumcision.Keywords: Circumcision, Pain, Postoperative, Dorsal penile nerve block Caudal epidural block, EMLA

Postoperative Behaviour after Primary Strabismus Surgery in Children: Is There an Influence of Intraoperative Topical Anaesthesia?

The course of the recovery phase after general anaesthesia, during which consciousness and pain gradually return, is essentially determined by the choice of anaesthetic drug, and its total dose or duration of application. This phase is often complicated by more or less severe agitation, especially in children. In the present study we investigated whether the application of a topical anaesthetic to the conjunctiva at the end of a strabismus operation had a positive effect on the recovery behaviour of the child. This prospective, randomised, blinded study was conducted with 50 healthy, ASA class I or II children, aged 3 to 8 years undergoing their first strabismus operation. Following the surgeon's randomisation two drops of a 0,5% tetracaine-HCl ophthalmic solution were applied to the operated conjunctiva three times at 30-s intervals immediately following wound closure. The postoperative evaluation encompassed heart rate, as well as COMFORT and CHEOPS scores. The first assessment was directly postoperatively with repetitions at 15, 30, 45, 60, 75, 90 and 120 min, as well as on the day after surgery. The CHEOPS scores did not differ significantly between children with or without topical anaesthesia at any time during the observation period. The COMFORT scores revealed a slight, but non-significant analgesic effect at 15 and 30 min. The 60 min score showed the opposite effect, possibly indicating a slight disadvantage of the topical anaesthesia. There were no significant differences with regard to time to first request for additional systemic analgesia, to the total dose of systemic pain medication, or to when the patient was eligible for discharge to the ward. The application of topical tetracaine-HCl immediately after wound closure had no positive effects on the course of the postoperative recovery period after strabismus surgery in children. There was no evidence of an effect on pain or emergence agitation.

Efficacy of dexmedetomidine on postoperative analgesia & sedation in children undergoing adenotonsillectomy

Background: Adenotonsillectomy is a common surgical procedure in pediatric population, but post-operative pain management is a challenging concern for anaesthetist. The present study was designed to assess the efficacy of dexmedetomidine on post-operative sedation and analgesia in paediatric cases undergoing adenotonsillectomy. Materials and methods: A total 80 pediatric cases undergoing adenotonsillectomy between age group 4-9 years belong to ASA grade I and II were recruited. Study consists of two groups i.e. group 1 with 1mcg/kg Dexmeditomidine and group 2 with 2 mcg/kg fentanyl. Parameters like heart rate, systolic blood pressure (SBP), diastolic blood pressure (DBP), requirement of post-operative analgesia and sedation assessed by Ramsay sedation score & CHEOPS score and emergence agitation were assessed. Results: The mean heart rate was significant between two study groups at the beginning, 5 min, 15 min, 20 min and at 25 min (p<0.005). The mean SBP in group 1 was high at the beginning, later the values were decreased when compared group 2. However, the mean DBP in group 1 was low when compared to the group 2 at all-time intervals. The mean Ramsay sedation score difference was statistically significant among two study groups at the beginning, 5 min, 10 min, 15 min and 45 min (p<0.005). The requirement of additional rescue doses were noticed more in group 2. Conclusion: Dexmedetomidine was effective in maintaining intraoperative heart rate, systolic blood pressure and diastolic blood pressure. Dexmedetomidine is an effective and safe analgesic substitute to fentanyl intra-operatively and reduces the requirement of postoperative rescue opioid. Dexmedetomidine was more effective in preventing emergence agitation, avoiding severe pain and reducing incidence of postoperative nausea and vomiting.

Comparison of the efficacy of ropivacaine and ropivacaine with dexmeditomidine in post tonsilectomy pain relief after peritonsillar infiltration- A prospective randomized double blind study

Introduction: Post operative pain relief is desired goal after tonsillectomy, infiltration of local anesthetic with or without adjuvant can reduce post tonsillectomy pain. Objective: To compare the postoperative analgesic efficacy and side-effects of peritonsillar-infiltration of ropivacaine with or without dexmeditomidine. Materials and Methods: Sixty patients aged 4-14 years posted for tonsillectomy under GA were randomly assigned in two groups of 30 each. In group R: Inj. ropivacaine (0.5%) 0.2ml/kg and in group RD: Inj.ropivacaine (0.5%) 0.2 ml/kg + Inj. dexmeditomidine 1mcg/kg were infiltrated in peritonsillar fossa post tonsillectomy. Patient were monitored for post-operative pain using VAS score, CHEOPS score and Wong baker pain rating scale at 30 minute, 1hr, 2hr, 4hr, 10 hr, 16hr and 24hr, pain on deglutination, time to first analgesic requirement, total dose of analgesics requirement in 24 hr postoperatively, amount of bleeding and parent’s satisfaction score. Results: VAS score, CHEOPS and Wong baker pain rating scale were comparable in both the groups at 30 min, 1hr, 2hr (P >0.05) but it was significantly low in group RD as compared to group R at 4hr, 10hr, 16hr and 24hr (P Conclusion: We concluded, peritonsillar infiltration of ropivacaine with or without dexmeditomidine is effective method for post-tonsillectomy pain relief. Addition of dexmeditomidine was found to prolong duration, decrease analgesic requirement and improve parent’s satisfaction score. Keywords: Tonsillectomy, Visual analog score, CHEOPS, Wong baker pain rating scale, Ropivacaine and dexmeditomidine.

Pediatrik Hematoloji Olgularinda Invazif Girisimler Oncesinde Dusuk Doz Oral Midazolam Kullanimi

Objective : Children with hematological diseases (especiallly with leukemias) often undergo painfull procedures that adds more stress to their underlying illness. The aim of this study was to investigate whether oral midazolam can decrease fear and distress when given together with usual intravenous sedoanalgesia. Methods: A total of 47 patients with 1- 18 years of age who were followed at hematology inpatient setting were included in the study. The study group consisted of patients undergoing bone marrow aspiration or lumbar puncture for acute lymphoblastic leukemia (ALL) , acute myeloblastic leukemia (AML) ,immune thrombocytopenic purpura ( ITP) , thrombocytosis, chronic myeloid leukemia (CML) and aplastic anemia. Patients were divided into placebo (n=23) and oral midazolam (n=24) groups in this double-blind randomized study. Midazolam group received 0.1 mg/kg(maximum 10 mg) orally 30 minutes before the procedure. Both groups were administered 0.5mg/kg ketamine intravenously before the procedure. Parents and children>7 years reported their fear and distress with visual analogous scale(VAS) and Wong-Baker Fascies Scale. CHEOPS score was filled by the blinded pediatric hematologist performing the procedures. Results: There was no difference of fear and distress levels of placebo and midazolam groups according to VAS ,Wong Baker Fascies and CHEOPS scores(p>0.05). We found no additional effect in decreasing pain and stress of oral midazolam versus placebo when administered together with intravenous ketamineanalgesia. Nausea according to analgesia was found to be more reduced in the midazolam group (p< 0.05). Conclusion: Low dose oral midazolam does not have an additional effect in decreasing fear and distress in pediatric hematology patients when administered together with intravenous ketamineanalgesia. More studies to evaluate its effect when used without intravenous analgesia is warranted.

Application of ultrasound-guided transversus abdominis plane block for operations of inguinal region in infants

One hundred and fifty ASA Ⅰ-Ⅱ infants scheduled to undergo surgery on unilateral inguinal region, were randomly assigned to 3 groups with 50 in each group. In groups Ⅰ and Ⅱ puncture was performed at traversus abdominis plane under ultrasound-guidance, 0.4 or 0.5/kg of 0.25% ropivacaine was injected respectively. In group Ⅲ the triangle of Petit was positioned through palpating and then 0.5 ml/kg of 0.25% ropivacaine was injected. HR, RR, SpO2, PETCO2, expired sevoflurane concentration and BIS value at the time of entering the operation room (T1), incision of skin (T2), pulling hernia sac (T3), ending the surgery (T4), waking (T5), the number of pressing the analgesia pump after operation were recorded. The results showed that HR at T2 and T3 of groups Ⅰ and Ⅱ was lower than group Ⅲ (P<0.05). The were significant differences in case numbers of insufficient intraoperative analgesia among 3 groups(χ2=10.500, P=0.005). The CHEOPS scores and the number of pressing analgesia pump after operation in groups Ⅰ and Ⅱ were lower than those in group Ⅲ (χ2=7.230, P=0.027). Results indicate that ultrasound-guided transversus abdominis plane block is safer and more effective than conventional method for operations of inguinal region in infants; it may reduce dose of local anesthetics and postoperative use of analgesics. Key words: Nerve block; Infant

The application of ketamine combined with butorphanol intravenous anesthesia for pediatric day surgery

Objective To compare the effects of ketamine combined with butorphanol for intravenous anesthesia with ketamine separately for pediatric day surgery.Methods In this double-blind trial,200 pediatric patients (ASA physical status 1 or 2,1 to 6 years old) undergoing inguinal hernia repair or circumcisions undergoing intravenous anesthesia were randomly allocated into two groups.Intravenous anesthesia was induced with 2 mg/kg ketamine combined with 2 ml saline (group KS,n=100) or 2 mg/ kg ketamine combined with 30 μg/kg butorphanol in the volume of 2 ml respectively (group KB,n=100).Repeat doses of ketamine 1 mg/kg were administered when the patients had motor responses.Total dosage of ketamine,variation of circulation and breath,awaken time were observed.Agitation and pain were assessed with sedative score and CHEOPS score respectively.The patients' parents were interviewed 24 h after surgery,and the adverse events were recorded.Results Group KB showed less consumption of ketamine (42.2±12.9) mg vs (75.0±25.3) mg (P＜0.05).Furthermore,the mean level of postoperative CHEOPS score and sedative score in the group KB was significantly lower than that in the group KS (P＜0.05).Awaken time was statistically longer in the group KS (P＜0.05),but the time spent in the PACU was similar in both groups.There was no significantly airway or hemodynamic effects observed in both groups.Conclusions Ketamine combined with butorphanol for pediatric day surgery is an ideal anesthesia and it has advantages such as safty,low dosage of keatmine to eliminate the adverse effect,providing a more comprehensive sedative and analgesic effect to reduce emergence agitation and postoperative pain in pediatric day surgery. Key words: Ketamine; Butorphanol; Intravenous anesthesia; Pediatric; Day surgery

CHEOPS score in tonsillectomy: a good tool to achieve good postoperative pain management in children: preliminary results of observational prospective study

CHEOPS score in tonsillectomy: a good tool to achieve good postoperative pain management in children: preliminary results of observational prospective study

Does pressure support ventilation improve the postoperative outcome of adeno-tonsillectomy patients? A prospective randomized trial

BackgroundSpontaneous ventilation (SV) is used for adeno/tonsillectomy in children. However, inhalational anesthetics produce dose dependent decrease in minute ventilation. We tested the impact of PSV on awakening time, and length of PACU stay.Methods34 patients were randomized into two groups; PS ventilation group and SV group. Premedication and induction were similar in both groups. Patients in PS group were ventilated with Pinsp set to deliver 8 ml/kg VT, keeping ETCO2 between 35 and 45 mmHg. Any episodes of hypoventilation were recorded and corrected by manual support of ventilation.Upon completion of surgery, time-to-extubate was recorded. Length of PACU stay, agitation and CHEOPS scores, PONV and desaturation episodes were also recorded. Results are presented as mean (SD), median (interquartile range), or number of patients as appropriate. A P value < 0.05 was considered significant.ResultsExtubation time (min) [mean (SD)] was longer in SV group than PS group [7.8 (2.1) vs. 5.5(1.4), P < 0.001]. In the SV group 9 patients had episodes of hypoventilation that necessitated manual assist of ventilation. Pain scores were higher in SV group than PS group. Duration of stay in PACU [mean (SD)] in minutes was longer in SV group than PS group [44.3(7.4) vs. 39.4(5.7), P = 0.02]. All but one patient in the PS group needed postoperative rescue meperidine analgesia. The mean (SD) time needed for rescue meperidine analgesia was 27.1(8.9) in PS group and 21.8(9.4) in SV group (P = 0.04).ConclusionPSV carries the advantages of overcoming the effects of narcotics and inhaled anesthetics on spontaneously ventilated adeno-tonsillectomy patients. They suffer less pain and spend less time in the PACU.

Comparison of peritonsillar infiltration effects of ketamine and tramadol on post tonsillectomy pain: a double-blinded randomized placebo-controlled clinical trial

AimTo assess the effect of peritonsillar infiltration of ketamine and tramadol on post tonsillectomy pain and compare the side effects.MethodsThe double-blind randomized clinical trial was performed on 126 patients aged 5-12 years who had been scheduled for elective tonsillectomy. The patients were randomly divided into 3 groups to receive either ketamine, tramadol, or placebo. They had American Society of Anesthesiologists physical status class I and II. All patients underwent the same method of anesthesia and surgical procedure. The three groups did not differ according to their age, sex, and duration of anesthesia and surgery. Post operative pain was evaluated using CHEOPS score. Other parameters such as the time to the first request for analgesic, hemodynamic elements, sedation score, nausea, vomiting, and hallucination were also assessed during 12 hours after surgery.ResultsTramadol group had significantly lower pain scores (P = 0.005), significantly longer time to the first request for analgesic (P = 0.001), significantly shorter time to the beginning of liquid regimen (P = 0.001), and lower hemodynamic parameters such as blood pressure (P = 0.001) and heart rate (P = 0.001) than other two groups. Ketamine group had significantly greater presence of hallucinations and negative behavior than tramadol and placebo groups. The groups did not differ significantly in the presence of nausea and vomiting.ConclusionPreoperative peritonsillar infiltration of tramadol can decrease post-tonsillectomy pain, analgesic consumption, and the time to recovery without significant side effects.Registration No: IRCT201103255764N2

Appropriate dosage of parexoxib sodium for postoperative analgesia in different ages children with day surgery

Objective To determine the appropriate dosage of parexoxib sodium for postoperative analgesia in different age children with day surgery.Methods One hundred and eighty ASA Ⅰ children aged 1-12 yr scheduled for day surgery undergoing sevoflurane anesthesia combined with lateral inguinal regional blockade were divided into 3 groups according to age ( n =60 each):group 1-3 yr (group Ⅰ ),group 4-6 yr (group Ⅱ ) and group 7-12 yr (group Ⅲ).Eeach group was randomly divided into 2 sub-groups( n =30): parecoxib sodium 0.5 mg/kg (sub-group A) and parecoxib sodium 1.0 mg/kg (sub-group B).Sub-groups A and B received iv injection of paracoxib sodium 0.5 or 1.0 mg/kg respectively immediately at skin incision.Analgesic effect was evaluated by FLACC score (group Ⅰ ),CHEOPS score (group Ⅱ ) and VAS scroe (group Ⅲ) at 6(T1 ),12(T2 )and 24 h (T3)after operation.The effective analgesia was defined as FLACC score≤3,CHEOPS score≤7 or VAS score≤ 3.Side effects were also observed.Results Compared with sub-group B,FLACC score was significantly increased at T1 in sub-group Ⅰ -A ( P ＜ 0.01 ).There was no significant difference in CHEOPS score or VAS score between sub-groups Ⅱ -A and Ⅱ -B,and between sub-groups Ⅲ-A and Ⅲ-B (P ＞ 0.05).The incidence of effective analgesia was 97％ in group Ⅰ (93％ in group sub-group Ⅰ -A,100％ in sub-group Ⅰ -B),100％ in group Ⅱ and 93％ in group Ⅲ (97％ in sub-group Ⅲ-A,90％ in sub-group Ⅲ-B).There was no significant difference in the incidence of side effect between sub-groups Ⅰ -A and Ⅰ -B,between sub-groups Ⅱ -A and Ⅱ -B,and between sub-groups Ⅲ-A and Ⅲ-B ( P ＞ 0.05).Conclusion Parecoxib sodium 1.0 or 0.5 mg/kg can be used in postoperative analgesia in children aged 1-3 yr or 4-12 yr with day surgery respectively. Key words: Cyclooxygenase 2 inhibitors; Child; Analgesia; Ambulatory surgical procedures

Effects of post-operative analgesia combined with parental presence on emergence agitation after sevoflurane anesthesia in children

Objective To evaluate effects of post-operative analgesia combined with parental presence on emergence agitation after sevoflurane anesthesia in children. Methods 60 patients were randomly assigned into three groups with 20 cases each. After sevoflurane inhalation and being given rocuronium, all patients were intubated for mechanical ventilation. Then patients received caudal block. Patiens in group A and B were treated with diclofenac sodium suppositories before operation. To maintain anesthesia patients were adopted sevoflurane inhalation. Patients in group A and C were cared by nurses in post anesthesia care unit, whereas patients in group B added parental presence. Emergence agitation incidence, modified Aldrete scale, PAEDS, CHEOPS were all recorded. Results Therewas no difference of modified Aldrete scale among three groups( F =0.652 ,P ＞0. 05) ,but emergence agitation incidence in group C was more than those of group A and B. At each point PAEDS scores of group B were lower than those of group C( x2 =4. 566,7. 234,4. 124,6. 126, P ＜ 0. 05) ,also scores of group B were lower than those of group A at 10 min and 30 min(F=0.654,P＞0.05). PAEDS scores of group A were lower than those of group C at 20min and 30min(t =3.256,3.778,4.556,4.223 ,all P＜0.05). At 20min and 30min CHEOPS scores of group C were higher than those of group A and B ( F =1. 987, P ＞ 0.05 ). Conclusion Post-operative analgesia combined with parental presence could decrease the incidence of emergence agitation after sevoflurane anesthesia in children. Key words: Analgesia; Resuscitation; Child

Epidural ropivacaine versus ropivacaine plus tramadol in postoperative analgesia in children undergoing major abdominal surgery: a comparison

In this study, we aimed to compare the effects of ropivacaine alone and ropivacaine plus tramadol administered epidurally for postoperative analgesia in children. Following Ethics Committee approval and informed parent consent, 44 children aged between 2 and 12years, with ASA physical status I or II, who were undergoing major abdominal surgery were included in the study. Following tracheal intubation, patients were placed into lateral decubitus position and an epidural catheter (22-24G) was inserted by using a Tuohy needle. Patients were randomly divided into two groups to receive either ropivacaine alone (0.2%), 0.7ml/kg, in group I, or ropivacaine (0.2%) plus tramadol (2mg/kg), with total volume 0.7ml/kg, in group II, epidurally in both groups. Hemodynamic variables, pain and sedation scores, duration of analgesia, and side effects were recorded postoperatively. The duration of analgesia was significantly longer in group RT than in group R (298.6±28 and 867.9±106.8min in group I and II, respectively) (P<0.05). CHEOPS scores were significantly lower in group RT at 30min, 45min, and 3h postoperatively than in group R (P<0.05). However, sedation scores were similar between the two groups. Twenty-two patients (100%) in group R and 13 patients (59%) in group RT needed supplemental analgesia postoperatively. There were no significant differences in side effects between the groups. In children undergoing major abdominal surgery, epidural tramadol, added to epidural ropivacaine, provided lower pain scores, longer duration of analgesia, and lower postoperative analgesic requirement.

An opioid-free anaesthetic using nerve blocks enhances rapid recovery after minor hand surgery in children

The aim of this prospective randomized study was to evaluate the quality of analgesia, postoperative comfort and subsequent duration of hospitalization after distal hand surgery and peripheral nerve block at the wrist for paediatric outpatients. Sixty consecutive ASA I or II children were randomly assigned to the following groups: in group B (block), intraoperative and postoperative analgesia was provided by peripheral nerve block; and in group O (opioids), intraoperative and postoperative analgesia was provided by intravenous opioids. The patients' age, sex and type of surgery were recorded as were the postoperative pain management and postoperative vomiting. Time to discharge from the recovery room, the postoperative ward and the time to discharge home were also noted. The two groups were similar with respect to age, sex, ASA physical status, weight, height and types of injuries. The incidence of postoperative pain (CHEOPS score >or=7) and the incidence of postoperative vomiting were significantly higher in group O than in group B: 26.6 versus 3.3%; P = 0.025, and 33.3 versus 6.6%; P = 0.011, respectively. The time before oral intake was significantly longer in group O than in group B [187 (75-265) min versus 60 (32-125) min, respectively, P = 0.0002]. The time to meet discharge home criteria was 277 (230-330) min in group O versus 210 (145-260) min in group B (P = 0.0039). The present study demonstrates for the first time that, after distal hand surgery in children, peripheral nerve block improves pain management, opioid analgesia-induced side effects and provides a shorter postoperative recovery time than systemic analgesia with opioids.

Bupivacaine versus normal saline for relief of post-adenotonsillectomy pain in children: A meta-analysis

Objective A meta-analysis was performed to explore the role of peri-operative bupivacaine infiltration in the relief of pain in adenotonsillectomy. Methods Data from Medline, EMBase, Springer and the Cochrane Collaboration database were searched. Reference lists from identified publications were scanned. RevMan 5.0 software was used for statistical analysis. Results 7 random controlled tests (a total of 286 cases) were included. Pain intensity was evaluated by VAS score or Cheops score. The pain of group bupivacaine (Group B) was less severe than group placebo (Group P). Analgesic requirement of Group B was less than Group P. Nevertheless the difference of complication between bupivacaine and placebo had no statistical difference. Conclusion Bupivacaine infiltration is a safe and effective method for relief of pediatric post-adenotonsillectomy pain.

Intraoperative small-dose ketamine does not reduce pain or analgesic consumption during perioperative opioid analgesia in children after tonsillectomy

Ketamine inhibits the NMDA receptors via non-competitive antagonism, resulting in an antihyperalgesic effect achieved by doses of ketamine much smaller than are required for analgesia. The aim of this study was to determine the extent to which small-dose ketamine, when used in conjunction with remifentanil, has a morphine-sparing effect in the perioperative period. In this randomized, double-blind, placebo-controlled prospective study, we enrolled 40 children undergoing tonsillectomy. Anesthetic care was standardized. Intraoperative analgesia was provided with remifentanil 0.5 microg x kg(-1) followed by an infusion of 0.25 microg x kg(-1) x min(-1). Group I (ketamine, n = 20) received a bolus dose of ketamine 0.5 mg x kg(-1) followed by a continuous infusion of 2 microg x kg(-1) x min(-1) before start of surgery. The infusion was stopped when surgery ended. Group II (placebo, n=20) received normal saline in the same manner. Pain was assessed postoperatively using the Children's Hospital Eastern Ontario Pain Scale (CHEOPS; range of scores 4 13), and total morphine consumption was recorded in the postanesthesia care unit (PACU). Patients were transferred to the ward and morphine was administered via a patient-controlled analgesia (PCA) device and analgesia was recorded using a visual analogue scale (VAS) (0 - 10). Intraoperative remifentanil consumption was not different between the ketamine group (0.29+/-0.09 microg x kg x min(-1) ) and the control group (0.24+/-0.07 microg x kg x min(-1)). There were no significant differences between CHEOPS scores and VAS score between the two groups. The total mean morphine consumption in the ward was not significantly different between the two groups: 376.5 +/-91.6 microg x kg(-1) with ketamine and 384.4+/-97.3 microg x kg(-1) with placebo. The time-to-first analgesic requirement was also similar in both groups. Small-dose ketamine did not decrease postoperative pain after tonsillectomy in children when added to a continuous intraoperative remifentanil infusion.

Diclofenac or Paracetamol for Analgesia in Paediatric Myringotomy Outpatients

This prospective, randomized, double-blind study compared the analgesic efficacy of oral diclofenac resinate 0.5 mg.kg(-1) with paracetamol 15 mg/kg(-1) for control of postoperative pain in paediatric patients for outpatient bilateral myringotomy and tube insertion. Paracetamol, the most commonly used oral analgesic for paediatric patients, was compared with a new palatable syrup formulation of diclofenac. Sixty-three ASA 1 orA SA 2 children aged one year and above were randomly assigned to receive diclofenac (Group A) or paracetamol (Group B). The study drug was given 30 to 60 minutes before induction of anaesthesia. Anaesthesia was induced with either inhalational sevoflurane or intravenous thiopentone. All subjects received intravenous fentanyl 1 microg/kg(-1) intraoperatively. Postoperative pain was assessed by a blinded observer using the CHEOPS score on eye-opening, and then at 10, 30 and 60 minutes. Children with a CHEOPS score > 7 received further fentanyl 1 microg x kg(-1). The number of cases requiring this "rescue" analgesia was recorded. Both groups were comparable in demographics, induction technique, duration of anaesthesia and time between premedication and induction of anaesthesia. Overall, CHEOPS scores were low for both groups at all times and did not differ between the groups at any time. Twenty per cent of the diclofenac group and 27% of the paracetamol group required rescue analgesia (not statistically significant). The efficacy of diclofenac 0.5 mg x kg(-1) and paracetamol 15 mg x kg(-1) as oral analgesic premedication for BMT was comparable in children receiving an anaesthetic which included intraoperative administration of fentanyl 1 microg x kg(-1).