Children And Infants Postoperative Pain Scale Research Articles

Abstract No.: ABS1828: A prospective randomised double blinded study to compare the analgesic efficacy of USG guided bilateral suprazygomatic maxillary nerve block(SMB) with 0.25% bupivacaineand 0.25% bupivacaine with dexmedetomidine in children undergoing cleft palate(CP)repair

Background & Aims:The aim of this study was to assess the analgesic efficacy of dexmedetomidine as an additive to bupivacaine in childrenundergoing cleft palate (CP) repair with regional nerve block. OFC is one of the most common birth defects in India.Methods:Suprazygomatic maxillary nerve block (SMB) is a simple technique providing effective analgesia with decreased perioperative opioid consumption and complications. • 46 children fulfilling the inclusion criteria planned for CP repair with ultrasound guided (USG) SMB were randomised into Group A and B with comparable demographics and received 0.25% bupivacaine with saline and 0.25% bupivacaine with 1 µg/kg dexmedetomidine respectively. Postoperatively, pain was assessed by Children and Infants Postoperative Pain Scale (CHIPPS) score every 30 minutes for 2 hours and then every 2 hours until 24 hours. The pain control was considered insufficient if CHIPPS score was >3 for which Inj. fentanyl 0.5 µg/kg during first 2 hours and after 2 hours until 24 hours Inj. paracetamol 15 mg/kg were administered respectively and recorded.Results:The CHIPPS score was significantly lower in Group B than Group-A with p-value < 0.05. None of the children in Group-Brequired rescue fentanyl compared to 6 children in Group-A which was statistically significant (p value 0.032). 65.2% children in Group-A required rescue Paracetamol with more frequent administrations compared to only 26% in Group-B which wasstatistically significant (p value 0.048). No significant differences in haemodynamic parameters were noted between the groups intraoperatively.Conclusion:Dexmedetomidine when used as an adjuvant to 0.25% bupivacaine increased the duration of analgesia, reduced postoperative pain and need for rescue analgesics. It also provided stable haemodynamics throughout the intraoperative period with nil complications.

A Comparative Study on the Analgesic Efficacy of Bilateral Suprazygomatic Maxillary Nerve Block Under Ultrasound Guidance with 0.25% Bupivacaine and 0.25% Bupivacaine with Dexmedetomidine in Paediatric Patients Undergoing Cleft Palate Repair - A Randomized Prospective Double Blinded Study

Objective: Cleft palate repair involves surgery on the both hard and soft palate leading to severe pain, intense sympathetic stimulation, and bleeding. In our study we analysed the analgesic efficacy of bupivacaine alone and bupivacaine with dexmedetomidine in ultrasound guided bilateral suprazygomatic maxillary nerve block (SMN) for cleft palate repair. Methods: This study was a randomized prospective double-blinded study. Fourty six children of the ASA class I and II posted for cleft palate repair were randomized into Group A and Group B. In Group A, 23 children had SMN block with 0.15 mL kg-1 of 0.25% bupivacaine with saline and the same procedure was repeated on other side. In Group B, 23 children received SMN block with a volume of 0.15 mL kg-1 of 0.25% bupivacaine with dexmedetomidine 0.5 µg kg-1 on each side. Primary outcomes analysed were pain scores in post operative period by Children and Infants Post-Operative Pain Scale (CHIPPS) and the analgesia duration. Postoperative pain scores were analysed at 30 minutes intervals for 2 hours in Post Anaesthesia Care Unit (PACU) and at every 2 hours interval for 24 hours in the postoperative ward. Results: Group A and B were comparable in demographic variables like age, gender, weight, ASA status, and duration of surgery. Children in Group B had significantly longer duration of analgesia when compared to that of Group A (12±4.73 hours vs 5.41± 3.9 hours) (p=0.003). Children had significantly lower pain scores in Group B at zero min in PACU (p=0.04), after 90 min (p=0.02), at 2 hours (p&lt;0.001), 4 hours (p&lt;0.001), 6 hours (p=0.006) and at 8 hours (p=0.02) when compared to that in Group A. Conclusion: Children who received bupivacaine with dexmedetomidine in SMN block had a longer analgesia duration and lesser postoperative pain scores than children who received bupivacaine alone. Keywords: Maxillary nerve block, Dexmedetomidine, pain scores, postoperative analgesia, rescue analgesia

Preemptive analgesic effectiveness of single dose intravenous ibuprofen in infants undergoing cleft palate repair: a randomized controlled trial

BackgroundCorrection surgery for cleft palate is recommended between 9 and 18 months of age. Patients suffer from acute pain after palatoplasty. Clinicians are hesitant to use opioids for analgesia concerning the potential high risk of respiratory adverse events. Intravenous ibuprofen perhaps be a suitable adjuvant to pain relief. We try to assess whether preoperative administration of intravenous ibuprofen can decrease opioid requirements following cleft palate repair in infants.MethodsThis single center prospective randomized clinical trial was performed from February to April 2021 at Department of Anesthesiology in Shanghai Children’s Medical Center. Forty patients ASA I-II, aged 9–24 months with isolated cleft palate and undergoing palatoplasty were randomized in a 1:1 ratio to receive either a single dose of 10 mg/kg ibuprofen intravenously or normal saline at induction. Children and infants postoperative pain scale (CHIPPS) was used for pain assessment. Those patients CHIPPS pain score equal or higher than 4 received analgesic rescue with titrating intravenous fentanyl 0.5 μg/kg and repeated in 10 min if required. The primary outcome was the amount of postoperative fentanyl used for rescue analgesia in postanesthesia care unit (PACU).ResultsPatients (n = 20 in each group) in IV-Ibuprofen group required less postoperative fentanyl than those in placebo group (p<0.001). There was no significant difference between two groups in first rescue analgesia time (p = 0.079) and surgical blood loss (p = 0.194). No incidence of obvious adverse events had been found within the first 24 h after surgery in both groups.ConclusionsPreemptive intravenous administration ibuprofen 10 mg/kg at induction had a significant opioid sparing effect in early postoperative period without obvious adverse effects in infants undergoing palatoplasty.Trial registrationCHICTR, CTR2100043718, 27/02/2021 http://www.chictr.org.cn/showproj.aspx?proj=122187

Pain in children undergoing tonsillotomy with alternating ibuprofen and paracetamol - a prospective observational study.

The optimal pain therapy for children undergoing tonsillotomy remains unknown. Our aim was to evaluate a standard pain therapy including the alternating application of ibuprofen and paracetamol. Pain intensity of 81 in-patients after tonsillotomy aged 2-12years was evaluated three times daily (mean observation 3.85days) using the Children's and Infants' Postoperative Pain Scale (CHIPPS) in children <5years, or with the Faces Pain Scale-Revised (FPS-R) in older children. Parents completed the Parents' Postoperative Pain Measure (PPPM-D) in addition. Exceeding the cut-off value in one of the scores implied the indication for an opioid rescue medication (RM). Endpoints were number of children with indication for the RM, course of pain, concordance between pain scales, and adverse events. Overall, 45.7% of children needed the RM either in the recovery room or on the ward. The rate of children having an indication for RM on the ward was 30.9%. The highest proportion of affected children was identified on the day of surgery (32.1%). Most indications were detected with the PPPM-D only. A comparison with an earlier study showed less affected children compared to ibuprofen monotherapy on the day of surgery and the first postoperative day. Eleven children (13.6%) developed fever. Although our pain therapy concept was effective from postoperative day 1 onwards, it needs improvement for the day of surgery. The overall concordance between the PPPM-D and CHIPPS or FPS-R was low. Fever might be a confounder for the pain intensity measurement with the PPPM-D.

Ultrasound-guided Quadratus Lumborum Block versus caudal block for postoperative analgesia in children undergoing acute appendicitis: a comparative study

Background: ultrasound (US)-guided Quadratus Lumborum Block (QLB) is an effective technique in providing analgesia for abdominal surgery. This study was designed to evaluate the efficacy of a US-guided Quadratus Lumborum Block (QLB) compare it with a caudal block in children after acute appendicitis.&#x0D; Patients and methods. Forty eight (48) ASA 1–2, 1–5-year-old children scheduled for elective acute appendicites were studied. All patients received general anesthesia; sevoflurane was used for induction and maintenance of anesthesia and laryngeal mask airway (LMA) was used to secure the airway. After securing an intravenous cannula, patients were randomized to a US-guided Quadratus Lumborum Block (QLB) (n = 24) (group Q) using 0.5 ml/kg of 0.25 % bupivacaine, injected on the same side of surgery, and group C received a caudal block using 1 ml/kg of 0.2 % bupivacaine (n = 24). Surgery was allowed 15 min after administration of the block. Block failure was considered in case of gross movement or more than 20 % change in heart rate and/or ABP persisting more than 1 min after skin incision. Any adverse events were recorded. After surgery, patients remained for 4 h in the recovery room. Postoperative analgesia was evaluated using Children and Infants Postoperative Pain Scale (CHIPPS). An anesthesiologist, who was not part of the study team, evaluated the need for rescue analgesia in the intraoperative and postoperative period and a recovery nurse collected the data. If the CHIPPS score was greater than 4, a rescue analgesia of 20 mg/kg acetaminophen was administered.&#x0D; Results. No difference was found in hemodynamics in both groups. Also, intraoperative fentanyl consumption was not different and no rescue analgesia was required in the postanesthesia care unit.&#x0D; Conclusion. US-guided Quadratus Lumborum Block (QLB) is as effective as caudal block in providing immediate postoperative analgesia in acute appendicitis.

Ultrasound-guided suprazygomatic maxillary nerve block in cleft palate surgery: The efficacy of adding dexmedetomidine to bupivacaine

ABSTRACT We have hypothesized that adding dexmedetomidine to bupivacaine in bilateral ultrasound-guided suprazygomatic maxillary nerve block (SMB) would provide prolonged postoperative analgesia following cleft palate (CP) repair. Children posted for CP repair were randomized to receive bilateral ultrasound-guided SMB, with either 0.15 ml/kg 0.25% bupivacaine on each side (B group; n = 40) or 0.5 µg/kg dexmedetomidine plus 0.15 ml/kg 0.25% bupivacaine on each side (BD group; n = 40). Children and Infants Postoperative Pain Scale (CHIPPS) was the primary outcome, the number of children required analgesia, the first time of rescue analgesia, the total nalbuphine consumption, sedation score, and time to feed were recorded. CHIPPS score was comparable between the two groups in the first 6 hours. However, it was significantly less in BD group than B group at 8 h, 12 h, 16 h, 20 h and 24 h postoperatively as well as the number of children required analgesia (7 vs. 26, respectively; P < 0.001) with delay of the first analgesic request (23.6 vs. 14.9 h) and reduced the total nalbuphine consumption (0.3 ± 0.7 vs. 2.1 ± 1.8 mg). Sedation score was higher in group BD at Postoperative Anesthesia Care Unit (P = 0.037). Time to feed was similar between both groups (P = 0.376). In bilateral SMB, the use of 0.5 µg/kg dexmedetomidine as an adjunct to bupivacaine 0.25% was associated with prolonged postoperative analgesia and decreased total analgesic consumption in children assigned for surgical correction of CP.

High dose ibuprofen as a monotherapy on an around-the-clock basis fails to control pain in children undergoing tonsil surgery: a prospective observational cohort study.

The optimal pain management concept in children after tonsil surgery is controversial. Ibuprofen on an "around-the-clock" basis has been suggested to control postoperative pain sufficiently. Therefore, we established a standard scheme with weight-adapted recommended maximum ibuprofen dose. A reliable assessment of pain intensity can be performed with the Children's and Infants' Postoperative Pain Scale (CHIPPS) in children < 5years, or with the Faces Pain Scale-Revised (FPS-R) in children aged ≥ 5years. The Parents' Postoperative Pain Measure (PPPM-D) may be a useful tool for both age groups. We hypothesized that not more than 30% of the children would need an opioid rescue medication during their in-hospital stay and analyzed the consistency of the PPPM-D with other pain scales. We included 158 in-patients aged 2-12years. Ibuprofen was orally administered every 8h. Three times daily, pain scores were assessed by CHIPPS or FPS-R, respectively. The PPPM-D was used in all children. Exceeding the cut-off value in one of the tools was regarded as relevant pain. A rescue medication was needed in 82.1% of children after tonsillectomy and 51.3% of children after tonsillotomy (P < 0.001). The cut-off value for relevant pain was mostly exceeded in the PPPM-D, but its overall concordance to the reference scales was low. High-dose ibuprofen "around-the-clock" is insufficient to control pain in children after tonsil surgery. Research is needed to find an optimal schema for management and assessment of postoperative pain.

Clinical observation of preemptive analgesia with gabapentin for adenotonsillectomy in children with obstructive sleep apnea hypopnea syndrome

Objective To evaluate the use of gabapentin in preemptive analgesia for adenotonsillectomy in children with obstructive sleep apnea hypopnea syndrome (OSAS). Methods Eighty OSAHS patients, American Society of Anesthesiologists (ASA)Ⅰ or Ⅱ , undergoing adenotonsillectomy were divided into two groups, according to a random number table:an observation group or a control group, with 40 patients in each group. Patients in the observation group were orally administered with gabapentin 30 mg/kg 3 h before entry in the operation room. In the control group, placebo was given 3 h before entry in the room. All patients received patient controlled intravenous analgesia (PCIA) with fentanyl, where 8 μg/kg fentanyl was diluted to 50 ml. The initial dose was 4 ml, without background dose, and the bolus was 2 ml, with a lockout time of 30 min. The bolus would be adjusted to 3 ml, if analgesia was inadequate 2 h later. Those with vomiting were intravenously injected with 0.1 mg/kg granisetron. The Children's and Infants Postoperative Pain Scale (CHIPPS) scores and the consumption of fentanyl were recorded 1, 2, 4, 8, 16 h and 24 h after surgery. The adverse reactions of both groups were recorded. Results The CHIPPS scores 1, 2, 4, 8, 16 h and 24 h after surgery and fentanyl doses were significantly lower in the observation group than those in the control group (P<0.05). Patients in the observation group reported less incidences of nausea, vomiting, anxiety and itching than the control (P<0.05). Conclusions The use of gabapentin in preemptive analgesia for adenotonsillectomy in children with OSAS can effectively relieve postoperative pain and reduce the consumption of opioids after operation. Key words: Gabapentin; Obstructive sleep apnea hypopnea syndrome; Preemptive analgesia; Postoperative analgesia; Children

A Comparative Study of Tramadol and Clonidine as an Additive to Levobupivacaine in Caudal Block in Pediatric Patients Undergoing Perineal Surgeries.

Background:Caudal block is a simple, safe procedure with fewer side effects to provide intraoperative and postoperative analgesia in pediatric patients. Many drugs were used as an additive to local anesthetics in caudal block. All these drugs had their own side effects.Aims:In this study, we compare the effects of tramadol and clonidine as an additive to levobupivacaine in caudal block in children undergoing perineal surgeries regarding hemodynamic changes, analgesic effects, and side effects.Settings and Design:This is a prospective, double-blind randomized, controlled study, conducted in Department of Paediatric Surgery, at King George's Medical University, Lucknow, Uttar Pradesh during 2017–2018.Materials and Methods:After informed consent and ethical clearance from institutional ethics committee, King Georges Medical University, Lucknow. Total 66 patients aged 1–10 year, planned for perineal surgery were randomly allocated according to computer-generated random number, into three groups. Group I - 0.25% levobupivacaine (1 mL.kg-1) alone, Group II - 0.25% levobupivacaine (1 mL.kg-1) with tramadol 1 mL.kg-1, and Group III - 0.25% levobupivacaine (1 mL.kg-1) with clonidine 1 μg.kg-1. Perioperative pain was the primary outcome. Hemodynamic parameters: heart rate, mean arterial pressure, and peripheral oxygen saturation were recorded. Postoperative pain assessed by Children and Infants Postoperative Pain Scale (CHIPPS), sedation by Ramsay sedation score and requirement of rescue analgesia were recorded at predetermined time intervals.Statistical Analysis:The values were represented in number (%) and mean ± standard deviation. Comparison of quantitative variables between the study groups was done using ANOVA test and Mann–Whitney U-test. Categorical data were analyzed using Chi-square test.Results:Postoperative analgesic effect was significantly longer in levobupivacaine with clonidine group as compared to tramadol with levobupivacaine group and levobupivacaine alone group.Conclusion:Clonidine in a dose of 1 μg.kg-1 when added to levobupivacaine in caudal block significantly prolongs the duration of analgesia as compared to tramadol with levobupivacaine and levobupivacaine alone without any clinically significant side effects. Thus, it is better to add additive like clonidine to enhance the effect of analgesia.

Need of analgetics in children aged 2-12 years after tonsil surgery

Tonsil surgery is one of the most painful operations in childhood. The Children's and Infants' Postoperative Pain Scale (CHIPPS), the Faces Pain Scale-Revised (FPS-R) and the little-known German version of the parents' postoperative pain measure (PPPM-D) are age-appropriate measures. Children undergoing intracapsular tonsillectomy (TO) or extracapsular tonsillectomy (TE) received the non-opioids ibuprofen (IBU) and paracetamol (PCM) on a "as needed"-basis requested by parents. A pain service checked pain scales and applied piritramide as rescue medication (RM) if required. Objective was evalution of sufficient analgesia. Endpoints were number of patients (PAT) needing the RM, doses of requested non-opioids, consistency of indications in different pain scales and correlation between pain and efficacy of the premedication or duration of the intervention. 3 measures were carried out daily: CHIPPS for PAT ≤ 4 years old, FPS-R from the age of 5. Parents completed the PPPM-D. Exceeding a cut-off score of 4 in CHIPPS or FPS-R or 6 in PPPM-D was rated as indication for RM. We included 68 PAT in an interim analysis. Mean daily doses of non-opioids within the first 3 postoperative days were as follows: PAT undergoing TE got 14,1-16,3 mg/Kg IBU and 4,2-12,4 mg/Kg PCM. PAT undergoing TO got 10,8-14,7 mg/Kg IBU and 5,2-8,8 mg/Kg PCM. On 212 visits PAT required RM, but 121 times it was detected in the PPPM-D only. After exclusion of potentially false-positive results remained 67 % PAT after TE and 48 % PAT after TO with at least 1 indication for RM. The study was terminated due to the high need for RM. The need of non-opioids was underrated. Combining the PPPM-D with established measures may improve the postoperative pain therapy.

Bilateral greater palatine nerve block for perioperative analgesia in children undergoing palatoplasty

Background The aim of this study is to evaluate the efficacy of greater palatine nerve block for perioperative analgesia in children undergoing palatoplasty.Patients and methods This prospective randomized double-blinded study was carried out on 40 patients in Alexandria Main University Hospital scheduled for cleft palate repair. General anaesthesia was induced to all children. Patients were randomly categorized into two equal groups. Group A patients received no block (control group), whereas group B patients received bilateral greater palatine nerve block with 2 ml of 0.25% bupivacaine, 1 ml on each side, before surgical stimulation. Vital signs, time to postanaesthesia awakening, time to first cry and time to feed were recorded. Children and Infants Postoperative Pain Scale (CHIPPS) was used for scoring, and first dose and total dose of analgesic were recorded.Results There were significantly lower postoperative heart rate, mean arterial blood pressure and CHIPPS values in group B than in group A. First dose of diclofenac sodium was given at 1 h postsurgery in group A and at 8 h postsurgery in group B. Total dose of postoperative analgesic requirements was significantly lower in group B (22.73±6.20 mg) than in group A (32.40±3.84 mg) (P≤0.001). The time to postanaesthesia awakening, time to first feed and time to first cry were significantly shorter in group B than in group A (P≤0.001).Conclusion Bilateral greater palatine nerve block provided adequate perioperative analgesia up to 8 h postsurgery, less postoperative analgesic requirements and it shortened the time to postanaesthesia awakening, time to first cry and time to feed.

A single dose of dezocine suppresses emergence agitation in preschool children anesthetized with sevoflurane-remifentanil

BackgroundEmergence agitation (EA) is a common phenomenon in preschool children during emergence from general anesthesia. This study evaluated the safety and efficacy of dezocine for emergence agitation in preschool children anesthetized with sevoflurane-remifentanil.MethodsA total of 100 preschool children, scheduled for elective laparoscopic repair of an inguinal hernia by high ligation of the hernia sac under sevoflurane-remifentanil anesthesia were randomized into two groups: Group C (n = 50) received Ringer’s lactate 10 mL and Group D received Ringer’s lactate 10 mL containing dezocine 0.1 mg/kg, postoperatively.ResultsIncidence of EA, defined as a score ≥ 3 on Aono’s four point scale or Pediatric Anesthesia Emergence Delirium (PAED) score ≥ 10 in the PACU (10% vs. 76%) and the percentage of patients with severe EA (PAED score ≥ 13) (12% vs. 76%) were significantly lower in Group D compared to Group C (P < 0.05). Mean Children and Infants Postoperative Pain Scale (CHIPPS) score was significantly lower in Group D compared to Group C (1.2 ± 0.5 vs. 5.2 ± 0.6; P < 0.05). Patients need for fentanyl (18% vs. 4%) or propofol rescue (20% vs. 0) was significantly greater in Group C compared to Group D. No significant differences in other relative aspects after surgery between groups.ConclusionAdministration of dezocine 0.1 mg/kg decreased the incidence and severity of EA in preschool children that had undergone laparoscopic repair of an inguinal hernia by high ligation of the hernia sac under sevoflurane-remifentanil anesthesia.Trial registrationA single dose of dezocine suppresses emergence agitation in preschool children anesthetized with sevoflurane-remifentanil effectively: A double-blind, prospective, randomized, controlled study, Chinese Clinical Trial Registry (ID: ChiCTR-IOR-16010033), retrospectively registered on November 21, 2016.

Effect of dexmedetomidine combined with sufentanil on preventing emergence agitation in children receiving sevoflurane anesthesia for cleft palate repair surgery.

The aim of the present study was to observe whether dexmedetomidine (DEX) combined with sufentanil decreased emergence agitation (EA) in children receiving sevoflurane anesthesia for cleft palate repair surgery. Children undergoing elective cleft palate repair surgery were randomly allocated into the DEX + sufentanil group (group DS; n=50) and the normal saline + fentanyl group (group SF; n=50). Patients in group DS were treated with 0.5 µg/kg DEX prior to induction of anesthesia, whereas patients in group SF received an equal volume of normal saline. Sufentanil (0.2 µg/kg) was administered to induce anesthesia, and 30 min before the end of surgery for patients in group DS. Fentanyl (2 µg/kg) was administered at the same time point for patients in group SF. Mean arterial pressure (MAP), heart rate (HR), duration of surgery and anesthesia, and the dosage of remifentanil were assessed. EA score, Pediatric Anesthesia Emergence Delirium (PAED) score and the Children and Infants Postoperative Pain Scale (CHIPPS) score were documented every 15 min in the post-anesthesia care unit (PACU). The number of cases requiring fentanyl (1 µg/kg) and the recovery profile data were analyzed. Compared with group DS (P<0.05) and the baseline (P<0.05), HR and MAP were significantly increased in group SF immediately following tracheal intubation and extubation. Mean values of maximum EA, PAED and CHIPPS scores were significantly reduced in group DS compared with group SF at 0 (P<0.01), 15 (P<0.05), and 30 min (P<0.05) after arrival at PACU. The incidence of EA in group SF was significantly increased compared with group DS (P<0.05). The dosage of remifentanil during the surgery and the number of cases requiring fentanyl (1 µg/kg) in group DS were significantly decreased compared with group SF (P<0.05). The findings of the present study suggested that DEX combined with sufentanil was able to effectively decrease the incidence of EA in children receiving sevoflurane anesthesia for cleft palate repair surgery.

Ultrasound-guided transversus abdominis plane block versus caudal block for postoperative analgesia in children undergoing unilateral open inguinal herniotomy: A comparative study

Background Ultrasound (US)-guided transversus abdominis plane (TAP) block is an effective technique in providing analgesia for abdominal surgery. This study was designed to evaluate the efficacy of a US-guided TAP block and to compare it with a caudal block in unilateral day-case open inguinal hernia repair in children. Patients and Methods Forty ASA I-II, 1-5-year-old children scheduled for elective unilateral open inguinal herniotomy were studied. All patients received general anesthesia; sevoflurane was used for induction and maintenance of anesthesia and laryngeal mask airway (LMA) was used to secure the airway. After securing an intravenous cannula, patients were randomized to a US-guided TAP block ( n = 20) (group T) using 0.5 ml/kg 0.25% bupivacaine, injected on the same side of surgery, and group C received a caudal block using 1 ml/kg 0.2% bupivacaine ( n = 20). Surgery was allowed 15 min after administration the block. Block failure was considered in case of gross movement or more than 20% change in heart rate and/or ABP persisting more than 1 min after skin incision. Any adverse events were recorded. After surgery, patients remained for 4 h in the recovery room. Postoperative analgesia was evaluated using Children and Infants Postoperative Pain Scale (CHIPPS). An anesthesiologist, who was not part of the study team, evaluated the need for rescue analgesia in the intraoperative and postoperative period and a recovery nurse collected the data. If the CHIPPS score was greater than 4, a rescue analgesia of 20 mg/kg acetaminophen was administered. Results No difference was found in hemodynamics in both groups. Also, intraoperative fentanyl consumption was not different and no rescue analgesia was required in the postanesthesia care unit. Conclusion A US-guided TAP block is as effective as a caudal block in providing immediate postoperative analgesia in inguinal hernia repair.

The effect of infraorbital nerve block on emergence agitation in children undergoing cleft lip surgery under general anesthesia with sevoflurane.

Sevoflurane is widely used in pediatric anesthesia. However, a high incidence of emergence agitation (EA) after general anesthesia with sevoflurane has been reported and pain has been regarded as a significant contributing factor. The objective of this prospective randomized, placebo-controlled trial was to determine whether infraorbital nerve block reduces EA in children undergoing repair of cleft lip after sevoflurane. In this randomized, placebo-controlled trial, we enrolled 110 children (5 months to 6 years of age), who were scheduled for cleft lip surgery, and randomized them to the following two groups: Group S and Group B, where 1.5 ml saline (Group S) or 1.5 ml 0.25% bupivacaine (Group B) were administered in the infraorbital foramen. Emergence behavior was assessed in the postanesthesia care unit using the Pediatric Anesthesia Emergence Delirium (PAED) scale and a 5-point scale described by Cole. Pain was evaluated using the Children and Infants Postoperative Pain Scale (CHIPPS). One-hundred children (n = 50 per group) completed the study. The endtidal concentration of sevoflurane in Group B was lower than that in Group S. The incidence of EA was 16% in Group B and 42% in Group S (P = 0.008). The PAED scale score in Group B (mean [95% CI] 9 [8-12]) was lower than that in Group S (11.5 [9.8-15]). The duration of EA in Group B was shorter than that in Group S. CHIPPS score in postanesthetic care unit were lower in Group B (mean [95% CI] 3 [2-3.3]) compared with that in Group S (5 [4-6]). In children undergoing cleft lip repair surgery, infraorbital nerve block at the beginning of surgery significantly decreased the incidence of EA and the duration of EA, and provided satisfactory postoperative analgesia without delaying the time to extubation with sevoflurane anesthesia.

Levobupivacaine-tramadol combination for caudal block in children: a randomized, double-blinded, prospective study1

The aim of this prospective study was to compare the postoperative analgesic efficacy and duration of analgesia after caudal levobupivacaine 0.125% or caudal tramadol 1.5 mg.kg(-1) and mixture of both in children undergoing day-case surgery. Sixty-three American Society of Anesthesiologists (ASA) I or II children between 1 and 7 years old scheduled for inguinal hernia repair under sevoflurane anesthesia were randomized to receive caudal levobupivacaine 0.125% (group L), caudal tramadol 1.5 mg.kg(-1) (group T) or mixture of both (group LT) (total volume of caudal solution was 1 ml.kg(-1)). Duration of analgesia and requirement for additional analgesics were noted. Postoperative pain was evaluated using the Children's and Infants' Postoperative Pain Scale (CHIPPS) every 15 min for the first hour, and after 2, 3, 4, 6, 12, and 24 h. Analgesia was supplemented whenever pain score was > or =4. No patient experienced significant intraoperative hemodynamic response to surgical incision. Duration of analgesia was significantly longer in group LT than in group L and group T (545 +/- 160 min vs 322 +/- 183 min and 248 +/- 188 min, respectively) (P < 0.01). There were no significant differences between the group L and group T for duration of analgesia (P > 0.05). There were no significant differences among the groups in the number of patients requiring analgesia after operation (P = 0.7). No signs of motor block were observed after the first postoperative hour in any of the patients. Addition of tramadol increased the duration of analgesia produced by caudal levobupivacaine in children.

The effects of caudal or intravenous clonidine on postoperative analgesia produced by caudal levobupivacaine in children

Clonidine is used increasingly in pediatric anesthesia practice to prolong the duration of action of caudal block with a local anesthetic agent. Which route of administration of clonidine is the most beneficial remains unknown. We compared the effects of caudal and intravenous clonidine on postoperative analgesia produced by caudal levobupivacaine. Sixty ASA I and II children, aged 2-8 undergoing inguinal hernia repair or orchidopexy surgery received standardized premedication with midazolam and general anesthesia. The children were randomized in a double-blind fashion to three groups. Group L (n = 20) patients received 0.75 ml x kg(-1) of caudal 0.25% levobupivacaine and i.v. 5 ml saline, Group L-Ccau (n = 20) patients received 0.75 ml x kg(-1) of caudal 0.25% levobupivacaine + 2 microg x kg(-1) clonidine and i.v. 5 ml saline, Group L-Civ (n = 20) patients received 0.75 ml x kg(-1) of caudal 0.25% levobupivacaine and i.v. 2 microg x kg(-1) clonidine in 5 ml of saline. Mean arterial blood pressure, heart rate, peripheral oxygen saturation, and end-tidal carbon dioxide values were recorded. Postoperative pain [Children and Infants Postoperative Pain Scale (CHIPPS) score], sedation (Ramsay Sedation Scale) and motor blockade (Modified Bromage Scale) were assessed at predetermined time points during the first 24 h after surgery. Caudal clonidine significantly delayed the time to first rescue analgesic and fewer patients required rescue analgesia in the 24 h after surgery. No motor block was observed in any of the three groups on awakening or during the study period. In Group L-Ccau, the CHIPPS score was lower than in Group L at all times through 240 min (P < 0.05), while the pain scores were lower in Group L-Civ only at extubation and at 240 min (P < 0.05). Caudal clonidine prolongs the duration of analgesia produced by caudal levobupivacaine without causing significant side effects and this is because of a spinal mode of action.

Postoperative Analgesia for the Surgical Correction of Congenital Clubfoot. Comparison between Peripheral Nerve Block and Caudal Epidural Block

Correction of congenital clubfoot (CCF) is associated with severe postoperative pain. Caudal epidural block associated with general anesthesia is the anesthetic technique used more often in children, but it is limited by the short duration of the postoperative analgesia. Peripheral nerve blocks are associated with a low incidence of complications and prolonged analgesia. The objective of this study was to compare the duration of analgesia in peripheral nerve blocks and caudal block, as well as morphine consumption in the first 24 hours after correction of CCF in children. This is a randomized, double-blind study with children undergoing surgeries for posteromedial release of CCF, who were divided in four groups according to the anesthetic technique: caudal (ACa), sciatic and femoral block (IF), sciatic and saphenous block (IS), and sciatic block and local anesthesia (IL), associated with general anesthesia. In the first 24 hours, patients received oral dypirone and acetaminophen, and they were evaluated by anesthesiologists who were unaware of the technique used. Oral morphine (0.19 mg x kg(1) per day) was administered according to the scores of the CHIPPS (Children's and infants' postoperative pain scale) scale. One hundred and eighteen children separated into four groups: ACa (30), IF (32), IS (28), and IL (28) participated in this study. The mean time between the blockade and the first dose of morphine was 6.16 hours in group ACa, 7.05 hours in group IF, 7.58 in IS, and 8.18 hours in IL. Morphine consumption was 0.3 mg.kg-1 per day in all four groups. Significant differences were not observed among the groups. peripheral nerve blocks did not promote longer lasting analgesia or a decrease in morphine consumption in the first 24 hours in children undergoing CCF correction when compared to caudal epidural block.

Continuous peripheral nerve blocks for postoperative analgesia in children: feasibility and side effects in a cohort study of 339 catheters

Perioperative continuous peripheral nerve blocks (CPNB) are increasingly being used in children. Only one previous study has reported adverse events of CPNB in a high number of pediatric cases. We evaluated the indications, block efficacy, and adverse events related to CPNB in children. All CPNBs that were performed in children for postoperative analgesia over a 5-year period at the Montpellier University Hospital in France were included in this study. The first bolus dose and the continuous doses of local anesthetic were not standardized. In the postoperative period, demographic data, quality of analgesia, amount of rescue analgesic medication, child/parent satisfaction, and adverse events were recorded in our Departmental Regional Anesthesia registry. A total of 339 catheters were evaluated in 292 children ASA physical status I to III. The median age was 8 yr (0.6-17 yr) and the median weight was 28 kg (7-116 kg). The main surgical indications were hip, femoral, or tibial osteotomies (44.5%) and club foot repair (27.4%). The local anesthetics used were either bupivacaine or ropivacaine. The mean volume of the local anesthetic bolus dose was 0.49 +/- 0.16 mL . kg(-1), and the mean regimen of local anesthetic continuous infusion was 0.11 +/- 0.04 mL . kg(-1) . hr(-1). The median duration of CPNB was 61.6 hr (range 0-264 hr). Pain relief, which was evaluated with the children at rest, was considered optimal in the majority of patients throughout the study period. The Children and Infants Postoperative Pain Scale (CHIPPS) was used in children age 0-6 yr and the Visual Analog Pain Scale (VAS) was used in children 7 yr and older. There were no major adverse events. There were 211 minor adverse events recorded in 153 CPNBs (45.1%). The most frequently reported complication (20.1%) involved mechanical problems with the catheter, followed by nausea and vomiting (14.7%). CPNBs are indicated after orthopedic surgery in children. Our results demonstrate that CPNBs are feasible in the pediatric setting, and in skilled hands, they promote prolonged analgesia in the majority of patients without major adverse events. The most common minor adverse events are catheter-related mechanical problems and postoperative nausea and vomiting.

Cross‐validation of the Children's and Infants' Postoperative Pain Scale in Brazilian Children

To validate CHIPPS (Children's and Infants' Postoperative Pain Scale) in Brazilian children. Cross-validation is needed in order to apply this scale in a different language and culture. We applied a Portuguese version of CHIPPS to 100 children aged 0 to 5 years. The scale was translated and tested for inter-rater reliability, internal consistency, and construct, content, and concurrent validity. The children's behavior was videotaped before, during and after a procedure in a primary care unit. Three observers then rated pain behavior from videotapes. The scale showed excellent inter-rater reliability (intraclass correlation coefficient: 0.89) and a very good internal consistency, with Cronbach's alpha of 0.86. The positive correlation between CHIPPS and Modified Behavior Pain Scale supports concurrent (criterion) validity (Spearman coefficient 0.70 before and 0.81 after vaccinations). Construct validity was determined by comparing the scores of each child before vaccination (without pain) and during the procedure (experiencing pain), and the difference in pain scores was statistically significant (Wilcoxon signed rank test; P < 0.001). Content validity (by expert review) was very good. Based on the results obtained, we can infer that CHIPPS is a valid and reliable tool for Brazilian children aged 0 to 5 years old.