Children's Hospital Of Eastern Ontario Pain Scale Research Articles

Ultrasound guided quadratus lumborum block versus interlaminar epidural block for analgesia in pediatric abdominal surgery: a randomized controlled trial

BackgroundAlthough the efficacy and safety of epidural block (EB) are fairly high, complications such as inadvertent dural puncture may limit its use. Ultrasound-guided quadratus lumborum block (QLB) is a relatively new regional technique that provides perioperative somatic and visceral analgesia for pediatric patients. This trial compared the quality of pain relief in pediatric patients undergoing abdominal surgery who received either QLB or EB.MethodsPatients were randomly allocated into two equal groups: Group E(n = 29): received EB; Group QL(n = 29): received QLB. Both groups were injected with 0.25% bupivacaine (0.5 ml/kg). Assessment of total analgesia consumption was the primary outcome measure, whereas the secondary outcome measures were assessment of postoperative analgesic effect by Children’s Hospital of Eastern Ontario Pain Scale (CHEOPS) and time of first analgesic request.ResultsOur study showed that the mean total fentanyl consumption was comparable between both groups(38.67 ± 5.02 and 36.47 ± 5.13 µg in the E and QL groups, respectively, P = 0.246). Only five patients did not require rescue analgesia (3 in the E group,2 in the QL group, P = 0.378). The mean duration of analgesia showed no significant difference between the two groups (9.9 ± 1.58 and 11.02 ± 1.74 h in the E and QL groups, respectively, P = 0.212). Evaluation of CHEOPS score values immediately in PACU and for the initial 24 h following operation showed no significant difference between the two study groups(P > 0.05).ConclusionQLB can achieve analgesic effects comparable to those of EB as a crucial part of multimodal analgesia in children undergoing abdominal surgeries.Clinical trial registration numberPACTR202203906027106.

The effect of listening to music and foot reflexology on nausea, pain and anxiety in children during perioperative period: A randomized controlled study

AimThe purpose of this research was to examine the effects of listening to music and foot reflexology during the perioperative period on nausea, pain and anxiety in children aged 7–12 years. Material and methodThe sample for the randomized controlled experimental study included children who underwent outpatient surgery in the Pediatric Surgery Clinic. Research data were collected. A total of 99 children were included in the study with 33 in the music group, 33 in the foot reflexology group, and 33 in the control group. ResultsIn the preoperative and postoperative periods, Children's Perioperative Multidimensional Anxiety Scale (CPMAS) scores for the music listening and reflexology groups were significantly lower than the control group (p < 0.05). In the postoperative period, the Children's Emotional Manifestation Scale (CEMS) scores for the reflexology and music listening groups after the application were significantly lower than the control group (p < 0.001). Postoperative Baxter Retching Faces (BARF) scores were found to be significantly lower in children who listened to music compared to the control group (p = 0.002). The Children's Hospital of Eastern Ontario Pain Scale (CHEOPS) scores for children in the control group were found to be significantly higher in the postoperative period than for children in the music and reflexology groups (p < 0.001). ConclusionsAs a result, listening to music and reflexology during the perioperative period were effective in reducing anxiety, pain and nausea in children. Practice implicationsIn the perioperative period, listening to music and reflexology for children can be recommended as non-pharmacological nursing interventions with low cost and easy implementation.

Efficacy of peritonsillar infiltration with dexmedetomidine versus tramadol in comparison to placebo for pain control and sedation after tonsillectomy in pediatric patients: A randomized clinical trial.

This article aimed to assess the efficacy of peritonsillar infiltration with dexmedetomidine-ropivacaine versus tramadol-ropivacaine for pain control and sedation after tonsillectomy in pediatric patients. This double-blind clinical trial recruited 99 eligible children (4-8 years old) undergoing tonsillectomy and assigned to three block-randomized groups, receiving dexmedetomidine-ropivacaine (group A), tramadol-ropivacaine (group B), or placebo-ropivacaine (group C). The vital signs included blood pressure, heart rate, and SaO2 before anesthesia induction, during surgery at regular intervals until 24 h after surgery. The duration of surgery and recovery, complications, and analgesic consumption were recorded and pain scores were measured by Children's Hospital of Eastern Ontario Pain Scale (CHEOPS) and Oucher scales as well as sedation scores by the Wilson sedation scale. Data were analyzed within SPSS 20 at a significance level of 0.05. The lowest pain scores were measured by the CHEOPS scale in the dexmedetomidine-ropivacaine group (P < 0.05). Statistically significant difference was observed in the CHEOPS pain score between the first two groups at 30 min, 1 h, 2 h, and 4 h after surgery (P < 0.01). The differences were revealed in the Oucher pain assessments among all groups from the time of recovery to four postoperative hours (P < 0.05), with the lowest in the dexmedetomidine-ropivacaine group whose sedation score was greater during recovery and 5 min after surgery (P < 0.05). Subjects in tramadol group had six cases of dizziness and nausea, while no side effects were observed in two other groups (P < 0.05). Only seven participants receiving dexmedetomidine required acetaminophen, but 29 in the tramadol group and all in the placebo group demanded to receive acetaminophen (P = 0.001). The authors concluded that dexmedetomidine as an adjuvant to ropivacaine has better performance in local infiltration for intra- and post-tonsillectomy analgesia and postoperative sedation, without any special side effects (like the placebo group), and that it hence is recommended to be used for local infiltration during tonsillectomy.

Comparison of ultrasound-guided transversus abdominis plane block and caudal epidural block for postoperative analgesia in paediatric lower abdominal surgeries: A randomised controlled trial.

Ultrasound-guided transversus abdominis plane (TAP) block is an effective technique for postoperative analgesia in lower abdominal surgeries. This study aims to compare the duration and efficacy of an ultrasound-guided TAP block with those of a caudal epidural for paediatric unilateral lower abdominal surgeries. After ethical approval, sixty children aged 1 to 9 years were randomised into ultrasound-guided TAP block or caudal block with general anaesthesia for unilateral lower abdominal surgeries. The primary endpoint was time for the first rescue analgesia in the postoperative period. The secondary endpoints were total postoperative opioid consumption, modified Children Hospital of Eastern Ontario Pain Scale (CHEOPS) and the Face, Legs, Activity, Cry and Consolability (FLACC) scale in the postoperative period. The mean time for first rescue analgesia was 11.33 ± 2.80 h in the TAP block group, while in the caudal group, it was 13.18 ± 2.67 h (95% confidence interval [CI] mean difference 2.58-10.58, P = 0.017). The total postoperative morphine requirement was comparable in both groups at both 12 h (TAP block group 0.50 ± 0.12 mg vs. caudal block group 0.56 ± 0.12 mg, 95% CI mean difference 0.09-0.02, P = 0.08) and 24 h (TAP block group 0.96 ± 0.30 mg vs. caudal block group 0.81 ± 0.34 mg, 95% CI mean difference 0.06-0.32, P = 0.06) time period. The mean time for first rescue analgesia was lesser in the TAP block group as compared to caudal group.

Association between ABO blood groups and postoperative pain in children after adenotonsillectomy: a prospective cohort study

BackgroundIt has been known that ABO blood groups are linked to the phenotypes of certain diseases; however, and the relationship between ABO blood groups and postoperative pain have not been extensively studied, especially in children. This study was to investigate whether there would be an association between the four major ABO blood groups and postoperative pain, as indicated by the differences in pain scores and rescue fentanyl requirements among blood groups in children after adenotonsillectomy.MethodsA total of 124 children, aged 3–7 years, ASA I or II, and undergoing elective adenotonsillectomy were enrolled in the study. Postoperative pain was evaluated using the Children’s Hospital of Eastern Ontario Pain Scale (CHEOPS) and the rescue fentanyl requirement in post anesthesia care unit (PACU) was analyzed. Pediatric Anesthesia Emergence Delirium (PAED) score and the duration of PACU were recorded. The postoperative nausea and vomiting (PONV) within 24 h were documented.ResultsAmong four blood type groups, no significant differences were observed regarding surgery time, and the gaps of fentanyl given at the anesthesia induction and the first rescue fentanyl injection in PACU. However, patients from AB and B blood groups had significantly higher pain score at initial CHEOPS assessment and consequently, higher consumption of rescue fentanyl during PACU stay. A significantly higher percentage of patients had received > 1 μg/kg rescue fentanyl. Higher PAED scores were also observed in AB and B blood groups.ConclusionPaediatric patients with AB and B blood type had higher postoperative CHEOPS pain score and required significantly more fentanyl for pain control than those with A and O blood type after T&A. The initial scores of PAED in patients with AB and B blood type were also higher than that in patients with A and O blood type.

Comparison of Analgesic Effect of Dexmedetomidine versus Tramadol as Adjuvants to Caudal Ropivacaine in Infraumbilical Surgeries among Pediatric Patients: A Randomized Double Blind Interventional Study

Objective: To compare the postoperative analgesic effects of 0.2% ropivacaine with Dexmedetomidine (2 g/kg) and tramadol (2 mg/kg) among pediatric patients undergoing infra umbilical surgery.Material and Methods: This hospital based, randomized double blind interventional study included 60 pediatric patients, aged 1–7 years, having American Society of Anaesthesiology grade I and II, weighing 7-25 kg, and undergoing infraumbilical surgeries under general anesthesia. Subjects were randomly allocated into two groups to receive either: 2 mcg/ kg of Dexmedetomidine or 2 mg/kg of Tramadol, as adjuvant to 0.2% of Ropivacaine. Pain intensity was assessed using the pediatric observational Children’s Hospital of Eastern Ontario Pain Scale (CHEOPS) score. Rescue analgesia was given, when the CHEOPS score was ≥6. Duration of analgesia was defined as: the time period between administrations of block until rescue analgesia was given. Level of sedation was assessed by the Ramsay sedation score.Results: Kaplan Meier analysis showed that the median time to first rescue analgesia (duration of analgesia) was significantly (p-value&lt;0.001) prolonged with Dexmedetomidine (780 minutes; 95% CI: 760.68–799.32 minutes) as compared to Tramadol (648 minutes; 95% CI: 635.92–660.38 minutes). Mean emergence time and duration of sedation were also significantly prolonged with Dexmedetomidine as compared to Tramadol.Conclusion: In pediatric patients undergoing infraumbilical surgeries, Dexmedetomidine as adjuvant to Ropivacaine provides an advantage of longer post-operative analgesia and lack of opioid related adverse events associated with Tramadol.

Efficacy and safety of low dose oral ketamine for controlling pain and distress during intravenous cannulation in children: a double-blind, randomized, placebo-controlled trial.

BackgroundKetamine is widely used in infants and young children for procedural sedation and anesthesia. The aim of this study was to evaluate the efficacy and safety of low dose oral ketamine to control pain and distress in children during intravenous (IV) cannulation.MethodsThis is a prospective, randomized, double-blind study, including children aged between 3 and 6 years requiring a non-emergent IV-line placement. Children were randomly assigned to two groups, treated either with oral ketamine or a placebo. All patients were monitored for vital signs. Pain was assessed using the Children’s Hospital of Eastern Ontario Pain Scale (CHEOPS) and Wong-Baker Faces Pain Rating Scale (WBFS) scales and sedation using a 5-point sedation score. The facility of IV-line placement was measured by a 3-point scale. Adverse effects were recorded after 1 and 24 hours.ResultsA total of 79 and 81 children were entered in the ketamine and placebo groups, respectively. The heart and respiratory rates increased significantly in the placebo group. The median CHEOPS 4 (95% confidence interval [CI] 3, 4, P < 0.001) and WBFS 6 (95% CI 4, 6, P < 0.001) scores decreased statistically in the ketamine group. IV-line placement was 50% easier in the ketamine group (95% CI 37%, 63%, P < 0.001). No serious adverse effects were observed in all cases.ConclusionsLow dose oral ketamine effectively decreased the pain and distress during IV cannulation in children without any significant adverse reactions.

Comparison between Caudal and TAP Blocks Post-Inguinal Surgery Analgesia in Children

Background: The optimal and lonely method to achieve typical analgesia post-inguinal surgeries in children is still not determined. This study compared the analgesic efficacy and adverse effects between caudal analgesia and TAP (Transversus Abdominis Plane) block. Methods: 40 children (male) between 3-9 years old, with parental consent and institutional board approval, undergoing elective inguinal hernia repair surgery, randomly divided in two groups were enrolled in this study. Both groups received induction on Sevoflurane, Fentanyl, Propofol and Atracurium (dose dependent), with laryngeal mask airway and mechanical ventilated, maintenance on Sevoflurane and smoothly recovered. The first group (C) received caudal analgesia of Bupivacaine 0.25% (1ml/kg). The second group (T) received TAP block of Bupivacaine 0.25% (0.5 ml/kg). Pain was assessed by CHEOPS (Children's Hospital of Eastern Ontario Pain Scale). Parents also assessed pain (after explain and orient them) with Wong-Baker scale 0 (no pain) and 10 (worst pain imaginable). Results: The first group (C) of patients had about 240 ± 30 minutes, while the second group (T) had about 360 ± 60 minutes, early ambulation and feeding and finally, most of them missed the pain till they were home discharged. Conclusion: TAP block enhances comfortable long-time post-op state for the patients, especially the young age group as they are hardly pain dealt off. Also TAP block has an easily performed procedure with less dose and complications compared to the caudal ones.

Improved postoperative recovery profile in pediatric oral rehabilitation with low-dose dexmedetomidine as an opioid substitute for general anesthesia: a randomized double-blind clinical trial.

BackgroundLow-dose dexmedetomidine may be a suitable alternative to opioids for pediatric ambulatory procedures under general anesthesia (GA). However, the recovery profile remains unclear. Herein, we aimed to evaluate the effects of low-dose dexmedetomidine on the recovery profile of children.MethodsSeventy-two children undergoing ambulatory oral rehabilitation under GA were randomly and equally distributed into two groups (D and F). Group D received an infusion of dexmedetomidine 0.25 µg/kg for 4 min for induction, followed by maintenance of 0.4 µg/kg/h. Group F received an infusion of fentanyl 1 µg/kg over 4 min for induction, followed by maintenance at 1 µg/kg/h. The primary outcome was the extubation time. The secondary outcomes were awakening time, end-tidal sevoflurane (ET-Sevo) requirement, change in hemodynamic parameters, Richmond Agitation–Sedation Scale (RASS), Children's Hospital of Eastern Ontario pain scale (CHEOPS) score, length of PACU stay, and incidence of adverse events.ResultsStatistically significant differences were observed in the recovery profile between the groups: the median time for extubation was 3.65 (3.44–6.2) vs. 6.25 (4.21–7) minutes in groups D vs. F (P = 0.001), respectively, while the corresponding awakening times were 19 (18.75–21) and 22.5 (22–24) minutes, respectively (P < 0.001). The mean ET-Sevo was low in group D (1.1 vs. 1.2; P < 0.001). The heart rate was significantly low across all time points in group D, without resulting in bradycardia. The median RASS and CHEOPS scores were also significantly lower in group D. No significant differences were observed in the mean arterial pressure, incidence of adverse events, or length of PACU stay.ConclusionLow-dose dexmedetomidine was more effective than fentanyl as an opioid substitute at providing a better recovery profile in pediatric ambulatory oral rehabilitation under GA. Dexmedetomidine also significantly reduced sevoflurane consumption without causing adverse events or prolonging hospital stay.

A Randomised Controlled Trial to Assess the Analgesic Efficacy of Reduced Dose 0.2% Ropivacaine-Dexmedetomidine Combination Compared to Standard 0.375% Ropivacaine in USG Guided TAP Block for Paediatric Hernia Repair.

Paediatric pain management has remained understated practice over a period of time. Recently ultrasound-guided (USG) guided techniques are gaining popularity for perioperative analgesia, especially in the paediatric population. So, the aim of the present study was to evaluate the efficacy of reduced dose ropivacaine-dexmedetomidine combination compared to standard 0.375% ropivacaine in USG guided transversus abdominis plane (TAP) block. Sixty children of either sex, aged 2-10 years, posted for elective open herniotomy under general anaesthesia were randomly divided into two groups of 30 patients each. Group RD received 0.2% ropivacaine with dexmedetomidine 1 mg kg 1 while group R received 0.375% ropivacaine at 0.5mL kg 1. Meantime to first rescue and total analgesics, Children's Hospital of Eastern Ontario Pain Scale (CHEOPS) and Ramsay sedation score, haemodynamic parameters and adverse effects were noted. Time to first rescue analgesia in group RD and group R were 16.32 6 3.11 hours and 10.82 6 2.16 hours, respectively (P < .0001). Mean CHEOPS score were 4.48 6 1.1 and 6.3 6 1.74 (P < .024) in group RD and R. Post-op Ramsay sedation score was significantly greater in group RD. Heart rate and blood pressure remained similar in either of the group. No episode of respiratory depression, bradycardia or hypotension was noted perioperatively. Combination of 1 mg kg 1 dexmedetomidine with reduced concentration of ropivacaine (0.2%) produced significantly longer duration of post-operative analgesia and lowered post-operative CHEOPS pain score in comparison with 0.375% ropivacaine alone in USG guided TAP block for paediatric hernia repair.

Effects of an individualized analgesia protocol on the need for medical interventions after adenotonsillectomy in children: a randomized controlled trial

BackgroundIt has been proposed that the dose of rescue opioids should be individually titrated to the severity of obstructive sleep apnea after adenotonsillectomy. However, a sleep study is not always available before adenotonsillectomy. This randomized, controlled and blinded trial evaluated a strategy of pain control individualized to the results of a fentanyl test, rather than the results of polysomnography, in children after adenotonsillectomy.MethodsA total of 280 children (3–10 years old) undergoing elective adenotonsillectomy were randomized into an individualized protocol (IP) group or a conservative protocol (CP) group. All patients received a fentanyl test before extubation. Pain was assessed every 10 min in the recovery room, and rescue morphine was given when the Children’s Hospital of Eastern Ontario Pain Scale (CHEOPS) score was > 6. In the IP group, the dose of rescue morphine was individualized to the results of the fentanyl test (10 μg/kg in the case of a positive result and 50 μg/kg in the case of a negative result). In the CP group, the dose was fixed (25 μg/kg). The primary outcome was the percentage of patients requiring at least one medical intervention. The secondary outcome was the median duration of CHEOPS scores > 6.ResultsFewer patients in the IP group than in the CP group required medical interventions [11.9% (16/134) vs 22.3% (29/130), P = 0.025]. The median duration of CHEOPS scores > 6 was shorter in the IP group than in the CP group [20 (95% CI: 17 to 23) min vs 30 (95% CI: 28 to 32) min, P < 0.001].ConclusionsCompared with a conservative dosing approach, this individualized protocol may improve analgesia without a significant increase in respiratory adverse events.Trial registrationClinicalTrials.gov NCT02990910, registered on 13/12/2016.

Assessment of Pain Intensity among Preschool-age Children during Venipuncture

Background: Venipuncture is a devastating medical, emotional, and physical problem for pediatric patients and their families. Blood drawing is one of the most frightening and distressing nursing procedures for hospitalized children. Aim: To assess pain intensity among preschool children during venipuncture. Research design: A descriptive research design was used in the current study. Sample included 60 preschool-age children undergoing venipuncture procedures over six months. Setting of the study: - Pediatric medical unit at Minia University Hospital for Obstetrics and Pediatrics. Tools: Tool (I): structured interview questionnaire which developed by the researcher Tool (II): Wong-Baker Faces Pain Rating Scale Tool (III): Children's Hospital of Eastern Ontario Pain Scale (CHEOPS). Results: The highest percentage of the studied preschool-age children experienced severe pain during venipuncture procedure according Wong-Baker Faces Pain Rating Scale. The total mean scores of Wong-Baker Faces Pain Rating Scale and Children's Hospital of Eastern Ontario Pain Scale were high markedly during venipuncture. There were statistically significant negative correlations between children's age and the total mean scores of the CHEOPS and Face Pain Rating Scale during venipuncture. Conclusion: it was concluded that preschool-age children complained from severe pain intensity during venipuncture procedure. Recommendation: An educational training program is mandatory for pediatric nurses about pain assessment and pain management strategy during venipuncture and other painful procedures.

Effect of intraoperative iv dexmedetomidine on emergence agitation after sevoflurane anaesthesia in children undergoing tonsillectomy with or without adenoidectomy

Introduction: Sevoflurane, a popular inhalational anaesthetic agent for paediatric anaesthesia is associated with high incidence of emergence agitation (up to 80%). This study aims to evaluate the effects of intraoperative dexmedetomidine on incidence and severity of emergence agitation (EA) in children after tonsillectomy with or without adenoidectomy under sevoflurane anaesthesia. Materials and Methods: This prospective, randomized double blind study included 70 patients aged 2-10 years with ASA physical status I and II who were randomly allocated into two groups. Group D (n = 35) received intravenous dexmedetomidine 0.3 µg/kg and Group C (n = 35) received normal saline, both given post intubation over 10 min. After extubation, emergence agitation (EA) was assessed using the Pediatric Anesthesia Emergence Delirium (PAED) score, the Children's Hospital of Eastern Ontario Pain Scale (CHEOPS) for evaluating postoperative pain and modified Aldrete score for PACU discharge time were noted. Results: Demographic profile was comparable between two groups. Incidence of emergence agitation was significantly less in Group D than Group C (20% vs 42.86%). Postoperative pain was significantly less in Group D in comparison of Group C (14.3% vs 37.15%). Emergence time, extubation time and PACU discharge time were significantly longer in Group D in comparison to Group C (8.1 ± 1.4 vs 7.1 ± 1.4 min, 9.06 ± 1.59 vs 8.06 ± 1.39 min and 23.1 ± 7.6 vs 18.1 ± 8.2 min respectively). No complications were observed between two groups except vomiting. Conclusion: Dexmedetomidine 0.3 µg/kg) given intravenously just after intubation may be considered as an effective drug to reduce emergence agitation after sevoflurane anaesthesia in children undergoing tonsillectomy with or without adenoidectomy. Keywords: Dexmedetomidine, Intraoperative, Emergence agitation, Sevoflurane, Tonsillectomy.

Randomized Controlled Trial of Scrotal versus Inguinal Orchidopexy on Postoperative Pain.

To compare the impact of orchidopexy approach (scrotal vs inguinal) on analgesic requirements, postoperative pain scores and complication rates. A superiority randomized controlled trial including boys 10 to 95 months of age at surgery, diagnosed with palpable undescended testis, was conducted. Patients with nonpalpable or bilateral undescended testis, previous inguinal surgery on the ipsilateral side and concurrent procedures were excluded. Block randomization with 1:1 allocation ratio and a standardized anesthesia protocol were employed. The primary outcome was postoperative pain and analgesic use in-hospital and at home using the validated pain scales FLACC (Face, Legs, Activity, Cry, and Consolability Behavioural Scale), CHEOPS (Children's Hospital of Eastern Ontario Pain Scale), PPPM (Parents Postoperative Pain Measure) and TPPPS (Toddler-Preschooler Postoperative Pain Scale). Secondary outcomes included operative time, conversion and success rates, and complications. An intention to treat protocol was followed. We enrolled 173 patients, and 12 withdrew. Of the 161 patients who completed followup, 80 had scrotal orchidopexy and 81 inguinal orchidopexy. In-hospital use of ibuprofen (p=0.02) and acetaminophen (p <0.01), as well as FLACC (p <0.01) and CHEOPS (p=0.04) pain scores were slightly higher in patients who underwent orchidopexy. No difference in mean operative time and median at-home administration of analgesic was noted. The conversion rate was 24% (19/80). Of these, 13 (68%) were canalicular testes. The overall complication rate was 4% (6/161): 1 testicular atrophy, 3 re-ascents and 2 wound infections. Of these, 5 underwent scrotal orchidopexy and 1 had inguinal orchidopexy (wound infection). Even though in-hospital mean postoperative pain scores and analgesic consumption were slightly lower for scrotal orchidopexy cases, the pain levels were mild across all scales. Median at-home analgesic use and pain scores were similar for both groups, as well as operative time and complication rates. Scrotal orchidopexy is an effective alternative to inguinal orchidopexy for low-lying undescended testis, as 68% of cases that needed conversion were canalicular testes.

The Efficacy of Meperidine for Pain Management in Orthopedic, Dental, and General Surgery in Children: A Review Study

Background: The present study aimed to assess the efficacy of Meperidine for pain relief in children after orthopedic, abdominal surgery, and laceration repair. Materials and Methods: A systematic serch was performed using the following online databases: Medline, Cochrane, Web of Science, Scopus, and Embase to 2 June 2020, with keywords: (Meperidine OR Pethidine) AND (Pain) AND (Child OR Children) with no language restriction. Results: The Acetaminophen had slightly higher pain scores compared to Meperidine after dental restoration among children. There was better sedation along with more rapid onset and recovery in the combined regimens of Atropine/Midazolam/Ketamine compared to Meperidine/Midazolam. Two studies reported the superiority of Morphine over Meperidine for pain management. A study found a significant increase in the mean pediatric pain scores in the Tramadol group compared to the Meperidine group after 24 hours. There was no difference in the Children’s Hospital of Eastern Ontario Pain Scale (CHEOPS) between MPC (Meperidine/Promethazine/Chlorpromazine), and OTFC (Oral Transmucosal Fentanyl Citrate) groups during the laceration repair. In the study on the incidence of sleep on the way home or shortly after arriving at home, there were differences in chloral hydrate, Meperidine, and Hydroxyzine regimen compared to Midazolam alone among children being sedated during endodontic procedures. Conclusion: Meperidine was effective for controlling pain in orthopedic, abdominal surgery, laceration repair, and dental restoration. However, it was only superior to the Tramadol group. Regarding dental surgery, a combination regimen were more effective compared to single Midazolam. The pain intensity during early recovery was slightly lower in Meperidine group. The regimen had better sedation with more rapid onset and recovery compared to Meperidine/Midazolam.

Comparison of preadministered and coadministered lidocaine for treating pain and distress associated with intranasal midazolam administration in children: A randomized clinical trial.

ObjectivePain and distress associated with intranasal midazolam administration can be decreased by administering lidocaine before intranasal midazolam (preadministered lidocaine) or combining lidocaine with midazolam in a single solution (coadministered lidocaine). We hypothesized coadministered lidocaine is non‐inferior to preadministered lidocaine for decreasing pain and distress associated with intranasal midazolam administration.MethodsRandomized, outcome assessor–blinded, noninferiority trial. Children aged 6 months to 7 years undergoing laceration repair received intranasal midazolam with preadministered or coadministered lidocaine. Pain and distress were evaluated with the Observational Scale of Behavioral Distress—Revised (OSBD‐R) (primary outcome; non‐inferiority margin 1.8 units) and the Children's Hospital of Eastern Ontario Pain Scale (CHEOPS) and Faces, Legs, Activity, Cry, Consolability (FLACC) scales and cry duration (secondary outcomes). Secondary outcomes also included adverse events, clinician and caregiver satisfaction, and pain and distress associated with intranasal lidocaine administration.ResultsFifty‐one patients were analyzed. Mean OSBD‐R scores associated with intranasal midazolam administration were 6.4 (95% confidence interval [CI] 5, 7.8) and 7 (95% CI 5.2, 8.9) units for preadministered and coadministered lidocaine, respectively. The difference of 0.6 (95% CI –1.7, 2.8) units represented an inconclusive non‐inferiority determination. CHEOPS and FLACC scores and cry duration were similar between groups. OSBD‐R, CHEOPS, and FLACC scores and cry duration associated with intranasal lidocaine administration were 3.8, 9.9, and 6 units, and 56 seconds, respectively. Clinicians considered coadministered lidocaine easier to administer.ConclusionPain and distress associated with intranasal midazolam administration were similar when using coadministered or preadministered lidocaine, but our non‐inferiority determination was inconclusive. Administration of intranasal lidocaine by itself was associated with a measurable degree of pain and distress.Keywords: intranasal, midazolam, anxiolysis, sedation, emergency department, emergency medicine, pain, distress, pediatric, lidocaine, laceration

Effects of different doses of intranasal dexmedetomidine on preoperative sedation and postoperative agitation in pediatric with total intravenous anesthesia undergoing adenoidectomy with or without tonsillectomy.

Dexmedetomidine is a highly selective α2 receptor agonist, this study aimed to investigate the effects of different doses of intranasal dexmedetomidine on the preoperative sedation and postoperative agitation in pediatric with total intravenous anesthesia (TIVA) for adenoidectomy with or without tonsillectomy.This is a double-blind placebo-controlled randomized trial. Pediatric were randomly divided into the D1, D2, and S groups, each group contained 30 patients. Twenty-five to 40 minutes before surgery, the D1 and D2 groups received intranasally dexmedetomidine 1 μg kg−1 or 2 μg kg−1, respectively, while the S group received saline of the same volume. A unified protocol of TIVA induction and maintenance was used for the three groups. The preoperative sedation, behavior of separation from parents, postoperative agitation, and postoperative pain of the children were evaluated.The proportions of satisfactory sedation in the D1, D2, and S groups were 63.3%, 76.7%, and 0%, respectively. There was a statistically significant difference between D1 and S groups (P = .000) and D2 versus S groups (P = .000), while there was no statistically significant difference between D1 and D2 groups (P = .399). As for scale on the behavior of separation from parents, there was a statistically significant difference between D1 and S groups (P = .009) and D2 versus S groups (P = .009), whereas there was no significant difference between D1 and D2 groups (P = 1). The incidence of postoperative agitation in the D1, D2, and S groups was 43.3%, 30.0%, and 63.3%, respectively, and there was a statistical difference between D2 and S groups (P = .010). There was a significant difference in the Pediatric Anesthesia Emergence Delirium (PAED) scale between D2 and S groups (P = .029). The Children's Hospital of Eastern Ontario Pain Scale (CHEOPS) in the D2 group was significantly lower than the S group (P = .013).The intranasal dexmedetomidine of 1 or 2 μg kg−1 25 to 40 minute before induction of anesthesia both could deliver effective preoperative sedation, reducing the children's distress of separation from parents. Moreover, intranasal dexmedetomidine of 2 μg kg−1 could deliver more effective postoperative analgesia and reduce postoperative agitation, without prolonging postoperative recovery or causing severe adverse events.

Efficacy of pre-incisional peritonsillar infiltration of ketamine for post-tonsillectomy analgesia in children.

To assess the efficacy of pre-incisional peritonsillar infiltration of two doses of ketamine on postoperative analgesia compared with peritonsillar normal saline in children undergoing tonsillectomy. Double blind, randomized controlled trial. Department of Anaesthesiology, Surgical Intensive Care and Pain Management, Civil Hospital, Karachi, Dow University of Health Sciences, from August 2008 to January 2009. Seventy-five ASA physical status one patients, aged 5 - 12 years scheduled for tonsillectomy were enrolled in this study. Patients were divided into three groups of 25 each. Group-A received normal saline, Group-B, ketamine 0.5 mg/kg while group-C ketamine 1 mg/kg respectively. All medications were 2 ml and were applied 1 ml per tonsil; 3 minutes before tonsillectomy incision. Anaesthesia was induced and maintained with standard technique. All patients were monitored throughout surgery. The Children's Hospital of Eastern Ontario Pain Scale (CHEOPS) and Wilson sedation scale were used to evaluate pain levels and sedation respectively after operation. Mean duration of analgesia was significantly higher in group-C (17.28 ± 5.33 hours) as compared to group-B (11.36 ± 4.15 hours) and A (3.2 ± 0.71 hours) as well as group-B was also significantly higher than group-A (p < 0.05). Group-A had significantly higher pain scores than group-B and group-C. Both B and C groups had comparable pain scores, which were statistically significant at 6 and 8 hours. Single 0.5 or 1 mg/kg injection of ketamine given before surgical incision by peritonsillar infiltration provides efficient pain relief during postoperative period without significant side-effects in children undergoing tonsillectomy.

Quantification of Pain and Distress Associated With Intranasal Midazolam Administration in Children and Evaluation of Validity of Four Observational Measures.

The aims of this study were to quantify the pain and distress associated with the administration of intranasal (IN) midazolam in young children using 4 observational measures and to evaluate the degree of validity of these measures. We conducted a prospective observational pilot study. Children aged 1 to 7 years requiring IN midazolam were enrolled. Children were videotaped, and scores were assigned to baseline and administration phases using the Observational Scale of Behavioral Distress-Revised (OSBD-R), Children's Hospital of Eastern Ontario Pain Scale (CHEOPS), and the Faces-Legs-Activity-Cry-Consolability (FLACC) scale. The cry duration following administration was assessed. Interrater reliability and convergent validity were determined for all 4 measures. Internal consistency and responsivity for the OSBD-R, CHEOPS, and FLACC scales were determined. We enrolled 20 children. The mean OSBD-R, CHEOPS, and FLACC scores associated with administration of IN midazolam were 27.1 (SD, 13.5), 11.5 (SD, 1.2), and 8.9 (SD, 2.7), respectively. The mean cry duration was 105.5 (SD, 68.8) seconds. The intraclass correlation coefficients for all measures ranged from 0.82 to 0.99. The Cronbach α's for the OSBD-R, CHEOPS, and FLACC were between 0.71 and 0.97. Pearson correlation coefficients for comparisons between OSBD-R, CHEOPS, and FLACC were between 0.82 and 0.96 but were between 0.32 and 0.51 for comparisons involving cry duration. We have identified estimates of pain and distress associated with administration of IN midazolam in young children that can be used to determine desired effect sizes for trials that study interventions to treat this pain and distress. The OSBD-R, CHEOPS, and FLACC scales are suitable choices for outcome measures.

Does Ketamine is Safe and Effective for Procedural Sedation in Percutaneous Liver Biopsy in Children? A Cohort Study in Iran

Background: Effective and safe procedural sedation is necessary for percutaneous liver biopsy in children. There are a number of different protocols for this purpose. The current study investigated ketamine and DPT cocktail (meperidine (Demerol®) + promethazine (Phenergan®) + chlorpromazine (Thorazine®)). Methods: The current cohort of 80 Iranian children aimed at investigating percutaneous liver biopsy. Each of the 2 study groups (ketamine and DPT) included 40 patients. Both groups were matched by age (number of participants under and above 7 years old). The current study evaluated the efficacy of 2 protocols by CHEOPS (children’s hospital of Eastern Ontario pain scale) and visual analogue scale (VAS) pain scoring system and sedation scoring A,B,C, and D. Results: Ketamine group was sedated and recovered much more rapidly than the DPT receiving patients. Also, they had significantly less pain during the biopsy. The most common side effect of ketamine was vomiting (27%); in the other group, transient hypotension and tachycardia were more common. Conclusions: Ketamine is a safe and effective choice for procedural sedation in percutaneous liver biopsy in children.