Postoperative Analgesia In Pediatric Patients Research Articles

English

Post-operative analgesia in children is a challenging task before the anesthesiologist. Caudal analgesia is an accepted and popular method of providing intraoperative and postoperative analgesia for genitourinary and inguinal surgeries in children. Because of short duration of action of Bupivacaine, various adjuncts have been tried by many anesthesiologists. Fentanyl and Clonidine are used along with local anesthetics to prolong duration of analgesia. Hence we are comparing 1 mcg/kg of Fentanyl and 1 mcg/kg of Clonidine as adjuvants to 0.25% bupivacaine at a volume of 0.75 ml/kg in children undergoing genitourinary and inguinal surgeries. AIMS AND OBJECTIVES: To compare the efficacy of Fentanyl and Clonidine as adjuncts to Bupivacaine for postoperative analgesia in pediatric patients and to evaluate the sequel and side effects of both. MATERIALS AND METHODS: Study design - Comparative randomized controlled study. Sample size: 120 children aged between 2-7 years posted for genitourinary and inguinal surgeries. Group I (B) received 0.75 ml/kg of 0.25% Bupivacaine alone caudally. Group II (BF) received 0.75 ml/kg of 0.25% Bupivacaine and 1 µg/kg Fentanyl caudally. Group III (BC) received 0.75 ml/kg of 0.25% Bupivacaine and 1 µg/kg Clonidine caudally. Postoperatively the duration of analgesia, motor blockade and sedation was assessed by Modified Objective Pain Scale, Ramsay Sedation Score and modified Bromage scale respectively. Side effects and complications, if present were recorded. Tests used for statistical analysis were Fishers exact test and student t test. RESULTS: The mean duration of analgesia in group BC (601.5 + 60.17 minutes) was much higher than group BF and B but with side effect of sedation. We observed that there was a statistically increased duration of analgesia in Clonidine group as compared to Fentanyl and plain Bupivacaine group with no difference in duration of motor blockade. There was increased sedation in group BC. Group BF had nausea and vomiting, shivering and pruritus as side effects. Hence we conclude that Clonidine is a better adjunct than Fentanyl in prolonging duration of analgesia of Bupivacaine in pediatric caudal block.

A comparison of paravertebral nerve block catheters and thoracic epidural catheters for postoperative analgesia following the Nuss procedure for pectus excavatum repair

Thoracic epidurals (TE) have been advocated as a superior method for controlling postoperative pain after repair of pectus excavatum with a Nuss procedure. However, three recent reports of permanent neurologic injury after the Nuss procedure with concurrent TE analgesia have raised concerns about the safety of this combination. Paravertebral nerve blocks (PVNB) are used successfully for analgesia of the chest, but no studies are available comparing TE and PVNB catheters for postoperative analgesia in this patient population. This study was conducted to compare the efficacy of PVNB catheters with TE catheters for postoperative analgesia in pediatric patients undergoing the Nuss procedure. We retrospectively reviewed the medical records of 20 adolescent males undergoing a thoracoscopic Nuss procedure with either bilateral PVNB catheters (n = 10) or TE catheter (n = 10) and compared postoperative opiate consumption and pain scores. There were no statistically significant differences between the groups with respect to demographics, opiate consumption measured in morphine equivalents, and pain scores. In this small series, bilateral PVNB catheters resulted in equivalent opioid consumption and pain scores when compared to TE for postoperative pain management in pediatric patients undergoing the Nuss procedure. Large prospective studies are needed to further compare the efficacy, incidence of side effects, and complications of TE and PVNB catheters for postoperative analgesia in this pediatric population.

Caudal anesthesia with sedation versus general anesthesia with local infiltration during pediatric cardiac catheterization: effect on perioperative hemodynamics and postoperative analgesia

Introduction Children undergoing cardiac catheterization are usually in need for perioperative analgesia. Aim and objective We studied the effects of local infiltration of bupivacaine at the groin in generally anesthetized children as against caudal bupivacaine combined with dexmedetomidine-ketamine sedation on intraoperative and postoperative hemodynamics and duration of postoperative analgesia in pediatric patients undergoing cardiac catheterization. Materials and methods A total of 40 patients (1-7 years) were randomly assigned into one of the two groups: one group (group GI) received general anesthesia (GA) together with local infiltration using 5 ml bupivacaine 0.25% at the beginning and at the end of the procedure and the other group (group SC) received sedation by ketamine at 3 mg/kg followed by infusion at a rate of 1 mg/kg/h to maintain sedation with caudal administration of a mixture of bupivacaine 0.25% at 3 mg/kg with dexmedetomidine 0.5 μcg/kg both diluted in normal saline to a volume of 1.2 ml/kg. Hemodynamic variables (blood pressure (BP) and heart rate (HR)) were evaluated at T1 (baseline, after induction), T2 (10 min after local infiltration/caudal administration), T3 (at time of puncture for vascular access), T4 (10 min after emergence), T5 (1 h after the procedure), and T6 (4 h after the procedure). Pain was evaluated 10 min after emergence (P1), after 1 h in the ICU (P2), after 4 h in the ICU (P3), and after 8 h (P4) by the FLACC (Face, Leg, Activity, Crying, Consolability) score. Side effects were observed for 12 h. Results The severity of pain was much less in the SC group than in the GI group. FLACC pain score was evaluated at P1 (10 min after emergence), P2 (1 h after procedure), P3 (4 h after procedure), and P4 (8 h after procedure) and it was found that pain is much less in the SC group than in the GI group during the first 4 h after the procedure with significant difference between the two groups (P There was a more stable hemodynamic profile for the SC group than for the GI group. The mean arterial pressure (MAP) and HR decreased from the baseline in both groups and they decreased more significantly in the SC group than in the GI group. In addition, the decrease in MAP and HR continued for a longer duration in the SC group than in the GI group. We observed a slightly prolonged analgesia with less need for supplemental analgesics in the SC group than in the GI group. Conclusion Combining caudal anesthesia using bupivacaine and dexmedetomidine with ketamine sedation provided prolonged and potent analgesia with much stable perioperative hemodynamic parameters than giving general anesthesia combined with local infiltration in the setting of pediatric cardiac catheterization.

Comparison of local infiltration anesthesia with different concentrations of ropivacaine for postoperative analgesia in pediatric patients undergoing tonsillectomy

Objective To compare local infiltration anesthesia with different concentrations of ropivacaine for postoperative analgesia in pediatric patients undergoing tonsillectomy.Methods Sixty ASA physical status Ⅰ patients of both sexes,aged 6-12 yr,weighing 18-41 kg,scheduled for elective tonsillectomy,were randomly divided into 3 groups (n =20 each) using a random number table:control group (group C); 0.2％ ropivacaine group (group R1) ; 0.5 ％ ropivacaine group (group R2).Anesthesia was induced with inhalation of sevoflurane,injection of sufentanil and cisatracurium and maintained with inhalation of sevoflurane and iv infusion of remifentanil.The tonsil was locally infiltrated vith 0.2 ％ and 0.5％ ropivacaine (3-5 ml on each side of the tonsil) before surgery in R1 and R2 groups,respectively.Tonsillectomy was performed under general anesthesia.At 1,3,6,12,and 24 h after surgery,pain was assessed using faces pain scale-revised (FPS-R).Paracetamol 5 mg/kg was used as rescue analgesic when FPS-R scores ≥4.The interval between awake extubation and the first request for analgesic,requirement for postoperative analgesic and development of adverse effects were recorded.Results Compared with group C,the interval between awake extubation and the first request for analgesic was significantly prolonged,and the requirement for postoperative analgesic was decreased in R1 and R2 groups (P ＜ 0.05).Compared with group R1,the interval between awake extubation and the first request for analgesic was significantly prolonged,and the requirement for postoperative analgesic was decreased in R2 group (P ＜ 0.05).There was no significant difference in the incidence of adverse effects between the two groups (P ＞ 0.05).Conclusion The optinum concentration of locally infiltrated ropivacaine is 0.5 ％ for postoperative analgesia in pediatric patients undergoing tonsillectomy. Key words: Amides ; Anesthesia, local ; Tonsillectomy ; Pain, postoperative ; Child

A prospective randomized double blind Study of the effects of caudal clonidine and dexmedetomidine as an adjunct to caudal bupivacaine for postoperative analgesia in paediatric patients undergoing subumblical surgery.

In this study, we compared the analgesic efficacy and safety of caudal dexmedetomidine and clonidine added to caudal bupivacaine for postoperative analgesia in children undergoing subumblical surgeries.90 patients aged 1 to 8 years scheduled for subumblical surgeries were randomly allocated into three groups of 30 patients each. Group A received 1ml/kg of 0.25% bupivacaine with dexmedetomidine 2μg/Kg in normal saline 1 ml. Group B received 1ml/kg of 0.25% bupivacaine with clonidine 2μg/Kg in normal saline 1 ml and Group C received 1ml/kg of 0.25% bupivacaine with normal saline 1ml. All the patients in our study remained hemodynamically stable throughout the intraoperative and postoperative period. Addition of either dexmedetomidine 2μg/kg or clonidine 2μg/kg to 0.25% caudal bupivacaine significantly prolonged the postoperative analgesia time without increasing the incidence of side effects like nausea, vomiting, pruritis or urinary retention. Moreover dexmedetomidine did not offer significant advantage over clonidine as regards the duration of postoperative analgesia.

Parasternal Intercostal Block With Ropivacaine for Postoperative Analgesia in Pediatric Patients Undergoing Cardiac Surgery: A Double-Blind, Randomized, Controlled Study

The objective of this study was to assess the effectiveness of 0.5% ropivacaine used for parasternal intercostal blocks for postoperative analgesia in pediatric patients undergoing cardiac surgery. A randomized, controlled, prospective, double-blind study. A tertiary care teaching hospital. Thirty children scheduled for cardiac surgery with a median sternotomy. A 0.5% ropivacaine injection with 5 doses of 0.5 to 2.0 mL on each side in the 2nd to 6th parasternal intercostal space with a total dose of ropivacaine below 5 mg/kg or the same volume of saline before sternal wound closure. The time to extubation was significantly lower in patients administered the parasternal blocks with ropivacaine than in the control group; the mean values were 2.66 hours and 5.31 hours, respectively (p < 0.001). The pain scores were lower in the ropivacaine group compared with the saline group; mean values were 2.20 for the ropivacaine group and 4.83 for the saline group on a scale of 10. The cumulative fentanyl dose requirement over a 24-hour period was higher in the saline group than the ropivacaine group (p < 0.001). Parasternal blocks with ropivacaine appear to be a simple, safe, and useful technique of supplementation of postoperative analgesia in pediatric patients undergoing cardiac surgery with a median sternotomy.

Comparison of bupivacaine alone and in combination with fentanyl or pethidine for bilateral infraorbital nerve block for postoperative analgesia in paediatric patients for cleft lip repair: A prospective randomized double blind study

Cleft lip repair is one of the common surgeries performed in India and the usual method used for post operative analgesia is perioperative opioids and NSAIDs. There has been an increase in use of regional techniques and Opioids are the common adjuvants but their efficacy and safety have not been studied extensively in children. PATIENTS #ENTITYSTARTX00026; A prospective, randomized, double blind study was done to compare the efficacy, duration and safety of intraoral infraorbital nerve block on post operative pain relief using bupivacaine alone or in combination with fentanylor pethidine in paediatric cleft lip repair. 45 children between the age group 5 - 60 months undergoing cleft lip surgery randomly allocated into 3 groups of 15 each received bilateral intraoral infraorbital nerve block with 0.75ml of solution. Group B received 0.25% bupivacaine; group P received 0.25% bupivacaine with 0.25mg kg(-1) pethidine, group F received 0.25% bupivacaine with 0.25microgm kg(-1) fentanyl. Sedation after recovery, post operative pain intensity and duration of post operative analgesia were assessed using Modified Hannallah Pain Score. The mean duration of analgesia was 17.8 hrs in Group B, 23.53 hrs in Group F and 35.13 hrs in Group P. There was statistically significant difference between the means of the three groups- ANOVA (p < 0.05). Thus we conclude that addition of fentanyl or pethidine to bupivacaine for Bilateral Intraoral Infraorbital Nerve Block prolong the duration of analgesia with no complications and can be used safely in paediatric patients.

Effects of perioperative intravenous low dose of ketamine on postoperative analgesia in children

Low dose of ketamine reduces postoperative pain and opioid consumption in adult studies. However, there are only a few data with controversial results in the paediatric population. The aim of this randomized controlled trial was to evaluate the use of low doses of intravenous ketamine on postoperative pain in children after surgery on the lower part of the body. Thirty-seven children with ASA 1 or 2 from 6 to 60 months of age, undergoing scheduled surgery, were prospectively enrolled in a double blind sequential trial using a triangular test, with analysis every 10 patients treated. The children were randomly assigned to intravenously receive saline or 0.15 mg kg(-1) ketamine before surgery, followed by a continuous infusion of 1.4 microg kg(-1) min(-1) over 24 h. After sevoflurane induction and tracheal intubation, a caudal anaesthesia was performed in all children (1 ml kg(-1) of bupivacaine 0.25% with epinephrine). The postoperative analgesic technique was standardized with intravenous paracetamol 15 mg kg(-1) 6 h(-1), rectal morniflumate (20 mg kg(-1) 12 h(-1)) and intravenous nalbuphine infusion 1.2 mg kg(-1) 24 h(-1) for 24 h. The Children's Hospital of Eastern Ontario Pain Scale (CHEOPS) scores, additional bolus of nalbuphine (if CHEOPS >7) and side effects were recorded from eye opening every 2 h over 24 h. The primary endpoint was the CHEOPS area under the curve. There was no difference in terms of additional bolus of nalbuphine as well as CHEOPS score area under the curve between groups, that is, 76 +/- 10 in the ketamine group versus 74 +/- 7 in the control group. No psychomimetic side effects were noted. The study failed to show any evidence of benefit of ketamine to improve analgesia in children when given in addition to a multimodal analgesic therapy with paracetamol, a NSAID and an opiate.

Anesthesia and Postoperative Analgesia in Pediatric Patients Undergoing Cardiac Surgery

Pediatric cardiac anesthesiologists care for patients ranging from premature infants weighing <2 kg to adults requiring surgical intervention for congenital heart disease. Along with their cardiac pathophysiologies, many of these patients also have other co-existing diseases that can affect their anesthetic management. Recent advances in monitoring include non-invasive neuromonitors, such as near-infrared spectroscopy and trans-cranial Doppler, which are assuming increasing importance in intraoperative management, particularly during cardiopulmonary bypass. A variety of anesthetic techniques, including regional anesthesia, can be used to facilitate early extubation in older infants and children with stable postoperative hemodynamics. In addition to regional anesthesia, other modalities for the management of postoperative pain include opioid infusions in critically ill children and the use of patient- or nurse-controlled analgesia pumps. Multiple pain assessment tools are available for children of varying ages and developmental levels to assist in providing appropriate postoperative pain management.

Clinical Practice of Deliberate Postoperative Analgesia in Paediatric Patients

Introduction Deliberate postoperative analgesia (DPA) has four essential elements: methodical prescription of the necessary analgesics, systematic assessment of the analgesic demand, planned preventive or therapeutic intervention according to the pain assessments and systematic documentation of the whole process. It is still unclear in which of these elements clinically relevant shortcomings or mistakes appear and what are the consequences. Thus by using a representative sample we studied which mistakes within the DPA influence the effectiveness of the postoperative analgesia in paediatric patients. Methods As of March 2001 the DPA was introduced into clinical practice at the University Clinic for Paediatric Surgery, Ruhr University Bochum. It consists of a methodical prescription following a fixed scheme on the use of basic analgesics (Paracetemol, Metamizol and Diclofenac) and rescue analgesics (Ketamine, Talvosilen and Piritramide), a systematic age-related assessment of the analgesic demand at fixed time intervals (CHIPPS, Bieri scale, VAS)(1, 2), application of the analgesics by the nursing staff on the wards according to the prescriptions and to the pain assessments and a systematic formal documentation of all data of the whole process. In a prospective study of all 351 children aged between 1 day and 16 years, who were treated consecutively in a period of 6 weeks at the Clinic for Paediatric Surgery of the Ruhr University Bochum, the documentation of the postoperative analgesic treatment was collected. The following problems were investigated: • whether the age-related systems for the assessment of pain were correctly selected and applied, • whether the analgesic demand was completely documented on the ward, • whether the prescription of basic and rescue analgesics complied with the proposals of the fixed scheme, • whether the applications on the wards conformed with the prescriptions • which deviation from the standardised process had an influence on the effectiveness of the DPA. DPA was defined as effective if the children had no analgesic demand postoperatively or if an existing analgesic demand was recognised and successfully treated by the application of the rescue analgesic. Results 15 anaesthetists gave the anaesthetics. The patients were treated on 2 wards. The surgical procedures comprised the whole spectrum of paediatric surgery with the exception of open heart surgery. 28 patients required postoperative intensive care, one patient followed a special nurse-controlled analgesia. All DPA documents on 285 patients could be collected (return rate 82%). In 68.4% the basic analgesic was sufficient, in additional 23.2% the rescue medication was effective. In 4.2% the DPA was ineffective and in another 4.2% it was not possible to assess the effectiveness of the DPA because of insufficient documentation. The following proportional deviations from the standardised procedures occurred (Table 1). Met Not met Influence on effectiveness of the DPA Significance Pain scale correctly selected: 97.5 2.5 No Not significant Prescription according to scheme: 80.4 19.6 Impairment P < 0.001 Application according to prescriptions: 63.5 36.5 Impairment P < 0.001 Systematic documentation 84.5 15.5 Impairment P < 0.001 Discussion Deviations from the fixed scheme impair the effectiveness of the DPA. Thus it cannot be claimed that the deviations were always targeted and occurred according to the demands of the individual case. Lack of documentation is due to an irregular survey of the patient. If an analgesic demand is not identified and/or documented, a therapeutic consequence or intervention will be missed. This influences the effectiveness of the DPA. Conclusion To ensure the success rate of the DPA in paediatric patients, systematic, complete documentation is just as necessary as the systematism of the preventive and therapeutic treatment.

Postoperative Use of Epidurally Administered Morphine in Children and Adolescents

Epidurally administered narcotics are increasingly used to provide relief of pain in adults after major surgical procedures. This report describes the use of epidurally administered morphine for postoperative analgesia in nine pediatric patients after 15 major surgical procedures. The mean dose of morphine was 0.12 ± 0.03 mg/kg of body weight, and the mean duration of analgesia per dose was 10.8 ± 4.0 hours. Catheters remained in place for a mean duration of 50.3 ± 16.0 hours. Increasing the dose of morphine to more than 0.1 mg/kg did not prolong the duration of analgesia but it did increase the frequency of side effects. No complications from placement of the catheter and no serious side effects were encountered. The postoperative requirements for narcotics were significantly less in the patients who received morphine epidurally than in those who received narcotics parenterally. Epidurally administered morphine can provide reliable postoperative analgesia in pediatric patients. The potential benefits include improved quality of pain relief at low total requirements, improved pulmonary function, and early ambulation.

Postoperative Use of Epidurally Administered Morphine in Children and Adolescents

Epidurally administered narcotics are increasingly used to provide relief of pain in adults after major surgical procedures. This report describes the use of epidurally administered morphine for postoperative analgesia in nine pediatric patients after 15 major surgical procedures. The mean dose of morphine was 0.12 +/- 0.03 mg/kg of body weight, and the mean duration of analgesia per dose was 10.8 +/- 4.0 hours. Catheters remained in place for a mean duration of 50.3 +/- 16.0 hours. Increasing the dose of morphine to more than 0.1 mg/kg did not prolong the duration of analgesia but it did increase the frequency of side effects. No complications from placement of the catheter and no serious side effects were encountered. The postoperative requirements for narcotics were significantly less in the patients who received morphine epidurally than in those who received narcotics parenterally. Epidurally administered morphine can provide reliable postoperative analgesia in pediatric patients. The potential benefits include improved quality of pain relief at low total requirements, improved pulmonary function, and early ambulation.