Postoperative Pain In Pediatric Patients Research Articles

Quadratus Lumborum Block is an Effective Postoperative Analgesic Technique in Pediatric Patients Undergoing Lower Abdominal Surgery: A Meta-Analysis

Quadratus lumborum (QL) block has shown promising analgesic efficacy in the adult population in previous meta-analyses. However, the response of the pediatric group to pain stimulation is stronger than that in the adult population, and the management of pediatric pain is constrained by limited available analgesia agents. All data analyzed during this study are collected from published articles. The purpose of our systematic review was to evaluate whether QL block is also an effective postoperative analgesic technique, compared to other analgesic skills in pediatric patients undergoing lower abdominal surgery. A meta-analysis. We identified randomized controlled trials (RCTs) from PubMed, Embase, the Cochrane Library, Web of Science, and Science Direct to compare QL block with other analgesic methods for relief of postoperative pain in pediatric patients undergoing lower abdominal surgeries under general anesthesia. The primary outcome was the rate of postoperative rescue analgesia; secondary outcomes include: pain scores at 30 minutes and 1, 2, 4, 6, 12, and 24 hours postoperatively, patient satisfaction, and block related complications. A total of 7 studies with 346 patients were included. QL block showed a significant reduction in the rate of postoperative rescue analgesia in the first 24 hours (RR = 0.41; 95% CI = 0.28 to 0.59; P < 0.001) compared to other analgesic techniques, without significant heterogeneity among the articles (I2 = 49%, P = 0.08). Compared with other analgesic methods, QL block significantly reduced the pain scores at 2 hours (Std.MD = -0.76; 95% CI = -1.16 to -0.35; P < 0.001) (I2 < 0.001%, P = 0.41), 4 hours (Std.MD = -0.34; 95% CI = -0.67 to -0.01; P = 0.04) (I2 < 0.001%, P = 0.53) and 12 hours postoperatively (Std.MD = -0.95; 95% CI = -1.44 to -0.47; P < 0.001) (I2 = 27%, P = 0.24). No significant differences were found between techniques at 30 minutes and 1, 6, or 24 hours postoperatively (P > 0.05). There was no statistically significant change in patient satisfaction (Std.MD = 0.49; 95% CI = -0.32 to 1.29; P = 0.24) or side effects (RD = -0.02; 95% CI = -0.06 to 0.02; P = 0.31) with QL block. The major limitation of this meta-analysis is the relatively few RCTs and limited results included. Similarly, the differences in block approaches among the control groups (TAP, ESP, caudal block, opioid-based analgesia), drug types and concentrations, and multimodal analgesia programs led to considerable heterogeneity. Furthermore, some relevant outcomes were not investigated. Our systematic review and meta-analysis suggests QL block use for the pediatric population undergoing lower abdominal surgery, based on the current limited research evidence, as this method was an effective postoperative analgesic technique.

Comparative Study between Different Additives to Levobupivacaine in Caudal Block for Postoperative Pain Management in Pediatrics Undergoing Hypospadias Repair: Randomized Controlled Study

Background: For both children and their caregivers, postoperative pain is an irritating experience. Several approaches have been used to treat postoperative pain in pediatric patients improving sleep quality, and extending sedation time. Objectives: This work aimed to compare the postoperative analgesic effect and any complications of addition of one of these drugs nalbuphine versus fentanyl versus dexamethasone to levobupivacaine in caudal block (CB) in pediatric patients undergoing hypospadias repair. Patient and Methods: 90 ASA status I and II patients aged 2 to 9 years underwent hypospadias repair were prospectively involved in this study. Patients were randomized into three equal groups (Group N, Group F and Group D). Result: There was no statistically significant difference between three groups as regards systolic blood pressure (SBP) except after 60 and 70 minutes after caudal block as there was a significant difference as SBP decreased in the group (N) more than in both groups (F and D). Also there was a significant deference between the three groups in SBP at 1, 1.5, 2 and 4 hours postoperatively. FLACC pain score between three groupsshowed a significant difference between three groups at 2, 6 and 8 hours postoperatively otherwise no significant difference Conclusion: Adding a nalbuphine to levobupivacaine in caudal block had longer duration for postoperative analgesia and showed more sedation time than that of fentanyl and dexamethasone with more stability in hemodynamics.

Prevalence and Contributing Factors Associated With Postoperative Pain in Pediatric Patients: A Cross-Sectional Follow-up Study

Background: Pain is a stressful condition considered to be a global health problem, and children are the most vulnerable and under-served population. Moderate to severe postoperative pain in pediatric population is associated with physiological, psychological and emotional adverse effects. This study aimed to assess the prevalence and contributing factors associated with postoperative pain in pediatric patients. Methods: Institution-based, cross sectional follow-up study was conducted from February 1 to April 30, 2020. Data were entered into Epi-info version 7 and analyzed by SPSS version 20. The strength of association of dependent and independent variables was presented by crude and adjusted odds ratio and 95% confidence interval. Binary logistic regression analysis was used and variables with a p-value of < 0.05 were considered statistically significant. The Face, Leg, Activity, Cry and Consolability (FLACC) scale was used to measure pain severity. Results: A total of 153 pediatric patients aged 2 to 12 years were included. The prevalence of moderate to severe pain after pediatric surgery was 40.5% (95% CI: 32.7, 48.4). Preoperative anxiety (AOR: 2.24, 95% CI: 1.02, 4.88), history of preoperative pain (AOR: 3.97, 95% CI: 1.55, 10.19), neurologic surgery [AOR: 8.32, 95% CI: 1.77, 39.12) and incision size greater than 10 cm (AOR: 3.41, 95% CI: 1.08, 10.77) were significantly associated with postoperative pain. Conclusion: The prevalence of moderate to severe post-operative pain was high. Preoperative anxiety, history of preoperative pain, type of surgery and incision length were significantly associated with postoperative pain. The magnitude of postoperative pain remains high and a plan for adequate pain management and preoperative anxiety reduction needs to be developed.

Application of intraoperative hypothermic saline to relieve postoperative pain for pediatric coblation tonsillectomy

ObjectivesTo evaluate the effect of hypothermic saline application for pediatric coblation tonsillectomy on postoperative pain. MethodsForty-eight children with adenotonsillar hyperplasia underwent tonsillectomy ± adenoidectomy. 24 children were in the HTS group (which used hypothermic saline as the coblation medium in operation), the other 24 children with the same age were in the control NTS group (who use normothermic saline as the coblation medium). All children and their parents were asked to complete a daily questionnaire for 7 days following their surgery. ResultsSignificant differences were observed when comparing the two outlet water temperatures of the coblation wand both at ablation power and at coagulation power (p = 0.000). Children in HTS group got lower scores than those in the NTS group (p < 0.05). No side effects were observed. ConclusionsUsing hypothermic normal saline as the media of coblation wand is potential for reduce postoperative pain in pediatric patients while also having no detrimental financial or medical effects on said patients.

Safety and efficacy of clonidine on postoperative vomiting and pain in pediatric ophthalmic surgery: A systematic review and meta-analysis.

Postoperative vomiting and pain are common, unpleasant phenomena in pediatric patients undergoing ophthalmic surgery. Clonidine has antiemetic and analgesic properties and thus may be used as premedication to reduce postoperative vomiting and pain. To assess whether clonidine premedication may safely decrease postoperative vomiting and postoperative pain in pediatric patients who received an ophthalmic surgery. We systematically searched PubMed, EMBASE, Cochrane Library, and Scopus databases from their inception to September 2018. Randomized clinical trials comparing clonidine premedication with a placebo or an active comparator that investigated postoperative vomiting or postoperative pain in pediatric patients undergoing ophthalmic surgery were included. The primary outcome was postoperative vomiting. The secondary outcome was postoperative pain. We also evaluated the safety of clonidine premedication by tracking hemodynamic instability associated with its use. Ten studies with 979 patients were eligible for inclusion. Clonidine achieved a significantly lower incidence of postoperative vomiting within 6hours postoperatively, 6-24hours postoperatively, and at the end of the study (risk difference: -0.15; 95% confidence interval: -0.32 to -0.05; risk difference: -0.15; 95% confidence interval: -0.29 to 0.01; and risk difference: -0.23; 95% confidence interval: -0.34 to -0.12, respectively) than placebo. For the subgroup of patients who received strabismus surgery, clonidine produced a lower incidence of postoperative vomiting than placebo (risk difference: -0.19; 95% confidence interval: -0.29 to -0.05). Compared to benzodiazepine, clonidine achieved a lower incidence of postoperative vomiting at the end of the study (risk difference: -0.19; 95% confidence interval: -0.31 to -0.07); the effect was only observed in patients receiving clonidine 4μg/kg. Furthermore, children receiving clonidine had lower postoperative pain scores, lower analgesic requirements, and more of them were pain-free compared to those who received a placebo. No patient using clonidine had any major hemodynamic instability. Compared to placebo or benzodiazepine, clonidine premedication was effective in reducing postoperative vomiting in pediatric patients undergoing ophthalmic surgery. Clonidine premedication also provided more reduction in postoperative pain when compared to placebo. The use of clonidine premedication was not associated with adverse hemodynamic events.

Metamizole for Postoperative Pain in Pediatric Patients Undergoing Subarachnoid Anesthesia.

Efficient postoperative pain management, which is aimed at decreasing the risk of complications and drug-induced side effects, without affecting the quality of analgesia, is part of today's concept of enhanced recovery after surgery, that is, fast-track surgery. The objective of this study was to determine whether effective management of acute postoperative pain was possible without opioids, while avoiding complications, drug-induced side effects, and suboptimal treatment. Introduction of metamizole, which has regained popularity, into a multimodal analgesia regimen was used, as opioids are not routinely administered. The study was prospective, observational, unrandomized, and without the control group. This study was performed in a pediatric hospital with 300 beds and an average of 1700 annual surgical interventions. The study group comprised 378 patients aged 1-17 years, undergoing lower abdominal or limb surgery between June 2016 and June 2017. Children underwent subarachnoid anesthesia combined with intravenous sedation and received not routinely but on demand postoperative opioid analgesia. The pain was self-assessed by the pediatric patient or was assessed by the nurse using pain scores. Metamizole proved to be safe, efficient, and very well tolerated by children. Multimodal analgesia using acetaminophen, nonsteroidal anti-inflammatory drug with metamizole for the treatment of moderate to severe pain in children undergoing surgery, required a single opioid dose in 292 patients (77.24%) of the 378 in this study. In pediatric patients undergoing surgery, subarachnoid anesthesia combined with intravenous sedation, multimodal analgesia that includes metamizole, and nonpharmacological complementary therapies in pain management enable avoidance or reduction of opioids to a single dose, without undertreatment. There is also a minimum of anesthesia, accelerated children's recovery and a rapid return to presurgical levels of function.

Comparison of Morphine- and Hydromorphone-Containing Patient-Controlled Epidural Analgesia Solutions in Pediatric Postoperative Patients.

The use of patient-controlled epidural analgesia (PCEA) in pediatric patients has been shown to be safe and effective in managing postoperative pain in children. However, the optimal opioid to use in the epidural regimen remains undetermined. Morphine, hydromorphone, and fentanyl have been the agents most often used, but comparison of effectiveness across studies is difficult. The goal of this study was to compare postoperative pain scores in patients receiving PCEA solutions that contained either ropivicaine plus morphine or ropivicaine plus hydromorphone. Retrospective chart review was used at a single center to identify pediatric patients between the ages of 5 and 17 years who used a morphine- or hydromorphone-containing PCEA solution postoperatively during an 18-month period. Maximum pain scores were recorded during 2 consecutive 24-hour periods postoperatively. The primary outcome was the number of patients who had a maximum pain score of ≤4 on postoperative day zero and postoperative day 1. Forty-six patients met the inclusion criteria and were analyzed. Patients prescribed morphine-containing PCEAs had a significantly higher incidence of maximal pain scores ≤4 in the 48 hours immediately after surgery compared with those patients prescribed hydromorphone-containing PCEAs (p = 0.03). Ropivicaine dosing in the epidural solution did not have a significant effect on pain scores and was not statistically different between opioid groups. Pediatric patients were able to effectively use the PCEA on-demand dose, with patients having pain scores >4 demanding significantly more on-demand doses from the PCEA than those patients with pain scores ≤4 (p ≤ 0.002). No serious adverse events were reported. Morphine-containing PCEAs may have an advantage in controlling postoperative pain in pediatric patients compared with hydromorphone-containing PCEAs. However, the heterogeneous nature of the procedures performed and the small sample size limit the generalizability of this study.

Managing Postoperative Pain in Pediatric Patients with Developmental Delay.

Managing Postoperative Pain in Pediatric Patients with Developmental Delay.

Postoperative pain management in patients undergoing thoracoscopic repair of pectus excavatum: A retrospective analysis of opioid consumption and adverse effects in adolescents.

Introduction:Although the Nuss procedure provides excellent cosmetic results for the correction of pectus excavatum, the provision of analgesia following such procedures can be challenging.Methods:The current study retrospectively reviews our experience over a 2.5 year period with thoracic epidural analgesia (TE), paravertebral blockade (PVB), and intravenous opioids delivered via patient-controlled analgesia (PCA) to provide postoperative analgesia.Results:The study cohort included 30 patients (mean age = 15.6 ± 1.5 years), 15 of whom were treated with PCA, 8 with TE, and 7 with PVB. There were no significant differences in pain scores between the 3 groups at any time point during the first 3 postoperative days. Compared to PCA, the PVB group had lower opioid consumption over the first 24 hours of hospitalization by 1.7 mg/kg morphine equivalents (95% CI of difference: 0.1, 3.3; p=0.035); but had higher opioid consumption by 2.0 mg/kg morphine equivalents than the TE group (95% CI of difference: 0.3, 3.7; p=0.024). There were no differences in opioid consumption between PVB and PCA or between PVB and TE at 48 or 72 hours. The number of intraoperative hypotension episodes was significantly lower in the PCA group when compared to the PVB group (p=0.001), with no difference between the PVB and TE groups.Conclusions:The use of regional anesthesia should be considered a viable option for the relief of postoperative pain in pediatric patients following the Nuss procedure albeit with a higher incidence of intraoperative hemodynamic effects. A randomized, prospective, study powered to compare all 3 techniques against one another would be necessary to confirm the significance of these findings.

The Effect of Systemic Magnesium on Postsurgical Pain in Children Undergoing Tonsillectomies: A Double-Blinded, Randomized, Placebo-Controlled Trial.

Tonsillectomy is a frequently performed surgical procedure in children; however, few multimodal analgesic strategies have been shown to improve postsurgical pain in this patient population. Systemic magnesium infusions have been shown to reliably improve postoperative pain in adults, but their effects in pediatric surgical patients remain to be determined. In the current investigation, our main objective was to evaluate the use of systemic magnesium to improve postoperative pain in pediatric patients undergoing tonsillectomy. We hypothesized that children who received systemic magnesium infusions would have less post-tonsillectomy pain than the children who received saline infusions. The study was a prospective, randomized, double-blinded, clinical trial. Subjects were randomly assigned using a computer-generated table of random numbers to 1 of the 2 intervention groups: systemic magnesium infusion (initial loading dose 30 mg/kg given over 15 minutes followed by a continuous magnesium infusion 10 mg/kg/h) and the same volume of saline. The primary outcome was pain scores in the postanesthesia care unit (PACU) measured by FLACC (Face, Legs, Activity, Cry, Consolability) pain scores. Pain reduction was measured by the decrement in the area under the pain scale versus 90-minute postoperative time curve using the trapezoidal method. Secondary outcomes included opioid consumption in the PACU, emergence delirium scores (measured by the pediatric anesthesia emergence delirium scale), and parent satisfaction. Sixty subjects were randomly assigned and 60 completed the study. The area under pain scores (up to 90 minutes) was not different between the study groups, median (interquartile range [IQR]) of 30 (0-120) score × min and 45 (0-135) score × min for the magnesium and control groups, respectively (P = 0.74). Similarly, there was no clinically significant difference in the morphine consumption in the PACU between the magnesium group, median (IQR) of 2.0 (0-4.44) mg IV morphine, compared with the control, median (IQR) of 2.5 (0-4.99) mg IV morphine (P = 0.25). The serum level of magnesium was significantly lower in the control group than in the treatment group at the end of the surgery (P < 0.001). Despite a large number of studies demonstrating the efficacy of systemic magnesium for preventing postsurgical pain in adults, we could not find evidence for a significant clinical benefit of systemic magnesium infusion in children undergoing tonsillectomies. Our findings reiterate the importance of validating multimodal analgesic strategies in children that have been demonstrated to be effective in the adult population.

Postoperative pain assessment using four behavioral scales in Pakistani children undergoing elective surgery.

Background:Several measurement tools have been used for assessment of postoperative pain in pediatric patients. Self-report methods have limitations in younger children and parent, nurse or physician assessment can be used as a surrogate measure. These tools should be tested in different cultures as pain can be influenced by sociocultural factors. The objective was to assess the inter-rater agreement on four different behavioral pain assessment scales in our local population.Materials and Methods:This prospective, descriptive, observational study was conducted in Pakistan. American Society of Anesthesiologists I and II children, 3-7 years of age, undergoing elective surgery were enrolled. Four pain assessment scales were used, Children's Hospital of Eastern Ontario Pain Scale (CHEOPS), Toddler Preschool Postoperative Pain Scale (TPPPS), objective pain scale (OPS), and Face, Legs, Activity, Cry, Consolability (FLACC). After 15 and 60 min of arrival in the postanesthesia care unit (PACU), each child evaluated his/her postoperative pain by self-reporting and was also independently assessed by the PACU nurse, PACU anesthetist and the parent. The sensitivity and specificity of the responses of the four pain assessment scales were compared to the response of the child.Results:At 15 min, sensitivity and specificity were >60% for doctors and nurses on FLACC, OPS, and CHEOPS scales and for FLACC and CHEOPS scale for the parents. Parents showed poor agreement on OPS and TPPS. At 60 min, sensitivity was poor on the OPS scale by all three observers. Nurses showed a lower specificity on FLACC tool. Parents had poor specificity on CHEOPS and rate of false negatives was high with TPPS.Conclusions:We recommend the use of FLACC scale for assessment by parents, nurses, and doctors in Pakistani children aged between 3 and 7.

Nurse-controlled analgesia for postoperative pain in pediatric patients: effects on nurses’ attitudes and patient care

Background: Because of the limited number of patient-controlled analgesia (PCA) pumps in our developing country, we proposed a technique of modified nurse-controlled analgesia (NCA) to relieve postoperative painin pediatric patients. Objective: We assessed efficacy, safety, compliance by nurses, and satisfaction including parent satisfaction of a modified NCA protocol compared with fixed-dose analgesia conventionally used for postoperative pain relief in pediatric patients. Methods: A prospective study design was conducted in pediatric patients who underwent major surgery in a university hospital. In the pre-NCA phase, patients received a conventional fixed-dose opioid after surgery. Inthe NCA phase, nurses could initiate two additional small doses autonomously, as prescribed, if the initial bolus was inadequate. Outcome measures were the number of moderate to severe pain scores, respiratory depression, compliance by nurses, and parent satisfaction. Results: There were 117 and 113 patients in the pre-NCA and NCA phases, respectively. Detection of moderate to severe pain ?2 episodes in 24 h after surgery was significantly higher in the NCA phase especially in moderate to severe pain procedures. Respiratory depression was not found in either phase. The majority of nurses showed positive attitudes to routine use of a modified NCA protocol. Parent satisfaction was high in both groups. Conclusion: The attitude of nurses toward the modified NCA protocol was positive and it significantly increased detection of episodes of moderate to severe postoperative pain, which accordingly increased patient care andpain relief without severe untoward effects. Keywords: Nurse-controlled analgesia, nurse attitude, pediatrics, postoperative pain

Cost-effectiveness comparison between caudal block and intravenous ketorolac as an early post-operative analgesic in pediatric patients underwent surgery below umbilicus segment

Post-operative pain treatment in pediatric is frequently inadequate that could lead to psychological, physiological and behavioral changes. Therefore, adequate pediatric pain management is needed. Some analgesics such as ketorolac and regional anesthesia techniques such as caudal block have been applied to relieve pain. Ketorolac and caudal block have its own advantages and disadvantages. The aim of study was to compare the cost-effectiveness of ketorolac and caudal blok as a post-operative analgesic in pediatric. This was double blind randomized controlled clinical trial with parallel design conducted in Dr. Sardjito General Hospital. The subjects were children who underwent surgery below umbilicus segment. Seventy patients were randomly divided into two groups with 35 patients in each group. Group I (Caudal block Group) was given caudal block with bupivacaine 0.12% 1 mL/kg body weight (BW) whereas Group II (Ketorolac Group) was given ketorolac 0.5 mg/kg BW intravenously (IV). The patient’s pain was scored at 0, 15, 30, 45 minute and 1, 2, 3 hours after the conscious patients using modified Children’s Hospital of Eastern Ontario Pain Scale (mCHEOPS). Furthermore, the cost-effectiveness the both interventions was also compared. The caudal block was more effective in reducing pain than the ketorolac at minutes 0 (27/8 vs 10/25) and 15 (34/1 vs 18/17) (p<0.05). However, at third hour the ketorolac revealed more effective than the caudal block (29/6 vs 32/3) (p<0.05). The cost of the caudal block was higher than the ketorolac (IDR 95.860 ± 5.745 vs IDR 7.200 ± 14.886) (p <0.05). However, the length of stay after the caudal block was shorter than the ketorolac (40.43 ± 13.899 vs 48.57 ± 14.068) (p <0.05). Morphine was more needed for rescue analgesic in the ketorolac (p < 0.05) in first hour of operation, whereas after three hour operation paracetamol was more needed in caudal block (p < 0.05). In conclusion, the caudal block is not more cost-effective than ketorolac in reducing post-operative pain in pediatric patients underwent surgery below umbilicus segment.

Original article. Nurse-controlled analgesia for postoperative pain in pediatric patients: effects on nurses’ attitudes and patient care

AbstractBackground: Because of the limited number of patient-controlled analgesia (PCA) pumps in our developing country, we proposed a technique of modified nurse-controlled analgesia (NCA) to relieve postoperative pain in pediatric patients.Objective: We assessed efficacy, safety, compliance by nurses, and satisfaction including parent satisfaction of a modified NCA protocol compared with fixed-dose analgesia conventionally used for postoperative pain relief in pediatric patients.Methods: A prospective study design was conducted in pediatric patients who underwent major surgery in a university hospital. In the pre-NCA phase, patients received a conventional fixed-dose opioid after surgery. In the NCA phase, nurses could initiate two additional small doses autonomously, as prescribed, if the initial bolus was inadequate. Outcome measures were the number of moderate to severe pain scores, respiratory depression, compliance by nurses, and parent satisfaction.Results: There were 117 and 113 patients in the pre-NCA and NCA phases, respectively. Detection of moderate to severe pain ≥2 episodes in 24 h after surgery was significantly higher in the NCA phase especially in moderate to severe pain procedures. Respiratory depression was not found in either phase. The majority of nurses showed positive attitudes to routine use of a modified NCA protocol. Parent satisfaction was high in both groups.Conclusion: The attitude of nurses toward the modified NCA protocol was positive and it significantly increased detection of episodes of moderate to severe postoperative pain, which accordingly increased patient care and pain relief without severe untoward effects.

The efficacy of caudal dexmedetomidine on stress response and postoperative pain in pediatric cardiac surgery

We studied efficacy of caudal dexmedetomidine (DEX) on attenuation of perioperative stress response and postoperative pain in pediatric patients undergoing cardiac surgery. Forty patients, (ASA II, III), 1-3-years old were randomly allocated into two groups; group BD received caudal bupivacaine 0.25%, 2.5 mg/kg and DEX 0.5 μg/kg and group BF received bupivacaine 2.5 mg/kg and fentanyl 1 μg/kg. Serum cortisol and blood glucose levels increased in both groups but increases were significantly less in group BD. Poststernotomy cortisol level (ug/dl) was 55.3 ± 5.1 vs. 90.4 ± 6.5; after cardio-pulmonary bypass (CPB) 84.1 ± 6.2 vs. 153.1 ± 8.5; after operation 78.3 ± 8.1 vs. 150.2 ± 9.8. Poststernotomy blood glucose level (mg/dl) was 93.6 ± 7.2 vs. 125.6 ± 5.5; after CPB 115.3 ± 3.7 vs. 175.3 ± 10.4; and after operation 97.3 2 ± 3 vs. 162.2 ± 12. Heart rate and mean arterial pressure decreased significantly after caudal block in group BD relative to the baseline and compared with group BF ( P < 0.05). Group BD had lower pain scores at first hour 2 ± 0.7 vs. 3 ± 1.1 ( P = 0.04); second hour 1.9 ± 0.5 vs. 3.7 ± 0.8, ( P = 0.008); fourth hour 2.4 ± 0.8 vs. 4.3 ± 0.5 ( P = 0.03); and eighth hour 2.5 ± 0.5 vs. 4.2 ± 1.1 ( P = 0.03). Caudal DEX attenuated stress response to surgical trauma and provided better postoperative analgesia.

Effects of Preemptive Epidural Infusion on Cytokine Response and Postoperative Pain in Pediatric Patients

Effects of Preemptive Epidural Infusion on Cytokine Response and Postoperative Pain in Pediatric Patients

PCA-derived factors that may be predictive of postoperative pain in pediatric patients: A possible role for the PCA ratio

No method exists to reliably predict which patients will develop severe postoperative pain. The authors hypothesized that data derived from patient-controlled analgesia (PCA) pumps (specifically the ratio of patient demands to pump deliveries) may predict which patients would develop severe pain after scoliosis repair. Quaternary, university-affiliated, pediatric hospital. Forty American Society of Anesthesiologists I-Il pediatric patients who had undergone elective scoliosis repair and had consented to recruitment to a randomized clinical trial investigating the effects of early morphine administration on remifentanil-induced hyperalgesia. To test the hypothesis of the current study, the authors calculated the PCA ratio of demand to delivery at every 4 hours throughout the first 24 hours after surgery for all the patients recruited to the original study. The authors compared calculated PCA ratios, numeric rating scale pain scores, and cumulative morphine consumption for those patients who developed severe postoperative pain and met the criteria for opioid rotation versus those patients who did not. Seven patients required opioid rotation from PCA morphine to PCA hydromorphone. Eight hours after surgery, the median PCA ratio for those seven patients (2.5[range, 1.8-4.3]) was significantly greater than that for all other recruited patients (1.3 [range, 0-2.7]; p < 0.001). Patients who developed severe postoperative pain and met the criteria for opioid rotation demonstrated significantly increased PCA ratios of demand to delivery as early as 8 hours after surgery.

Comparison of Postoperative Pain in Pediatric Patients Undergoing Coblation Tonsillectomy versus Cautery Tonsillectomy

To compare postoperative pain scores between monopolar electrocautery and coblation subcapsular tonsillectomy. Prospective double-blind randomized study. Tertiary care children's hospital. Between December 2004 and April 2008, 61 children, ages 4 to 20 years (mean age, 10 years; SD, 4 years), were randomized to have one tonsil removed by electrocautery and the other tonsil removed by coblation. Subjects used the FACES scale to rate pain on each side immediately postoperatively, 2 days postoperatively, and 2 weeks postoperatively. Postoperative hemorrhage was also tracked. Coblation tonsillectomy resulted in statistically less pain than electrocautery immediately after surgery, but this difference was not clinically significant. Pediatric pain is similar following monopolar electrocautery or coblation subcapsular tonsillectomy.

(267) Effectiveness of aerosolized intraperitoneal bupivacaine in reducing post-operative pain in pediatric patients undergoing laparoscopic surgery

Despite the small incisions and shorter hospitalizations associated with laparoscopic surgery, many patients still complain of severe, diffuse abdominal and shoulder pain after surgery. It has been speculated that the peritoneal stretching and diaphragmatic irritation associated with the pneumoperitoneum may be the etiology of this pain. Instillation of local anesthetics into the peritoneal cavity intraoperatively has shown variable efficacy in relieving this type of pain in adults. The authors wished to determine if the recently-described bupivacaine aerosolization technique during laparoscopic surgery would reduce this type of pain in children.

A qualitative systematic review of morphine treatment in children with postoperative pain

Postoperative pain management in children is often empirical rather than evidence based. Morphine is the pharmacological treatment most widely used and although considered safe for children, adequate scientific data on morphine's pharmacokinetics, efficacy and safety are lacking. This systematic review aimed to evaluate the available literature examining different pediatric morphine regimens with respect to dosage, analgesic efficacy and incidence of side effects. Thirty-six randomized, double-blind controlled clinical trials with 49 comparisons, including multiple dosage regimens and routes of administration were included. The primary outcome measures for analgesic efficacy (pain intensity, time to first analgesic request and need for rescue analgesics) together with the incidence of morphine-related side effects were evaluated qualitatively by significant difference (P < 0.05) as reported in the original investigations. Overall, significant improvements in the defined outcome measures on analgesic efficacy were only observed when morphine was compared with inactive control interventions. No relation between morphine dosage and analgesic efficacy was detected. The most common morphine-related side effects were vomiting and sedation, with significantly higher incidences observed after morphine administration in half of all comparisons. Although several factors may justify its use as first line therapy in many parts of the world, morphine alone is not the most suitable analgesic for postoperative pain in pediatric patients, as it does not have superior analgesic effect and a higher incidence of side effects compared with active control interventions. More standardized clinical trials with multimodal regimens as well as guidelines for evaluating pediatric medicines are desirable in the future.