Rectal Paracetamol Research Articles

Unlocking the Optimal Analgesic Potential: A Systematic Review and Meta-Analysis Comparing Intravenous, Oral, and Rectal Paracetamol in Equivalent Doses.

Paracetamol (acetaminophen) is an extensively used analgesic for acute and chronic pain management. Currently, paracetamol is manufactured for oral, rectal, and intravenous (IV) use. Research has shown varied results on the analgesic properties of IV paracetamol compared to oral and rectal paracetamol; however, research on the same doses of paracetamol is limited. Therefore, this review was constructed to explore the analgesic properties of IV paracetamol compared with oral and rectal paracetamol administered in equivalent doses. A broad and thorough literature search was performed on five electronic databases, including PubMed, ScienceDirect, Medline, Scopus, and Google Scholar. Statistical analysis of all outcomes in our review was then performed using the Review Manager software. Outcomes were categorized as primary (pain relief and time to request rescue analgesia) and secondary (adverse events after analgesia). An extensive quality appraisal was also done using the Review Manager software's Cochrane risk of bias tool. The literature survey yielded 2,945 articles, of which 12 were used for review and analysis. The pooled analysis for patients undergoing surgical procedures showed that IV paracetamol had statistically similar postoperative pain scores at two (mean difference (MD) = -0.14; 95% confidence interval (CI) -0.58-0.29; p = 0.51), 24 (MD = 0.09; 95% CI = -0.02-0.21; p = 0.12), and 48 (MD = 0.04; 95% CI = -0.08-0.16; p = 0.52)hours as oral paracetamol. Similarly, the data on time to rescue analgesia showed no considerable difference between the IV and oral paracetamol groups (MD = -1.58; 95% CI = -5.51-2.35; p = 0.43). On the other hand, the pooled analysis for patients presenting non-surgical acute pain showed no significant difference in the mean pain scores between patients treated with IV and oral paracetamol (MD = -0.35; 95% CI = -2.19-1.48; p = 0.71). Furthermore, a subgroup analysis of analgesia-related adverse events showed that the incidences of vomiting/nausea and pruritus did not differ between patients receiving IV and oral paracetamol (odds ratio (OR) = 0.71; 95% CI = 0.45-1.11; p = 0.13 and OR = 0.48; 95% CI = 0.18-1.29; p = 0.05, respectively). A review of information from two trials comparing equal doses of IV and rectal paracetamol suggested that the postoperative pain scores were statistically similar between the groups. IV paracetamol is not superior to oral or rectal paracetamol administered in equal doses. Therefore, we cannot recommend or refute IV paracetamol as the first-line analgesia for acute and postoperative pain.

Using sodium dithionite as a reducing agent in the synthesis of propacetamol hydrochroride from phenol

Propacetamol, a prodrug form of paracetamol, is used in injections for fast and effective pain relief. Propacetamol is water soluble and is used in postoperative care as well as intravenous administration in case the patients cannot take oral or rectal paracetamol. Studies on propacetamol synthesis at laboratory scale as well as industrial scale with safe, simple and economic procedures are crucial. In this study, we synthesized propacetamol from phenol as the starting material. In the first step, phenol was converted to p-nitrosophenol through a nitrosation process. This nitrosation reaction yielded the optimal result as the reaction selectively occured, the product was not plasticized. Next, p-nitrosophenol was reduced to p-aminophenol in the presence of sodium dithionite as the reducing agent. The reaction produced p-aminophenol at a yield of 89,6% with high selectivity and less impurity. After that, paracetamol was obtained through acetylation of p-aminophenol. Ochloroacetylation of paracetamol was performed by using the amount of diethylamine reduced by 2,5 times compared to previous studies to form 4-acetamidophenyl-2-chloroacetate in 85,5% yield. This intermediate was then alkylated to form propacetamol base, followed by treatment with HCl solution in acetone at low temperature to obtain propacetamol hydrochloride in 32,5% yield. The study has shown that propacetamol hydrochloride was successfully achieved with high efficiency and safety from phenol as the starting compound.

Caudal block with rectal diclofenac and paracetamol for pediatrics infra umbilical surgery at a comprehensive specialized teaching hospital in Ethiopia

BackgroundCaudal block is a common regional technique performed for infra umbilical surgery in pediatrics. Its limited duration of analgesia remains a gap in routine clinical practice. This study aimed to assess the analgesic effectiveness of caudal block with rectal diclofenac or rectal paracetamol among pediatric patients who underwent infra umbilical surgery. MethodsA prospective cohort study was conducted on patients aged 1–10 years that underwent elective infra umbilical surgery. Patients were allocated into the Caudal block with rectal Diclofenac, Caudal block with rectal Paracetamol, and Caudal block alone groups based on a postoperative pain management plan. Analysis of variance was used for normally distributed data and the Kruskal Wallis H test was used for non-normally distributed. The Tukey for post hoc test was used to compare the difference between groups one with the others. Categorical data were analyzed by using Pearson Chi-squared or Fisher's exact test as appropriate. A p-value < 0.05 considered as statistically significant. ResultsThe postoperative median pain score was lower in CD compared to CP and CA group (p-value < 0.001) at the 4th and 8th hour. Time to first analgesic request was significantly longer within CD 735 (540–1200 min) compared to CP 445 (240–840 min p = 0.029) and CA 315 (240–720 min p < 0.001). ConclusionThe pain score and total postoperative analgesic consumption were significantly reduced in addition to prolonged-time to request the first analgesia in the CD group compared to CA and CP group.

The prophylactic effect of rectal diclofenac versus intravenous pethidine on postoperative pain after tonsillectomy in children

BackgroundPostoperative pain in children is common after tonsillectomy. Rectal diclofenac has been used effectively for postoperative pain management in small children.AimTo evaluate the prophylactic effect of rectal diclofenac versus intravenous pethidine on postoperative pain management in children undergoing tonsillectomy.MethodsThis was a prospective, double-blinded randomized study. A total of 100 children, aged 3–10 years, American Society of Anesthesiologists status I or II, and scheduled for elective tonsillectomy or adenotonsillectomy, were recruited for the study. Patients were randomized to receive either rectal diclofenac 2 mg/kg (group A) or intravenous pethidine 0.5 mg/kg (group B) after induction of general anesthesia. The postoperative pain was assessed using Face, Legs, Activity, Cry, and Consolability scale for the first 6 h. The need for rescue analgesic, rectal paracetamol 40–60 mg/kg, was recorded also after surgery. Moreover, estimation of sedation using Ramsay sedation scale was assessed. Postoperative complications considering mainly vomiting and respiratory depression were recorded. Data were statistically described in terms of mean ± SD, median and range, or frequencies (number of cases) and percentages when appropriate.ResultsPain scores were significantly lower in diclofenac group at different times and needed less rescue analgesic. Postoperative sedation and vomiting were significantly higher in pethidine group. Respiratory depression occurred only in pethidine group.ConclusionProphylactic rectal diclofenac is effective in reducing pain after adenotonsillectomy and postoperative analgesic requirement. Moreover, it is generally safe.

Comparison of Oral Versus Normal and High-Dose Rectal Paracetamol in the Treatment of Fever in Children

Correction: On 13th June 2018 the author Yog Raj Sharma was changed to Yograj SharmaIntroduction: Paracetamol is the most commonly used drug in paediatrics with the standard dose (15 mg/kg) of oral and rectal paracetamol preparations interchangeably is used to treat fever in children, assuming they have equal antipyretic effect. We did a study to compare the effectiveness of two different rectal doses of paracetamol: 15 mg/kg and 30 mg/kg to that of a standard oral dose of 15 mg/kg.Material and Methods: This is a prospective, interventional, randomized controlled study done in Western Regional Hospital, Nepal in which 192 children with fever aged six months to six years. Study duration was August 2015 to October 2015. The sample included 63 in the oral normal dose group (15mg/kg), 59 in normal dose rectal group (15mg/kg) and 70 in high dose (30mg/kg) rectal paracetamol group. Temperature was recorded before and after the administration of paracetamol at an interval of 30, 60, 120, and 180 minutes by using a digital thermometer.Results: Total of 59 patients received 15 mg/kg rectal Paracetamol (group A), 70 received 30 mg/kg rectal Paracetamol (group B), and 63 received 15 mg/kg oral Paracetamol (group C). Mean temperature before giving medication in Group A, B and C respectively were 101.7° F, 101.9° F and 101.5° F. At 30 min temperature was 100.8° F, 100.8° F and 100.66° F, while at 60 minutes temperature was 99.9° F, 99.7° F, and 99.7° F respectively for Group A,B and C. But at 120 and 180 minutes temperature decreased significantly who got rectal 30 mg/kg of paracetamol.Conclusions: Rectal paracetamol in a dose of 30mg/kg is more effective than oral paracetamol in a dose of 15 mg/kg. However oral paracetamol given in a dose of 15 mg/ kg is more effective than rectal paracetamol in a same dose.

The analgesic effects of rectal diclofenac versus rectal paracetamol following caudal-bupivacaine for pediatric day-case inguinal herniotomies: a randomized controlled prospective trial

BackgroundPostoperative pain is a common complaint in day-case inguinal herniotomy, thus there is a need to provide effective analgesia. This study compared the postoperative analgesic effects of the combinations of caudal-bupivacaine and rectal diclofenac with caudal-bupivacaine and rectal-paracetamol in children scheduled for daycase inguinal-herniotomy. MethodsNinety children of ASA I scheduled for elective day-case inguinal-herniotomy were randomly assigned into Group A (1ml/kg of 0.25% caudal-bupivacaine and 1mg/kg rectal-diclofenac), Group B (1ml/kg of 0.25% caudal-bupivacaine and 30mg/kg rectal paracetamol) and Group C (1ml/kg of 0.25% caudal-bupivacaine). The duration of analgesia, pain scores, postoperative analgesic consumption and side effects were assessed and recorded. Data collected was analyzed with the statistical package for social sciences 17 for windows. ResultsEighty-seven children completed the study, and it was found that the duration of analgesia was prolonged in Group A compared to Groups B and C (p<0.01). ConclusionCaudal-bupivacaine and rectal-diclofenac combination provides a more prolonged postoperative analgesia, and lower pain score compared to caudal-bupivacaine and rectal-paracetamol combination or caudal-bupivacaine alone. Level of evidenceLevel 1 evidence treatment study. Randomized controlled trials with adequate statistical power to detect differences (narrow confidence intervals) and follow up >80%.

Sub-Tenon's injection versus paracetamol in pediatric strabismus surgery.

Background:Emergence agitation, vomiting, and oculocardiac reflex (OCR) in children undergoing strabismus surgery under general anesthesia are common problems. The purpose of this study was to determine whether the effect of analgesia can reduce the incidence of these problems. We compared the effects of sub-Tenon's injection versus intravenous (IV) and rectal paracetamol in this surgery.Methods:In a prospective, randomized, double-blind study, ninety patients ranging in age from 4 to 8 years scheduled for extraocular muscle surgery for strabismus were included in this study. After induction of anesthesia, just before the surgery, children were divided into three groups (n = 30 for each group) Group A received sub-Tenon's anesthesia with 2.5% bupivacaine (0.08 ml/kg). Group B received IV paracetamol (20 mg/kg). Group C received paracetamol rectal suppository (40 mg/kg). The occurrence of oculocardiac reflex (OCR) intraoperatively was recorded. Then, in the Postanesthesia Care Unit, patients were assessed for their emergence behaviors. Vomiting was also noticed.Results:The OCR developed in few patients, and there was no significant difference between the groups. The highest number of patients with agitation was in Group C followed by Group B then Group A. Vomiting was significantly low in Group A followed by Group B then Group C.Conclusion:Sub-Tenon block in strabismus surgery in children decreased the incidence of postoperative agitation and vomiting compared with IV paracetamol then rectal paracetamol. There was no difference between sub-Tenon block and paracetamol in the incidence of oculocardiac reflex.

Comparison of Intravenous Infusion of Tramadol Alone with Combination of Tramadol and Paracetamol for Postoperative Pain after Major Abdominal Surgery in Children.

Background:Pain is a common complaint after surgery and seems to be difficult to manage in children because of fear of complications of pain treatment or misconception that infants and small children do not feel pain at all or feel less pain. A survey reported that 40% of pediatric surgical patients experienced moderate or severe postoperative pain and that more than 75% had insufficient analgesia. Our study was carried to provide continuous infusion of intravenous (i.v.) tramadol alone using a dedicated infusion device Graseby 2100 syringe pump and compared it to a combination of i.v. tramadol infusion and per rectal paracetamol.Subjects and Methods:A total of 124 children aged 1–8 years selected for the study were randomized into two groups using a table of random numbers. Power calculation had suggested a sample size of 62 in each group with a power of 80% and significance level of 5%. Group A comprising 62 children, received i.v. infusion of tramadol in a dose of 0.25 mg/kg/h for 24 h postoperatively. Group B comprising 62 children, received i.v. infusion of tramadol in a dose of 0.25 mg/kg/h for 24 h postoperatively in addition to per rectal suppository of paracetamol in a dose of 90 mg/kg in 24 h (30 mg/kg as first dose followed by 20 mg/kg every 6 hourly for the next 18 h). Postoperatively, patients were observed for 24 h.Results:A statistically significant difference (P ≤ 0.001) in Face, Legs, Activity, Cry, Consolability pain scores was seen between two groups at 4, 6, and 8 h. Pain scores being less in Group B patients who had received infusion of tramadol and per rectal suppositories of paracetamol compared to Group A patients who received only infusion of tramadol. A statistically significant difference (P < 0.05) was found in mean analgesic consumption during the first 24 h between the groups. Consumption was more in Group A as compared to Group B. In Group A, 13 patients (21%) required rescue analgesia as compared to only 4 patients (6.5%) in Group B.Conclusion:We recommend use of an infusion of tramadol in a dose of 0.25 mg/kg/h in the first 24 h after surgery, in combination with a regular per rectal paracetamol in a daily dose of 90 mg/kg/day in four divided doses for children after major abdominal surgery. However, a close nursing supervision is essential to increase the safety profile.

Comparison of maintenance, emergence and recovery characteristics of sevoflurane and desflurane in pediatric ambulatory surgery.

Background and Aims:Increasing number of pediatric ambulatory surgeries are being carried out in general anesthesia using supraglottic airways (SGAs). Literature comparing sevoflurane and desflurane for the maintenance of SGA-based anesthesia is limited. Hence, we planned this prospective randomized study to compare the maintenance, emergence and recovery characteristics of sevoflurane and desflurane for pediatric ambulatory surgery.Material and Methods:Sixty children aged 6 months to 6 years posted for short surgical procedures were enrolled into the study. Anesthesia was induced with intravenous propofol (maximum 4 mg/kg), SGA was inserted, and children were randomized to receive sevoflurane or desflurane for the maintenance of anesthesia. No muscle relaxants were administered, and all children received caudal block and rectal paracetamol suppository. Demographic data, perioperative hemodynamics and adverse events, emergence and recovery characteristics, postoperative pain, and emergence agitation (EA) were recorded. Data were analyzed using SPSS (version 16.0, IBM Corporation, Armonk, New York, USA). P < 0.05 was considered statistically significant.Results:Demography, perioperative hemodynamics, and duration of inhalational anesthesia were comparable between two groups. There were no respiratory adverse events in either group during maintenance. Time to awakening and time to removal of SGA were shorter with desflurane (5.3 ± 1.4 and 5.8 ± 1.3 min) than sevoflurane (9.1 ± 2.4 and 10.0 ± 1.6 min) (P < 0.0001). Recovery (steward recovery score = 6) was faster with desflurane (18 ± 8.4 min) than sevoflurane (45.3 ± 9.7 min) (P < 0.001). The incidence of EA was 16.7% with desflurane and 10% with sevoflurane (P = 0.226).Conclusion:Desflurane provides faster emergence and recovery in comparison to sevoflurane when used for the maintenance of anesthesia through SGA in children. Both sevoflurane and desflurane can be safely used in children for lower abdominal surgeries.

Study to Compare the Effect of Oral, Rectal, and Intravenous Infusion of Paracetamol for Postoperative Analgesia in Women Undergoing Cesarean Section Under Spinal Anesthesia.

Background:Effective pain relief therapy after caesarean section is essential for the parturient's comfort and early ambulation. Paracetamol has an excellent safety profile when compared to opioids.Aim:To assess and evaluate the effect of oral, rectal, and intravenous infusion of paracetamol for post-operative analgesia in women undergoing caesarean section under spinal anaesthesia.Settings and Design:We conducted a prospective, randomized controlled study (18-35 years of age) of the ASA- I and II parturient scheduled for lower segment caesarean section were included.Methods and Materials:They were randomly allocated to 3 groups of 50 each. Group A received oral paracetamol tablet 650mg (1 tablet) 20min before shifting to operation room, group B received rectal paracetamol suppository 35-45 mg/kg immediately after spinal anaesthesia and group C received i.v. paracetamol infusion of 10-15mg/kg over 15min duration 20min before finishing the operation. Duration of analgesia was evaluated as primary outcome and other parameters as secondary outcome.Statistical Tests:All statistical analyses were performed using the SPSS statistical package 17.0 version. Results were analyzed using Chi Square test for non-parametric data and ANOVA for parametric data. P value of less than 0.05 was considered significant and less than 0.001 as highly significant.Results:Duration of analgesia was significantly longer in group B as compared to group A and C. The requirement of supplemental rescue analgesia was also lower in group B compared to group A and C. No significant haemodynamic derangements and adverse effects were noted among all the three groups.Conclusion:Paracetamol when given rectally improves the quality and duration of postoperative analgesia to a greater extent as compared to oral and intravenous route of paracetamol without any side effects.

Comparison of Role of Different Doses of Rectal Paracetamol with Rectal Diclofenac as Pre-emptive Analgesics for Postoperative Pain Relief in Paediatric Surgeries

Background: Post operative pain is a major concern in children particularly in developing countries were opioids are not freely available. Use of opioids is associated with side effects increasing patient discomfort and delaying patient discharge from hospital. We conducted a study comparing the use of different doses of rectal paracetamol with rectal diclofenac when used as pre-emptive analgesics on postoperative pain and recovery in paediatric patients considering the relative risk of diclofenac to increase bleeding in surgeries like tonsillectomy, cleft lip and cleft palate. Methods: Study groups included 20 patients in each. Group P40 receiving 40 mg/kg rectal paracetamol, Group P20 receiving 20 mg/kg rectal paracetamol, Group D receiving rectal diclofenac 1 mg/kg. Pain scoring was done by TPPPS (Toddler Pre-schooler postoperative pain scale) time to first need of analgesia and total dose of analgesia was noted. The rates of recovery were evaluated by using “Modified Steward Coma Scale”at 5 and 10 minutes after extubation. Results: Time of first demand of analgesic was delayed in Group-P40 as compared to Group-D and Group-P20 and difference was statically significant. TPPPS of the three studied groups varied significantly at different time intervals in favour of Group-P40. Total duration of analgesia in Group- P40 was (646±9.94) min Group- D (501±10.63) min and in Group-P20 (294±23.17) min Total analgesic requirement was also low in Group P40 and the difference between groups was significant. Conclusion: Pre-emptive high dose rectal paracetamol appears to be more effective than rectal diclofenac sodium suppository for postoperative analgesia in children without additional risk of bleeding in surgeries like tonsillectomy and cleft lip and cleft palate repair. Hence, high dose rectal paracetamol can be used as an alternative to diclofenac sodium due to higher risks of bleeding with diclofenac sodium in surgeries with increased risk of bleeding.

A Randomized Controlled Trial of Defervescent Efficacy of Oral versus Rectal Paracetamol in a Pediatric Acute Care Setting

Objective : To assess the comparative efficacy of oral versus rectal paracetamol in reducing fever in a pediatric acute care setting. Methods : 200 children with body temperature >39oc were randomized to receive oral or rectal paracetamol, together with tepid sponging. Their body temperatures were measured at enrollment, after fever reduction protocol had been completed and at 30-minute and 60-minute intervals. General linear model was used to assess the effect of time and type of medication on fever reduction. Results : Mean log [temperature] differed significantly between time intervals (F(1.275, 248.576) = 32.766, p<0.001) and the test of between subject effects showed that there was a significant effect of antipyretic types on mean body temperature of children at different time intervals (F(1, 995) = 4.040, p<0.05). Conclusion : Rectal paracetamol was shown to be more effective overall at lowering body temperature, especially at the termination of fever reduction protocol, and at 60 minutes. Keywords : Paracetamol, fever, rectal suppository, defervescence

Rectal Diclofenac Versus Rectal Paracetamol: Comparison of Antipyretic Effectiveness in Children.

BackgroundFever is the most common complaint in pediatric medicine and its treatment is recommended in some situations. Paracetamol is the most common antipyretic drug, which has serious side effects such as toxicity along with its positive effects. Diclofenac is one of the strongest non-steroidal anti-inflammatory (NSAID) drugs, which has received little attention as an antipyretic drug.ObjectivesThis study was designed to compare the antipyretic effectiveness of the rectal form of Paracetamol and Diclofenac.Patients and MethodsThis double-blind controlled clinical trial was conducted on 80 children aged six months to six years old. One group was treated with rectal Paracetamol suppositories at 15 mg/kg dose and the other group received Diclofenac at 1 mg/kg by rectal administration (n = 40). Rectal temperature was measured before and one hour after the intervention. Temperature changes in the two groups were compared.ResultsThe average rectal temperature in the Paracetamol group was 39.6 ± 1.13°C, and 39.82 ± 1.07°C in the Diclofenac group (P = 0.37). The average rectal temperature, one hour after the intervention, in the Paracetamol and the Diclofenac group was 38.39 ± 0.89°C and 38.95 ± 1.09°C, respectively (P = 0.02). Average temperature changes were 0.65 ± 0.17°C in the Paracetamol group and 1.73 ± 0.69°C in the Diclofenac group (P < 0.001).ConclusionsIn the first one hour, Diclofenac suppository is able to control the fever more efficient than Paracetamol suppositories.

Comparison of preoperative rectal paracetamol with paracetamol - diclofenac combination for postoperative analgesia in pediatric surgeries under general anesthesia.

Context:Traditionally, pain in children is a topic that has received only minimal attention. However, in the recent times, considerable progress has been made in the field of neonatal and pediatric pharmacology. The concept of preemptive analgesia is important in combating postoperative pain in children. In this study, we sought to compare the effectiveness of preemptive analgesia provided by paracetamol alone and by its combination with diclofenac when administered per rectum.Aims:To compare the efficacy of preoperative rectal paracetamol with paracetamol - diclofenac combination for postoperative analgesia in pediatric surgeries under general anesthesia.Settings and Design:Prospective randomized double-blind study.Subjects and Methods:Sixty children scheduled for various surgeries under general anesthesia were randomly allocated into two Groups A and B, with 30 in each. Children in Group A received paracetamol suppository 20 mg/kg and those in Group B received paracetamol 20 mg/kg + diclofenac 2 mg/kg as suppository immediately after tracheal intubation. All the children were assessed for 24 h from the time of extubation. The pain was measured using numerical rating scale in children above 7 years and face-legs-activity-cry-consolability scale in children below 7 years. The time interval between extubation and the administration of the first dose of rescue analgesic was taken as the duration of postoperative analgesia.Statistical Analysis Used:Descriptive and inferential statistical methods were used to analyze the data.Results:The duration of postoperative analgesia was significantly longer in paracetamol + diclofenac group (21.13 ± 2.68 h) as compared to paracetamol alone group (10.18 ± 2.39 h).Conclusions:The combination of paracetamol and diclofenac administered per rectum preoperatively is more effective than paracetamol alone in providing postoperative analgesia in children.

Pain Treatment of Newborns: Paracetamol Rectal Versus Intravenous Administration, A Randomised Open Clinical Trial

Background and aim: Early recognition and treatment of pain is of great importance in the neonatal period. Paracetamol is the most frequent prescribed medicine for pain treatment. Administration of rectal paracetamol has limitations and the effectiveness can be variable in neonates. This study is based on the hypothesis that intravenous (iv) paracetamol is well tolerated, less variable and therefore more reliable in preterm neonates compared to rectal paracetamol. We therefore compared the effectiveness of intravenous and rectal administration in (preterm) neonates during a period of sickness accompanied by pain. Methods: We included 21 neonates with pain, post menstrual age (PMA) of 28-44 weeks. They received paracetamol rectal or intravenous according to Dutch guidelines. Serum concentrations at steady state (t = 0, 0.5, 1, 2, 4, 6 hours) were determined. Results: Clearance was dependent of weight, not of PMA. Estimated mean serum concentrations after four administrations were 4,8 ± 0,7, 8,1 ± 1,9 and 10,2 ± 3,1 mg/L and after rectal administration 4,1 (n=1), 12,6 ± 6,0 and 14,0 ± 6,7 mg/L. Hepato- or renal dysfunction were not observed. Conclusion: Rectal and intravenous administration of paracetamol is well tolerated in (preterm) neonates. Rectal administration gives no paracetamol absorption or a major variation with inter- and intra-individual variation, which turns out to be unreliable especially in (pre)term neonates. Dosing of paracetamol (rectal and iv) should be based on weight instead of PMA. Further research is needed to define the exact dosing regime and target concentration of intravenous paracetamol in (preterm) neonates in comparison to the pain experience especially in preterm neonates.

A comparative evaluation of per rectal diclofenac sodium and paracetamol for postoperative analgesia in case of hydrocephalus

Background: Hydrocephalus is one of the most painful conditions, especially in pediatric population. Analgesia after neurosurgery requires good communication and close cooperation between members of the perioperative team. Diclofenac is a nonsteroidal anti-inflammatory drug with pronounced antirheumatic, anti-inflammatory, analgesic, and antipyretic properties. Diclofenac inhibits prostaglandin synthesis, which contributes to inflammation, pain, and fever. Paracetamol produces analgesia and antipyresis by a mechanism similar to that of salicylate, which involves inhibition of prostaglandin synthesis. Objectives: To compare the analgesic efficacy of rectally administered diclofenac sodium and paracetamol postoperatively in patients with hydrocephalus for postoperative pain relief. Also, to compare side effects of both the drugs. Materials and Methods: Fifty patients aged 1-8 years scheduled for ventriculoperitoneal shunt under general anesthesia were selected for the study. All the patients were divided into two groups, Group D and Group P. At the end of surgery, 15 min before extubation, patients of Group D were rectally administered with inj. diclofenac 1 mg/kg whereas those of Group P with inj. paracetamol 15 mg/kg. Pain was assessed using Wong–Baker Faces Pain Rating Scale (WBFPS). When the score was 4 or more, then inj. paracetamol 15 mg/kg was administered intravenously as rescue analgesia. Patients were also observed for duration and analgesia. We have also compared hemodynamic parameters and complications in both the groups postoperatively. Results: Heart rate and SpO2 were stable in after the operation. Pain score on WBFPS was statistically nonsignificant between both the groups. Duration of analgesia was significantly longer in Group D than in Group P. Incidence of side effects and complications were also comparable in both the groups. Conclusion: We conclude that both paracetamol and diclofenac are very well tolerated by rectal route with prolonged duration of analgesia with diclofenac for postoperative pain relief in pediatric patients with hydrocephalus.

Ketamine versus magnesium sulfate with caudal bupivacaine block in pediatric inguinoscrotal surgery: A prospective randomized observer-blinded study.

Introduction:Possible approaches for postoperative analgesia after pediatric inguinoscrotal surgery are caudal block by bupivacaine/ketamine (BK) and bupivacaine/magnesium sulfate (BM).Aim:The purpose of the following study is to compare the analgesic efficacy and safety of ketamine and magnesium sulfate in combination with bupivacaine for caudal blockade in pediatric patients after inguinoscrotal operations.Materials and Methods:Patients randomly received one of the two solutions for caudal epidural injection after induction of general anesthesia. Group-BK: Were given a mixture of 0.25% bupivacaine and 0.5 mg/kg of ketamine. Group-BM: Were given a mixture of 0.25% bupivacaine and 50 mg magnesium sulfate. Postoperatively, a blinded post-anesthesia care unit nurse assessed the quality of analgesia with a visual pain analog scale (VPAS). Significant pain is defined as one that has a VAPS of ≥3.Results:Forty American Society of Anesthesiologists I-II children (20 in each group) completed the study. The two groups were comparable regards age, sex, body mass index, anesthesia and surgery durations, recovery time and sevoflurane concentration. The mean duration of caudal analgesia ± standard deviation was 462 ± 17.2 min versus 398.05 ± 12.9 min for BK and BM groups, receptively (P < 0.001). Supplemental rectal paracetamol within 12 h postoperatively were 15% for BK group versus 25% for BM (P = 0.05). Four patients in BK group only experienced postoperative nausea and vomiting (P = 0.053).Conclusion:Caudal administration of BK is efficient and safe for pediatric inguinoscrotal operations with longer postoperative analgesia than BM sulfate.

Comparison of Postoperative Pain Relief Impact between Caudal Bupivacaine Alone and Caudal Bupivacaine - Dexamethasone Mixture Administration for Pediatric Local Tube Urethroplasty

Objective: To compare the postoperative analgesic influence between caudal bupivacaine only and caudal bupivacaine-dexamethasone combination administration in children undergoing local tube urethroplasty. Methods: This prospective, randomized and clinical trail investigation included 162 male pediatric patients, classed I by the American society of anesthesiologists, aged 11-14 years and assigned for local tube urethroplasty at Queen Rania Hospital, King Hussein Medical Center, Amman-Jordan, during the year of 2013. General anesthesia was induced using inhalational sevoflurane / oxygen anesthesia, after which a laryngeal mask airway was inserted and an intravenous line was secured. All subjects were repositioned to receive caudal sacral block using randomly either plain bupivacaine 0.25% mixed with normal saline 0.9% (Group I, n=80) or plain bupivacaine 0.25% mixed with dexamethasone 0.1mg/kg (Group II, n=82), not exceeding a total volume of 0.5ml/kg and not exceeding a maximum dose of 2mg/kg of bupivacaine in both groups, dividing the total volume in ¾ for bupivacaine and ¼ for dexamethasone, saline or both. Postoperatively, in the recovery room, rectal paracetamol 10 mg/kg was administered if the numerical rating scale was more or equal to four. Postoperative analgesia quality was assessed. Statistical discrepancies between the two groups were evaluated using Students t and Chisquare tests. Variance was used to assess inter-group differences in changes of pain scores. A value of P<0.05 was considered significant. Results: Postoperative mean pain free period was significantly less in group I (186 min) than in group II (272 min) (P<0.05).The mean time to first rectal paracetamol dose was 192 min. in group II and 125 min. in group I (P<0.05).

Assesment of The Effect of Multimodal Preemptive Analgesia in Children

Background: Preemptive analgesia, an evolving clinical concept, involves the introduction of an analgesic regimen before the onset of noxious stimuli, with the goal of preventing sensitization of the nervous system to subsequent stimuli that could amplify pain. Pain is inevitable after any surgery. Surgery offers the most promising setting for preemptive analgesia because the timing of noxious stimuli is known.Materials &amp; Methods: This prospective double blind study included 60 children (30 in each group), undergoing major surgery under general anesthesia. Each patient in the study group (Group II) received pre-emptive analgesia (Local anesthesia, per-rectal diclofenac just prior to surgery, per-rectal paracetamol 2 hours prior to surgery) and regular pattern of postoperative pain intervention with per rectal diclofenac and per rectal or oral paracetamol in different phases of postoperative pain management up to 48 hours. On the other hand, each patient of control group (Group I) received pre-emptive analgesia (Local anesthesia &amp; per-rectal diclofenac) regular pattern of postoperative pain intervention with per-rectal diclofenac in different phases of postoperative pain up to 48 hours. The degree of postoperative pain was assessed by universal pain assessment tools (VAS) at defined intervals.Results: Most children in the study group (Group II) has significantly better postoperative pain control with only mild pain at 4th postoperative hours. It is obvious that less pain in Group-II due to synergistic effect of paracetamol and diclofenac. In the control group (Group I) there was persistence of mild pain throughout the observation period i.e. up to 48 postoperative hours. The breakthrough pain occurred more in latter group, two patients needed rescue analgesia. Whereas no patient experienced breakthrough pain requiring rescue analgesia in study group (Group II).Conclusion: Therefore this study concludes that administrations of multimodal pre-emptive analgesia control pain more effectively in children in view of both the degree of pain control and sustainability of pain free state.DOI: http://dx.doi.org/10.3329/jpsb.v2i2.19545

Ring block with levobupivacaine 0.25% and paracetamol vs. paracetamol alone in children submitted to three different surgical techniques of circumcision: A prospective randomized study

Background:circumcision in children is a painful procedure. We aim compare the intraoperative and postoperative efficacy of three different surgical procedures of the ring block using levobupivacaine 0.25% combined with rectal paracetamol as opposed to rectal paracetamol alone.Methods:the study included 106 boys scheduled to undergo circumcision. The patients were randomly assigned within two groups to receive either ring block with levobupivacaine 0.25% and rectal paracetamol 30 mg/kg, or rectal paracetamol 30 mg/kg alone. The following surgical procedures were performed: sutureless proctoplasty, preputial plasty, and conventional circumcision. The efficacy of intraoperative analgesia was estimated on the basis of increases in heart rate and mean arterial pressure. Postoperatively, children were assessed for pain, pain-free (PF) period, and the total doses of analgesics administered during hospitalization, on the day after discharge, and on the first and second postoperative days.Results:all children remained stable during anesthesia. Postoperatively, the mean pain score did not show statistical differences between the groups. Children who received combined analgesia had a longer PF period (P < 0.001). However, the total doses of paracetamol administered during the observational period showed no differences. Children undergoing sutureless prepuceplasty received lower doses of paracetamol postoperatively (P < 0.001).Conclusion:subcutaneous ring block either with levobupivacaine 0.25% plus rectal paracetamol or rectal paracetamol alone provides adequate intraoperative and postoperative analgesia in circumcised children. However, combined analgesia allows a longer PF period. The need for less analgesic administration in children undergoing sutureless prepuceplasty could mean that the circumcision techniques might be a mitigating factor in terms of pain.