Search

Two prior reviews highlight the scarcity and conflicting nature of available data on chronic postsurgical pain in children, reporting a wide prevalence range of 3.2% to 64% (at ≥3 months). This updated systematic review aimed to consolidate information on the prevalence of pediatric chronic postsurgical pain. A thorough literature search of full English‐text publications from April 2014 to August 2021 was conducted using Ovid MEDLINE, PubMed, and Cochrane Database of Systematic Reviews, with search terms: postoperative pain, child, preschool, pediatrics, adolescent, chronic pain. Seventeen relevant studies were identified. Most assessed chronicity once greater than 3 months duration postoperatively (82%), were predominantly prospective (71%) and conducted in inpatient settings (88%). The surgeries examined included orthopedic (scoliosis and limb), urological, laparotomy, inguinal, and cardiothoracic procedures, involving numbers ranging from 36 to 750, totaling 3137 participants/2792 completers. The studies had wide variations in median age at surgery (6 days to 16 years), the percentage of female participants (unspecified or 12.5% to 90%), and follow‐up duration (2.5 months to 9 years). Various pain, functional, psychosocial, and health‐related quality of life outcomes were documented. Chronic postsurgical pain prevalence varied widely from 2% to 100%. Despite increased data, challenges persist due to heterogeneity in definitions, patient demographics, mixed versus single surgical populations, diverse perioperative analgesic interventions, follow‐up durations and reported outcomes. Interpretation is further complicated by limited information on impact, long‐term analgesia and healthcare utilization, and relatively small sample sizes, hindering the assessment of reported associations. In some cases, preoperative pain and deformity may not have been addressed by surgery and persisting pain postoperatively may then be inappropriately termed chronic postsurgical pain. Larger‐scale, procedure‐specific data to better assess current prevalence, impact, and whether modifiable factors link to negative long‐term outcomes, would be more useful and allow targeted perioperative interventions for at‐risk pediatric surgical patients. [ABSTRACT FROM AUTHOR]

Background: Chemotherapy‐induced oral mucositis can result in severe pain. Intravenous (IV) opioids are recommended, but management protocols vary. We systematically reviewed studies reporting IV opioid use for pain related to chemotherapy‐induced severe oral mucositis in children and conducted a large single‐center case series. Methods: Ovid MEDLINE, PubMed, and Cochrane databases were searched for studies reporting IV opioid duration and/or dose requirements for severe mucositis. Secondly, our pain service database was interrogated to describe episodes of opioid administration by patient‐ or nurse‐controlled analgesia (PCA/NCA) for children with mucositis and cancer treatment‐related pain. Results: Seventeen studies (six randomized trials, two prospective observational, three retrospective cohort, six retrospective case series) included IV opioid in 618 patients (age 0.3–22.3 years), but reported parameters varied. Mucositis severity and chemotherapy indication influenced IV opioid requirements, with duration ranging from 3 to 68 days and variable dose trajectories (hourly morphine or equivalent 0‐97 mcg/kg/h). Our 7‐year series included PCA/NCA for 364 episodes of severe mucositis (302 patients; age 0.12–17.2 years). Duration ranged from 1 to 107 days and dose requirements in the first 3 days from 1 to 110 mcg/kg/h morphine. Longer PCA/NCA duration was associated with: higher initial morphine requirements (ρ = 0.46 [95% CI 0.35, 0.57]); subsequent increased pain and need for ketamine co‐analgesia (118/364 episodes with opioid/ketamine 13.9 [9.8–22.2] days vs opioid alone 6.0 [3.9–10.8] days; median [IQR]); but not with age or sex. Conclusions: Management of severe mucositis pain can require prolonged IV opioid therapy. Individual and treatment‐related variability in analgesic requirements highlight the need for regular review, titration, and management by specialist services. [ABSTRACT FROM AUTHOR]

Background: The erector spinae plane block is a novel regional anesthetic technique that is gaining popularity in pediatrics. However, the efficacy of erector spinae plane block in children is unclear. The aim of the systematic review and meta‐analysis was to investigate effects of erector spinae plane block on postoperative pain relief in children. Methods: We searched MEDLINE, Cochrane Library, EMBASE, China National Knowledge Infrastructure, and Wan fang databases for randomized controlled trials that compared erector spinae plane block with no block or other types of block in pediatric patients undergoing surgeries. The primary outcomes were pain intensity at rest within 24 h postoperatively and the number of patients requiring rescue analgesics. Data were analyzed using the fixed‐ or random‐effects model, depending on whether the heterogeneity tested by the I2 statistic was >30%. We assessed the quality of evidence for the outcomes using the Grading of Recommendations, Assessment, Development, and Evaluation method. Results: Seven randomized controlled trials involving 379 patients were reviewed. Compared with no block, erector spinae plane block slightly reduced the pain scores at 0 h (standardized mean difference [SMD]: −1.07; 95% confidence interval [CI]: −1.60 to −0.54; I2 = 52%), 6 h (SMD: −0.82; 95% CI: −1.39 to −0.25; I2 = 79%) postoperatively at rest and significantly reduced the need for rescue analgesics (odds ratio 0.09; 95% CI: 0.04 to 0.21; I2 = 16%). One trial demonstrated the analgesic effect of erector spinae plane block was similar to a quadratus lumborum block, while another trial demonstrated the analgesic effect of ESPB was superior to an ilioinguinal nerve block. Conclusions: This review provides low‐quality evidence that erector spinae plane block exhibits superior analgesia compared to no block in children. Due to the limited data, evidence regarding the comparison with other regional blocks remains unclear. Future large‐sized and well‐designed randomized controlled trials are needed. [ABSTRACT FROM AUTHOR]

All peripheral regional anesthetics performed at BCH from January 1, 2019, to April 30, 2021, were tallied and sorted by type of block: single injection, inpatient nerve catheter, or CPNB home catheter. Single-injection blocks are shown in red, inpatient continuous peripheral nerve block (CPNB) catheters in blue, and CPNB home catheters in green. Future studies will focus on analysis of the Regional Anesthesia Database for outcome data related to pediatric home catheters, including opioid-use reduction in patients discharged with home CPNBs. [Extracted from the article]

The article offers information on the use of tramadol, a weak opioid in children as a second-line analgesic. Topics discussed include warning issued by the U.S. Food and Drug Administration (FDA) following a number of deaths attributed to overdoses; role of CYP2D6 enzyme system for metabolism of other analgesic drugs; and recommends limited dose of tramadol for acute pain after tonsillectomy.

The article discusses opioid use in children perioperatively by referring to the Society for Pediatric Anesthesia (SPA) evidence¿based recommendations for perioperative use of opioids in children published within the periodical. Topics discussed include awareness of potential long¿term effects of pain and tissue injury on developing pain pathways, the public health issues related to opioid misuse, and the use of oral morphine in neonates.

We looked at 10 consecutive patients having bilateral lower extremity surgery with a single surgeon and compared each patient with a control patient matched by GMFCS, age, diagnosis, and procedure. Keywords: acute pain; limb surgery; orthopedics; outcomes; regional EN acute pain limb surgery orthopedics outcomes regional 582 583 2 03/30/22 20220401 NES 220401 DATA AVAILABILITY STATEMENT Data available on request from the authors. [Extracted from the article]

Aim: To compare diazepam use, muscle spasm, analgesia, and side effects when clonidine or fentanyl are added to epidural bupivacaine in children with cerebral palsy after multilevel orthopaedic surgery.Method: Fifty children were prospectively randomized to receive clonidine (n=24, mean age 10y 10mo [SD 2y 11mo]) or fentanyl (n=26, mean age 10y 11mo [SD 2y 10mo]).Results: There was no difference in primary outcome measures: median diazepam use (fentanyl 0, interquartile range [IQR] 0-0; clonidine 0, IQR 0-0; p=0.46), any muscle spasm (no muscle spasms in: fentanyl, 36%; clonidine, 62%; p=0.11), painful muscle spasm (fentanyl 40%; clonidine 25%; p=0.46), or pain score ≥6 (none: fentanyl 44%; clonidine 42%; p=0.29). There were differences in secondary outcome measures: no vomiting (clonidine 63%; fentanyl 20%); vomiting occurred more frequently with fentanyl (32% vomited more than three times; clonidine none; p=0.001). Fentanyl resulted in more oxygen desaturation (at least two episodes: fentanyl 20%; clonidine 0; p<0.001). Clonidine resulted in lower mean (SD) area under the curve for systolic blood pressure (fentanyl 106.5 [11.0]; clonidine 95.7mmHg [7.9]) and heart rate (fentanyl 104.9 beats per minute [13.6]; clonidine 85.3 [11.5]; p<0.001).Interpretation: Clonidine and fentanyl provide adequate analgesia with low rates of muscle spasm, resulting in low diazepam use. The choice of epidural additive should be based upon the most tolerable side-effect profile. [ABSTRACT FROM AUTHOR]

Pain following ambulatory surgery is often poorly managed at home. Certain procedures, such as tonsillectomy, cause high levels of pain for at least 1 week postoperatively. This impacts significantly on recovery and postoperative morbidity with regards to oral intake, sleep, and behavior. Barriers to effective postoperative pain management at home following discharge have been investigated and incorporate: parental factors, such as the ability to recognize and assess their child's pain, and misconceptions about analgesics; child factors, such as refusal to take medication; medication factors, such as ineffective medication or inadequate formulation or dose of analgesics; and system factors, such as poor discharge instructions, difficulty in obtaining medication and lack of information provision. A number of interventions have been suggested and trialled in an effort to address these barriers, which encompass educational strategies, improved information provision, improved medication regimens, and the provision of tools to aid parents in the pain management of their children. All in all, improvements in pain outcomes have been minor, and a more holistic approach, that appreciates the complex and multifaceted nature of pain management at home, is required. [ABSTRACT FROM AUTHOR]

Aim To determine if the addition of adrenaline, clonidine, or their combination altered the pharmacokinetic profile of levobupivacaine administered via the caudal epidural route in children. Methods Children aged <18 years old scheduled to undergo sub-umbilical surgery were administered caudal levobupivacaine plain 2.5 mg·ml−1 or with adjuvants adrenaline 5 mcg·ml−1 or clonidine 2 mcg·ml−1 or their combination. Covariate analysis included weight and postnatal age (PNA). Time-concentration profile analysis was undertaken using nonlinear mixed effects models. A one-compartment linear disposition model with first-order input and first-order elimination was used to describe the data. The effect of either clonidine or adrenaline on absorption was investigated using a scaling parameter ( Fabs CLON, Fabs ADR) applied to the absorption half-life (Tabs). Results There were 240 children (median weight 11.0, range 1.9-56.1 kg; median postnatal age 16.7, range 0.6-167.6 months). Absorption of levobupivacaine was faster when mixed with clonidine (Fabs CLON 0.60; 95% CI 0.44, 0.83) but slower when mixed with adrenaline (Fabs ADR 2.12; 95% CI 1.45, 3.08). The addition of adrenaline to levobupivacaine resulted in a bifid absorption pattern. While initial absorption was unchanged (Tabs 0.15 h 95% CI 0.12, 0.18 h), there was a late absorption peak characterized by a Tabs LATE 2.34 h (95% CI 1.44, 4.97 h). The additional use of clonidine with adrenaline had minimal effect on the bifid absorption profile observed with adrenaline alone. Neither clonidine nor adrenaline had any effect on clearance. The population parameter estimate for volume of distribution was 157 l 70 kg−1. Clearance was 6.5 l·h−1 70 kg−1 at 1-month PNA and increased with a maturation half-time of 1.6 months to reach 90% of the mature value (18.5 l·h−1 70 kg−1) by 5 months PNA. Conclusions The addition of adrenaline decreases the rate of levobupivacaine systemic absorption, reducing peak concentration by half. Levobupivacaine concentrations with adrenaline adjuvant were reduced compared to plain levobupivacaine for up to 3.5 hours. Clonidine as an adjuvant results in faster systemic absorption of levobupivacaine and similar concentration time profile to levobupivacaine alone. Adding adrenaline with clonidine does not alter the concentration profile observed with adrenaline alone. [ABSTRACT FROM AUTHOR]

Pediatric pain services were first established in larger pediatric centers over two decades ago. Children's acute pain was poorly managed at the time owing to misconceptions, safety concerns, and variability in practice. While many larger pediatric centers now have acute pain services, there remains a need for better pain management in facilities and geographic locations with fewer resources. Institutional acknowledgement and desire to change, appropriate staffing, and funding are major obstacles. Better recognition and assessment as well safer and more efficacious treatment of pain are the principal objectives when establishing a pain service. It is important to determine whether the proposed service intends to treat acute, chronic, procedural, and/or cancer and palliative pain as each requires different skills and resources. An ideal and comprehensive pediatric pain service should be equipped to diagnose and treat acute, persistent (chronic), procedural, and cancer/palliative pain. It is not feasible or necessary for every hospital to manage all. Establishing the scope of practice (based on case mix and caseload) in any given hospital will determine which resources are desired. Country-specific standards, local staffing, and fiscal constraints will influence which resources are available. [ABSTRACT FROM AUTHOR]

Summary Objectives: To provide parents of children with accurate information regarding postoperative pain, its management, and functioning following common surgical procedures. Background: The increasing prevalence of pediatric day-case procedures demands a more thorough understanding of the recovery profiles associated with these operations. Aim: To document postdischarge pain profiles, analgesia requirements, and functional limitation in children following tonsillectomy, orchidopexy, or inguinal hernia repair (IHR). Methods: Following hospital discharge, parents were asked to record their children's pain levels, analgesia consumption, and degree of functional limitation each day until complete recovery. Pain and functional limitation were measured using the Parents' Postoperative Pain Measurement (PPPM) scale and Functional Activity Score, respectively. Significant pain was defined as PPPM ≥ 6. Results: One hundred and five patients (50, tonsillectomy; 24, orchidopexy; and 31, IHR) were recruited. Median PPPM was always <6 after IHR, ≥6 only on day 1 after orchidopexy and persisted through to day 8 after tonsillectomy. Mild or severe functional limitation was observed after all surgeries and persisted for 4, 5, and 4 days after median PPPM < 6 after IHR, orchidopexy, and tonsillectomy, respectively. Combination analgesia was commonly administered after orchidopexy and tonsillectomy but less so after IHR. The general practitioner consultation rate following tonsillectomy was 54%. Conclusions: After tonsillectomy, children experience significant pain and severe functional limitation for 7 days after surgery. For many children, pain and functional limitation persists throughout the second postoperative week. In children undergoing orchidopexy, paracetamol and ibuprofen provide adequate analgesia. Pain begins to subside after the first postoperative day, and normal activity resumes after 7 days. After IHR, children experience mild pain that can be treated with paracetamol and return to normal functioning after 4 days. [ABSTRACT FROM AUTHOR]

One of the cardinal symptoms of compartment syndrome is pain. A literature review was undertaken in order to assess the association of epidural analgesia and compartment syndrome in children, whether epidural analgesia delays the diagnosis, and to identify patients who might be at risk. Evidence was sought to offer recommendations in the use of epidural analgesia in patients at risk of developing compartment syndrome of the lower limb. Increasing analgesic use, increasing/breakthrough pain and pain remote to the surgical site were identified as important early warning signs of impending compartment syndrome in the lower limb of a child with a working epidural. The presence of any should trigger immediate examination of the painful site, and active management of the situation (we have proposed one clinical pathway). Avoidance of dense sensory or motor block and unnecessary sensory blockade of areas remote to the surgical site allows full assessment of the child and may prevent any delay in diagnosis of compartment syndrome. Focusing on excluding the diagnosis of compartment syndrome rather than failure of analgesic modality is vital. In the pediatric cases reviewed there was no clear evidence that the presence of an epidural had delayed the diagnosis. [ABSTRACT FROM AUTHOR]

An epidural catheter was inserted after induction of anesthesia in a 28.2 kg 9-year-old boy scheduled to undergo bilateral femoral varus derotational osteotomies. There was no gravity free flow of blood down the catheter and there was no blood aspirated with a 2 ml syringe. After a negative test dose of a 4 ml solution of 0.25% levobupivacaine with epinephrine 1 : 200 000, a further 8 ml was administered via the epidural catheter. No significant increase in heart rate was noted. On surgical skin incision the heart rate increased from 94 to 116 b·min−1 and blood pressure increased from 104/44 to 116/46 mmHg. A further 3 ml 0.25% levobupivacaine with epinephrine and clonidine 2 μg·kg−1 were administered via the epidural catheter. The operation continued uneventfully although it was noted that the heart rate increased intermittently during the procedure. In view of the unexplained tachycardia and a history of cerebral palsy with the potential for postoperative muscle spasms, it was felt important to have a reliable epidural. To confirm placement, 2 ml of Isovue 300 (Iopamidol) was administered via the epidural catheter. X-ray screening demonstrated intravascular placement and the rapid disappearance of contrast. The catheter was removed and reinserted. Contrast demonstrated good spread in the epidural space. The merits of screening with contrast for epidural catheter placement in children are discussed. [ABSTRACT FROM AUTHOR]

Background : We aimed to identify and quantify major factors describing the variability of levobupivacaine clearance in children. Methods : Data from three published studies were used to estimate population pharmacokinetics of levobupivacaine in children who were given epidural regional blockade. Covariate analysis included weight and postnatal age (PNA). Time–concentration profile analysis was undertaken using nonlinear mixed effects models. A one-compartment linear disposition model with first order input and first order elimination was used to describe the data. Results : There were 86 children (weight 9.4,sd 5.5, range 1.9–23 kg; PNA 16.1,sd 22.7, range 0.6–98 months). The population parameter estimate for volume of distribution ( V) was 189 l·70 kg−1. Clearance (CL) was 5.8 l·h−1·70 kg−1 at 1-month PNA and increased with a maturation half-time of 2.3 months to reach 80% of the mature value (22.1 l·h−1·70 kg−1) by 6-month PNA. The between subject variability (BSV) for V and CL were 48.5% and 35.2%. Overall, 85.7% of the variability of CL was predictable. Weight alone explained 62.4% and the addition of PNA a further 23.3%. Overall, 69.2% of the variability of V was predictable and attributable to weight; V did not change with age in this cohort. The absorption half-time decreased from 0.36 h at 1-month PNA to 0.14 h (CV 48.1%) at 6-month PNA with a maturation half-time of 0.8 months. Conclusions : Size and PNA are the major contributors to clearance variability in children. These covariates should be considered when establishing safe epidural infusion regimens. Reduced clearance and slower absorption half-time contribute to delayed Tmax in neonates and young infants. [ABSTRACT FROM AUTHOR]

SummaryA 13-year-old female with a past history of lumbar laminectomy developed a subdural block 18 h after the commencement of an epidural infusion of bupivacaine 0.125% and fentanyl 2 μg·ml-1. Signs at presentation included bilateral abducens nerve palsies in the absence of headache and a previously unreported unilateral third cranial nerve palsy. An epidurogram displayed subdural placement. [ABSTRACT FROM AUTHOR]

Editorial. Discusses the effects of continuous epidural infusions on children. Difference between continuous opioid analgesia and epidural analgesia in terms of side-effects; Cost of inserting epidural catheter; Need to determine the true incidence of problems associated with epidural catheter insertion and continuous epidural analgesia.

A review of the article "Structured intervention for management of pain following day surgery in children" by S. Walther-Larsen and others, which appeared in the journal "Pediatric Anesthesia" on November 12, 2015 is presented.

A response from the authors of the article regarding the alternative to pain service and pain management team within a hospital is presented.