Sedoanalgesia in paediatric intensive care: a survey of 19 Italian units.

AIM: To analyse the methods used to manage and monitor sedoanalgesia at Italian paediatric intensive care units (ICUs). METHODS: Data were collected by administering a questionnaire that aimed to investigate whether ICUs adopted a validated protocol to manage sedoanalgesia. RESULTS: The results revealed that a majority of the ICUs adopt a protocol for dealing with sedation and analgesia, but this protocol is implemented with difficulty or not at all in routine clinical practice. The most often used pharmacological combination, is midazolam and fentanyl. Several weaknesses remain in terms of the methods used to assess sedoanalgesia, which are generally not standardized, but rather based on recording the patient's physiological parameters. CONCLUSION: Sedation and analgesia are priority issues in the management of critically ill children. None of the numerous drugs available is ideal and the protocols currently used in clinical practice involve the combined use of different drugs. There is currently no shared and validated approach as to which is the most effective and safest sedoanalgesic regimen in critically ill children.

Type II sialidosis: review of the clinical spectrum and identification of a new splicing defect with chitotriosidase assessment in two patients.

Sialidosis is a lysosomal storage disease caused by the deficiency of alpha-N-acetyl neuraminidase-1 (NEU1). Sialidosis is classified into two main clinical variants: Type I, the milder form of the disease, and Type II, which can in turn be subdivided into three forms: congenital, infantile and juvenile. We report herein the clinical, biochemical and molecular characterisation of two patients with Type II sialidosis exhibiting the congenital (P1) and infantile forms (P2). We also review clinical data on the rare Type II forms of sialidosis in the hope of improving understanding of the disorder and facilitating its diagnosis. The genetic characterization of the two patients showed one known [c. 679G > A (p.G227R)] NEU1 missense mutation (detected in P2), and the new c.807 + 1G > A splicing defect (detected in P1), a genetic lesion that is extremely rare in this disease. Interestingly, P2 presented an extremely elevated level of chitotriosidase in plasma. This is the first pathological detection of chitotriosidase in sialidosis patients.

Pain knowledge among doctors and nurses: a survey of 4912 healthcare providers in Tuscany.

BACKGROUND: The purpose of this investigation was to get an overview of the understanding of doctors and nurses on pain experienced by patients in the hospitals of Tuscany in order to plan education in the weakest areas. METHODS: A questionnaire was distributed to assess the knowledge of pain: it included 13 questions intended for 3631 nurses and 1281 doctors throughout all the hospitals and sanitary concerns in Tuscany. The total percentage of right answers corresponded to 70.2% with a variability among questions ranging between 30.5% and 95.6%. RESULTS: There is a statistically significant difference between the mean number of correct answers of doctors (9.57/13) and nurses (8.87/13). For doctors working in critical areas, the mean is statistically significant in comparison with other areas. For nurses, those working in the surgical and critical areas show a statistically significant difference in comparison to the nurses of the general practice and other areas. CONCLUSION: The data show that general knowledge of patient pain is good (86.5%), but that great gaps exist in the field of opiates (51.4%). Thus, education should focus on this area, as well as on prejudices concerning pain reported from 50.9% of healthcare providers.

Redox status in very-low birth-weight newborns.

Inborn metabolic diseases, such as disorders in pyruvate metabolism, in gluconeogenesis or in the respiratory chain, may present with lactic acidosis in newborn infants. A simple tool to screen for the efficacy of mitochondrial oxidation reduction activity is the detection of the redox status through simultaneous measurements of plasma lactate, pyruvate and ketone bodies, which are strongly influenced by feeding and stress. We present the redox status values of 55 very-low birth-weight infants under different nutritional conditions. We were able to demonstrate that the redox status values are not dependent on the type of nutrition (oral feeding or continuous enteral nutrition). Instead we observed a strong difference between newborns with intrauterine growth retardation and newborns with appropriate growth. Newborns with intrauterine growth retardation show lower preprandial values of glucose and ketone bodies than newborns with appropriate weight, but higher levels of lactate and pyruvate; nevertheless the lactate/pyruvate and beta-hydroxybutyrate/acetoacetate ratios are normal. The results of the redox status study could suggest the reduced activity of gluconeogenesis and, probably, of beta-oxidation in very-low birth-weight newborns with intrauterine growth retardation.

[Preoperatory anxiety in children: psychological evaluation of premedication and parental presence efficacy]. / Ansia preoperatoria del bambino: valutazione psicologica dell'efficacia della premedicazione e della presenza dei genitori.

OBJECTIVES: The induction of anaesthesia for surgery is a stressful event for child. To treat pre-operative anxiety in children pharmalogical methods (premedication) and behavioural methods (the presence of parents during the induction of anesthesia) are used in combination with each other. The purpose of this investigation was to study the effect of two interventions to alleviate preoperative anxiety of 39 children who are undergoing minor surgery. We studied the influence of some psichological and social characteristics of child and parents on operative period. METHODS: We studied 39 italian speaking children aged 2-14 years ASA 1. We used STAI, a semi structured interview, with questions in the social-demographical area, a valuation scale of the behaviour of the child completed by the anesthesist, a questionaire after surgery for the parent. The descriptive analysis has been performed taking into account the nature of variables (frequency distributions for nominal and ordinal variables; means and standard deviations for cardinal variables). RESULTS: The results show that the age of the child is strongly conditional to the level of stress: negative reactions are more usual in children of pre-school age. The sedative premedication is not an important factor in relieving anxiety, and this result contrasts with published studies, stating the premedication is more effective than presence of a parent. We obtained interesting results by relating the level of stress in the child with other variables: which parent, the level of stress according to the STAI, level of education, type of residence of parents. CONCLUSIONS: Mother's presence during induction resulted of paramount importance. This study shows that the premedication alone is not effective. Some social-demographical factors of the parents have influence.

Developments in the treatment of postoperative pain in paediatrics.

Although appreciation of pain has long been ignored, and even denied, in children its prevention and treatment is now an integral part of standard patient management. The current state of strategies of pain management in infants and children are detailed in this article and we focused on new trends and future developments.

Percutaneous central venous catheterization in small infants: axillary block can facilitate the insertion rate.

Central venous cannulation through a peripheral vein is the technique of choice in awake nonsedated critically ill infants. Such a technique has a high failure rate. We undertook a retrospective study to determine whether a brachial plexus block performed via the axillary approach could improve the success rate for the insertion of a central venous catheter from a peripheral vein of the upper limb in small infants. Data from 128 infants, submitted or not submitted to the axillary block, were analysed. The failure rate for insertion of the central venous catheter was 27% in the group without the use of the axillary block and 9% with the axillary block (P<0.05). The use of brachial plexus block via the axillary route, although evaluated retrospectively, improves the success rate for the insertion of small diameter central venous silicon catheter from a peripheral vein of the upper limb in small infants.

[Percutaneous catheterization of the newborn: control of pain and easy insertion with brachial plexus block]. / Cateterismo percutaneo nel neonato: controllo del dolore e facilità d'esecuzione col blocco del plesso brachiale.

The increasingly prolonged survival of extremely premature infants who required long-term venous access means that this is often a major problem in modern neonatal unit. The insertion of central venous catheters has become an established practice and the development of silastic catheters inserted by newer percutaneous techniques through a peripheral vein is, now, the choice technique in awake non sedated critically-ill infants. Such technique has an high percentage of failure. We have undertaken a retrospective study to determine whether the brachial plexus block performed via the axillary approach could improve the success rate for the insertion of central venous catheter from a peripheral vein of the upper limb in infants minimizing physical and emotional stress to the neonates. Data from 157 low and very low birthweight infants, submitted or not submitted to the axillary block, were examined. The failure rate for the insertion of the central venous catheter was 27% without using the brachial plexus block vs. 9% in the patients that underwent the block. Use of the brachial plexus block via the axillary route, although retrospectively evaluated, improves the success rate and the pain control for the insertion of small diameter central venous silicon catheter from a peripheral vein of the upper limb in low and very low birthweight infants.

Comparison of ropivacaine with bupivacaine for paediatric caudal block.

In a double-blind, multicentre study 245 children aged 1-10 yr undergoing elective minor surgery as inpatients were randomly allocated to receive a single caudal extradural injection of 1 ml kg-1 of either 0.25% bupivacaine or 0.2% ropivacaine after induction of light general anaesthesia. The groups were comparable for age, weight, vital signs and duration of surgery. The onset time was similar for ropivacaine and bupivacaine (9.7 vs 10.4 min). Further analgesia was not required in 40% of children. The mean time to first analgesia in the remainder was 233 min in the bupivacaine group and 271 min in the ropivacaine group. No motor block was measurable in either group. Ropivacaine 2 mg kg-1 was as effective as bupivacaine 2.5 mg kg-1 for caudal analgesia in children.

Comparison of two application techniques of EMLA and pain assessment in pediatric oncology patients.

BACKGROUND AND OBJECTIVES: The study was designed to compare the analgesic efficacy of the local anesthetic EMLA when applied as a patch and as a cream in combination with a Tegaderm dressing to pediatric oncology patients undergoing repeated lumbar punctures. METHODS: The analgesic effect of the two products was assessed by a continuous or discrete visual analog scale in 24 children 3-16 years old, during two lumbar punctures. Distress was rated by use of the Observational Scale of Behavioral Distress. RESULTS: No significant differences were found between the pain and distress scores for the different preparations of EMLA. CONCLUSION: The EMLA patch and the EMLA cream are equally effective in alleviating pain associated with lumbar puncture. The EMLA patch simplifies and speeds up the application of EMLA. It also allows for control of the dose administered per application, thus preventing both over- and underdosing.

[Effects of ondansetron and metoclopramide on postoperative nausea and vomiting after epidural anesthesia in children]. / Effets de l'ondansétron et du métoclopramide sur les nausées et vomissements postopératoires après anesthésie péridurale chez l'enfant.

We studied the preventive effect on postoperative nausea and vomiting (PONV) of ondansetron, metoclopramide and placebo associated with epidural anaesthesia. Sixty children, ASA I or II, 4 to 12 yr old underwent surgery for inguinal hernia repair (n = 30) or orchidopexy (n = 30). Children were randomly assigned to a postinduction intravenous medication group, ondansetron (5 mg.m-2), metoclopramide (0,12 mg.kg-1) or a saline solution placebo. After a general anaesthesia was obtained with halothane, nitrous oxide and oxygen delivered by mask, caudal or lumbar epidural anaesthesia was performed with plain mepivacaine. General performed with plain mepivacaine. General anaesthesia was interrupted and light narcosis maintained with diazepam during surgery. There were no significant differences in age and weight between the three groups. There were no adverse reactions to either ondansetron or metoclopramide. vomiting was not present in ondansetron group. The incidence of postoperative emesis in the metoclopramide group was 25%, whereas that of placebo group was 10%. The administration of ondansetron was associated with a lower (P = 0.017) incidence of postoperative vomiting if compared to the metoclopramide group. In conclusion ondansetron given preoperatively had proven to be an effective treatment for PONV after epidural block for lower abdominal surgery.