A retrospective study of multimodal analgesic treatment after laparoscopic appendectomy in children.

BACKGROUND: Laparoscopic appendectomy is a common emergency pediatric surgery procedure accompanied by substantial pain (pain scores >4 for >60% of the time) in 33% of these patients. We introduced a bundle of pain management interventions including local anesthetic infiltration at the incision site, intravenous (IV) opioids by patient-controlled analgesia (PCA), and scheduled doses of IV ketorolac and oral acetaminophen/hydrocodone. OBJECTIVES: To evaluate the effect of these pain management interventions on pain control after laparoscopic appendectomy. METHODS: We retrospectively studied pain in 206 children above 7 years of age undergoing laparoscopic appendectomy from December 2011 to February 2012 at our institution. We extracted data on patient demographics, duration of anesthesia and surgery, intraoperative opioids, local anesthetic infiltration, surgical procedure reports, along with pain scores, postoperative PCA use, and opioid-related complications and hospital stays. Patients were divided into two groups - simple appendicitis without peritonitis and appendicitis with generalized peritonitis. RESULTS: The incidence of substantial pain when the multimodal regimen was used was 12%, which is significantly lower than earlier reports (Fisher's exact test P < 0.001). Patients with generalized peritonitis experienced more pain, consumed more opioids, had more unmet PCA demands, and a higher incidence of respiratory depression compared with those with simple appendicitis. CONCLUSION: The multimodal regimen of local anesthetic infiltration, opioid by PCA, NSAIDs, and oral acetaminophen/hydrocodone reduced the incidence of substantial pain. Additional studies are required to identify subgroups of patients with minimal opioid requirements who can benefit from modifications of this regimen.

Persistent and untreated tropical infectious diseases among Sudanese refugees in the United States.

A comprehensive medical evaluation to identify persistent and untreated tropical infections among members of the Sudanese group "Lost Boys of Sudan" living in Atlanta, GA, was initiated. Medical examinations and laboratory testing including blood cell counts, liver function tests, stool studies for parasites, hepatitis B serologies, and serologic testing for Schistosoma spp., Strongyloides, and filariae were performed. Preliminary results showed a high prevalence of untreated active schistosomiasis and strongyloidiasis infections in this group, 5 years after their resettlement in the United States. In addition, we found that many of them were infected with onchocerciasis and hepatitis B. We suggest that based on these preliminary results, pre-departure presumptive treatment and/or testing algorithms need to address some of these persistent tropical infections.

Retrospective Comparison of Intranasal Dexmedetomidine and Oral Chloral Hydrate for Sedated Auditory Brainstem Response Exams.

OBJECTIVE: Satisfactory conditions for auditory brainstem responses (ABR) screening tests for pediatric hearing loss are usually achieved with oral chloral hydrate (CH) sedation. When the US manufacture of this drug was discontinued for business reasons, we developed an alternative sedation regimen using intranasal dexmedetomidine (IN DEX) 4 µg/kg. This institutional review board-approved retrospective study compared the efficacy and adverse effect profiles of these 2 sedative regimens. METHODS: Medical records of children receiving oral CH or IN DEX for ABR were surveyed for demographic data and times from sedative administration to start and completion of the ABR procedure and recovery times. We also noted if the examination was completed with or without interruptions, failed for inadequate sedation, and if predefined cardiorespiratory adverse events occurred. RESULTS: In the IN DEX cohort, the examination could be completed more frequently with a single dose of medication (P = .002). Satisfactory sedation in these patients permitted an earlier start of both the ABR examination and recovery to the awake status (P < .001 and < .045, respectively). Hypoxia requiring oxygen therapy was more frequent in the CH group. CONCLUSIONS: This retrospective study found that IN DEX provides effective sedation for ABR examinations, with the benefits of an ability to begin the test sooner and complete the examination with a single dose, in addition to a decreased incidence of hypoxemia. A randomized controlled trial should test the hypothesis that the IN DEX technique is superior to the well-established standard oral CH regimen.

Postoperative pain and the use of ultrasound-guided regional analgesia in pediatric supracondylar humerus fractures.

A total of 230 children undergoing closed reduction and percutaneous pinning of supracondylar humerus fractures were analyzed retrospectively. Severe pain (score ≥ 7/10) was reported in 10% of general anesthesia-only patients in the postanesthesia care unit and in 28% of the 130 admitted patients. The 36 patients who received ultrasound-guided regional analgesia+general anesthesia had decreased intraoperative opioid consumption and postanesthesia care unit pain scores. After admission, pain scores and opioid consumption did not differ between fracture and anesthesia types. No patient developed compartment syndrome. Severe pain is frequent after closed reduction and percutaneous pinning of supracondylar humerus fractures. Further study of ultrasound-guided regional analgesia is needed.