The management of paediatric acute pain in Spain in 2021: Results of a national survey among paediatric anaesthesiologists.

OBJECTIVE: To improve knowledge about routine clinical practice in the management of paediatric acute pain in Spain. METHODS: A telematic survey was conducted via the Internet on a representative sample of healthcare professionals involved in the management of paediatric acute pain (specifically anaesthesiologists) in Spain. The survey included 28 questions about their usual clinical practice in the assessment and treatment of acute pain, and also training and organisational aspects in paediatric acute pain. RESULTS: The survey was completed during March 2021 by 150 specialists in anaesthesiology. The respondents widely experienced in the management of acute paediatric pain (mean years of experience: 14.3: SD: 7.8), essentially in acute postoperative pain (97% of cases). Although 80% routinely used validated paediatric acute pain assessment scales, only 2.6% used specific scales adapted for patients with cognitive impairment. Most of the respondents routinely used analgesic drugs such as paracetamol (99%) or metamizole (92%), but only 84% complemented these drugs with a loco-regional blocking technique or other non-steroidal anti-inflammatory drugs (62%). Furthermore, only 62.7% acknowledged having received specific training in paediatric acute pain, only 45% followed hospital institutional protocols, and a scant 28% did so through paediatric pain units. CONCLUSIONS: The survey identified important points for improvement in the training and organisation of acute pain management in Spanish paediatric patients.

Review of electrical impedance tomography in the pediatric patient.

Electrical impedance tomography (EIT) is a new method of monitoring non-invasive mechanical ventilation, at the bedside and useful in critically ill patients. It allows lung monitoring of ventilation and perfusion, obtaining images that provide information on lung function. It is based on the physical principle of impedanciometry or the body's ability to conduct an electrical current. Various studies have shown its usefulness both in adults and in pediatrics in respiratory distress syndrome, pneumonia and atelectasis in addition to pulmonary thromboembolism and pulmonary hypertension by also providing information on pulmonary perfusion, and may be very useful in perioperative medicine; especially in pediatrics avoiding repetitive imaging tests with ionizing radiation.

Clinical differences in a multidisciplinary pediatric pain unit between primary and secondary chronic pain.

INTRODUCTION: Chronic pain affects an important part of the pediatric population in developed countries. secondary chronic pain (SCP) can have a well-defined medical cause, but primary chronic pain (PCP) can have an unknown etiology. In Spain, there is as yet no information on the clinical differences between patients treated in multidisciplinary units. METHODS: Retrospective analysis of the clinical records of patients seen in 2018 at the Children's Chronic Pain Unit in University La Paz Hospital. RESULTS: A total of 92 patients were included, (age between 3 and 19 years), with a mean age of 12.4 (SD = 4.1) years, mostly female (55%), with a mean duration of pain of 11.3 (SD = 10.4) months. A comparison of patients with PCP (n = 31) and SCP (n = 61) showed that both groups, on average, presented intense pain (X = 5.9; SD = 2.2; range = 0-10), with similar duration and functional repercussions, although PCP was less likely to be associated with neuropathic descriptors than SCP (p = 0.040), and was more extensive (p < 0.001). Both groups received similar treatment, based on rehabilitation, psychotherapy, invasive techniques and analgesic medication, although patients in the PCP group received less analgesic medication (gabapentinoids and opioids) than the SCP (p = 0.011). CONCLUSION: Patients treated in a multidisciplinary Child Pain Unit for PCP or SCP present a very similar clinical profile, though with differences in the number and type of analgesic drugs used. This shows the importance of etiologic diagnosis for adequate pharmacological treatment.

Perioperative management of patients with arrhythmogenic syndromes refractory to medical treatment: A clinical case report.

Family heart diseases related to sudden death are a group of cardiovascular diseases (cardiomyopathies, channelopathies, aortic diseases …) that require familiarity of the anesthesiologist with the perioperative treatment of complex hemodynamic disorders, as well as their surgical treatment.1 We present the case of a 12-year-old man diagnosed with non-obstructive hypertrophic cardiomyopathy (MHNO), after cardiorespiratory arrest (PCR), who underwent video-guided thoracoscopy-guided left sympathectomy (VATS) for frequent syncope, despite pharmacological treatment and implantation of an implantable automatic defibrillator (ICD). Whenever arrhythmic syncope occurs in the setting of familial heart disease, left heart denervation should be considered as the next step in the treatment plan.2.

Perioperative management of patients with arrhythmogenic syndromes refractory to medical treatment: A clinical case report. / Valoración y tratamiento perioperatorio de los pacientes con síndromes arritmogénicos refractarios a tratamiento médico: a propósito de un caso clínico.

Family heart diseases related to sudden death are a group of cardiovascular diseases (cardiomyopathies, channelopathies, aortic diseases...) that require familiarity of the anesthesiologist with the perioperative treatment of complex hemodynamic disorders, as well as their surgical treatment1. We present the case of a 12-year-old man diagnosed with non-obstructive hypertrophic cardiomyopathy, after cardiorespiratory arrest, who underwent video-guided thoracoscopy-guided left sympathectomy for frequent syncope, despite pharmacological treatment and implantation of an implantable automatic defibrillator. Whenever arrhythmic syncope occurs in the setting of familial heart disease, left heart denervation should be considered as the next step in the treatment plan2.

Original and minimally invasive approach to a left-lung refractory atelectasis after reparation of an aortic recoarctation in a lactant: Selective endobronchial CPAP.

Atelectasis is one of the most common respiratory complications in pediatric patients after open-heart surgery, and may lead to weaning failure and increased morbidity. We report the use of an original, minimally invasive approach to refractory left lung atelectasis after repair of an aortic coarctation in a 2 month-old infant, in which a CPAP system connected to a flexible endobronchial tube resolved the atelectasis.

[Thoracic epidural analgesia vs patient-controlled analgesia with intravenous fentanyl in children treated for pectus excavatum with the Nuss procedure]. / Analgesia epidural torácica frente a analgesia con fentanilo controlada por el paciente en niños operados de pectus excavatum con la técnica de Nuss.

BACKGROUND AND OBJECTIVE: Thoracic epidural analgesia and patient-controlled analgesia (PCA) with intravenous fentanyl have both been shown to be effective in pediatric patients treated surgically for pectus excavatum using the Nuss procedure. We compare the efficacy and safety of these techniques. METHODS: Retrospective study of pediatric cases in which the Nuss procedure was used to treat pectus excavatum between October 1997 and February 2009. Weight, age, sex, and Haller index were analyzed. Pain was assessed every 8 hours on a visual analog scale of 0 to 10 or on a scale based on observation of distress (LLANTO scale). Daily use of analgesics was also recorded. The incidence of catheter-related complications or adverse events of treatment such as nausea, vomiting, and respiratory depression were also noted. RESULTS: We identified 31 patients in 2 groups: the epidural group (n=22) and the PCA group (n=9). Demographic characteristics, the incidences of complications or adverse events, and mean (SD) pain scores (epidural group, 1.8 [3.8]; PCA group, 2.1 [3.4]; P = .775) were statistically similar in the 2 groups. However, analgesic requirements and the duration of analgesic use in days differed significantly, at 2.9 (1.1) days in the epidural group and 5.9 (1.4) days in the PCA group (P =.001). CONCLUSIONS: The efficacy and safety of thoracic epidural analgesia is similar to that of PCA with intravenous fentanyl, although the use of epidural analgesia is associated with a markedly shorter duration of requirement for postoperative analgesia.

Painapple®. Validation and evaluation of an electronic application for the management of acute pain in pediatric patients. / PainAPPle. Validación y evaluación de una aplicación electrónica para el manejo del dolor agudo en pacientes pediátricos.

INTRODUCTION: The digital version of the assessment scales recommended for the pediatric patient could contribute to its improvement and to implement the quality indicators described for the management of acute pain. MATERIAL AND METHODS: Psychometric validation (validity and reliability) of pain assessment and treatment side effects scales incorporated in the electronic application PainAPPle. For this, both formats (paper and electronic) of all the scales were applied in two measurements with 30minutes of difference in 44 patients from 4 to 18years of the Acute Pain Unit in the immediate postoperative period. In addition, the data collected by PainAPPle was evaluated by retrospectively applying the quality indicators described for the management of acute postoperative pain. RESULTS: Reliability was studied analyzing the high correlation (Spearman greater than 0.5, P<.001) that we obtained for the values of each scale in two moments with 30minutes of difference, in the same patients. For validity, the high correlation (Spearman greater than 0.5, P<.001) between the values of the paper scales (gold rule) and PainAPPle at both minute 0 and 30 was analyzed. Concordance obtained taking into account the cut-off point of the scales that would force a treatment were also statistically significant (P<.005). CONCLUSIONS: PainAPPle is a validated instrument for the management of acute pain in pediatric patients. The collected data allow to apply the quality indicators described for the management of acute postoperative pain.

[Ultrasound guidance in pediatric regional anesthesia]. / Uso de la ecografía en anestesia regional pediátrica.

Ultrasound imaging is being used to guide pediatric nerve block procedures. Difficulties that arise because of the smaller anatomical structures in children can be compensated for by the greater aqueous consistency and reduced calcification. Given the shorter distance between the surface of the skin and nerves, it is advisable to use a linear array transducer working at a high frequency (7-10 MHz). Like adults, children benefit when ultrasound guidance is used in the performance of neuraxial nerve trunk blocks, particularly of the umbilical and ilioinguinal nerves, and in greater measure in spinal blocks. Ultrasound guidance enhances efficacy and also affords the important advantage of greater safety. The main disadvantages are the cost of equipment and the necessary learning curve.

The importance of bilateral monitoring of cerebral oxygenation (NIRS): Clinical case of asymmetry during cardiopulmonary bypass secondary to previous cerebral infarction. / Importancia de la monitorización bilateral de la oxigenación cerebral: caso clínico de asimetría durante el bypass cardiopulmonar secundaria a infarto cerebral previo.

Cerebral oximetry based on near infrared spectroscopy (NIRS) technology is used to determine cerebral tissue oxygenation. We hereby present the clinical case of a 12-month old child with right hemiparesis secondary to prior left middle cerebral artery stroke 8 months ago. The child underwent surgical enlargement of the right ventricular outflow tract (RVOT) with cardiopulmonary bypass. During cardiopulmonary bypass, asymmetric NIRS results were detected between both hemispheres. The utilization of multimodal neuromonitoring (NIRS-BIS) allowed acting on both perfusion pressure and anesthetic depth to balance out the supply and demand of cerebral oxygen consumption. No new neurological sequelae were observed postoperatively. We consider bilateral NIRS monitoring necessary in order to detect asymmetries between cerebral hemispheres. Although asymmetries were not present at baseline, they can arise intraoperatively and its monitoring thus allows the detection and treatment of cerebral ischemia-hypoxia in the healthy hemisphere, which if undetected and untreated would lead to additional neurological damage.

Cardiac arrest related to anaesthesia in Williams-Beuren syndrome. / Parada cardíaca relacionada con la anestesia en el síndrome Williams-Beuren.

Williams-Beuren syndrome is the clinical manifestation of a congenital genetic disorder in the elastin gene, among others. There is a history of cardiac arrest refractory to resuscitation manoeuvres in anaesthesia. The incidence of myocardial ischaemia is high during anaesthetic induction, but there are patients who do not have this condition yet also have had very serious cardiac events, and issues that are still to be resolved. Case descriptions will enable the common pathophysiological factors to be defined, and decrease morbidity and mortality. We report the case of a 3-year-old boy with cardiac arrest at induction, rescued with circulatory assistance with extracorporeal membrane oxygenation and hypothermia induced for cerebral protection.

Agreement between child self-reported and parent-reported scores for chronic pain secondary to specific pediatric diseases. / Concordancia en pacientes con dolor crónico secundario a enfermedades pediátricas entre la autovaloración y las puntuaciones reportadas por sus padres.

BACKGROUND: Parental report on a child's secondary chronic pain is commonly requested by anesthesiologists when the child cannot directly provide information. Daily pain intensity is reported as highest, average and lowest. However, it is unclear whether the parents' score is a valid indicator of the child's pain experience. METHODS: Nineteen children (aged 6-18years) with secondary chronic pain attending our anesthesiologist-run pediatric pain unit participated in this study. Identification of highest, average and lowest pain intensity levels were requested during initial screening interviews with the child and parents. Pain intensity was scored on a 0-10 numerical rating scale. Agreement was examined using: (i) intraclass correlation coefficient (ICC), and (ii) the Bland-Altman method. RESULTS: The ICC's between the children and the parents' pain intensity reports were: 0.92 for the highest, 0.68 for the average, and 0.50 for the lowest pain intensity domains. The limits of agreement set at 95% between child and parental reports were respectively +2.19 to -2.07, +3.17 to -3.88 and +5.15 to -5.50 for the highest, average and lowest pain domains. CONCLUSIONS: For the highest pain intensity domain, agreement between parents and children was excellent. If replicated this preliminary finding would suggest the highest pain intensity is the easiest domain for reporting pain intensity when a child cannot directly express him or herself.

Clinical experience with desflurane for paediatric anaesthesia outside the operating room. / Experiencia clínica con desflurano para anestesia pediátrica fuera de quirófano.

BACKGROUND: Desflurane has been used in paediatric patients for several surgical indications. This article analyses the efficacy and safety of desflurane for diagnostic-therapeutic procedures in remote areas far from operating room in a group of selected patients with no known associated respiratory disease. MATERIAL AND METHODS: A retrospective analysis was performed on 2,072 general anaesthesia procedures stored in a computer database, in which desflurane was used in a Paediatric Pain Unit during the years 2013 and 2014. An analysis was also performed using the patient demographics, type of procedure, anaesthetic technique, type of airway management, patient cooperation, and incidence of anaesthetic complications. RESULTS: The study included 876 patients, with a mean age of 8.8 years. The main procedures were bone marrow aspirates (23%), lumbar punctures (20%), panendoscopies (15%), and colonoscopies (5%). Induction was intravenous with propofol (26%) or inhalation with sevoflurane in the remaining 74%. Maintenance consisted of remifentanil and desflurane at mean end tidal concentrations of 6.2±2.1%. The airway was managed through a nasal cannula or face mask in spontaneous ventilation. The effectiveness was 98%, and the incidence of side effects was 15%, which included agitation (6%), headache (4%), nausea-vomiting (3%), and laryngospasm (2%). CONCLUSION: The maintenance with desflurane (at concentrations close to the hypnotic-MAC in spontaneous ventilation) was effective, with a rapid recovery, and with a low incidence of adverse effects.

[Jehovah's Witnesses refusal of blood: religious, legal and ethical aspects and considerations for anesthetic management]. / Fundamentos del rechazo a la transfusión sanguínea por los Testigos de Jehová. Aspectos etico-legales y consideraciones anestésicas en su tratamiento.

The refusal of Jehovah's Witnesses to agree to blood or blood product transfusion based on religious beliefs is one of the most challenging conflictive issues health care givers have to face today. Such conflict is a by product of the ideological and religious diversity in society today. The perioperative care of such patients constitutes a genuine challenge for anesthesiologists and surgeons from technical, scientific, ethical, and legal perspectives. We review the reasons why Jehovah's Witnesses refuse transfusion and discuss the ethical, legal, and anesthetic aspects of their care. The literature up to August 2005 was reviewed by MEDLINE search. The following search terms were used: Jehovah's Witnesses, anesthesia (and anaesthesia), legislation and jurisprudence, ethics, blood transfusion, alternatives, anemia (and anaemia), erythropoietin, trigger, and critical care. To further cover ethical and legal aspects, we reviewed current laws in Spain and similar practice settings.

[Bispectral index during induction and awakening from sedation with sevoflurane for magnetic resonance imaging in children]. / Indice biespectral durante la inducción y despertar de sedación con sevoflurano para resonancia magnética en pacientes pediátricos.

OBJECTIVES: To determine the bispectral (BIS) index during induction of sedation with sevoflurane and awakening in children undergoing magnetic resonance imaging (MRI). MATERIAL AND METHODS: We studied 50 pediatric patients sedated only with 2% sevoflurane in oxygen and air administered through a face mask. BIS was monitored during induction, before MRI, after MRI, during awakening, upon first movement, and upon eye opening or first cry. RESULTS: The scan was performed successfully in all patients (none moved during the procedure) even though there was great variability in BIS indices (before MRI, 59.5 [SD, 11.1]; after MRI, 52.8 [13.7]). BIS indices before and after MRI were correlated, although the index after MRI was significantly lower than the index before the scan (P<0.01), indicating that hypnosis became deeper during the procedure. The first spontaneous movement and crying or eye opening produced significantly higher BIS indices (P<0.01) (movement, 75.4 [15.9]; crying, 79.8 [15.6]), although variation was also greater. The BIS index did not exceed 70 for 15 patients (31.3%) upon eye opening and for 12 (27.3%) at the first cry. Children under 6 months of age had significantly lower BIS indices before and after MRI scans than did the older children (P<0.01). CONCLUSIONS: In the absence of painful stimuli, the BIS index reflects the patient's level of hypnosis but does not predict recovery of consciousness.

[Intrathecal baclofen for children with chronic pain related to severe spasticity: advantages of tunneling the catheter in the testing phase]. / Baclofeno intratecal en niños con dolor crónico por espasticidad intensa: ventajas de la tunelización del cateter en la fase diagnóstica.

OBJECTIVE: To document the effectiveness and safety of intrathecal baclofen administered through a tunneled catheter during a diagnostic procedure, prior to implantation of a subcutaneous pump, in children with chronic pain due to severe spasticity. METHODS: This was a retrospective study of 6 children with intense chronic pain due to spasticity caused by cerebral palsy or genetic dystonia. Increasing doses of intrathecal baclofen in continuous perfusion through a tunneled catheter were tested. RESULTS: Lumbar intrathecal catheters were tunneled for 48 to 80 hours in 5 males and 1 female aged 8 to 18 years old. Intrathecal baclofen was administered in continuous perfusion up to maximum rates that ranged between 105 and 570 microg/day. For 5 patients the score on the visual analog pain scale (0-10) changed from over 7 to 0 by the end of the test. In 2 patients, side effects of analgesia were noted, specifically sedation, bradycardia, and bradypnea. No serious complications, such as meningitis, spinal abscess, or hematoma, were reported. The families of 4 patients chose to accept implantation of a subcutaneous pump. Pump therapy remained effective and free of complications when checked 23 or 55 months after placement. CONCLUSIONS: Performing a trial of increasing doses of intrathecal baclofen therapy in continuous perfusion through a tunneled catheter facilitated selection of patients for whom chronic administration of intrathecal baclofen is effective and free of complications.

[Clinical characteristics of children with chronic pain in a pediatric pain unit: oncologic pain versus non-oncologic pain]. / Análisis de las características clínicas de los pacientes con dolor crónico tratados por la unidad de dolor infantil: dolor oncológico frente a no oncológico.

BACKGROUND: Despite undoubted scientific advances in the field of chronic pain in children, there is no evidence of clinical application of this knowledge. OBJECTIVE: To describe the experience of a pediatric pain unit (PPU) specifically dedicated to the treatment of chronic pain in children. MATERIAL AND METHODS: We performed an analytic, observational, retrospective, cohort study of the clinical features of the first 42 patients treated for chronic pain in the PPU during a two-year period. The patients were assigned to two groups: an oncologic group and a non-oncologic group. ANOVA was used to analyze quantitative variables and the Chi-square test was used to analyze qualitative variables. RESULTS: No significant differences were found between the two groups in the demographic variables studied (age and sex). Concerning the type of treatment used, no significant differences were found in effectiveness or compliance. However, treatment duration was significantly longer in the non-oncologic group than in the oncologic group (74.2 days vs 37.5 days, p(0.008). The duration of non-oncologic chronic pain before attending the PPU (mean: 557 days) influenced the effectiveness (r 5 0.781; p 5 0.0001) and duration of treatment (r 5 0.61; p 5 0.0051). However, the duration of previous chronic oncologic pain was significantly shorter (mean: 34 days) and showed no influence on treatment effectiveness or duration. CONCLUSIONS: The pediatric population presents chronic pain syndromes that can be appropriately treated in a PPU with conventional, easy to manage analgesics. We recommend the establishment of pediatric pain units similar to those for adults, using a multidisciplinary approach to mitigate children's suffering.

[Influence of a child's age on anesthetic technique based on analgesia with remifentanil]. / Influencia de la edad pediátrica en la técnica de anestesia basada en la analgesia con remifentanilo.

AIMS: To study the possible pharmacodynamic differences in children under anesthesia based on remifentanil. METHODS: This multicenter observational study enrolled 275 patients scheduled for minor pediatric surgery (herniorrhaphy, prepuceplasty, and plastic surgery). The children were grouped by age: 1-3 years, 4-7 years, 8-12 years. Premedication was with midazolam, induction with sevoflurane or propofol, and maintenance with sevoflurane 0.5%-0.8%, N2O/O2 30%/70%, and remifentanil 0.25 microg/kg/min. Postoperative analgesia (metamizol, morphine or regional block) was administered at least 30 minutes before the end of surgery. RESULTS: No differences were found between age groups with regard to remifentanil requirements, end tidal concentrations of sevoflurane, or mean times until spontaneous ventilation or extubation. Nor were there differences in the percentages of complications (5.4%), of which 4 were cases of intense postoperative muscular rigidity, or in the incidence of nausea-vomiting (3.4%). The quality of recovery from anesthesia (Aldrete test) was better in the 8-12-year-old group (P < 0.05), however, while agitation (Postoperative Agitation Score) and pain (visual analog scale or observational scales) were greater in the group of 1-3-year-olds (P < 0.05). The evaluation of the technique by participating caregivers was excellent for 20%, very good for 41%, good for 29%, adequate for 8% and poor for 2% of the cases.

[Physiopathologic implications of the anesthesiologic management of pediatric laparoscopic surgery]. / Implicaciones fisiopatológicas en el manejo anestésico de la cirugía laparoscópica pediátrica.

We study gas exchange and hemodynamic repercussions during pediatric laparoscopic surgery. We provided balanced anesthesia with muscle relaxation while ventilation was maintained with FiO2 at 0.4 and flow volume between 10-15 ml/kg-1 during abdominal laparoscopic procedures performed in 10 ASA I-II children (4-14 years). Pneumoperitoneum was produced with CO2 insufflated up to a pressure of 15 mmHg. Airways pressure (PIP), PaO2, PaCO2, heart rate (HR), systolic arterial pressure (SAP) and diastolic arterial pressure (DAP) were measured before insufflation and 5, 30 and 60 minutes afterwards. We calculated the ratio of dead space to flow volume (VD/VT), thoracic distensibility and metabolic production of CO2 (VCO2). Insufflation caused an immediate reduction (29-33%) in dynamic thoracic distensibility (p = 0.0004), but no hypoventilation or increases in VD/VT. The decrease in PaO2 was small (5-6%) but statistically significant (p = 0.0188). Hypercapnia (14-21%) was due to an increase in VCO2 caused by gradual peritoneal absorption of CO2 (24-32%, p = 0.0013). We also found increases in SAP (10%, p = 0.02) and DAP (32%, p = 0.0001) at 5 min, along with an increase in HR (8%, p = 0.0163) at 60 min. Arterial CO2 levels were held within physiological limits by compensatory hyperventilation (+25% of physiological VT). Capnography proved to be an excellent guide. Any clinical repercussion of hemodynamic effects was blocked by a dose of atropine given before insufflation and by the excess loading volume (10 ml/kg of crystalloids). Laparascopic surgery in children diminishes thoracic distensibility and causes hypercapnia, making it necessary to measure PefCO2 to regulate ventilation.