Intraperitoneal Local Anesthetic for Laparoscopic Appendectomy in Children: A Randomized Controlled Trial.

OBJECTIVE: The aim of this study was to investigate the efficacy of intraperitoneal local anesthetic (IPLA) on pain after acute laparoscopic appendectomy in children. SUMMARY OF BACKGROUND: IPLA reduces pain in adult elective surgery. It has not been well studied in acute peritoneal inflammatory conditions. We hypothesized that IPLA would improve recovery in pediatric acute laparoscopic appendectomy. METHODS: This randomized controlled trial in acute laparoscopic appendectomy recruited children aged 8 to 14 years to receive 20 mL 0.25% or 0.125% bupivacaine (according to weight) atomized onto the peritoneum of the right iliac fossa and pelvis, or 20 mL 0.9% NaCl control. Unrestricted computer-generated randomization was implemented by surgical nurses. Participants, caregivers, and outcome assessors were blinded. The primary outcome was pain score. Analysis was by a linear mixed-effects model. RESULTS: Of 184 randomized participants (92 to each group), the final analysis included 88 IPLA and 87 control participants. There was no statistically significant difference in overall pain scores (effect estimate 0.004, standard error 0.028, 95% confidence interval -0.052, 0.061), and no difference in right iliac fossa or suprapubic site-specific pain scores, opioid use, recovery parameters, or complications. No child experienced a complication related to the intervention. CONCLUSION: IPLA imparted no clinical benefit to children undergoing acute laparoscopic appendectomy and cannot be recommended in this setting.

Rectus sheath and transversus abdominis plane blocks in children: a systematic review and meta-analysis of randomized trials.

INTRODUCTION: The role of rectus sheath blocks (RSB) and transversus abdominis plane (TAP) blocks in pediatric surgery has not been well established. OBJECTIVE: We aimed to determine if RSB and TAP blocks decrease postoperative pain and improve recovery in children. DATA SOURCES: Duplicate searching of MEDLINE, EMBASE, Cochrane, Web of Science, and trial registries databases by two reviewers. STUDY SELECTION: Included were randomized trials in children on RSB or TAP block in abdominal operations, excluding inguinal procedures. DATA EXTRACTION: Independent duplicate data extraction and quality assessment using a standardized form. RESULTS: Ten trials met inclusion criteria (n = 599), RSB in five and TAP block in five. A linear mixed effects model on patient level data from three trials showed nerve blocks lowered morphine requirements 6-8 h after surgery, -0.03 mg · kg(-1) (95% CI -0.05, -0.002). Pooled analysis of summary data showed nerve blocks lowered 0-10 scale pain scores immediately after the operation, -0.7 (95% CI -1.3, -0.1); lowered 4-16 scale pain scores, -2.0 (95% CI -2.3, -1.7); and delayed the time to first rescue analgesia, 17 min (95% CI 1.3, 33). Quality assessment showed some studies at moderate to high risk of bias. CONCLUSION: Abdominal wall blocks reduce pain and opiate use in children. We advise cautious interpretation of the results given the heterogeneity of studies.

Validity and reliability of a pain location tool for pediatric abdominal surgery.

For children with surgical problems, pain location conveys important clinical information. We developed a Location and Level of Intensity of Postoperative Pain (Lolipops) tool consisting of a body outline with a seven-sector abdominal grid, the International Association for the Study of Pain Revised Faces Pain Scale, and a recording chart. The aim of the study was to assess the validity and reliability of Lolipops. Children aged 5-14 years who had undergone laparoscopic appendectomy took both nurse- and investigator-administered Lolipops, and an investigator administered Varni Thompson Pediatric Pain Questionnaires, within 24 hours of surgery. The average age of the 42 participants was 10.7 years; 64% were boys; 24 (57.1%) had acute appendicitis, 13 (31%) had perforated appendicitis, and 5 (11.9%) were uninflamed. Pain scores were higher at the laparoscopic port incision sites than in upper abdominal sites distant from incisions or expected inflammation, mean (SD) 3.3 (2.3) and 1.1 (1.8), respectively (p < .0001). In children with acute appendicitis, pain scores were higher in the right iliac fossa than in upper abdominal sites, mean (SD) 3.3 (2.5) and 0.4 (0.7), respectively (p = .001). In children with perforated appendicitis, Lolipops demonstrated a more widespread pain pattern. Correlations between nurse and investigator were fair to moderate with an overall intraclass correlation coefficient of 0.597. This study presents a new tool to measure the location of pain in pediatric surgical patients and shows it to be valid and reliable.

Warm, humidified carbon dioxide gas insufflation for laparoscopic appendicectomy in children: a double-blinded randomized controlled trial.

OBJECTIVE: To investigate clinical benefits of warm, humidified carbon dioxide (CO(2)) insufflation for acute laparoscopic appendicectomy on postoperative pain and recovery in children (age 8-14 years). BACKGROUND: Conventional CO(2) insufflation leads to desiccation-related peritoneal inflammation and injury, which is preventable with warm, humidified CO2 gas. We hypothesized that reduced peritoneal desiccation would improve patient-centered outcomes in children after laparoscopic appendicectomy. METHOD: A double-blinded, randomized controlled trial was conducted. Intervention group participants received warm (37°C), humidified (98% relative humidity) CO(2) gas insufflation, whereas control participants received standard room temperature (20°C) gas with 0% relative humidity. Perioperative analgesia and anesthesia were standardized. Postoperative opiate usage was converted to morphine equivalent daily dosages (MEDD) for comparison, and pain intensity at rest and on moving was rated by participants using visual analog scales. Postoperative recovery and return to normal activities was assessed using a questionnaire on day 10. RESULTS: Between February 2010 and March 2011, a total of 190 participants were randomized. Both intervention and control groups were matched at baseline. Postoperative MEDD and pain scores were also similar. There were no differences in postoperative recovery parameters. CONCLUSIONS: Warm, humidified CO(2) insufflation for acute laparoscopic appendicectomy has no short-term clinical benefits on postoperative outcomes in pediatric patients (ClinicalTrials.gov trial identifying code: NCT01027455).

The relationship between age and morphine infusion rate in children.

AIM: We performed a retrospective audit of intravenous morphine infusion administered to children in an effort to characterize the relationship between dose and age. METHODS: A retrospective audit of morphine infusions was reviewed for a 24-months period and included all children who received continuous intravenous nurse-controlled morphine infusions and patient-controlled analgesia; a population undergoing acute and elective surgical procedures, as well as medical and oncological treatments. The relationship between age and infusion rate was investigated using nonlinear mixed effects models. RESULTS: There were 886 children whose data were acceptable for review. Morphine dose increased with age from 9.97 (CV 28%) µg · kg(-1) per h in neonates. The Hill equation with an exponential of 1.5 best described these changes. Morphine rate reached 90% of its mean final rate of 22.5 (CV 167%) µg · kg(-1) per h, observed in teenagers, at approximately 5 years of age. There was considerable uncertainty of this age-morphine rate profile, and the maturation half-life of this profile was 20 months of age (CV 632%). An increase in dosing variability was observed with increasing age. CONCLUSIONS: Morphine infusions at steady-state did not mirror clearance maturation in children nursed in our hospital. We suggest that initial infusion rates in children are started at 10 µg · kg(-1) per h in neonates, 15 µg · kg(-1) per h in toddlers and 25 µg · kg(-1) per h in children above the age of 5 years. The large variability associated with infusion rates means that subsequent infusion rates will depend on feedback from pain scores, adjuvant medications and adverse effects.

Reliability and refinement of a pain location tool for children's abdominal surgery.

AIM: To determine the 'inter-rater' and test-retest reliability of a pain location tool for children. MATERIALS & METHODS: In children aged 5-14 years who had undergone a laparoscopic operation, pain scores at each of seven abdominal locations, and at the shoulder tip, were recorded at baseline and after a 5- and 30-min interval. RESULTS: Intraclass correlation coefficients were predominantly in the 'moderate' to 'substantial' range for both 'inter-rater' and test-retest reliability. Three quarters of children would prefer an electronic version of the tool. Thematic analysis showed accuracy, usability, utility and usefulness were areas for future development. CONCLUSION: Children can reliably indicate where they hurt after laparoscopic surgery. An electronic version could increase acceptability to children and usability by professionals.

Does amethocaine gel influence blood results obtained from capillary sampling?

UNLABELLED: In many children routine blood samples are obtained by capillary sampling, a technique that appears to cause high levels of pain and distress in the child. Topical anaesthesia might alleviate the pain associated with capillary blood sampling but would it affect the blood sample? AIM: a preliminary study to determine whether topical local anaesthetic would affect the values of commonly performed biochemical tests METHOD: 22 healthy adult volunteers were recruited; each volunteer acted as his or her own control. Ametop was applied to a socially clean digit and covered with an occlusive dressing. After 30 minutes the dressing was taken off and excess gel was removed using a cotton wool ball. Two capillary samples were obtained from each volunteer, one from the Ametop treated digit and one from a digit on the opposing hand. The samples were analysed for sodium, potassium, glucose, urea, alkaline phosphatase (ALP), aspartate aminotransferase (AST), alinine aminotransferase (ALT) and bilirubin using a Vitros Chemistry analyser. Statistical analysis was performed on the blood results using Student's paired t-test. RESULTS: Sodium and potassium levels were significantly higher in the samples from digits with Ametop applied, and alkaline phosphatase was significantly lower. CONCLUSION: The use of amethocaine gel (Ametop) appears to affect the results of both sodium and potassium in capillary blood samples and therefore it cannot be recommended as a suitable agent for topical anaesthesia prior to this procedure.

Intraperitoneal Local Anesthetic in Pediatric Surgery: A Systematic Review.

Introduction Systematic reviews report intraperitoneal local anesthetic (IPLA) effective in adults but until now no review has addressed IPLA in children. The objective of this review was to answer the question, does IPLA compared with control reduce pain after pediatric abdominal surgery. Materials and Methods Data sources: MEDLINE, EMBASE, Cochrane databases, trials registries, ProQuest, Web of Science, Google Scholar, and Open Gray. STUDY SELECTION: Independent duplicate searching for randomized controlled trials of IPLA versus no IPLA/placebo in children ≤ 18 years of age, reporting pain, or opioid use outcomes. DATA EXTRACTION: Independent duplicate data extraction and quality assessment using standardized fields. Results The selection process uncovered three eligible published trials and one unpublished study, all in laparoscopy surgery. Qualitative synthesis suggested that IPLA may reduce pain scores, opioid use, time to first opioid, and the need for rescue analgesia, with no effect on hospital stay. Risk of bias was significant. Conclusions IPLA appears promising in pediatric surgery. The high absorptive capacity of the peritoneum and high peritoneal surface area to volume ratio in children presents a dose limitation. In comparison to adult surgery, IPLA has been understudied in pediatric surgery.

Rectus sheath block for laparoscopic appendicectomy: a randomized clinical trial.

BACKGROUND: The rectus sheath block is effective in elective paediatric operations, but has not been previously studied in acute laparoscopic surgery. We investigated its effect on pain after laparoscopic appendicectomy for acute appendicitis. METHODS: Children aged 8-14 years admitted to a paediatric teaching hospital participated in a randomized clinical trial comparing a rectus sheath block using bupivacaine plus adrenaline with saline control. The primary outcomes were pain scores and opiate use, and secondary outcomes were time in the post-anaesthetic care unit, duration of hospitalization and recovery. RESULTS: Children in the nerve block group reported significantly reduced global pain scores compared with controls in the first 3 h after surgery, estimated mean 2.22 versus 3.94, effect size -1.80 (P = .008). Pain scores after 3 h did not differ between the groups. The groups did not differ in opiate requirements, length of hospital stay or recovery after discharge. CONCLUSIONS: In children undergoing acute laparoscopic appendicectomy, a rectus sheath block reduced early post-operative pain, and could contribute to a multimodal recovery programme.

Historical aspects of appendicitis in children.

Evidence of appendicitis exists from ancient Egyptian mummies but the appendix was not discovered as an anatomical entity until the renaissance in Western European literature. Much confusion reigned over the cause of right iliac fossa inflammatory disease until the late 19th century, when the appendix was recognized as the cause of the great majority of cases. Coining the term 'appendicitis' and making the case for early surgery, Fitz in 1886 set the scene for recovery from appendicitis through operative intervention.

The management of a postdural puncture headache in a child.

We present a case of an 11-year old girl who underwent an elective pyeloplasty and had an epidural catheter placed for per- and postoperative analgesia. Postoperatively she developed a postural headache and severe nausea, and a diagnosis of postdural puncture headache (PDPH) was made. Her symptoms failed to respond to conservative management. An epidural blood patch was performed with immediate and complete resolution of her symptoms. We present this case to highlight the occurrence of PDPH in children and to outline the considerations for management.