Postoperative pain management in children: guidance from the Pain Committee of the European Society for Paediatric Anaesthesiology (ESPA Pain Management Ladder Initiative) Part II.

The ESPA Pain Management Ladder Initiative is a clinical practice advisory based upon expert consensus supported by the current literature to help ensure a basic standard of perioperative pain management for all children. In 2018 the perioperative pain management of six common pediatric surgical procedures was summarised. The current Pain Management Ladder recommendations focus on five more complex pediatric surgical procedures and suggest basic, intermediate, and advanced pain management methods. The aim of this paper is to encourage best possible pain management practice and to support institutions to create their own pain management concepts according to their financial and human resources due to the diversity of clinical settings in Europe. Furthermore, the authors underline that these recommendations are intended for inpatients only.

[THE SCALP AS A SPLIT-THICKNESS GRAFT DONOR IN THE TREATMENT OF A MASSIVE THERMAL INJURY]. / VLASISTE KAO DONOR TRANSPLANTATA DJELOMICNE DEBLJINE KOZE U LIJECENJU MASIVNE TERMALNE OZLJEDE.

We are presenting our initial experience with the utilization of the scalp as a donor for split thickness skin grafting in the treatment of massive thermal injuries. Rapid donor reepithelization, absence of hypertrophic scarring in the donor area, inconspicuous donor area and a large area for the procurement of grafts in the pediatric population are the advantages that are emphasized in the literature. The outcome in a 3-year-old boy who suffered a burn injury from an open fire in the family house on the 57% of his total body surface area (48% full thickness burn) showed that the "take rate", in the absence of a massive local infection, was around 80% and that the scalp can be utilized again as a donor area after a period of 14 days. Folliculitis and alopecia are complications that should be kept in mind when using this technique.

[Delirium incidence in pediatric intensive care unit]. / Ucestalost delirija u pedijatrijskim jedinicama za intenzivno lijecenje.

Delirium is a serious neuropsychiatric disorder and pediatric delirium (PD) is a similarly serious condition. PD is understudied and very often misdiagnosed, especially in pediatric intensive care units (PICU). It is important to early diagnose PD, so that early psychosocial interventions and therapy can be introduced. Valid diagnostic instruments are needed at PICU to assess PD. There are many scales and tests to diagnose delirium but none of them is specific enough to diagnose PD. Although PD is a serious complication at PICU, clinical guidelines for PD are still lacking, therefore additional investigations are needed to bring them out.

Reversal of thrombocytopenia and bleeding tendency in a preterm neonate with recombinant activated factor VII: case report.

A male neonate, born at 26 weeks of postmenstrual age, with intracranial hemorrhage grade IV and thoracic drainage for artificial tension pneumothorax on day 6 of his life is presented. Despite prior transfusions, the preprocedural hemogram showed marked anemia and thrombocytopenia. To reverse thrombocytopenia and to avoid volume overload, the patient was administered 110 microg kg(-1) of recombinant activated factor VII (rFVIIa) and drainage of the pneumothorax was performed uneventfully.

[Acute childhood pancreatitis caused by valproate]. / Akutni pankreatitis u djeteta uzrokovan valproatom.

Signs of pancreatitis in children are simmilar to those in adults: disturbed general condition, abdominal pain, vomitting, elevated amylase level. Mainstays in intensive therapy and indications for surgical interventions are also sim-milar. Contrary to adults, in childhood pancreatitis adverse effects of various drugs are common causes. Natrium valproate, antiepileptic drug in use for many years, can rarely induce pancreatitis. We report of such case in a girl treated with valproate for Rett's syndrome. Abdominal ultrasound can be unspecific in acute pancreatitis. If clinical signs and amylases elevated in a child on valproate therapy do not suffice, abdominal computer tomography should be done to confirm the grounded suspicion.

Central venous catheters for chemotherapy of solid tumors--our results in the last 5 years.

Central venous catheters provide an easy access for intravenous medications. Having a central line in place will relieve a child from the discomfort and danger of multiple regular intravenous lines for chemotherapy. The use of indwelling central venous catheters has become commonplace in the management of children undergoing oncological treatment. There are two types of central lines commonly used. There are Broviac catheters and Port-A-Cath (PAC) catheters. In the last 5 years we inserted 194 catheters in 175 children. We inserted 121 Broviac catheters and 73 PAC catheters. During the follow up of 39382 catheter days 44 complications were observed. In Broviac group the median follow up was 155 days and in PAC group was 230 days. We observed differences in the incidence between two devices. In Broviac group infections were more frequent and in PAC group other complications were more frequent than infections.

Experience with gabapentin for neuropathic pain in adolescents: report of five cases.

Summary Gabapentin is an antiepileptic drug indicated for the treatment of partial seizures in children. Many studies have proved its analgesic action in the treatment of neuropathic pain in adults and we have noticed an analgesic action of gabapentin in neuropathic pain in children. Five patients treated in the Children's Hospital Pain Control Service for intractable neuropathic pain were included in gabapentin treatment. Four were cancer patients and one suffered from neuropathic pain in the neck (C3). The visual analog scale (VAS) scores of pain were compared before and during treatment with gabapentin. We noticed a rapid improvement, in 1 week, of our patients' VAS scores (from 9 or 10 to 4 or 3) with minimal adverse effects. In the follow-up period of 6 months we gradually reduced the dose of gabapentin. Our findings are that gabapentin should be included earlier in the treatment of neuropathic pain in adolescents, because it rapidly improves analgesia and has minimal side effects.

Hirschsprung's disease and Rehbein's procedure--our results in the last 30 years.

Hirschsprung's disease is congenital anomaly of the intestine and Harald Hirschsprung gave the first description of this disease'. The aim of this follow-up study was to evaluate the results of Rehbein's procedure in the treatment of Hirschsprung's disease in the last 30 years in Children's Hospital Zagreb. Hirschsprung's disease is congenital intestinal aganglionosis as the results of arrested fetal development of the myenteric nervous system. Hirschsprung's disease is affecting between 1:5000 to 1:8000 live births. A total of 124 children underwent Rehbein's lower anterior resection at Children's Hospital Zagreb. The principle of Rehbein'procedure is to remove aganglionic narrow segment and dilated sigmoid colon and anastomosis between normal intestine with rectal stump. The postoperative outcome was analysed for early and late complications like wound infections, abscesses, anastomotic insufficiency, postoperative enterocolitis, constipation, fecal incontinence, need for reoperation, ileus and mortality. On the basis of our results and data from literature we concluded that Rehbein's procedure is an excellent method for treatment Hirschsprung's disease.

Comparison of laser acupuncture and metoclopramide in PONV prevention in children.

BACKGROUND: Postoperative nausea and vomiting (PONV) are frequent side effects of general anesthesia in children. The aim of this study was to compare the effectiveness of laser acupuncture with metoclopramide in prevention of PONV in children after sevoflurane anesthesia. METHODS: A total of 120 children ASA I and II, scheduled for hernia repair, circumcision or orchidopexy were randomly assigned into three groups: group I, received laser acupuncture on P6 point and saline infusion; group II, metoclopramide 0.1 mg.kg(-1) i.v. and sham laser; group III had sham laser and saline infusion. Anesthesia was maintained with sevoflurane and N(2)O/O(2). Patients were monitored for any symptoms of retching and vomiting at 2, 6 and 24 h postoperatively. RESULTS: The incidence of vomiting was higher in the control group in the first 2 h postoperatively (P < 0.001), compared with the other groups. There was no statistically significant difference between acupuncture and metoclopramide groups in occurrence and timing of vomiting (P < 0.001). CONCLUSION: Laser acupuncture is equally effective as metoclopramide in preventing PONV in children.