Parents' perspective on recovery at home following adenotonsillectomy: a prospective single-centre qualitative analysis.

PURPOSE: In North America, pediatric adenotonsillectomy (TA) is conducted as an ambulatory procedure, thus shifting the burden of postoperative care to parents. The purpose of this study was to describe this parental experience. METHODS: We conducted a prospective single-centre qualitative study, recruiting the families of children (n = 317) undergoing elective TA in 2018. Parents were invited to submit written comments to two open-ended questions. We coded the comments from 144 parents in a grounded theory analysis and report representative exemplars. Themes and subthemes for the problems encountered, and strategies employed by parents, were developed. We then coded and classified factors that helped/hindered parents and developed models of the experience. RESULTS: Some parents felt ill-prepared for the severity and duration of pain. Specific findings included a lack of strategies to manage pain at night, refusals, and night terrors. Parents identified the use of pain scales, pain diaries, and liaison with the research team as helpful supports at home. Inconsistent messaging was a barrier. The odynophagia associated with elixirs of acetaminophen and ibuprofen was a barrier to achieving analgesia. CONCLUSIONS: The findings from this qualitative analysis provide insight into the challenges faced by parents when caring for their children at home following TA; these challenges included difficulties managing physical needs and pain. The analysis suggests that educational content should be standardized and include the use of pain scales and diaries, and both pharmacologic and nonpharmacologic strategies. Development of support at home, including a practicable liaison with health care providers, seems to be warranted. STUDY REGISTRATION: ClinicalTrials.gov (NCT03378830); registered 20 December 2017.

RéSUMé: OBJECTIF: En Amérique du Nord, l'adéno-amygdalectomie pédiatrique est réalisée en intervention ambulatoire, transférant ainsi le fardeau des soins postopératoires aux parents. Le but de cette étude était de décrire cette expérience parentale. MéTHODE: Nous avons réalisé une étude qualitative prospective monocentrique, recrutant les familles d'enfants (n = 317) subissant une adéno-amygdalectomie non urgente en 2018. Les parents ont été invités à soumettre des commentaires écrits sur deux questions ouvertes. Nous avons codé les commentaires de 144 parents dans une analyse théorique ancrée et rapporté des exemples représentatifs. Des thèmes et sous-thèmes pour les problèmes rencontrés, ainsi que des stratégies employées par les parents, ont été développés. Nous avons ensuite codé et classé les facteurs qui aidaient / gênaient les parents et développé des modèles de l'expérience. RéSULTATS: Certains parents se sentaient mal préparés à la gravité et à la durée de la douleur. Les résultats spécifiques comprenaient un manque de stratégies pour gérer la douleur la nuit, les refus et les terreurs nocturnes. Les parents ont indiqué que l'utilisation d'échelles de douleur, de journaux de douleur et de liaison avec l'équipe de recherche étaient des soutiens utiles à la maison. Le manque d'uniformité des messages a constitué un obstacle. L'odynophagie associée aux élixirs d'acétaminophène et d'ibuprofène était un obstacle à l'analgésie. CONCLUSION: Les résultats de cette analyse qualitative donnent un aperçu des défis auxquels font face les parents lorsqu'ils et elles s'occupent de leurs enfants à la maison après une adéno-amygdalectomie; ces défis comprenaient des difficultés à gérer les besoins physiques et la douleur. L'analyse suggère que le contenu éducatif devrait être normalisé et inclure l'utilisation d'échelles et de journaux de douleur, ainsi que de stratégies pharmacologiques et non pharmacologiques. L'élaboration d'un soutien à domicile, y compris d'une communication fonctionnelle avec les prestataires de soins de santé, semble justifiée. ENREGISTREMENT DE L'éTUDE: ClinicalTrials.gov (NCT03378830); enregistrée le 20 décembre 2017.

Validation of the parent's postoperative pain measure with an age-appropriate reference pain scale for children 2-12 years old during a 14-day recovery after tonsillectomy: A prospective cohort study.

BACKGROUND: Adenotonsillectomy is associated with severe postoperative pain. The parent's postoperative pain measure (PPPM), a 15-item instrument to measure a child's pain at home, has been validated with a seven-point faces scale in children 7-12 years and with the parents' global report of pain in children 2-6 years. AIMS: Our primary objective was to validate the PPPM with a recommended age-appropriate pain scale in children 2-12 years after adenotonsillectomy. Our secondary objective was to reduce the PPPM components and validate this reduced PPPM. METHODS: We recruited 319 children out of the 563 adenotonsillectomies performed between December 19, 2017, and December 18, 2018. Parents recorded administration of analgesics and their child's pain scores twice daily for 14 days: PPPM for all children and either the face, legs, arms, crying, consolability (FLACC) pain scale for children 2-3 years or the faces pain scale-revised (FPS-R) for children 4-12 years. In addition, parents recorded analgesics. RESULTS: Among the 354 eligible children, 9% of parents declined. 252 (79%) families submitted pain diaries. The median age was 2.9 [2.5-3.3] years for FLACC (n = 114) and 5.6 [4.5-7.2] years for FPS-R (n = 138). Across the 14-day recovery period, Cronbach's alpha for PPPM was 0.77 to 0.87. Generalized linear mixed models evaluated the association between PPPM and reference pain scales after adjustment for potential confounders. Time of day and postoperative days were included as predictors in the models. PPPM was strongly associated with FLACC and FPS-R (beta coefficient = 0.4; p < 0.0001). The association decreased over time, and the reduction was more significant for FPS-R than FLACC (beta coefficient = -0.13 vs. -0.04, respectively; p < 0.0001). There was a positive association between PPPM and the use of analgesics. A reduction analysis eliminated items from the original PPPM: four for FLACC and five for FPS-R, suggesting age-related differences. The reduced PPPM instruments achieved similar associations with their respective reference pain scales (beta coefficient = 0.5; p < 0.0001). CONCLUSIONS: This study extends previous work by validating the PPPM in children as young as 2 years with a recommended age-appropriate pain scale over 14-day convalescence after adenotonsillectomy. The reduced PPPM instruments differed in the two age groups. Future studies might explore these age-appropriate reduced PPPM instruments to assess pain at home following adenotonsillectomy.

Postoperative pain following minimally invasive repair of pectus excavatum: A descriptive study.

BACKGROUND: Minimally Invasive Repair of Pectus Excavatum (MIRPE) is associated with significant postoperative pain. The objective of our study was to characterize the severity and duration of this pain, and to investigate possible associations with pectus severity. METHODS: We conducted a retrospective cohort study of pediatric patients who underwent MIRPE from January 2014 to April 2018. Pectus excavatum (PE) severity was determined with 3 indices measured from computed tomography: Depression Index (DI), Correction Index (CI), and Haller index (HI). Mean pain scores for every 6-hour period and the presence of pain and intake of analgesics during follow-up were extracted from the medical record. RESULTS: The cohort included 57 patients with a mean age of 15.9 ± 1.3 years. All 3 severity indices were positively correlated, with a correlation coefficient of 0.8 between the DI and CI. The requirement for 2 bars was significantly associated with higher indices (95% CI:0.18-0.63, p = 0.01). Pain was managed with thoracic epidural analgesia for all but one patient. Growth linear modeling identified five different pain trajectory subgroups of patients up to post-operative day 5. None of the tested predictors (age, gender, body image, physical activity level, DI, CI, HI, difference deformity-epidural level) were significantly associated with class membership. Persistent pain at one-year follow-up was present in 18% of patients, all with severe deformity (DI≥0.8). CONCLUSION: Pain trajectory and intensity after MIRPE can be classified into discrete patterns but are not influenced by PE severity. Severe deformity seems to predict persistent pain at one year.

Parental Engagement of a Prototype Electronic Diary in an Ambulatory Setting Following Adenotonsillectomy in Children: A Prospective Cohort Study.

Adenotonsillectomy is performed in children on an outpatient basis, and pain is managed by parents. A pain diary would facilitate pain management in the ambulatory setting. Our objective was to evaluate the parental response rate and the compliance of a prototype electronic pain diary (e-diary) with cloud storage in children aged 2-12 years recovering from adenotonsillectomy and to compare the e-diary with a paper diary (p-diary). Parents recorded pain scores twice daily in a pain diary for 2 weeks post-operation. Parents were given the choice of an e-diary or p-diary with picture message. A total of 208 patients were recruited, of which 35 parents (16.8%) chose the e-diary. Most parents (98%) chose to be contacted by text message. Eighty-one families (47%) returned p-diaries to us by mail. However, the response rate increased to 77% and was similar to that of the e-diary (80%) when we included data texted to the research phone from 53 families. The proportion of diaries with Complete (e-diary:0.37 vs. p-diary:0.4) and Incomplete (e-diary:0.43 vs. p-diary:0.38) data entries were similar. E-diaries provide a means to follow patients in real time after discharge. Our findings suggest that a smartphone-based medical health application coupled with a cloud would meet the needs of families and health care providers alike.

Transient abdominal wall deformity in an infant Blaming the caudal?

Locoregional anesthesia is an important aspect of perioperative analgesia. It decreases requirements for anesthetic agents and opioids, decreases the surgical stress response, and provides postoperative analgesia. Nonetheless, pediatric patients, especially infants, demonstrate specificities towards regional anesthesia techniques, as an increased sensitivity to local anesthetics (LA) and a higher ease of LA spread especially when using blocks that rely on the volume of LA and its spread as those used for abdominal wall analgesia or caudal. Thus, we present a case of transient abdominal wall deformity following caudal anesthesia in an infant.

An acute pain service improves postoperative pain management for children undergoing selective dorsal rhizotomy.

BACKGROUND: A continuous epidural infusion of morphine is the pain treatment modality for children undergoing selective dorsal rhizotomy (SDR) in our institution. The aim of the study was to evaluate the impact of having an organized acute pain service (APS) on postoperative pain management of these children. METHODS: We conducted a retrospective cohort study using anesthetic records and the APS database to compare the postoperative pain management of children undergoing SDR before and after the introduction of the APS at the Montreal Children's Hospital in April 2001. Ninety-two consecutive children who had their surgery between January 1997 and July 2006 were included. We collected data regarding postoperative pain, opioid-induced side effects, complications (sedation, desaturations < 92%), and hospital length of stay. RESULTS: Pain scores were documented more frequently after the implementation of the APS (61% vs 48.5%). Sedation scores were documented only after the implementation of the APS. Postoperative desaturation was significantly more frequent in the pre-APS group compared to the APS group (45.5% vs 6.8%, P < 0.001). Despite the fact that the epidural catheter was in place for the same duration for both groups [median of 3 days (3-3 25-75%ile)], the duration of hospitalization was 1 day shorter in the APS group compared to the pre-APS group [median of 5 (5-5 25-75%ile) vs 6 (5-6 25-75%ile) days, P < 0.001]. CONCLUSIONS: Although we recognize that it is possible that there were changes in care not related specifically to the introduction of a dedicated APS that occurred in our institution that resulted in improvements in general postoperative care and in length of stay, our study did show that having an organized APS allowed to significantly decrease the incidence of postoperative oxygen desaturation and to decrease the hospital length of stay by 1 day.

Does ketamine affect intraoperative electrophysiological monitoring in children undergoing selective posterior rhizotomy?

OBJECTIVE: Direct dorsal rootlet stimulation with intraoperative electrophysiological monitoring is an adjunct to clinical evaluation during selective posterior rhizotomy. The purpose of this study was to evaluate the impact of ketamine on intraoperative electrophysiological monitoring during selective posterior rhizotomy. Specifically, we sought to determine if low dose ketamine given as part of the anesthesia was associated with changes in intraoperative electrophysiological monitoring in patients who underwent selective posterior rhizotomy. METHODS: A retrospective cohort study was conducted using anesthetic records and electrophysiological records of 32 children who had intraoperative electrophysiological monitoring during selective posterior rhizotomy under general anesthesia. Administration and dosage of ketamine preceding the stimulation of dorsal roots was determined from the anesthetic record. A pediatric neurologist, blinded to patient, and to ketamine exposure, evaluated different electrophysiological criteria. RESULTS: Eight children received ketamine and 24 did not receive it. The mean average dose of ketamine was 0.18 mg x kg(-1) (sd: 0.04). We did not find any statistically significant difference in intraoperative electrophysiological response between the ketamine and the control groups. However, we noted some trends: Administration of ketamine preceding the stimulation of dorsal roots was associated with a lower maximal threshold (2.7 mA vs 3.5 mA, P = 0.663) and root thresholds compared with children who did not receive ketamine. In addition, the train response following delivery of the suprastimulation tended to last longer with the presence of ketamine. CONCLUSIONS: Administration of low dose ketamine preceding the stimulation of dorsal roots during selective posterior rhizotomy might be associated with lower maximal thresholds and a more sustained train response following stimulation. Physicians should be aware of this finding in order to avoid misinterpreting intraoperative electrophysiological monitoring.

Ondansetron treatment in a child presenting with chronic intractable pruritus.

The case of a seven-year-old boy with chronic pruritus secondary to a giant congenital melanocytic nevus is presented. The pruritus did not respond to conventional antipruritic drug treatment, but responded to ondansetron, a selective antagonist of 5-hydroxytryptamine type 3 receptors.

Bowel hematoma following an iliohypogastric-ilioinguinal nerve block.

We report a case of a subserosal small bowel hematoma following an ilioinguinal-iliohypogastric nerve block for an appendicectomy in a 6-year-old girl. The bowel hematoma was noted in the wall of the terminal ileum after opening the peritoneum. The hematoma was nonobstructing and the child remained asymptomatic. We discuss the technical aspects of this block.

Maternal infection and risk of cerebral palsy in term and preterm infants.

OBJECTIVE: We tested the hypothesis that term and preterm infants exposed to maternal infection at the time of delivery are at increased risk of developing cerebral palsy (CP). STUDY DESIGN: A population-based case-control study was conducted using Washington State birth certificate data linked to hospital discharge data. Cases (688) were children

Supplemental oxygen causes increased signal intensity in subarachnoid cerebrospinal fluid on brain FLAIR MR images obtained in children during general anesthesia.

PURPOSE: To prospectively test the hypothesis that high levels of the fraction of inspired oxygen (Fio(2)) during general anesthesia cause subarachnoid cerebrospinal fluid (CSF) hyperintensity during fluid-attenuated inversion-recovery (FLAIR) magnetic resonance (MR) imaging. MATERIALS AND METHODS: At brain MR imaging during general anesthesia with propofol, two FLAIR sequences were performed in 20 children with American Society of Anesthesiologists physical status classification system grades of 3 or lower. The first FLAIR sequence was performed with the child breathing 100% oxygen; the second was performed with the child breathing 30% oxygen. CSF signal intensity was quantified on a three-point ordinal scale (0 = hypointense to brain parenchyma, 1 = isointense to brain parenchyma, 2 = hyperintense to brain parenchyma) by a pediatric neuroradiologist who was blinded to the Fio(2) level. The Wilcoxon signed rank test was used to determine if CSF hyperintensity was correlated with Fio(2). RESULTS: CSF hyperintensity was present in all 20 children (age range, 1.9-16.7 years; 12 children were boys) when the Fio(2) was 100%. The hyperintensity partially or completely disappeared in the basilar cisterns (P <.001) and cerebral sulcal subarachnoid space (P <.001) after Fio(2) was reduced from 100% to 30%. CONCLUSION: These findings are consistent with the hypothesis that increased arterial oxygen tension and consequently increased CSF Po(2) resulting from administration of high Fio(2) during general anesthesia are responsible for the increased CSF signal intensity noted on brain FLAIR MR images.

Fraction of inspired oxygen in relation to cerebrospinal fluid hyperintensity on FLAIR MR imaging of the brain in children and young adults undergoing anesthesia.

OBJECTIVE: Cerebrospinal fluid (CSF) hyperintensity has been described on fluid-attenuated inversion recovery (FLAIR) imaging in anesthetized patients who underwent MR imaging without apparent subarachnoid abnormality. The purpose of our study was to delineate likely causes for this hyperintensity. Specifically, we sought to determine whether a high inspired oxygen fraction given as part of the anesthetic was responsible for the CSF hyperintensity seen on FLAIR imaging. MATERIALS AND METHODS: A retrospective study was conducted using anesthetic records and brain MR images of 70 children and young adults who had a FLAIR sequence while undergoing general anesthesia. Information about inspired oxygen fraction, oxygen saturation, and type of anesthetic agents preceding the FLAIR sequence was obtained from the anesthetic record. A pediatric neuroradiologist who was unaware of the inspired oxygen fraction and anesthetic agent ascertained the presence of CSF hyperintensity in the basilar cisterns and cerebral sulcal subarachnoid space. RESULTS: Twenty-one patients received an inspired oxygen fraction less than or equal to 0.60, and 49 received an inspired oxygen fraction greater than 0.60. Inspired oxygen fraction greater than 0.60 was significantly associated with the presence of CSF hyperintensity in the basilar cisterns (p < 0.001) and in the cerebral sulcal subarachnoid space (p = 0.03). The type of anesthetic agent, patient's sex, or status (based on the American Society of Anesthesiology physical status and classification system), and presence of cardiopulmonary disease or seizure disorder were not associated with CSF hyperintensity. CONCLUSION: High inspired oxygen fraction during anesthesia is associated with CSF hyperintensity in the basilar cisterns and the cerebral sulcal subarachnoid space on FLAIR imaging in children and young adults. Physicians should be aware of this finding to avoid misinterpreting this artifact as an abnormality.