Cosyntropin for the Treatment of Refractory Postdural Puncture Headache in Pediatric Patients: A Retrospective Review.

OBJECTIVES: Postdural puncture headache is a challenging complication of diagnostic, therapeutic, and unintentional lumbar puncture. Literature evidence supports cosyntropin as a viable noninvasive therapy for adults who have failed conservative management, but pediatric data are limited. The purpose of this retrospective chart review was to describe the use of intravenous cosyntropin for refractory pediatric postdural puncture headache at a single free-standing tertiary care pediatric hospital. METHODS: Patients who had received cosyntropin were identified. Charts were retrospectively reviewed for indication, dosing information, efficacy, and side effects. The response was defined as a 50% reduction in pain score, with a secondary efficacy measure of time to discharge after the first dose. RESULTS: Over a 5-year period, 26 patients received 37 doses of cosyntropin. Dosing ranged from 5 to 15 mcg/kg (median, 10.4 mcg/kg). There was a significant reduction in pain scores after the first dose of cosyntropin (P=0.008). Eighty-one percent of patients (n=21) achieved either a 50% reduction in pain or were discharged within 24 hours after the first dose. The median time to 50% pain reduction in 13 patients who achieved it before or discharge was 5 hours (range, 1 to 30 h). The median time to discharge after the first dose was 20 hours (range, 2 to 72 h). Ten patients received >1 dose of cosyntropin. Three patients required an epidural blood patch. No adverse effects related to treatment were identified. DISCUSSION: This study suggests that while further research is warranted, cosyntropin is a potential alternative to epidural blood patch for pediatric patients with postdural puncture headache who fail conservative management.

Opioid Use Disorder in Children and Adolescents: Risk Factors, Detection, and Treatment.

Opioid medications are an important tool in the management of pain and have been used in clinical practice for centuries. However, due to the highly addictive nature of this class of medications coupled with the life-threatening side effect of respiratory depression, opioid misuse has become a significant public health crisis worldwide. Children and adolescents are at risk for opioid misuse, and early detection is imperative to facilitate treatment and improve outcomes. This review will address the current state of opioid misuse and treatment in children and adolescents in the United States.

Perioperative Management and In-Hospital Outcomes After Minimally Invasive Repair of Pectus Excavatum: A Multicenter Registry Report From the Society for Pediatric Anesthesia Improvement Network.

BACKGROUND: There are few comparative data on the analgesic options used to manage patients undergoing minimally invasive repair of pectus excavatum (MIRPE). The Society for Pediatric Anesthesia Improvement Network was established to investigate outcomes for procedures where there is significant management variability. For our first study, we established a multicenter observational database to characterize the analgesic strategies used to manage pediatric patients undergoing MIRPE. Outcome data from the participating centers were used to assess the association between analgesic strategy and pain outcomes. METHODS: Fourteen institutions enrolled patients from June 2014 through August 2015. Network members agreed to an observational methodology where each institution managed patients based on their institutional standards and protocols. There was no requirement to standardize care. Patients were categorized based on analgesic strategy: epidural catheter (EC), paravertebral catheter (PVC), wound catheter (WC), no regional (NR) analgesia, and intrathecal morphine techniques. Primary outcomes, pain score and opioid consumption by postoperative day (POD), for each technique were compared while adjusting for confounders using multivariable modeling that included 5 covariates: age, sex, number of bars, Haller index, and use of preoperative pain medication. Pain scores were analyzed using repeated-measures analysis of variance with Bonferroni correction. Opioid consumption was analyzed using a multivariable quantile regression. RESULTS: Data were collected on 348 patients and categorized based on primary analgesic strategy: EC (122), PVC (57), WC (41), NR (120), and intrathecal morphine (8). Compared to EC, daily median pain scores were higher in patients managed with PVC (POD 0), WC (POD 0, 1, 2, 3), and NR (POD 0, 1, 2), respectively (P < .001-.024 depending on group). Daily opioid requirements were higher in patients managed with PVC (POD 0, 1), WC (POD 0, 1, 2), and NR (POD 0, 1, 2) when compared to patients managed with EC (P < .001). CONCLUSIONS: Our data indicate variation in pain management strategies for patients undergoing MIRPE within our network. The results indicate that most patients have mild-to-moderate pain postoperatively regardless of analgesic management. Patients managed with EC had lower pain scores and opioid consumption in the early recovery period compared to other treatment strategies.

Tumor necrosis factor-alpha levels in HIV-1 seropositive injecting drug users.

TNF-alpha is a highly pleiotropic cytokine and plays an important role in regulating HIV-1 replication. It may compromise the integrity of the blood-brain-barrier and, thus, may contribute to the neurotoxicity of HIV-1-infection. Both intravenous drug abuse (IDU) and HIV infection can increase TNF-alpha activity, but little information is available on the effects of a combination of these factors on TNF-alpha. We investigated plasma TNF-alpha levels and mRNA in the peripheral monocytes of 166 men and women in three groups: HIV-1-positive IDUs, HIV-1-negative IDUs, and HIV-negative non-IDU control participants. HIV-1-positive IDUs had higher TNF-alpha levels than HIV-1-negative IDUs who, in turn, had higher levels than controls. TNF-alpha mRNA expression in peripheral monocytes was significantly increased in both HIV-1-positive and negative IDUs compared to controls. These findings show that the effects of HIV infection and intravenous drug use may be additive in increasing TNF-alpha levels. Given the multiple effects of TNF-alpha in HIV infection, additional investigation of its role is needed.