Multisite prospective study of perioperative pain management practices for anterior cruciate ligament reconstruction in adolescents: Society for Pediatric Anesthesia Improvement Network (SPAIN) Project Report.

INTRODUCTION: Although 200 000 adolescents undergo anterior cruciate ligament reconstruction (ACLR) surgery annually, no benchmarks for pediatric post-ACLR pain management exist. We created a multicenter, prospective, observational registry to describe pain practices, pain, and functional recovery after pediatric ACLR. METHODS: Participants (n=519; 12-17.5 years) were enrolled from 15 sites over 2 years. Data on perioperative management and surgical factors were collected. Pain/opioid use and Lysholm scores were assessed preoperatively, on postoperative day 1 (POD1), POD3, week 6, and month 6. Descriptive statistics and trends for opioid use, pain, and function are presented. RESULTS: Regional analgesia was performed in 447/519 (86%) subjects; of these, adductor canal single shot was most frequent (54%), nerve catheters placed in 24%, and perineural adjuvants used in 43%. On POD1, POD3, week 6, and month 6, survey response rates were 73%, 71%, 61%, and 45%, respectively. Over these respective time points, pain score >3/10 was reported by 64% (95% CI: 59% to 69%), 46% (95% CI: 41% to 52%), 5% (95% CI: 3% to 8%), and 3% (95% CI: 1% to 6%); the number of daily oxycodone doses used was 2.8 (SD 0.19), 1.8 (SD 0.13), 0, and 0. There was considerable variability in timing and tests for postdischarge functional assessments. Numbness and weakness were reported by 11% and 4% at week 6 (n=315) and 16% and 2% at month 6 (n=233), respectively. CONCLUSION: We found substantial variability in the use of blocks to manage post-ACLR pain in children, with a small percentage experiencing long-term pain and neurological symptoms. Studies are needed to determine best practices for regional anesthesia and functional assessments in this patient population.

Quadratus Lumborum Block and Transversus Abdominis Plane Block in Non-emergency Cesarean Delivery: A Systematic Review and Meta-analysis.

PURPOSE: Investigate the analgesic efficacy of quadratus lumborum (QL) block versus transversus abdominis plane (TAP) block in postoperative pain management in nonemergent cesarean section. DESIGN: Systematic review with meta-analysis. METHODS: PubMed, Cochrane, CINAHL, Google Scholar, and gray literature were searched for evidence. Only randomized controlled trials examining the effects of QL and TAP block for nonemergent cesarean delivery were included. Mean difference (MD) was used to estimate continuous outcomes with appropriate effect models. The quality of evidence was rated using the Risk of Bias and Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) system. FINDINGS: Six studies involving 543 parturients were included. Compared to the TAP block, the cumulative 24-hour pain score at rest (MD, -0.60; 95% CI, -1.03 to -0.17; P = .007) and during activity (MD, -1.05; 95% CI, -1.54 to -0.56; P < .0001) were significantly lower in QL block. Time to the first analgesic rescue (MD, 21.67; 95% CI, -18.58 to 61.91; P = .29) and opioid consumption (MD, -1.96; 95% CI, -4.59 to 0.66; P = .14) were similar in both groups. No difference was found in the incidence of postoperative nausea and vomiting and sedation. However, patients treated with QL block reported higher patient satisfaction scores. CONCLUSIONS: There is limited evidence to suggest that QL block is superior to TAP block for postoperative pain management in nonemergent cesarean delivery. The study limitations must be considered when extrapolating the review's findings to clinical practice.

The use of the FLACC pain scale in pediatric patients undergoing adenotonsillectomy.

OBJECTIVES: 1) Determine the usage rate of opioid pain medication after adenotonsillectomy (T&A). 2) Review the use of the Face, Legs, Activity, Cry, Consolability (FLACC) pain scale for T&A patients 3) Determine the rate of postoperative physician contacts for pain related complaints. METHODS: A retrospective case series review was performed on 125 pediatric patients undergoing T&A and subsequent 23-hour postoperative observation at an academic tertiary care center from June-August of 2015. Postoperative pain scores using the FLACC pain scale, the utilization of opioid pain medications, and the number of postoperative contacts for pain were recorded. RESULTS: Average age of patients was 5.7 years and 50% were female. 90% of T&A's were performed for adenotonsillar hypertrophy. The post-tonsillectomy hemorrhage rate was 4%. 70 (56%) patients required postoperative opioid pain medication, with (30) 43% of these patients requiring more than one dose. The mean number of opioid doses was 1.64 ± 0.9 and was not related to age, weight or gender. FLACC scores were highly associated (spearman correlation 0.77) with the amount of opioid medication given. Mean FLACC scores decreased over time after T&A. 20% of patients contacted a physician for unsatisfactory pain control postoperatively with 6% requiring emergency department visits and 14% contacting the office via phone call. CONCLUSIONS: A significant portion of pediatric patients undergoing T&A require postoperative opioids for pain control. The FLACC scale is a valuable way of quantifying post-operative T&A pain in pediatric patients. Despite routine pain management postoperatively, a significant proportion of patients require contact with a physician postoperatively for pain management.

Use of dexmedetomidine for monitored anesthesia care for diskography in adolescents.

Procedural sedation in children and adolescents is becoming increasingly employed to facilitate successful diagnostic imaging studies. Keeping the patient adequately sedated yet easily arousable can be of utmost importance during image-guided diskography. Dexmedetomidine provides an adequate level of sedation for diagnostic imaging studies. This sedation is unique in that the patients are sedated and sleepy but are easily aroused when stimulated and are able to follow commands appropriately. In addition, it preserves respiratory function even when administered in higher-than-recommended doses for sedation. This case series describes our clinical experience in using dexmedetomidine as the sole sedative agent to facilitate diskography in 4 adolescent patients, ranging in age from 15 to 18 years, who presented with chief complaints of back pain and degenerative diskitis. The clinical endpoints of sedation and analgesia were cooperative and still patients during needle placement in the intervertebral disks.

A randomized trial comparing sevoflurane and propofol in children undergoing MRI scans.

OBJECTIVES: We compared three primary outcomes of pausing the magnetic resonance imaging (MRI) scan, emergence quality and respiratory complications. AIM: To measure and compare the quality between sevoflurane and propofol in children undergoing MRI scans. BACKGROUND: No randomized controlled trial exists comparing the quality between sevoflurane and propofol for MRI. METHODS/MATERIALS: Two hundred unpremedicated children (18 months to 7 years) scheduled for brain MRI scans were recruited. After induction with sevoflurane, children were randomized to receive sevoflurane [general anesthesia with sevoflurane (GAS)] via laryngeal mask airway (LMA) or propofol [general anesthesia with propofol (GAP)] bolus and infusion for their scan. The three primary outcomes of pausing the MRI scan (P), agitation (A), and respiratory complications (R) were compared. Timeliness of care was also measured. RESULTS: No MRI scan pauses were found in 92% and 80% in the GAS and GAP groups. The median and interquartile A scores were 3 (0, 7) in GAS and 0 (0, 4) in GAP groups respectively. There was no difference in respiratory complications between GAS and GAP (P = 0.62). The median and interquartile postanesthesia care unit (PACU) times were 25 (18, 34) for GAS and 31 (25, 44) for GAP (P = 0.0001). The median and interquartile total times were 78 (69, 90) for GAS and 88 (78, 100) for GAP (P = 0.0002). CONCLUSION: Our study compared the three primary outcomes of pausing, agitation, and respiratory complications between the two groups, and we found no difference in respiratory complications. However, the GAP group had more pausing and less agitation than the GAS group.