Psychosocial and psychophysical assessment in paediatric patients and young adults with chronic back pain: A cluster analysis.

BACKGROUND: Identifying subgroups with different clinical profiles may inform tailored management and improve outcomes. The objective of this study was to identify psychosocial and psychophysical profiles of children and adolescents with chronic back pain. METHODS: One hundred and ninety-eight patients with chronic back pain were recruited for the study. Pain assessment was mainly conducted in the form of an interview and with the use of validated pain-related questionnaires assessing their psychosocial factors and disability. All patients underwent mechanical and thermal quantitative sensory tests assessing detection and pain thresholds, and conditioned pain modulation efficacy. RESULTS: Hierarchal clustering partitioned our patients into three clusters accounting for 34.73% of the total variation of the data. The adaptive cluster represented 45.5% of the patients and was characterized to display high thermal and pressure pain thresholds. The high somatic symptoms cluster, representing 19.2% of patients, was characterized to use more sensory, affective, evaluative and temporal descriptors of pain, more likely to report their pain as neuropathic of nature, report a more functional disability, report symptoms of anxiety and depression and report poor sleep quality. The pain-sensitive cluster, representing 35.4% of the cohort, displayed deep tissue sensitivity and thermal hyperalgesia. CONCLUSIONS: This study identified clinical profiles of children and adolescents experiencing chronic back pain based on specific psychophysical and psychosocial characteristics highlighting that chronic pain treatment should address underlying nociceptive and non-nociceptive mechanisms. SIGNIFICANCE: To our current knowledge, this study is the first to conduct cluster analysis with youth experiencing chronic back pain and displays clinical profiles based on specific physical and psychosocial characteristics. This study highlights that in a clinical context, chronic pain assessment should include multiple elements contributing to pain which can be assessed in a clinical context and addressed when pathoanatomical symptoms are unidentifiable.

Emergence delirium or pain after anaesthesia--how to distinguish between the two in young children: a retrospective analysis of observational studies.

BACKGROUND: Early postoperative negative behaviour in preschool children after general anaesthesia is a common problem. The distinction between emergence delirium (ED) and pain is difficult, but management differs between the two. The aim of the current analysis was to identify individual observational variables that can be used to diagnose ED and allow distinction from postoperative pain. METHODS: This retrospective analysis of data from three previous prospective observational studies included children undergoing general anaesthesia for elective adeno-tonsillectomy, sub-umbilical surgery, and MRI scanning. Two trained observers simultaneously applied the Face, Legs, Activity, Cry, Consolability Scale; the Children's Hospital Eastern Ontario Pain Scale; the Children's and Infants' Postoperative Pain Scale or the Paediatric Anaesthesia Emergence Delirium (PAED) scale. Data from each domain of the scales were available at awakening and at five, 10, and 15 min after anaesthesia. Each patient was analysed over time, and subsequently, each evaluation was considered as a single event. The descriptive behaviour items overlapping in the assessed scales were identified as dichotomous variable ('true/false') and then were applied for each evaluation. RESULTS: Children (n=512) were assessed for a total of 2048 evaluations. Most children (69%) displayed at least one episode of ED and/or pain. Almost 15% of children demonstrated both ED and pain. Children with ED showed 'no eye contact' and 'no awareness of surroundings'. Children with pain displayed 'abnormal facial expression', 'crying', and 'inconsolability'. CONCLUSIONS: 'No eye contact' and 'no awareness of surroundings' identifies ED. 'Abnormal facial expression', 'crying', and 'inconsolability' indicate acute pain in children in the early postoperative period.

Preoperative evaluation in infants and children: recommendations of the Italian Society of Pediatric and Neonatal Anesthesia and Intensive Care (SARNePI).

BACKGROUND: The preoperative assessment involves the process of evaluating the patient's clinical condition, which is intended to define the physical status classification, eligibility for anesthesia and the risks associated with it, thus providing elements to select the most appropriate and individualized anesthetic plan. The aim of this recommendation was provide a framework reference for the preoperative evaluation assessment of pediatric patients undergoing elective surgery or diagnostic/therapeutic procedures. METHODS: We obtained evidence concerning pediatric preoperative evaluation from a systematic search of the electronic databases MEDLINE and Embase between January 1998 and February 2012. We used the format developed by the Italian Center for Evaluation of the Effectiveness of Health Care's scoring system for assessing the level of evidence and strength of recommendations. RESULTS: We produce a set of consensus guidelines on the preoperative assessment and on the request for preoperative tests. A review of the existing literature supporting these recommendations is provided. In reaching consensus, emphasis was placed on the level of evidence, clinical relevance and the risk/benefit ratio. CONCLUSION: Preoperative evaluation is mandatory before any diagnostic or therapeutic procedure that requires the use of anesthesia or sedation. The systematic prescription of complementary tests in children should be abandoned, and replaced by a selective and rational prescription, based on the patient history and clinical examination performed during the preoperative evaluation.

Intraperitoneal nebulization of ropivacaine for pain control after laparoscopic cholecystectomy: a double-blind, randomized, placebo-controlled trial.

BACKGROUND: Intraperitoneal local anaesthetic nebulization is a relatively novel approach to pain management after laparoscopic surgery. This randomized, double-blind, placebo-controlled trial evaluated the effects of intraperitoneal ropivacaine nebulization on pain control after laparoscopic cholecystectomy. METHODS: Patients undergoing laparoscopic cholecystectomy were randomized to receive intraperitoneal nebulization of ropivacaine 1% (3 ml) before surgical dissection and normal saline 3 ml at the end of surgery (preoperative nebulization group); intraperitoneal nebulization of normal saline 3 ml before surgical dissection and ropivacaine 1% (3 ml) at the end of surgery (postoperative nebulization group); or intraperitoneal nebulization of normal saline 3 ml before surgical dissection and at the end of surgery (placebo group). Intraperitoneal nebulization of ropivacaine or saline was performed using the Aeroneb Pro(®) device. Anaesthetic and surgical techniques were standardized. The degree of pain on deep breath or movement, incidence of shoulder pain, morphine consumption, and postoperative nausea and vomiting were collected in the post-anaesthesia care unit and at 6, 24, and 48 h after surgery. RESULTS: Compared with placebo, ropivacaine nebulization significantly reduced postoperative pain (-33%; Cohen's d 0.64), referred shoulder pain (absolute reduction -98%), morphine requirements (-41% to -56% Cohen's d 1.16), and time to unassisted walking (up to -44% Cohen's d 0.9) (P<0.01). There were no differences in pain scores between ropivacaine nebulization groups. CONCLUSIONS: Ropivacaine nebulization before or after surgery reduced postoperative pain and referred shoulder pain after laparoscopic cholecystectomy. Furthermore, ropivacaine nebulization reduced morphine requirements and allowed earlier mobility.

Multidetector computed tomography (MDCT) for preoperative airway assessment in children with mucopolysaccharidoses.

BACKGROUND: Accumulation of glycosaminoglycans is known to cause significant problems in the anesthetic management of children with mucopolysaccharidoses (MPS). Clinical and standard radiological evaluation may convey insufficient information about the upper airway and trachea in children with MPS. Multidetector computed tomography (MDCT) images have been used to define the central airway and previous studies have recommended this tool to assess the airway of children who are considered at risk of difficult intubation. However, MDCT has not been recommended in MPS children. The aim of this clinical scenario study was to verify whether information from MDCT reconstruction of the airway is useful in airway management planning of children with MPS. METHODS: In a two phase questionnaire-based study, 26 pediatric anesthesiologists were asked to produce airway management plans for 5 children with MPS. An initial plan for airway control was reported after assessment of standard preoperative anesthetic charts. A subsequent airway strategy was then described after reviewing tracheal MDCT images of each patient. RESULTS: MDCT images provided additional clinically-relevant information in 87% (95% CI: 79-92%) of the evaluations. Reduction of tracheal size was the most common finding provided by the MDCT images. After reviewing the MDCT images, anesthesiologists changed their primary airway device selection in 21% of the evaluations (P=0.01). CONCLUSION: Airway reconstruction using MDCT images from a previous CT scan may provide a useful assessment tool for preoperative airway evaluation and planning in MPS children.

WITHDRAWN Simulation training in pediatric anesthesia.

Ahead of Print article withdrawn by publisher Although anesthesia has become increasingly safe, there remain significant differences among countries in terms of training standards and practice regulations. There is evidence and widespread consensus that the occasional practice of pediatric anesthesia should be avoided, and there is a trend towards the centralization of pediatric surgical activity. Limited access to adequate learning opportunities and reduced practice in non-pediatric centers can be addressed with the integrated use of traditional and modern training tools, and the availability of different pediatric simulator mannequins is rapidly filling the previously existing gap in simulation training. Medical simulation can be particularly useful in allowing the teaching and integration of technical and non-technical skills, and simulation courses for training and continuing medical education in pediatric anesthesia have been designed. In recent years, focus has been directed at validating the efficacy of simulation training and at its cost-effectiveness for improving learning and patient outcomes. Future challenges will include the best way to integrate simulation into the existing pediatric anesthesia training curricula, the determination of better evidence of its impact on clinical performance and the design and validation of assessment tools for technical and non-technical skills.

Relative potencies of bupivacaine, levobupivacaine, and ropivacaine for neonatal spinal anaesthesia.

BACKGROUND: Comparing the relative potency of new local anaesthetics such as levobupivacaine and ropivacaine with bupivacaine by the minimum local analgesic concentration model has not been described for neonatal spinal anaesthesia. This information is important to compare agents and to determine the most effective spinal dose. METHODS: We performed a two-stage study to determine the ED50, the ED95, and the relative analgesic potency of isobaric spinal bupivacaine, levobupivacaine, and ropivacaine in infants. In phase 1, 81 infants were randomized in a Dixon-Massey study to describe the minimum local analgesic dose. In phase 2, a further 70 patients were randomly allocated to receive spinal anaesthesia with doses in the upper dose-response range to define the ED95. RESULTS: The ED50 doses for bupivacaine, levobupivacaine, and ropivacaine were estimated by isotonic regression to be 0.30 mg kg(-1) [95% confidence interval (CI) 0.25-0.43], 0.55 mg kg(-1) (0.50-0.64), and 0.50 mg kg(-1) (0.43-0.64), respectively. The ED(95), respectively, of bupivacaine, levobupivacaine, and ropivacaine were 0.96 mg kg(-1) (95% CI 0.83-0.98), 1.18 mg kg(-1) (1.05-1.22), and 0.99 mg kg(-1) (0.73-1.50). The relative potency ratios at the ED(50) were bupivacaine:levobupivacaine 0.55 (95% CI 0.39-0.88), bupivacaine:ropivacaine 0.61 (0.41-1.00), and levobupivacaine:ropivacaine 1.09 (0.84-1.45). CONCLUSIONS: Appropriate doses for infant spinal anaesthesia are 1 mg kg(-1) of isobaric 0.5% bupivacaine and ropivacaine and 1.2 mg kg(-1) of isobaric 0.5% levobupivacaine.

New trends in pediatric anesthesia.

The authors illustrate some relevant emerging topics in pediatric anesthesia. Endotracheal cuffed tubes have entered into routine clinical practice in younger patients. Concerns about tracheal stenosis were overcome when manufactures began to produce a new class of high volume, low pressure endotracheal tubes. Ultrasound-guided central venous cannulation helped anesthesiologists and intensivists to more efficaciously and safely perform the invasive monitoring required by ever more invasive surgical procedures. The utility of ultrasonography in peripheral nervous blocking has also been demonstrated. Better knowledge of the pathophysiology of both hypovolemic shock and coagulation dysfunction helped made it possible to face and successfully perform even major surgical procedures and treat more dramatic trauma. The introduction of devices to monitor anesthesia depth helped clinicians to better understand the pharmacodynamic effects of anesthetics, resulting in the maintenance of a more stable level of narcosis and the reduction of the incidence of awareness.

Analgesic effectiveness of caudal levobupivacaine and ketamine.

BACKGROUND: Ketamine is used increasingly in paediatric anaesthetic practice to prolong the action of a caudal block. This study was designed to determine if adding S(+)-ketamine 0.5 mg kg(-1) allows a lower concentration of levobupivacaine to be used for caudal anaesthesia without loss of clinical effectiveness. METHODS: One hundred and sixty-four children (ASA I or II) aged 3 months-6 yr were randomly allocated to receive 1 ml kg(-1) of levobupivacaine 0.15% with 0.5 mg kg(-1) S(+)-ketamine (Group 1), levobupivacaine 0.175% with 0.5 mg kg(-1) S(+)-ketamine (Group 2), or levobupivacaine 0.2% (Group 3) by the caudal route. Pain, motor block, sedation, and requirement for postoperative analgesia were assessed up to 6 h after operation. RESULTS: There was no significant difference between the groups in effectiveness at first surgical incision. Significantly lower analgesic requirements were reported in Group 2 compared with Group 3 at wakeup, 180 and 360 min after operation. Time to first rescue analgesia was longer in Group 2 compared with Group 1 or 3. Kaplan-Meier survival analysis of analgesia free time demonstrated a significant advantage of Group 2 over Groups 1 and 3 (log rank P=0.05). The incidence of postoperative motor block was not significantly different between the groups. No excess sedation or dysphoric reactions were observed in the ketamine groups. CONCLUSIONS: The addition of 0.5 mg kg(-1) S(+)-ketamine to levobupivacaine 0.175% for caudal analgesia for lower abdominal and urological surgery is significantly more effective in providing postoperative analgesia than levobupivacaine 0.15% with 0.5 mg kg(-1) S(+)-ketamine or levobupivacaine 0.2%.

Randomized controlled trial of duration of analgesia following intravenous or rectal acetaminophen after adenotonsillectomy in children.

BACKGROUND: Doses of acetaminophen 40 mg kg(-1) rectally and 15 mg kg(-1) i.v. produce similar effect-site concentrations. However, the clinical effectiveness of these routes has not been compared. The aim of this study was to compare duration and efficacy of analgesia in children following adenotonsillectomy after acetaminophen either 40 mg kg(-1) rectally or 15 mg kg(-1) i.v. METHODS: Fifty children aged between 2 and 5 yr were recruited. They received a standardized anaesthetic, including 2 microg kg(-1) of fentanyl. Children were randomized to receive either rectal or i.v. acetaminophen. Postoperative pain was assessed regularly with the Children and Infants Postoperative Pain Scale score and rescue analgesia provided if scores were 4 or greater. The primary outcome measure was time to first analgesia. Results were plotted with a Kaplan-Meier analysis and median time to rescue analgesia compared between the groups. RESULTS: The protocol was successfully completed in 46 children. Forty-five children required rescue medication. The time to first rescue analgesia was longer in children receiving rectal acetaminophen (median 10 h, inter-quartile range 9-11 h) compared with those receiving i.v. acetaminophen (7, 6-10 h) with a P-value of 0.01 by log-rank test for equality in survivor function. Few children in either group required rescue analgesia within the first 6 h with differences between the groups being most prominent in the period from 6 to 10 h. CONCLUSIONS: Rectal acetaminophen 40 mg kg(-1) provides longer analgesia for moderately painful procedures when compared with 15 mg kg(-1) acetaminophen i.v.

Epidural analgesia in children: planning, organization and development of a new program.

BACKGROUND: The goal of the present work is to describe the development and results of the pediatric epidural analgesia program at the ''Hospital Nacional de Pediatria Prof. Dr. J. P. Garrahan'' in Argentina. METHODS: Patients with thoracotomy, abdominal surgery, osteotomy, amputations or severe trauma were included in the program. The program provided training to the entire staff, control and record of pain treatment and its consequences, 24 h a day availability of anesthesia staff and standard polices and procedures. RESULTS: One hundred fifty children under 16 years of age (median age 11 years, median weight 35 kg) were included in the program during the first 18 months. The median of maximum pain reported during activity was 1 (interquartile range 1 to 4 points) using the Visual Analogue Scale (VAS) or Objective Pain Scale (OPS). Eighty seven children (CI 95% 50% to 67%) presented with postoperative nausea and vomiting, urinary retention, itching, motor blockade or sedation. No patient presented with respiratory depression, hypotension, local anaesthetic toxicity, epidural catheter related infection or death during the program evaluation. The postoperative care program enabled a 98-day reduction in treatment in the intensive care unit. CONCLUSION: The safe use of pediatric epidural analgesia in general wards may require the careful selection of patients, systematic assessment by trained personnel, training of medical and nursing personnel, clear distribution of responsibilities, use of printed indications, systematic record of pain, sedation and complications, information and education of patients and parents, supply of systems for airway resuscitation and management and continuous quality control and revision of the methods.

Bupivacaine caudal epidural anesthesia: assessing the effect of general anesthetic technique on block onset.

BACKGROUND: The primary objective of this prospective, randomized trial was to compare the effect of propofol and sevoflurane on effectiveness of regional anesthesia. As a secondary objective, we aimed at evaluating the influence of age on neuraxial block profile. METHODS: One hundred and thirteen healthy children aged <10 years, scheduled for general or urological surgical procedures were randomly allocated to receive either propofol or sevoflurane induction and maintenance. Children received caudal or lumbar epidural block depending on their weight and expected surgery. Time to onset of surgical anesthesia, intraoperative analgesic effectiveness, residual motor blockade, postoperative pain, and adverse effects were evaluated. To assess the influence of age on these measures children were further divided into three age groups: 0-24, 25-60 and >60 months. RESULTS: The mean time to onset of surgical anesthesia was significantly shorter in the sevoflurane group than the propofol group (3.1 vs 4.7 min, P < 0.01), independent of the type of regional technique employed. Distress on arousal in recovery was increased in children receiving sevoflurane (P = 0.03). There was no significant difference in residual motor blockade between the groups but children between 0 and 24 months receiving sevoflurane had a higher incidence of residual motor blockade 3 h after local anesthetic injection (P = 0.01). CONCLUSIONS: This study has demonstrated that general anesthesia with sevoflurane decreases the time to onset of surgical anesthesia relative to propofol anesthesia. This effect was most marked when sevoflurane anesthesia preceded caudal epidural blockade. The basis for this effect is most likely to be related to differential binding of the two anesthetic agents to receptors in the spinal cord that mediate immobility in response to surgical stimuli.

Interactions between general and regional anesthesia.

Neuraxial blockade is commonly used to abolish sensations elicited by noxious stimuli during surgical procedures. Proven advantages of combined anesthesia include early recovery from general anesthesia and postoperative analgesia, together with likely decreases in blood loss, cardiac dysrhythmias, or ischemic events and postoperative deep vein thrombosis. The side effects of the technique are related to the dose or site of local anesthetic administration and to light general anesthesia, which can result in awareness during surgery. Varying degrees of synergistic interactions have been reported among the drugs used to achieve the anesthetic state. Spinal anaesthesia appears to have sedative effects, and local anesthetics used for neuraxial blockade have been found to reduce the induction and maintenance dosage of midazolam, thiopental, propofol and inhaled anesthetics. The growing interest in combining local and general anesthesia has led to studies investigating possible interactions between general anesthesia and local anesthetics administered via spinal or epidural routes. Neuraxial blockade reduces sedative and anesthetic requirements by decreasing ascending sensory input into the brain. This has important clinical implications, as anesthetists should expect to reduce anesthetic and sedative drug doses during neuraxial blockade, unless the blockade involves lower dermatomes alone. Clinical practice of anesthesia is a polypharmacy, wherein the anesthetic state is the net result of the action of different drugs and their interaction in the presence of a surgical stimulus.

Postoperative sedation and analgesia after pediatric liver transplantation.

The goal of sedation in the pediatric intensive care unit (PICU) is to produce a calm and comfortable child, free from pain and discomfort. Children receiving liver transplantation need analgesics to control pain from surgical incisions, drains, vascular access, or endotracheal suctioning. Sedatives are used to facilitate the delivery of nursing care, to prevent self-extubation, and to facilitate mechanical ventilation. Optimal sedation produces a state in which the patient is somnolent, responsive to the environment but untroubled by it, and with no excessive movements. A common problem in the PICU is the fluctuation in the delivery of sedatives and analgesics depending on the health care providers and on a breakdown in communication between physicians and nurses to define end points for pharmacological therapy. This variability more often leads to oversedation rather than undersedation. Oversedation delays extubation, promotes ventilator-associated pneumonia, and increases the risk of reintubation. The use of written sedation policies to guide practice at the bedside reduces the length of time for which patients require mechanical ventilation and the length of PICU stay. Protocols for drug administration practices increase patient safety during mechanical ventilation, promote nursing autonomy, and facilitate communication between nurses and physicians as well as between nurses.

Central blocks with levobupivacaina in children.

Regional anesthesia has become a routine practice in paediatric anesthesia and local anaesthetics are now widely used in infants and children. Although local anaesthetics are generally quite safe and effective, they may produce systemic toxic reactions affecting the heart and brain. Because postoperative analgesia is often the primary justification for regional anesthesia in infants and children, bupivacaine, a long-acting local anaesthetic, is the most commonly used local anaesthetic for paediatric regional anesthesia. Levobupiva-caine has been used in children by caudal injection, by lumbar epidural route for anesthesia during operation, by continuous epidural infusion for pain control after operation and for spinal anesthesia. Levobupivacaine had shown comparable clinical profiles to that of bupivacaine but produced lower incidence of residual motor blockade. Efforts to minimize the risk of complications during caudal anesthesia must be directed towards measures that reduce accidental intravenous and intraosseous injections, reduce the total amount of local anaesthetic used and use drugs with lower toxic potential. In patients under general anesthesia, when using a large amount of local anaesthetic, in case of accidental intravenous infusion, patients receiving levobupivacaine may tolerate larger doses before manifestation of toxicity compared with those receiving bupivacaine. There are clinical situations including prolonged local anaesthetic infusions, use in neonates or small babies, and caudal block, where replacement of bupivacaine with levobupivacaine appears to be safer.

Randomized, double-blind, phase III, controlled trial comparing levobupivacaine 0.25%, ropivacaine 0.25% and bupivacaine 0.25% by the caudal route in children.

BACKGROUND: The rationale for replacing racemic bupivacaine with the s-enantiomers levobupivacaine and ropivacaine is to provide a wider margin of safety with the same analgesic efficacy and less postoperative motor block. In a randomized, double-blind, phase III, controlled trial we compared the caudal administration of levobupivacaine 0.25% and ropivacaine 0.25% with bupivacaine 0.25% in children. METHODS: Ninety-nine ASA I-II children less than 10 yr old scheduled for elective sub-umbilical surgery were randomized to receive caudal block with bupivacaine 0.25%, ropivacaine 0.25% or levobupivacaine 0.25%. The primary outcome of the study was the clinical efficacy of the caudal block during the operation. Secondary outcome measures were analgesic onset time, pain relief after the operation and residual motor blockade. RESULTS: The proportion of children with effective analgesia during the operation was similar among groups. There were no significant differences in the analgesic onset time of the caudal block. Bupivacaine produced a significant incidence of residual motor block compared with levobupivacaine or ropivacaine at wake-up (P<0.01). There were no significant differences in the number of patients receiving rescue analgesia after surgery. However, analgesic block lasted significantly longer in patients receiving bupivacaine (P=0.03). CONCLUSION: During sub-umbilical surgery, caudal levobupivacaine, ropivacaine and bupivacaine provided comparable analgesic efficacy. Bupivacaine produced a higher incidence of residual motor blockade and a longer analgesic block than ropivacaine and levobupivacaine.

Neuropathic pain in children.

The International Association for the Study of Pain (IASP) defines neuropathic pain as being caused by a lesion or dysfunction of the nervous system. Characteristics that would define neuropathic pain and differentiate it from other types of pain include: pain and sensory symptoms that persist beyond the healing period; presence, in variable degree, of neurological sensory signs manifesting as negative and positive sensory phenomena; presence, in variable degree, of other neurological signs, including motor, manifesting as negative and positive motor phenomena or autonomic signs. Many of the conditions causing neuropathic pain in adults are rare in children, but some forms of neuropathic pain do affect children and adolescents as complex regional pain syndrome or phantom limb pain. Treatment strategies that have demonstrated to be efficacious in adults have been extrapolated to be used in children, including medications, nerve blocks, physical therapy, and behavioral medicine. A multidisciplinary program that combines all of these approaches provides the best chance of relief.