Literature Reviews
By Sabine Kost-Byerly, MD
Former Director, Pediatric Pain Management,
Former Director, Multi-disciplinary Pediatric Pain Clinic, Kennedy Krieger Institute
Associate Professor of Anesthesiology and Critical Care Medicine, Emeritus
Johns Hopkins University School of Medicine
Baltimore, Maryland
Ultrasound-Guided Quadratus Lumborum Block Compared to Caudal Ropivacaine/Morphine in Children Undergoing Surgery for Vesicoureteric Reflux
Sato M. Paediatr Anaeth 2019 Apr 29. doi: 10.1111/pan.13650
Ultrasound-guided (USG) quadratus lumborum (QL) block can provide analgesia for abdominal surgery. This study compared the efficacy and duration of a QL block to a caudal block for ureteral reimplantation in children; a surgery associated with somatic and visceral pain as well as bladder spasms.
Methods
An RCT included 47 (including three eventually ineligible) patients (age 1-17 yrs) undergoing ureteral reimplantation surgery via low transverse incision. Blocks were performed under general anesthesia prior to incision. Ropivacaine 0.2% (1 mL/kg) with morphine (0.03 mg/kg) was injected caudally and confirmed by ultrasound. The bilateral USG QL block via an in-plane, transverse, posterior approach was performed with ropivacaine 0.2% (total volume 1 mL/kg). Patients received IV acetaminophen and had access to rescue opioid analgesia via PCA. Outcomes evaluated were need for opioid analgesics, pain scores, emesis and other complications up to 48 hours postoperatively.
Results
Patients in the QL block group required higher doses of remifentanil to maintain cardiovascular homeostasis during surgery but needed significantly fewer doses of rescue analgesia within the first 24 hours postoperatively. No significant differences were observed at 30 min, 4 hours or 48 hours for analgesic rescue. Pain scores were the same in both groups as was the incidence of nausea and emesis. There were no other postoperative complications in either group.
Conclusion
The QL block was superior to a caudal block within the first 24 hours after a ureteral reimplantation in children via a low transverse incision. The need for rescue opioid analgesia was diminished. Pain scores in the PACU, at four and 48 hours were similar between the two groups.
Analgesic Efficacy and Impact of Caudal Block on Surgical Complications of Hypospadias Repair: A Systematic Review and Analysis
Zhu C, Wei R, Tong Y, et al. Reg Anesth Pain Med 2019;44(2)
Caudal epidural analgesia has been utilized for pediatric hypospadias repairs for decades. In recent years surgical complications such as urethrocutaneous fistulae have been associated with this technique although surgical technique and/or the severity of the defect itself have also been blamed. This study assessed analgesic efficacy and relative complication risk for caudal block in hypospadias repair.
Methods
The authors performed a meta-analysis after identifying studies (up to December 2017) comparing caudal block versus peripheral nerve block or no block and reviewing the reported analgesic efficacies and complications. Data from four RCTs (N=298) and seven observational (one cohort, six case-control) studies (N=1726) was analyzed separately.
Results
In RCTs children with caudal blocks had similar needs for additional analgesia within 24 hours after surgery as patients with peripheral nerve blocks, nevertheless there is lower level evidence that caudal block was associated with a shorter duration of analgesia and an increased need for morphine but also lower pain scores at 24 hours post-op. Only one RCT noted an increased risk of urethrocutaneous fistula after caudal block but the trial suffered from heterogeneity of surgical techniques. No differences concerning other adverse effects such as PONV and motor weakness were noted. The authors stressed that significant heterogeneity in the data and potential bias selection in the observational studies were a limitation of this meta-analysis.
Conclusion
Analgesic quality seems to be similar between peripheral nerve blocks and caudal blocks for hypospadias repair. Evidence for an association of caudal block with surgical complications is limited to one study and has not been seen in other ones.
Effect of Intranasal Ketamine vs Fentanyl on Pain Reduction for Extremity Injuries in Children: the PRIME Randomized Clinical Trial
Frey TM, Florin TA, Caruso M. JAMA Pediatr. 2019;173(2):140-146
Children continue to experience inadequate pain control in EDs, partially due to prolonged delays in treatment. Opioids are commonly administered in EDs but can be associated with adverse events. Ketamine has been shown to be an effective anesthetic for painful procedures. This Pain Reduction with Intranasal Medications for Extremity Injuries (PRIME) study aims to examine the noninferiority of ketamine to fentanyl in the ED.
Methods
The authors performed a prospective, double-blind, randomized, noninferiority clinical trial comparing intranasal ketamine (1.5 mg/kg) to intranasal fentanyl (2 mcg/kg) in children aged 8-17 yrs with moderate to severe pain (VAS score>35 mm) due to an extremity injury (N=86). Primary outcome was difference in pain reduction 30 min post administration. Secondary outcomes were sedation level, capnography values, change in VS, need for rescue analgesia, or other adverse events.
Results
Both ketamine and fentanyl resulted in significant pain reduction at 15, 30, and 60 min after administration. Pain relief was similar, ketamine was found to be not inferior to fentanyl. Sedation scores were similar in both groups (Michigan sedation score <3) and vital signs were stable. Within the first 15 min after administration of the drugs the ketamine group had a higher incidence of brief self-limited decreases in capnometry values without hypoxia than the fentanyl group (20.9% vs 4.8%) and also experienced more minor adverse events (77% vs 31%). The need for rescue analgesia was similar (25% vs 21.4%).
Conclusion
Both intranasal fentanyl and intranasal ketamine were able to provide comparable reduction in pain associated with extremity injuries in children.
Prevalence and Characteristics of Pediatric Opioid Exposures and Poisonings in the United States
Patel AM, Wheeler DC, Rose SR, et al. J Pediatr 2019;206(3):148-155.e4
The wide availability of opioid analgesics has been associated with increased nonmedical opioid use, overdoses and poisonings. This study examined the prevalence of opioid exposure and poisonings in children and tried to analyze factors associated with serious pediatric opioid exposure.
Methods
The authors retrospectively performed a cross-sectional study of log information collected in the American Association of Poison Control Centers (AAPCC) National Poison Data System (NPDS) for 5 years from 2010 to 2014. Data from closed cases with at least one opioid exposure in children<18yrs was included (N=83,418). Serious outcomes analysis was limited to single-drug exposures.
Results
The prevalence of opioid exposure was 22.6/ 100,000 children over the five-year period, declining from 25.5 in 2010 to 20/100,000 children in 2014. Slightly more than half of the exposures (52.2%) resulted in poisonings. The number of poisonings has declined less than the one of exposures. More than 60% of the exposures were in children <6 years of age, almost three fourths were unintentional, and 90% occurred at home. Almost 5000 children <6 years of age required ED or inpatient care per year. Serious outcomes were associated with older age, single substance opioid (especially buprenorphine and methadone), and nonaccidental intent.
Conclusion
Pediatric opioid exposure and poisonings declined from 2010 to 2014 but morbidity remained high. State-level variance (up to three-fold) of higher prevalence corresponded to higher numbers of opioid prescriptions per 100 persons.
Long-Term Outcomes of Adolescents with Juvenile-Onset Fibromyalgia into Adulthood and Impact of Depressive Symptoms on Functioning Over Time
Kashikar-Zuck S, Cunningham N, Peugh J, et al. Pain 2019;160(2):433-441
Juvenile-onset fibromyalgia (JFM) is a chronic pain condition with widespread pain and functional impairment. Information on long-term outcomes into adulthood is limited. This study aimed to assess physical and psychosocial outcomes, trajectories of pain and depressive symptoms, and their longitudinal impact on physical functioning into adulthood.
Methods
The study presents a follow-up (time 4) of a previously recruited (2001-2006, time 1) and described (time 1, 2, and 3) cohort of 116 adolescent (age at recruitment 12-18 years) with JFM. At time 4 (2012-2015) 86/116 (74.1%) participants (mean age 24.2 [minimum 21] years) remained. The current study consisted of a web-based self-report questionnaire and a home visit by a trained assessor.
Results
At time 4 the majority of the participants were female (94.2%) and white (87.2%). Two thirds were single, 25.6% were married, and 26.7% had children. All reported FM symptoms with 58% meeting full ACR 2010 criteria for adult FM. The cohort reported impaired physical functioning (SF-36) and lower perceived health status. The participants described moderate to severe anxiety (60%), moderate to severe depression (26%), pain medication (40%), and antidepressant medication (30%) use. Opioid use was less than 5%. Pain intensity trajectories over all time points consisted of a large “steady improvement” group (91%) and a small group with rebounding pain at time 4. Depressive symptoms were low and stable or improving in most participants except for a smaller group with worsening symptoms at time 3 and 4 (14%). The later group had markedly lower functioning across physical and psychosocial domains.
Discussion
A substantial number of patients with JFM may continue to have FM symptoms in young adulthood. While the pain levels for most of them will reduce over time a subgroup may experience worsening depressive symptoms and physical impairment.
Provision of Palliative and Hospice Care to Children in the Community: A Population Study of Hospice Nurses
Kaye EC, Gattas M, Kiefer A, et al. J Pain Symptom Manage 2019;57(2):241-250
Although many children experience life-limiting illnesses and may be hospice-eligible every year, few hospice agencies provide formal pediatric programs. This study evaluated the level of training, experience and comfort of hospice nurses providing care for children in community-based programs.
Methods
The authors recruited on-site study facilitators from hospice leadership in programs providing hospice or palliative care for pediatric patients as needed in the tristate area of Tennessee, Mississippi, and Arkansas. Programs were identified via the National Hospice Locator. Nurses at the participating programs were invited to complete a survey developed based on a literature review and expert guidance.
Results
Enrollment was successful for 71 of the 91 eligible programs, reaching from 69.2% in Mississippi to 91.7% in Tennessee. Surveys were completed by 551/1366 (40.3%) eligible nurses. The majority of nurses had never received formal training in pediatric palliative or hospice care (89.8%) and took care of children only sporadically (85.7%). Most (70-80%) reported limited or no experience with pain and non-pain symptom assessment and management or medication management. Participants expressed limited or no experience with communication with children or parents concerning psychosocial needs, hopes or goals of care. Almost half of the nurses reported some or significant discomfort providing care for children during the active dying process and an inability to access debriefing services for themselves. About a third felt discomfort providing bereavement support for family members.
Discussion
Training, experience and comfort of hospice nurses with pediatric care is limited in the examined area. Despite a known need for pediatric hospice care resources in the community may be limited. Policies, standardized programmatic resources and processes as well as educational interventions are needed.
Other Publications of Note:
A Study of the Dosage and Duration of Levobupivacaine Infusion by the Caudal-Epidural Route in Infants Aged Three to Six Months.
Vashisht R, Bendon AA, Okonkwo I et al. Pediatr Anesth 2019:44(2):161-168
Pharmacokinetic study and modeling.
Pain Relief in the Palm of Your Hand: Harnessing Mobile Health to Manage Pediatric Pain
Hunter JF, Kain ZN, Fortier MA Pediatr Anaesth 2019;29(2):120-124
Special Interest Article.
PRISM: A Brief Screening Tool to Identify Risk in Parents of Youth with Chronic Pain
Simmons LE, Lewandowski Holley A, Phelps E, et al. Pain 2019;160(2):367-374
This study presents a self-report screening tool for parent psychosocial function and behavioral responses to child pain.
Increased Pain Sensitivity but Normal Pain Modulation in Adolescents with Migraine
Nahman-Averbuch H, Leon E, Hunter BM, et al. Pain 2019;160(5):1019-1028
This study comparing adolescents with migraines to two groups of healthy participants also noted alterations in pain processing in asymptomatic teenagers with a family history of migraines.
Procedural Predictors of Epidural Blood Patch Efficacy in Spontaneous Intracranial Hypotension
Pagani-Estévez GL, Cutsforth-Gregory JK, Morris JM, et al. Reg Anesth Pain Med 2019;44(2)
This study in adult patients may be helpful for pediatric practitioner consulted for adolescent patients with SIH.
Gender Effects in Medical Education: Implications for Training and Gender Equity in Regional Training
Sidhu NS, Civil N. Reg Anesth Pain Med 2019;44(4)
Several recent studies have shown that patients of female providers fare better. If improved quality of patient care is the ultimate goal maybe we need to pay more attention to stressing humility in male trainees than assertiveness in female trainees. Just a thought…
