Pain Management in Children: NSAID Use in the Perioperative and Emergency Department Settings

Quadriceps and hamstring muscles strength differences in adolescent and adult recreational athletes 6 months after autograft bone-patellar-tendon-bone anterior cruciate ligament reconstruction: A retrospective study

BACKGROUND

Knee muscle strength recovery after anterior cruciate ligament reconstruction (ACLR) is crucial for a safe return to sport (RTS) but it is poorly described in the adolescent population. Therefore, we compared the knee muscle strength at 6 months post-surgery in adults and adolescents. We hypothesized a greater muscular strength in adolescents 6 months after ACLR.

METHODS

This was a retrospective analysis of 55 adolescents (13-18 years old) and 76 adults (19-39 years old) who underwent ACLR with autograft bone-patellar-tendon-bone (BPTB), subjected to isokinetic tests 6 months after surgery. The following outcomes were analyzed: (1) the maximum torque of hamstrings (H) and quadriceps (Q) during flexion and extension at 30°/s normalized by body weight; (2) hamstrings to quadriceps strength ratio (HQ ratio); (3) injured to uninjured leg muscle strength ratio (limb-symmetry index, LSI).

RESULTS

Both adults and adolescents produced lower Q torque with the injured leg compared with uninjured, but similar H torque. In adolescents, the injured Q torque and the Q-LSI were higher compared with adults. In both populations, the Q-LSI was lower than the H-LSI and the HQ ratio in the injured leg was higher compared with uninjured. Adolescents showed a lower HQ ratio in injured legs.

CONCLUSIONS

At 6 months after ACLR both adolescents and adults did not recover Q strength in the injured leg. However, adolescents showed larger Q strength compared with adults. The HQ ratio analysis showed that 6 months after surgery both groups are not ready for a safe RTS.

Postoperative Analgesic Effects of Quadratus Lumborum Block Versus Transversus Abdominis Plane Block in Pediatric Lower Abdominal Surgeries: A Systematic Review and Meta-Analysis

Objective

Management of postoperative pain in pediatric patients is challenging. Traditional methods of postoperative pain management may not always provide adequate relief. We aim to compare the effect of Quadratus Lumborum Block (QLB) and Transversus Abdominis Plane Block (TAPB) on the quality of postoperative analgesia in pediatrics undergoing lower abdominal surgeries.

Methods

We systematically searched PubMed, Scopus, Web of Science, and Cochrane Library up to August 2024 for studies that compared QLB and TAPB in the context of pediatric lower abdominal surgery. Pooled mean difference (MD), standardized mean difference (SMD), and odds ratio (OR) were calculated by a random effect model using RevMan 5.4.

Results

Nine studies met the pre-defined inclusion criteria. Pooled analysis indicated that postoperative pain measured by the FLACC score was lower in the QLB group compared to the TAPB group (MD: -0.37; 95% CI: -0.51, -0.23; P < 0.00001). QLB was also associated with lower rescue analgesic demand (OR: 0.25; 95% CI, 0.13, 0.49; P < 0.0001), higher parent satisfaction (SMD: 0.78; 95% CI: 0.53, 1.02; P < 0.00001), longer time without the need for analgesic administration (MD: 1.04; 95% CI: 0.38, 1.71; P = 0.002), and lower paracetamol consumption (SMD: -1.40; 95% CI: -2.43, -0.36; P = 0.008). However, no significant difference was found in terms of postoperative nausea, vomiting, and heart rate.

Conclusion

QLB provides superior analgesia compared to TAPB in pediatrics undergoing lower abdominal surgeries.

The Challenge of Managing Neuropathic Pain in Children and Adolescents with Cancer

Neuropathic pain (NP) is a common complication associated with some types of childhood cancer, mainly due to nerve compression, chronic post-surgical pain, chemotherapy, and radiotherapy. NP is usually less responsive to traditional analgesics, and there is generally a lack of evidence on its management in cancer patients, leading to recommendations often based on clinical trials conducted on other forms of non-malignant NP. In pediatric oncology, managing NP is still very challenging for physicians. Different factors contribute to increasing the risk of undertreatment: (a) children may be unable to describe the quality of pain; therefore, the risk for NP to be underestimated or remain unrecognized; (b) specific tools to diagnose NP have not been validated in children; (c) there is a lack of randomized clinical trials involving children, with most evidence being based on case series and case reports; (d) most drugs used for adult patients are not approved for childhood cancers, and drug regulation varies among different countries; (e) recommendations for pediatric pain treatment are still not available. In this paper, a multidisciplinary team will review the current literature regarding children with cancer-related NP to define the best possible diagnostic strategies (e.g., clinical and instrumental tests) and propose a therapeutic care pathway, including both non-pharmacological and pharmacological approaches, which could help pediatricians, oncologists, neurologists, and pain therapists in designing the most effective multidisciplinary approach.

Updating Clinical Practice: Improving Perioperative Pain Management for Adeno-Tonsillectomy in Children

BACKGROUND/OBJECTIVE

Perioperative acute pain management in pediatric patients is essential to reduce complications. Adenoidectomy-Tonsillectomy are surgical procedures requiring pain control, and risk minimization for postoperative bleeding, nausea, and vomiting. Despite their known secondary effects, the use of opioid analgesics is still preponderant in pediatric perioperative management. We performed a comprehensive review on adeno-tonsillectomy perioperative pain management in children. We developed and implemented a multimodal analgesia protocol aimed to improve patients' pain management while consistently reducing opioids use.

METHODS/RESULTS

relevant Information was summarized, then compared to our clinical needs. Learnings were used to create and implement a multimodal analgesia protocol that we use in patients 3-9 years-old undergoing adenoidectomy/tonsillectomy. The full protocol is presented. Analgesic strategies have emerged to reduce or avoid the use of opioids. Among these strategies, combining different non-opioid analgesics (Ibuprofen, Paracetamol, Metamizole) has been shown to be an effective and safe pharmacological strategy when implemented as part of perioperative multimodal analgesia protocols. Considerable evidence associating the use of NSAIDs with a bigger risk of postoperative bleeding does not exist.

CONCLUSIONS

Perioperative management of adenotonsillectomy pain should include preventive and multimodal analgesia, which have shown to provide significantly more effective analgesia than some opioid regimens. Ibuprofen offers highly effective analgesia for postoperative pain, particularly when combined with acetaminophen.

Venipuncture in pediatric emergency department by using Koala Attachment Distraction method: Randomized clinical trial

OBJECTIVE

To assess, compare and relate the toddler's pain and anxiety during venipuncture by using either the Koala Attachment Distraction method or the physical restraint method and to evaluate the level of anxiety perceived by the companions in both groups.

METHOD

Randomised, single-blind, controlled clinical trial in two arms (control and intervention group) conducted in the paediatric emergency department of a tertiary university hospital. The study variables were pain and stress of the child and anxiety perceived by the accompanying persons in both groups at the time before and during the technique. The pain rating scale Face, Leg, Activity, Cry, Consolability; the Groningen stress scale and the STAI questionnaire were used.

RESULTS

A total of 113 participants aged 3 to 4 years participated in the trial (n=113). 50% (55) were girls, mean total age 3.83±0.59 years and accompanying persons 37.17±6.96. During the technique the mean pain in control and intervention groups was 5.64±3.30 and 3.87±3.01; stress, 3.25±1.22 and 2.67±1.24, respectively. No statistically significant differences were found in the assessment of anxiety between the groups.

CONCLUSIONS

Patients who underwent the Koala Attachment Distraction method venipuncture show a lower level of pain and anxiety than those who received physical restraint, and the anxiety perceived by the companion is similar in both groups.

Damage-associated molecular patterns as a mechanism of sevoflurane-induced neuroinflammation in neonatal rodents

BACKGROUND

General anesthesia is inevitable for pediatric patients undergoing surgery, though volatile anesthetic agents may cause neuroinflammation and neurodevelopmental impairment; however, the underlying pathophysiology remains unclear. We aimed to investigate the neuroinflammation mechanism in developing rat brains associated with sevoflurane exposure time, by identifying the specific damage-associated molecular patterns (DAMPs) pathway and evaluating the effects of non-steroidal anti-inflammatory drugs (NSAIDs) in alleviating neuroinflammation.

METHODS

A three-step experiment was conducted to investigate neuroinflammation induced by sevoflurane. First, the exposure time required for sevoflurane to cause neuroinflammation was determined. Next, the specific pathways of DAMPs involved in neuroinflammation by sevoflurane were identified. Finally, the effects of NSAIDs on sevoflurane-induced neuroinflammation were investigated. The expression of various molecules in the rat brain were assessed using immunohistochemistry, immunofluorescence, quantitative real-time polymerase chain reaction, western blot analysis, and enzyme-linked immunosorbent assay.

RESULTS

In total, 112 rats (aged 7 days) were used, of which six rats expired during the experiment (mortality rate, 5.3%). Expression of CD68, HMGB-1, galectin-3, TLR4, TLR9, and phosphorylated NF-κB was significantly increased upon 6 h of sevoflurane exposure. Conversely, transcriptional levels of TNF-α and IL-6 significantly increased and IFN-γ significantly decreased after 6 h of sevoflurane exposure. Co-administration of NSAIDs with sevoflurane anesthesia significantly attenuated TNF-α and IL-6 levels and restored IFN-γ levels.

CONCLUSIONS

In conclusion, 6 h of sevoflurane exposure induces neuroinflammation through the DAMPs pathway, HMGB-1, and galectin-3. Co-administration of ibuprofen reduced sevoflurane-induced neuroinflammation.

Ibuprofen for acute postoperative pain in children

BACKGROUND

Children often require pain management following surgery to avoid suffering. Effective pain management has consequences for healing time and quality of life. Ibuprofen, a frequently used non-steroidal anti-inflammatory drug (NSAID) administered to children, is used to treat pain and inflammation in the postoperative period.

OBJECTIVES

1) To assess the efficacy and safety of ibuprofen (any dose) for acute postoperative pain management in children compared with placebo or other active comparators. 2) To compare ibuprofen administered at different doses, routes (e.g. oral, intravenous, etc.), or strategies (e.g. as needed versus as scheduled).

SEARCH METHODS

We used standard Cochrane search methods. We searched CENTRAL, MEDLINE, Embase, CINAHL and trials registries in August 2023.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) in children aged 17 years and younger, treated for acute postoperative or postprocedural pain, that compared ibuprofen to placebo or any active comparator. We included RCTs that compared different administration routes, doses of ibuprofen and schedules.

DATA COLLECTION AND ANALYSIS

We adhered to standard Cochrane methods for data collection and analysis. Our primary outcomes were pain relief reported by the child, pain intensity reported by the child, adverse events, and serious adverse events. We present results using risk ratios (RR) and standardised mean differences (SMD), with the associated confidence intervals (CI). We used GRADE to assess the certainty of the evidence.

MAIN RESULTS

We included 43 RCTs that enroled 4265 children (3935 children included in this review). We rated the overall risk of bias at the study level as high or unclear for 37 studies that had one or several unclear or high risk of bias judgements across the domains. We judged six studies as having a low risk of bias across all domains. Ibuprofen versus placebo (35 RCTs) No studies reported pain relief reported by the child or a third party, or serious adverse events. Ibuprofen probably reduces child-reported pain intensity less than two hours postintervention compared to placebo (SMD -1.12, 95% CI -1.39 to -0.86; 3 studies, 259 children; moderate-certainty evidence). Ibuprofen may reduce child-reported pain intensity, two hours to less than 24 hours postintervention (SMD -1.01, 95% CI -1.24 to -0.78; 5 studies, 345 children; low-certainty evidence). Ibuprofen may result in little to no difference in adverse events compared to placebo (RR 0.79, 95% CI 0.51 to 1.23; 5 studies, 384 children; low-certainty evidence). Ibuprofen versus paracetamol (21 RCTs) No studies reported pain relief reported by the child or a third party, or serious adverse events. Ibuprofen likely reduces child-reported pain intensity less than two hours postintervention compared to paracetamol (SMD -0.42, 95% CI -0.82 to -0.02; 2 studies, 100 children; moderate-certainty evidence). Ibuprofen may slightly reduce child-reported pain intensity two hours to 24 hours postintervention (SMD -0.21, 95% CI -0.40 to -0.02; 6 studies, 422 children; low-certainty evidence). Ibuprofen may result in little to no difference in adverse events (0 events in each group; 1 study, 44 children; low-certainty evidence). Ibuprofen versus morphine (1 RCT) No studies reported pain relief or pain intensity reported by the child or a third party, or serious adverse events. Ibuprofen likely results in a reduction in adverse events compared to morphine (RR 0.58, 95% CI 0.40 to 0.83; risk difference (RD) -0.25, 95% CI -0.40 to -0.09; number needed to treat for an additional beneficial outcome (NNTB) 4; 1 study, 154 children; moderate-certainty evidence). Ibuprofen versus ketorolac (1 RCT) No studies reported pain relief or pain intensity reported by the child, or serious adverse events. Ibuprofen may result in a reduction in adverse events compared to ketorolac (RR 0.51, 95% CI 0.27 to 0.96; RD -0.29, 95% CI -0.53 to -0.04; NNTB 4; 1 study, 59 children; low-certainty evidence).

AUTHORS' CONCLUSIONS

Despite identifying 43 RCTs, we remain uncertain about the effect of ibuprofen compared to placebo or active comparators for some critical outcomes and in the comparisons between different doses, schedules and routes for ibuprofen administration. This is largely due to poor reporting on important outcomes such as serious adverse events, and poor study conduct or reporting that reduced our confidence in the results, along with small underpowered studies. Compared to placebo, ibuprofen likely results in pain reduction less than two hours postintervention, however, the efficacy might be lower at two hours to 24 hours. Compared to paracetamol, ibuprofen likely results in pain reduction up to 24 hours postintervention. We could not explore if there was a different effect in different kinds of surgeries or procedures. Ibuprofen likely results in a reduction in adverse events compared to morphine, and in little to no difference in bleeding when compared to paracetamol. We remain mostly uncertain about the safety of ibuprofen compared to other drugs.

Preoperative preparation and postoperative care in children in thoracic surgery

Anesthesia for pediatric patients undergoing thoracic surgery continues to be distinctive due to differing anatomical and physiological characteristics compared to adults. Adequate preoperative preparation, appropriate tool selection for providing one-lung ventilation, perioperative pain management, and a multidisciplinary approach can ensure higher quality postoperative care. In this review, the perioperative anesthesia management for pediatric patients undergoing thoracic surgery will be discussed, starting from the preoperative preparation phase. Additionally, the issues related to the application and management of one-lung ventilation will also be assessed.

Clinical use of ketoprofen lysine salt: a reappraisal in adolescents with acute respiratory infections

Upper respiratory infections are widespread, and they are mainly of viral etiology. It has to be remarked that every infection is always associated with an inflammatory response. Inflammation implicates a cascade of bothersome symptoms, including fever, pain (headache, myalgia, and arthralgia), malaise, and respiratory complaints. As a result, anti-inflammatory medications could be beneficial as they act on different pathogenetic pathways. The ketoprofen lysine salt (KLS) has a potent anti-inflammatory activity associated with effective analgesic and antipyretic effects and has a valuable safety profile. However, adolescents present peculiar psychological characteristics that determine their difficulty to be managed. In this regard, an adolescent with a respiratory infection requires a prompt and adequate cure. KLS, thanks to its pharmacologic profile, could be favorably used in this regard. A recent primary-care experience outlined its effectiveness in this issue.

Pain Management in Children Admitted to the Emergency Room: A Narrative Review

Pain is a biopsychosocial experience characterized by sensory, physiological, cognitive, affective, and behavioral components. Both acute and chronic pain can have short and long-term negative effects. Unfortunately, pain treatment is often inadequate. Guidelines and recommendations for a rational approach to pediatric pain frequently differ, and this may be one of the most important reasons for the poor attention frequently paid to pain treatment in children. This narrative review discusses the present knowledge in this regard. A literature review conducted on papers produced over the last 8 years showed that although in recent years, compared to the past, much progress has been made in the treatment of pain in the context of the pediatric emergency room, there is still a lot to do. There is a need to create guidelines that outline standardized and easy-to-follow pathways for pain recognition and management, which are also flexible enough to take into account differences in different contexts both in terms of drug availability and education of staff as well as of the different complexities of patients. It is essential to guarantee an approach to pain that is as uniform as possible among the pediatric population that limits, as much as possible, the inequalities related to ethnicity and language barriers.

Pain Evaluation and Treatment in Children: A Practical Approach

Pain is the most common complaint reported by children who access the emergency departments, but despite its frequency and the availability of many international guidelines, it often remains underreported and undertreated. Recently, the American Academy of Pediatrics and the American Pain Society have reiterated the importance of a multidisciplinary approach in order to eliminate pain in children. In all pediatric settings, an adequate assessment is the initial stage in a proper clinical approach to pain, especially in the emergency departments; therefore, an increasing number of age-related tools have been validated. A wide range of analgesic agents are currently available for pain management, and they should be tailored according to the patient's age, the drug's pharmacokinetics and the intensity of pain. In order to facilitate the choice of the appropriate drug, a treatment algorithm based on a ladder approach can be used. Moreover, non-pharmacological techniques should be considered to alleviate anxiety and distress in pediatric age. This review aims to offer a simple but intuitive description of the best strategies for pain relief in children, starting with the prompt recognition and quantification of pain through adequate assessment scales, and following with the identification of the most appropriate therapeutic choice among the ones available for pediatric age.

The Analgesic Effects of the Addition of Intravenous Ibuprofen to a Multimodal Analgesia Regimen for Pain Management After Pediatric Cardiac Surgery: A Randomized Controlled Study

OBJECTIVE

Intravenous ibuprofen is used to control fever and pain. This study aimed to assess the analgesic effects of the addition of intravenous ibuprofen to a multimodal analgesia regimen for pain management after pediatric cardiac surgery.

DESIGN

A randomized, controlled, double-blinded, superiority study.

SETTING

University hospital.

PARTICIPANTS

Seventy-eight pediatric patients who underwent open cardiac surgery using midline sternotomy incision were screened for eligibility; 10 patients were excluded, leaving 68 patients (34 patients in the ibuprofen group and 34 patients in the control group) for final data analysis.

INTERVENTIONS

Patients were randomly allocated to either the ibuprofen group, in which the patient received intravenous ibuprofen infusion of 10 mg/kg/6 hours for 24 hours, or the control group, in which the patient received a placebo 0.9% saline.

MEASUREMENTS AND MAIN RESULTS

The primary endpoint was the 24-hour postoperative fentanyl consumption, and the secondary endpoints were postoperative modified objective pain score and the incidence of ibuprofen-related side effects (eg, vomiting, epigastric pain, bleeding, and renal dysfunction). The mean total fentanyl consumption (μg/kg) during the first postoperative 24 hours after extubation was significantly lower (p<0.001) in the ibuprofen group (3.5 ± 1.3) than the control group (5.1 ± 1.4). The median postoperative modified objective pain score was significantly lower (p < 0.05) in the ibuprofen group than the control group at 0 hours, 2 hours, 12 hours, 16 hours, 20 hours, and 24 hours postoperatively. Ibuprofen did not cause significant increases in the incidences of bleeding, epigastric pain, and vomiting. Postoperative renal dysfunction was not reported in any patient.

CONCLUSIONS

The addition of intravenous ibuprofen to a multimodal analgesia regimen for pain management after pediatric cardiac surgery improved postoperative analgesia in terms of reduction of opioid consumption and pain scores.

Oral ibuprofen versus oral ketorolac for children with moderate and severe acute traumatic pain: a randomized comparative study

This study is to compare ibuprofen and ketorolac for children with trauma-related acute pain. We conducted a multicentre randomized, double-blind, controlled trial in the Paediatric Emergency Department setting. We enrolled patients aged 8 to 17 who accessed the emergency department for pain related to a limb trauma that occurred in the previous 48 h. At the admission, patients were classified based on numeric rating scale-11 (NRS-11) in moderate (NRS 4-6) and severe (NRS 7-10) pain groups. Each patient was randomized to receive either ibuprofen (10 mg/kg) or ketorolac (0.5 mg/kg) and the placebo of the not given drug in a double dummies design. NRS-11 was asked every 30 min until 2 h after drug and placebo administration. The primary outcome was NRS-11 reduction at 60 min. Among 125 patients with severe pain, NRS-11 reduction after 60 min from drug administration was 2.0 (IQR 1.0-4.0) for ibuprofen and 1.0 (IQR 1.0-3.0) for ketorolac (p = 0.36). Ibuprofen was significantly better, considering secondary outcomes, at 90 min with a lower median of NRS-11 (p 0.008), more patients with NRS-11 less than 4 (p 0.01) and a reduction of pain score of more than 3 NRS-11 points (p 0.01). Among 87 patients with moderate pain, the NRS-11 reduction after 60 min from drug administration was 1.63 (± 1.8) for ibuprofen and 1.8 (± 1.6) for ketorolac, with no statistically significant difference.Conclusions: Oral ibuprofen and ketorolac are similarly effective in children and adolescents with acute traumatic musculoskeletal pain.Trial registration: ClinicalTrial.gov registration number: NCT04133623.

Comparison of intravenous ibuprofen versus ketorolac for postoperative analgesia in children undergoing lower abdominal surgery: A randomized, controlled, non-inferiority study

BACKGROUND

Non-steroidal anti-inflammatory drugs are often used as part of multimodal analgesia to control postoperative pain. This randomized, controlled, double-blinded, non-inferiority study aimed to compare the postoperative analgesic effects of intravenous ibuprofen versus ketorolac in children undergoing open unilateral lower abdominal surgery. The authors hypothesized that postoperative analgesia produced by intravenous ibuprofen would be non-inferior to that of intravenous ketorolac.

METHODS

Sixty-six children aged 2 to 8 years who were scheduled to undergo unilateral lower abdominal surgery, were recruited. Patients in the ibuprofen group received 10mg/kg/6h intravenous ibuprofen. Patients in the ketorolac group were given 0.5mg/kg/6h intravenous ketorolac. The primary outcome measure was 24-h postoperative morphine consumption. The secondary outcome measures were postoperative pain score, the incidence of early postoperative fever and the incidence of ibuprofen and ketorolac adverse effects including pain during drug infusion, vomiting, epigastric pain and allergic reaction.

RESULTS

Fifty-nine patients completed the study (30 ibuprofen, 29 ketorolac). There was no significant difference (P=0.305) in the mean (SD) 24-h postoperative morphine consumption (μ/kg) between intravenous ibuprofen, 16.00 (5.31), and ketorolac, 14.65 (4.61). The reported pain scores were similar in both groups. The incidence of postoperative fever was significantly lower (p=0.039) in the ibuprofen group (3%) than the ketorolac group (20%). The incidence of adverse effects was similar in both ibuprofen and ketorolac groups.

CONCLUSIONS

Intravenous ibuprofen can be used as an alternative to ketorolac for postoperative analgesia in children undergoing unilateral lower abdominal surgery because both drugs similarly provide safe and effective postoperative analgesia.