Postoperative Pain Management in children: guidance from the Pain Committee of the European Society for Paediatric Anaesthesiology (ESPA Pain Management Ladder Initiative) Part II

Improving Postoperative Pediatric Recovery by Efficient Recovery Room Care-A Comprehensive Review

Background/Objectives: Efficient postoperative recovery room care in pediatric patients is crucial for optimizing perioperative safety, patient outcome, and effective pain management. However, this area is frequently underemphasized, leading to higher complication rates compared to the operating room, which in turn increases healthcare costs. Improving pediatric recovery room care offers a significant opportunity to enhance the quality and safety of perioperative pediatric care. From an economic perspective, this is prudent; however, more importantly, every child has the right to the highest attainable standard of health, as outlined by the United Nations. Key aspects of recovery room care include ensuring adequate staffing and equipment, while also prioritizing the child's privacy and parental presence, both of which are crucial for enhancing patient well-being. A +multimodal approach to postoperative pain management is essential for minimizing fear and stress, alongside strict adherence to established guidelines for the management of postoperative nausea, vomiting, and emergence delirium. Furthermore, addressing risk factors such as hypothermia and airway complications, as well as promoting early intake of clear fluids, plays a crucial role in optimizing pediatric recovery. Organizational strategies such as quality improvement initiatives, structured handovers, standardized care protocols with checklists, continuous staff training, and well-defined discharge criteria are further essential components to reduce translational gaps and to enhance postoperative pediatric safety. Conclusions: Improving pediatric postoperative anesthetic care is a multifaceted challenge for all healthcare providers that can significantly enhance care quality and safety while also reducing costs. Success in this area requires addressing both structural and medical factors.

Intravenously Administered Nonsteroidal Anti-Inflammatory Drugs in Clinical Practice: A Narrative Review

Intravenously administered nonsteroidal anti-inflammatory drugs (NSAIDs) constitute a crucial component of multimodal analgesia strategies in surgical settings. This narrative review aims to provide an up-to-date evaluation of the efficacy, safety, and clinical use of intravenous (IV) NSAIDs for perioperative pain management in adults and children. The NSAIDs and selective COX-2 inhibitors (coxibs) approved in Europe for the short-term symptomatic treatment of acute, moderate perioperative pain via IV infusion in adults and/or children have been influenced by US and global guidelines and practice: the drugs primarily reviewed here are ibuprofen, ketorolac, ketoprofen, naproxen, paracetamol, and acetylsalicylic acid. Furthermore, intravenous ibuprofen is authorized for the short-term symptomatic treatment of fever. In contrast to intravenous ketoprofen, intravenous ibuprofen is authorized for administration to children over 6 years of age or weighing more than 20 kg. Overall, IV ibuprofen had a more favorable profile with regard to peri- and postoperative opioid sparing and pain relief. Oral ibuprofen and IV ibuprofen have similar levels of efficacy, although IV ibuprofen has a shorter onset of action and is required in patients who are unable to take oral medications. The frequency of significant adverse events appears to be similar for ibuprofen and paracetamol. Systematic reviews and meta-analyses report that intravenous NSAIDs reduce postoperative opioid consumption by approximately 20-60%, improving pain management with fewer opioid-related side effects. In indications in infants, the choice of medication is limited, and the oral route is not always feasible; IV formulations of ibuprofen are preferred in this setting. Topics for further research should include head-to-head trials of IV NSAIDs.

Oxycodone for analgesia in children undergoing endoscopic retrograde cholangiopancreatography: a randomized, double-blind, parallel study

Background

Postoperative visceral pain is a common complication after endoscopic retrograde cholangiopancreatography (ERCP). In this study, we compared the analgesic and anti-inflammatory effects of oxycodone and fentanyl in children undergoing ERCP.

Methods

A single-center, randomized, double-blind study was conducted at a tertiary care hospital affiliated with Shanghai Jiao Tong University. Eighty-two pediatric patients aged 2-18 years who were scheduled for elective ERCP were randomly assigned to receive either oxycodone (0.2 mg/kg) or fentanyl (2 μg/kg). The postoperative pain was evaluated after 10 min, 20 min, and 30 min in the post-anesthesia care unit (PACU) as well as 6 h and 24 h in the ward following ERCP. Additionally, inflammatory cytokines in the serum, including tumor necrosis factor (TNF)-α, interleukin (IL)-6, and IL-10 were examined by blood sampling at baseline, 6 h, and 24 h after ERCP.

Results

Compared to fentanyl, children receiving oxycodone had significantly lower pain scores at 30 min, 6 h, and 24 h after ERCP, while the scores at 10 and 20 min were similar in both groups. We also found that fewer patients had pain scores ≥3 at 6 h and 24 h after the procedure in the oxycodone group [36.6% (15/41) vs. 61.0% (25/41) at 6 h, 34.1% (14/41) vs. 58.5% (24/41) at 24 h, p = 0.027 for both cases]. Furthermore, fewer children in the oxycodone group had elevated inflammatory cytokines (IL-6 at 6 h and TNF-α at 24 h after ERCP) compared to the fentanyl group. The incidence of postoperative vomiting was also lower among children receiving oxycodone [14.1% (7/41) vs. 24.4% (10/41), p = 0.032].

Conclusion

Oxycodone (0.2 mg kg-1) can provide effective analgesia and stable hemodynamics in children undergoing ERCP. This analgesic characteristic may be related to amelioration of inflammation after ERCP.

Clinical Trial Registration

www.chictr.org.cn, identifier ChiCTR2300074473.