1
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Cunico D, Rossi A, Verdesca M, Principi N, Esposito S. Pain Management in Children Admitted to the Emergency Room: A Narrative Review. Pharmaceuticals (Basel) 2023; 16:1178. [PMID: 37631093 PMCID: PMC10459115 DOI: 10.3390/ph16081178] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2023] [Revised: 08/11/2023] [Accepted: 08/16/2023] [Indexed: 08/27/2023] Open
Abstract
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.
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Affiliation(s)
- Daniela Cunico
- Pediatric Clinic, Department of Medicine and Surgery, University of Parma, 43126 Parma, Italy; (D.C.); (A.R.); (M.V.)
| | - Arianna Rossi
- Pediatric Clinic, Department of Medicine and Surgery, University of Parma, 43126 Parma, Italy; (D.C.); (A.R.); (M.V.)
| | - Matteo Verdesca
- Pediatric Clinic, Department of Medicine and Surgery, University of Parma, 43126 Parma, Italy; (D.C.); (A.R.); (M.V.)
| | | | - Susanna Esposito
- Pediatric Clinic, Department of Medicine and Surgery, University of Parma, 43126 Parma, Italy; (D.C.); (A.R.); (M.V.)
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2
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Kinoshita M, Borges do Nascimento IJ, Styrmisdóttir L, Bruschettini M. Systemic opioid regimens for postoperative pain in neonates. Cochrane Database Syst Rev 2023; 4:CD015016. [PMID: 37018131 PMCID: PMC10075508 DOI: 10.1002/14651858.cd015016.pub3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/06/2023]
Abstract
BACKGROUND Postoperative pain clinical management in neonates has always been a challenging medical issue. Worldwide, several systemic opioid regimens are available for pediatricians, neonatologists, and general practitioners to control pain in neonates undergoing surgical procedures. However, the most effective and safe regimen is still unknown in the current body of literature. OBJECTIVES To determine the effects of different regimens of systemic opioid analgesics in neonates submitted to surgery on all-cause mortality, pain, and significant neurodevelopmental disability. Potentially assessed regimens might include: different doses of the same opioid, different routes of administration of the same opioid, continuous infusion versus bolus administration, or 'as needed' administration versus 'as scheduled' administration. SEARCH METHODS Searches were conducted in June 2022 using the following databases: Cochrane Central Register of Controlled Trials [CENTRAL], PubMed, and CINAHL. Trial registration records were identified via CENTRAL and an independent search of the ISRCTN registry. SELECTION CRITERIA We included randomized controlled trials (RCTs), quasi-randomized, cluster-randomized, and cross-over controlled trials evaluating systemic opioid regimens' effects on postoperative pain in neonates (pre-term or full-term). We considered suitable for inclusion: I) studies evaluating different doses of the same opioid; 2) studies evaluating different routes of administration of the same opioid; 3) studies evaluating the effectiveness of continuous infusion versus bolus infusion; and 4) studies establishing an assessment of an 'as needed' administration versus 'as scheduled' administration. DATA COLLECTION AND ANALYSIS According to Cochrane methods, two investigators independently screened retrieved records, extracted data, and appraised the risk of bias. We stratified meta-analysis by the type of intervention: studies evaluating the use of opioids for postoperative pain in neonates through continuous infusion versus bolus infusion and studies assessing the 'as needed' administration versus 'as scheduled' administration. We used the fixed-effect model with risk ratio (RR) for dichotomous data and mean difference (MD), standardized mean difference (SMD), median, and interquartile range (IQR) for continuous data. Finally, we used the GRADEpro approach for primary outcomes to evaluate the quality of the evidence across included studies. MAIN RESULTS In this review, we included seven randomized controlled clinical trials (504 infants) from 1996 to 2020. We identified no studies comparing different doses of the same opioid, or different routes. The administration of continuous opioid infusion versus bolus administration of opioids was evaluated in six studies, while one study compared 'as needed' versus 'as scheduled' administration of morphine given by parents or nurses. Overall, the effectiveness of continuous infusion of opioids over bolus infusion as measured by the visual analog scale (MD 0.00, 95% confidence interval (CI) -0.23 to 0.23; 133 participants, 2 studies; I² = 0); or using the COMFORT scale (MD -0.07, 95% CI -0.89 to 0.75; 133 participants, 2 studies; I² = 0), remains unclear due to study designs' limitations, such as the unclear risk of attrition, reporting bias, and imprecision among reported results (very low certainty of the evidence). None of the included studies reported data on other clinically important outcomes such as all-cause mortality rate during hospitalization, major neurodevelopmental disability, the incidence of severe retinopathy of prematurity or intraventricular hemorrhage, and cognitive- and educational-related outcomes. AUTHORS' CONCLUSIONS: Limited evidence is available on continuous infusion compared to intermittent boluses of systemic opioids. We are uncertain whether continuous opioid infusion reduces pain compared with intermittent opioid boluses; none of the studies reported the other primary outcomes of this review, i.e. all-cause mortality during initial hospitalization, significant neurodevelopmental disability, or cognitive and educational outcomes among children older than five years old. Only one small study reported on morphine infusion with parent- or nurse-controlled analgesia.
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Affiliation(s)
- Mari Kinoshita
- Department of Pediatrics, Clinical Sciences Lund, Lund University, Lund, Sweden
- Fetal Medicine Research Center, University of Barcelona, Barcelona, Spain
| | - Israel Junior Borges do Nascimento
- School of Medicine and University Hospital, Universidade Federal de Minas Gerais (UFMG), Belo Horizonte, Brazil
- Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | | | - Matteo Bruschettini
- Paediatrics, Department of Clinical Sciences Lund, Lund University, Skåne University Hospital, Lund, Sweden
- Cochrane Sweden, Department of Research and Education, Lund University, Skåne University Hospital, Lund, Sweden
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3
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Kinoshita M, Borges do Nascimento IJ, Styrmisdóttir L, Bruschettini M. Systemic opioid regimens for postoperative pain in neonates. Cochrane Database Syst Rev 2023; 1:CD015016. [PMID: 36645224 PMCID: PMC9841767 DOI: 10.1002/14651858.cd015016.pub2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
BACKGROUND Postoperative pain clinical management in neonates has always been a challenging medical issue. Worldwide, several systemic opioid regimens are available for pediatricians, neonatologists, and general practitioners to control pain in neonates undergoing surgical procedures. However, the most effective and safe regimen is still unknown in the current body of literature. OBJECTIVES To determine the effects of different regimens of systemic opioid analgesics in neonates submitted to surgery on all-cause mortality, pain, and significant neurodevelopmental disability. Potentially assessed regimens might include: different doses of the same opioid, different routes of administration of the same opioid, continuous infusion versus bolus administration, or 'as needed' administration versus 'as scheduled' administration. SEARCH METHODS Searches were conducted in June 2022 using the following databases: Cochrane Central Register of Controlled Trials [CENTRAL], PubMed, and CINAHL. Trial registration records were identified via CENTRAL and an independent search of the ISRCTN registry. SELECTION CRITERIA We included randomized controlled trials (RCTs), quasi-randomized, cluster-randomized, and cross-over controlled trials evaluating systemic opioid regimens' effects on postoperative pain in neonates (pre-term or full-term). We considered suitable for inclusion: I) studies evaluating different doses of the same opioid; 2) studies evaluating different routes of administration of the same opioid; 3) studies evaluating the effectiveness of continuous infusion versus bolus infusion; and 4) studies establishing an assessment of an 'as needed' administration versus 'as scheduled' administration. DATA COLLECTION AND ANALYSIS According to Cochrane methods, two investigators independently screened retrieved records, extracted data, and appraised the risk of bias. We stratified meta-analysis by the type of intervention: studies evaluating the use of opioids for postoperative pain in neonates through continuous infusion versus bolus infusion and studies assessing the 'as needed' administration versus 'as scheduled' administration. We used the fixed-effect model with risk ratio (RR) for dichotomous data and mean difference (MD), standardized mean difference (SMD), median, and interquartile range (IQR) for continuous data. Finally, we used the GRADEpro approach for primary outcomes to evaluate the quality of the evidence across included studies. MAIN RESULTS In this review, we included seven randomized controlled clinical trials (504 infants) from 1996 to 2020. We identified no studies comparing different doses of the same opioid, or different routes. The administration of continuous opioid infusion versus bolus administration of opioids was evaluated in six studies, while one study compared 'as needed' versus 'as scheduled' administration of morphine given by parents or nurses. Overall, the effectiveness of continuous infusion of opioids over bolus infusion as measured by the visual analog scale (MD 0.00, 95% confidence interval (CI) -0.23 to 0.23; 133 participants, 2 studies; I² = 0); or using the COMFORT scale (MD -0.07, 95% CI -0.89 to 0.75; 133 participants, 2 studies; I² = 0), remains unclear due to study designs' limitations, such as the unclear risk of attrition, reporting bias, and imprecision among reported results (very low certainty of the evidence). None of the included studies reported data on other clinically important outcomes such as all-cause mortality rate during hospitalization, major neurodevelopmental disability, the incidence of severe retinopathy of prematurity or intraventricular hemorrhage, and cognitive- and educational-related outcomes. AUTHORS' CONCLUSIONS: Limited evidence is available on continuous infusion compared to intermittent boluses of systemic opioids. We are uncertain whether continuous opioid infusion reduces pain compared with intermittent opioid boluses; none of the studies reported the other primary outcomes of this review, i.e. all-cause mortality during initial hospitalization, significant neurodevelopmental disability, or cognitive and educational outcomes among children older than five years old. Only one small study reported on morphine infusion with parent- or nurse-controlled analgesia.
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Affiliation(s)
- Mari Kinoshita
- Department of Pediatrics, Clinical Sciences Lund, Lund University, Lund, Sweden
- Fetal Medicine Research Center, University of Barcelona, Barcelona, Spain
| | - Israel Junior Borges do Nascimento
- School of Medicine and University Hospital, Universidade Federal de Minas Gerais (UFMG), Belo Horizonte, Brazil
- Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | | | - Matteo Bruschettini
- Department of Clinical Sciences Lund, Paediatrics, Lund University, Skåne University Hospital, Lund, Sweden
- Cochrane Sweden, Lund University, Skåne University Hospital, Lund, Sweden
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Rodieux F, Ivanyuk A, Besson M, Desmeules J, Samer CF. Hydromorphone Prescription for Pain in Children-What Place in Clinical Practice? Front Pediatr 2022; 10:842454. [PMID: 35547539 PMCID: PMC9083226 DOI: 10.3389/fped.2022.842454] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2021] [Accepted: 03/25/2022] [Indexed: 11/13/2022] Open
Abstract
While morphine is the gold standard treatment for severe nociceptive pain in children, hydromorphone is increasingly prescribed in this population. This review aims to assess available knowledge about hydromorphone and explore the evidence for its safe and effective prescription in children. Hydromorphone is an opioid analgesic similar to morphine structurally and in its pharmacokinetic and pharmacodynamic properties but 5-7 times more potent. Pediatric pharmacokinetic and pharmacodynamic data on hydromorphone are sorely lacking; they are non-existent in children younger than 6 months of age and for oral administration. The current data do not support any advantage of hydromorphone over morphine, both in terms of efficacy and safety in children. Morphine should remain the treatment of choice for moderate and severe nociceptive pain in children and hydromorphone should be reserved as alternative treatment. Because of the important difference in potency, all strategies should be taken to avoid inadvertent administration of hydromorphone when morphine is intended.
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Affiliation(s)
- Frédérique Rodieux
- Division of Clinical Pharmacology and Toxicology, Department of Anesthesiology, Pharmacology and Intensive Care, Geneva University Hospitals, Geneva, Switzerland
| | - Anton Ivanyuk
- Division of Clinical Pharmacology and Toxicology, Department of Anesthesiology, Pharmacology and Intensive Care, Geneva University Hospitals, Geneva, Switzerland
| | - Marie Besson
- Division of Clinical Pharmacology and Toxicology, Department of Anesthesiology, Pharmacology and Intensive Care, Geneva University Hospitals, Geneva, Switzerland.,Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Jules Desmeules
- Division of Clinical Pharmacology and Toxicology, Department of Anesthesiology, Pharmacology and Intensive Care, Geneva University Hospitals, Geneva, Switzerland.,Faculty of Medicine, University of Geneva, Geneva, Switzerland.,Institute of Pharmaceutical Sciences of Western Switzerland (ISPSO), School of Pharmaceutical Sciences, University of Geneva, Geneva, Switzerland
| | - Caroline F Samer
- Division of Clinical Pharmacology and Toxicology, Department of Anesthesiology, Pharmacology and Intensive Care, Geneva University Hospitals, Geneva, Switzerland.,Faculty of Medicine, University of Geneva, Geneva, Switzerland
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5
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Spénard S, Gélinas C, D Trottier E, Tremblay-Racine F, Kleiber N. Morphine or hydromorphone: which should be preferred? A systematic review. Arch Dis Child 2021; 106:1002-1009. [PMID: 33461958 DOI: 10.1136/archdischild-2020-319059] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2020] [Revised: 11/20/2020] [Accepted: 12/13/2020] [Indexed: 11/04/2022]
Abstract
OBJECTIVE To systematically review available paediatric literature on comparisons between morphine (Mo) and hydromorphone (Hm), to guide clinicians to rationally use these medications. DESIGN Systematic review within four databases for all studies published from 1963 to July 2019. SETTING All paediatric settings. ELIGIBILITY All studies comparing Mo to Hm in individuals younger than 21 years. MAIN OUTCOME MEASURES The primary outcome was to compare clinical efficacy and side effects of Mo and Hm. The secondary outcomes were the comparison of pharmacokinetic profiles and the description of predefined Mo to Hm conversion ratios used across the paediatric literature. RESULTS Among 754 abstracts reviewed, 59 full-text articles met inclusion criteria and 24 studies were included in the analysis: 4 studies compared pharmacodynamics of Mo and Hm and 20 studies reported the use of a predefined Mo to Hm conversion ratio. Most studies had a poor methodological quality. Available evidence suggests that, when given intravenously, the equianalgesic ratio of Mo to Hm is 5:1. Intravenous administration with this ratio results in a similar rate of adverse effects, including pruritus and nausea. The epidural administration with a ratio of 10:1 results in more pruritus and urinary retention with Mo than Hm. Pharmacokinetic data were reported in only one study. A wide range of pre-established ratios for different routes of administration were reported, but few were based on evidence. CONCLUSION Current literature does not permit a rational choice between Mo and Hm. A ratio of 5:1 seems adequate for intravenous administration and leads to a similar rate of adverse effects.
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Affiliation(s)
- Sarah Spénard
- Faculty of Medicine, Université de Montréal, Montreal, Quebec, Canada.,Department of Pediatrics and Child Health, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Charles Gélinas
- Department of Anesthesia, McGill University, Montreal, Quebec, Canada
| | - Evelyne D Trottier
- Department of Pediatrics, Division of Pediatric Emergency Medicine, Centre Hospitalier Universitaire Sainte-Justine, Montreal, Quebec, Canada
| | - Fannie Tremblay-Racine
- Library, CHU Sainte-Justine, Montreal, Quebec, Canada.,Institut Universitaire de Réadaptation en Déficience Physique de Montréal (IURDPM), CIUSSS Centre-Sud-de-l'Ile-de-Montreal, Montreal, Quebec, Canada
| | - Niina Kleiber
- Department of Pediatrics, Division of General Pediatrics And Clinical Pharmacology Unit, Centre Hospitalier Universitaire Sainte-Justine, Montreal, Quebec, Canada .,Research Center, Centre Hospitalier Universitaire Sainte-Justine, Montreal, Quebec, Canada.,Department of Pharmacology and Physiology, Université de Montréal, Montréal, Quebec, Canada
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6
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Yaster M, Flack SH, Martin LD, Morgan PG. An interview with Dr. Anne Marie Lynn, a pioneering woman in medicine. Paediatr Anaesth 2021; 31:1040-1045. [PMID: 34293231 DOI: 10.1111/pan.14258] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Accepted: 07/17/2021] [Indexed: 11/26/2022]
Abstract
Dr. Anne Marie Lynn (1949-present), Professor Emeritus of Anesthesiology, Pain Medicine, and Pediatrics at the University of Washington, Seattle, was one of the most influential women in pediatric anesthesiology of her generation. Dr. Lynn embodies the spirit of discovery and advancement that have created the practice of pediatric anesthesiology as we know it today. A pioneer in pain medicine pharmacology, particularly morphine and ketorolac, her research transformed pediatric anesthesia, pediatric pain medicine, and pediatric intensive care medicine. Through her journal articles, book chapters, national and international lectures, mentoring of residents, fellows, and faculty, and leadership in the Society for Pediatric Anesthesia, she inspired a generation of women and men physicians by demonstrating that gender should not be a barrier to undertaking roles once only held only by men. In 2017, for her many contributions, she was awarded the Society for Pediatric Anesthesia's Myron Yaster lifetime achievement award.
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Affiliation(s)
- Myron Yaster
- Departments of Anesthesiology, Critical Care Medicine and Pediatrics, The Johns Hopkins University, Baltimore, Maryland, USA
| | - Sean H Flack
- Department of Anesthesiology and Pain Medicine, Seattle Children's, University of Washington, Seattle, Washington, USA
| | - Lynn D Martin
- Department of Anesthesiology and Pain Medicine, Seattle Children's, University of Washington, Seattle, Washington, USA
| | - Philip G Morgan
- Department of Anesthesiology and Pain Medicine, Seattle Children's, University of Washington, Seattle, Washington, USA
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7
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Abstract
Management of acute pain in children is fundamental to our practice. Its myriad benefits include reduced suffering, improved patient satisfaction, more rapid recovery, and a reduced risk of developing postsurgical chronic pain. Although a multimodal analgesic approach is now routinely used, informed and judicious use of opioid receptor agonists remains crucial in this treatment paradigm, as long as the benefits and risks are fully understood. Further, an ongoing public health response to the current opioid crisis is required to help prevent new cases of opioid addiction, identify opioid-addicted individuals, and ensure access to effective opioid addiction treatment, while at the same time continuing to safely meet the needs of patients experiencing pain.
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8
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Opioids: A Review of Pharmacokinetics and Pharmacodynamics in Neonates, Infants, and Children. Eur J Drug Metab Pharmacokinet 2020; 44:591-609. [PMID: 31006834 DOI: 10.1007/s13318-019-00552-0] [Citation(s) in RCA: 52] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Pain management in the pediatric population is complex for many reasons. Mild pain is usually managed quite well with oral acetaminophen or ibuprofen. Situations involving more severe pain often require the use of an opioid, which may be administered by many different routes, depending on clinical necessity. Acute and chronic disease states, as well as the constantly changing maturational process, produce unique challenges at every level of pediatrics in dosing and management of all medications, especially with regard to high-risk opioids. Although there has been significant progress in the understanding of opioid pharmacokinetics and pharmacodynamics in neonates, infants, children, and adolescents, somewhat limited data exist from which necessary information, concerning the safe and effective use of these agents, may be drawn. The evidence here provided is intended to be helpful in directing the practitioner to patient-specific reasons for preferring one opioid over another. As our knowledge of opioids and their effects has grown, it has become clear that older medications like codeine and meperidine (pethidine) have very limited use in pediatrics. This review provides pharmacokinetic and pharmacodynamic evidence on the currently available opioids: morphine, fentanyl (and derivatives), codeine, meperidine, oxycodone, hydrocodone, hydromorphone, methadone, buprenorphine, butorphanol, nalbuphine, pentazocin, ketobemidone, tramadol, piritramide, naloxone and naltrexone. Morphine, being the most studied opioid analgesic, is the standard against which all others are compared. Pharmacokinetic parameters of morphine that have been found in neonates, i.e., higher volume of distribution, immature metabolic processes that develop at various rates, elimination that is variable based on age and weight, as well as treated and untreated disease processes, are an example of all opioids in the population discussed in this review. Outside the premature and neonatal population, the use of opioids in infants, children, and adolescents quickly begins to resemble the established values found in adults. As such, the concerns (risks) of these medications become comparable to those seen in adults.
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9
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Abstract
Neuraxial (spinal and epidural) anesthesia has become commonplace in the care of neonates undergoing surgical procedures. These techniques afford many benefits, and, when properly performed, are extremely safe. This article reviews the benefits, risks, and applications of neuraxial anesthesia in neonates.
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10
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Martin LD, Adams TL, Duling LC, Grigg EB, Bosenberg A, Onchiri F, Jimenez N. Comparison between epidural and opioid analgesia for infants undergoing major abdominal surgery. Paediatr Anaesth 2019; 29:835-842. [PMID: 31140664 DOI: 10.1111/pan.13672] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2018] [Revised: 05/21/2019] [Accepted: 05/24/2019] [Indexed: 11/27/2022]
Abstract
BACKGROUND Epidural analgesia is considered optimal for postoperative pain management after major abdominal surgery. The potential to decrease anesthetic and opioid exposure is particularly desirable for infants, given their vulnerability to respiratory depression and concern for anesthetic neurotoxicity. We reviewed our experience with infants undergoing major abdominal surgery to determine if epidural catheter use decreased anesthetic and opioid exposure and improved postoperative analgesia. METHODS This retrospective cohort study included infants (<12 months) who underwent exploratory laparotomy, ureteral reimplantation, or bladder exstrophy repair between November 2011 and November 2014. Primary outcomes of anesthetic exposure (mean endtidal sevoflurane) and intraoperative opioid administration were compared between infants who received epidural catheters and those who did not. Secondary outcomes included postoperative pain and sedation scores and morphine equivalents administered 0-24 and 24-48 hours after surgery. RESULTS Of 158 eligible infants, 82 were included and 47 received epidurals. Patients with epidurals underwent bladder exstrophy repair (N = 9), ureteral reimplantation (N = 8), and exploratory laparotomy (N = 30). Infants with epidurals received less intraoperative fentanyl (2.6 mcg/kg (0,4.5) vs 3.3 mcg/kg (2.4,5.8), P = 0.019) and morphine (6% (3/47) vs 26% (9/35), P = 0.014) in univariate analysis. After controlling for age and emergency surgery, differences in long-acting opioid administration persisted, with significantly less morphine given in the epidural group (OR 0.181; 95% CI 0.035-0.925; P = 0.040). Mean endtidal sevoflurane concentrations were similar between groups. There was no significant difference in postoperative median morphine equivalents. CONCLUSION Placement of epidural catheters in infants undergoing major abdominal surgery is associated with decreased long-acting opioid requirements intraoperatively. Epidural placement does not preclude opioid exposure however, as opioids may be administered for indications other than nociceptive pain in the difficult-to-assess postoperative infant. Further prospective studies are warranted to better quantify the effect of epidural analgesia on intraoperative anesthetic exposure in infants.
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Affiliation(s)
- Lizabeth D Martin
- Department of Anesthesiology and Pain Management, University Washington Medical School, Seattle Children's Hospital, Seattle, Washington
| | - Trevor L Adams
- Department of Anesthesiology and Pain Management, University Washington Medical School, Seattle Children's Hospital, Seattle, Washington
| | - Laura C Duling
- Department of Anesthesiology and Pain Management, University Washington Medical School, Seattle Children's Hospital, Seattle, Washington
| | - Eliot B Grigg
- Department of Anesthesiology and Pain Management, University Washington Medical School, Seattle Children's Hospital, Seattle, Washington
| | - Adrian Bosenberg
- Department of Anesthesiology and Pain Management, University Washington Medical School, Seattle Children's Hospital, Seattle, Washington
| | - Frankline Onchiri
- Core for Biomedical Statistics, Center for Clinical and Translational Research, Seattle Children's Research Institute, Seattle, Washington
| | - Nathalia Jimenez
- Department of Anesthesiology and Pain Management, University Washington Medical School, Seattle Children's Hospital, Seattle, Washington
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11
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Krekels EHJ, DeJongh J, van Lingen RA, van der Marel CD, Choonara I, Lynn AM, Danhof M, Tibboel D, Knibbe C. Predictive Performance of a Recently Developed Population Pharmacokinetic Model for Morphine and its Metabolites in New Datasets of (Preterm) Neonates, Infants and Children. Clin Pharmacokinet 2017; 50:51-63. [PMID: 27975238 DOI: 10.2165/11536750-000000000-00000] [Citation(s) in RCA: 44] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
BACKGROUND AND OBJECTIVE Model validation procedures are crucial when models are to be used to develop new dosing algorithms. In this study, the predictive performance of a previously published paediatric population pharmacokinetic model for morphine and its metabolites in children younger than 3 years (original model) is studied in new datasets that were not used to develop the original model. METHODS Six external datasets including neonates and infants up to 1 year were obtained from four different research centres. These datasets contained postoperative patients, ventilated patients and patients on extracorporeal membrane oxygenation (ECMO) treatment. Basic observed versus predicted plots, normalized prediction distribution error analysis, model refitting, bootstrap analysis, subpopulation analysis and a literature comparison of clearance predictions were performed with the new datasets to evaluate the predictive performance of the original morphine pharmacokinetic model. RESULTS The original model was found to be stable and the parameter estimates were found to be precise. The concentrations predicted by the original model were in good agreement with the observed concentrations in the four datasets from postoperative and ventilated patients, and the model-predicted clearances in these datasets were in agreement with literature values. In the datasets from patients on ECMO treatment with continuous venovenous haemofiltration (CVVH) the predictive performance of the model was good as well, whereas underprediction occurred, particularly for the metabolites, in patients on ECMO treatment without CVVH. CONCLUSION The predictive value of the original morphine pharmacokinetic model is demonstrated in new datasets by the use of six different validation and evaluation tools. It is herewith justified to undertake a proof-of-principle approach in the development of rational dosing recommendations - namely, performing a prospective clinical trial in which the model-based dosing algorithm is clinically evaluated.
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Affiliation(s)
- Elke H J Krekels
- Division of Pharmacology, Leiden/Amsterdam Center for Drug Research, Leiden, The Netherlands.,Department of Pediatric Surgery, Erasmus MC-Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Joost DeJongh
- Division of Pharmacology, Leiden/Amsterdam Center for Drug Research, Leiden, The Netherlands.,LAP&P Consultants BV, Leiden, The Netherlands
| | - Richard A van Lingen
- Princess Amalia Department of Pediatrics, Division of Neonatology, Isala Clinics, Zwolle, The Netherlands
| | - Caroline D van der Marel
- Department of Pediatric Surgery, Erasmus MC-Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Imti Choonara
- Academic Division of Child Health, University of Nottingham, Derbyshire Children's Hospital, Derby, UK
| | - Anne M Lynn
- Department of Anesthesiology and Pain Medicine, Seattle Children's Hospital/University of Washington School of Medicine, Seattle, Washington, USA
| | - Meindert Danhof
- Division of Pharmacology, Leiden/Amsterdam Center for Drug Research, Leiden, The Netherlands
| | - Dick Tibboel
- Department of Pediatric Surgery, Erasmus MC-Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Catherijne Knibbe
- Division of Pharmacology, Leiden/Amsterdam Center for Drug Research, Leiden, The Netherlands. .,Department of Pediatric Surgery, Erasmus MC-Sophia Children's Hospital, Rotterdam, The Netherlands. .,Department of Clinical Pharmacy, St Antonius Hospital, PO Box 2500, 3430 EM, Nieuwegein, The Netherlands.
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12
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Abstract
Pain management in the neonatal ICU remains challenging for many clinicians and in many complex care circumstances. The authors review general pain management principles and address the use of pain scales, non-pharmacologic management, and various agents that may be useful in general neonatal practice, procedurally, or at the end of life. Chronic pain and neonatal abstinence are also noted.
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Affiliation(s)
- Brian S Carter
- Department of Pediatrics, Division of Neonatology, University of Missouri at Kansas City School of Medicine, 2401 Gillham Rd, Kansas City, MO 64108; Children׳s Mercy Bioethics Center, Kansas City, MO.
| | - Jessica Brunkhorst
- Department of Pediatrics, Division of Neonatology, University of Missouri at Kansas City School of Medicine, 2401 Gillham Rd, Kansas City, MO 64108
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13
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Weiner C, Penrose S, Manias E, Cranswick N, Rosenfeld E, Newall F, Williams A, Borrott N, Kinney S. Difficulties with assessment and management of an infant's distress in the postoperative period: Optimising opportunities for interdisciplinary information-sharing. SAGE Open Med Case Rep 2017; 4:2050313X16683628. [PMID: 28228956 PMCID: PMC5308436 DOI: 10.1177/2050313x16683628] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2016] [Accepted: 11/16/2016] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVES The importance of accurate paediatric patient assessment is well established but under-utilised in managing postoperative medication regimens. METHODS Data for this case report were collected through observations of clinical practice, conduct of interviews, and retrieval of information from the medical record. This case report involving a hospitalised 1-year-old boy demonstrates the difficulties associated with assessing and managing postoperative distress, including pain and other clinical conditions related to the surgical procedure. RESULTS Postoperatively, there were difficulties in managing pain and an episode of over-sedation, occasioning opiate reversal with naloxone. In addition, he had decreasing oxygen saturation and increased work of breathing. X-ray showed changes consistent with either atelectasis or aspiration, and he was commenced on antibiotics. The patient experienced respiratory distress and required intervention from the medical emergency team. CONCLUSION This case demonstrated the importance of comprehensive assessment and careful consideration of alternative causes of an infant's distress using the results of assessment tools to aid decision-making. Communication moderates effective patient care, and more favourable outcomes could be achieved by optimising interdisciplinary information-sharing.
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Affiliation(s)
- Carlye Weiner
- Melbourne School of Health Sciences, The University of Melbourne, Carlton, VIC, Australia
| | - Sueann Penrose
- Children’s Pain Management Service, The Royal Children’s Hospital, Parkville, VIC, Australia
| | - Elizabeth Manias
- Melbourne School of Health Sciences, The University of Melbourne, Carlton, VIC, Australia
- Faculty of Health, School of Nursing and Midwifery, Deakin University, Burwood, VIC, Australia
- The Royal Melbourne Hospital and The University of Melbourne, Parkville, VIC, Australia
- Elizabeth Manias, Faculty of Health, School of Nursing and Midwifery, Deakin University, 221 Burwood Highway, Burwood, VIC 3125, Australia.
| | - Noel Cranswick
- Clinical Pharmacology Unit, Department of Medicine, The Royal Children’s Hospital, Melbourne, VIC, Australia
- Australian Paediatric Pharmacology Research Unit (APPRU), Murdoch Childrens Research Institute and The Royal Children’s Hospital, Melbourne, VIC, Australia
- The University of Melbourne, Parkville, VIC, Australia
| | - Ellie Rosenfeld
- Melbourne School of Health Sciences, The University of Melbourne, Carlton, VIC, Australia
| | - Fiona Newall
- Nursing Research, The Royal Children’s Hospital, Melbourne, VIC, Australia
- Clinical Haematology, Departments of Nursing and Paediatrics, The University of Melbourne, Parkville, VIC, Australia
- Murdoch Childrens Research Institute, Parkville, VIC, Australia
| | - Allison Williams
- School of Nursing and Midwifery, Monash University, Clayton, VIC, Australia
| | - Narelle Borrott
- Melbourne School of Health Sciences, The University of Melbourne, Carlton, VIC, Australia
| | - Sharon Kinney
- Nursing Research, The Royal Children’s Hospital, Melbourne, VIC, Australia
- Departments of Nursing and Paediatrics, The University of Melbourne, Parkville, VIC, Australia
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Martin LD, Jimenez N, Lynn AM. A review of perioperative anesthesia and analgesia for infants: updates and trends to watch. F1000Res 2017; 6:120. [PMID: 28232869 PMCID: PMC5302152 DOI: 10.12688/f1000research.10272.1] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/03/2017] [Indexed: 01/13/2023] Open
Abstract
This review focuses on pharmacokinetics and pharmacodynamics of opioid and non-opioid analgesics in neonates and infants. The unique physiology of this population differs from that of adults and impacts drug handling. Morphine and remifentanil are described as examples of older versus recently developed opiates to compare and contrast pharmacokinetics and pharmacodynamics in infants. Exploration of genetics affecting both pharmacokinetics and pharmacodynamics of opiates is an area of active research, as is the investigation of a new class of mu-opiate-binding agents which seem selective for analgesic pathways while having less activity in pathways linked to side effects. The kinetics of acetaminophen and of ketorolac as examples of parenteral non-steroidal analgesics in infants are also discussed. The growth in regional anesthesia for peri-operative analgesia in infants can fill an important role minimizing intra-operative anesthetic exposure to opioids and transitioning to post-operative care. Use of multi-modal techniques is recommended to decrease undesirable opiate-related side effects in this vulnerable population.
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Affiliation(s)
- Lizabeth D Martin
- University of Washington School of Medicine, Department of Anesthesiology & Pain Medicine, Seattle Children’s Hospital, Seattle, WA, USA
| | - Nathalia Jimenez
- University of Washington School of Medicine, Department of Anesthesiology & Pain Medicine, Seattle Children’s Hospital, Seattle, WA, USA
| | - Anne M Lynn
- University of Washington School of Medicine, Department of Anesthesiology & Pain Medicine, Seattle Children’s Hospital, Seattle, WA, USA
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15
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Välitalo PA, Krekels EH, van Dijk M, Simons S, Tibboel D, Knibbe CA. Morphine Pharmacodynamics in Mechanically Ventilated Preterm Neonates Undergoing Endotracheal Suctioning. CPT-PHARMACOMETRICS & SYSTEMS PHARMACOLOGY 2017; 6:239-248. [PMID: 28109060 PMCID: PMC5397563 DOI: 10.1002/psp4.12156] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/03/2016] [Accepted: 11/03/2016] [Indexed: 11/08/2022]
Abstract
To date, morphine pharmacokinetics (PKs) are well quantified in neonates, but results about its efficacy are ambiguous. This work presents an analysis of a previously published study on pain measurements in mechanically ventilated preterm neonates who received either morphine or placebo to improve comfort during invasive ventilation. The research question was whether morphine reduces the pain associated with endotracheal or nasal suctioning before, during, and after suctioning. Because these neonates cannot verbalize their pain levels, pain was assessed on the basis of several validated pain measurement instruments (i.e., COMFORT‐B, preterm infant pain profile [PIPP], Neonatal Infant Pain Scale (NIPS), and visual analogue scale (VAS)). The item response theory (IRT) was used to analyze the data in order for us to handle the data from multiple‐item pain scores. The analysis showed an intra‐individual relationship between morphine concentrations and pain reduction, as measured by COMFORT‐B and VAS. However, the small magnitude of the morphine effect was not considered clinically relevant for this intervention in preterm neonates.
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Affiliation(s)
- P A Välitalo
- Division of Pharmacology, Leiden University, Leiden, The Netherlands
| | - E H Krekels
- Division of Pharmacology, Leiden University, Leiden, The Netherlands
| | - M van Dijk
- Intensive Care and Department of Pediatric Surgery Erasmus MC Sophia Children's Hospital, Rotterdam, The Netherlands.,Department of Pediatrics, Division of Neonatology, Erasmus MC Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Shp Simons
- Department of Pediatrics, Division of Neonatology, Erasmus MC Sophia Children's Hospital, Rotterdam, The Netherlands
| | - D Tibboel
- Intensive Care and Department of Pediatric Surgery Erasmus MC Sophia Children's Hospital, Rotterdam, The Netherlands
| | - C A Knibbe
- Division of Pharmacology, Leiden University, Leiden, The Netherlands.,Intensive Care and Department of Pediatric Surgery Erasmus MC Sophia Children's Hospital, Rotterdam, The Netherlands.,Department of Clinical Pharmacy, St Antonius Hospital, Nieuwegein, The Netherlands
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16
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Developmental pharmacokinetics and pharmacodynamics of parenteral opioids and nonsteroidal anti-nflammatory drugs in neonates and infants☆. COLOMBIAN JOURNAL OF ANESTHESIOLOGY 2017. [DOI: 10.1097/01819236-201701000-00012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
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17
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Martin L, Jimenez N, Lynn AM. Developmental pharmacokinetics and pharmacodynamics of parenteral opioids and nonsteroidal anti-nflammatory drugs in neonates and infants. COLOMBIAN JOURNAL OF ANESTHESIOLOGY 2017. [DOI: 10.1016/j.rcae.2016.11.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
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18
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Martin L, Jimenez N, Lynn AM. Farmacología del desarrollo de analgésicos opioides y no esteroideos en neonatos e infantes. COLOMBIAN JOURNAL OF ANESTHESIOLOGY 2017. [DOI: 10.1016/j.rca.2016.10.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
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19
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Baarslag MA, Allegaert K, Van Den Anker JN, Knibbe CAJ, Van Dijk M, Simons SHP, Tibboel D. Paracetamol and morphine for infant and neonatal pain; still a long way to go? Expert Rev Clin Pharmacol 2016; 10:111-126. [PMID: 27785937 DOI: 10.1080/17512433.2017.1254040] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
INTRODUCTION Pharmacologic pain management in newborns and infants is often based on limited scientific data. To close the knowledge gap, drug-related research in this population is increasingly supported by the authorities, but remains very challenging. This review summarizes the challenges of analgesic studies in newborns and infants on morphine and paracetamol (acetaminophen). Areas covered: Aspects such as the definition and multimodal character of pain are reflected to newborn infants. Specific problems addressed include defining pharmacodynamic endpoints, performing clinical trials in this population and assessing developmental changes in both pharmacokinetics and pharmacodynamics. Expert commentary: Neonatal and infant pain management research faces two major challenges: lack of clear biomarkers and very heterogeneous pharmacokinetics and pharmacodynamics of analgesics. There is a clear call for integral research addressing the multimodality of pain in this population and further developing population pharmacokinetic models towards physiology-based models.
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Affiliation(s)
- Manuel A Baarslag
- a Intensive Care and department of Pediatric Surgery , Erasmus MC-Sophia Children's Hospital , Rotterdam , the Netherlands
| | - Karel Allegaert
- a Intensive Care and department of Pediatric Surgery , Erasmus MC-Sophia Children's Hospital , Rotterdam , the Netherlands.,b Department of development and regeneration , KU Leuven , Leuven , Belgium
| | - John N Van Den Anker
- a Intensive Care and department of Pediatric Surgery , Erasmus MC-Sophia Children's Hospital , Rotterdam , the Netherlands.,c Division of Clinical Pharmacology , Children's National Health System , Washington , DC , USA.,d Division of Pediatric Pharmacology and Pharmacometrics , University of Basel Children's Hospital , Basel , Switzerland
| | - Catherijne A J Knibbe
- e Department of Clinical Pharmacy , St. Antonius Hospital , Nieuwegein , The Netherlands.,f Division of Pharmacology, Leiden Academic Center for Drug Research , Leiden University , Leiden , the Netherlands
| | - Monique Van Dijk
- a Intensive Care and department of Pediatric Surgery , Erasmus MC-Sophia Children's Hospital , Rotterdam , the Netherlands.,g Department of Pediatrics, division of Neonatology , Erasmus MC-Sophia Children's Hospital , Rotterdam , the Netherlands
| | - Sinno H P Simons
- g Department of Pediatrics, division of Neonatology , Erasmus MC-Sophia Children's Hospital , Rotterdam , the Netherlands
| | - Dick Tibboel
- a Intensive Care and department of Pediatric Surgery , Erasmus MC-Sophia Children's Hospital , Rotterdam , the Netherlands
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Abstract
A growing body of evidence demonstrates that untreated pain is associated with adverse consequences that can compromise clinical and developmental outcomes in children but that these adverse consequences can be prevented or attenuated by appropriate analgesic therapy. Thus, effective treatment of acute pain must be a clinical priority for children of all ages. Over the past 20 years, extensive pediatric research exploring pain assessment, developmental pharmacology of analgesics, and the clinical use of analgesics has dispelled many myths and misconceptions about pain management in pediatric patients; proven that analgesics can be used safely in neonates, infants, and children; and provided a framework for the development of pediatric pain management guidelines. This article reviews guidelines recommended for managing acute pain in pediatric patients and the treatment options for children experiencing acute pain. Contemporary issues regarding acetaminophen, nonsteroidal anti-inflammatory agents, and opioids are discussed.
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Affiliation(s)
- Paul C. Walker
- Departement of Pharmacy Services, University of Michigan Health System, College of Pharmacy at the University of Michigan,
| | - Deborah S. Wagner
- College of Pharmacy and Medical School, University of Michigan and Clinical Pharmacist, Department of Pharmacy Services, University of Michigan Health System
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21
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Abstract
As a standard of care for preterm/term newborns effective pain management may improve their clinical and neurodevelopmental outcomes. Neonatal pain is assessed using context-specific, validated, and objective pain methods, despite the limitations of currently available tools. Therapeutic approaches reducing invasive procedures and using pharmacologic, behavioral, or environmental measures are used to manage neonatal pain. Nonpharmacologic approaches like kangaroo care, facilitated tucking, non-nutritive sucking, sucrose, and others can be used for procedural pain or adjunctive therapy. Local/topical anesthetics, opioids, NSAIDs/acetaminophen and other sedative/anesthetic agents can be incorporated into NICU protocols for managing moderate/severe pain or distress in all newborns.
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22
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Confronting the challenges of effective pain management in children following tonsillectomy. Int J Pediatr Otorhinolaryngol 2014; 78:1813-27. [PMID: 25241379 DOI: 10.1016/j.ijporl.2014.08.011] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2014] [Accepted: 08/11/2014] [Indexed: 12/29/2022]
Abstract
Tonsillectomy is an extremely common surgical procedure associated with significant morbidity and mortality. The post-operative challenges include: respiratory complications, post-tonsillectomy hemorrhage, nausea, vomiting and significant pain. The present model of care demands that most of these children are managed in an ambulatory setting. The recent Federal Drug Agency (FDA) warning contraindicating the use of codeine after tonsillectomy in children represents a significant change of practice for many pediatric otolaryngological surgeons. This introduces a number of other safety concerns when deciding on a safe alternative to codeine, especially since most tonsillectomy patients are managed by lay primary caregiver's at home. This review outlines the safety issues and proposes, based on currently available evidence, a preventative multi-modal strategy to manage pain, nausea and vomiting without increasing the risk of post-tonsillectomy bleeding.
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23
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Czarnecki ML, Hainsworth K, Simpson PM, Arca MJ, Uhing MR, Varadarajan J, Weisman SJ. Is there an alternative to continuous opioid infusion for neonatal pain control? A preliminary report of parent/nurse-controlled analgesia in the neonatal intensive care unit. Paediatr Anaesth 2014; 24:377-85. [PMID: 24417623 PMCID: PMC4331187 DOI: 10.1111/pan.12332] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/20/2013] [Indexed: 11/28/2022]
Abstract
BACKGROUND Continuous opioid infusion (COI) remains the mainstay of analgesic therapy in the neonatal intensive care unit (NICU). Parent/nurse-controlled analgesia (PNCA) has been accepted as safe and effective for pediatric patients, but few reports include use in neonates. This study sought to compare outcomes of PNCA and COI in postsurgical neonates and young infants. METHODS Twenty infants treated with morphine PNCA were retrospectively compared with 13 infants treated with fentanyl COI in a Midwestern pediatric hospital in the United States. Outcome measures included opioid consumption, pain scores, frequency of adverse events, and subsequent methadone use. RESULTS The PNCA group (median 6.4 μg · kg(-1) · h(-1) morphine equivalents, range 0.0-31.4) received significantly less opioid (P < 0.001) than the COI group (median 40.0 μg · kg(-1) · h(-1) morphine equivalents; range 20.0-153.3), across postoperative days 0-3. Average daily pain scores (based on 0-10 scale) were low for both groups, but median scores differed nonetheless (0.8 PNCA vs 0.3 COI, P < 0.05). There was no significant difference in the frequency of adverse events or methadone use. CONCLUSION Results suggest PNCA may be a feasible and effective alternative to COI for pain management in postsurgical infants in the NICU. Results also suggest PNCA may provide more individualized care for this vulnerable population and in doing so, may potentially reduce opioid consumption; however, more studies are needed.
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Affiliation(s)
- Michelle L. Czarnecki
- Jane B. Pettit Pain Management Center, Children’s Hospital of Wisconsin, Milwaukee, USA
| | - Keri Hainsworth
- Jane B. Pettit Pain Management Center, Children’s Hospital of Wisconsin, Milwaukee, USA,Department of Anesthesiology, Medical College of Wisconsin, Milwaukee, USA
| | - Pippa M. Simpson
- Department of Quantitative Health Sciences, Medical College of Wisconsin, Milwaukee, USA,Department of Pediatrics, Medical College of Wisconsin, Milwaukee, USA
| | - Marjorie J. Arca
- Department of Surgery, Medical College of Wisconsin, Milwaukee, USA,Department of Pediatrics, Medical College of Wisconsin, Milwaukee, USA
| | - Michael R. Uhing
- Department of Pediatrics, Medical College of Wisconsin, Milwaukee, USA,Department of neonatology, Medical College of Wisconsin, Milwaukee, USA
| | - Jaya Varadarajan
- Jane B. Pettit Pain Management Center, Children’s Hospital of Wisconsin, Milwaukee, USA,Department of Anesthesiology, Medical College of Wisconsin, Milwaukee, USA
| | - Steven J. Weisman
- Jane B. Pettit Pain Management Center, Children’s Hospital of Wisconsin, Milwaukee, USA,Department of Anesthesiology, Medical College of Wisconsin, Milwaukee, USA,Department of Pediatrics, Medical College of Wisconsin, Milwaukee, USA
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24
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Bernard R, Salvi N, Gall O, Egan M, Treluyer JM, Carli PA, Orliaguet GA. MORPHIT: an observational study on morphine titration in the postanesthetic care unit in children. Paediatr Anaesth 2014; 24:303-8. [PMID: 24205822 DOI: 10.1111/pan.12286] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/02/2013] [Indexed: 11/29/2022]
Abstract
BACKGROUND Little information is available on the titration of morphine postoperatively in children. This observational study describes the technique in terms of the bolus dose, the number of boluses required, the time to establish analgesia, and side effects noted. METHODS Morphine was administered if pain score (VAS or FLACC) was >30. Patients weighing less than 45 kg received a 50 μg·kg(-1) bolus of morphine with subsequent boluses of 25 μg kg(-1) as required. Patients weighing over 45 kg received boluses of 2 mg. Pain and Ramsay scores were recorded up to 90 min after the end of the titration and any side effect or complication was noted. Data are presented as the median [interquartile Q1-Q3 range]. RESULTS Overall, 103 children were studied. The median age was 4.2 years [0.8-12.2 years]. The median weight was 15.5 kg [8.2-35.0 kg]. The protocol was effective for pain control with a significant decrease in pain scores over time. The median pain score (VAS or FLACC) was 70 [50-80] prior to the initial bolus and 0 [0-10] 90 min after the last bolus. Median Ramsay score was 1 [1-2] before the initial bolus administration and 4 [2-4] at 90 min. The median total dose of morphine was 100 [70-140] μg·kg(-1) , and the median number of boluses was 3 [2-5]. Side effects were observed in 17% of cases. No serious complications were observed. CONCLUSIONS Our study of morphine titration for children shows that our protocol was effective for pain control with a significant decrease in pain scores over time. No serious complications were encountered. More studies on larger cohorts of patients are needed to confirm the efficacy and safety of this protocol.
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Affiliation(s)
- Remy Bernard
- Service d'Anesthésie Réanimation, Hôpital Universitaire Necker - Enfants Malades, Université Paris Descartes, Assistance Publique Hôpitaux de Paris, Paris, France
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Maitra S, Baidya DK, Khanna P, Ray BR, Panda SS, Bajpai M. Acute perioperative pain in neonates: An evidence-based review of neurophysiology and management. ACTA ACUST UNITED AC 2014; 52:30-7. [DOI: 10.1016/j.aat.2014.02.004] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2013] [Accepted: 02/10/2014] [Indexed: 10/25/2022]
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Krekels EHJ, Tibboel D, de Wildt SN, Ceelie I, Dahan A, van Dijk M, Danhof M, Knibbe CAJ. Evidence-Based Morphine Dosing for Postoperative Neonates and Infants. Clin Pharmacokinet 2014; 53:553-63. [DOI: 10.1007/s40262-014-0135-4] [Citation(s) in RCA: 60] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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27
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Wang C, Sadhavisvam S, Krekels EHJ, Dahan A, Tibboel D, Danhof M, Vinks AA, Knibbe CAJ. Developmental changes in morphine clearance across the entire paediatric age range are best described by a bodyweight-dependent exponent model. Clin Drug Investig 2014; 33:523-34. [PMID: 23754691 DOI: 10.1007/s40261-013-0097-6] [Citation(s) in RCA: 51] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND AND OBJECTIVE Morphine clearance has been successfully scaled from preterm neonates to 3-year-old children on the basis of a bodyweight-based exponential (BDE) function and age younger or older than 10 days. The aim of the current study was to characterize the developmental changes in morphine clearance across the entire paediatric age range. METHODS Morphine and morphine-3-glucuronide (M3G) concentration data from 358 (pre)term neonates, infants, children and adults, and morphine concentration data from 117 adolescents were analysed using NONMEM 7.2. Based on available data, two models were developed: I. using morphine data; II. using morphine and M3G data. RESULTS In model I, morphine clearance across the paediatric age range was very well described by a BDE function in which the allometric exponent decreased in a sigmoidal manner with bodyweight (BDE model) from 1.47 to 0.88, with half the decrease in exponent reached at 4.01 kg. In model II, the exponent for the formation and elimination clearance of M3G was found to decrease from 1.56 to 0.89 and from 1.06 to 0.61, with half the decrease reached at 3.89 and 4.87 kg, respectively. Using the BDE model, there was no need to use additional measures for size or age. CONCLUSION The BDE model was able to scale both total morphine clearance and glucuronidation clearance through the M3G pathway across all age ranges between (pre)term neonates and adults by allowing the allometric exponent to decrease across the paediatric age range from values higher than 1 for neonates to values lower than 1 for infants and children.
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Affiliation(s)
- Chenguang Wang
- LACDR, Division of Pharmacology, Leiden University, Leiden, The Netherlands
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28
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Abstract
The interplay of pain, discomfort, and fear can cause agitation in critically ill children. Therefore, sedation and analgesia are essential components in the intensive care unit setting and are best managed with a multidisciplinary team approach. No one standard approach exists to assess and manage pain and anxiety. Many tools are available for the assessment of pain and sedation, but each tool has its advantages and disadvantages. Clinicians should consider adopting a validated tool for routine continuous assessment. Multiple pharmacological therapies are available to manage pain, anxiety, fear, and agitation. Dosing of these agents can be influenced by age-related pharmacokinetic and pharmacodynamic changes. Agents should be selected on the basis of the child's disease state, desired level of sedation, and cardiac and respiratory status.
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Abstract
OBJECTIVES To determine the cumulative opioid doses administered to patients with Down syndrome after cardiac surgery and compare them with patients without Down syndrome. DESIGN Retrospective observational comparative study. SETTING PICU in a university-affiliated freestanding pediatric teaching hospital. PATIENTS Infants and children who presented to our institution for heart surgery after July 1, 2008, and met the following criteria: 1) no opioid medications for 48 hours prior to surgery, 2) sternotomy approach with primary closure, and 3) no additional operative procedures in the 5 days after surgery. All patients with Down syndrome were included, and patients without Down syndrome with similar age, type of cardiac lesion, and length of surgical procedure were selected in a ~2:1 ratio, blinded to opioid exposure. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Clinical and demographic data were extracted from electronic medical record data. Univariate analyses and multivariate linear regression modeling were performed to determine the influence of Down syndrome, patient characteristics, and clinical covariates on weight-adjusted opioid dose. The differences in median cumulative opioid doses between those with Down syndrome (n = 44) and those without Down syndrome (n = 77) were not significant in the first 24 hours (+0.39 mg/kg [95% CI, -0.45 to +1.39 mg/kg]) or 96 hours (+0.54 mg/kg [95% CI, -0.59 to +2.07 mg/kg]) after surgery. Age, cardiac bypass time, benzodiazepines, and neuromuscular blocking agents were significantly correlated with opioid dose, but Down syndrome, gender, pain score, creatinine, acetaminophen, nonsteroidal anti-inflammatory drugs, and steroid medications were not. Patients with Down syndrome had longer hospital stays; in multivariate analysis, higher opioid exposures in the first 96 hours after surgery and higher peak serum creatinine values correlated with longer hospitalization. CONCLUSIONS This cohort did not provide evidence for opioid resistance in patients with Down syndrome. Younger age, longer cardiac bypass time, exposure to benzodiazepines, and neuromuscular blockade did correlate with increased opioid doses after cardiac surgery.
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30
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Wong C, Lau E, Palozzi L, Campbell F. Pain management in children: Part 2 - A transition from codeine to morphine for moderate to severe pain in children. Can Pharm J (Ott) 2013; 145:276-279.e1. [PMID: 23509589 DOI: 10.3821/145.6.cpj276] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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31
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Abstract
The provision of care to the newborn or young infant at the end of life is primarily motivated by concern and compassion. When examining the evidence base for most interventions, it is lacking - but this is not unique to this aspect of neonatal care. Nevertheless, a redirection of care from cure-oriented and life-extending measures to comfort and limitations of life-sustaining technologic interventions requires the neonatologist to apply practical knowledge skillfully and with prudence. Clinicians can acknowledge that patient needs require managing their end-of-life symptoms now; neither these patients nor their families should have to wait for research to catch up to their current needs.
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Affiliation(s)
- Brian S Carter
- University of Missouri-Kansas City, Bioethics Center & Section of Neonatology, Children's Mercy Hospital, Kansas City, MO, USA.
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32
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33
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Jimenez N, Anderson GD, Shen DD, Nielsen SS, Farin FM, Seidel K, Lynn AM. Is ethnicity associated with morphine's side effects in children? Morphine pharmacokinetics, analgesic response, and side effects in children having tonsillectomy. Paediatr Anaesth 2012; 22:669-75. [PMID: 22486937 PMCID: PMC3366036 DOI: 10.1111/j.1460-9592.2012.03844.x] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVES/AIMS To examine whether morphine pharmacokinetics (PK) and/or genetic polymorphisms in opioid-related genes, underlie differences in analgesic response and side effects to morphine in Latino (L) vs non-Latino Caucasian (NL) children. BACKGROUND Morphine has high interindividual variability in its analgesic response and side effects profile. Earlier studies suggest that morphine response may vary by race and ethnicity. METHODS Prospective cohort study in L and NL children, 3-17 years of age comparing pain scores, occurrence of side effects, plasma morphine, morphine-6- and morphine-3-glucuronide concentrations measured after a single morphine IV bolus administration. Noncompartmental pharmacokinetic analysis and genotyping for 28 polymorphisms in eight genes (UGT1A8, UGT2B7, ABCB1, COMT, STAT6, MC1R, OPRM1, and ARRB2) were performed. RESULTS We enrolled 68 children (33 L, 35 NL). There were no differences in pain scores or need for rescue analgesia. Statistically significant differences in the occurrence of side effects were documented: While 58% of L children experienced at least one side effect only 20% of NL did (P = 0.001). Pruritus was four times (P = 0.006) and emesis seven times (P = 0.025) more frequent in L compared with NL. PK parameters were similar between groups. None of the assessed polymorphisms mediated the association between ethnicity and side effects. CONCLUSIONS We found statistically significant differences in the occurrence of side effects after morphine administration between L and NL children. Neither differences in morphine or metabolite concentrations, nor the genetic polymorphisms examined explain these findings. Studies are needed to further investigate reasons for the increase in morphine side effects by Latino ethnicity.
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Affiliation(s)
- Nathalia Jimenez
- Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, WA, USA.
| | | | - Danny D. Shen
- Department of Pharmacy; University of Washington, Seattle, WA
| | | | - Federico M. Farin
- Environmental and Occupational Health Sciences, University of Washington, Seattle, WA
| | - Kristy Seidel
- Biostatistical Services Seattle Children's Hospital, Seattle, WA
| | - Anne M. Lynn
- Department of Anesthesiology and Pain Medicine; University of Washington, Seattle, WA
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Aubrun F, Mazoit JX, Riou B. Postoperative intravenous morphine titration. Br J Anaesth 2012; 108:193-201. [DOI: 10.1093/bja/aer458] [Citation(s) in RCA: 98] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Krekels EHJ, van Hasselt JGC, Tibboel D, Danhof M, Knibbe CAJ. Systematic evaluation of the descriptive and predictive performance of paediatric morphine population models. Pharm Res 2011; 28:797-811. [PMID: 21153913 PMCID: PMC3063866 DOI: 10.1007/s11095-010-0333-1] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2010] [Accepted: 11/17/2010] [Indexed: 11/13/2022]
Abstract
PURPOSE A framework for the evaluation of paediatric population models is proposed and applied to two different paediatric population pharmacokinetic models for morphine. One covariate model was based on a systematic covariate analysis, the other on fixed allometric scaling principles. METHODS The six evaluation criteria in the framework were 1) number of parameters and condition number, 2) numerical diagnostics, 3) prediction-based diagnostics, 4) η-shrinkage, 5) simulation-based diagnostics, 6) diagnostics of individual and population parameter estimates versus covariates, including measurements of bias and precision of the population values compared to the observed individual values. The framework entails both an internal and external model evaluation procedure. RESULTS The application of the framework to the two models resulted in the detection of overparameterization and misleading diagnostics based on individual predictions caused by high shrinkage. The diagnostic of individual and population parameter estimates versus covariates proved to be highly informative in assessing obtained covariate relationships. Based on the framework, the systematic covariate model proved to be superior over the fixed allometric model in terms of predictive performance. CONCLUSIONS The proposed framework is suitable for the evaluation of paediatric (covariate) models and should be applied to corroborate the descriptive and predictive properties of these models.
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Affiliation(s)
- Elke H. J. Krekels
- Division of Pharmacology, Leiden/Amsterdam Center for Drug Research, Leiden, The Netherlands
- Department of Pediatric Surgery, Erasmus MC-Sophia Children’s Hospital, Rotterdam, The Netherlands
| | - Johan G. C. van Hasselt
- Division of Pharmacology, Leiden/Amsterdam Center for Drug Research, Leiden, The Netherlands
| | - Dick Tibboel
- Department of Pediatric Surgery, Erasmus MC-Sophia Children’s Hospital, Rotterdam, The Netherlands
| | - Meindert Danhof
- Division of Pharmacology, Leiden/Amsterdam Center for Drug Research, Leiden, The Netherlands
| | - Catherijne A. J. Knibbe
- Division of Pharmacology, Leiden/Amsterdam Center for Drug Research, Leiden, The Netherlands
- Department of Pediatric Surgery, Erasmus MC-Sophia Children’s Hospital, Rotterdam, The Netherlands
- Department of Clinical Pharmacy, St. Antonius Hospital, P.O. Box 2500, Nieuwegein, 3430 EM The Netherlands
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Durrmeyer X, Vutskits L, Anand KJS, Rimensberger PC. Use of analgesic and sedative drugs in the NICU: integrating clinical trials and laboratory data. Pediatr Res 2010; 67:117-27. [PMID: 20091937 DOI: 10.1203/pdr.0b013e3181c8eef3] [Citation(s) in RCA: 108] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Recent advances in neonatal intensive care include and are partly attributable to growing attention for comfort and pain control in the term and preterm infant requiring intensive care.Limitation of painful procedures is certainly possible, but most critically ill infants require unavoidable painful or stressful procedures such as intubation, mechanical ventilation, or catheterization.Many analgesics (opioids and nonsteroidal anti-inflammatory drugs)and sedatives (benzodiazepines and other anesthetic agents) are available but their use varies considerably among units. This review summarizes current experimental knowledge on the effects of sedative and analgesic drugs on brain development and reviews clinical evidence that speaks for or against the use of common analgesic and sedative drugs in the NICU but avoids any discussion of anesthesia during surgery. Risk/benefit ratios of intermittent boluses or continuous infusions for the commonly used sedative and analgesic agents are discussed in the light of clinical and experimental studies. The limitations of extrapolating experimental results from animals to humans must be considered while making practical recommendations based on the currently available evidence.
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Affiliation(s)
- Xavier Durrmeyer
- Neonatal Intensive Care Unit, Centre Hospitalier Intercommunal de Créteil, Créteil 94000, France
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37
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Gall O. Comment utiliser les morphiniques en périopératoire ? Spécificités pédiatriques. ACTA ACUST UNITED AC 2009; 28:e43-7. [DOI: 10.1016/j.annfar.2008.12.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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38
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Fitzgerald M, Walker SM. Infant pain management: a developmental neurobiological approach. ACTA ACUST UNITED AC 2009; 5:35-50. [DOI: 10.1038/ncpneuro0984] [Citation(s) in RCA: 194] [Impact Index Per Article: 12.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2008] [Accepted: 10/31/2008] [Indexed: 12/21/2022]
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Abstract
Significant advances in the assessment and management of acute pain in children have been made, and are supported by an increase in the availability and accessibility of evidence-based data. However, methodological and practical issues in the design and performance of clinical paediatric trials limit the quantity, and may influence the quality, of current data, which lags behind that available for adult practice. Collaborations within research networks, which incorporate both preclinical and clinical studies, may increase the feasibility and specificity of future trials. In early life, the developing nervous system responds differently to pain, analgesia, and injury, resulting in effects not seen in later life and which may have long-term consequences. Translational laboratory studies further our understanding of developmental changes in nociceptor pathway structure and function, analgesic pharmacodynamics, and the impact of different forms of injury. Chronic pain in children has a negative impact on quality of life, resulting in social and emotional consequences for both the child and the family. Despite age-related differences in many chronic pain conditions, such as neuropathic pain, management in children is often empirically based on data from studies in adults. There is a major need for further clinical research, training of health-care providers, and increased resources, to improve management and outcomes for children with chronic pain.
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Affiliation(s)
- S M Walker
- Portex Department of Anaesthesia, UCL Institute of Child Health and Great Ormond Street Hospital NHS Trust, 30 Guilford Street, London WC1N 1EH, UK.
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40
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El Sayed MF, Taddio A, Fallah S, De Silva N, Moore AM. Safety profile of morphine following surgery in neonates. J Perinatol 2007; 27:444-7. [PMID: 17592487 DOI: 10.1038/sj.jp.7211764] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
OBJECTIVE To determine the effect of morphine on duration of mechanical ventilation, apnoea and hypotension among full-term neonates who underwent thoracic or abdominal surgery in a level III neonatal intensive care unit. METHOD Medical records of 82 infants were reviewed retrospectively and data including patient demographics, clinical diagnosis, type of surgery, postoperative opioid administration, duration of mechanical ventilation, hypotension, apnoea and pain scores (premature infant pain profile (PIPP) score) were collected. RESULT Sixty-two neonates (76%) received morphine following surgery as a continuous intravenous infusion during the postoperative period. Linear regression analysis showed that morphine dosage and duration were significantly associated with the duration of mechanical ventilation. An increase in morphine infusion rate by 10 microg kg(-1) h(-1) was associated with an increase in the duration of mechanical ventilation by 24 h (P<0.0001) and an increase in morphine duration of 1 hour was associated with a longer duration of mechanical ventilation by 38 min (P<0.0001). Logistic regression analysis showed no association between morphine infusion rate or duration and hypotension. Apnoea was not associated with morphine dosage or duration of infusion in neonates receiving morphine following extubation. Score on the PIPP correlated significantly with morphine infusion rate across time (r=0.47, P<0.01). CONCLUSION Postoperative morphine dose and duration may prolong the duration of mechanical ventilation but there are no significant dose-dependent effects on other parameters including apnoea or hypotension following extubation in term neonates. More research is needed to determine the safety profile of morphine for management of pain in non-ventilated neonates.
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MESH Headings
- Analgesics, Opioid/administration & dosage
- Analgesics, Opioid/adverse effects
- Analgesics, Opioid/therapeutic use
- Female
- Humans
- Infant, Newborn
- Infant, Newborn, Diseases/surgery
- Infusions, Intravenous
- Intensive Care Units, Neonatal
- Male
- Medical Records
- Morphine/administration & dosage
- Morphine/adverse effects
- Morphine/therapeutic use
- Ontario
- Pain, Postoperative/prevention & control
- Postoperative Complications
- Respiration, Artificial
- Retrospective Studies
- Safety
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Affiliation(s)
- M F El Sayed
- Department of Paediatrics, Division of Neonatology, Sick Kids, Toronto, ON, Canada.
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Peters JWB, Anderson BJ, Simons SHP, Uges DRA, Tibboel D. Morphine metabolite pharmacokinetics during venoarterial extra corporeal membrane oxygenation in neonates. Clin Pharmacokinet 2006; 45:705-14. [PMID: 16802851 DOI: 10.2165/00003088-200645070-00005] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
OBJECTIVE To examine morphine metabolite serum concentrations in neonates undergoing venoarterial extra corporeal membrane oxygenation (ECMO) and to quantify clearance differences between these neonates and those subjected to noncardiac major surgery. PATIENTS AND METHODS This was an observational study in level III referral centre. Fourteen neonates (< 7 days old) undergoing ECMO were included. Morphine and concomitant medications were given by protocol, adapted to the clinical conditions of the neonates. Pharmacokinetic findings were compared with those from a previous study in infants after noncardiac major surgery. Nonlinear mixed-effect modelling was used. Parameter estimates were standardised to a 70 kg person using allometric modeling RESULTS Morphine-3-glucuronide (M3G) was the predominant metabolite. Formation clearance to M3G at the start of ECMO on day 1 was lower than those in postoperative children, but matured more rapidly. After 10 days formation clearances of M3G in neonates on ECMO equalled those of postoperative children. Higher ECMO flows were associated with reduced formation clearances. Elimination clearances of M3G, but not morphine-6-glucuronide (M6G), were lower in the ECMO neonates; this was attributable to reduced renal clearance. These elimination clearances were correlated positively with ECMO flow and negatively with dopamine dose. Haemofiltration cleared M3G and M6G, but not morphine. CONCLUSION Formation clearance to M3G, the predominant metabolite, is reduced during the first 10 days of ECMO. Elimination clearance of M3G and M6G is related to creatinine clearance. ECMO flow had a small effect on metabolite clearance. Higher flows were associated with decreased formation clearances, possibly reflecting illness severity. Dopamine dose reflected decreased renal clearance.
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Affiliation(s)
- Jeroen W B Peters
- Department of Pediatric Surgery, Erasmus MC-Sophia, Rotterdam, The Netherlands.
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42
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Zissen MH, Zhang G, McKelvy A, Propst JT, Kendig JJ, Sweitzer SM. Tolerance, opioid-induced allodynia and withdrawal associated allodynia in infant and young rats. Neuroscience 2006; 144:247-62. [PMID: 17055659 PMCID: PMC1858640 DOI: 10.1016/j.neuroscience.2006.08.078] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2005] [Revised: 08/23/2006] [Accepted: 08/29/2006] [Indexed: 10/24/2022]
Abstract
Our laboratory has previously characterized age-dependent changes in nociception upon acute morphine withdrawal. This study characterizes changes in mechanical and thermal nociception following acute, intermittent, or continuous morphine administration in infant (postnatal days 5-8) and young (postnatal days 19-21) rats. Morphine was given as a single acute administration (AM), intermittently twice a day for 3 days (IM), or continuously for 72 h via pump (CM). AM did not produce long-term changes in mechanical or thermal nociception in either infant or young rats. CM produced changes in mechanical nociception that included the development of tolerance, opioid-induced mechanical allodynia and withdrawal-associated mechanical allodynia in young rats, but only tolerance and a prolonged withdrawal-associated mechanical allodynia in infant rats. IM produced withdrawal-associated mechanical allodynia in both infant and young rats. Measuring paw withdrawal responses to thermal stimuli, infant and young rats showed tolerance without opioid-induced thermal hyperalgesia or withdrawal-associated thermal hyperalgesia following CM. In contrast to CM, withdrawal-associated thermal hyperalgesia was seen in both ages following IM. In conclusion, CM versus IM differentially modified mechanical and thermal nociception, suggesting that opioid-dependent thermal hyperalgesia and mechanical allodynia can be dissociated from each other in infant and young rats. Furthermore, tolerance, opioid-induced hypersensitivity, and withdrawal-associated hypersensitivity are age-specific and may be mediated by distinct mechanisms.
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Affiliation(s)
- Maurice H. Zissen
- Department of Anesthesia, Stanford University School of Medicine, Stanford, CA 94305
| | - Guohua Zhang
- Department of Pharmacology, Physiology, Neuroscience, University of South Carolina School of Medicine, Columbia, SC 29229
| | - Alvin McKelvy
- Department of Pharmacology, Physiology, Neuroscience, University of South Carolina School of Medicine, Columbia, SC 29229
| | - John T. Propst
- Department of Pharmacology, Physiology, Neuroscience, University of South Carolina School of Medicine, Columbia, SC 29229
| | - Joan J. Kendig
- Department of Anesthesia, Stanford University School of Medicine, Stanford, CA 94305
| | - Sarah M. Sweitzer
- Department of Pharmacology, Physiology, Neuroscience, University of South Carolina School of Medicine, Columbia, SC 29229
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Simons SHP, Anand KJS. Pain control: opioid dosing, population kinetics and side-effects. Semin Fetal Neonatal Med 2006; 11:260-7. [PMID: 16621750 DOI: 10.1016/j.siny.2006.02.008] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Neonates undergoing invasive procedures, postoperative pain or ventilatory support commonly receive opioids for treating pain and stress. Randomized clinical trials have examined the benefits and adverse effects of morphine or fentanyl for ventilated neonates and other indications. This paper summarizes the current evidence for opioid dosing in newborns, reviews their side-effects and explains the use of population kinetics and non-linear mixed-effects modeling to analyze the data from clinical trials. Opioid use should be reserved for severe pain postoperatively or during intensive care in neonates, using continuous infusions rather than intermittent boluses. The safety and efficacy data from prolonged opioid use, particularly on the long-term outcomes of neonates, is still lacking. The pharmacodynamics and pharmacogenetics of opioid use in infancy needs further investigation, using non-linear mixed-effects models to drive individualized therapy. The current interest in opioid research will reap rich dividends in providing pain relief for neonates and avoiding dangerous side effects.
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Affiliation(s)
- Sinno H P Simons
- Department of Pediatric Surgery, Erasmus-MC/Sophia Children's Hospital, Rotterdam, The Netherlands.
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Berde CB, Jaksic T, Lynn AM, Maxwell LG, Soriano SG, Tibboel D. Anesthesia and analgesia during and after surgery in neonates. Clin Ther 2006; 27:900-21. [PMID: 16117991 DOI: 10.1016/j.clinthera.2005.06.020] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/20/2005] [Indexed: 10/25/2022]
Abstract
BACKGROUND Historically, the use of anesthetics and analgesics in neonates and infants has been based on extrapolations from studies performed in adults and older children. Over the past 20 years, there has been a growing body of research on the clinical pharmacology and clinical outcomes of these agents in neonates and infants. OBJECTIVE This article summarizes clinical pharmacology and clinical outcomes studies of opioids, opioid antagonists, sedative-hypnotics, nonsteroidal anti-inflammatory drugs and acetaminophen, and local anesthetics in neonates and infants to highlight gaps in the available knowledge, review some concerns about study design, and identify drugs that should receive high priority for future study. METHODS Relevant studies were identified through a search of MEDLINE and a review of textbooks, conference proceedings, and abstracts. The available literature was subjected to expert committee-based review. CONCLUSIONS There is a growing body of information on analgesic and anesthetic pharmacokinetics, pharmacodynamics, and clinical outcomes in neonates and infants, permitting safe and effective use in some clinical settings. Major gaps in knowledge persist, however. Future research may involve a combination of clinical trials and preclinical studies in suitable infant animal surrogate models.
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Affiliation(s)
- Charles B Berde
- Department of Anaesthesia, Children's Hospital, Harvard Medical School, Boston, MA 02115, USA.
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45
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Edginton AN, Schmitt W, Voith B, Willmann S. A Mechanistic Approach for the Scaling of Clearance in Children. Clin Pharmacokinet 2006; 45:683-704. [PMID: 16802850 DOI: 10.2165/00003088-200645070-00004] [Citation(s) in RCA: 160] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
BACKGROUND AND OBJECTIVE Clearance is an important pharmacokinetic concept for scaling dosage, understanding the risks of drug-drug interactions and environmental risk assessment in children. Accurate clearance scaling to children requires prior knowledge of adult clearance mechanisms and the age-dependence of physiological and enzymatic development. The objective of this research was to develop and evaluate ontogeny models that would provide an assessment of the age-dependence of clearance. METHODS Using in vitro data and/or in vivo clearance values for children for eight compounds that are eliminated primarily by one process, models for the ontogeny of renal clearance, cytochrome P450 (CYP) 3A4, CYP2E1, CYP1A2, uridine diphosphate glucuronosyltransferase (UGT) 2B7, UGT1A6, sulfonation and biliary clearance were developed. Resulting ontogeny models were evaluated using six compounds that demonstrated elimination via multiple pathways. The proportion of total clearance attributed to each clearance pathway in adults was delineated. Each pathway was individually scaled to the desired age, inclusive of protein-binding prediction, and summed to generate a total plasma clearance for the child under investigation. The paediatric age range included in the study was premature neonates to sub-adults. RESULTS There was excellent correlation between observed and predicted clearances for the model development (R2 = 0.979) and test sets (Q2 = 0.927). Clearance in premature neonates could also be well predicted (development R2 = 0.951; test Q2 = 0.899). CONCLUSION Paediatric clinical trial development could greatly benefit from clearance scaling, particularly in guiding dosing regimens. Furthermore, since the proportion of clearance via different elimination pathways is age-dependent, information could be gained on the developmental extent of drug-drug interactions.
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Affiliation(s)
- Andrea N Edginton
- Competence Center Systems Biology, Bayer Technology Services GmbH, Leverkusen, Germany.
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46
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Abstract
Pediatric hospitalists should make pain assessment and treatment a high priority and a central part of their daily practice. Efforts at improving pain treatment in pediatric hospitals should be multidisciplinary and should involve combined use of pharmacologic and nonpharmacologic approaches. Although available information can permit effective treatment of pain for most children in hospitals, there is a need for more research on pediatric analgesic pharmacology, various nonpharmacologic treatments, and different models of delivery of care.
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Affiliation(s)
- Christine Greco
- Department of Anesthesia, Children's Hospital Boston, 300 Longwood Avenue, Room 555, Boston, MA 02115, USA
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Peters JWB, Anderson BJ, Simons SHP, Uges DRA, Tibboel D. Morphine pharmacokinetics during venoarterial extracorporeal membrane oxygenation in neonates. Intensive Care Med 2005; 31:257-63. [PMID: 15678314 DOI: 10.1007/s00134-004-2545-5] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2004] [Accepted: 12/15/2004] [Indexed: 10/25/2022]
Abstract
OBJECTIVE To study morphine pharmacokinetics in neonates undergoing venoarterial ECMO and to quantify differences between these neonates and neonates subjected to noncardiac major surgery. DESIGN AND SETTING Observational study in a level III referral center. PATIENTS AND METHODS Pharmacokinetic estimates from 14 neonates undergoing ECMO were compared with findings from a previous study in 0- to 3-year-olds after noncardiac major surgery using a nonlinear mixed effect model. A one-compartment linear disposition model with zero-order input (infusion) and first-order elimination was used to describe all data. RESULTS Clearance in neonates (age <7 days) at the start of ECMO (2.2 l per hour per 70 kg) was lower than that in postoperative neonates (10.5 l per hour per 70 kg) but increased rapidly (maturation half-life 30 and 70 days, respectively) and equaled that of the postoperative group after 14 days. Clearance was affected by size and age only. Exchange transfusion, when used, contributed only 1.1% (CV 46%) of total clearance. Distribution volume increased with age and was 2.5 times (CV 102%) greater in ECMO children than in postoperative children. The between-subject variability values for volume of distribution and clearance were 49.4% and 38.7%. Weight and age information explained 83% of the overall clearance variability and 60% of overall distribution volume variability. CONCLUSIONS Morphine clearance is reduced in infants requiring ECMO, possibly reflecting severity of illness. Clearance maturation on ECMO is rapid and normalizes within 2 weeks. Initial morphine dosing may be guided by age and weight, but clearance and distribution volume changes (and their variability) during prolonged ECMO suggests that morphine therapy should be subsequently guided by clinical monitoring.
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Affiliation(s)
- Jeroen W B Peters
- Department of Pediatric Surgery, Erasmus Medical Center-Sophia, P.O. Box 2060, 3000 CB, Rotterdam, The Netherlands.
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Nandi R, Beacham D, Middleton J, Koltzenburg M, Howard RF, Fitzgerald M. The functional expression of mu opioid receptors on sensory neurons is developmentally regulated; morphine analgesia is less selective in the neonate. Pain 2004; 111:38-50. [PMID: 15327807 DOI: 10.1016/j.pain.2004.05.025] [Citation(s) in RCA: 63] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2004] [Revised: 05/11/2004] [Accepted: 05/20/2004] [Indexed: 11/29/2022]
Abstract
Opioid requirements in neonatal patients are reported to be lower than older infants and this may be a reflection of the developmental regulation of opioid receptors. In this study we have investigated the postnatal regulation of Mu opioid receptor (MOR) function in both rat lumbar dorsal root ganglion (DRG) cultures and behavioural mechanical and thermal reflex tests in rat pups. Immunostaining with MOR and selective neurofilament (NF200) antibodies was combined with calcium imaging of MOR function in cultured neonatal and adult rat dorsal root ganglion cells. Calcium imaging showed that a significantly greater number of neonatal DRG neurons expressed functional MOR compared to adult (56.5+/-3.4 versus 39.9+/-1.5%, n=8, mean+/-SEM, P<0.001). This expression is confined to the large, neurofilament positive sensory neurons, while expression in small, nociceptive, neurofilament negative neurons remains unchanged. Sensory threshold testing in rat pups showed that the analgesic potency of systemic morphine to mechanical stimulation is significantly greater in the neonate and declines with postnatal age. Morphine analgesic potency in thermal nociceptive tests did not change with postnatal age. These experiments show that the MOR expressed on large DRG neurons in neonates are functional and are subject to postnatal developmental regulation. This changing functional receptor profile is consistent with greater morphine potency in mechanical, but not thermal, sensory tests in young animals. These results have important clinical implications for the use of morphine in neonates and provide a possible explanation for the differences in morphine requirements observed in the youngest patients.
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Affiliation(s)
- Reema Nandi
- Department of Anatomy and Developmental Biology, University College London, Gower Street, London WC1E6BT, UK.
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Bozkurt P, Kaya G, Yeker Y, Altintaş F, Bakan M, Hacibekiroglu M, Bahar M. Effectiveness of morphine via thoracic epidural vs intravenous infusion on postthoracotomy pain and stress response in children. Paediatr Anaesth 2004; 14:748-54. [PMID: 15330957 DOI: 10.1111/j.1460-9592.2004.01278.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND Thoracotomy causes severe pain in the postoperative period. The aim was to evaluate effectiveness of two pain treatment methods with morphine on postthoracotomy pain and stress response. METHODS Thirty-two children undergoing major thoracotomy for noncardiac thoracic surgery were allocated to receive either single dose of thoracic epidural morphine 0.1 mg x kg(-1) in 0.2 ml x kg(-1) saline (TEP group, n = 16) or morphine infusion at 0.02 mg x kg(-1) h(-1) (INF group, n = 16) following bolus dose of 0.05 mg x kg(-1) postinduction. Pain and sedation scores and incidence of complications were recorded for 24 h and cortisol, blood glucose, insulin and morphine serum levels were evaluated following induction, 1, 8, 12, and 24 h after initial morphine administration. RESULTS Five patients in TEP and one in INF required rescue morphine. The cortisol, insulin and blood glucose increased during the study and returned to normal levels at 24th hour (P < 0.05), similarly in both groups (P > 0.05). The morphine levels were variable within and between groups (P < 0.05). A common complication was nausea and vomiting with both the techniques (P > 0.05). CONCLUSION Single dose TEP morphine offers no advantage over INF for pain treatment for thoracotomy in children and neither technique provided suppression of stress hormones in the first 24 h postoperatively.
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Affiliation(s)
- Pervin Bozkurt
- Department of Anaesthesiology, Istanbul University, Cerrahpaşa Medical Faculty, Istanbul, Turkey.
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Bouwmeester NJ, Anderson BJ, Tibboel D, Holford NHG. Developmental pharmacokinetics of morphine and its metabolites in neonates, infants and young children. Br J Anaesth 2004; 92:208-17. [PMID: 14722170 DOI: 10.1093/bja/aeh042] [Citation(s) in RCA: 235] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Descriptions of the pharmacokinetics and metabolism of morphine and its metabolites in young children are scant. Previous studies have not differentiated the effects of size from those related to age during infancy. METHODS Postoperative children 0-3 yr old were given an intravenous loading dose of morphine hydrochloride (100 micro g kg(-1) in 2 min) followed by either an intravenous morphine infusion of 10 micro g h(-1) kg(-1) (n=92) or 3-hourly intravenous morphine boluses of 30 micro g kg(-1) (n=92). Additional morphine (5 micro g kg(-1)) every 10 min was given if the visual analogue (VAS, 0-10) pain score was >/=4. Arterial blood (1.4 ml) was sampled within 5 min of the loading dose and at 6, 12 and 24 h for morphine, morphine-3-glucuronide (M3G) and morphine-6-glucuronide (M6G). The disposition of morphine and formation clearances of morphine base to its glucuronide metabolites and their elimination clearances were estimated using non-linear mixed effects models. RESULTS The analysis used 1856 concentration observations from 184 subjects. Population parameter estimates and their variability (%) for a one-compartment, first-order elimination model were as follows: volume of distribution 136 (59.3) litres, formation clearance to M3G 64.3 (58.8) litres h(-1), formation clearance to M6G 3.63 (82.2) litres h(-1), morphine clearance by other routes 3.12 litres h(-1) per 70 kg, elimination clearance of M3G 17.4 (43.0) litres h(-1), elimination clearance of M6G 5.8 (73.8) litres h(-1). All parameters are standardized to a 70 kg person using allometric 3/4 power models and reflect fully mature adult values. The volume of distribution increased exponentially with a maturation half-life of 26 days from 83 litres per 70 kg at birth; formation clearance to M3G and M6G increased with a maturation half-life of 88.3 days from 10.8 and 0.61 litres h(-1) per 70 kg respectively at birth. Metabolite formation decreased with increased serum bilirubin concentration. Metabolite clearance increased with age (maturation half-life 129 days), and appeared to be similar to that described for glomerular filtration rate maturation in infants. CONCLUSION M3G is the predominant metabolite of morphine in young children and total body morphine clearance is 80% that of adult values by 6 months. A mean steady-state serum concentration of 10 ng ml(-1) can be achieved in children after non-cardiac surgery in an intensive care unit with a morphine hydrochloride infusion of 5 micro g h(-1) kg(-1) at birth (term neonates), 8.5 micro g h(-1) kg(-1) at 1 month, 13.5 micro g h(-1) kg(-1) at 3 months and 18 micro g h(-1) kg(-1) at 1 year and 16 micro g h(-1) kg(-1) for 1- to 3-yr-old children.
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Affiliation(s)
- N J Bouwmeester
- Department of Anaesthesiology and Paediatric Surgery, Sophia Children's Hospital, University Hospital Rotterdam, Dr Molewaterplein 60, 3015 GJ Rotterdam, The Netherlands
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