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de Bruijn CMA, Rexwinkel R, Gordon M, Benninga M, Tabbers MM. Antidepressants for functional abdominal pain disorders in children and adolescents. Cochrane Database Syst Rev 2021; 2:CD008013. [PMID: 33560523 PMCID: PMC8094232 DOI: 10.1002/14651858.cd008013.pub3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND Functional Abdominal Pain Disorders (FAPDs) present a considerable burden to paediatric patients, impacting quality of life, school attendance and causing higher rates of anxiety and depression disorders. There are no international guidelines for the management of this condition. A previous Cochrane Review in 2011 found no evidence to support the use of antidepressants in this context. OBJECTIVES To evaluate the current evidence for the efficacy and safety of antidepressants for FAPDs in children and adolescents. SEARCH METHODS In this updated review, we searched the Cochrane Library, PubMed, MEDLINE, Embase, PsycINFO and two clinical trial registers from inception until 03 February 2020. We also updated our search of databases of ongoing research, reference lists and 'grey literature' from inception to 03 February 2020. SELECTION CRITERIA We included randomised controlled trials (RCTs) comparing antidepressants to placebo, to no treatment or to any other intervention, in children aged 4 to 18 years with a FAPD diagnosis as per the Rome or any other defined criteria (as defined by the authors). The primary outcomes of interest included treatment success (as defined by the authors), pain severity, pain frequency and withdrawal due to adverse events. DATA COLLECTION AND ANALYSIS Two review authors checked all citations independently, resolving disagreement with a third-party arbiter. We reviewed all potential studies in full text, and once again made independent decisions, with disagreements resolved by consensus. We conducted data extraction and 'Risk of bias' assessments independently, following Cochrane methods. Where homogeneous data were available, we performed meta-analysis using a random-effects model. We conducted GRADE analysis. MAIN RESULTS We found one new study in this updated search, making a total of three trials (223 participants) eligible for inclusion: two using amitriptyline (AMI) and one using citalopram. For the primary outcome of treatment success, two studies used reports of success on a symptom-based Likert scale, with either a two-point reduction or the two lowest levels defined as success. The third study defined success as a 15% improvement in quality of life (QOL) ratings scales. Therefore, meta-analysis did not include this final study due to the heterogeneity of the outcome measure. There is low-certainty evidence that there may be no difference when antidepressants are compared with placebo (risk ratio (RR) 1.17, 95% confidence interval (CI) 0.87 to 1.56; 2 studies, 205 participants; I2 = 0%). We downgraded the evidence for significant imprecision due to extremely sparse data (see Summary of findings table 1). The third study reported that participants receiving antidepressants were significantly more likely than those receiving placebo to experience at least a 15% improvement in overall QOL score at 10 and 13 weeks (P = 0.007 and P = 0.002, respectively (absolute figures were not given)). The analysis found no difference in withdrawals due to adverse events between antidepressants and placebo: RR 3.17 (95% CI 0.65 to 15.33), with very low certainty due to high risk of bias in studies and imprecision due to low event and participant numbers. Sensitivity analysis using a fixed-effect model and analysing just for AMI found no change in this result. Due to heterogeneous and limited reporting, no further meta-analysis was possible. AUTHORS' CONCLUSIONS There may be no difference between antidepressants and placebo for treatment success of FAPDs in childhood. There may be no difference in withdrawals due to adverse events, but this is also of low certainty. There is currently no evidence to support clinical decision making regarding the use of these medications. Further studies must consider sample size, homogenous and relevant outcome measures and longer follow up.
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Affiliation(s)
| | | | - Morris Gordon
- School of Medicine, University of Central Lancashire, Preston, UK
| | - Marc Benninga
- Department of Paediatric Gastroenterology, Emma Children's Hospital/AMC, Amsterdam, Netherlands
| | - Merit M Tabbers
- Pediatric Gastroenterology, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
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Tayeb BO, Eidelman A, Eidelman CL, McNicol ED, Carr DB. Topical anaesthetics for pain control during repair of dermal laceration. Cochrane Database Syst Rev 2017; 2:CD005364. [PMID: 28230244 PMCID: PMC6464542 DOI: 10.1002/14651858.cd005364.pub3] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Topical local anaesthetics provide effective analgesia for patients undergoing numerous superficial procedures, including repair of dermal lacerations. The need for cocaine in topical anaesthetic formulations has been questioned because of concern about adverse effects, thus novel preparations of cocaine-free anaesthetics have been developed. This review was originally published in 2011 and has been updated in 2017. OBJECTIVES To assess whether benefits of non-invasive topical anaesthetic application occur at the expense of decreased analgesic efficacy. To compare the efficacy of various single-component or multi-component topical anaesthetic agents for repair of dermal lacerations. To determine the clinical necessity for topical application of the ester anaesthetic, cocaine. SEARCH METHODS For this updated review, we searched the following databases: Cochrane Central Register of Controlled Trials (CENTRAL; 2016, Issue 11), Cumulative Index to Nursing and Allied Health Literature (CINAHL; 2010 to December 2016), Embase (2010 to December 2016) and MEDLINE (2010 to December 2016). We did not limit this search by language or format of publication. We contacted manufacturers, international scientific societies and researchers in the field. Weemailed selected journalsand reviewed meta-registers of ongoing trials. For the previous version of this review, we searched these databases to November 2010. SELECTION CRITERIA We included randomized controlled trials (RCTs) that evaluated the efficacy and safety of topical anaesthetics for repair of dermal laceration in adult and paediatric participants. DATA COLLECTION AND ANALYSIS Two review authors independently assessed trial quality and extracted data. We contacted study authors for additional information when needed. We collected adverse event information from trial reports. We assessed methodological risk of bias for each included study and employed the GRADE approach to assess the overall quality of the evidence. MAIN RESULTS The present updated review included 25 RCTs involving 3278 participants. The small number of trials in each comparison group and the heterogeneity of outcome measures precluded quantitative analysis of data for all but one outcome: pain intensity. In two pooled studies, the mean self-reported visual analogue scale (VAS; 0 to 100 mm) score for topical prilocaine-phenylephrine (PP) was higher than the mean self-reported VAS (0 to 100 mm) score for topical tetracaine-epinephrine-cocaine (TAC) by 5.59 points (95% confidence interval (CI) 2.16 to 13.35). Most trials that compared infiltrated and topical anaesthetics were at high risk of bias, which is likely to have affected their results. Researchers found that several cocaine-free topical anaesthetics provided effective analgesic efficacy. However, data regarding the efficacy of each topical agent are based mostly on single comparisons in trials with unclear or high risk of bias. Mild, self-limited erythematous skin induration occurred in one of 1042 participants who had undergone application of TAC. Investigators reported no serious complications among any of the participants treated with cocaine-based or cocaine-free topical anaesthetics. The overall quality of the evidence according to the GRADE system is low owing to limitations in design and implementation, imprecision of results and high probability of publication bias (selective reporting of data). Additional well-designed RCTs with low risk of bias are necessary before definitive conclusions can be reached. AUTHORS' CONCLUSIONS We have found two new studies published since the last version of this review was prepared. We have added these studies to those previously included and have conducted an updated analysis, which resulted in the same review conclusions as were presented previously.Mostly descriptive analysis indicates that topical anaesthetics may offer an efficacious, non-invasive means of providing analgesia before suturing of dermal lacerations. Use of cocaine-based topical anaesthetics might be hard to justify, given the availability of other effective topical anaesthetics without cocaine. However, the overall quality of the evidence according to the GRADE system is low owing to limitations in design and implementation, imprecision of results and high probability of publication bias (selective reporting of data). Additional well-designed RCTs with low risk of bias are necessary before definitive conclusions can be reached.
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Affiliation(s)
- Baraa O Tayeb
- Tufts University School of MedicinePain Research, Education and Policy (PREP) Program, Department of Public Health and Community Medicine136 Harrison Avenue, Stearns 203BostonMassachusettsUSA
- King Abdulaziz UniversityCollege of MedicineJeddahSaudi Arabia
| | - Anthony Eidelman
- Division of Neuromedicine Pain, University of RochesterDepartment of NeurosurgeryRochesterNew YorkUSA
| | - Cristy L Eidelman
- Children’s Mercy HospitalDepartment of Clinical Pharmacology,Toxicology, and Individualized Pediatric TherapeuticsKansas CityMissouriUSA
| | - Ewan D McNicol
- Tufts University School of MedicinePain Research, Education and Policy (PREP) Program, Department of Public Health and Community Medicine136 Harrison Avenue, Stearns 203BostonMassachusettsUSA
- Tufts Medical CenterDepartment of Anesthesiology and Perioperative MedicineBostonMassachusettsUSA
- Tufts Medical CenterDepartment of PharmacyBostonMassachusettsUSA
| | - Daniel B Carr
- Tufts University School of MedicinePain Research, Education and Policy (PREP) Program, Department of Public Health and Community Medicine136 Harrison Avenue, Stearns 203BostonMassachusettsUSA
- Tufts Medical CenterDepartment of AnesthesiologyBostonMassachusettsUSA
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Rubinstein O, Barkan S, Breitbart R, Berkovitch S, Toledano M, Weiser G, Karadi N, Nassi A, Kozer E. Efficacy of oral ketamine compared to midazolam for sedation of children undergoing laceration repair: A double-blind, randomized, controlled trial. Medicine (Baltimore) 2016; 95:e3984. [PMID: 27368000 PMCID: PMC4937914 DOI: 10.1097/md.0000000000003984] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVE To assess the efficacy of oral ketamine versus oral midazolam for sedation during laceration repair at a pediatric emergency department. METHODS Children between 1 and 10 years requiring laceration repair were randomly assigned to 2 groups, treated either with oral midazolam (0.7 mg/kg) or with oral ketamine (5 mg/kg).Main outcomes measured were level of pain during local anesthesia, as assessed by the parent on a 10-cm visual analog scale (VAS) and the number of children who required intravenous sedation. Secondary outcomes included VAS by physician, pain assessment by child, maximal sedation depth assessed by the University of Michigan Sedation Scale, time until University of Michigan Sedation Scale 2 or more, general satisfaction of a parent and treating physician, length of procedure, total sedation time, and the incidence of any adverse events. RESULTS Sixty-eight children were recruited of which 33 were girls. Average age was 5.08 ± 2.14 years. Thirty-seven children were treated with ketamine and 31 with midazolam. Parent-assessed VAS in ketamine treated patients was 5.07 ± 0.75 compared with 3.68 ± 0.7 in midazolam treated patients [mean difference = 1.39 95% confidence interval (CI) -0.47 to 3.26]. Twelve (32%) of the children treated with ketamine required the addition of IV sedation compared to only 2 children (6%) of the children treated with midazolam [odds ratio (adjusted for age and gender) 6.1, 95% CI: 1.2 to 30.5]. The rest of the measured variables were similar between the groups, with no statistical significance. DISCUSSION No difference in the level of pain was found between ketamine and midazolam treated patients. Compared with oral midazolam (0.7 mg/kg), oral ketamine (5 mg/kg) was associated with higher rates of sedation failure, and thus is not recommended as a single agent for oral sedation in children requiring laceration repair.
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Affiliation(s)
- Orit Rubinstein
- Pediatric Emergency Unit, Assaf Harofeh Medical Center, Zerifin
| | - Shiri Barkan
- Pediatric Emergency Unit, Assaf Harofeh Medical Center, Zerifin
| | - Rachelle Breitbart
- Pediatric Emergency Unit, Assaf Harofeh Medical Center, Zerifin
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv
| | | | - Michal Toledano
- Department of Pharmacy, Assaf Harofeh Medical Center, Zerifin
| | - Giora Weiser
- Pediatric Emergency Medicine, Shaare Zedek Medical Center, Jerusalem, Israel
| | - Natali Karadi
- Pediatric Emergency Unit, Assaf Harofeh Medical Center, Zerifin
| | - Anat Nassi
- Pediatric Emergency Unit, Assaf Harofeh Medical Center, Zerifin
| | - Eran Kozer
- Pediatric Emergency Unit, Assaf Harofeh Medical Center, Zerifin
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv
- Correspondence: Eran Kozer, MD, Assaf Harofeh Mediacl Center Zerifin, Israel (e-mail: )
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Barkan S, Breitbart R, Brenner-Zada G, Feldon M, Assa A, Toledano M, Berkovitch S, Shavit I, Kozer E. A double-blind, randomised, placebo-controlled trial of oral midazolam plus oral ketamine for sedation of children during laceration repair. Emerg Med J 2013; 31:649-53. [DOI: 10.1136/emermed-2012-202189] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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Eidelman A, Weiss JM, Baldwin CL, Enu IK, McNicol ED, Carr DB. Topical anaesthetics for repair of dermal laceration. Cochrane Database Syst Rev 2011:CD005364. [PMID: 21678347 DOI: 10.1002/14651858.cd005364.pub2] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Topical local anaesthetics are recognized as providing effective analgesia for numerous superficial procedures, including repair of dermal lacerations. The need for cocaine in topical anaesthetic formulations has been questioned due to concern about adverse effects, and so novel preparations of cocaine-free anaesthetics have been developed. OBJECTIVES To compare the efficacy and safety of infiltrated local anaesthetics with those of topical local anaesthetics for repair of dermal lacerations and to evaluate the efficacy and safety of various single or multi-component topical anaesthetics to identify cocaine-free topically applied local anaesthetics that may provide equivalent analgesia to those containing cocaine. SEARCH STRATEGY We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2010, Issue 10); MEDLINE (1966 to November 2010); EMBASE (1980 to November 2010); CINAHL (1982 to November 2010); and reference lists of articles. We also handsearched selected journals, reviewed abstracts presented at international society meetings, reviewed metaregisters of ongoing trials and contacted manufacturers and researchers in the field. SELECTION CRITERIA We included randomized controlled trials (RCTs) that evaluated the efficacy and safety of topical anaesthetics for repair of torn skin in adult and paediatric patients. DATA COLLECTION AND ANALYSIS Two authors independently assessed trial quality and extracted data. We contacted study authors for additional information. We collected adverse event information from the trials. MAIN RESULTS We included 23 RCTs involving 3128 patients. The small number of trials in each comparison group and the heterogeneity of outcome measures precluded quantitative analysis of data in all but one outcome, pain scores using a visual analogue scale. The majority of trials that compared infiltrated and topical anaesthetics are at high risk of bias, which is likely to affect the interpretation of the results. Several cocaine-free topical anaesthetics were found to provide effective analgesic efficacy. However, the data regarding the efficacy of each topical agent is mostly based upon single comparisons, in trials that have unclear or high risk of bias. Mild, self-limited erythematous skin induration occurred in one case after application of topical tetracaine-adrenaline-cocaine (TAC) where a total of 1042 patients were exposed. No serious complications were reported in any of the patients treated with either cocaine-based or cocaine-free topical anaesthetics. AUTHORS' CONCLUSIONS Based on mostly descriptive analysis, topical anaesthetics are possibly an efficacious, non-invasive means of providing analgesia prior to suturing of dermal lacerations. However, additional well designed RCTs with low risk of bias are necessary before definitive conclusions can be made.
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Affiliation(s)
- Anthony Eidelman
- Department of Anesthesiology, Division of Pain Medicine, Barnes Jewish Hospital, Washington University School of Medicine, 660 South Euclid Ave,, Camous Box 8054, St Louis, MO, USA, 63110
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Andersson C, Johnsson KO, Berglund M, Ojehagen A. Measurement properties of the Arnetz and Hasson stress questionnaire in Swedish university freshmen. Scand J Public Health 2009; 37:273-9. [PMID: 19124596 DOI: 10.1177/1403494808099970] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND The aim of this study was to evaluate the measurement properties of the Arnetz and Hasson seven-item stress questionnaire in order to select high-risk freshmen for a stress and alcohol intervention research project. METHODS Two complete cohorts of university freshmen at two universities were asked to participate in an intervention study. All subjects responded to seven Visual Analogue Scales (VAS) measuring common areas associated with stress. Measurement properties were evaluated by analysing internal consistency and construct validity. RESULTS A total of 2,032 (72%) freshmen agreed to participate. In total 14,184 out of 14,224 (99.7%) of the Visual Analogue Scales were answered. The Chronbach's alpha coefficient for the complete scale was 0.787. The Varimax rotation factor analysis, using an eigen value of 1, resulted in one factor that covered all items with factor scores of 0.50 and over. This factor explained 46% of the variance. A logistic regression analysis established that mental symptoms, living outside a serious relationship, and female gender were associated with a high stress level. CONCLUSIONS The Arnetz and Hasson stress questionnaire is easy to use and offers sufficient internal consistency and construct validity.
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Affiliation(s)
- Claes Andersson
- Clinical Alcohol Research, Lund University, Malmö University Hospital, Malmö, Sweden.
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Bahar RJ, Collins BS, Steinmetz B, Ament ME. Double-blind placebo-controlled trial of amitriptyline for the treatment of irritable bowel syndrome in adolescents. J Pediatr 2008; 152:685-9. [PMID: 18410774 DOI: 10.1016/j.jpeds.2007.10.012] [Citation(s) in RCA: 101] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2007] [Revised: 09/27/2007] [Accepted: 10/15/2007] [Indexed: 12/19/2022]
Abstract
OBJECTIVES To determine the efficacy of amitriptyline (AMI) in treating irritable bowel syndrome (IBS) in adolescents. STUDY DESIGN Adolescents 12 to 18 years with newly diagnosed IBS were surveyed with a symptom checklist, pain rating scale, visual analog scale, and IBS quality of life (QOL) questionnaire. Subjects were randomized in a double-blinded fashion to receive AMI or placebo, and again completed surveys at 2, 6, 10, and 13 weeks. RESULTS Thirty-three patients (24 female) were enrolled. Patients receiving AMI were more likely to experience improvement from baseline in overall QOL at 6, 10, and 13 weeks (P = .019, .004, and .013). Patients receiving AMI were also more likely to experience a reduction in IBS-associated diarrhea at 6 and 10 weeks (P = .029 for both), a reduction in periumbilical pain at 10 weeks (P = .018), and a reduction in right lower quadrant pain at 6, 10, and 13 weeks (P = .014, .039, and .004). CONCLUSION AMI significantly improves overall QOL in adolescents with IBS and should be a therapeutic option for adolescents with this disorder.
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Affiliation(s)
- Ron J Bahar
- Department of Pediatrics, Division of Gastroenterology, Hepatology, and Nutrition, UCLA Geffen School of Medicine, Los Angeles, CA 91316, USA.
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Abstract
The authors review the current state of procedural sedation and analgesia research and clinical practice in adults and children, discuss the limitations in research methodology, and propose future areas of investigation.
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Affiliation(s)
- James R Miner
- Department of Emergency Medicine, Hennepin County Medical Center, and University of Minnesota Medical School, Minneapolis, MN, USA.
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Shields BJ, Palermo TM, Powers JD, Fernandez SA, Smith GA. The Role of Developmental and Contextual Factors in Predicting Children's Use of a Visual Analogue Scale. CHILDRENS HEALTH CARE 2005. [DOI: 10.1207/s15326888chc3404_3] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
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Eidelman A, Weiss JM, Enu IK, Lau J, Carr DB. Comparative efficacy and costs of various topical anesthetics for repair of dermal lacerations: a systematic review of randomized, controlled trials. J Clin Anesth 2005; 17:106-16. [PMID: 15809126 DOI: 10.1016/j.jclinane.2004.05.006] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2004] [Accepted: 05/24/2004] [Indexed: 11/16/2022]
Abstract
STUDY OBJECTIVES To compare the efficacy of infiltrated local anesthesia with topical anesthesia for repair of dermal laceration, to analyze the efficacy of single or multicomponent topical anesthetics, and to identify topical formulations that are potentially less costly and equally efficacious as cocaine-containing topical anesthetics. DESIGN Systematic review of randomized controlled trials. SETTING University-affiliated hospital. PATIENTS Pediatric and adult subjects. MEASUREMENTS AND MAIN RESULTS Twenty-two trials that randomized more than 3000 patients were identified. The majority of studies demonstrated equivalent or superior analgesic efficacy for topical formulations compared with conventional intradermal infiltration. We found that cocaine is not a mandatory component of topical anesthesia. The literature discloses no significant difference in anesthetic efficacy between topical tetracaine-epinephrine-cocaine and each of the following 6 cocaine-free formulations: lidocaine-epinephrine-tetracaine, lidocaine-epinephrine, tetracaine-phenylephrine, tetracaine-lidocaine-phenylephrine, bupivicaine-norepinephrine, or prilocaine-phenylephrine. CONCLUSION Topical anesthetics are an efficacious, noninvasive means of providing analgesia before suturing of dermal lacerations. The use of cocaine-containing topical anesthetics can no longer be justified in light of its high cost and potential adverse effects. We have summarized the evidence, mostly favorable, supporting the use of various non-cocaine-containing topical anesthetics.
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Affiliation(s)
- Anthony Eidelman
- Department of Anesthesiology and Pain Medicine, Caritas St. Elizabeth's Medical Center, Boston, MA 02135, USA
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Gazal G, Bowman R, Worthington HV, Mackie IC. A double-blind randomized controlled trial investigating the effectiveness of topical bupivacaine in reducing distress in children following extractions under general anaesthesia. Int J Paediatr Dent 2004; 14:425-31. [PMID: 15525311 DOI: 10.1111/j.1365-263x.2004.00587.x] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE This study was designed to investigate the effectiveness of topical bupivacaine (0.25%) in reducing postoperative distress following extraction of teeth under general anaesthesia in children. DESIGN The study was a double-blind randomized controlled trial. SETTING The study was conducted in a dental hospital. SAMPLE The sample comprised 135 children aged between 2 and 12 years of age who were undergoing outpatient general anaesthesia for simple dental extractions. METHODS The children were randomly allocated to one of two groups: the bupivacaine group (the study group) comprised 68 children whilst the sterile water group (the control group) comprised 67. Following the extraction of their teeth, children had swabs soaked in the appropriate solution placed over the exposed teeth sockets. A five-point face scale was employed by an independent observer to evaluate the distress for each child. Evaluation of distress was made preoperatively, on recovery from the general anaesthetic, and again, 15 min following recovery from the anaesthetic. RESULTS There were no statistically significant differences between the mean distress scores for the bupivacaine and sterile water groups preoperatively, postoperatively or 15 min postoperatively. For both groups, however, there were significant increases in distress scores between the preoperative and 15 min postoperative assessment scores. CONCLUSION Extraction of teeth under general anaesthesia does cause distress in children. There is no evidence that topical bupivacaine reduces this distress when compared to sterile water.
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Affiliation(s)
- G Gazal
- Unit of Paediatric Dentistry, University Dental Hospital, Manchester, UK
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13
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Green SM. Pediatric wound triage protocols. Ann Emerg Med 2003; 42:25-6. [PMID: 12827119 DOI: 10.1067/mem.2003.229] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Affiliation(s)
- Steven M Green
- Departments of Emergency Medicine and Pediatrics, Loma Linda University Medical Center A-108 and Children's Hospital, 11234 Anderson Street, Loma Linda, CA 92354, USA
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Shields BJ, Cohen DM, Harbeck-Weber C, Powers JD, Smith GA. Pediatric pain measurement using a visual analogue scale: a comparison of two teaching methods. Clin Pediatr (Phila) 2003; 42:227-34. [PMID: 12739921 DOI: 10.1177/000992280304200306] [Citation(s) in RCA: 77] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The goals of this study were to evaluate the validity of the visual analogue scale (VAS) for young children and to compare a newly developed method of teaching children to use a VAS with one used in our previous studies. It was hypothesized that the new method would increase the number of children who understand the VAS and correctly mark their responses on the VAS line. The association between child's age and ability to understand the VAS was also evaluated. One hundred-six children with a laceration requiring sutures and receiving a lidocaine injection for local anesthesia participated in the study. They ranged in age from 5 to 14 years. Two outcome measures were used to assess the baseline and lidocaine injection pain: a 5-point Likert scale and a VAS. A calibration study was used to determine whether the subjects were able to use the VAS to make proportional judgments about their perceptions. Teaching method had no effect on the number of subjects who could correctly mark their responses on the VAS line, nor did it significantly increase the number of subjects who could understand the concept of the VAS. Subjects who were able to understand the VAS were significantly older (mean = 9.8 years, SD = 2.8) than those who did not (mean = 8.2 years, SD = 2.5). Overall, only about one third of the subjects were able to correctly mark the VAS and understand the concept of the VAS. Other measures of pain that are better understood by young children may be more valid indicators of pain than the VAS.
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Affiliation(s)
- Brenda J Shields
- Center for Injury Research and Policy, The Ohio State University College of Medicine and Public Health, Columbus, OH 43205, USA
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Flood RG, Krauss B. Procedural sedation and analgesia for children in the emergency department. Emerg Med Clin North Am 2003; 21:121-39. [PMID: 12630735 DOI: 10.1016/s0733-8627(02)00084-6] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
PSA for children continues to be an integral part of the practice of emergency medicine. The advancement of knowledge for all health care professionals must continue so that pain and anxiety in children may be minimized during their visits to EDs.
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Affiliation(s)
- Robert G Flood
- Division of Emergency Medicine, Children's Hospital, 300 Longwood Avenue, Boston, MA 02115, USA.
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Affiliation(s)
- Charles B Berde
- Department of Anesthesia, Children's Hospital, Boston, MA 02115, USA
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Affiliation(s)
- S Bush
- Accident and Emergency Department, St Jame's University Hospital, Leeds, UK.
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Abstract
The use of local anesthetic in facial plastic surgical procedures is well established as an effective and safe mode of anesthesia delivery. Local infiltration of anesthesia may be used alone for minor surgical procedures, or it may be used with general anesthesia or intravenous sedation and analgesia for more complex, lengthy procedures. When considered independently, the use of local anesthetic agents has undeniable limitations. Local anesthetics can cause toxicity and side effects. Injection of local anesthetics for subcutaneous infiltration frequently is painful until sensory anesthesia occurs. Local anesthetics have limited efficacy with respect to the intensity and duration of sensory blockade that can be achieved. In some situations, use of local anesthesia with the maintenance of an awake patient also may be undesirable for the surgeon and impractical for the patient. Despite these shortcomings, local anesthetics are fundamentally ideal for use in facial plastic surgery.
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Affiliation(s)
- Karen K Ahlstrom
- Division of Otolaryngology, Plastic, and Reconstructive Surgery, University of New Mexico Health Sciences Center, Albuquerque, New Mexico 87106, USA
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Abstract
BACKGROUND Dermatologic procedures in children may require the use of topical and local anesthetics, sedatives, and general anesthesia. OBJECTIVE To review developments in topical and local anesthetics, sedatives, and general anesthesia relevant to dermatologic procedures in children. METHODS Review of the medical literature. RESULTS Topical anesthetics, including EMLA and liposome-encapsulated lidocaine cream, amethocaine, cetacaine, and benzocaine products may be useful for decreasing the pain of cutaneous procedures including intra-lesional lidocaine infiltration. A variety of sedative and hypnotic agents may be utilized for pediatric dermatology procedures, and guidelines for their appropriate use have been published. General anesthesia for dermatologic procedures in the pediatric population is appropriate for a variety of procedures including laser treatment of capillary malformations. CONCLUSION A variety of anesthetic, analgesic, and sedatives may be useful for pediatric cutaneous surgery.
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Affiliation(s)
- B K Chen
- Department of Pediatrics, University of California, San Diego School of Medicine, San Diego, California, USA
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Chen BK, Cunningham BB. Topical anesthetics in children: agents and techniques that equally comfort patients, parents, and clinicians. Curr Opin Pediatr 2001; 13:324-30. [PMID: 11717557 DOI: 10.1097/00008480-200108000-00007] [Citation(s) in RCA: 35] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Topical anesthetics are increasingly important, as the number of outpatient surgeries for dermatologic problems in infants and children is steadily growing. This noninvasive modality of anesthetic delivery in conjunction with a reassuring environment may minimize the discomfort of otherwise painful procedures. Since the 1880s, when cocaine was first used as a topical ophthalmologic anesthetic, many ester-and amide-based local anesthetics have been developed for a variety of simple and complex procedures. The pediatric dermatologist's arsenal of topical anesthetic preparations is increasing with the development of novel vehicles of transdermal delivery and the use of anesthetics in combination. Eutectic mixture of local anesthetics is currently the most frequently prescribed topical agent, though the use of ELA-max, another lidocaine-containing preparation, is gaining momentum, especially in the neonatal population. Amethocaine, tetracaine, iontophoresis, and the S-caine patch, a product on the horizon for use in the pediatric population, also are included in this discussion.
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Affiliation(s)
- B K Chen
- Pediatric and Adolescent Dermatology Children's Hospital, San Diego, and University of California, San Diego School of Medicine, San Diego, California, USA
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22
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Affiliation(s)
- N S Adzick
- Department of Surgery, Children's Hospital of Philadelphia, and the University of Pennsylvania School of Medicine, 19104, USA
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23
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Abstract
The challenge for emergency medicine physicians in the new millennium is to use these drugs and drug combinations to make ED visits pain-free and safe experiences. With dedication to research, a willingness to take the time to explore new options, and expansion of pharmacologic and nonpharmacologic interventions, physicians can make this lofty dream a reality.
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Affiliation(s)
- A S Brent
- Division of Emergency Medicine, All Children's Hospital, St. Petersburg, Florida, USA
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24
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Affiliation(s)
- B Krauss
- Division of Emergency Medicine, Children's Hospital and Harvard Medical School, Boston, MA 02115, USA.
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25
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Kennedy RM, Luhmann JD. The "ouchless emergency department". Getting closer: advances in decreasing distress during painful procedures in the emergency department. Pediatr Clin North Am 1999; 46:1215-47, vii-viii. [PMID: 10629683 DOI: 10.1016/s0031-3955(05)70184-x] [Citation(s) in RCA: 62] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Painful and frightening injuries and illnesses are frequent reasons for children to seek care in an emergency department. Painful therapeutic procedures are often a necessary part of emergency care and are very distressful for the children, their parents, and healthcare providers. Inadequately relieved pain and distress have acute and long-term consequences, yet methods for pain and anxiety reduction during frightening minor and major procedures are often not used because of lack of detailed knowledge of techniques and fear of adverse effects. This article reviews psychologic and pharmacologic means of safe and effective reduction of anxiety and pain during emergency department procedures.
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Affiliation(s)
- R M Kennedy
- Department of Pediatrics, Washington University School of Medicine, St. Louis Children's Hospital, Missouri, USA
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26
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Moseley HS, Kumar AY, Shankar KB. Anesthesia outside the operating room for emergency procedures. Curr Opin Anaesthesiol 1999; 12:411-5. [PMID: 17013343 DOI: 10.1097/00001503-199908000-00003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Non-anesthetists usually provide sedation and anesthesia outside the operating room for emergency procedures. Techniques vary from no sedation to deep sedation using drugs with a good safety profile and few side effects. Newer methods of airway control may allow volatile agents such as sevoflurane to be used. Anesthetists may need to join sedation teams if they are to maintain control of their specialty.
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Affiliation(s)
- H S Moseley
- University of West Indies, Barbados, West Indies
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27
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Abstract
Over the last 10 years, there has been a fundamental change in physicians' attitudes toward analgesia and sedation in pediatrics. In this time, basic and clinical research have provided a wealth of information. In this paper we review important advances registered in the past year, including new molecular and physiological mechanisms of antinociception and sedation, behavioral and psychoemotional implications of pain, and advances in the clinical practice of pediatric analgesia and sedation. Fortunately, the attitude of physicians toward these matters has changed significantly and much more attention is now paid to the alleviation of pain and provision of adequate sedation. However, there remains, according to most estimates, incongruity between these advances and what is practiced clinically.
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Affiliation(s)
- G R Ganea
- Yale University School of Medicine, Department of Pediatrics, New Haven, CT 06520-8064, USA
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28
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Kanegaye JT. A rational approach to the outpatient management of lacerations in pediatric patients. CURRENT PROBLEMS IN PEDIATRICS 1998; 28:205-34. [PMID: 9740986 DOI: 10.1016/s0045-9380(98)80048-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Lacerations are a frequent reason for pediatric health care visits. Many are referred to EDs or to surgical specialists but may be treated by the pediatrician who has the time and interest in maintaining wound care skills. Although skin closure is often viewed as the primary event in wound care, local anesthesia and wound toilet are equally important aspects in which expertise is often undervalued. On occasion, patient anxiety and resistance complicates wound care, and a variety of sedative techniques facilitates completion of procedures that otherwise would require general anesthesia. Adherence to basic principles and the occasional use of innovations in wound care enable the clinician to bring about optimal outcomes.
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Affiliation(s)
- J T Kanegaye
- Division of Emergency Medicine, Children's Hospital and Health Center, San Diego, California, USA
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