Ketorolac for postoperative pain management in children

Safety and Efficacy of Ketorolac After Craniotomy for Tumor Resection

OBJECTIVE

Postoperative pain is the most common undesirable outcome after neurosurgery. Ketorolac is a nonsteroidal anti-inflammatory drug (NSAID) that is administered parenterally and carries a theoretical increased risk of bleeding. Our study aims to determine whether ketorolac after craniotomy for tumor resection significantly changes the rate of postoperative adverse events, adequately controls pain, and decreases concurrent narcotic use.

METHODS

We performed a retrospective chart review of all adult patients who underwent craniotomy for brain tumor resection from 2013 to 2022. Analysis of patients who received ketorolac and those who did not in the postoperative period were compared for adverse events associated with ketorolac use. Secondary outcomes included patient-reported pain scores and postoperative opioid use.

RESULTS

In total, 1114 patients were included, of whom 70 received ketorolac in the postoperative period. Ketorolac was typically administered to patients in whom narcotics had failed to provide sufficient pain relief. Patients receiving ketorolac were younger (P = 0.001) and had a lower comorbidity index (P = 0.041) compared with the nonketorolac group. Patients receiving ketorolac did not experience a significantly increased rate of bleeding events (P = 0.850). Patients receiving ketorolac had significantly greater baseline levels of pain (P = 0.018) and opioid use (P = 0.047). When matched for chronic comorbidities including pain disorders, the ketorolac group only displayed greater levels of pain early in the postoperative course (postoperative day 0-1) but not in latter part of the initial postoperative period.

CONCLUSIONS

Ketorolac is a safe and effective option for pain control after craniotomy for tumor resection. Prospective data are needed to better validate these retrospective observations.

Ketorolac vs Morphine for Severe Vaso-Occlusive Crisis in Sickle Cell Disease: An Open-Label Randomized Controlled Trial (KISS Study)

OBJECTIVES

To compare the efficacy and safety of intravenous (IV) ketorolac and IV morphine in the management of severe vaso-occlusive crisis (VOC) in children with sickle cell disease (SCD).

METHOD

An open-label, randomized controlled trial was conducted from January 2021 to July 2022 wherein children with SCD aged 3 to 15 years, presenting with severe VOC (score > 6 on the Wong-Baker Faces Pain scale) were included. Block randomization with minimization was done and participants received either IV ketorolac (intervention) or IV morphine infusion (standard). The pain score was reassessed three hourly and if the pain score exceeded 6, the drug dose was escalated every 3 hours, upto a maximum of three escalating doses. A pain score of ≤ 6 were regarded as response.

RESULTS

The mean (SD) pain scores at admission in the ketorolac and morphine groups were 9.28 (0.89) and 9.12 (1.01), respectively (P = 0.636). At 3, 6, 9, and 12 hours of infusion, the mean pain scores in the ketorolac and morphine groups were 8.04 (1.24) vs 8.28 (1.24), P = 0.313; 7.04 (1.210) vs 7.28 (1.28), P = 0.331; 6.40 (1.26) vs 6.28 (1.17), P = 0.860; and 5.56 (1.00) vs 5.60 (1.04), P = 0.817, respectively. Five and eleven children developed minor side effects in the ketorolac and morphine groups, respectively (P = 0.069). Overall, one child in the ketorolac group and two in the morphine persisted to have severe pain even after 12 hours of therapy (P = 0.55).

CONCLUSION

Intravenous ketorolac may be considered as a good alternative to IV morphine in the management of severe VOC in SCD.

Effect of Ketorolac Administration on the Rate of Nonunion of Operatively Treated Pediatric Long-Bone Fractures: A Matched Cohort Analysis

BACKGROUND

Nonunion is a rare yet serious complication in pediatric fracture healing that can lead to patient morbidity and economic burden. The administration of nonsteroidal anti-inflammatory drugs (NSAIDs) has been associated with an increased risk of fracture nonunion in adults, but data are lacking in the pediatric population. This study examines the relationship between postoperative ketorolac administration and nonunion in operatively managed pediatric long-bone fractures.

METHODS

A retrospective cohort study was conducted with use of TriNetX, a research network that encompasses data from the United States, Canada, and Western Europe. A total of 462,260 patients from 52 health-care organizations met the inclusion criteria. Patients <18 years old with operatively managed upper or lower-extremity long-bone fractures were included. The exposure of interest was ketorolac administration within 30 days postoperatively between 2003 and 2023. Nonunion was identified and verified with use of the pertinent medical codes. Absolute risks and hazard ratios (HRs) were calculated for both study groups. Significance was set at p < 0.05.

RESULTS

After propensity score matching, 48,778 patients were identified per group. The incidence of nonunion was 2.19% in the ketorolac group and 0.93% in the non-ketorolac group (HR, 2.71; 95% confidence interval [CI]: 2.46, 3.21; p < 0.0001). Subgroup analyses demonstrated a higher risk of nonunion in patients with lower-extremity fractures (HR, 3.45; 95% CI: 3.14, 3.75; p < 0.0001) than in those with upper-extremity fractures (HR, 2.11; 95% CI: 1.84, 2.32; p < 0.0001). Among the fracture location subgroups, the greatest HR for nonunion was observed in patients with femoral fractures, followed sequentially by those with tibial and/or fibular fractures, humeral fractures, and radial and/or ulnar fractures.

CONCLUSIONS

To our knowledge, this is the largest study to date to explore postoperative ketorolac use and nonunion in the setting of operatively managed pediatric long-bone fractures. Nonunion in children was rare, occurring in <1% of all included patients. Ketorolac administration was associated with a 2 to 3-fold increase in nonunion risks, with pronounced implications for patients with lower-extremity fractures, particularly those with femoral fractures. Clinicians should weigh the therapeutic advantages of non-opiate analgesia with ketorolac against the risk of nonunion in order to optimize postoperative pain management and recovery.

LEVEL OF EVIDENCE

Therapeutic Level III . See Instructions for Authors for a complete description of levels of evidence.

Wilderness Medical Society Clinical Practice Guidelines for the Treatment of Acute Pain in Austere Environments: 2024 Update

The Wilderness Medical Society (WMS) convened an expert panel to develop evidence-based guidelines for the management of pain in austere environments. Recommendations are graded based on the quality of supporting evidence as defined by criteria put forth by the American College of Chest Physicians. This is an update of the 2014 version of the "WMS Practice Guidelines for the Treatment of Acute Pain in Remote Environments" published in Wilderness & Environmental Medicine 2014; 25:41-49.

An analysis of harms reporting in systematic reviews regarding ketorolac for management of perioperative pain

BACKGROUND

Owing to the frequent perioperative use of ketorolac tromethamine and its ability to minimise postoperative opioid requirements, it is important to continually reassess harms associated with its use. Our primary objective was to investigate the extent of harms reporting in systematic reviews (SRs) on ketorolac for perioperative pain.

METHODS

In May 2022, we conducted a search of major databases, MEDLINE (PubMed and Ovid), Embase, Epistemonikos, and the Cochrane Database of Systematic Reviews to identify eligible SRs on ketorolac for perioperative pain. Screening and data extraction were performed in masked, duplicate fashion. A MeaSurement Tool to Assess systematic Reviews-2 (AMSTAR-2) was used to appraise the methodological quality of included SRs. Corrected covered area (CCA) was calculated to determine overlap of primary studies between SR dyads.

RESULTS

A total of 28 SRs evaluating 630 primary studies met the inclusion criteria. Seven SRs (7/28, 25%) reported no harms and 17 SRs (17/28, 60.7%) reported ≤50% of harms items. A significant association was found between completeness of harms reporting and whether harms were specified as a primary outcome (P<0.001). No other associations were statistically significant. Regarding methodological quality, 22 SRs were appraised as 'critically low' (22/28, 78.6%), 5 as 'low' (5/28, 17.9%), and 1 as 'high' (1/28, 3.6%). One SR dyad had a CCA >50% but neither reported harms.

CONCLUSIONS

The extent of harms reporting in systematic reviews was inadequate. Given the importance that systematic reviews have on guiding perioperative decision-making, it is essential to improve the completeness of harms reporting.

Ketorolac use and risk of bleeding after appendectomy in children with perforated appendicitis

BACKGROUND

Ketorolac is an opioid sparing agent commonly used in children. However, ketorolac may be avoided in children with peritonitis owing to a possible increased risk of bleeding.

METHODS

A retrospective cohort study of healthy children 2-18 years who underwent appendectomy for perforated appendicitis was performed using the Pediatric Health Information System (2009-2019). Multivariable logistic regression was used to evaluate the association between perioperative ketorolac use and postoperative blood transfusions within 30 days of surgery, adjusting for patient and hospital level factors. An interaction between ketorolac and ibuprofen was evaluated to identify synergistic effects.

RESULTS

Overall, 55,603 children with perforated appendicitis underwent appendectomy and 82.3% (N = 45,769) received ketorolac. Of those, 32% (N = 14,864) also received ibuprofen. Receipt of a blood transfusion was infrequent (N = 189, 0.3%). On multivariable logistic regression analysis, perioperative ketorolac administration was associated with decreased odds of a blood transfusion (OR 0.53, 95% CI: 0.35-0.79). However, children receiving ketorolac and ibuprofen were more likely to require a blood transfusion (OR 1.99, 95% CI: 1.42-2.79). In a subset of children receiving ketorolac, each additional day of ketorolac was associated with an increase odds of blood transfusion (OR 1.39, 95% CI: 1.30-1.49).

CONCLUSION

Perioperative ketorolac alone is not associated with an increased risk of significant bleeding in children undergoing appendectomy for perforated appendicitis. However, use of both ketorolac and ibuprofen during hospitalization was associated with increased risk of bleeding, although precise timing of administration of these medications was unable to be determined. Extended ketorolac use was also associated with increased risk of bleeding requiring blood transfusion.

LEVEL OF EVIDENCE

Level III.

Does perioperative ketorolac increase bleeding risk after intracapsular tonsillectomy?

IMPORTANCE

Conflicting evidence exists regarding the post-tonsillectomy bleed risk associated with perioperative ketorolac use in the pediatric population. Surgical technique for tonsillectomy can further confound this risk.

OBJECTIVE

The primary objective was to retrospectively quantify the post-tonsillectomy bleed rate after single-dose administration of ketorolac in pediatric patients following intracapsular tonsillectomy. The secondary objective was to determine if age, sex, body mass index, medical comorbidities, and indication for surgery increased post-tonsillectomy bleed risk.

DESIGN

Retrospective cohort study of 1920 children who underwent intracapsular tonsillectomies between January 2017 and December 2018.

SETTING

This study was completed at a tertiary-care pediatric referral center.

PARTICIPANTS

1920 children who underwent intracapsular tonsillectomies between January 2017 and December 2018 at a single tertiary-care children's hospital.

EXPOSURES

Patients were divided into two cohorts: 1458 patients (75.9%) received ketorolac (K+), and 462 (24.1%) did not (NK). Age, sex, body mass index, comorbidities, and indication for surgery also were evaluated for association with post-tonsillectomy bleed risk.

MAIN OUTCOME(S) AND MEASURE(S)

Primary study outcome for both cohorts was post-tonsillectomy hemorrhage requiring operative intervention.

RESULTS

1920 study participants were included with an average age of 6.5 years; 51.5% of participants were males; and, 63.9% were white. Overall, the postoperative bleeding rate was 1.5%. However, there was no significant difference when comparing bleeding rates for the ketorolac group and the non-keterolac group (1.4%-1.7%; P = .82) Age, chronic tonsillitis, higher body mass index Z-scores, attention-deficit/hyperactivity disorder, and behavioral diagnoses were statistically significant risk factors for post-tonsillectomy hemorrhage.

CONCLUSIONS AND RELEVANCE

Single-dose postoperative ketorolac does not appear to be associated with increased risk of post-tonsillectomy bleed in pediatric patients undergoing intracapsular tonsillectomy. Providers should not avoid using ketorolac in patients undergoing intracapsular tonsillectomy due to concerns over bleeding risk.

Preoperative and perioperative intervention reduces the risk of recurrence of endometriosis in mice caused by either incomplete excision or spillage and dissemination

RESEARCH QUESTION

Can preoperative or perioperative intervention reduce the risk of recurrence of endometriosis caused by either incomplete excision or spillage and dissemination?

DESIGN

A mouse model of endometriosis recurrence caused by spillage and dissemination was first established using 24 female Balb/c mice. The spillage and dissemination model was used to test the efficacy of preoperative use of ketorolac, perioperative use of aprepitant and combined use of propranolol and andrographolide in a prospective, randomized mouse experiment involving 75 mice. The efficacy of these preoperative and perioperative interventions in a mouse recurrence model caused by incomplete excision was also tested using 72 mice. In all experiments, the baseline body weight and hotplate latency of all mice were measured and recorded before the induction of endometriosis, before the primary surgery and before sacrifice. In addition, all lesions were excised, weighed and processed for quantification and immunohistochemistry analysis of E-cadherin, α-SMA, VEGF, ADRB2 and putative markers of recurrence PR-B, p-p65, as well as Masson trichrome staining.

RESULTS

All interventions substantially and significantly suppressed the outgrowth of endometriotic lesions and reduced the risk of recurrence caused by either spillage and dissemination or incomplete excision (P = 0.0007 to 0.042). These interventions also significantly attenuated the generalized hyperalgesia, inhibited the staining of α-SMA, p-p65, VEGF and ADRB2 but increased staining of E-cadherin and PR-B, resulting in reduced fibrosis.

CONCLUSION

Given the excellent safety profiles of these drugs, these data strongly suggest that preoperative and perioperative intervention may potentially reduce the risk of endometriosis recurrence effectively.

Current State of Analgesia and Sedation in the Pediatric Intensive Care Unit

Critically ill pediatric patients often require complex medical procedures as well as invasive testing and monitoring which tend to be painful and anxiety-provoking, necessitating the provision of analgesia and sedation to reduce stress response. Achieving the optimal combination of adequate analgesia and appropriate sedation can be quite challenging in a patient population with a wide spectrum of ages, sizes, and developmental stages. The added complexities of critical illness in the pediatric population such as evolving pathophysiology, impaired organ function, as well as altered pharmacodynamics and pharmacokinetics must be considered. Undersedation leaves patients at risk of physical and psychological stress which may have significant long term consequences. Oversedation, on the other hand, leaves the patient at risk of needing prolonged respiratory, specifically mechanical ventilator, support, prolonged ICU stay and hospital admission, and higher risk of untoward effects of analgosedative agents. Both undersedation and oversedation put critically ill pediatric patients at high risk of developing PICU-acquired complications (PACs) like delirium, withdrawal syndrome, neuromuscular atrophy and weakness, post-traumatic stress disorder, and poor rehabilitation. Optimal analgesia and sedation is dependent on continuous patient assessment with appropriately validated tools that help guide the titration of analgosedative agents to effect. Bundled interventions that emphasize minimizing benzodiazepines, screening for delirium frequently, avoiding physical and chemical restraints thereby allowing for greater mobility, and promoting adequate and proper sleep will disrupt the PICU culture of immobility and reduce the incidence of PACs.

Ketorolac in Postoperative Neonates and Infants: A Systematic Review

OBJECTIVE

To evaluate the pharmacokinetics and pharmacodynamics, dosing, efficacy, and safety of ketorolac in postoperative patients younger than 6 months of age.

METHODS

PubMed (1988-July 2020), Medline (1946-July 2020), and EBSCO Discovery Service (1988-July 2020) were searched to identify relevant published articles using the following search terms: ketorolac, neonate, infant. English-language articles evaluating the use of ketorolac in infants younger than 6 months of age were included.

RESULTS

Eight reports that included 239 infants receiving ketorolac were included. Of the included patients, 237 were younger than 6 months of age. Ketorolac exhibits rapid elimination of the analgesia-producing S (-) isomer, elimination half-life of 0.83 hours. Most patients received 0.5 mg/kg/dose every 6 hours for 48 to 72 hours. Analgesia was demonstrated by reduced use of open-label morphine and significant lowering of Neonatal/Infant Pain Scale scores. Adverse effects were minimal when ketorolac was used in term neonates and infants without baseline renal dysfunction.

CONCLUSIONS

Randomized placebo-controlled trials of ketorolac use in this population are lacking; however, most published reports noted efficacy and safety with ketorolac in properly selected infants.

Impact of enantiomer-specific changes in pharmacokinetics between infants and adults on the target concentration of racemic ketorolac: A pooled analysis

AIMS

Ketorolac is a nonsteroidal anti-inflammatory racemic drug with analgesic effects only attributed to its S-enantiomer. The aim of this study is to quantify enantiomer-specific maturational pharmacokinetics (PK) of ketorolac and investigate if the contribution of both enantiomers to the total ketorolac concentration remains equal between infants and adults or if a change in target racemic concentration should be considered when applied to infants.

METHODS

Data were pooled from 5 different studies in adults, children and infants, with 1020 plasma concentrations following single intravenous ketorolac administration. An allometry-based enantiomer-specific population PK model was developed with NONMEM 7.3. Simulations were performed in typical adults and infants to investigate differences in S- and R-ketorolac exposure.

RESULTS

S- and R-ketorolac PK were best described with a 3- and a 2-compartment model, respectively. The allometry-based PK parameters accounted for changes between populations. No maturation function of ketorolac clearance could be identified. All model parameters were estimated with adequate precision (relative standard error <50%). Single dose simulations showed that a previously established analgesic concentration at half maximal effect in adults of 0.37 mg/L, had a mean S-ketorolac concentration of 0.057 mg/L, but a mean S-ketorolac concentration of 0.046 mg/L in infants. To match the effective adult S-ketorolac-concentration (0.057 mg/L) in typical infants, the EC50-racemic should be increased to 0.41 mg/L.

CONCLUSION

Enantiomer-specific changes in ketorolac PK yield different concentrations and S- and R-ketorolac ratios between infants and adults at identical racemic concentrations. These PK findings should be considered when studies on maturational pharmacodynamics are considered.

Perioperative ketorolac analgesia for patients undergoing adenoidectomy: A retrospective analysis

OBJECTIVE

To analyze a case series of adenoidectomy patients who received interoperative ketorolac. To also analyze a case series of adenoidectomy patients who did not receive ketorolac.

METHOD

This is a retrospective chart review, analyzing 429 patients aged 2-18 years of age who underwent adenoidectomy without tonsillectomy. Data collected included patient age at surgery, gender, secondary procedures, medication, post-operative care, post-operative bleeding, and bleeding, and medical history. Statistical analysis was performed using JMP ® Pro, Version 14.0.0. SAS Institute Inc., Cary, NC, 1989-2019. The primary study outcomes were returning to the operating room prior to discharge from hospital or any return to the emergency department within 4 weeks of the surgery with active bleeding.

RESULTS

The average age on the day of surgery for those that received ketorolac was 3.35 years and 62% (n = 61) were male. Of the 98 patients who received interoperative ketorolac, none had a bleeding episode. The remaining 331 adenoidectomy patients who did not receive ketorolac also had 0 bleeds. The numbers of patients are insufficient to support an equivalence study.

CONCLUSIONS

Bleeds after adenoidectomy are scarce, with or without ketorolac, and thus it is difficult to detect an increase in complications. A much larger study would be necessary to generate enough statistical power. There are no findings in this study that pre-empt further investigation into whether ketorolac truly increases perioperative adenoidectomy bleed rates in medically eligible patients.

Postoperative Ketorolac Administration Is Not Associated with Hemorrhage in Cranial Vault Remodeling for Craniosynostosis

Nonsteroidal anti-inflammatory drugs have been used as part of multimodal postoperative analgesic regimens to reduce the necessity of opioids. However, due to its effect on platelet function, there is a hesitation to utilize ketorolac postoperatively. The goal of this study is to analyze our experience utilizing ketorolac in patients who underwent major cranial vault remodeling (CVR) for craniosynostosis with an emphasis on postoperative hemorrhage and complications.

The development of an opioid sparing anesthesia protocol for pediatric ambulatory tonsillectomy and adenotonsillectomy surgery-A quality improvement project

Pain management following pediatric tonsillectomy and adenotonsillectomy surgery is challenging and traditionally involves perioperative opioids. However, the recent national opioid shortage compelled anesthesiologists at Bellevue Surgery Center to identify an alternative perioperative analgesic regimen that minimizes opioids yet provides effective pain relief. We assembled an interdisciplinary quality improvement team to trial a series of analgesic protocols using the Plan-Do-Study-Act cycle. Initially, we replaced intraoperative morphine and acetaminophen (M/A protocol) with intraoperative dexmedetomidine and preoperative ibuprofen (D/I protocol). However, when results were not favorable, we rapidly transitioned to intraoperative ketorolac and dexmedetomidine (D/K protocol). The following measures were evaluated using statistical process control chart methodology and interpreted using Shewhart's theory of variation: maximum pain score in the postanesthesia care unit, postoperative morphine rescue rate, postanesthesia care unit length of stay, total anesthesia time, postoperative nausea and vomiting rescue rate, and reoperation rate within 30 days of surgery. There were 333 patients in the M/A protocol, 211 patients in the D/I protocol, and 196 patients in the D/K protocol. With the D/I protocol, there were small increases in maximum pain score and postanesthesia care unit length of stay, but no difference in morphine rescue rate or total anesthesia time compared to the M/A protocol. With the D/K protocol, postoperative pain control and postanesthesia care unit length of stay were similar compared to the M/A protocol. Both the D/I and D/K protocols had reduced nausea and vomiting rescue rates. Reoperation rates were similar between groups. In summary, we identified an intraoperative anesthesia protocol for pediatric tonsillectomy and adenotonsillectomy surgery utilizing dexmedetomidine and ketorolac that provides effective analgesia without increasing recovery times or reoperation rates.

Efficacy and Safety of Intravenous Ketorolac versus Nalbuphine in Relieving Postoperative Pain after Tonsillectomy in Children

BACKGROUND

Pain is a major postoperative complication worldwide, which in turn impairs normal body performance and increases postoperative morbidity, hospitalisation, and the susceptibility to infections which also lead to chronic pain development.

AIM

The purpose of this study was to evaluate the efficacy of intravenous ketorolac versus nalbuphine as analgesia after adenotonsillectomy surgery to determine the optimal procedure for pain control and postoperative reduction of analgesic use.

METHODS

A group of 100 pediatric patients undergoing tonsillectomy or adenotonsillectomy were assigned as follows to two equal groups: Group A: 50 patients received intravenous ketorolac 0.9 mg/Kg. Group B: 50 patients received intravenous nalbuphine 0.25 mg/Kg.

RESULTS

FLACC (Face, Legs, Activity, Cry, Consolability) pain score was measured after recovery from anaesthesia (postoperative). There was a statistically significant difference concerning pain score between group 'A' and group 'B' as pain score in 'A' (ranging from 3.18 ± 0.87 to 4.68 ± 0.74) is lower compared to 'B' (ranging from 3.90 ± 0.76 to 5.54 ± 0.73) and probability value < 0.05 except at 90 & 120 min which was observed statistically insignificant. There was no serious postoperative complication detected in either group.

CONCLUSION

It is concluded that intravenous ketorolac is more effective than intravenous nalbuphine in reducing pain intensity and postoperative analgesic requirements after adenotonsillectomy in children.

Perioperative Ketorolac Use and Postoperative Hematoma Formation in Reduction Mammaplasty: A Single-Surgeon Experience of 500 Consecutive Cases

BACKGROUND

In light of the escalating opioid crisis, surgeons are increasingly focused on minimizing opioid use. Ketorolac has well-documented opioid-sparing effects in the postoperative period; however, its use is limited because of concerns of postoperative bleeding and hematoma formation. This study explores the relationship between hematoma formation and administration of perioperative ketorolac in adolescent female patients and young adult women undergoing reduction mammaplasty. It also aims to determine the effect of perioperative ketorolac administration on the requirement for opioid analgesia.

METHODS

The authors reviewed the medical records of 500 consecutive female patients who underwent reduction mammaplasty for bilateral macromastia from 2007 to 2017. The authors collected data pertaining to perioperative analgesia use and postoperative hematoma formation.

RESULTS

Five-hundred patients were included in analyses. The average age of the patients was 18.1 ± 2.2 years. Three hundred eighty-nine patients (77.8 percent) received intravenous ketorolac during the perioperative period. Seven patients (1.4 percent) developed a postoperative hematoma. Hematoma was not associated with intraoperative, postoperative, and perioperative ketorolac use (p > 0.43, all). Intraoperative ketorolac use was associated with lower total intraoperative dosing of fentanyl and morphine, and postoperative ketorolac use was associated with lower total postoperative doses of oxycodone and morphine (p < 0.001, all).

CONCLUSIONS

Ketorolac use was largely associated with decreased perioperative opioid use, but not with hematoma formation. Ketorolac may be a safe alternative to opioids in adolescents and young women undergoing reduction mammaplasty without increasing the risk of hematoma formation.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.

Ketorolac for postoperative pain in children

BACKGROUND

Children who undergo surgical procedures in ambulatory and inpatient settings are at risk of experiencing acute pain. Nonsteroidal anti-inflammatory drugs (NSAIDs) can reduce moderate to severe pain without many of the side effects associated with opioids. However, NSAIDs may cause bleeding, renal and gastrointestinal toxicity, and potentially delay wound and bone healing. Intravenous administration of ketorolac for postoperative pain in children has not been approved in many countries, but is routinely administered in clinical practise.

OBJECTIVES

To assess the efficacy and safety of ketorolac for postoperative pain in children.

SEARCH METHODS

We searched the following databases, without language restrictions, to November 2017: CENTRAL (The Cochrane Library 2017, Issue 10); MEDLINE, Embase, and LILACS. We also checked clinical trials registers and reference lists of reviews, and retrieved articles for additional studies.

SELECTION CRITERIA

We included randomised controlled trials that compared the analgesic efficacy of ketorolac (in any dose, administered via any route) with placebo or another active treatment, in treating postoperative pain in participants zero to 18 years of age following any type of surgery.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane. Two review authors independently considered trials for inclusion in the review, assessed risk of bias, and extracted data. We analyzed trials in two groups; ketorolac versus placebo, and ketorolac versus opioid. However, we performed limited pooled analyses. We assessed the overall quality of the evidence for each outcome using GRADE, and created a 'Summary of findings' table.

MAIN RESULTS

We included 13 studies, involving 920 randomised participants. There was considerable heterogeneity among study designs, including the comparator arms (placebo, opioid, another NSAID, or a different regimen of ketorolac), dosing regimens (routes and timing of administration, single versus multiple dose), outcome assessment methods, and types of surgery. Mean study population ages ranged from 356 days to 13.9 years. The majority of studies chose a dose of either 0.5 mg/kg (as a single or multiple dose regimen) or 1 mg/kg (single dose with 0.5 mg/kg for any subsequent doses). One study administered interventions intraoperatively; the remainder administered interventions postoperatively, often after the participant reported moderate to severe pain.There were insufficient data to perform meta-analysis for either of our primary outcomes: participants with at least 50% pain relief; or mean postoperative pain intensity. Four studies individually reported statistically significant reductions in pain intensity when comparing ketorolac with placebo, but the studies were small and had various risks of bias, primarily due to incomplete outcome data and small sample sizes.We found limited data available for the secondary outcomes of participants requiring rescue medication and opioid consumption. For the former, we saw no clear difference between ketorolac and placebo; 74 of 135 (55%) participants receiving ketorolac required rescue analgesia in the post-anaesthesia care unit (PACU) versus 81 of 127 (64%) receiving placebo (relative risk (RR) 0.85, 95% confidence interval (CI) 0.71 to 1.00, P = 0.05; 4 studies, 262 participants). For opioid consumption in the PACU, we saw no clear difference between ketorolac and placebo (P = 0.61). For the time period zero to four hours after administration of the interventions, participants receiving ketorolac received 1.58 mg less intravenous morphine equivalents than those receiving placebo (95% CI -2.58 mg to -0.57 mg, P = 0.002; 2 studies, 129 participants). However, we are uncertain whether ketorolac has an important effect on opioid consumption, as the data were sparse and the results were inconsistent. Only one study reported data for opioid consumption when comparing ketorolac with an opioid. There were no clear differences between the ketorolac and opioid group at any time point. There were no data assessing this outcome for the comparison of ketorolac with another NSAID.There were insufficient data to allow us to analyze overall adverse event or serious adverse event rates. Although the majority of serious adverse events reported in those receiving ketorolac involved bleeding, the number of events was too low to conclude that bleeding risk was increased in those receiving ketorolac perioperatively. There was not a statistically significant increase in event rates for any specific adverse event, either in pooled analysis or in single studies, when comparing ketorolac and placebo. When comparing ketorolac with opioids or other NSAIDs, there were too few data to make any conclusions regarding event rates. Lastly, withdrawals due to adverse events were vary rare in all groups, reflecting the acute nature of such studies.We assessed the quality of evidence for all outcomes for each comparison (placebo or active) as very low, due to issues with risk of bias in individual studies, imprecision, heterogeneity between studies, and low overall numbers of participants and events.

AUTHORS' CONCLUSIONS

Due to the lack of data for our primary outcomes, and the very low-quality evidence for secondary outcomes, the efficacy and safety of ketorolac in treating postoperative pain in children were both uncertain. The evidence was insufficient to support or reject its use.

Dermatochirurgie bei Kindern: Gegenwärtiger Stand zu Indikation, Anästhesie, Analgesie und potentiellen perioperativen Komplikationen

HINTERGRUND

Anders als Erwachsene benötigen Kinder bei dermatochirurgischen Eingriffen besondere Aufmerksamkeit; die Anwendung verschiedener Analgetika, Anästhetika oder Sedativa erfordert eine gründliche Kenntnis von Pharmakokinetik und -dynamik der Medikamente. Außerdem können Medikamente zur Sedierung/Allgemeinanästhesie bei operierten Kindern zu Anästhesie- oder Analgesie-bedingten Komplikationen einschließlich Störungen der geistigen Entwicklung führen. ZIEL: Auf Basis unserer klinischen Erfahrung und einer Literaturübersicht stellen wir die gängigsten in der pädiatrischen Dermatochirurgie verwendeten Analgetika, Anästhetika und Sedativa dar und diskutieren Risiken und Komplikationen nach dermatochirurgischen Eingriffen.

ERGEBNISSE

Topische Anästhetika können bei Kindern für oberflächliche dermatologische Eingriffe oder vor einer Infiltrationsanästhesie eingesetzt werden. Die Berechnung der empfohlenen Maximaldosen auf Basis des Körpergewichts ist erforderlich, um eine Überdosierung von Lokalanästhetika zu vermeiden. Die Allgemeinanästhesie gilt bei der Dermatochirurgie als sicher und hat eine geringe Nebenwirkungsrate. Allerdings ist bei Kindern im ersten Lebensjahr aufgrund potentieller langfristiger neurologischer Nebenwirkungen Vorsicht angebracht. NSAR und Opioide spielen bei der Analgesie von Kindern eine bedeutende Rolle.

SCHLUSSFOLGERUNGEN

Dieser Artikel gibt eine Übersicht über die derzeit verfügbaren Daten zu Analgesie, Anästhesie und Komplikationen, die im Rahmen der pädiatrischen Dermatochirurgie auftreten können. Diese Daten können dabei helfen, die Sicherheit und Qualität der Versorgung zu optimieren und die Beratung der Eltern zu verbessern.

Dermatologic surgery in children: an update on indication, anesthesia, analgesia and potential perioperative complications

BACKGROUND

Children undergoing dermatosurgical procedures require, unlike adults, particular attention; the administration of various analgesics, anesthetics or sedatives requires a thorough knowledge of drug pharmacokinetics and pharmacodynamics. Furthermore, there are concerns that drugs used for sedation/general anesthesia may result in anesthetic/analgesic complications in children undergoing surgery, with a risk of impaired mental development.

OBJECTIVES

Based on our clinical experience and a literature review, we illustrate the most commonly used analgesic, anesthetic and sedative drugs in pediatric dermatosurgery, and identify risk factors and complications following dermatosurgical procedures.

RESULTS

Topical anesthetics can be used in children for superficial dermatologic procedures or prior to infiltration anesthesia. Maximum recommended doses based on body weight should be calculated in order to avoid overdosage of local anesthetics. General anesthesia in dermatosurgery is considered safe and has a low rate of side effects. However, caution is advised in children under the age of one due to potential long-term neurological side-effects. NSAIDs and opioids play a significant role in analgesia for children.

CONCLUSIONS

This article reviews currently available data on analgesia, anesthesia and complications that may arise in pediatric dermatosurgery. These data may be useful in optimizing the safety and quality of care and in improving parent counseling.

The pharmacokinetics of intravenous ketorolac in children aged 2 months to 16 years: A population analysis

BACKGROUND

Intravenous ketorolac is commonly administered to children for the control of postoperative pain. An effect site EC₅₀ for analgesia of 0.37 mg^. L^-1 is described in adults.

AIMS

The aim of this study was to review age- and weight-related effects on ketorolac pharmacokinetic parameters in children and current dosing schedules.

METHODS

Pooled intravenous ketorolac (0.5 mg^. kg^-1 ) concentration-time data in children aged 2 months to 16 years were analyzed using nonlinear mixed-effects models. Allometry was used to scale to a 70 kg person.

RESULTS

There were 64 children aged 2 months to 16 years (641 plasma concentrations) available for analysis. A two-compartment mammillary model was used to describe pharmacokinetics. Clearance was 2.53 (CV 45.9%) L^. h^-1. 70 kg^-1 and intercompartment clearance was 4.43 (CV 95.6%) L^. h^-1. 70 kg^-1 . Both central (V1) and peripheral (V2) volumes of distribution decreased with age over the first few years of postnatal life to reach V1 6.89 (CV 30.3%) L^. 70 kg^-1 and V2 5.53 (CV 47.6%) L^. 70 kg^-1 .

CONCLUSION

Clearance, expressed as L^. h^-1. kg^-1 , decreased with age from infancy. A dosing regimen of 0.5 mg^. kg^-1 every 6 hours maintains a trough concentration larger than 0.37 mg^. L^-1 in children 9 months to 16 years of age. This dosing regimen is consistent with current recommendations.

Demonstration of analgesic effect of intranasal ketamine and intranasal fentanyl for postoperative pain after pediatric tonsillectomy

OBJECTIVE

Tonsillectomy is one of the oldest and most commonly performed surgical procedure in otolaryngology. Postoperative pain management is still an unsolved problem. In this study, our aim is to demonstrate the efficacy of intranasal ketamine and intranasal fentanyl for postoperative pain relief after tonsillectomy in children.

MATERIAL AND METHOD

This randomized-controlled study was conducted to evaluate the effects of intranasal ketamine and intranasal fentanyl in children undergoing tonsillectomy. Tonsillectomy performed in 63 children were randomized into three groups. Group I received: Intravenous paracetamol (10 mg/kg), Group II received intranasal ketamine (1.5 mg/kg ketamine), Group III received intranasal fentanyl (1.5 mcg/kg). The Children's Hospital of Eastern Ontario Pain Scale (CHEOPS) and Wilson sedation scale scores were recorded at 15, 30, 60 min, 2 h, 6hr, 12 h and 24 h postoperatively. Patients were interviewed on the day after surgery to assess the postoperative pain, nightmares, hallucinations, nausea, vomiting and bleeding.

RESULTS

Intranasal ketamine and intranasal fentanyl provided significantly stronger analgesic affects compared to intravenous paracetamol administration at postoperative 15, 30, 60 min and at 2, 6, 12 and 24 h in CHEOPS (p < 0.05). Sedative effects were observed in three patients in the intranasal ketamine administration group. No such sedative effect was seen in the groups that received intranasal fentanyl and intravenous paracetamol in Wilson Sedation Scale (p < 0.05). Cognitive impairment, constipation, nausea, vomiting and bleeding were not observed in any of the groups.

CONCLUSION

This study showed that either intranasal ketamine and intranasal fentanyl were more effective than paracetamol for postoperative analgesia after pediatric tonsillectomy. Sedative effects were observed in three patients with the group of intranasal ketamine. There was no significant difference in the efficacy of IN Ketamine and IN Fentanyl for post-tonsillectomy pain.

Immediate Postoperative Pain and Recovery Time after Pulpotomy Performed under General Anaesthesia in Young Children

Background

The aim of this retrospective study was to compare immediate postoperative pain scores and need for rescue analgesia in children who underwent pulpotomies and restorative treatment and those who underwent restorative treatment only, all under general anaesthesia.

Methods

Ninety patients aged between 3 and 7 years who underwent full mouth dental rehabilitation under general anaesthesia were enrolled in the study and reviewed. The experimental group included patients who were treated with at least one pulpotomy, and the control group was treated with dental fillings only. The Wong-Baker FACES scale was used to evaluate self-reported pain and need for rescue analgesia. The data were analysed using the Kruskal-Wallis test, two sample t-tests, chi-square tests, and Pearson's correlation analysis.

Results

Ninety percent of the children experienced postoperative pain in varying degrees of severity. Immediate postoperative pain scores in experimental group were found to be significantly higher than in control group (x² = 24.82, p < 0.01). In the experimental group, 48% of the children needed rescue analgesia, compared with only 13% of the children in the control group (x² = 13.27, p < 0.05).

Conclusion

Children who underwent pulpotomy treatment had higher postoperative pain scores and greater need for rescue analgesia than control group who underwent only dental fillings.

Efficacy of Analgesic Treatments to Manage Children's Postoperative Pain After Laparoscopic Appendectomy: Retrospective Medical Record Review

Knowledge of the effectiveness of multimodal analgesic treatments to manage children's postoperative pain during hospital stays is limited. Our retrospective chart review of a convenience sample of 200 pediatric surgical patients' pain experiences during the first 24 hours after laparoscopic appendectomy demonstrates the benefits of a multimodal analgesic approach. We found that pediatric patients who received perioperative IV ketorolac in addition to opioids reported statistically significantly lower mean pain intensity (n = 134, mean [M] = 2.9, standard deviation [SD] = 1.7) during the first 24 hours after surgery when compared with the pain intensity of patients who did not receive perioperative IV ketorolac (n = 66, M = 3.7, SD = 1.7, t = 3.14, P = .002). Patients who received perioperative IV ketorolac (M = 0.94, SD = 0.71) also received significantly fewer morphine equivalents of postoperative opioids during the first 24 hours after surgery than those who did not (M = 1.21, SD = 0.78, t = 2.41, P = .02). We will use data from these patients to introduce the potential for a personalized medicine approach to postoperative pain.

Pharmacokinetics and analgesic effectiveness of intravenous parecoxib for tonsillectomy ± adenoidectomy

BACKGROUND

Few pharmacokinetic (PK) and pharmacodynamic (PD) data exist for COX-2 selective inhibitors in children. We wished to characterize the PKPD of parecoxib and its active metabolite, valdecoxib, in this population.

METHODS

Children (n = 59) were randomized to parecoxib 0.25 mg·kg^-1 , 1 mg·kg^-1 , and 2 mg·kg^-1 during tonsillectomy ± adenoidectomy. Samples (4-6 per child) were obtained from indwelling cannula over 6 h. A second group of inpatient children (n = 15) given 1 mg·kg^-1 contributed PK data from 6 to 24 h. Pain scores and rescue medication for the first group were recorded postoperatively for up to 24 h. PK data were pooled with those (10 samples/24 h) from a published study of children (n = 38) who underwent surgery. A three-compartment parent and one-compartment metabolite model with first-order elimination was used to describe data using nonlinear mixed effects models. An E_MAX model described the relationship between dose and rescue morphine equivalents during recovery.

RESULTS

Parecoxib PK parameter estimates were CL_PARECOXIB 19.1 L·h^-1 ·70 kg^-1 , V1_PARECOXIB 4.2 L·70 kg^-1 , Q2_PARECOXIB 6.29 L·h^-1 ·70 kg^-1 , V2_PARECOXIB 130 L·70 kg^-1 , Q3_PARECOXIB 6.02 L·h^-1 ·70 kg^-1 , and V3_PARECOXIB 2.03 L·70 kg^-1 . We assumed all parecoxib was metabolized to valdecoxib with CL_VALDECOXIB 9.53 L·h^-1 ·70 kg^-1 and V_VALDECOXIB 51 L·70 kg^-1 . There was no maturation of clearance over the age span studied. There were no differences in pain scores between groups on waking, discharge, 12 h, or 24 h. There were no differences in analgesia consumption over 24 h between groups for tramadol, fentanyl, and morphine rescue use. Fentanyl and morphine consumption, expressed as morphine equivalents (0.13 mg·kg^-1 ) in the 0.25 mg·kg^-1 group, was greater than that observed in the 1 or 2 mg·kg^-1 groups (0.095 mg·kg^-1 ) in PACU.

CONCLUSIONS

Parecoxib 0.9 mg·kg^-1 in a 2-year-old, 0.75 mg·kg^-1 in a 7-year-old, and 0.65 mg·kg^-1 in a 12-year-old child achieves dose equivalence of 40 mg in a standard 70 kg person. Clearance maturation may occur in infants younger than the current cohort. Parecoxib doses above 1 mg·kg^-1 add no additional analgesia.

Acute Pain Management

Acute pain management is improving steadily over the past few years, but training and professional education are still lacking in many professions. Untreated or undertreated acute pain could have detrimental effects on the patient in terms of comfort and recovery from trauma or surgery. Acute undertreated pain can decrease a patient's vascular perfusion, increase oxygen demand, suppress the immune system, and possibly risk increased incidence of venous thrombosis. Although acute postoperative pain needs to be managed aggressively, patients are most vulnerable during this period for developing adverse effects, and therefore, patient assessment and careful drug therapy evaluation are necessary processes in therapeutic planning. Acute pain management requires careful and thorough initial assessment and follow-up reassessment in addition to frequent dosage adjustments, and managing analgesic induced side effects. Analgesic selection and dosing must be based on the patient's past and recent analgesic exposure. There is no single acute pain management regimen that is suitable for all patients. Analgesics must be tailored to the individual patient.

An integrated overview on pyrrolizines as potential anti-inflammatory, analgesic and antipyretic agents

Despite the existence of huge number of NSAIDs, the quest for safer drugs is still in the focus of several drug discovery programs. Pyrrolizine heterocyclic system is among the privileged scaffolds utilized in this regard. At least one of these pyrrolizines, ketorolac, has reached the market. The current review represents a collective effort to highlight the reported pyrrolizines with anti-inflammatory and analgesic potential and categorize them into eight different classes. Furthermore, the various synthetic approaches, structure-activity relationship as well as metabolic pathways have been discussed. Taken together, this review sets a base for researchers to design and synthesize novel pyrrolizine-based libraries for further development into safer and efficient anti-inflammatory and analgesic agents.

Routine perioperative ketorolac administration is not associated with hemorrhage in pediatric neurosurgery patients

OBJECT NSAIDs are effective perioperative analgesics. Many surgeons are reluctant to use NSAIDs perioperatively because of a theoretical increase in the risk for bleeding events. The authors assessed the effect of routine perioperative ketorolac use on intracranial hemorrhage in children undergoing a wide range of neurosurgical procedures. METHODS A retrospective single-institution analysis of 1451 neurosurgical cases was performed. Data included demographics, type of surgery, and perioperative ketorolac use. Outcomes included bleeding events requiring return to the operating room, bleeding seen on postoperative imaging, and the development of renal failure or gastrointestinal tract injury. Variables associated with both the exposure and outcomes (p < 0.20) were evaluated as potential confounders for bleeding on postoperative imaging, and multivariable logistic regression was performed. Bivariable analysis was performed for bleeding events. Odds ratios and 95% CIs were estimated. RESULTS Of the 1451 patients, 955 received ketorolac. Multivariate regression analysis demonstrated no significant association between clinically significant bleeding events (OR 0.69; 95% CI 0.15-3.1) or radiographic hemorrhage (OR 0.81; 95% CI 0.43-1.51) and the perioperative administration of ketorolac. Treatment with a medication that creates a known bleeding risk (OR 3.11; 95% CI 1.01-9.57), surgical procedure (OR 2.35; 95% CI 1.11-4.94), and craniotomy/craniectomy (OR 2.43; 95% CI 1.19-4.94) were associated with a significantly elevated risk for radiographically identified hemorrhage. CONCLUSIONS Short-term ketorolac therapy does not appear to be associated with a statistically significant increase in the risk of bleeding documented on postoperative imaging in pediatric neurosurgical patients and may be considered as part of a perioperative analgesic regimen. Although no association was found between ketorolac and clinically significant bleeding events, a larger study needs to be conducted to control for confounding factors, because of the rarity of these events.

Wilderness Medical Society practice guidelines for the treatment of acute pain in remote environments: 2014 update

The Wilderness Medical Society convened an expert panel to develop evidence-based guidelines for the management of pain in austere environments. Recommendations are graded on the basis of the quality of supporting evidence as defined by criteria put forth by the American College of Chest Physicians. This is an updated version of the original WMS Practice Guidelines for the Treatment of Acute Pain in Remote Environments published in Wilderness & Environmental Medicine 2014;25(1):41-49.

The enantioselective population pharmacokinetics of intravenous ketorolac in children using a stereoselective assay suitable for microanalysis†

Objective

To describe the effect of age and body size on enantiomer selective pharmacokinetic (PK) of intravenous ketorolac in children using a microanalytical assay.

Methods

Blood samples were obtained at 0, 15 and 30 min and at 1, 2, 4, 6, 8 and 12 h after a weight-dependent dose of ketorolac. Enantiomer concentration was measured using a liquid chromatography tandem mass spectrometry method. Non-linear mixed-effect modelling was used to assess PK parameters.

Key findings

Data from 11 children (1.7–15.6 years, weight 10.7–67.4 kg) were best described by a two-compartment model for R(+), S(−) and racemic ketorolac. Only weight (WT) significantly improved the goodness of fit. The final population models were CL = 1.5 × (WT/46)0.75, V1 = 8.2 × (WT/46), Q = 3.4 × (WT/46)0.75, V2 = 7.9 × (WT/46), CL = 2.98 × (WT/46), V1 = 13.2 × (WT/46), Q = 2.8 × (WT/46)0.75, V2 = 51.5 × (WT/46), and CL = 1.1 × (WT/46)0.75, V1 = 4.9 × (WT/46), Q = 1.7 × (WT/46)0.75 and V2 = 6.3 × (WT/46)for R(+), S(−) and racemic ketorolac.

Conclusions

Only body weight influenced the PK parameters for R(+) and S(−) ketorolac. Using allometric size scaling significantly affected the clearances (CL, Q) and volumes of distribution (V1, V2).

Adjunctive Pain Control Methods Lower Narcotic Use and Pain Scores for Patients With Adolescent Idiopathic Scoliosis Undergoing Posterior Spinal Fusion

STUDY DESIGN

This was a retrospective review of patients with adolescent idiopathic scoliosis (AIS) undergoing posterior spinal fusion (PSF).

OBJECTIVES

To determine whether the use of adjunctive pain medications (bupivacaine pump, dexmedetomidine, and ketorolac) will reduce the need for opioids, reduce postoperative pain, and shorten length of hospital stay in patients with AIS undergoing PSF.

SUMMARY OF BACKGROUND DATA

Posterior spinal fusion and instrumentation for AIS can cause significant postoperative pain. Adjunctive pain control modalities, including the use of ketorolac, dexmedetomidine, and subcutaneous bupivacaine pumps, all can lessen the effects of postoperative pain.

METHODS

Retrospective review of adolescents aged 10-18 years with AIS receiving PSF surgery over the past 10 years at a tertiary care children's hospital. All patients with AIS undergoing PSF were included in the study. Patients older than 18 or younger than 10 years and those undergoing PSF for other diagnoses, including neuromuscular scoliosis, congenital scoliosis, and kyphosis, were excluded from the study. Patients' pain was managed postoperatively with adjunctive medications in addition to intravenous and oral opioids. Variables of interest were local anesthetic bupivacaine delivered through a subcutaneous pump, sedative/analgesic dexmedetomidine, and ketorolac. Primary outcomes analyzed were normalized opioid requirement after surgery, visual analog scale (VAS) pain scores, and length of stay in the hospital.

RESULTS

A total of 196 children were analyzed with no significant differences in demographics. Univariate analysis showed that all 3 adjunct medications improved outcomes. A multivariate regression model of the outcomes with respect to the 3 medication variables of interest was built, showing that the bupivacaine pump significantly reduced normalized opioid requirement by 0.98 mg/kg (p = .001) and reduced VAS pain scores by 0.67 points (p = .004). Dexmedetomidine significantly reduced the average VAS pain scores in the first 24 hours by 0.62 points (p = .005).

CONCLUSIONS

Use of the bupivacaine pump provided improved analgesia with lower pain scores, lower opioid requirements, and a lower length of stay.

Tonsillitis and sore throat in children

Surgery of the tonsils is still one of the most frequent procedures during childhood. Due to a series of fatal outcomes after hemorrhage in children in Austria in 2006, the standards and indications for tonsillectomy have slowly changed in Germany. However, no national guidelines exist and the frequency of tonsil surgery varies across the country. In some districts eight times more children were tonsillectomized than in others. A tonsillectomy in children under six years should only be done if the child suffers from recurrent acute bacterially tonsillitis. In all other cases (i.e. hyperplasia of the tonsils) the low risk partial tonsillectomy should be the first line therapy. Postoperative pain and the risk of hemorrhage are much lower in partial tonsillectomy (=tonsillotomy). No matter whether the tonsillotomy is done by laser, radiofrequency, shaver, coblation, bipolar scissor or Colorado needle, as long as the crypts are kept open and some tonsil tissue is left behind. Total extracapsular tonsillectomy is still indicated in severely affected children with recurrent infections of the tonsils, allergy to antibiotics, PFAPA syndrome (periodic fever, aphthous stomatitis, pharyngitis, and cervical adenitis) and peritonsillar abscess. With regard to the frequency and seriousness of the recurrent tonsillitis the indication for tonsillectomy in children is justified if 7 or more well-documented, clinically important, adequately treated episodes of throat infection occur in the preceding year, or 5 or more of such episodes occur in each of the 2 preceding years (according to the paradise criteria). Diagnosis of acute tonsillitis is clinical, but sometimes it is hard to distinguish viral from bacterial infections. Rapid antigen testing has a very low sensitivity in the diagnosis of bacterial tonsillitis and swabs are highly sensitive but take a long time. In all microbiological tests the treating physician has to keep in mind, that most of the bacterials, viruses and fungi belong to the healthy flora and do no harm. Ten percent of healthy children even bear strepptococcus pyogenes all the time in the tonsils with no clinical signs. In these children decolonization is not necessary. Therefore, microbiological screening tests in children without symptoms are senseless and do not justify an antibiotic treatment (which is sometimes postulated by the kindergartens). The acute tonsillitis should be treated with steroids (e.g. dexamethasone), NSAIDs (e.g. ibuprofene) and betalactam antibiotics (e.g. penicillin or cefuroxime). With respect to the symptom reduction and primary healing the short-term late-generation antibiotic therapy (azithromycin, clarithromycin or cephalosporine for three to five days) is comparable to the long-term penicilline therapy. There is no difference in the course of healing, recurrence or microbiological resistance between the short-term penicilline therapy and the standard ten days therapy. On the other hand, only the ten days antibiotic therapy has proven to be effective in the prevention of rheumatic fever and glomerulonephritic diseases. The incidence of rheumatic heart disease is currently 0.5 per 100,000 children of school age. The main morbidity after tonsillectomy is pain and the late haemorrhage. Posttonsillectomy bleeding can occur till the whole wound is completely healed, which is normally after three weeks. Life-threatening haemorrhages occur often after smaller bleedings, which can spontaneously cease. That is why every haemorrhage, even the smallest, has to be treated properly and in ward. Patients and parents have to be informed about the correct behaviour in case of haemorrhage with a written consent before the surgery. The handout should contain important addresses, phone numbers and contact persons. Almost all cases of fatal outcome after tonsillectomy were due to false management of haemorrhage. Haemorrhage in small children can be especially life-threatening because of the lower blood volume and the danger of aspiration with asphyxia. A massive haemorrhage is an extreme challenge for every paramedic or emergency doctor because of the difficult airway management. Intubation is only possible with appropriate inflexible suction tubes. All different surgical techniques have the risk of haemorrhage and even the best surgeon will experience a postoperative haemorrhage. The lowest risk of haemorrhage is after cold dissection with ligature or suturing. All "hot" techniques with laser, radiofrequency, coblation, mono- or bipolar forceps have a higher risk of late haemorrhage. Children with a hereditary coagulopathy have a higher risk of haemorrhage. It is possible, that these children were not identified before surgery. Therefore it is recommended by the Society of paediatrics, anaesthesia and ENT, that a standardised questionnaire should be answered by the parents before tonsillectomy and adenoidectomy. This 17-point-checklist questionnaire is more sensitive and easier to perform than a screening with blood tests (e.g. INR and PTT). Unfortunately, a lot of surgeons still screen the children preoperatively by coagulative blood tests, although these tests are inappropriate and incapable of detecting the von Willebrand disease, which is the most frequent coagulopathy in Europe. The preoperative information about the surgery should be done with the child and the parents in a calm and objective atmosphere with a written consent. A copy of the consent with the signature of the surgeon and both custodial parents has to be handed out to the parents.

Pain management following the Nuss procedure: a survey of practice and review

BACKGROUND

Pectus excavatum is the most common congenital chest wall deformity. The Nuss procedure is frequently used for surgical correction and this technique has been associated with severe and prolonged post-operative pain. At the present time, the optimal analgesic strategy for managing patients following this procedure has not been determined.

METHODS

A web-based survey was sent to representatives from 108 primarily pediatric hospitals in North America, Europe, Asia and Australia. One individual per institution was contacted to complete the survey on behalf of their department.

RESULTS

Survey response rate was 54% and 55 institutions reported using the Nuss procedure for correction of pectus excavatum. Annual case volume is less than or equal to 25 cases in 57% of institutions, and the most common age of patients is 14 to 17 years old. A clinical protocol for patient post-operative pain management is used in 45% of institutions. Thoracic epidural is utilized as a primary analgesic modality by 91% of institutions. Concomitant use of intravenous patient-controlled analgesia is reported by 27% of institutions. Nine respondents (16%) reported that they had recently stopped performing epidurals because of surgeon preference. Referral of one or more patients annually for chronic pain management was reported in 22% of surveys.

CONCLUSIONS

Post-operative pain management following the Nuss procedure is variable and poorly characterized. Clinical trials or large observational registries comparing the safety and efficacy of primary modalities and long-term outcomes are needed to enable evidence-based decision-making for the management of these patients.

Evaluation of dexmedetomidine and postoperative pain management in patients with adolescent idiopathic scoliosis: conclusions based on a retrospective study at a tertiary pediatric hospital

OBJECTIVES

This study evaluated the effectiveness of dexmedetomidine in decreasing opioid use in children with adolescent idiopathic scoliosis following posterior spinal fusion surgery at a pediatric tertiary care hospital over the past 10 years.

DESIGN

This was a retrospective chart review. Patients were separated into two groups: those that received opioid via patient-controlled analgesia pain therapy alone and those that received opioid via patient-controlled analgesia pain therapy with dexmedetomidine.

SETTING

A tertiary pediatric free-standing hospital. The study focused on care administered in the perioperative period, including the operating room, ICU, and general hospital floor.

PATIENTS

One hundred sixty-three children with adolescent idiopathic scoliosis.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Measurements included patient demographics, American Society of Anesthesiologists Physical Status Classification System, levels of spinal fusion, length of hospital stay, complications, numeric pain scores, opioid requirement, elastomeric pain pump use, length of time until ambulation, adverse effects, and naloxone use. Data were collected through the first 72 hours of the perioperative period. One hundred six patients received opioids via patient-controlled analgesia therapy with dexmedetomidine and 57 received opioids via patient-controlled analgesia alone. Within the groups, there were 46 patients who received local anesthetic infusions via elastomeric pumps in the patient-controlled analgesia with dexmedetomidine group and 16 patients had pumps in the patient-controlled analgesia-alone group. There was no overall difference in postoperative use of morphine (or equivalents) between the two groups. However, the use of elastomeric pain pumps demonstrated a statistically significant decrease in mean overall opioid consumption (42.6 mg vs 63.1 mg, p < 0.001).

CONCLUSIONS

There was no difference in opioid use related to dexmedetomidine on any postoperative day. The only variable showing a significant opioid sparing effect was the use of local anesthetic infusions via elastomeric pumps. Using continuous local anesthetic infusions instead of dexmedetomidine could eliminate the need for ICU admission, require shorter hospital stays, and reduce costs while still providing safe and effective pain control.

Ketorolac tromethamine - routes and clinical implications

Opioids have long been used for analgesic purposes for a wide range of procedures. However, the binding of these drugs to opiate receptors has created various challenges to the clinician due to unfavorable side effect profiles and the potential for tolerance and abuse. In 1989, ketorolac became an approved nonsteroidal inflammatory drug (NSAID) for injectable use as an analgesic. Over the last 20 years, numerous studies have been conducted involving ketorolac. These studies have provided additional information about various routes of administration and their effect on the efficacy and the side effect profile of ketorolac. Moreover, ketorolac has been compared with several widely used analgesics. This review evaluates both the potential benefits and potential drawbacks of ketorolac generally, and specifically discusses routes of administration, including their advantages and disadvantages when compared to several traditional analgesics in both inpatient and outpatient settings.

Attention to postoperative pain control in children

Even with the rapid development of pediatric postoperative pain management, pediatric patients have remained undertreated for postoperative pain because of difficulty in pain assessment and concerns regarding side effects of opioid analgesics. Although there are no perfect pain assessment techniques and no absolutely safe analgesics, proper monitoring and an individualized analgesic plan after due consideration of age, operative procedures, and underlying illness, using multimodal analgesics may improve the quality of pain control in children.

Wilderness Medical Society practice guidelines for the treatment of acute pain in remote environments

The Wilderness Medical Society convened an expert panel to develop evidence-based guidelines for the management of pain in austere environments. Recommendations are graded based on the quality of supporting evidence as defined by criteria put forth by the American College of Chest Physicians.

Pharmacotherapy for acute pain in children: current practice and recent advances

INTRODUCTION

Acute pain in children may be undertreated. Improved understanding of developmental neurobiology and paediatric pharmacokinetics should facilitate better management of pharmacotherapy. The objective of this review is to discuss current paediatric practice and recent advances with these analgesic agents by using an evidence-based approach.

AREAS COVERED

Using PubMed an extensive literature review was conducted on the commonly used analgesic agents in children from 2000 to April 2010.

EXPERT OPINION

A multimodal analgesic regimen provides better pain control and functional outcome in children. The choice of pharmacological treatment is determined by the severity and type of pain. However, more research and evidence is required to determine the optimal drug combinations.

Ketorolac or fentanyl continuous infusion for post-operative analgesia in children undergoing ureteroneocystostomy

BACKGROUND

children undergoing ureteroneocystostomy suffer from post-operative pain due to the surgical incision and bladder spasm. A single-shot caudal block is a common technique for paediatric analgesia, but a disadvantage is the limitation of a short duration in spite of the additives co-administered. A few clinical trials have shown that ketorolac provides an effective post-operative analgesia and reduces the bladder spasms after ureteral implantation in children. We compared the efficacy of a continuous infusion of ketorolac and fentanyl in post-operative analgesia and bladder spasm in children who underwent ureteroneocystostomy.

METHODS

fifty-two children were allocated to the ketorolac group (Group K, n=26) and fentanyl group (Group F, n=26). After general anaesthesia, a caudal block was performed with 1.5 ml/kg of 0.15% ropivacaine. At the beginning of surgery, an infusion was started after the bolus injection of ketorolac 0.5 mg/kg or fentanyl 1 microg/kg. An infusion device was programmed to deliver ketorolac 83.3 microg/kg/h or fentanyl 0.17 microg/kg/h for 48 h.

RESULTS

two of Group F and three of Group K were excluded from the study. Post-operative pain scores were similar between the two groups. One of Group K (4%) and seven of Group F (30.4%) experienced bladder spasms. The rescue analgesic requirements were significantly less in Group K.

CONCLUSIONS

a Continuous infusion of ketorolac provided effective analgesia after operation in children who underwent ureteroneocystostomy as well as a low dosage of fentanyl. Ketorolac was more effective in reducing the frequency of bladder spasms and rescue analgesic requirements.

Fentanyl sparing effects of combined ketorolac and acetaminophen for outpatient inguinal hernia repair in children

PURPOSE

In this prospective, randomized, double-blinded study we sought to evaluate the efficacy and safety of combined use of intravenous ketorolac and acetaminophen in small children undergoing outpatient inguinal hernia repair.

MATERIALS AND METHODS

We studied 55 children 1 to 5 years old who were undergoing elective repair of unilateral inguinal hernia. After induction of general anesthesia children in the experimental group (28 patients) received 1 mg/kg ketorolac and 20 mg/kg acetaminophen intravenously. In the control group (27 patients) the same volume of saline was administered. All patients received 1 microg/kg fentanyl intravenously before incision. We also evaluated the number of patients requiring postoperative rescue fentanyl, total fentanyl consumption, pain scores and side effects.

RESULTS

Significantly fewer patients receiving ketorolac-acetaminophen received postoperative rescue fentanyl compared to controls (28.6% vs 81.5%). A significantly lower total dose of fentanyl was administered to patients receiving ketorolac-acetaminophen compared to controls (0.54 vs 1.37 microg/kg). Pain scores were significantly higher in the control group immediately postoperatively but eventually decreased. The incidences of sedation use (55.6% vs 25.0%) and vomiting (33.3% vs 10.7%) were significantly higher in controls.

CONCLUSIONS

Preoperative intravenous coadministration of ketorolac and acetaminophen is a simple, safe and effective method for relieving postoperative pain, and demonstrates highly significant fentanyl sparing effects in small children after outpatient inguinal hernia repair.