Deborah Wagner

Epidural Analgesia Compared With Intravenous Analgesia After Pediatric Posterior Spinal Fusion

Background Pain management remains challenging for pediatric patients after posterior spinal fusion (PSF). This study compares the effectiveness of hydromorphone and bupivacaine administered through patient-controlled epidural analgesia (PCEA) with hydromorphone patient-controlled intravenous analgesia (IV-PCA) in this population. Methods Patients aged 8 to 18 years undergoing PSF for idiopathic scoliosis were randomized to receive either PCEA (0.1% bupivacaine plus hydromorphone 10 mcg/mL at 8 mL/h plus bolus dosing) or IV-PCA (hydromorphone 2 mcg/kg/h continuous infusion; 2 mcg/kg bolus dose). Pain scores, severity of muscle spasms, and analgesic doses were recorded for 3 postoperative days (PODs). Adverse events were followed until discharge. Results Thirty-eight patients were included (19 PCEA and 19 IV-PCA). Seven in the PCEA group (37%) experienced early epidural failure, and 2 in the IV-PCA group remained intubated, sedated, and ventilated for several hours postoperatively; these patients were included in the intention-to-treat analysis. All data are presented as “per protocol” unless otherwise specified. Pain scores were significantly lower on days 2 and 3 (P≤0.042). Eight percent of the patients who received PCEA experienced moderate-to-severe spasms through POD 3 compared with 35% of those in the IV-PCA group (P=NS). Seven (58%) patients in the PCEA group and 17 (100%) in the IV-PCA group required diazepam (P=0.007). Conclusions Epidural catheters provide modestly improved analgesia in patients after PSF for idiopathic scoliosis. However, the high failure rate in this population emphasizes a need for a close assessment for adequate blockade early in the recovery period. This study provides an excellent platform on which to build future trials that could include increased baseline dosing for the epidural medications, radiographic confirmation of catheter placement, and dual catheter techniques toward the goal of improving pain control in these patients. Level of Evidence Level 2, randomized, controlled trial.

In vitro clearance of dexmedetomidine in extracorporeal membrane oxygenation.

Dexmedetomidine (DMET) is a useful agent for sedation, both alone and in combination with other agents, in critically ill patients, including those on extracorporeal membrane oxygenation (ECMO) therapy. The drug is a clonidine-like derivative with an 8-fold greater specificity for the alpha 2-receptor while maintaining respiratory and cardiovascular stability. An in vitro ECMO circuit was used to study the effects of both “new” and “old” membrane oxygenators on the clearance of dexmedetomidine over the course of 24 hours. Once primed, the circuit was dosed with 840 μg of dexmedetomidine for a final concentration of 0.9 μg/ml. Serial samples, both pre- and post-oxygenator, were taken at 5, 60, 360, and 1440 minutes. Concentrations of the drug were expressed as a percentage of the original concentration remaining at each time point, both for new and old circuits. The new circuits were run at a standard flow for 24 hours, after which time the circuit was considered old and re-dosed with dexmedetomidine and the trial repeated. Results show that dexmedetomidine losses occur early in the circuits and then continue to decline. Initial losses in the first hour were 11+-65% and 59-73% pre- and post-oxygenator in the new circuit and 36-50% and 42-72% in the old circuit. The clearance of the drug through the membrane oxygenator exhibits no statistical difference between pre and post or new and old circuits. Dexmedetomidine can be expected to exhibit concentration changes during ECMO therapy. This effect appears to be more related to adsorption to the polyvinyl chloride (PVC) tubing rather than the membrane oxygenator. Dosage adjustments during dexmedetomidine administration during ECMO therapy may be warranted in order to maintain adequate serum concentrations and, hence, the desired degree of sedation.*(Lack of equilibrium)

Oral granisetron for strabismus surgery in children.

PurposeTo determine the efficacy of oral granisetron in preventing postoperative vomiting (POV) following strabismus repair in children.MethodsIn a randomized, double-blind, placebo-controlled trial, 73 pediatric patients received either placebo, 20 μg·kg−1 or 40 μg·kg−1 granisetronpo 20 min before induction of anesthesia. No premedication was given, induction was with halothane and all children breathed spontaneously via a laryngeal mask airway. Maintenance was with isoflurane without the use of opioids. Ketorolac and acetaminophen were used for analgesia. The number of episodes and the severity of vomiting and retching were recorded for the first 24 hr postoperatively, as was the use of rescue antiemetics.ResultsGranisetron 20 μ·kg−1 and 40 μg·kg−1 were more effective than placebo in reducing the incidence of POV during the first 24 hr (29% in both the granisetron groupsvs 84% in the placebo group,P < 0.05). In addition, the number of children experiencing severe vomiting (≥ 3 episodes) was reduced in the granisetron 20 μg·kg−1 and 40 μg·kg−1 groups compared with placebo (4%, 8% and 48% respectively,P < 0.05). Patients in the granisetron group were discharged home earlier ( 105 min vs 124 min,P = 0.04). There was no difference in the incidence of POV between the two granisetron groups.ConclusionPreoperative oral granisetron in a dose of 20 μg·kg−1 provided effective prophylaxis against POV in children undergoing stabismus repair.RésuméObjectifDéterminer l’efficacité du granisétron, administré par voie orale, à prévenir les vomissements postopératoires (VPO) suivant la correction du strabisme chez des enfants.MéthodeLors d’un essai contre placebo, en double aveugle, 73 patients pédiatriques ont reçu soit un placebo, soit 20 μg·kg−1 ou 40 μg·kg−1 de granisétronpo 20 min avant l’induction de l’anesthésie. Aucune prémédication n’a été administrée, l’induction s’est faite avec de l’halothane et l’anesthésie a été maintenue chez tous les enfants en utilisant la ventilation spontanée au moyen d’un masque laryngé. On a maintenu l’anesthésie avec de l’isoflurane sans employer d’opioïdes. Les analgésiques étaient du kétorolac et de l’acétaminophène. Le nombre et la sévérité des épisodes de vomissements et de haut-le-coeur ont été notés, pendant les vingt-quatre premières heures postopératoires, de même que le recours à des antiémétiques.RésultatsLe granisétron à 20 μg·kg−1 et à 40 μg·kg−1 a été plus efficace que le placebo en réduisant l’incidence des VPO pendant les vingt-quatre premières heures (29 % dans les deux groupes qui ont reçu du granisétron vs 84 % dans le groupe qui a reçu le placebo, P < 0,05). De plus, le nombre d’enfants qui ont eu des vomissements sévères (≥ 3 épisodes) était réduit dans les groupes recevant du granisétron en doses de 20 μg·kg−1 et de 40 μg·kg−1 à comparer au groupe recevant le placebo (4 %, 8% et 48 % respectivement,P < 0,05). Les patients du groupe granisétron ont reçu leur congé plus tôt ( 105 min vs 124 min,P = 0,04). Il n’y a pas eu de différence entre les deux groupes qui ont reçu du granisétron concernant l’incidence des VPO.ConclusionLadministration orale préopératoire de granisétron en doses de 20 μg·kg−1 prévenait de façon efficace les VPO chez les enfants ayant subi une correction de strabisme.

Assessing parents preferences for the avoidance of undesirable anesthesia side effects in their children undergoing surgical procedures

Background:  Willingness to pay (WTP) surveys have proven to be useful tools in determining patient preferences though relatively few pediatric studies have utilized them. Studies in the adult surgical population have used such methods to assess patients’ perspectives regarding the avoidance of anesthesia side effects or outcomes. The purpose of this survey was to assess parental preferences, using a relative WTP model, for the avoidance of anesthesia side effects in their children undergoing surgery.

Retrospective evaluation of antimicrobial prophylaxis in prevention of surgical site infection in the pediatric population.

Few studies have been conducted in pediatric patients evaluating efficacy of prophylactic antibiotics for prevention of surgical site infection (SSI). This retrospective study was undertaken to determine the effect of antibiotic prophylaxis in the prevention of SSI in children.

Glycopyrrolate does not reduce the incidence of perioperative adverse events in children with upper respiratory tract infections.

Two recent studies have identified copious secretions as an independent risk factor for perioperative adverse events in children who present for elective surgery in the presence of an upper respiratory tract infection (URI). We designed this study, therefore, to determine whether the administration of the anticholinergic drug, glycopyrrolate, to children with URIs would reduce the incidence of adverse perioperative respiratory events. One hundred thirty children (1 mo to 18 yr of age) who presented for elective surgery with a URI were randomized to receive either 0.01 mg/kg glycopyrrolate or placebo and were followed for the appearance and severity of any perioperative respiratory adverse events. The two groups were similar with respect to demographics, presenting URI symptoms, anesthetic management, and surgical procedure. In the intention-to-treat analysis, there were no statistical differences in the incidence or severity of perioperative respiratory adverse events between the glycopyrrolate and placebo groups (45.2% vs 37.5% respectively, P = NS). Furthermore, there were no differences in outcome between the two groups when children with congestion and secretions were analyzed separately (45.0% vs 37.0%, respectively). However, compared with the placebo group, children in the glycopyrrolate group had significantly shorter discharge times (83.9 min vs 111.4 min, P = 0.024), and significantly less postoperative nausea and vomiting (10.7% vs 33.3%, P = 0.005). These results suggest that glycopyrrolate, administered after induction of anesthesia to children with URIs, does not reduce the incidence of perioperative respiratory adverse events, and thus may not be clinically indicated for routine use in this population.

Early adjuvant use of nonopioids associated with reduced odds of serious postoperative opioid adverse events and need for rescue in children

Examine factors associated with opioid adverse drug events (ADE) in children.

Dolasetron for the prevention of postoperative vomiting in children undergoing strabismus surgery

Background: Children undergoing strabismus surgery have a high incidence of postoperative vomiting (POV). The purpose of this study was to assess the efficacy and safety of dolasetron for the prevention of emesis comparing a single 0.35 mg·kg−1 or 12.5 mg dose with placebo.

Safety and efficacy of recombinant activated factor VII for refractory hemorrhage in pediatric patients on extracorporeal membrane oxygenation: a single center review

Background: Medically refractory hemorrhage in patients on ECMO (extracorporeal membrane oxygenation) support can have catastrophic complications. Recombinant-Activated Factor VII (rFVIIa; NovoSeven®) may provide lifesaving hemostasis; however, there are reports of catastrophic thrombosis related to its administration. Objective: This review attempts to add safety and efficacy data to existing literature regarding the use of rFVIIa for refractory hemorrhage in pediatric patients on ECMO support. Design/Methods: A retrospective chart review was performed for all pediatric patients on ECMO who received rFVIIa for refractory hemorrhage from 2004 to 2009. Data was extracted for each refractory bleeding event, including patient blood loss and transfused blood products in the 6 hours before the first dose, between rFVIIa doses and in the 6 hours after the final dose. For purposes of data collection, a hemorrhagic event was defined as new onset hemorrhage or a hemorrhage occurring at least 12 hours after the most recent dose of rFVIIa. Results: In total, seven patients aged 1 month to 15 years received rFVIIa for 14 different hemorrhagic events. There was no significant difference in blood loss or blood product transfusion associated with rFVIIa administration. There was one patient-related and one ECMO-related complication temporally associated with rFVIIa administration: decreased ECMO circuit oxygenator efficiency and the development of an intra-gastric clot requiring surgical evacuation. Conclusion: These data suggest limited efficacy for rFVIIa use for refractory hemorrhage in pediatric patients on ECMO support. There were two non-catastrophic complications temporally associated with its administration.

The effects of an informational video on patient knowledge, satisfaction and compliance with venous thromboembolism prophylaxis: A pilot study

OBJECTIVE Venous thromboembolism (VTE) is the leading cause of preventable death in hospitalized patients. Educational videos have been effectively used to increase patient satisfaction and knowledge. This study examined possible benefits of an educational video about VTE. METHODS Medical patients receiving VTE prophylaxis were screened within 48 h of admission. Upon enrollment, patients were randomly assigned to either watch a 5 min educational video on VTE or not, in addition to standard VTE education. Within 24-48 h after randomization, all patients completed a survey assessing VTE prophylaxis knowledge and satisfaction. RESULTS Patients who watched the video averaged 83% correct responses to knowledge-based questions (regarding VTE risk, symptoms, and preventative measures) versus an average score of 62% for patients in the no video group (p<0.001). Patients who watched the video were more satisfied with their VTE education (4.8 vs. 3.4 out of 5, p<0.001). CONCLUSION This educational video effectively provided baseline information to patients about VTE and improved patient satisfaction. PRACTICE IMPLICATIONS A VTE educational video can be an effective tool for improving patient knowledge of the condition.