Lynn M. Rusy

A double-blind evaluation of ketorolac tromethamine versus acetaminophen in pediatric tonsillectomy: analgesia and bleeding.

The study was designed to compare intravenous ketorolac to rectal acetaminophen for analgesia and bleeding in pediatric patients undergoing tonsillectomy.We studied 50 patients, aged 2-15 yr undergoing tonsillectomy with or without adenoidectomy. In a randomized, prospective double-blind fashion, patients were assigned to receive either ketorolac (1 mg/kg) or rectal acetaminophen (35 mg/kg). Bleeding was evaluated by measuring intraoperative blood loss and noting extra measures required to obtain hemostasis. Bleeding times were also measured before and during surgery. Pain was evaluated using a standard objective pain score for the first 3 h. Persistent pain was treated with morphine, acetaminophen, and codeine and recorded for 24 h. Blood for determination of acetaminophen levels was drawn at 20 and 40 min after the administration of study drugs. Pain scores were not significantly different between the ketorolac and acetaminophen groups. The majority of patients in both groups required additional opioid in the postoperative period. Acetaminophen levels were all less than the therapeutic range. Intraoperative bleeding times were normal in all patients, but blood loss was significantly higher in the ketorolac group (2.67 mL/kg) compared to the acetaminophen group (1.44 mL/kg), P = 0.025. Significantly more measures to achieve hemostasis were required in the ketorolac group (P = 0.012). We conclude that ketorolac is no more effective than high-dose rectal acetaminophen for analgesia in the patient undergoing tonsillectomy. Hemostasis during tonsillectomy was significantly more difficult to achieve in patients receiving ketorolac. (Anesth Analg 1995;80:226-9)

Electroacupuncture Prophylaxis of Postoperative Nausea and Vomiting following Pediatric Tonsillectomy with or without Adenoidectomy

Background Electrical stimulation of acupuncture point P6 reduces the incidence of postoperative nausea or vomiting (PONV) in adult patients. However, acupressure, laser stimulation of P6, and acupuncture during anesthesia have not been effective for reducing PONV in the pediatric population. The authors studied the effect of electrical P6 acupuncture in awake pediatric patients who had undergone surgery associated with a high incidence of PONV. Methods Patients aged 4–18 yr undergoing tonsillectomy with or without adenoidectomy were randomly assigned to acupuncture, sham acupuncture, or control groups. Acupuncture needles at P6 and a neutral point were placed while patients were anesthetized, and low-frequency electrical stimulation was applied to these points for 20 min in the recovery room while the patients were awake (P6 Acu group). This treatment was compared with sham needles along the arm at acupuncture points not associated with antiemesis (sham group) and a no-needle control group. The arms were wrapped to prevent identification of treatment group, and anesthetic, analgesic, and surgical technique were standardized. Assessed outcomes were occurrence of nausea, occurrence and number of episodes of vomiting, time to vomiting, and use of antiemetic rescue medication. Results One hundred twenty patients were enrolled in the study, 40 per group. There were no differences in age, weight, sex, or opioid administration between groups. The PONV incidence was significantly lower with P6 acupuncture (25 of 40 or 63%; odds ratio, 0.135; number needed to treat, 3.3;P < 0.001) compared with controls (37 of 40 or 93%). Sham puncture had no effect on PONV (35 of 40 or 88%;P = not significant). Occurrence of nausea was significantly less in P6 Acu (24 of 40 or 60%; odds ratio, 0.121;P < 0.01), but not in the sham group (34 of 40 or 85%) compared with the control group (37 of 40 or 93%). Vomiting occurred in 25 of 40 or 63% in P6 Acu; 35 of 40 or 88% in the sham group, and 31 in 40 or 78% in the control group (P = not significant). Patients receiving sham puncture vomited significantly earlier (P < 0.02) and needed more rescue treatment (33 of 40 or 83%; odds ratio, 3.48;P < 0.02) compared with P6 Acu (23 of 40 or 58%) and the control group (24 of 40 or 60%). Conclusions Perioperative P6 electroacupuncture in awake patients significantly reduced the occurrence of nausea compared with the sham and control groups, but it did not significantly reduce the incidence or number of episodes of emesis or the use of rescue antiemetics. Sham acupuncture may exacerbate the severity but not the incidence of emesis. The efficacy of P6 acupuncture for PONV prevention is similar to commonly used pharmacotherapies. Its appropriate role in prevention and treatment of PONV requires further study.

Culture of bacteria from lumbar and caudal epidural catheters used for postoperative analgesia in children

Background and Objectives. Continuous epidural analgesia has been used with increasing frequency to provide postoperative pain relief for children. Epidural space infection is a potential complication of epidural catheter placement. This study investigated the incidence of bacterial colonization on lumbar and caudal epidural catheter tips in postoperative pediatric patients. Methods. In this prospective study, lumbar and caudal epidural catheters were placed in the operating room with aseptic technique. Dilute local anesthetic and/or opioid infusions were used for postoperative analgesia. On discontinuation of the epidural infusion, the skin site was decontaminated with 70% alcohol and then cultured. The distal catheter tip and hub were cultured. Semiquantitative and qualitative aerobic cultures were performed. Results. Data from 91 epidural catheters were available (45 caudal versus 46 lumbar). Of the 45 caudal catheter tips 9 (20%) were colonized, compared with 2 of the 46 (4%) lumbar catheter tips (P < .02). Staphylococcus epidermidis was the predominant skin and catheter tip organism isolated in both groups. Four of nine caudal catheter tips grew gram‐negative bacteria. Statistical analyses did not show that time, skin site inflammation, or dressing condition were independent predictors of catheter tip colonization. No patient developed a clinical epidural infection during the study period. Conclusions. The results of this study suggest that the risk of clinical epidural infection associated with caudal or lumbar postoperative catheters is low. However, the incidence of epidural catheter tip colonization is increased with the caudal route of insertion, and the bacteria differ from those cultured from the lumbar insertion site.

Epidural analgesia improves outcome following pediatric fundoplication: A retrospective analysis

Background and Objectives. Nissen fundoplication is a common procedure in high‐risk pediatric patients. This cohort study evaluated the influence of epidural versus intravenous opioid analgesia on the postoperative course of infants and children undergoing fundoplication. Methods. A retrospective review was made of the perioperative courses of 155 consecutive patients, aged 1 month to 19 years, who underwent elective open fundoplication from January 1993 to October 1994. Of these 155 patients, 72 received perioperative analgesia with epidural opioids, while 83 received parenteral opioids. Outcome variables included major morbidity factors, recovery of bowel and bladder function, and economic impact. Results. Patients in the epidural and parenteral groups did not differ with respect to age, weight, or associated preoperative medical diagnoses. The postoperative complication rate was significantly decreased in the epidural group (5.5% versus 20%) (P < .001). In the epidural group 4 patients required mechanical ventilation for longer than 24 hours, compared with 15 in the parenteral group. Patients in the epidural group were discharged earlier from the hospital and incurred approximately 20% less in hospital charges on average than their cohorts in the intravenous group. Conclusions. These findings suggest that perioperative epidural analgesia, administered by a dedicated pain service, amy improve outcome in high‐risk pediatric patients undergoing fundoplication.

Gabapentin use in pediatric spinal fusion patients: a randomized, double-blind, controlled trial.

BACKGROUND: Gabapentin has opioid-sparing effects in adult surgical patients, but no reported studies have involved children and adolescents. In a double-blind, randomized, controlled trial, we examined whether gabapentin decreases postoperative opioid consumption for pediatric spinal fusion patients with idiopathic scoliosis. METHODS: Patients, aged 9 to 18 years, received preoperative gabapentin (15 mg/kg, treatment) or placebo. Anesthesia was standardized. After surgery, all patients received standardized patient-controlled analgesia opioid and continued on either gabapentin (5 mg/kg) or placebo 3 times per day for 5 days. Opioid use was calculated in mg/kg/time intervals. Pain scores and opioid side effects were recorded. RESULTS: Data from 59 patients (30 placebo and 29 gabapentin) did not differ in demographics. Total morphine consumption (mg/kg/h ± SD) was significantly lower in the gabapentin group in the recovery room (0.044 ± 0.017 vs 0.064 ± 0.031, P = 0.003), postoperative day 1 (0.046 ± 0.016 vs 0.055 ± 0.017, P = 0.051), and postoperative day 2 (0.036 ± 0.016 vs 0.047 ± 0.019, P = 0.018). In addition, gabapentin significantly reduced first pain scores in the recovery room (2.5 ± 2.8 vs 6.0 ± 2.4, P < 0.001) and the morning after surgery (3.2 ± 2.6 vs 5.0 ± 2.2, P < 0.05), but otherwise pain scores were not significantly different. There were no differences in opioid-related side effects over the course of the study. CONCLUSION: Perioperative oral gabapentin reduced the amount of morphine used for postoperative pain after spinal fusion surgery, but not overall opioid-related side effects. Initial pain scores were lower in the treatment group. Perioperative use of gabapentin seems to be an effective adjunct to improve pain control in the early stages of recovery in children and adolescents undergoing spinal fusion.

Gabapentin in Phantom Limb Pain Management in Children and Young Adults: Report of Seven Cases

Seven children and young adults with phantom limb pain (PLP) were treated with gabapentin. PLP resolved in six patients within two months. One patient still had symptoms to a lesser degree. Mean follow up time was 1.74 years. Gabapentin may be a useful adjunct to pain management in patients with PLP symptoms.

Treatment of Tremors in Complex Regional Pain Syndrome

A 14-year-old girl presented with Complex Regional Pain Syndrome, Type I (CRPS-1) of the left ankle after a remote history of sprain. Allodynia, pain, temperature and color changes, and swelling were successfully treated with physical therapy, transcutaneous electrical nerve stimulation (TENS), gabapentin, amitriptyline, and tramadol. Five weeks later, she presented with a continuous, involuntary, intermittent coarse tremor of the left foot causing increased pain. The electromyogram showed rhythmic discharges of 3 Hz frequency lasting 20-80 milliseconds in the left tibialis, peroneus and gastrocnemius, suggestive of either basal ganglia or spinal origin. Tremor and pain were controlled with epidural bupivacaine, but the tremor reappeared after discontinuing epidural blockade. Carbidopa/levodopa 25/100 (Sinemet) was started and the tremor disappeared after two days. With continued physical therapy, pain and swelling resolved within two months and carbidopa/levodopa was discontinued after five weeks with no recurrence of the tremor. Our success in the treatment of CRPS-associated tremor in this young girl with carbidopa/levodopa suggests that this patient may have had underlying movement disorder which was unmasked by the peripheral injury.

Pediatric fibromyalgia and dizziness: evaluation of vestibular function.

Twelve children with fibromyalgia and complaints of chronic dizziness were evaluated with both clinical office maneuvers of vestibular function and laboratory tests composed of electronystagmography and sinusoidal harmonic acceleration rotary chair testing. All test results were normal for spontaneous nystagmus with or without visual fixation, oculocephalic reflex, dynamic visual acuity, head-shaking nystagmus, Quix test, and Dix-Hallpike maneuver. Electronystagmography test results were essentially normal for saccades, gaze, Dix-Hallpike, pendular tracking, and caloric evaluation. Rotary chair testing was normal in all 12 patients. These findings suggest that central (brainstem) and peripheral vestibular (inner ear) mechanisms do not account for the complaints of dizziness in the pediatric patient with fibromyalgia. The common musculoskeletal abnormalities of fibromyalgia may affect their proprioceptive orientation, therefore giving them a sense of imbalance.

Increased numbers of neuroepithelial bodies (NEB) in lungs of fetal Rhesus monkeys following maternal dexamethasone treatment

SummaryNumbers of neuroepithelial bodies in the lungs of fetal Rhesus monkeys increase in a dose-dependent manner when mothers are treated antenatally with dexamethasone. Maternal doses of 15 mg/kg result in numbers of neuroepithelial bodies in lungs of fetuses of 135-day gestational age not different from those of the mature control group at 162 days. Controls at 135 days are significantly different from those at 162 days. Serotonin immunoreactive neuroepithelial bodies were localized by immunocytochemistry.

Developing an in-patient acupuncture treatment in a pediatric hospital.

Abstract: Little is known about the broad application of acupuncture as adjuvant treatment for in-patient pediatric populations. We review a series of cases involving acupuncture for conditions ranging from insomnia to cyclic vomiting. The details of the protocol for each are included. This case series illustrates the benefits of an in-patient acupuncture treatment service, as well as the subtleties of an acupuncture protocol when treating children and adolescents.