Neil S. Morton

Treatment with paracetamol in infants

Background: Paracetamol (N‐acetyl‐p‐amino‐phenol) or acetaminophen has become the most widely used analgesic and antipyretic in children. However, there is a wide discrepancy between the extent to which paracetamol is used and the limited available pharmacological data in small infants. The purpose of this article is to present a review of the current literature regarding the use of paracetamol in neonates and infants with a particular emphasis on pharmacological issues.

APA national audit of pediatric opioid infusions

Introduction:  A prospective audit of neonates, infants, and children receiving opioid infusion techniques managed by pediatric acute pain teams from across the United Kingdom and Eire was undertaken over a period of 17 months. The aim was to determine the incidence, nature, and severity of serious clinical incidents (SCIs) associated with the techniques of continuous opioid infusion, patient‐controlled analgesia, and nurse‐controlled analgesia in patients aged 0–18.

Educational outcome in adolescence following pyloric stenosis repair before 3 months of age: a nationwide cohort study

Immature animals exposed to anesthetics display apoptotic neurodegeneration with subsequent long‐term cognitive dysfunctions. Young age at anesthetic exposure is believed to be critical, but human studies are scarce. This study investigated the association between exposure to surgery and anesthesia for pyloric stenosis (PS) before 3 months of age and subsequent educational outcome in adolescence.

A simple microanalytical technique for the determination of paracetamol and its main metabolites in blood spots.

The use of blood spot collection cards is a simple way to obtain specimens for analysis of drugs with a narrow therapeutic window. We describe the development and validation of a microanalytical technique for the determination of paracetamol and its glucuronide and sulphate metabolites from blood spots. The method is based on reversed phase high-performance liquid chromatography with ultraviolet detection. The limit of detection of the method is 600 pg on column for paracetamol. Intra- and inter-day precision of the determination of paracetamol was 7.1 and 3.2% respectively. The small volume of blood required (20 microl), combined with the simplicity of the analytical technique makes this a useful procedure for monitoring paracetamol concentrations. The method was applied to the analysis of blood spots taken from neonates being treated with paracetamol.

Pain assessment in children

Pain is difficult to measure precisely and reliably in behavioural, affective, sociocultural and environmental factors all affect pain assessment. This fits children and this has led to the proliferation of a with what the good clinician or nurse does when multiplicity of pain measurement tools and scores caring for a child after surgery. Knowing the child’s for neonates, infants and children. It is very difficult age, social circumstances and cultural background, for the clinician to see which measurement system they make a judgement of that particular child at is applicable to daily pain management of paediatric that particular time in that particular medical patients of various ages in the very different clinical environment having undergone a specific surgical settings of the general postoperative ward, day procedure. Is the child exhibiting behavioural, surgery unit, accident and emergency department, physiological or emotional evidence of pain and if outpatient clinic or intensive care unit. The clinician’s so how severe is it? What intervention is appropriate needs for a pragmatic system which reliably tracks to try to control the pain? Having intervened, an the child’s pain experience and the efficacy of pain assessment of whether the intervention is adequate control over time does not sit well with the is made and if necessary further intervention is researcher’s requirement for a tool which is undertaken. This is the essence of the concept of rigorously proven for reliability in individual titration. Staff may almost unconsciously compare children when different observers are involved and this child with previous children they have cared for for validity (i.e. the tool is actually measuring the at this stage after such an operation to judge whether child’s pain and not something else). Clinicians are they are following the anticipated path to recovery. often criticised for trying to apply simple clinical Measurements with pain tools or scores should be scores to research projects while research workers regarded as an aid to this more complex holistic often imply that their particular pain tool is the assessment process (1,2). answer to the clinician’s prayer! This assumes that clinicians and nurses are adequately trained and sensitive to the manifestations of acute pain in various age groups and Pain assessment and pain measurement are experienced in intervening safely, effectively and Pain assessment is a broader concept than pain appropriately to control the pain. The classic scenario measurement and takes into account the many of the uncomplaining silent child who lies still and dimensions of pain experience. Seven dimensions of rigid after an abdominal operation scoring zero for acute pain should be considered when assessing pain pain at rest may seem like the ideal patient to in a holistic way. Most pain measurement tools and inexperienced staff. The child may be terrified to scores try to assign a numerical value to just one of move in case it hurts and may not complain in case he gets an intramuscular injection. these dimensions. Cognitive, physiological, sensory,

Anesthesia and outcome after neonatal surgery: The role for randomized trials

Editor’s Note: This is the second in a three-part series of Editorial Views regarding design of clinical trials to address the effect of anesthesia on the developing brain. Animal studies have suggested that anesthetic exposure could affect neurocognitive development, and there is an urgent need for clinical trials to determine whether this effect occurs in humans. This series presents the opinions of three world thought leaders in the possible designs of such clinical trials.

Plasma paracetamol concentrations and pharmacokinetics following rectal administration in neonates and young infants.

Background: Despite widespread use in children pharmacokinetic data about paracetamol are relatively scarce, not the least in the youngest age groups. This study aimed to describe plasma paracetamol concentrations and pharmacokinetics of a single rectal paracetamol dose in neonates and young infants.

Overview of total intravenous anesthesia in children

Total intravenous anesthesia (TIVA) can be defined as a technique, in which general anesthesia is induced and maintained using purely i.v. agents. TIVA has become more popular and possible in recent times because of the pharmacokinetic (PK) and pharmacodynamic properties of propofol and the availability of short‐acting synthetic opioids. Also, new concepts in PK modeling and advances in computer technology have allowed the development of sophisticated delivery systems, which make control of anesthesia given by the i.v. route as straightforward and user friendly as conventional, inhalational techniques. Monitoring of depth of anesthesia is being validated for these techniques, and in the future, measurements of expired propofol may be possible to guide administration. TIVA is being used increasingly in children.

Ondansetron reduces nausea and vomiting after paediatric adenotonsillectomy.

The efficacy, safety and resource implications of a single intravenous dose of ondansetron (0.1 mg·kg−1, maximum 4 mg) were assessed in a multinational, multicentre, randomized, double‐blind, placebo‐controlled trial of 427 children aged 1–12 years, undergoing tonsillectomy with/without adenoidectomy. Emesis (retching and/or vomiting) and nausea were analysed separately. Significantly more ondansetron‐treated children had no episodes of emesis (127/212 (60%) vs 100/215 (47%); P=0.004) and experienced no postoperative nausea (135/211 (64%) vs 108/213 (51%); P=0.004) in the first 24 h. Ondansetron also reduced the number of emetic episodes (P<0.001), the time to the first emetic episode (P<0.001) and overall nausea severity (P=0.003). Significantly fewer ondansetron‐treated children were rescued or withdrawn from the study (5%vs 10%; P=0.042). Fewer ondansetron‐treated patients required nursing intervention (34%vs 45%; P=0.007) and the average intervention time was significantly shorter (4.6 vs 8.1 minutes; P=0.001). Resources used to manage PONV were significantly reduced by ondansetron (43%vs 57%; P=0.014).

Propofol in paediatric anaesthesia

Propofol has been used in paediatric anaesthesia since 1985 and an increasing body of evidence has shown that it is a safe, effective induction agent which has dose‐related side‐effects comparable with other agents. Pain on injection can be ameliorated by the use of antecubital veins or by pre‐mixing an adequate amount of lignocaine with propofol immediately prior to administration. The pharmacokinetics of propofol are different in children with their larger central compartment volume and clearance reflected in higher dose requirements for induction and maintenance of anaesthesia. This has important implications when propofol is given for sedation or anaesthesia by continuous infusion.