Pervin Bozkurt

Use of tramadol in children

Some progress has been made in alleviating pain in children in the last two decades. A growing body of knowledge about the nature of pain from intrauterine life to childhood has changed practices in pediatric pain treatment. However, the availability of potent analgesic medications labeled for children is limited. These medications include paracetamol, nonsteroidal anti-inflammatory drugs (NSAIDs) and opioids; NSAIDs have restricted approval for children and may cause a bleeding tendency, renal impairment and aggravate asthma, and opioids have the risk of respiratory depression. Thus, pediatric anesthesiologists mainly depend on paracetamol and regional techniques, especially in day-case surgery of children. A drug with different formulations, which would enable proper dosing and be effective in relieving moderate to severe pain in children, is still needed. Although tramadol was launched in the area of pain practice 30 years ago in Germany, its use is still limited to those over the age of 12 in some countries, whereas it is licenced for use in children older than 1 year in some others. Also, a new oral tablet form, which is a combination of paracetamol and tramadol, has been introduced to the market but is not yet approved for use in children. This review focuses on the pharmacokinetic and pharmacodynamic profile of tramadol in children and its use in the treatment of postoperative and chronic pain. Pharmacodynamic profile

Effects of low dose ketamine before induction on propofol anesthesia for pediatric magnetic resonance imaging

Background : We aimed to investigate effects of low dose ketamine before induction on propofol anesthesia for children undergoing magnetic resonance imaging (MRI).

Does tramadol wound infiltration offer an advantage over bupivacaine for postoperative analgesia in children following herniotomy

Background : It has been demonstrated that tramadol is an effective analgesic. We aimed to compare postoperative analgesic effects of wound infiltration with tramadol (T) or bupivacaine (B) and intramuscular tramadol (I) after herniotomy in children.

The analgesic efficacy and neuroendocrine response in paediatric patients treated with two analgesic techniques: using morphine-epidural and patient-controlled analgesia

Background: Pain treatment is one of the main concerns of paediatric anaesthesiologists. The purpose of this study was to assess and compare the quality of analgesia and stress suppression by morphine when used [epidural (single shot) (EP) or with intravenous (i.v.) for patient‐controlled analgesia (PCA) in children].

The efficacy of pre- versus postsurgical axillary block on postoperative pain in paediatric patients.

We compared the effects of pre‐ and postsurgical axillary block on pain after hand and forearm surgery in 55 children in a double‐blind randomized study. The successful blocks are reported here (n=49). Children aged 1–11 years and ASA I or II were allocated randomly to receive axillary block with 2 mg.kg−1 of 0.25% bupivacaine, either after induction but before the surgery (presurgical group, n=25) or immediately after surgery, before the end of anaesthesia (postsurgical, n=24). In all patients, a standard general anaesthesia technique was used. The Faces Pain Scale (FPS) and analgesic requirements were recorded for 24 h at various times after operation. Eight patients (32%) in the presurgical group and 20 patients (83.33%) in the postsurgical group did not require additional analgesic within the first 24 h after operation (P< 0.05). In patients who had pain during the observation period, the pain started 13.66±2.61 h in the presurgical group and 13.14±2.34 h in the postsurgical group after performing block (P> 0.05). The FPS scores were similar in both groups during the first 8 h in the postoperative period (P> 0.05). There was a significant difference at 10 h after surgery (P< 0.05). Cumulative FPS score was higher in the presurgical group (10.50±1.06) than in the postsurgical group (9.45±1.28) (P< 0.05), but both groups had effective analgesia overall, the mean FPS score being less than 2. Additional analgesic consumption was similar in these patients in both groups. A lower isoflurane concentration was used in the presurgical group (0.68%vs 1.72%, P< 0.001). We did not demonstrate the superiority of preemptive analgesia, but our results indicate that presurgical axillary block with 0.25% bupivacaine allows the use of inhalational anaesthetics at lower concentrations while providing a reasonably painless postoperative period.

Histological changes following epidural injection of midazolam in the neonatal rabbit

Midazolam can produce antinociceptive effects when used via intrathecal or epidural routes. Neurotoxicity studies are scanty especially for neonates. The aim of this study was to carry out electron microscopic (EM) examinations in the neonatal rabbit to determine the histological effects of epidural midazolam on spinal cord. Twenty white New Zealand neonatal rabbits were randomly assigned to three groups receiving single dose of 0.9% saline (Group I; Control, n=4), 0.9% saline titrated to pH=3.9 by addition of hydrochloric acid (Group II; n=6), midazolam 250 μg·kg−1 (Group III; n=12) epidurally. Half of each group were sacrificed on the second day and the remainder on the seventh day and spinal cord sections were evaluated by EM. Control group displayed normal histology on grids. Group II and II showed a variable degree of neurotoxic effects such as degeneration of vacuoles, cytoplasm and neurofilaments, disruption of myelin sheaths, lysis of cell membranes, perivascular oedema, pyknosis of nuclei. The toxic effects of acidic saline and midazolam are similar, in view of these results the epidural use of acidic midazolam (commercially available preparations) in neonates should be avoided.

Single-injection lumbar epidural morphine for postoperative analgesia in children: A report of 175 cases

Background and Objectives. Since the first report of epidural opioid administration to pediatric patients, several studies have described the quality of analgesia, doses, pharmacokinetics, and side effects of this procedure. A pediatric series using an easy and cheap single‐injection technique of epidural morphine administration for postoperative analgesia is presented. Methods. Postoperative analgesia was achieved with a single lumbar epidural morphine injection (0.1 mg/kg in 0.2 mL/kg saline), which was given via a 22‐gauge intramuscular needle to 153 pediatric patients (aged 4 months‐17 years) following 175 lower abdominal or urologic operations. Injections were given by 43 anesthesiology residents under the supervision of pediatric anesthesiologists, after termination of surgery performed under general anesthesia. Results. The success rate of epidural puncture on the first attempt was 92%. Pain control was considered excellent in 76% of patients for 24 hours. The remaining patients had analgesia lasting 10.9 ± 5.5 hours after epidural morphine administration. No alterations in hemodynamic parameters were observed. Two patients (1.1%) developed respiratory depression during early postoperative care and one, with a history of apneic spells, had an episode of apnea 5 hours after morphine administration. The incidences of minor side effects were: nausea, 33.9%; vomiting, 42.9%; pruritis 9%; and urinary retention 12.5%. Conclusions. This technique is easy to perform, even for trainees in anesthesiology. With appropriate patient selection and avoidance of the concomitant use of narcotics and sedatives, epidural morphine provides prompt, effective, safe, and prolonged analgesia in children.

Psychological effects of repeated general anesthesia in children

Background:  Although methods for reducing preoperative anxiety have been a major interest of pediatric anesthesiologists, there are no reports of the effects of repeated anesthesia on psychological development of children.

Effects of systemic and epidural morphine on antidiuretic hormone levels in children.

Background: Although the use of opioids during general anaesthesia suppresses stress response to surgery and pain, the effects on antidiuretic hormone (ADH) are controversial. The aim of this study was to find the effects of morphine with either intravenous infusion or epidural route on ADH and other stress hormones.

Effectiveness of morphine via thoracic epidural vs intravenous infusion on postthoracotomy pain and stress response in children

Background : Thoracotomy causes severe pain in the postoperative period. The aim was to evaluate effectiveness of two pain treatment methods with morphine on postthoracotomy pain and stress response.