Pain treatment in children

Liječenje boli djece specifično je zbog anatomskih, fizioloških i psiholoških razlika koje postoje između djece i odraslih. I u dječjoj dobi razlikujemo akutnu i kroničnu, malignu i nemalignu, nocicepcijsku i neuropatsku bol. Intenzitet boli mjerimo skalama odgovarajućima za dob i kognitivni razvoj djeteta. Akutna bol u dječjoj dobi ima zaštitnu ulogu i lakše ju je prepoznati. Susrećemo je u hitnom prijmu, u poslijeoperacijskom tijeku, pri invazivnim dijagnostičkim i terapijskim postupcima. Kronična bol dječje dobi nemalignog je i malignog podrijetla; potonja je somatska, visceralna ili neuropatska, nastaje od progresije tumora, ali i od liječenja. Boli malignog podrijetla liječe se prema trostupanjskoj ljestvici SZO-a, uz titraciju, rotaciju i konverziju opioida. Kronična bol nemalignog podrijetla obuhvaća muskuloskeletnu bol, glavobolje, tenzijske ili migrenske i neuropatsku bol različitih uzroka. Bol u dječjoj dobi liječi se farmakološkim i nefarmakološkim metodama, na načelima preemptivne i multimodalne analgezije.Differences in anatomy, physiology and psychology between children and adults make paediatric pain treatment specific. Acute and chronic pain, malignant and non-malignant chronic pain, nociceptive and neuropathic pain also occur in childhood. The intensity of pain is measured by using scales appropriate for a child’s age and cognitive development. Acute pain in children has a protective function and its assessment is easy in emergency departments, and in postoperative, invasive diagnostic and therapeutic settings. The origin of chronic paediatric pain is both malignant and non-malignant; the latter has somatic, visceral and neuropathic components, originating from tumour progression and chemo- and irradiation therapy. Malignant pain is treated in line with the WHO’s three-step model, with titration, rotation and conversion of opioids. Chronic non-malignant pain includes musculoskeletal pain, tension and migrainous headaches, and neuropathic pain of different origins. Pharmacological and non-pharmacological pain treatment in children is based on pre-emptive and multimodal principles of therapy

SOME PEDIATRIC SYNDROMES WITH DIFFICULT AIRWAYS IN NESTHESIA INDUCTION

Među velikim brojem pedijatrijskih sindroma ima nekih kod kojih je problem otežano osiguranje dišnog puta. Defi nicija otežanog dišnog puta uključuje probleme ventilacije kroz masku, poteškoće kod laringoskopije ili kod intubacije traheje. Najčešći problemi otežanog dišnog puta kod djece s pedijatrijskim sindromima uzrokovani su deformacijama glave, maksilarnom ili mandibularnom hipoplazijom, malim ustima, ograničernim usnim otvorom. velikim jezikom, mikro- i retrognatijom i ograničenom pokretljivošću vrata. Pedijatrijski sindromi s teškoćama dišnog puta su: Alpertov sindrom, Beckwith-Wiedemannov sindrom, sindrom Cornelia De Lange, ahondroplazija, sindrom CHARGE, sindrom cri du chat, Crouzonov sindrom, Pffeiferov sindrom, Downov sindrom, Hunterov sindrom, Hurlerov sindrom, Goldenharov sindrom, Klippel-Failov sindrom, Pierre Robinov sindrom, Treacher Collinsov sindrom i epidermolysis bullosa. Uz svaki sindrom prikazana su pomagala za osiguranje dišnog puta, tj. supraglotična pomagala kao što je laringealna maska za dišne puteve, stilet uvodnik za intubaciju – gumirana elastična bužija, stilet sa svjetlom, fi beroptički stilet, fl eksibilni fi beroptički bronhoskop, indirektni rigidni laringoskop i videolaringoskop. Ovaj pregled pedijatrijskih sindroma s otežanim osiguranjem dišnog puta kao i pregled pomagala za postupke osiguranja dišnog puta namijenjen je anesteziolozima koji periodički ili svakodnevno anesteziraju djecu.Out of a large number of pediatric syndromes, some pose a problem of diffi cult pediatric airway. The defi nition of diffi cult airway includes problems with facemask ventilation, diffi culties with laryngoscopy or with tracheal intubation. The most common diffi cult airway problems in children with pediatric syndromes are caused by head deformities, maxillary or mandibular hypoplasia, small mouths, limited mouth opening, big tongues, micro- and retrognathy, and limited neck mobility. Pediatric syndromes with diffi cult airways include Apert sy, Beckwith-Wiedemann sy, Cornelia De Lange sy, achondroplasia, CHARGE sy, Cri du chat sy, Crouzon sy, Pffeifer sy, Down sy, Hunter sy, Hurler sy, Goldenhar sy, Klippel- Feil sy, Pierre Robin sy, Treacher Collins sy and epidermolysis bullosa. Rescue devices for diffi cult pediatric airway management are shown along with each syndrome, e.g., supraglottic devices such as laryngeal mask airway, intubating introducer – gum elastic bougie, lighted stylet, fi beroptic stylet, fl exible fi beroptic bronchoscope, indirect rigid laryngoscope and video laryngoscope. This overview of pediatric syndromes with diffi cult airways, as well review of devices for diffi cult pediatric airway management is intended for anesthesiologists who anesthetize children daily or periodically

Hirschsprung’s Disease and Rehbein’s Procedure – Our Results in the Last 30 Years

Hirschsprung’s disease is congenital anomaly of the intestine and Harald Hirschsprung gave the first description of this disease1. The aim of this follow-up study was to evaluate the results of Rehbein’s procedure in the treatment of Hirschsprung’s disease in the last 30 years in Children’s Hospital Zagreb. Hirschsprung’s disease is congenital intestinal aganglionosis as the results of arrested fetal development of the myenteric nervous system. Hirschsprung’s disease is affecting between 1:5000 to 1:8000 live births. A total of 124 children underwent Rehbein’s lower anterior resection at Children’s Hospital Zagreb. The principle of Rehbein’ procedure is to remove aganglionic narrow segment and dilated sigmoid colon and anastomosis between normal intestine with rectal stump. The postoperative outcome was analysed for early and late complications like wound infections, abscesses, anastomotic insufficiency, postoperative enterocolitis, constipation, fecal incontinence, need for reoperation, ileus and mortality. On the basis of our results and data from literature we concluded that Rehbein’s procedure is an excellent method for treatment Hirschsprung’s disease

Serious complications of an obstructive upper airway infection in a young child

A 15-month old boy was admitted to our intensive care unit (ICU) cyanotic, unresponsive, apneic, pulseless, with fixed, dilated pupils and a Glasgow Coma Score (GCS) of 3/15. Prompt cardiopulmonary resuscitation (CPR) was initiated and cardiac function was resumed after 10 minutes. The boy was intubated but could not be ventilated because of a thick, viscous secretion obstructing the trachea and causing total airway obstruction. Bronchoscopy revealed laryngotracheitis as the reason for airway obstruction. A computed tomography (CT) scan of the brain showed diffuse edema and ischemic brain injury, which were considered responsible for the boy\u27s comatose situation. Clinical status remained unchanged for 11 days, after which the boy was transported to another hospital. In children presenting with upper airway obstructing syndromes, not responding to therapy, the diagnosis of bacterial tracheitis should be considered and the child should be monitored in a pediatric intensive care unit

Paravertebral block: review of the literature

Background: Paravertebral Block (PVB) is an established regional anesthetic technique. It is technically easy to perform and is being used increasingly for intra-operative and post-operative analgesia. This popularity is mainly due to the ease of the technique and fewer complications. Materials and Methods: This is quantitative systematic review of literature database with the aim to assess the efficacy and safety of Paravertebral block in thoracic, abdominal and breast surgery. Results: Six randomised control trials that included 386 patients were reviewed. Authors of reviewed articles reported 100% success in block effectivenes and low incidence of complications. Conclusion: Paravertebral block is effectiv anesthetic/analgetic technique with very few complications

Zbrinjavanje otežanog dišnog puta – vječni izazov: prikaz bolesnika

Introduction: Obtaining a secured airway is a vital aspect during reconstructive surgery in patients with extensive post-burn mentosternal scar contractures. Such contractures can potentially lead to a “can’t intubate, can’t ventilate” scenario, otherwise rare but life-threatening situation. We present a case of successful management of a paediatric case of anticipated difficult airway due to burn injury. Case description: A 14-year-old boy presented for repair of an extensive skin contracture of the neck, thorax and face due to mutilating scarring. The boy was treated for 80% burn caused by gasoline flame 14 months prior to this surgery. Burn healing and scarring resulted in massive distortion of the facial and cervical anatomy, all implying difficult airway with a high probability of “can’t intubate, can’t ventilate” situation. Flexible fiberoptic bronchoscope with loaded cuffed endotracheal tube N° 6.0 was used for visualisation of vocal cords through the mouth in light sedation with spontaneous breathing. After visualisation of the vocal cords, fentanyl (Fentanyl, GlaxoSmithKline) and thiopental (Thiopental, Rotexmedica) were administered and the trachea was intubated at the first attempt. Balanced general anaesthesia was initiated and planned surgical procedure was successfully completed. The trachea was extubated on the first postoperative day without any complication. Conclusion: Difficult paediatric airway and particularly “can’t intubate, can’t ventilate” situation is a problem associated with significant risks and complications. Anticipating a difficult airway, having a structured approach with appropriate preparation, and understanding of difficult airway management algorithms are essential for success.Uvod: Zbrinjavanje dišnog puta od vitalne je važnosti za bolesnika kod kojeg je indiciran rekonstruktivni zahvat nakon opsežnihopeklina lica i vrata. Kontrakture koje nastaju nakon takvih ozljeda mogu dovesti do nemogućnosti intubacije i ventilacije, što predstavljarijetku ali životno ugrožavajuću situaciju. Prikazati ćemo uspješno zbrinjavanje pedijatrijskog bolesnika sa očekivano otežanimzbrinjavanjem dišnog puta.Prikaz slučaja: Četrnaestogodišnji dječak sa opsežnom opeklinom lica, vrata i prsnog koša bio je predviđen za rekonstruktivni zahvat.Cijeljenje opekline, koja je nastala 14 mjeseci prije planiranog zahvata, rezultiralo je opsežnom kontrakturom i promjenom anatomijelica i vrata. Radi promijenjenih anatomskih odnosa bilo je očekivano da će zbrinjavanje dišnog puta biti otežano. Za vizualizacijuglasnica korišten je fleksibilni fiberoptički bronhoskop s pripremljenim endotrahealnim tubusom dok je bolesnik bio u plitkoj sedacijii disao spontano. Nakon vizualizacije glasnica bolesnik je dobio fentanil (Fentanyl, GlaxoSmithKline) i tiopental (Thiopental, Rotexmedica)te je potom intubiran iz prvog pokušaja. Nastavljena je balansirana opća anestezija, planirani zahvat je uspješno dovršen.Bolesnik je ekstubiran prvi postoperativni dan bez ikakvih komplikacija.Zaključak: Otežani dišni put u pedijatrijskih bolesnika je problem povezan s brojnim rizicima i komplikacijama. Prepoznavanje otežanogdišnog puta uz adekvatnu pripremu i poznavanje algoritama za zbrinjavanje otežanog dišnog puta ključno je za sigurnostbolesnika

Bol i palijativna medicina – tempus projekt u Hrvatskoj

Pain and Palliative Medicine Project (PPMP), funded by the TEMPUS programme of the European Union, has been established with a goal of sharing knowledge and experience from countries in which palliative care is already substantially developed to partner countries whose palliative care encountered more problems. Croatia as partner country, has tried to improve national palliative care systems through education of medical and non-medical personnel. Protocols of collaboration and training courses in pain management and palliative medicine at the Universities of Florence and Lyon, including options of collaboration with some university and clinical institutions in Croatia have been presented. After their two-year project, the Croatian team has noted significant progress in the fields of education, infrastructure and legislative support for development of palliative care. These results show the need for improving Croatian palliative care system as well as possible solutions for overcoming obstacles derived from nation’s traditional views on the treatment of the terminally ill.Bol i palijativna medicina (PPMP) je projekt u okviru TEMPUS programa Europske Unije s ciljem prenošenja znanja i iskustava zemalja, u kojima je palijativna skrb dobro razvijena, zemljama u kojima je palijativna skrb manje aktivna. Hrvatska, kao zemlja partner, nastoji poboljšati nacionalni program palijativne skrbi kroz edukaciju medicinskog i ne-medicinskog osoblja. Prikazani su protokoli suradnje i tečajeva o boli i palijativnoj medicine na Sveučilištima u Firenci i Lyonu, kao i na nekim sveučilišnim i kliničkim institucijama u Hrvatskoj. Nakon dvogodišnjeg projekta hrvatski tim zabilježio je značajni napredak u poljima edukacije, infrastrukture i zakonske potpore razvoju palijativne skrbi. Ovi rezultati su pokazali potrebu za daljnjim poboljšavanjem hrvatske palijativne skrbi kao i moguća rješenja za prevladavanje prepreka koje proizlaze iz tradicionalnih pogleda društva na skrb terminalno bolesnih

Bol i palijativna medicina – tempus projekt u Hrvatskoj

Pain and Palliative Medicine Project (PPMP), funded by the TEMPUS programme of the European Union, has been established with a goal of sharing knowledge and experience from countries in which palliative care is already substantially developed to partner countries whose palliative care encountered more problems. Croatia as partner country, has tried to improve national palliative care systems through education of medical and non-medical personnel. Protocols of collaboration and training courses in pain management and palliative medicine at the Universities of Florence and Lyon, including options of collaboration with some university and clinical institutions in Croatia have been presented. After their two-year project, the Croatian team has noted significant progress in the fields of education, infrastructure and legislative support for development of palliative care. These results show the need for improving Croatian palliative care system as well as possible solutions for overcoming obstacles derived from nation’s traditional views on the treatment of the terminally ill.Bol i palijativna medicina (PPMP) je projekt u okviru TEMPUS programa Europske Unije s ciljem prenošenja znanja i iskustava zemalja, u kojima je palijativna skrb dobro razvijena, zemljama u kojima je palijativna skrb manje aktivna. Hrvatska, kao zemlja partner, nastoji poboljšati nacionalni program palijativne skrbi kroz edukaciju medicinskog i ne-medicinskog osoblja. Prikazani su protokoli suradnje i tečajeva o boli i palijativnoj medicine na Sveučilištima u Firenci i Lyonu, kao i na nekim sveučilišnim i kliničkim institucijama u Hrvatskoj. Nakon dvogodišnjeg projekta hrvatski tim zabilježio je značajni napredak u poljima edukacije, infrastrukture i zakonske potpore razvoju palijativne skrbi. Ovi rezultati su pokazali potrebu za daljnjim poboljšavanjem hrvatske palijativne skrbi kao i moguća rješenja za prevladavanje prepreka koje proizlaze iz tradicionalnih pogleda društva na skrb terminalno bolesnih

AIRWAY MANAGEMENT IN A CHILD WITH EDWARD’S SYNDROME

Prikazujemo zbrinjavanje dišnog puta u djevojčice s mozaičnim tipom Edwardsovog sindroma za planirani zahvat laparotomije u općoj anesteziji. Manifestacije Edwardsovog sindroma među ostalima su kraniofacijalne malformacije te je moguća otežana ventilacija i intubacija. U našem slučaju djevojčica je, ovisno o potrebi zahvata, imala postavljeno supraglotično pomagalo tijekom anestezije za dijagnostičku pretragu magnetskom rezonancijom (MR), intubirana je fi berbronhoskopski za elektivni zahvat laparoskopije, a u jedinici intenzivne medicine direktnom laringoskopijom. Ventilacija i intubacija protekle su bez komplikacija. Poslijeoperacijski oporavak komplicirao se hipotonijom, pneumonijom te potrebom za reintubacijom i mehaničkom ventilacijom.We report on airway management in a girl with mosaic type of Edward’s syndrome for elective surgery, laparotomy in general anesthesia. In Edward’s syndrome, among other manifestations, craniofacial anomalies are expressed and there is a possibility of diffi cult ventilation and intubation. In this case, we secured the airway with supraglottic airway device during diagnostics (anesthesia for magnetic resonance imaging), we performed fi beroptic intubation for elective laparoscopy, and in the intensive care unit, she was intubated with direct laryngoscopy. Ventilation and intubation were accomplished without problems. Postoperative recovery was complicated with hypotonia, pneumonia and the need of reintubation and mechanical ventilation

DELIRIUM INCIDENCE IN PEDIATRIC INTENSIVE CARE UNIT

Delirij je ozbiljan neuropsihijatrijski poremećaj a delirij djece u jedinicama intenzivnog liječenja je kao klinički entitet neprepoznat. Rana dijagnoza delirija djece važna je zbog pravovremene terapije i raznih psihosocijalnih postupaka. Dijagnostika delirija u dječjoj populaciji je otežana jer postoji više ljestvica i testova ali niti jedan nije dovoljno specifičan i osjetljiv za procjenu mentalnog statusa djece u jedinicama intenzivnog liječenja. Algoritam za dijagnostiku i liječenje delirija djece u jedinicama intenzivnog liječenja ne postoji te je potrebno dodatnih kliničkih ispitivanja i radova radi poboljšanja dijagnostike i terapije tog ozbiljnog kliničkog entiteta.Delirium is a serious neuropsychiatric disorder and pediatric delirium (PD) is a similarly serious condition. PD is understudied and very often misdiagnosed, especially in pediatric intensive care units (PICU). It is important to early diagnose PD, so that early psychosocial interventions and therapy can be introduced. Valid diagnostic instruments are needed at PICU to assess PD. There are many scales and tests to diagnose delirium but none of them is specific enough to diagnose PD. Although PD is a serious complication at PICU, clinical guidelines for PD are still lacking, therefore additional investigations are needed to bring them out