Ropivacaine decreases tissue oxygen saturation following peripheral nerve block in children

Background: Local anesthetics can cause vasoconstriction and disrupt neuronal impulses, reducing regional blood flow and increasing tissue oxygen consumption. This could alter regional oxygen supply and demand. Because microcirculation modifies during development and oxygen consumption kinetics differ between children and adults, we aimed to assess effects of ropivacaine Peripheral Nerve Block (PNB) on regional tissue saturation in children and young adults using Near-Infrared Spectroscopy (NIRS). Methods: Following Institutional Review Board approval and informed consent, 20 patients undergoing PNB for various orthopedic surgeries were studied. NIRS sensors were placed on the operative limb, contralateral limb, and forehead. Tissue saturations (rSO2) were recorded at baseline and every 5 minutes for 60 minutes following ropivacaine PNB. Mean rSO2 was assessed with repeated measures ANOVA. Correlation of tissue rSO2 with cerebral oximetry was calculated and significance determined with student’s t-test. Results: In all patients, blocked limb rSO2 decreased significantly compared to control limb 20 minutes after injection and remained lower. Control limb rSO2 and cerebral oximetry did not change over time. Non-blocked limb rSO2 demonstrated weak but significant correlation with cerebral oximetry while blocked limb rSO2 showed no correlation. Mean change in blocked limb rSO2 from baseline was significantly negative compared to a net positive mean change in the non-blocked limb. Conclusions: Decreased rSO2 following PNB suggests reduced local blood flow due to vasoconstriction, increased tissue oxygen consumption, or both. Changes in rSO2 provide an opportunity to develop NIRS as a non-invasive tool to identify successful PNB. Local anesthetic-induced decline in rSO2 could have implications in operative settings with ischemia or low-flow

Low-dose ketamine for children and adolescents with acute sickle cell disease related pain: A single center experience

Background: Opioids are the mainstay of therapy for painful vasoocclusive episodes (VOEs) in sickle cell disease (SCD). Based on limited studies, low-dose ketamine could be a useful adjuvant analgesic for refractory SCD pain, but its safety and efficacy has not been evaluated in pediatric SCD. Procedure: Using retrospective chart review we recorded and compared characteristics of hospitalizations of 33 children with SCD hospitalized with VOE who were treated with low-dose ketamine and opioid PCA vs. a paired hospitalization where the same patients received opioid PCA without ketamine. We seek to 1) describe a single center experience using adjuvant low-dose ketamine with opioid PCA for sickle cell related pain, 2) retrospectively explore the safety and efficacy of adjuvant low-dose ketamine for pain management, and 3) determine ketamine’s effect on opioid consumption in children and adolescents hospitalized with VOE. Results: During hospitalizations where patients received ketamine, pain scores and opioid use were higher (6.48 vs. 5.99; p=0.002 and 0.040 mg/kg/h vs. 0.032 mg/kg/h; p=0.004 respectively) compared to hospitalizations without ketamine. In 3 patients, ketamine was discontinued due to temporary and reversible psychotomimetic effects. There were no additional short term side effects of ketamine. Conclusions: Low-dose ketamine has an acceptable short-term safety profile for patients with SCD hospitalized for VOE. Lack of an opioid sparing effect of ketamine likely represents use of low-dose ketamine for patients presenting with more severe VOE pain. Prospective randomized studies of adjuvant low-dose ketamine for SCD pain are warranted to determine efficacy and long-term safety

Dexmedetomidine for anterior mediastinal mass computed tomography-guided biopsy: A case series

BACKGROUND: Sedation of children undergoing biopsies of anterior mediastinal masses can be challenging because of the absolute necessity of ensuring minimal smooth muscle relaxation and preventing airway collapse. Furthermore, positive pressure ventilation may be difficult or impossible and may also pose the additional risks of hemodynamic compromise in the pediatric patient. CASE REPORTS: We present a case series of 3 children who were successfully sedated for computed tomography (CT)-guided mediastinal biopsies with dexmedetomidine. CONCLUSION: Dexmedetomidine, a selective alpha-2 adrenoreceptor agonist that maintains the smooth musculature of the pediatric airway, provides the ability to sustain spontaneous ventilation in patients with airway compression. Dexmedetomidine is a safe, reliable anesthetic for biopsy of children with anterior mediastinal masses

Investigating the Use of Gabapentin to Manage Transient Peripheral Neuropathy in Children Treated with Chimeric 14.18 Antibody

Background: Chimeric 14.18 (ch 14.18) is a human-mouse chimeric monoclonal antibody against GD2 ganglioside which is used to treat high-risk neuroblastoma in children, leading to increased survival. However, ch 14.18 therapy causes transient neuropathic pain-like syndrome and allodynia. In children, this transient pain syndrome can be managed with IV opioids safely and effectively but may be associated with respiratory depression or pruritus. Gabapentin, an anti-epileptic drug used for neuropathic pain, may be effective in managing ch 14.18 induced transient neuropathic-like pain and in decreasing opioid use. Objective: The objective of this study is to assess whether the addition of gabapentin to IV opioids improved analgesia and decreased opioid use in children undergoing ch 14.18 therapy for high-risk neuroblastoma. Methods: Electronic medical records were retrospectively reviewed to identify patients with high-risk neuroblastoma undergoing ch 14.18 therapy at Children’s National from November 2009 to August 2017. All patients received opioids via nurse-controlled analgesia (NCA) or patient-controlled analgesia (PCA). Demographic data, gabapentin doses, opioid use, pain scores, and pain location were recorded from their first cycle and last cycle of ch14.18. 24 hours opioid consumption (mg/kg/d) and mean daily pain score for each patient were obtained. Daily opioid use was log transformed, and daily mean pain score was square root transformed for analysis. Results: 29 patients were identified. 7 of 29 children received gabapentin in addition to opioid PCA while undergoing ch 14.18 therapy. During the first cycle of therapy, root transformed average pain score in patients without gabapentin was 1.12 vs.0.83 with gabapentin. These values decreased to 0.60 vs. 0.69 respectively during the last cycle. Log transformed daily opioid use were -0.83 mg/kg/d in those not receiving gabapentin vs. -0.55 in those receiving gabapentin during the first cycle, and -0.91 vs. -0.86 respectively during the last cycle. Conclusions: There was an overall decrease in average daily pain scores and opioid use between the first and last cycle but was not statistically significant. The addition of gabapentin did not decrease pain scores or opioid use during the first or last cycle. Due to the small sample size and the retrospective nature of this study, these results warrant further exploration of analgesic adjuncts to improve analgesia and reduce opioid use in children with transient neuropathic pain syndrome

Dexmedetomidine as a non-opiate adjunct to multimodal perioperative pain control in pediatric patients undergoing craniofacial reconstructive surgery: a retrospective study

Purpose: Craniofacial (CF) reconstruction surgery involves a surgical approach to the CF region to repair cranial vault and facial deformities. The surgery is extensive, often requiring wide scalp dissections and multiple osteotomies and is associated with significant postoperative pain and analgesic requirements. Dexmedetomidine is a highly selective alpha-2 receptor agonist that mediates central nervous system sympathetic activity and pain modulation, thus producing both analgesia and sedation. Intraoperative use of dexmedetomidine could be particularly helpful in these surgeries as a means of reducing postoperative opioid administration and opioid-induced side effects. We hypothesized that intraoperative administration of dexmedetomidine in children undergoing CF reconstructive surgery would have a greater reduction in postoperative opioid requirements, pain, sedation scores, and opioid-induced side effects compared to patients who did not receive dexmedetomidine. Methods: All patients with craniosynostosis who underwent either CVR or BFOA at Children’s National Health System between July 1, 2013 and June 30, 2017 (48 months duration) were retrospectively evaluated. Thirty-nine patients received dexmedetomidine intraoperatively while 41 patients did not receive dexmedetomidine. Demographic data was analyzed and a multitude of continuous and categorical perioperative variables were assessed. Primary outcome measure was mean postoperative morphine equivalent requirements. Secondary outcome measures included presence of opioid related side effects, pain scores, mechanical ventilator days, and ICU and hospital length of stay. Normality of all continuous outcomes was determined and means were compared using a student’s t-test. Categorical outcomes were compared using a Fisher’s exact test. A p-value of \u3c0.05 was considered statistically significant. Results: There were significant demographic differences in terms of age and weight between the two groups in which those receiving dexmedetomidine were younger and weighed less than those that did not receive dexmedetomidine. Intraoperative dexmedetomidine use was not associated with significantly lower postoperative opioid requirements or pain scores. However, patients who received higher doses of intraoperative dexmedetomidine did have significantly lower rescue medication administration for nausea and vomiting postoperatively. Conclusion: Contrary to the hypothesis, dexmedetomidine was not associated with reduced postoperative opioid requirements or pain scores in children undergoing CF reconstructive surgery. Interestingly, our findings suggest that dexmedetomidine may be protective in terms of postoperative opioid-induced nausea. A prospective, randomized controlled trial is needed to better analyze the relationship between intraoperative dexmedetomidine use and postoperative opioid requirements, opioid-related side effects, and pain scores in children undergoing such surgery