Evidence for the Efficacy of Systemic Opioid-Sparing Analgesics in Pediatric Surgical Populations: A Systematic Review

Abstract

While a large number of studies has examined the efficacy of opioid-sparing analgesics in adult surgical populations, fewer studies are available to guide postoperative pain treatment in pediatric patients. We systematically reviewed available publications on the use of systemic nonopioid agents for postoperative analgesia in pediatric surgical populations. A comprehensive literature search identified meta-analyses and randomized controlled trials (RCTs) assessing the effects of systemic, nonopioid agents on postoperative narcotic requirements or pain scores in pediatric surgical populations. If a meta-analysis was located, we summarized its results and any RCTs published after it. We located and reviewed 11 acetaminophen RCTs, 1 nonsteroidal anti-inflammatory drug (NSAID) meta-analysis, 2 NSAID RCTs, 1 dexamethasone meta-analysis, 3 dexamethasone RCTs, 2 ketamine meta-analyses, 5 ketamine RCTs, 2 gabapentin RCTs, 1 clonidine meta-analysis, 3 magnesium RCTs, 2 dexmedetomidine meta-analyses, and 1 dextromethorphan RCT. No meta-analyses or RCTs were found assessing the perioperative efficacy of intravenous lidocaine, amantadine, pregabalin, esmolol, or caffeine in pediatric surgical patients. The available evidence is limited, but suggests that perioperative acetaminophen, NSAIDs, dexamethasone, ketamine, clonidine, and dexmedetomidine may decrease postoperative pain and opioid consumption in some pediatric surgical populations. Not enough, or no, data exist from which to draw conclusions on the perioperative use of gabapentin, magnesium, dextromethorphan, lidocaine, amantadine, pregabalin, esmolol, and caffeine in pediatric surgical patients. Further pharmacokinetic and pharmacodynamics studies to establish both the clinical benefit and efficacy of nonopioid analgesia in pediatric populations are needed.

Analgesic Efficacy and Safety of Local Infiltration of Tramadol in Pediatric Tonsillectomy Pain: A Systematic Review and Meta‐Analysis

“…Despite its attractive analgesic profile, ketamine has been postulated to trigger undesired augmentation of systemic hemodynamics, PONV, and psychomimetic manifestations, with hallucinations being the predominant one among them . Yet, a bulk of evidence demonstrates that the risk of the aforementioned side‐effects becomes trivial when analgesic doses of ketamine (<2 mg/kg) are applied . Our results showed that the combined use of pre‐incisional infiltration of tramadol with local or intravenous ketamine provided better postoperative pain control and quality of recovery than using each drug separately, with minor adverse effects .…”

“…Although the CHEOPS constitutes a reliable and widely implemented clinical practice pain intensity tool for pediatric populations, it mainly relies on behavioral expression. This implies that the CHEOPS actually measures pain in an indirect manner as it indicates the intensity of pain‐related distress and pain reactivity rather than the intensity of pain …”

A Critical Review on the Relevance of Paracetamol for Procedural Pain Management in Neonates

“…There is meta-analytical evidence on the opioid-sparing effects of paracetamol administration to treat post-operative or posttraumatic pain in adults and in children. In contrast, the demonstration of a clinically significant reduction in opioidrelated adverse effects (like sedation and nausea) is much less robust (48,49). In contrast, data in neonatal cohorts on paracetamol-related opioid-sparing effects in neonates were only more recently reported in two different cohorts (surgical and medical intensive care, respectively).…”

Role of magnesium sulfate in the treatment of acute postoperative pain

“…Postoje dokazi, mada ograničeni, da perioperativno primenjen paracetamol, nesteroidni antiinflamatorni lekovi, deksametazon, ketamin, klonidin i deksmedetomidin mogu umanjiti postoperativni bol i potrošnju opioida u nekim populacijama pedijatrijskih hirurških bolesnika (71). Nedavno je sprovedena metaanaliza deset randomizovanih kontrolisanih studija (sa ukupno 665 učesnika) koje su ispitivale uticaj intravenski primenjenog magnezijum-sulfata na postoperativne komplikacije kod dece koja su podvrgnuta tonzilektomiji (72).…”