Interventions for postoperative pain in children: An overview of systematic reviews

Abstract

The aim of this study was to conduct an overview of systematic reviews that summarizes the results about efficacy and safety from randomized controlled trials involving the various strategies used for postoperative pain management in children. We searched the Cochrane Database of Systematic Reviews, CINAHL, Database of Reviews of Effect, Embase, MEDLINE, and PsycINFO from the earliest date to January 24, 2016. This overview included 45 systematic reviews that evaluated interventions for postoperative pain in children. Out of 45 systematic reviews that investigated various interventions for postoperative pain in children, 19 systematic reviews (42%) presented conclusive evidence of efficacy. Positive conclusive evidence was reported in 18 systematic reviews (40%) for the efficacy of diclofenac, ketamine, caudal analgesia, dexmedetomidine, music therapy, corticosteroid, epidural analgesia, paracetamol, and/or nonsteroidal anti-inflammatory drugs and transversus abdominis plane block. Only one systematic review reported conclusive evidence of equal efficacy that involved a comparison of dexmedetomidine vs morphine and fentanyl. Safety of interventions was reported as conclusive in 14 systematic reviews (31%), with positive conclusive evidence for dexmedetomidine, corticosteroid, epidural analgesia, transversus abdominis plane block, and clonidine. Seven systematic reviews reported equal conclusive safety for epidural infusion, diclofenac intravenous vs ketamine added to opioid analgesia, bupivacaine, ketamine, paracetamol, and dexmedetomidine vs intravenous infusions of various opioid analgesics, oral suspension and suppository of diclofenac, only opioid, normal saline, no treatment, placebo, and midazolam. Negative conclusive statement for safety was reported in one systematic review for caudal analgesia vs noncaudal regional analgesia. More than half of systematic reviews included in this overview were rated as having medium methodological quality. Of 45 included systematic reviews, 10 were Cochrane reviews and they had higher methodological quality than non-Cochrane reviews. As evidence concerning efficacy and safety is inconclusive for most of the analyzed interventions, our review points out the need for more rigorous trials concerning pain management in children.

Comparative efficacy of continuous infusion of bupivacaine/fentanyl and ropivacaine/fentanyl for paediatric pain control after the Ravitch procedure and thoracotomy. A prospective randomized study

“…During the entire observation period, the nurses took pain measurements 5947 times, including 2214 (37.2%) at rest, 1912 (32.1%) during deep breathing and 1821 (30.6%) while coughing. There was no significant difference between the BF and the RF group in terms of the number of pain measurements at rest (Me: 22 [20][21][22][23][24][25] vs. 24 [21-26.5], Z = -1.285, P = 0.197), during deep breathing (Me: 20 [18][19][20][21][22] vs. 20.5 [17.5-22], Z = -0.239, P = 0.810) and coughing (Me: 20 [18][19][20][21] vs. 19.5 [17][18][19][20][21][22], Z = 0.234, P = 0.813). Table 2 provide descriptive statistics for pain intensity (mean, maximal).…”

“…It is well documented that inadequate pain control may delay recovery, increase morbidity and mortality, increase anxiety, decrease patient satisfaction, and lead to chronic persistent postsurgical pain 14,15 . Unfortunately, results of many studies conducted in different countries show that the treatment of postoperative pain in children is inadequate -too many children still experience intense pain [16][17][18][19][20][21] .…”

Leading papers in pediatric anesthesia from the last year

“…Em um estudo muito interessante sobre dor pós-Principais artigos de anestesia pediátrica do último ano -operatória em crianças foi a revisão sistemática de Boric et al 70 , onde 45 revisões sistemáticas foram analisadas. Foram encontradas boas evidências para uso de diclofenaco, cetamina, analgesia caudal, música, corticoide, analgesia epidural, paracetamol, dexmedetomidina e bloqueio transverso do abdome.…”

Pharmacokinetics of an intravenous bolus dose of clonidine in children undergoing surgery

“…Clonidine acts as an alpha2‐adrenoceptor agonist and is approved for the treatment of hypertension, as an adjunct for epidural pain management, and for the management of pediatric attention deficit hyperactivity disorder. Clonidine is used off‐label in pediatric anesthesia for several indications, for example, treatment of acute pain, sedation in intensive care, treatment and prevention of postoperative agitation and to counter withdrawal symptoms in children after long‐term sedation 1‐5 . Pharmacokinetic knowledge is helpful for optimal clinical use, and clonidine pharmacokinetics in children has been investigated for oral, 6 intranasal, 7 rectal, 8 epidural, 9,10 and intravenous administration 11‐13 .…”