The use of NSAIDs in pediatric scoliosis surgery – a survey of physicians' prescribing practice

Background:  Pediatric scoliosis surgery is associated with considerable postoperative pain requiring opioids for analgesia. Nonsteroidal antiinflammatory drugs (NSAIDs) can be used as adjuvants for analgesia; however, the potential of these agents to affect bone healing raises concerns. No large-scale prospective studies have been performed to evaluate the benefit-to-risk ratio of NSAID use after pediatric scoliosis surgery. Given the lack of evidence in the literature, a survey of practice patterns of anesthesiologists from around the world was conducted with respect to the use of NSAIDs after pediatric spinal fusion surgery for scoliosis.
Methods:  One hundred and fourteen anesthesiologists from international academic pediatric hospitals were asked to complete an online survey. After 1 month, nonresponders were sent a second e-mail asking for their participation. All questions were developed specifically for this study.
Results:  Out of 80 anesthesiologists who responded 61 were included in the final analysis. Fifty-nine percent routinely use NSAIDs, the most common agents being intravenous ketorolac and oral ibuprofen. The majority of respondents begin to administer NSAIDs within the first three postoperative days for a duration of four or more days. The primary reason for not routinely prescribing NSAIDs was the risk of bone nonunion.
Conclusions:  This survey demonstrates that the practice patterns of pediatric anesthesiologists from around the world with respect to the administration of NSAIDs for the management of postoperative pain after pediatric spinal fusion reflects the conflicting evidence in the literature and the lack of high-quality studies in humans.     

Carney's triad: a new case

Carney's triad is a very unusual syndrome, associating three different tumours on the same patient, a young woman generally: a gastric leiomyoblastoma, a pulmonary chondroma and an extra-adrenal paraganglioma. The authors report through the literature review and a new case of Carney's syndrome associating gastric leiomyoblastoma and extra-adrenal paragangliomas, the different diagnostic and therapeutic criterias.     

Carney's triad: a 16-year follow-up

We report a female teenager who presented with a gastrointestinal stromal tumor of the stomach and a paraganglioneuroma. She later developed a pulmonary chondroma, fulfilling the requirements of Carney's triad. This patient demonstrates the course of the disease, which included severe emotional symptoms. She died, at 30 years of age, 16 years after the onset of disease, riddled with metastases. Many patients with Carney's triad survive for many years, but we can not predict the prognosis in any patient. During her lifetime, the patient had considerable emotional suffering, perhaps because of her disease.     

T-lymphocyte activation in steroid-sensitive nephrotic syndrome in childhood

We undertook a sequential study in 29 children with steroid-sensitivenephrotic syndrome (SSNS) off treatment to seek evidence forT-cell activation in relapse. T-cell subsets and activationmarkers were analysed using two-colour flow cytometry. SolubleIL2 receptor (sIL2R) was measured in serum and urine by enzyme-linkedimmunosorbent assay (ELISA). Fifteen children were examinedin remission and subsequent relapse (group A) and fourteen remainedin remission (group B). In group A the proportion of CD4⁺ cellsexpressing the activation marker CD25 (alpha-chain of the IL2receptor) increased significantly from remission to relapse:CD4⁺25⁺ cells rose from 5.6 to 7.0% of total lymphocytes, andfrom 15.8 to 19.1% of CD4⁺ lymphocytes (paired t test: P<0.0005and <0.001 respectively). No correlations were found betweenCD4⁺25⁺ cells and plasma albumin or cholesterol concentrations.SIL2R concentration in serum did not change in relapse, butincreased significantly in urine from 272 to 592 U/mg creatinine(P<0.01). No significant difference was found in remissionbetween groups A and B. We conclude that early relapse in SSNSis associated with activation of CD4⁺ (T-helper) cells whichis not secondary due to the nephrotic state itself.     

Autoimmune progesterone dermatitis in a parturient for emergency caesarean section

A parturient with a 14-year history of autoimmune progesterone dermatitis presented in labour at 36 weeks' gestation. She had suffered recurrent episodes of angioedema over a long period and had been scheduled for elective caesarean hysterectomy and bilateral oophorectomy at 37 weeks' gestation. In most cases surgical oophorectomy provides prolonged relief from the recurrent angioedema and dermatological manifestations that are typical of autoimmune progesterone dermatitis. Spinal anaesthesia was chosen in order to avoid airway manipulation, a factor frequently implicated in the development of angioedema. Delivery was uneventful and the obstetricians proceeded to hysterectomy and oophorectomy. Forty minutes after delivery the patient experienced an attack of angioedema, she was markedly hypotensive and was given fluids, ephedrine and phenylephrine with good effect. As she remained normotensive, she was given intramuscular rather than intravenous epinephrine to provide a slower release. She recovered well and stabilised without the need for intubation or ventilation. This case reinforces the rationale for regional anaesthesia in these patients and demonstrates how intramuscular epinephrine contributed towards a positive outcome.     

Anaphylaxis to intravenous gelatin-based solutions: a case series examining clinical features and severity

The proportion of patients receiving intravenous gelatin-based colloids has increased in the last decade due to safety concerns about starch-based products. Recent research suggests hypersensitivity reactions to intravenous gelatin-based solutions occur at similar rates per administration as non-depolarising neuromuscular blocking agents such as rocuronium (6.2/100,000 administrations). There are scant published data on clinical features, diagnosis and time course of these reactions. We undertook a review of cases reported and tested at one of the UK's largest drug allergy clinics. All patients seen in the drug allergy clinic at Imperial College Healthcare NHS Trust (London, UK) with a confirmed diagnosis of anaphylaxis to gelatin-based solutions between May 2013 and May 2018 were included. We retrospectively reviewed clinical histories, skin test results and severity of reactions in this cohort of patients. Twelve patients with anaphylaxis to gelatin-based solutions were identified (eight women, mean (SD) age 58 (17) years). Eleven reactions were severe or life-threatening with three progressing to cardiac arrest. Presentation was commonly delayed; only three patients suffered reactions within 5 min of the solution being administered with a further six presenting 10–70 min later. Where measured, tryptase was elevated in all patients (median (IQR [range]) 14.7 (8.2–23.8 [6.5–83.4]) ng.ml⁻¹). Reactions to gelatin-based solutions are usually severe and can present with latency uncommon with other intravenous anaesthetic triggers. The use of gelatin-based solutions in the peri-operative setting should be re-assessed given the risk of severe allergy.     

Local infiltration with NSAIDs for postoperative analgesia: evidence for a peripheral analgesic action

BACKGROUND: In order to investigate the evidence for a peripheral analgesic effect of local infiltration with nonsteroidal antiinflammatory drugs (NSAIDs) in postoperative pain, we conducted a systematic review. METHODS: Randomised controlled and double-blind trials were evaluated. Outcome measures were pain scores, the use of supplementary analgesics, and time to first analgesic request. Efficacy was estimated by significant difference (P<0.05) as reported in the original reports and by calculation of the weighted mean difference of pain scores between treatment groups. RESULTS: Sixteen studies with data from 844 patients were considered appropriate for analysis. The NSAIDs were administered as intra-articular injections, as components of intravenous regional anaesthesia (IVRA), and by wound infiltration and were compared with systemic administration or placebo. In the four studies comparing intra-articular NSAIDs with systemic administration a statistically significant effect in favour of intraarticular NSAIDs was found. Only one study compared IVRA NSAID with systemic administration, showing a significant effect in favour of IVRA administration. No more than two of the five studies comparing intrawound NSAIDs with systemic administration showed significant effect after intrawound administration. Most of the studies comparing local infiltration with placebo showed significant effect in favour of local infiltration. CONCLUSION: There is evidence for a clinically relevant peripheral analgesic action of intra-articular NSAIDs while results of IVRA and wound infiltration with NSAIDs in postoperative pain are inconclusive. Trials without a systemic control group were not considered to provide evidence for a local effect.     

NSAIDs in orthopaedic practice: management guidelines for arthritis patients

Guidelines are provided for prescribing nonsteroidal antiinflammatory drugs (NSAIDs) pre- and postoperatively for arthritis patients. Most NSAIDs impair platelet aggregation and prolong bleeding time, increasing the risk of complications during and immediately following surgery; thus, the effects of individual NSAIDs must be considered prior to surgery. Postoperative treatment issues that must be considered include gastrointestinal safety, renal and hepatic safety, safety in the elderly, and efficacy of various NSAIDs. Various strategies to improve gastrointestinal safety, including use of NSAIDs with low ulcerogenic potential such as nabumetone, low-dose ibuprofen, and etodolac, are discussed. As all NSAIDs can reduce pain and inflammation, selection of a particular NSAID should be based on careful consideration of pharmacologic and clinical differences.     

Attentional and processing skills following traumatic brain injury in early childhood

Primary objective: Attentional deficits are common following TBI in adults. This study examined whether these skills are also vulnerable following early childhood injury, when such skills are rapidly developing. Research design: This study investigated attention 30 months post-TBI in pre-schoolers (n = 56) and age-matched controls (n = 26). TBI children were divided into mild, moderate and severe injury groups. Methods and procedure: Pre-injury data were collected at time of injury. Assessment of attention included the Continuous Performance Test, Wechsler Intelligence Scale and Personality Inventory for Children. Main outcomes and results: Severe TBI was associated with reduced accuracy and slowed processing, particularly on complex motor responses. Sustained attention was more intact. Parental reports indicate internalized behavioural problems and somatic complaints. Conclusions: Young children with severe TBI are at risk for severe, persisting attentional impairments. Children with mild and moderate TBI show better outcome, with pre-injury behaviour and age also predictive of attentional skills at 30 months post-injury.     

Continuous versus intermittent portal triad clamping for liver resection: a controlled study

OBJECTIVE: The authors compared the intra- and postoperative course of patients undergoing liver resections under continuous pedicular clamping (CPC) or intermittent pedicular clamping (IPC). SUMMARY BACKGROUND DATA: Reduced blood loss during liver resection is achieved by pedicular clamping. There is controversy about the benefits of IPC over CPC in humans in terms of hepatocellular injury and blood loss control in normal and abnormal liver parenchyma. METHODS: Eighty-six patients undergoing liver resections were included in a prospective randomized study comparing the intra- and postoperative course under CPC (n = 42) or IPC (n = 44) with periods of 15 minutes of clamping and 5 minutes of unclamping. The data were further analyzed according to the presence (steatosis >20% and chronic liver disease) or absence of abnormal liver parenchyma. RESULTS: The two groups of patients were similar in terms of age, sex, nature of the liver tumors, results of preoperative assessment, proportion of patients undergoing major or minor hepatectomy, and nature of nontumorous liver parenchyma. Intraoperative blood loss during liver transsection was significantly higher in the IPC group. In the CPC group, postoperative liver enzymes and serum bilirubin levels were significantly higher in the subgroup of patients with abnormal liver parenchyma. Major postoperative deterioration of liver function occurred in four patients with abnormal liver parenchyma, with two postoperative deaths. All of them were in the CPC group. CONCLUSIONS: This clinical controlled study clearly demonstrated the better parenchymal tolerance to IPC over CPC, especially in patients with abnormal liver parenchyma.     

Allergy, plasma IgE level and anaphylactoid response: a hypothesis

Any simple test predictive of immediate hypersensitivity-like (anaphylactoid) response to anaesthetic agents would be clinically useful. Possession of the traits of allergy or atopy, and of raised plasma IgE levels, all easily established, have previously been reported as predisposing factors. The usefulness of such observations has been limited by the fact that many reactions are not immune and do not involve IgE antibodies. This hypothesis suggests how IgE levels may be widely predictive of other reaction mechanisms and partially explains some of the divergent views on the mechanisms of anaphylactoid response which occur in the literature.     

Thyroid gland morphology in young adults: normal subjects versus those with prior low-dose neck irradiation in childhood

Thyroid glands obtained at autopsy from young adults were studied to establish more accurately the "normal" morphology in the groups 20 to 40 years of age. A total of 56 autopsy specimens (many obtained from trauma victims) were examined in detail by totally embedding and sectioning the thyroid glands. The morphology of these thyroid glands also was compared to that of surgically removed thyroid glands from 47 young adult patients with prior low-dose neck irradiation. The "normal" thyroid specimens frequently showed morphologic features, such as thyroid tissue outside the recognizable capsule of the gland (40 of 56 patients) and in the strap muscles of the neck (six of 56 patients), which are conditions commonly considered as evidence for invasive thyroid carcinoma. The thyroid glands from the "normal" young adult population were significantly different from those thyroid glands surgically removed from patients who had received irradiation. The irradiated thyroid glands invariably showed multiple nodules of a wide variety of histologic types, extensive lymphocytic infiltrates, and distorting fibrosis as well as a high incidence of malignancy (27 of 47 patients). A single 0.1 cm focus of papillary carcinoma was found in one specimen in the nonirradiated thyroid group. This study suggests that "occult" thyroid carcinomas in the group 20 to 40 years of age are rare and are significantly fewer in number than in the older population (P less than 0.02).