Comparison of perioperative ketoprofen 2.0 mg kg-1 with 0.5 mg kg-1 i.v. in small children during adenoidectomy

We have investigated if ketoprofen 0.5 mg kg-1 i.v. provided as good analgesia with less adverse effects compared with ketoprofen 2.0 mg kg- 1 i.v. in 107 children, aged 1-7 yr, after adenoidectomy, in a randomized, double-blind, parallel group study design. A standard anaesthetic method was used and all children received fentanyl 1 microgram kg-1 i.v. during induction. Children in group 2.0 received ketoprofen 2.0 mg kg-1 and children in group 0.5, 0.5 mg kg-1 i.v. during induction. If the child was in pain, fentanyl 1 microgram kg-1 was given i.v. as rescue analgesia. We found that ketoprofen provided good analgesia and only 49% of children required fentanyl in the post- anaesthesia care unit. There were no differences between the groups in the number of fentanyl doses, pain scores or frequency of adverse reactions. No serious adverse reactions occurred.      

I.v. intraoperative ketoprofen in small children during adenoidectomy: a dose-finding study

We have investigated if a low dose of ketoprofen (0.3 mg kg-1) i.v., provided as good analgesia with less adverse effects than higher doses (1.0 and 3.0 mg kg-1) in 220 children, aged 1-7 yr, undergoing adenoidectomy, in a prospective, randomized, double-blind, placebo- controlled, parallel group study. The postoperative analgesic effect was notable even after the lowest dose of ketoprofen. However, the higher doses seemed to provide better analgesia with no increase in adverse events or intraoperative bleeding. None of the children experienced postoperative bleeding which would have required intervention or delayed discharge from hospital. This study confirms the efficacy and safety of intraoperative ketoprofen in children during adenoidectomy.      

The feasibility of pain treatment at home after adenoidectomy with ketoprofen tablets in small children

In this study, we investigated the feasibility of pain treatment using ketoprofen 25 mg tablets (5 mg x kg(-1) x day(-1)) at home in children after daycase adenoidectomy. We also determined the adverse events and the incidence of postoperative bleeding during the first week after surgery. Initially, we studied 611 children aged 1-9 years. The study design was prospective, longitudinal, and open. The final data consisted of 555 (91%) children, and 522 children who received ketoprofen at home. The parents administered four (1-10, median with 10th and 90th percentiles) ketoprofen tablets to their children during the first week. A total of 20% of the parents experienced problems in administering tablets, and problems were three times more common in children under 48 months compared to older children. The main problems were swallowing difficulties and the unpleasant taste of the tablet. Neither serious adverse events, nor clinically significant bleeding occurred. Ketoprofen at the dose of 5 mg x kg(-1) x day(-1) proved to be a safe analgesic in children for short-term use after adenoidectomy.     

Comparison of intravenous and oral ketoprofen for postoperative pain after adenoidectomy in children

One hundred children, aged 1–9 yr, undergoing adenoidectomywere randomized to receive ketoprofen 1 mg kg^–1either i.v. with an oral placebo (n=40) or ketoprofen 1 mg kg^–1orally with an i.v. placebo (n=40), or both oral and i.v. placebo(n=20). The study design was prospective and double blind withparallel groups. The pain was assessed at rest and during swallowingusing the Maunuksela pain scale (0=no pain, 10=worst possiblepain) after surgery for 3 h. Fentanyl 0.5 µg kg^–1i.v. was given for rescue analgesia. Children in the i.v. groupneeded significantly less doses (1, 1–3; median and 10th/90thpercentiles) of rescue analgesic compared with the oral group(2, 1–3; P=0.024). Of those who needed rescue analgesic,three out of 30 children in the i.v. group required three ormore doses of fentanyl compared with 10 out of 28 children inthe oral group. There were no differences between the groupswith respect to pain scores, operation times, perioperativebleeding or frequency of adverse events. Br J Anaesth 2000; 85: 224–7 ^* Corresponding author     

Perioperative intravenous ketoprofen neither prolongs operation time nor delays discharge after adenoidectomy in children

Because nonsteroidal anti-inflammatory drugs, such as ketoprofen, prolong bleeding time, their preoperative administration may both prolong operation time and delay discharge. Therefore, charts of 335 children who had undergone adenoidectomy were evaluated to determine the effect of ketoprofen on operation time (OPERTIME) and length of hospital stay (ACTUAL LOS). The study was conducted in three phases (I-III) which differed from each other in the dose of i.v. ketoprofen, 0.3-3 mg x kg(-1). All phases were conducted with parallel groups using a prospective, randomized, and double blind design; moreover, phases I and III were placebo-controlled. OPERTIMEs were similar between Placebo groups and Ketoprofen groups. The dose of ketoprofen did not affect OPERTIME or ACTUAL LOS. In phase I, ACTUAL LOS was significantly longer in the Placebo group (251 +/- 46 min, mean +/- SD) compared to the Ketoprofen group (225 +/- 44 min, P=0.006). In conclusion, preincisional ketoprofen did not prolong OPERTIME or delay discharge in children undergoing adenoidectomy.     

Postoperative pain after adenoidectomy in children

We have investigated if pain intensity or analgesic requirements in hospital predicted pain intensity, pain duration or analgesic requirements at home in 611 children, aged 1-7 yr, after day-case adenoidectomy. We also investigated if ketoprofen 0.3-3.0 mg kg-1, administered pre-emptively i.v. during operation, modified pain at home. In hospital, a prospective, randomized, double-blind, placebo- controlled study design was performed. A standard anaesthetic technique was used in all children and fentanyl i.v. was available for rescue analgesia. After discharge, the study design was open, experimental, prospective and longitudinal. On return home, children were prescribed ketoprofen tablets 5 mg kg-1 day-1. Parents were asked to complete an analgesia diary; non-responders were contacted by telephone. The response rate was 91%. The number of doses of fentanyl given in hospital correlated with pain intensity at home (P < 0.001). There were no other correlations and no pre-emptive effect of ketoprofen.      

Pain management after adenoidectomy with ketoprofen: comparison of rectal and intravenous routes

We compared the efficacy of rectally and intravenously administeredketoprofen for pain management after day-case adenoidectomy.Patients (123 children aged 1–9 yr) were allocatedrandomly to receive on induction of anaesthesia ketoprofen 25 mgrectally with an i.v. placebo, ketoprofen 25 mg i.v. witha rectal placebo, or placebo both i.v. and rectally. The methodof anaesthesia and the operative technique were standardized.Postoperative pain was assessed at rest and during swallowingusing the Maunuksela pain scale (0=no pain, 10=worst possiblepain). Fentanyl 0.5 µg kg^–1 was givenas rescue analgesia. There was no significant difference betweenthe two ketoprofen groups in their requirement for rescue analgesics.However, both the proportion of children needing rescue analgesics[55 of 84 children (65%) vs. 33 of 39 children (84%); difference19%, 95% confidence interval 4–34%, P=0.029] and the numberof rescue analgesic doses [mean 1.2 (SD 1.2) vs. 2.2 (1.4);mean difference 0.9, 95% confidence interval 0.4–1.4,P=0.001] were significantly lower among children receiving ketoprofenthan in children receiving placebo. Adverse events, durationof operation, perioperative bleeding, pain scores and time ofdischarge were similar in the three groups. Br J Anaesth 2000; 85: 836–40     

The prevention of emergence agitation with tropisetron or clonidine after sevoflurane anesthesia in small children undergoing adenoidectomy

Postoperative agitation is a common problem after sevoflurane anesthesia in children. In the present study, we evaluated if tropisetron or clonidine could reduce the incidence of postoperative agitation after day case adenoidectomy in small children. We included 75 unpremedicated children aged 1-7 yr who were randomly assigned to receive either placebo, tropisetron (0.1 mg/kg) or clonidine (1.5 microg/kg) after anesthesia induction. Anesthesia was induced and maintained with sevoflurane. Patients also received alfentanil (20 microg/kg) and diclofenac (1 mg/kg). Postoperative pain was treated with IV oxycodone (0.05 mg/kg). Time to achieve discharge criteria was recorded. Modified pain/discomfort scale was used assess the postoperative behavior. The incidence of postoperative agitation was significantly less (32%, 8/25 patients) in the tropisetron group compared with placebo (62%, 16/26 patients), P < 0.05). Clonidine could not prevent agitation (incidence 54%, 13/24). No adverse effects were noted during the study. Discharge times were similar between the groups (between 80 and 99 min on average). In conclusion, tropisetron 0.1 mg/kg significantly reduced the incidence of postoperative agitation after sevoflurane anesthesia. Clonidine 1.5 microg/kg did not differ from placebo with respect to postoperative agitation.     

Recovery after halothane anaesthesia induced with thiopental, propofol-alfentanil or halothane for day-case adenoidectomy in small children

We studied recovery from halothane anaesthesia in 93 children, aged 1-3 yr, undergoing day-case adenoidectomy. Children were allocated randomly to receive thiopental 5 mg kg-1 (group TH), alfentanil 10 micrograms kg- 1 and propofol 3 mg kg-1 (group PAH) or 5% halothane (group HH) for induction of anaesthesia. In group TH, tracheal intubation was facilitated with succinylcholine (suxamethonium) 1.5 mg kg-1. In groups PAH and HH, tracheal intubation was performed without neuromuscular block, and succinylcholine was used only if required. Anaesthesia was maintained with 1-3% halothane during spontaneous respiration. Times to achieving predetermined recovery end-points were recorded. Quality of recovery was assessed using a score of 1-9 (best to worst) for sedation, crying, restlessness and agitation. A postoperative questionnaire was used to determine the well-being of the child at home, 24 h after operation. Emergence from anaesthesia (response to non- painful stimuli) occurred earlier in group HH (mean 9 (SD 6) min) than in groups PAH (13 (6) min, P < 0.01) and TH (18 (14) min, P < 0.01). Sitting up, walking and home readiness were achieved earlier in groups PAH and HH than in group TH (P < 0.05 for each variable). Children in group TH were more sedated during the first 30 min after anaesthesia than those in the two other groups (P < 0.05) while emergence-related delirium was more common in group HH than in group TH (P < 0.01). Well- being at home was similar in all groups. We conclude that induction of halothane anaesthesia with propofol-alfentanil or halothane provided more rapid recovery and earlier discharge than that with thiopental.      

Parenteral ketoprofen for pain management after adenoidectomy: comparison of intravenous and intramuscular routes of administration

BACKGROUND: Different parenteral routes of administration of NSAIDs such as ketoprofen have not been properly compared in children. This study was designed to compare the analgesic efficacy of intravenous and intramuscular ketoprofen for pain management in children after day-case adenoidectomy. METHODS: A total of 120 children, aged 1-9 years, who were scheduled to undergo adenoidectomy, were randomized to receive ketoprofen 2 mg/kg either intravenously with intramuscular placebo (n = 40) or ketoprofen 2 mg/kg intramuscularly with intravenous placebo (n = 40), or both intravenous and intramuscular placebo (n = 40) at induction of anesthesia. The study design was prospective and double-blind with parallel groups. Pain was assessed at rest and during swallowing using the Maunuksela pain scale during 3 h after surgery, and fentanyl i.v. was given for rescue analgesia. RESULTS: Children in the Placebo group needed significantly more doses of fentanyl (72 doses) than either children in the intravenous group (47 doses) or children in the intramuscular group (51 doses) (P = 0.021). In addition, a higher proportion of children in the Placebo group than in the two ketoprofen groups (P = 0.03) demanded rescue analgesic. No difference in the need for rescue analgesia or in pain scores was found between the two ketoprofen groups. Children in the intravenous group had less pain than children in the Placebo group. The difference was significant during swallowing at 1 h after surgery (P = 0.046) and for the worst pain observed during swallowing for 3 h after surgery (P = 0.022). There were no differences between the three groups with respect to operation times, amount of perioperative bleeding, or rate or extent of adverse events. CONCLUSION: The efficacy of intravenous and intramuscular ketoprofen was similar, and they both differed from placebo.     

The effect of paracetamol or diclofenac administered before operation on postoperative pain and behaviour after adenoidectomy in small children

We compared the effects of rectally administered diclofenac (12.5 mg) with paracetamol (125 mg) on pre- and postoperative behaviour and the need for supplementary analgesia in 44 children scheduled for adenoidectomy (with or without myringotomy). The study drugs were given in combination with diazepam (0.5 mg.kg-1) about 20 min before the children were taken to the operating theatre. On arrival there, the children who had received diclofenac were significantly quieter (< 0.05), easier to handle (p < 0.01) and cried less (p < 0.05) than those in the paracetamol group. During recovery, children in the diclofenac group needed fewer supplementary doses of intravenous pethidine than those receiving paracetamol (p < 0.001). There were no obvious differences between the groups in intra-operative bleeding (as estimated by the surgeon), or in measured blood loss. No postoperative complications became evident. The pre-operative rectal administration of diclofenac for pain relief after adenotomy is safe and effective.     

Effect of pre-treatment with intravenous atropine or glycopyrrolate on cardiac arrhythmias during halothane anaesthesia for adenoidectomy in children

We studied the effect of anticholinergics on the incidence of cardiac arrhythmias during paediatric anaesthesia. ASA I-II children (n = 77) undergoing adenoidectomy were randomly allocated to three groups. Intravenous atropine 0.02 mg kg-1 was given in group A (n = 25), glycopyrrolate 0.004 mg kg-1 in group G (n = 27) and physiological saline in group P (n = 25) 3 min before the induction of anaesthesia. The children breathed spontaneously under halothane anaesthesia with 66% nitrous oxide in oxygen after induction with thiopentone and succinylcholine. Perioperative monitoring of the ECG (Holter recordings) and oxygen saturation was carried out. Ventricular tachycardia occurred in 16.0%, 18.5% and 12.0% of the children in groups A, G and P respectively (ns). The incidence of ventricular arrhythmias (ventricular tachycardia, ventricular bigeminy, ventricular premature beats > 10) was 20.0% in group A, 44.4% in group G and 36.0% in group P (ns). Bradycardia (< 70 beats min-1) was observed in 0.0%, 14.8% and 24.0% of patients in groups A, G and P respectively (A vs P, P < 0.05). The use of anticholinergics did not influence the incidence of ventricular arrhythmias during halothane anaesthesia in children. Bradycardia was more common in the placebo group than in the atropine group.      

Pharmacokinetics of a 24-hour intravenous ketoprofen infusion in children

BACKGROUND: No pharmacokinetic data are available with respect to the plasma concentration of ketoprofen during intravenous infusion in children. METHODS: We present here the pharmacokinetics of ketoprofen after a 10-min intravenous infusion of 1 mg/kg followed by a 24-h infusion of 4 mg/kg in 18 children aged 7 months to 16 years. Venous blood samples were collected at 5 min, 1, 2, 4, 24 h following the loading dose, and then 1, 2 and 4 h after the end of the infusion. A validated HPLC method was used to measure plasma levels of ketoprofen. RESULTS: The steady state plasma concentration of ketoprofen was 2.0 microg/mL (range 1.3-2.7 microg/mL). The clearance of ketoprofen was 0.09 L x h(-1) x kg(-1) (range 0.06-0.13 L x h(-1) x kg(-1)). The distribution volume was 0.16 L/kg (range 0.12-0.21 L/kg). The terminal half-life was 1.3 h (range 0.8-1.7 h). CONCLUSION: The pharmacokinetics of ketopofen in children is similar to that reported in adults. Our results indicate that ketoprofen is a feasible drug for continuous intravenous infusion in acute pain treatment in children.     

Dexmedetomidine: perioperative applications in children

Dexmedetomidine is a highly specific and selective alpha‐2‐adrenergic agonist with sedative, anxiolytic, and organ protective effects. Its clinical applications in children include premedication, prevention of emergence delirium, as part of multimodal anesthetic regimen and sedation in the pediatric intensive care unit. Its role in neuroprotection in children undergoing anesthesia should be explored. In this review, various uses of dexmedetomidine are discussed in detail.