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Nallakumarasamy A, Shrivastava S, Rangarajan RV, Jeyaraman N, Devadas AG, Ramasubramanian S, Jeyaraman M. Optimizing bone marrow harvesting sites for enhanced mesenchymal stem cell yield and efficacy in knee osteoarthritis treatment. World J Methodol 2025; 15:101458. [DOI: 10.5662/wjm.v15.i2.101458] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2024] [Revised: 11/07/2024] [Accepted: 11/20/2024] [Indexed: 11/27/2024] Open
Abstract
Knee osteoarthritis (OA) is a debilitating condition with limited long-term treatment options. The therapeutic potential of mesenchymal stem cells (MSCs), particularly those derived from bone marrow aspirate concentrate, has garnered attention for cartilage repair in OA. While the iliac crest is the traditional site for bone marrow harvesting (BMH), associated morbidity has prompted the exploration of alternative sites such as the proximal tibia, distal femur, and proximal humerus. This paper reviews the impact of different harvesting sites on mesenchymal stem cell (MSC) yield, viability, and regenerative potential, emphasizing their relevance in knee OA treatment. The iliac crest consistently offers the highest MSC yield, but alternative sites within the surgical field of knee procedures offer comparable MSC characteristics with reduced morbidity. The integration of harvesting techniques into existing knee surgeries, such as total knee arthroplasty, provides a less invasive approach while maintaining therapeutic efficacy. However, variability in MSC yield from these alternative sites underscores the need for further research to standardize techniques and optimize clinical outcomes. Future directions include large-scale comparative studies, advanced characterization of MSCs, and the development of personalized harvesting strategies. Ultimately, the findings suggest that optimizing the site of BMH can significantly influence the quality of MSC-based therapies for knee OA, enhancing their clinical utility and patient outcomes.
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Affiliation(s)
- Arulkumar Nallakumarasamy
- Department of Orthopaedics, Datta Meghe Institute of Higher Education and Research, Wardha 442004, Maharashtra, India
- Department of Regenerative Medicine, Mother Cell Regenerative Centre, Tiruchirappalli 620017, Tamil Nadu, India
| | - Sandeep Shrivastava
- Department of Orthopaedics, Datta Meghe Institute of Higher Education and Research, Wardha 442004, Maharashtra, India
| | - Ravi Velamoor Rangarajan
- Department of Regenerative Medicine, Mother Cell Regenerative Centre, Tiruchirappalli 620017, Tamil Nadu, India
| | - Naveen Jeyaraman
- Department of Orthopaedics, Datta Meghe Institute of Higher Education and Research, Wardha 442004, Maharashtra, India
- Department of Regenerative Medicine, Mother Cell Regenerative Centre, Tiruchirappalli 620017, Tamil Nadu, India
| | - Avinash Gandi Devadas
- Department of Regenerative Medicine, Mother Cell Regenerative Centre, Tiruchirappalli 620017, Tamil Nadu, India
| | - Swaminathan Ramasubramanian
- Department of Orthopaedics, Government Medical College, Omandurar Government Estate, Chennai 600002, Tamil Nadu, India
| | - Madhan Jeyaraman
- Department of Regenerative Medicine, Mother Cell Regenerative Centre, Tiruchirappalli 620017, Tamil Nadu, India
- Department of Orthopaedics, ACS Medical College and Hospital, Dr MGR Educational and Research Institute, Chennai 600077, Tamil Nadu, India
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Hall EA, Shelton CM, Hagemann TM, Jasmin HM, Grey K, Anghelescu DL. A Narrative Review of Pain in Pediatric Oncology: The Opioid Option for Procedural and Surgical Pain. Paediatr Drugs 2025; 27:19-39. [PMID: 39333447 PMCID: PMC11775022 DOI: 10.1007/s40272-024-00654-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/03/2024] [Indexed: 09/29/2024]
Abstract
This narrative review examines the evolving role of opioids in managing procedural and surgical pain in pediatric oncology patients. The review evaluates studies on opioid use across various oncological surgeries including thoracic, abdominal, orthopedic, and neurosurgical procedures, as well as for common painful procedures such as bone marrow aspirations and lumbar punctures. While opioids remain important for acute procedural and postoperative pain management in pediatric oncology patients, there is an increasing emphasis on multimodal, opioid-sparing approaches. The evidence presented within this review highlights the growing focus on judicious postoperative opioid prescribing to mitigate risks of adverse effects and persistent use or potential misuse. The review synthesizes findings from studies investigating various analgesic regimens, including the use of regional anesthesia techniques like epidural analgesia and peripheral nerve blocks, which have shown promise in reducing opioid requirements. For procedural pain, the review explores the efficacy of combining opioids with sedatives like midazolam or propofol, as well as the potential of ketamine as an opioid-sparing alternative. Key findings indicate that opioid-sparing techniques can effectively reduce overall opioid consumption without compromising pain control or patient satisfaction. Several studies demonstrated that regional anesthesia techniques and non-opioid adjuncts can significantly lower postoperative opioid requirements across various surgical procedures. For procedural pain, ketamine-based regimens often showed comparable or superior pain control to opioid-based approaches, with some studies reporting better patient satisfaction. This review also addresses the importance of tailored postoperative opioid prescribing, with some studies presenting algorithms to predict outpatient opioid needs more accurately. These approaches aim to ensure adequate pain control while minimizing excess opioid dispensing.
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Affiliation(s)
- Elizabeth A Hall
- Department of Clinical Pharmacy and Translational Science, University of Tennessee Health Science Center, Memphis, TN, USA.
| | - Chasity M Shelton
- Department of Clinical Pharmacy and Translational Science, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Tracy M Hagemann
- Department of Clinical Pharmacy and Translational Science, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Hilary M Jasmin
- Health Sciences Library, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Karissa Grey
- College of Pharmacy, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Doralina L Anghelescu
- Department of Global Pediatric Medicine, St. Jude Children's Research Hospital, Memphis, TN, USA
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3
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Liang S, Li S, Zhong Z, Luo Q, Nie C, Hu D, Li Y. The Effect of Lidocaine-Prilocaine Cream Combined with or Without Remimazolam on VAS and APAIS Anxiety Score in Patient Undergoing Spinal Anesthesia. Drug Des Devel Ther 2024; 18:3429-3441. [PMID: 39105187 PMCID: PMC11299647 DOI: 10.2147/dddt.s468486] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2024] [Accepted: 07/25/2024] [Indexed: 08/07/2024] Open
Abstract
Purpose This study aimed to investigate patients' expectative pain of spinal anesthesia puncture and anxiety pre-anesthesia, and to examine the effect of lidocaine-prilocaine cream and remimazolam prior to spinal anesthesia puncture on pain relief and anxiety release. Methods Patients undergoing spinal anesthesia were divided into control, lidocaine-prilocaine cream, and lidocaine-prilocaine cream with remimazolam groups. A questionnaire consisting of The Amsterdam Preoperative Anxiety and Information Scale (APAIS) and patient's concerns and Visual Analog Scale (VAS) was used to evaluate patient's anxiety and pain. The primary outcomes were differences in VAS and anxiety scores. Patient's spinal anesthesia-related concerns, advent events and hemodynamic index were also recorded. Results The expected spinal anesthesia puncture pain was 5.34±0.27 and anxiety scores before spinal anesthesia was 10.88 ± 0.64. A statistically significant positive correlation of 31.3% was detected between VAS and APAIS scores (r = 0.313; P=0.003). The VAS score at the time of puncture decreased by 29.7% (3.78±0.40, P=0.001) in lidocaine-prilocaine cream group and 29.2% (3.75±0.39, P=0.001) in lidocaine-prilocaine cream with remimazolam group compared with the expected VAS score. Lidocaine-prilocaine cream combined with or without remimazolam reduced the percentage of moderate pain (21.4% and 31.3% vs 50.0%, P=0.0001) and increased mild pain (60.7% vs 59.4% vs 22.7%, P=0.03). Anxiety score in lidocaine-prilocaine cream group was reduced by 2.84 (8.04±0.76 vs 10.88 ± 0.46, P=0.05) when compared with pre-anesthesia. Concerns about postoperative pain (P=0.03) and fear of the needle or intervention (P=0.000) both decreased post-anesthesia among groups. Conclusion Approximately half of the patients scheduled for spinal anesthesia experienced a moderate level of preoperative anxiety. The patient's pain expectation from the spinal anesthesia puncture was moderate, which was higher than the actual pain. Lidocaine-prilocaine cream with or without remimazolam sedative before spinal anesthesia puncture reduced the patient's pain and anxiety scores after surgery.
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Affiliation(s)
- Shuqing Liang
- Department of Anesthesiology, The First Affiliated Hospital of Jinan University, Guangzhou, 510630, People’s Republic of China
| | - Shuai Li
- Department of Anesthesiology, The First Affiliated Hospital of Jinan University, Guangzhou, 510630, People’s Republic of China
| | - Zhao Zhong
- Department of Anesthesiology, The First Affiliated Hospital of Jinan University, Guangzhou, 510630, People’s Republic of China
| | - Qichen Luo
- Department of Anesthesiology, The First Affiliated Hospital of Jinan University, Guangzhou, 510630, People’s Republic of China
| | - Cai Nie
- Department of Anesthesiology, The First Affiliated Hospital of Jinan University, Guangzhou, 510630, People’s Republic of China
| | - Donghua Hu
- Department of Anesthesiology, The First Affiliated Hospital of Jinan University, Guangzhou, 510630, People’s Republic of China
| | - Yalan Li
- Department of Anesthesiology, The First Affiliated Hospital of Jinan University, Guangzhou, 510630, People’s Republic of China
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Jeyaraman M, Bingi SK, Muthu S, Jeyaraman N, Packkyarathinam RP, Ranjan R, Sharma S, Jha SK, Khanna M, Rajendran SNS, Rajendran RL, Gangadaran P. Impact of the Process Variables on the Yield of Mesenchymal Stromal Cells from Bone Marrow Aspirate Concentrate. Bioengineering (Basel) 2022; 9:57. [PMID: 35200410 PMCID: PMC8869489 DOI: 10.3390/bioengineering9020057] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2021] [Revised: 01/18/2022] [Accepted: 01/20/2022] [Indexed: 02/07/2023] Open
Abstract
Human bone marrow (BM) has been highlighted as a promising source of mesenchymal stromal cells (MSCs) containing various growth factors and cytokines that can be potentially utilized in regenerative procedures involving cartilage and bone. However, the proportion of MSCs in the nucleated cell population of BM is only around 0.001% to 0.01% thereby making the harvesting and processing technique crucial for obtaining optimal results upon its use in various regenerative processes. Although several studies in the literature have given encouraging results on the utility of BM aspiration concentrate (BMAC) in various regenerative procedures, there is a lack of consensus concerning the harvesting variables such as choice of anesthetic agent to be used, site of harvest, size of the syringe to be used, anticoagulant of choice, and processing variables such as centrifugation time, and speed. In this review article, we aim to discuss the variables in the harvesting and processing technique of BMAC and their impact on the yield of MSCs in the final concentrate obtained from them.
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Affiliation(s)
- Madhan Jeyaraman
- Department of Orthopaedics, Faculty of Medicine, Sri Lalithambigai Medical College and Hospital, Dr MGR Educational and Research Institute, Chennai 600095, India;
- Department of Biotechnology, School of Engineering and Technology, Sharda University, Greater Noida 201310, India;
- Indian Stem Cell Study Group (ISCSG) Association, Lucknow 226010, India; (S.K.B.); (M.K.)
| | - Shiva Kumar Bingi
- Indian Stem Cell Study Group (ISCSG) Association, Lucknow 226010, India; (S.K.B.); (M.K.)
- Fellow in Orthopaedic Rheumatology, Dr. RML National Law University, Lucknow 226010, India
| | - Sathish Muthu
- Department of Biotechnology, School of Engineering and Technology, Sharda University, Greater Noida 201310, India;
- Indian Stem Cell Study Group (ISCSG) Association, Lucknow 226010, India; (S.K.B.); (M.K.)
- Department of Orthopaedics, Government Medical College and Hospital, Dindigul 624304, India
| | - Naveen Jeyaraman
- Indian Stem Cell Study Group (ISCSG) Association, Lucknow 226010, India; (S.K.B.); (M.K.)
- Fellow in Orthopaedic Rheumatology, Dr. RML National Law University, Lucknow 226010, India
- Fellow in Joint Replacement, Department of Orthopaedics, Atlas Hospitals, Tiruchirappalli 620002, India
| | | | - Rajni Ranjan
- Department of Orthopaedics, School of Medical Sciences and Research, Sharda University, Greater Noida 201310, India;
| | - Shilpa Sharma
- Department of Paediatric Surgery, All India Institute of Medical Sciences, New Delhi 110029, India;
| | - Saurabh Kumar Jha
- Department of Biotechnology, School of Engineering and Technology, Sharda University, Greater Noida 201310, India;
| | - Manish Khanna
- Indian Stem Cell Study Group (ISCSG) Association, Lucknow 226010, India; (S.K.B.); (M.K.)
- Department of Orthopaedics, Prasad Institute of Medical Sciences, Lucknow 226401, India
| | - Sree Naga Sowndary Rajendran
- Department of Medicine, Sri Venkateshwaraa Medical College Hospital and Research Centre, Puducherry 605102, India;
| | - Ramya Lakshmi Rajendran
- Department of Nuclear Medicine, School of Medicine, Kyungpook National University, Daegu 41944, Korea;
| | - Prakash Gangadaran
- Department of Nuclear Medicine, School of Medicine, Kyungpook National University, Daegu 41944, Korea;
- BK21 FOUR KNU Convergence Educational Program of Biomedical Sciences for Creative Future Talents, Department of Biomedical Sciences, School of Medicine, Kyungpook National University, Daegu 41944, Korea
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A Pilot Study on the Addition of Tramadol or Eutectic Mixture of Local Anesthetics (Prilocaine Plus Lignocaine) to Local Lignocaine Infiltration for Prevention of Bone Marrow Aspiration/Biopsy Associated Pain. South Asian J Cancer 2021; 10:190-194. [PMID: 34938684 PMCID: PMC8687864 DOI: 10.1055/s-0041-1731904] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022] Open
Abstract
Objectives Bone marrow aspiration although being a common procedure is associated with significant pain and its reduction remains an unmet need. We evaluated the use of tramadol and eutectic mixture of local anesthetics (prilocaine plus lignocaine) (EMLA) for reducing the severity of pain. Materials and Methods In this pilot study, we compared the addition of either tramadol 50 mg per oral (T) or EMLA local application (E) or no intervention (L) in addition to the usual procedure of local infiltration with lignocaine 2% before bone marrow aspiration and biopsy (BMAB) in adults suspected/confirmed with malignancy. Both, tramadol and EMLA were administered 1 hour prior to the procedure. Primary end point was reduction in pain intensity with these interventions compared with local infiltration alone. Pain was assessed using numerical FACES pain scale, a visual analogue scale. Secondary end points were to see the effect on pre procedure apprehension and to find out the other factors associated with increased pain related to the procedure. Statistical Analysis and Results A total of 300 patients were included in the study, 100 each in tramadol (T), EMLA (E), and only lignocaine local infiltration (L) arms, respectively. The mean pain intensity on the visual scale was significantly lower in the tramadol arm (T, E, L-3.4, 4.4, 4.7, respectively) ( p < 0.0005). There was a significant reduction in percentage of patients who experienced moderate/severe pain (four or more) in the tramadol arm (T, E, L-45, 77, 82%, respectively) ( p < 0.0005). Duration of procedure >10 minutes, body mass index >30, ECOG (Eastern Oncology Group) performance status ≥3, and age >50 years were positively correlated with more pain. Leukemia patients experienced significantly more pain compared with patients with lymphoma and other solid malignancies. Tramadol was well tolerated. No significant effect on pre-procedure apprehension was noted in any of the arms. Conclusion Tramadol appears to have a preventive effect on bone marrow aspiration/biopsy-associated pain and appears to be well tolerated, whereas EMLA was not associated with such an effect. Larger studies may be done to ascertain the same.
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Cruickshank A, Qeadan F, Kuttesch JF, Agarwal HS. Eutectic mixture of lidocaine and prilocaine versus 1% lidocaine injection for lumbar punctures in pediatric oncology patients. Pediatr Blood Cancer 2019; 66:e27957. [PMID: 31423750 DOI: 10.1002/pbc.27957] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2019] [Revised: 07/10/2019] [Accepted: 07/22/2019] [Indexed: 11/09/2022]
Abstract
BACKGROUND The role of local analgesics for lumbar punctures (LPs) in pediatric oncology patients has not been specifically studied. AIM To compare the efficacy of eutectic mixture of local anesthetics (EMLA) cream to 1% lidocaine injection for LPs. METHOD This was a retrospective observational study of all patients receiving either EMLA cream (EMLA group) or 1% lidocaine subcutaneous injection (lidocaine group) in addition to fentanyl and propofol for LPs over 18 months. Demographics, vital parameters, procedural and recovery times, propofol and fentanyl doses, and adverse events were studied. RESULTS Two hundred ninety LPs in 49 children were studied: 148 in the EMLA group and 142 in the lidocaine group. There was no difference in demographics or preprocedural parameters between the two groups. LPs in the EMLA group were completed in a shorter time (7.5 minutes [CI 7.0-8.1] vs 9.4 minutes [CI 8.9-9.9]) with a faster recovery time (38.7 minutes [CI 36.9-40.9] vs 43.9 minutes. [CI 41.9-45.9]) as compared with the lidocaine group (P < 0.001). The EMLA group required less maintenance doses (0.54 mg/kg [CI 0.47-0.62] vs 1.14 mg/kg [CI 1.06-1.21]) and total doses (2.58 mg/kg [CI 2.42-2.75] vs 3.12 mg/kg [CI 2.95-3.29]) of propofol as compared with the lidocaine group (P < 0.0001). Adverse events in the EMLA group were less (19% vs 41%) as compared with the lidocaine group (P < 0.0001). CONCLUSION The addition of EMLA cream for procedural sedation for LPs in pediatric oncology patients significantly improves pain management in comparison with 1% lidocaine injection.
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Affiliation(s)
- Amy Cruickshank
- Department of Pediatrics, University of New Mexico Health Sciences Center, Albuquerque, New Mexico.,University of New Mexico, Albuquerque, New Mexico
| | - Fares Qeadan
- Department of Internal Medicine, Division of Epidemiology, Biostatistics, and Preventive Medicine, University of New Mexico Health Sciences Center, Albuquerque, New Mexico
| | - John F Kuttesch
- Department of Pediatrics, University of New Mexico Health Sciences Center, Albuquerque, New Mexico.,University of New Mexico, Albuquerque, New Mexico
| | - Hemant S Agarwal
- Department of Pediatrics, University of New Mexico Health Sciences Center, Albuquerque, New Mexico.,University of New Mexico, Albuquerque, New Mexico
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Zarnegar-Lumley S, Lange KR, Mathias MD, Nakajima-Hatano M, Offer KM, Ogu UO, Ortiz MV, Tan KS, Kellick M, Modak S, Roberts SS, Basu EM, Dingeman RS. Local Anesthesia With General Anesthesia for Pediatric Bone Marrow Procedures. Pediatrics 2019; 144:e20183829. [PMID: 31366683 PMCID: PMC6855828 DOI: 10.1542/peds.2018-3829] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/07/2019] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Pediatric patients with cancer undergo repeated painful procedures, including bone marrow aspirations and biopsies (BMABs). Optimal management of procedure-related pain can reduce discomfort, anxiety, and distress. METHODS Children with neuroblastoma were randomly assigned to 1 of 2 arms on a prospective, single-blind, crossover trial conducted at Memorial Sloan Kettering Cancer Center from October 2016 to January 2018 (www.clinicaltrials.gov, identifier NCT02924324). Participants underwent 2 sequential BMABs: one with general anesthesia (GA) alone, the other with GA plus local anesthesia (LA) (GA + LA). The objective was to assess procedure-related pain and its interference with quality of life (QoL) with GA versus GA + LA. Primary outcome was percentage of participants requiring postprocedural opioids. Secondary outcomes were total opioid and nonopioid analgesics, pain scores, time to first analgesic, QoL, and toxicity. Management of postprocedural pain was standardized. RESULTS Of 56 participants randomly assigned (3-16.5 years old), 46 completed both procedures. There was no significant difference in percentage of participants requiring opioids with GA versus GA + LA (24% vs 20%, P = .5). Pain scores in the recovery room were significantly lower for GA + LA versus GA (median [IQR]: 0 [0-2] vs 2 [0-4], P = .002). There were no statistically significant differences in total opioid or nonopioid analgesic, 6- and 24-hour pain scores, median time to first analgesic, or pain interference. No adverse events occurred. CONCLUSIONS LA was associated with significant improvement in pain scores in the immediate recovery period. LA did not reduce postprocedural opioid use, nor did it improve QoL for patients undergoing BMAB with GA.
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Affiliation(s)
- Sara Zarnegar-Lumley
- Departments of Pediatrics,
- Division of Hematology/Oncology, Department of Pediatrics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Katharine R Lange
- Departments of Pediatrics
- Children's Minnesota Hematology Oncology, Minneapolis, Minnesotta
| | - Melissa D Mathias
- Departments of Pediatrics
- Regeneron Pharmaceuticals, Tarrytown, New York
| | | | - Katharine M Offer
- Departments of Pediatrics
- Children's Cancer Institute, Joseph M. Sanzari Children's Hospital, Hackensack University Medical Center, Hackensack, New Jersey
| | - Ugochi O Ogu
- Departments of Pediatrics
- Division of Hematology, Department of Oncology, Montefiore Medical Center, Bronx, New York; and
| | | | | | | | | | | | | | - R Scott Dingeman
- Departments of Pediatrics
- Anesthesiology and Critical Care Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
- Division of Pediatric Anesthesiology, Department of Anesthesiology and Critical Care Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland
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Duffy EA, Adams T, Thornton CP, Fisher B, Misasi J, McCollum S. Evidence-Based Recommendations for the Appropriate Level of Sedation to Manage Pain in Pediatric Oncology Patients Requiring Procedures: A Systematic Review From the Children's Oncology Group. J Pediatr Oncol Nurs 2019; 37:6-20. [PMID: 31303100 PMCID: PMC7492720 DOI: 10.1177/1043454219858610] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
Repeated invasive and painful procedures are often necessary components of pediatric cancer treatment. Adequate pain control during procedures is essential; however, procedure-related pain may be underestimated and undertreated. Currently, there is not a standard approach for the appropriate level of sedation to manage procedure-related pain in children with cancer. A team was assembled to review the evidence and develop recommendations to determine the appropriate level of sedation necessary for pain control in patients undergoing pediatric oncology procedures. After a systematic search of the literature, 15 research-based articles were synthesized and critically appraised. A recommendation was made related to the level of sedation utilized for bone marrow aspirates and bone marrow biopsies. There is a need for further research related to the necessary level of sedation for patients undergoing pediatric oncology procedures.
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Affiliation(s)
| | - Tara Adams
- Dell Children’s Medical Center, Austin,
TX, USA
| | - Clifton P. Thornton
- Johns Hopkins School of Nursing,
Baltimore MD, USA
- Herman and Walter Samuelson Children’s
Hospital at Sinai, Baltimore, MD, USA
| | - Beth Fisher
- Aflac Cancer and Blood Disorder Center,
Atlanta, GA, USA
- Clemson University, Clemson, SC,
USA
- Prisma Health, Greenville, SC, USA
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Li Y, He R, Niu Y, Li F. Paper-Based Electrochemical Biosensors for Point-of-Care Testing of Neurotransmitters. JOURNAL OF ANALYSIS AND TESTING 2019. [DOI: 10.1007/s41664-019-00085-0] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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10
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Hilkens P, Lambrichts I, Bronckaers A. Current and Future Views on Pulpal Angiogenesis. CLINICAL APPROACHES IN ENDODONTIC REGENERATION 2019:37-53. [DOI: 10.1007/978-3-319-96848-3_3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/04/2025]
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Thiamylal Plus Pentazocine Shows Similar Efficacy as Ketamine Plus Midazolam for Painful Procedures in Children With Leukemia. J Pediatr Hematol Oncol 2018; 40:e263-e265. [PMID: 29240029 DOI: 10.1097/mph.0000000000001053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
This retrospective study compared the use of thiamylal plus pentazocine (TP) to ketamine plus midazolam (KM) in children with leukemia who were undergoing bone marrow aspiration and/or intrathecal chemotherapy. A total of 268 procedures in 35 children with leukemia were retrospectively analyzed for efficacy and adverse events. All procedures were successfully completed without severe adverse events. TP induced significantly faster sedation. The incidents of desaturation were significantly greater in the TP group, but were transient and recovered by oxygen supplementation alone. Therefore, TP can be a useful combination with a similar efficacy as KM for painful procedures in children.
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12
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Wang Y, Liu Q, Yu JN, Wang HX, Gao LL, Dai YL, Jin X, Zuo F, Liu J, Bai CF, Mu GX, Chai XM, Zhang YJ, Li YX, Yu JQ. Perceptions of parents and paediatricians on pain induced by bone marrow aspiration and lumbar puncture among children with acute leukaemia: a qualitative study in China. BMJ Open 2017; 7:e015727. [PMID: 28939570 PMCID: PMC5623544 DOI: 10.1136/bmjopen-2016-015727] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
OBJECTIVE To obtain in-depth insight into the perceptions of parents and paediatricians in China regarding current procedural pain management on bone marrow aspirations and lumbar punctures in paediatric haemato-oncology department. DESIGN, SETTING AND PARTICIPANTS This qualitative study was conducted in a 4500-bed university hospital in northwest China. To collect data, in-depth semistructured interviews were conducted with parents of children with acute leukaemia (n=12) and haemato-oncology paediatricians (n=11) using purposive sampling. Interviews were audiotaped and transcribed and subjected to thematic analysis. RESULTS The suffering of procedural pain among paediatric patients was not adequately recognised and properly treated at the paediatric haemato-oncology department. The current paediatric procedural pain management is inadequate for paediatric patients. Crucial factors were identified including lack of awareness about the damage of uncontrolled pain in children, parents' low supportive ability, the limited capacity to provide general analgesia by anaesthetists, inadequate knowledge in the usage of analgesia and sedation and lack of efficient analgesic for children's procedural pain. The participants strongly expected optimal interventions to improve paediatric procedural pain management. CONCLUSIONS The result suggested a perceived and actual poor management of paediatric procedural pain in haemato-oncology department in northwest China. A relevant pain management education programme for paediatricians and parents as well as an effective pain medication are urgently needed in northwest China. TRIAL REGISTRATION Chinese Clinical Trial Registry. Identifier: ChiCTR-INR-16007989.
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Affiliation(s)
- Yu Wang
- Nursing School, Ningxia Medical University, Yinchuan, China
| | - Qiang Liu
- Nursing School, Ningxia Medical University, Yinchuan, China
| | - Jia-Ning Yu
- Department of Paediatric Hematology-Oncology, General Hospital of Ningxia Medical University, Yinchuan, China
| | - Hai-Xia Wang
- Shanghai Mental Health Center, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Lu-Lu Gao
- Nursing School, Ningxia Medical University, Yinchuan, China
| | - Ya-Liang Dai
- Nursing School, Ningxia Medical University, Yinchuan, China
| | - Xin Jin
- Neurological Surgery Department, Ningxia People’s Hospital, Yinchuan, China
| | - Feng Zuo
- Department of Paediatric Hematology-Oncology, General Hospital of Ningxia Medical University, Yinchuan, China
| | - Juan Liu
- Nursing School, Ningxia Medical University, Yinchuan, China
| | - Cai-Feng Bai
- Nursing School, Ningxia Medical University, Yinchuan, China
| | - Guo-Xia Mu
- Nursing School, Ningxia Medical University, Yinchuan, China
| | - Xiao-Min Chai
- Nursing School, Ningxia Medical University, Yinchuan, China
| | - Yin-Juan Zhang
- Nursing School, Ningxia Medical University, Yinchuan, China
| | - Yu-Xiang Li
- Nursing School, Ningxia Medical University, Yinchuan, China
| | - Jian-Qiang Yu
- Department of Pharmacology, College of Pharmacy, Ningxia Medical University, Yinchuan, China
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Does Topical Anesthetic Reduce Pain During Intraosseous Pin Removal in Children? A Randomized Controlled Trial. J Pediatr Orthop 2016; 36:126-31. [PMID: 25730292 DOI: 10.1097/bpo.0000000000000408] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND The purpose of this study was to determine the effectiveness of topical liposomal lidocaine in reducing the pain perceived by children undergoing percutaneous intraosseous pin (PP) removal in the outpatient orthopaedic clinic. METHODS A triple-blinded, randomized, placebo-controlled clinical trial comparing topical liposomal lidocaine to a placebo was conducted at the Stollery Children's Hospital between September 2008 and February 2011. Subjects undergoing the removal of PP in the orthopaedic outpatient clinic between ages 3 and 16 years were recruited. A computer-generated variable-block randomization scheme was used to determine each subject's group assignment. Pain was recorded just before randomization and immediately after the procedure using the Oucher Scale (for subjects) and a 10-cm Visual Analog Scale (for parents and an observing orthopaedic technician). In a subset of individuals, follow-up telephone calls were made 24 hours postprocedure to inquire about any adverse event from the use of the topical liposomal lidocaine. Data were analyzed using the Student t test. RESULTS Of a total of 296 recruited subjects, complete data were available on 281 subjects (140 intervention and 141 control). There were no significant differences between the 2 groups with regards to baseline characteristics, including preprocedure pain scores. Although postprocedure pain scores demonstrated an increase in pain in both groups (2.3 points in the treatment group and 2.0 points in the placebo group), no statistically significant difference was seen in postprocedure pain scores between groups (P=0.81). No adverse events were observed or reported. CONCLUSIONS Topically applied liposomal lidocaine was not effective in reducing pain during this procedure, compared with a placebo. However, this study demonstrates that PP removal is a painful procedure in children. Given the large volume of patients who undergo this procedure and the long-term consequences of experiencing painful procedures in childhood, it is important to find safe and fast-acting methods to decrease procedural pain associated with PP removal.
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Prospective randomized crossover evaluation of three anesthetic regimens for painful procedures in children with cancer. J Pediatr 2013; 162:137-41. [PMID: 22883421 PMCID: PMC3529769 DOI: 10.1016/j.jpeds.2012.06.056] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2012] [Revised: 05/18/2012] [Accepted: 06/27/2012] [Indexed: 11/23/2022]
Abstract
OBJECTIVE To identify the most effective sedation regimen for bone marrow aspiration and lumbar puncture procedures with a prospective trial of 3 combinations of sedation/analgesia. STUDY DESIGN In this double-blind crossover study, we randomly assigned 162 children with acute lymphoblastic leukemia or lymphoblastic lymphoma to receive fentanyl 1 mcg/kg, fentanyl 0.5 mcg/kg, or placebo, in addition to propofol and topical anesthetic for 355 procedures. RESULTS We found no significant differences among the 3 regimens in the frequency of pain (pain score > 0) or severe pain (pain score ≥ 5) during recovery, or a >20% increase in hemodynamic/respiratory variables during anesthesia. Treatment with fentanyl 1 mcg/kg was associated with a lower frequency of movement during procedure compared with treatment with fentanyl 0.5 mcg/kg (P = .0476) or treatment with placebo (P = .0545). The placebo group required longer time to recover (median, 18 minutes) compared with the fentanyl 0.5 mcg/kg group (median, 9 minutes) (median difference 2.0, P = .007) and the fentanyl 1 mcg/kg (median 8 minutes), (median difference 2.0, P = .15). The placebo group also required larger total dose of propofol (median 5 mg/kg) compared with that of the fentanyl 1 mcg/kg group (median, 3.5 mg/kg) and the fentanyl 0.5 mcg/kg group (median 3.5 mg/kg) (median differences 1.5, P < .00005, in both comparisons). CONCLUSION The addition of fentanyl 1 mcg/kg to propofol for brief painful procedures reduces movement, propofol dose, and recovery time.
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Hockenberry MJ, McCarthy KS, Taylor OA, Hesselgrave J, Bernhardt MB, Daves M, Kamdar K. Using Improvement Science to Promote Evidence-Based Practice in a Childhood Cancer and Hematology Center. J Pediatr Oncol Nurs 2012; 29:5-13. [DOI: 10.1177/1043454211434203] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
A major children’s cancer and hematology center established a Quality Transformation (QT) Core to develop and monitor empirical outcomes that demonstrate excellence in clinical care. The QT Core, based on the Institute of Medicine’s domains of quality health care, aims to ensure that care is safe, effective, patient centered, timely, efficient, and equitable. Specific goals for the first year of the QT Core were to develop a team of improvement science experts, engage faculty and staff in QT initiatives, promote accountability for excellence in clinical care, and establish specific metrics to evaluate process, structure, and outcomes for QT Core projects. The purpose of this article is to discuss the successful development of a quality transformation core within a pediatric subspecialty and demonstrate the principles of improvement science through an actual quality transformation project designed to implement an evidence-based guideline for procedural sedation for children with cancer. The QT Core within this subspecialty was founded on principles of successful transformation of patient care that includes motivation to change, leaders committed to quality, active engagement of staff in meaningful problem-solving initiatives, alignment with organization goals with resource allocation, and integration to bridge boundaries throughout an organization. These key principles are demonstrated through the discussion of the development of the QT Core and implementation of an evidence-based procedure sedation guideline. Pediatric and pediatric subspecialty groups can be on the forefront of national initiatives that promote quality health care, exemplified by the QT Core developed within the cancer and hematology center.
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Affiliation(s)
| | | | | | | | | | | | - Kala Kamdar
- Baylor College of Medicine, Houston, TX, USA
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16
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Do topical anesthetics reduce periareolar injectional pain before sentinel lymph node biopsy? Am J Surg 2011; 202:707-11; discussion 711-2. [DOI: 10.1016/j.amjsurg.2011.06.040] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2011] [Revised: 06/28/2011] [Accepted: 06/28/2011] [Indexed: 11/23/2022]
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Alados-Arboledas F, Millán-Bueno P, Expósito-Montes J, de la Cruz-Moreno J, Pérez-Parras A, Arévalo-Garrido A. Seguridad y eficacia del propofol en perfusión continua para la realización de endoscopias digestivas altas diagnósticas en respiración espontánea. An Pediatr (Barc) 2011; 75:124-8. [DOI: 10.1016/j.anpedi.2010.11.012] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2010] [Revised: 11/18/2010] [Accepted: 11/22/2010] [Indexed: 11/30/2022] Open
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Perrot S, Laroche F, Marie P, Payen-Champenois C. Are there risk factors for musculoskeletal procedural pain? A national prospective multicentre study of procedural instantaneous pain and its recall after knee and spine injections. Joint Bone Spine 2011; 78:629-35. [PMID: 21441058 DOI: 10.1016/j.jbspin.2011.02.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2010] [Accepted: 02/03/2011] [Indexed: 10/18/2022]
Abstract
BACKGROUND Little is known about the risk factors for procedural pain during spinal and joint injections. METHODS In this prospective national multicentre study, procedural pain was investigated by rheumatologists who visited four consecutive patients undergoing synovial aspiration and infiltrations of the knee (K), and four consecutive patients undergoing spinal (S) injections. Pain assessments were carried out just before, during, and 48 hours after the procedure. RESULTS The 249 rheumatologists enrolled 1350 patients (720 K and 630 S; 64 ± 14 years, 64.6% female). Instantaneous procedure-induced pain was reported in 76.1% of cases, was generally mild (mean 2.6 ± 2.5 on 10) and not different between the two sites. The frequency of procedure-induced pain increased significantly with pain related to the underlying disease and level of anxiety before the procedure. Procedure-induced pain was recalled after 48 hours later by 66.2% of the patients, with an intensity of 2.4 ± 2.6. The recall of procedure-induced pain increased with pain due to the underlying condition, with the intensity of instantaneous procedure-induced pain, with the level of anxiety, but was less frequent if the patient underwent the procedure for the first time. Patients' and physicians' estimates of procedural pain were poorly concordant (kappa coefficient 0.45), physicians tended to overestimate the frequency of pain but to underestimate its intensity. CONCLUSION Procedural pain is common, but mild, in patients undergoing musculoskeletal injections. Instantaneous procedural pain and its recall 48 hours later depend principally on the level of underlying pain and anxiety, regardless of the injection site and the analgesic procedure performed.
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Affiliation(s)
- Serge Perrot
- Service de médecine interne et thérapeutique, Hôtel-Dieu, AP-HP, université Paris Descartes, Paris, France.
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Lechtzin N, Busse AM, Smith MT, Grossman S, Nesbit S, Diette GB. A randomized trial of nature scenery and sounds versus urban scenery and sounds to reduce pain in adults undergoing bone marrow aspirate and biopsy. J Altern Complement Med 2011; 16:965-72. [PMID: 20799901 DOI: 10.1089/acm.2009.0531] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES Bone marrow aspiration and biopsy (BMAB) is painful when performed with only local anesthetic. Our objective was to determine whether viewing nature scenes and listening to nature sounds can reduce pain during BMAB. DESIGN This was a randomized, controlled clinical trial. Adult patients undergoing outpatient BMAB with only local anesthetic were assigned to use either a nature scene with accompanying nature sounds, city scene with city sounds, or standard care. The primary outcome was a visual analog scale (0-10) of pain. Prespecified secondary analyses included categorizing pain as mild and moderate to severe and using multiple logistic regression to adjust for potential confounding variables. RESULTS One hundred and twenty (120) subjects were enrolled: 44 in the Nature arm, 39 in the City arm, and 37 in the Standard Care arm. The mean pain scores, which were the primary outcome, were not significantly different between the three arms. A higher proportion in the Standard Care arm had moderate-to-severe pain (pain rating ≥4) than in the Nature arm (78.4% versus 60.5%), though this was not statistically significant (p = 0.097). This difference was statistically significant after adjusting for differences in the operators who performed the procedures (odds ratio = 3.71, p = 0.02). CONCLUSIONS We confirmed earlier findings showing that BMAB is poorly tolerated. While mean pain scores were not significantly different between the study arms, secondary analyses suggest that viewing a nature scene while listening to nature sounds is a safe, inexpensive method that may reduce pain during BMAB. This approach should be considered to alleviate pain during invasive procedures.
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Affiliation(s)
- Noah Lechtzin
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, The Johns Hopkins University School of Medicine, Baltimore, MD, USA.
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Tomlinson D, von Baeyer CL, Stinson JN, Sung L. A systematic review of faces scales for the self-report of pain intensity in children. Pediatrics 2010; 126:e1168-98. [PMID: 20921070 DOI: 10.1542/peds.2010-1609] [Citation(s) in RCA: 375] [Impact Index Per Article: 25.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
CONTEXT Numerous faces scales have been developed for the measurement of pain intensity in children. It remains unclear whether any one of the faces scales is better for a particular purpose with regard to validity, reliability, feasibility, and preference. OBJECTIVES To summarize and systematically review faces pain scales most commonly used to obtain self-report of pain intensity in children for evaluation of reliability and validity and to compare the scales for preference and utility. METHODS Five major electronic databases were systematically searched for studies that used a faces scale for the self-report measurement of pain intensity in children. Fourteen faces pain scales were identified, of which 4 have undergone extensive psychometric testing: Faces Pain Scale (FPS) (scored 0-6); Faces Pain Scale-Revised (FPS-R) (0-10); Oucher pain scale (0-10); and Wong-Baker Faces Pain Rating Scale (WBFPRS) (0-10). These 4 scales were included in the review. Studies were classified by using psychometric criteria, including construct validity, reliability, and responsiveness, that were established a priori. RESULTS From a total of 276 articles retrieved, 182 were screened for psychometric evaluation, and 127 were included. All 4 faces pain scales were found to be adequately supported by psychometric data. When given a choice between faces scales, children preferred the WBFPRS. Confounding of pain intensity with affect caused by use of smiling and crying anchor faces is a disadvantage of the WBFPRS. CONCLUSIONS For clinical use, we found no grounds to switch from 1 faces scale to another when 1 of the scales is in use. For research use, the FPS-R has been recommended on the basis of utility and psychometric features. Data are sparse for children below the age of 5 years, and future research should focus on simplified measures, instructions, and anchors for these younger children.
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Affiliation(s)
- Deborah Tomlinson
- Child Health Evaluative Services, Hospital for Sick Children, Toronto, Ontario, Canada.
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Professional skills and competence for safe and effective procedural sedation in children: recommendations based on a systematic review of the literature. Int J Pediatr 2010; 2010:934298. [PMID: 20652062 PMCID: PMC2905952 DOI: 10.1155/2010/934298] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2009] [Accepted: 05/07/2010] [Indexed: 11/18/2022] Open
Abstract
Objectives. To investigate which skills and competence are imperative to assure optimal effectiveness and safety of procedural sedation (PS) in children and to analyze the underlying levels of evidence. Study Design and methods. Systematic review of literature published between 1993 and March 2009. Selected papers were classified according to their methodological quality and summarized in evidence-based conclusions. Next, conclusions were used to formulate recommendations. Results. Although the safety profiles vary among PS drugs, the possibility of potentially serious adverse events and the predictability of depth and duration of sedation define the imperative skills and competence necessary for a timely recognition and appropriate management. The level of effectiveness is mainly determined by the ability to apply titratable PS, including deep sedation using short-acting anesthetics for invasive procedures and nitrous oxide for minor painful procedures, and the implementation of non-pharmacological techniques. Conclusions. PS related safety and effectiveness are determined by the circumstances and professional skills rather than by specific pharmacologic characteristics. Evidence based recommendations regarding necessary skills and competence should be used to set up training programs and to define which professionals can and cannot be credentialed for PS in children.
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Safety of general anesthesia for lumbar puncture and bone marrow aspirate/biopsy in pediatric oncology patients. J Pediatr Hematol Oncol 2009; 31:465-70. [PMID: 19564738 DOI: 10.1097/mph.0b013e3181a974a1] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Painful short duration procedures such as bone marrow aspiration/biopsy and the lumbar puncture with or without intrathecal chemotherapy are frequently performed during the treatment of children with cancer. This study evaluated the frequency and severity of complications of bone marrow aspiration biopsy and lumbar puncture/intrathecal chemotherapy under general anesthesia. PATIENTS AND METHODS A prospective observational study was performed from November 2003 to August 2005. Patients with cancer younger than 21 years old, receiving treatment at the Pediatric Oncology Unity of Hospital de Clínicas de Porto Alegre, undergoing diagnostic and/or therapeutic short duration procedures carried out under general anesthesia in the outpatient surgery unit. RESULTS One hundred and thirty-seven patients were submitted to 423 procedures under general anesthesia. There were 61% boys, mean age of 7.5 years (0.2 to 21) and ASA II 98%. Eighty seven percent of the procedures were carried out in patients with leukemia or lymphoma. The majority of the procedures had no adverse events during intraoperative and postoperative periods. No procedure had to be suspended after it had begun. One patient had lumbar pain after the procedure and was admitted to the ward with suspected subdural bleeding, but this was not confirmed. No patient needed cardiopulmonary reanimation or treatment in the intensive care unit. CONCLUSIONS General anesthesia for short duration painful procedures in children undergoing treatment for malignancies is safe when carried out by trained professionals in outpatient clinical surgery unit.
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Mercadante S, Musso M, Villari P, Porretto F, Gioia M. Bedside anesthesia for painful procedures in onco-hematology. J Palliat Med 2008; 11:8-9. [PMID: 18370884 DOI: 10.1089/jpm.2007.0188] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Ellis JA, Villeneuve K, Newhook K, Ulrichsen J. Pain management practices for lumbar punctures: are we consistent? J Pediatr Nurs 2007; 22:479-87. [PMID: 18036468 DOI: 10.1016/j.pedn.2007.04.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2007] [Revised: 02/08/2007] [Accepted: 04/29/2007] [Indexed: 11/25/2022]
Abstract
In most pediatric oncology centers across Canada, it is now standard practice for children to be sedated for lumbar punctures (LPs). Although the use of sedation for LPs is well established in the pediatric oncology population, its use in other hospital units is not well documented. A patient record audit was completed to understand the types of pain management strategies used for LPs performed throughout a pediatric hospital. Fifty-nine patients aged between 3 days and 17 years underwent a total of 67 LPs. Pain management strategies varied among the different patient service units. Oncology patients were consistently sedated for an LP, whereas patients in the emergency department were less likely to be given any type of sedation. Recommendations are aimed at providing consistent best practice pain management for LPs throughout the hospital.
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Affiliation(s)
- Jacqueline A Ellis
- Department of Nursing, Children's Hospital of Eastern Ontario, Ottawa, ON, Canada.
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Breakey VR, Pirie J, Goldman RD. Pediatric and emergency medicine residents' attitudes and practices for analgesia and sedation during lumbar puncture in pediatric patients. Pediatrics 2007; 119:e631-6. [PMID: 17283179 DOI: 10.1542/peds.2006-0727] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE Analgesia and sedation for painful procedures in children are safe and effective, yet our experience is that pain management during lumbar puncture is suboptimal. We aim to document factors that influence residents' decisions to use analgesia and sedation during lumbar puncture and to compare pediatric and emergency medicine residents' practices. METHODS A survey was developed and sent to pediatric and emergency medicine residents from across Canada that inquired about clinical practices, learning experiences, current use of analgesia and sedation for lumbar puncture, and their clinical reasoning for using or abstaining from using analgesia and sedation. The Student's t and chi2 tests were used to compare the 2 resident groups. RESULTS Of the 374 residents to whom the survey was sent, 245 completed the survey. Pediatric residents reported performing lumbar punctures with no local anesthetic much more frequently. Pediatric residents used EMLA (AstraZeneca, Wilmington, DE) more frequently and injectable lidocaine less frequently. Pediatric residents used sedation for lumbar puncture at least once, more frequently than emergency medicine residents, and used mostly benzodiazepines. Both groups used ketamine at a similar rate. Pediatric residents reported that they witnessed adverse events of sedation more frequently. Although pediatric residents were responsible for teaching trainees the lumbar-puncture procedure significantly more frequently, they reported less educational opportunities during residency themselves and that they were less likely to recommend the use of local anesthetic during lumbar puncture when teaching the procedure. CONCLUSIONS Several significant differences exist between the pediatric residents and emergency medicine residents we surveyed. Pediatric residents were using less injectable local anesthesia for lumbar puncture in children and more sedation for the procedure and have had notably less training in the use of sedation. Pediatric residents have more teaching responsibilities than their emergency medicine residents colleagues and are inconsistently recommending the use of local anesthetics for lumbar puncture.
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Affiliation(s)
- Vicky R Breakey
- Division of Hematology and Oncology, Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada M5G 1X8
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Bilotta F, Ferri F, Soriano SG, Favaro R, Annino L, Rosa G. Lidocaine pretreatment for the prevention of propofol-induced transient motor disturbances in children during anesthesia induction: a randomized controlled trial in children undergoing invasive hematologic procedures. Paediatr Anaesth 2006; 16:1232-1237. [PMID: 17121552 DOI: 10.1111/j.1460-9592.2006.01970.x] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
BACKGROUND We examined the effect of lidocaine pretreatment before propofol administration on the incidence of transient motor disturbances and on propofol requirements for anesthesia induction in infants and children undergoing repeated painful diagnostic and therapeutic hematological procedures. METHODS A series of 358 children subgrouped according to the presence of a peripheral-vein or central venous catheter were randomly assigned to receive an intravenous dose of 2% lidocaine (2.0 mg.kg(-1)) or an equivalent volume of saline, 1 min before propofol (1.5-3.5 mg.kg(-1)) injected for anesthesia induction. RESULTS The incidence of spontaneous movements was significantly lower in patients pretreated with lidocaine than in those receiving placebo (2.5% vs 29%; P < 0.001, by chi-square test), as was the propofol induction dose (1.6 +/- 0.2 mg.kg(-1) vs 2.2 +/- 0.3 mg.kg(-1); P < 0.001) and pain at the injection site in patients peripheral-vein catheter (12% vs. 54%; P < 0.001). Lidocaine administration also improved children's acceptance as reported by parents on the Observational Scale of Behavioral Distress administered 2 h after the procedure (6.5 +/- 2.5 vs. 9.4 +/- 3.3; P < 0.001). Bouts of coughing developed significantly more frequently after lidocaine pretreatment than after placebo (62.5% vs. 17.5%; P < 0.001). CONCLUSIONS Because lidocaine pretreatment before the induction of propofol-based anesthesia decreases propofol-induced motor disturbances, lowers hypnotic requirements and reduces pain at the injection site, without inducing untoward events, thus improving children's and parental acceptance, it should become standard practice in infants and children undergoing repeated painful diagnostic and therapeutic hematological procedures.
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Affiliation(s)
- Federico Bilotta
- Department of Anesthesiology, Intensive Care and Pain Medicine, University of Rome La Sapienza, Rome, Italy.
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Niscola P, Scaramucci L, Romani C, Giovannini M, Maurillo L, del Poeta G, Cartoni C, Arcuri E, Amadori S, De Fabritiis P. Opioids in pain management of blood-related malignancies. Ann Hematol 2006; 85:489-501. [PMID: 16572325 DOI: 10.1007/s00277-005-0062-4] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2005] [Accepted: 12/01/2005] [Indexed: 10/24/2022]
Abstract
Opioids are basic analgesics used in the treatment of moderate to severe pain in patients affected by blood-related malignancies. They should be sequentially administered according to the World Health Organisation scale for cancer pain. Initial treatment and titration with opioids should be based on immediate-release preparations, to be administered at appropriate intervals in order to relieve pain and to satisfy the individual opioid requirement. Once a relatively good pain control has been achieved, a slow release formulation at equivalent doses can be given. Most patients can be adequately managed using oral formulation opioids. However, a small group, such as those presenting severe mucositis or requiring a rapid pain relief, should be managed by intravenous continuous infusion and/or by a patient-controlled analgesia system; while for patients in the community, there are distinct advantages to using the subcutaneous route. Other available routes of administration for opioids, can be used in selected circumstances, including rectal, transdermal, epidural, intrathecal and intramuscular. The invasive neuraxial route has a very limited role in patients with haematological malignancies, given the high risk of infection and bleeding. Through a close observation and a careful management, opioid-related side effects can be effectively prevented and treated. This article reviews the principles of opioid therapy and how opioids can be adapted for patients with pain due to haematological malignancies.
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Affiliation(s)
- Pasquale Niscola
- Hematology Division, Sant'Eugenio Hospital, Tor Vergata University, Via dell'Umanesimo 10, 00144, Rome, Italy.
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Barbi E, Badina L, Marchetti F, Vecchi R, Giuseppin I, Bruno I, Zanazzo G, Sarti A, Ventura A. Attitudes of children with leukemia toward repeated deep sedations with propofol. J Pediatr Hematol Oncol 2005; 27:639-43. [PMID: 16344667 DOI: 10.1097/01.mph.0000193474.06870.9c] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Procedural sedation is generally recommended for children requiring repeated painful diagnostic or therapeutic procedures. A child with leukemia undergoes an average of 20 procedures such as lumbar puncture and bone marrow aspiration through the course of illness. No data are currently available about the psychological impact of repeated sedations on children. The objective of this study was to evaluate the attitudes of patients with leukemia toward repeated deep sedations using propofol. A questionnaire addressing sedation-related distress was given to 30 children with leukemia. Procedure-related distress was evaluated using the Amended Observational Scale of Behavioural Distress. Another questionnaire concerning the same issues was given to an historical group of 39 children who had undergone painful procedures without sedation in previous years. Fear and distress were significantly reduced in the sedation group compared with the historical one. Fear of sedation was reported by 17% of children of this group. Distressed behavior was observed in 27%. In conclusion, sedation-related distress was observed in a subgroup of patients; in these cases, specific strategies could be considered to reduce sedation-related distress.
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Affiliation(s)
- Egidio Barbi
- Pediatric Sedation Unit, Pediatric Department, IRCCS Burlo Garofolo, University of Trieste, Trieste, Italy.
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Weber M, Schüz J, Kuball J, Gamm H, Jage J. Schmerzerfassung bei invasiven diagnostischen Prozeduren. Schmerz 2005; 19:513-6, 518-9. [PMID: 15815930 DOI: 10.1007/s00482-005-0393-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
BACKGROUND AND OBJECTIVE Pain measurement during diagnostic procedures is an accepted prerequisite for appropriate therapy. In this study, the agreement between rankings of pain intensity on a numerical and a verbal rating scale was analyzed. METHODS Patients attending a haematological outpatient clinic who underwent bone marrow puncture were requested to assess pain intensity perceived during the procedure on a elen-point numerical and a six-point verbal rating scale. RESULTS Analysis of patients' pain ratings in 263 bone marrow punctures showed a very good correlation between numerical and verbal rating scale (Spearman correlation coefficient 0,86). By means of a transfer instruction categories of the verbal rating scale were assigned to figures of the numerical rating scale (0 - no pain, 1 or 2 - mild p., 3, 4 or 5 moderate p., 6 or 7 severe p., 8, 9 or 10 - very severe and worst possible pain). The resulting transfer table showed a good agreement with a weighted kappa of 0.72 (95% confidence interval: 0.66-0.79). CONCLUSION Both scales can be employed efficiently for pain assessment during diagnostic procedures. Verbal categories can be assigned to numerical values and vice versa numerical values to verbal categories. However, in view of the inter-individual variations it appears appropriate to re-assure pain perception with each patient in order to avoid over- or undertreatment.
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Affiliation(s)
- M Weber
- III. Medizinische Klinik, Universitätskliniken Mainz.
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Abstract
OBJECTIVES To present the more frequent solid tumors, that require a general anaesthesia and to describe the particularities of the anaesthetic management. DATA SOURCES AND EXTRACTION The PUBMED database was searched for articles (1990 - 2005) combined with references analysis of major articles on the topics. DATA SYNTHESIS Neoplasma is the first cause of paediatric death. In children less than 5 years of age, neuroblastoma and nephroblastoma are the more frequent of the tumour. The incidence of each pathology is low. However a general anaesthesia is required in numerous situations: bone marrow aspiration and biopsy, central venous catheter insertion, various biopsies under computed tomography, ultrasound, thoracoscopy or laparoscopy, MRI scan, surgery and body radiation. The key points of successful anaesthetic management include complete preoperative evaluation together with the oncology paediatric team. Particularly, cardiotoxicity may result from chemotherapy and hypertension is frequently associated with neuroblastoma and nephroblastoma. Mediastinal location of lymphomas induced a significant risk of cardiopulmonary complications during induction of general anaesthesia. A peak expiratory flow rate or a tracheal cross-section area less than 50% of predicted values are contraindication to general anaesthesia. Cephalic rhabdomyosarcoma may be responsible of difficult airway management. Specific guidelines are available for platelet and red cell transfusion in paediatric oncology patients. Surgical antibioprophylaxis are adapted in immunodepressed children to a potential increased risk of postoperative infectious complications, according personal previous history, microbiological ecology and body bacterial flora. Dosage of anaesthetic agents takes into account denutrition, hydroelectrolytic disturbances and hypovolemia.
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Affiliation(s)
- C Lejus
- Service anesthésie-réanimation chirurgicale, Hôtel-Dieu-hôpital Mère-Enfant, CHU de Nantes, 44093 Nantes cedex, France.
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Abstract
Pediatric hospitalists should make pain assessment and treatment a high priority and a central part of their daily practice. Efforts at improving pain treatment in pediatric hospitals should be multidisciplinary and should involve combined use of pharmacologic and nonpharmacologic approaches. Although available information can permit effective treatment of pain for most children in hospitals, there is a need for more research on pediatric analgesic pharmacology, various nonpharmacologic treatments, and different models of delivery of care.
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Affiliation(s)
- Christine Greco
- Department of Anesthesia, Children's Hospital Boston, 300 Longwood Avenue, Room 555, Boston, MA 02115, USA
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O??Brien L, Kemp S, Dupuis L, Taddio A. Pharmacologic Management of Painful Oncology Procedures in Pediatrics. ACTA ACUST UNITED AC 2003. [DOI: 10.2165/00024669-200302060-00003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
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