Guidelines regarding ineffective maintenance of organ functions (futile therapy) in paediatric intensive care units
Anesthesiology; Critical care; Futile therapy; Paediatric intensive care unit; Palliative care
In Poland, guidelines for the management of ineffective treatment of children in neonatal and paediatric departments developed by the Polish Neonatal Society and the Polish Paediatric Society, have been published. The specific problems of futile therapy in paediatric anaesthesiology and intensive care units should be defined and solved separately. For this purpose, the guidelines presented below were prepared. They present the principles for managing children for whom therapeutic options available in paedia-tric anaesthesiology and intensive care units have been exhausted and ineffectiveness of maintaining organ functions, i.e. futile therapy, has been suspected. The decision to withdraw futile therapy of a child is undoubtedly one of the most difficult for both doctors and parents, and for this reason, it should be made collectively, respecting the dignity of the child and his/her parents or legal representatives, and continuing the management aimed at relieving the child's pain and suffering, as well as minimising anxiety and fear. Due to the small amount of reliable evidence-based data, the guidelines constitute the consensus of the Group of Experts and are dedicated to minor patients treated in paediatric anaesthesiology and intensive care units.
Bartkowska-Śniatkowska A; Byrska-Maciejasz E; Cettler M; Damps M; Jarosz K; Mierzewska-Schmidt M; Migdał M; Ożóg-Zabolska I; Piotrowski A; Rawicz M; Świder M; Tałałaj M; Zielińska M
Anaesthesiology Intensive Therapy
2021
<a href="http://doi.org/10.5114/ait.2021.111451" target="_blank" rel="noreferrer noopener">10.5114/ait.2021.111451</a>
Validation of the Non-communicating Children's Pain Checklist-Postoperative Version
Child; Female; Humans; Male; Pain; Communication; Nurses; Facial Expression; Observer Variation; Predictive Value of Tests; Motor Activity; adolescent; Non-U.S. Gov't; Research Support; caregivers; Social Behavior; Behavior/physiology; Postoperative/diagnosis; Mental Retardation/psychology; Pain Measurement/methods/standards
BACKGROUND: This study evaluated the psychometric properties of the Non-communicating Children's Pain Checklist-Postoperative Version (NCCPC-PV) when used with children with severe intellectual disabilities. METHODS: The caregivers of 24 children with severe intellectual disabilities (aged 3-19 yr) took part. Each child was observed by one of their caregivers and one of the researchers for 10 min before and after surgery. They independently completed the NCCPC-PV and made a visual analog scale rating of the child's pain intensity for those times. A nurse also completed a visual analog scale for the same observations. RESULTS: The NCCPC-PV was internally reliable (Cronbach alpha = 0.91) and showed good interrater reliability. A repeated-measures analysis of variance indicated NCCPC-PV total and subscale scores were significantly higher after surgery and did not differ by observer. Postoperative NCCPC-PV scores correlated with visual analog scale ratings provided by caregivers and researchers, but not with those of nurses. A score of 11 on the NCCPC-PV, by caregivers, provided 0.88 sensitivity and 0.81 specificity for classifying children with moderate to severe pain. CONCLUSIONS: The NCCPC-PV displayed good psychometric properties when used for the postoperative pain of children with severe intellectual disabilities and has the potential to be useful in a clinical setting. The results suggest familiarity with an individual child with intellectual disabilities is not necessary for pain assessment.
2002
Breau LM; Finley GA; McGrath PJ; Camfield CS
Anesthesiology
2002
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Journal Article
<a href="http://doi.org/10.1097/00000542-200203000-00004" target="_blank" rel="noreferrer">10.1097/00000542-200203000-00004</a>
Frontiers in translational research: the etiology of incisional and postoperative pain
Humans; Pain; Anesthetics; Local/therapeutic use; Hyperalgesia/drug therapy/physiopathology; Postoperative/drug therapy/physiopathology
2002
Brennan TJ
Anesthesiology
2002
Article information provided for research and reference use only. PedPalASCNET does not hold any rights over the resource listed here. All rights are retained by the journal listed under publisher and/or the creator(s).
Journal Article
<a href="http://doi.org/10.1097/00000542-200209000-00003" target="_blank" rel="noreferrer">10.1097/00000542-200209000-00003</a>
A Randomized Study of the Effects of Single-dose Gabapentin versus Placebo on Postoperative Pain and Morphine Consumption after Mastectomy
Background: The anticonvulsant gabapentin has proven effective for neuropathic pain in three large placebo-controlled clinical trials. Experimental and clinical studies have demonstrated antihyperalgesic effects in models involving central neuronal sensitization. It has been suggested that central neuronal sensitization may play an important role in postoperative pain. The aim of the study was to investigate the effect of gabapentin on morphine consumption and postoperative pain in patients undergoing radical mastectomy. Methods: In a randomized, double-blind, placebo-controlled study, 70 patients received a single dose of oral gabapentin (1,200 mg) or placebo 1 h before surgery. Patients received patient-controlled analgesia with morphine at doses of 2.5 mg with a lock-out time of 10 min for 4 h postoperatively. Pain was assessed on a visual analog scale at rest and during movement, and side effects were assessed on a four-point verbal scale 2 and 4 h postoperatively. Results: Thirty-one patients in the gabapentin group and 34 patients in the placebo group completed the study. Gabapentin reduced total morphine consumption from a median of 29 (interquartile range, 21–33) to 15 (10–19) mg (P < 0.0001). Pain during movement was reduced from 41 (31–59) to 22 (10–38) mm at 2 h postoperatively (P < 0.0001) and from 31 (12–40) to 9 (3–34) mm at 4 h postoperatively (P 0.018). No significant differences between groups were observed with regard to pain at rest or side effects. Conclusion: A single dose of 1,200 mg oral gabapentin resulted in a substantial reduction in postoperative morphine consumption and movement-related pain after radical mastectomy, without significant side effects. These promising results should be validated in other acute pain models involving central neuronal sensitization.
2002
Dirks J; Fredensborg BB; Christensen D; Fomsgaard JS; Flyger H; Dah Jørgen B
Anesthesiology
2002
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Journal Article
<a href="http://doi.org/10.1097/00000542-200209000-00007" target="_blank" rel="noreferrer">10.1097/00000542-200209000-00007</a>
Modulation of peripheral endogenous opioid analgesia by central afferent blockade
Male; Analgesics; Animals; Rats; Injections; Immunohistochemistry; Spinal; Enkephalin; beta-Endorphin/metabolism; Wistar; Pain Threshold/drug effects; Neurons; Afferent/drug effects; Central Nervous System/drug effects; Endorphins/metabolism/physiology; Flow Cytometry; Foot/pathology; Inflammation/pathology; Methionine/metabolism; Morphine/administration & dosage/pharmacology; Opioid/administration & dosage/pharmacology; Peripheral Nerves/drug effects; Psychomotor Performance/drug effects
BACKGROUND: Peripheral tissue injury causes a migration of opioid peptide-containing immune cells to the inflamed site. The subsequent release and action of these peptides on opioid receptors localized on peripheral sensory nerve terminals causes endogenous analgesia. The spinal application of opioid drugs blocks the transmission of nociceptive information from peripheral injury. This study investigates the influence of exogenous spinal opioid analgesia on peripheral endogenous opioid analgesia. METHODS: Six and forty-eight hours after initiation of continuous intrathecal morphine infusion and administration of Freund's complete adjuvant into the hind paw of rats, antinociceptive and antiinflammatory effects were measured by paw pressure threshold, paw volume, and paw temperature, respectively. Inflammation and quantity of opioid-containing cells were evaluated by immunocytochemistry and flow cytometry. Cold water swim stress-induced endogenous analgesia was examined 24 h after discontinuation of intrathecal morphine administration. RESULTS: Intrathecal morphine (10 micro g/h) resulted in a significant and stable increase of paw pressure threshold ( P 0.05). At 48 but not at 6 h after Freund's complete adjuvant, the number of beta-endorphin-containing cells and cold water swim-induced antinociception were significantly reduced in intrathecal morphine-treated rats compared with those treated with intrathecal vehicle ( P< 0.05). CONCLUSIONS: These findings suggest an interplay of central and peripheral mechanisms of pain control. An effective central inhibition of pain apparently signals a reduced need for recruitment of opioid-containing immune cells to injured sites.
2003
Schmitt TK; Mousa SA; Brack A; Schmidt DK; Rittner HL; Welte M; Schafer M; Stein C
Anesthesiology
2003
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Journal Article
<a href="http://doi.org/10.1097/00000542-200301000-00030" target="_blank" rel="noreferrer">10.1097/00000542-200301000-00030</a>
Mobilization of opioid-containing polymorphonuclear cells by hematopoietic growth factors and influence on inflammatory pain
Male; Animals; Rats; Biomarkers of Pain; Inflammation/complications; RNA; Pain Measurement/drug effects; Radioimmunoassay; Pain/drug therapy/physiopathology; Wistar; Neutrophils/metabolism; Messenger/biosynthesis; DNA Primers; Reverse Transcriptase Polymerase Chain Reaction; Flow Cytometry; Cell Adhesion Molecules/pharmacology; Cell Separation; Chemokines/biosynthesis; Chemotaxis; Granulocyte-Macrophage Colony-Stimulating Factor/pharmacology; Hindlimb/physiology; Leukocyte/drug effects; Light; Narcotics/metabolism/pharmacology; Stem Cell Factor/pharmacology
BACKGROUND: Leukocytes can control inflammatory pain by secretion of opioid peptides, stimulated by cold-water swimming or local injection of corticotropin-releasing factor, and subsequent activation of opioid receptors on peripheral sensory neurons. This study investigated whether mobilization of polymorphonuclear cells (PMN) by granulocyte colony-stimulating factor (G-CSF) and stem cell factor (SCF) enhances immigration of opioid-containing PMN and peripheral opioid analgesia in rats with Freund complete adjuvant-induced hind paw inflammation. METHODS: In circulating PMN of rats treated with G-CSF+SCF and sham-treated rats, opioid peptide content was measured by radioimmunoassay. Expression of adhesion molecules (CD62L, CD49d, CD18), in vitro migration in the Boyden chamber, and infiltrating leukocytes were analyzed by flow cytometry. Chemokine messenger RNA transcription was quantified by LightCycler polymerase chain reaction. Paw pressure threshold was measured at baseline, after cold-water swimming, and after injection of corticotropin-releasing factor. RESULTS: G-CSF+SCF treatment increased circulating PMN (11-fold, P 0.05). CONCLUSIONS: G-CSF+SCF mobilized circulating opioid-containing PMN but had a minor influence on cell migration and peripheral analgesia, probably because of the low expression of chemokines in the inflamed paw and one of the decreased beta-endorphin content in PMN.
2004
Brack A; Rittner HL; Machelska H; Beschmann K; Sitte N; Schafer M; Stein C
Anesthesiology
2004
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Journal Article
<a href="http://doi.org/10.1097/00000542-200401000-00024" target="_blank" rel="noreferrer">10.1097/00000542-200401000-00024</a>
Tissue monocytes/macrophages in inflammation: hyperalgesia versus opioid-mediated peripheral antinociception
Male; Analgesics; Animals; Rats; Biomarkers of Pain; Injections; Pain Measurement/drug effects; Freund's Adjuvant; Wistar; Flow Cytometry; Foot/pathology; Opioid/administration & dosage/pharmacology; Clodronic Acid/pharmacokinetics/pharmacology; Fentanyl/administration & dosage/pharmacology; Heat; Hyperalgesia/chemically induced/pathology/psychology; Inflammation/chemically induced/pathology; Liposomes; Macrophages/pathology; Monocytes/pathology; Non-Narcotic/pharmacokinetics/pharmacology; Pressure
BACKGROUND: Opioid-containing leukocytes migrate to peripheral sites of inflammation. On exposure to stress, opioid peptides are released, bind to opioid receptors on peripheral sensory neurons, and induce endogenous antinociception. In later stages of Freund's complete adjuvant-induced local inflammation, monocytes/macrophages are a major opioid-containing leukocyte subpopulation, but these cells also produce proalgesic cytokines. In this study, the role of tissue monocytes/macrophages in hyperalgesia and in peripheral opioid-mediated antinociception was investigated. METHODS: After intraplantar injection of Freund's adjuvant, leukocyte subpopulations and opioid-containing leukocytes were analyzed by flow cytometry in the inflamed paw in the presence or absence of monocyte/macrophage depletion by intraplantar injection of clodronate-containing liposomes (phosphate-buffered saline and empty liposomes served as controls). Paw volume was measured with a plethysmometer. Hyperalgesia was determined by measuring heat-induced paw withdrawal latency and paw pressure threshold. Paw pressure threshold was also measured after swim stress and injection of fentanyl. RESULTS: At 48 and 96 h of inflammation, it was found that (1). monocytes/macrophages were the largest leukocyte subpopulation (> 55% of all leukocytes) and the predominant producers of opioid peptides (71-77% of all opioid-containing leukocytes in the paw), (2). clodronate-containing liposomes depleted monocytes/macrophages by 30-35% (P 0.05), and (4) opioid-containing leukocytes and swim stress but not fentanyl-induced antinociception were significantly decreased by clodronate-containing liposomes (P 0.05, all by t test; opioid-containing cells and swim stress-induced increase of paw pressure threshold were reduced by 35-42% and 20%, respectively). CONCLUSION: Partial depletion of tissue monocytes/macrophages impairs peripheral endogenous opioid-mediated antinociception without affecting hyperalgesia.
2004
Brack A; Labuz D; Schiltz A; Rittner HL; Machelska H; Schafer M; Reszka R; Stein C
Anesthesiology
2004
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Journal Article
<a href="http://doi.org/10.1097/00000542-200407000-00031" target="_blank" rel="noreferrer">10.1097/00000542-200407000-00031</a>
Self-administration of intravenous analgesics
Equipment and Supplies; Injections; Hospital; Analgesics/administration & dosage; Intravenous/instrumentation; Self Medication/instrumentation
1970
Forrest WH; Smethurst PW; Kienitz ME
Anesthesiology
1970
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Journal Article
<a href="http://doi.org/10.1097/00000542-197009000-00023" target="_blank" rel="noreferrer">10.1097/00000542-197009000-00023</a>
Pharmacokinetics of methadone in children and adolescents in the perioperative period
Child; Analgesics; Methadone; Narcotics; adolescent; Opioid; Antitussive Agents; Biological Transport; Kinetics; Perioperative Care; Pharmacokinetics
Introduction Previous studies by Gourlay and coworkers1-3 have demonstrated that in adults undergoing surgery, methadone has slow elimination and a very long duration of effective analgesia. For children, intramuscular injections are a major source of distress in the peri-operative period. If methadone behaves in children as it does for adults, then use of methadone intravenously should provide a steady analgesic effect. For these reasons, we have undertaken studies of methadone in children and adolescents undergoing major surgery. Methods Fifteen children and adolescents, ages 1-18 years were enrolled with informed parental and patient consent according to procedures approved by the institutional Human Studies committee. Enrollment was restricted to patients requiring prolonged surgery (greater than 3 hours) and placement of arterial cannulae or multiple venous cannulae. Included in the studey were 3 one-year olds, 2 two-year olds and 2 three-year olds. Following tracheal intubation and line placement, methadone (0.2 mg/kg) was administered via rapid intravenous bolus. Heparinized plasma samples for methadone assay were obtained at approzimately 1, 2, 3, 4, 7, 10, and 30 minutes and 1, 3, 6, 12, 18, 24, 48, and 72 hours. Methadone assay (gas-liquid chromatography with mass spectrometry) yielded a lower detection limit of 5 ng/ml; for several patients the final 1-4 points fell below the detection limit and were excluded from analysis. Concentration versus time curves were fitted to a bioexponential equation using nonlinear least-squares. Results Kinetic parameters are summarized in Table 1. It is apparent that in children and adolescents ages 1 to 18 years, methadone has very prolonged elimination and a low clearance rate. For this population, regression analysis showed no dependence of half-lives or normalized volumes and clearances on patient age or weight. Areas under the concentration-versus-time curves from the equation parameters and from the trapezoid rule (model-independent) agreed to within 4%. Discussion Methadone has not been studied previously for post-operative pain in children. Observation of the patients in this study and of 16 additional children suggests that methadone provides prolonged analgesia; many children remained comfortable and required no analgesia for 12-36 hours post-operatively. Studies in progress are directed at testing these impressions via double-blinded administration and formal pain assessment scales. If these studies confirm that methadone's dynamics as well as kinetics are similar in children and adults, then peri-operative administration would be a safe, inexpensive and convenient means for providing prolonged analgesia and decreasing the use of painful intramuscular narcotic injections in children following major surgery. In adults ages 29-69 years, there was a positive correlation between age and beta half life. In the present study, we found no dependence of elimination half-life or normalized clearance on age for patients ages 1-18. The mean value for elimination half-life in the present study, 19.2 hours, is indistinguishable from that of the youngest adults in the previous study. As with adults, there is substantial variability among children in the rates and volumes of methadone distribution and elimination. It therefore seems prudent to follow an approach similar to that used in adults with titration to clinical effect. To date, at least 40 children have received methadone (via blinded or unblinded administration) in this fashion without requiring naloxone or assisted ventilation postoperatively. Further study is required before these conclusions can be extrapolated to newborns and very young infants.
1987
Berde CB; Sethna NF; Holzman RS; Reidy P; Gondek EJ
Anesthesiology
1987
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Journal Article
<a href="http://doi.org/10.1097/00000542-198709001-00519" target="_blank" rel="noreferrer">10.1097/00000542-198709001-00519</a>
Opioid peptide-expressing leukocytes: identification, recruitment, and simultaneously increasing inhibition of inflammatory pain
Male; Pain Measurement; Analgesia; Animals; Rats; beta-Endorphin/blood; Biomarkers of Pain; Pain/physiopathology; Immunohistochemistry; Radioimmunoassay; Biomarkers Reference List; Wistar; Antibodies; Antigens; CD45/isolation & purification; Fluorescent Dyes; Hematopoietic Stem Cells/immunology; Immunomagnetic Separation; Inflammation/chemically induced/metabolism/pathology; Leukocytes/metabolism; Lymphocytes/immunology; Monoclonal/pharmacology; Opioid Peptides/biosynthesis
BACKGROUND: Inflammatory pain can be effectively controlled by an interaction of opioid receptors on peripheral sensory nerve terminals with opioid peptides released from immune cells upon stressful stimulation. To define the source of opioid peptide production, we sought to identify and quantify populations of opioid-containing cells during the course of Freund's complete adjuvant-induced hind paw inflammation in the rat. In parallel, we examined the development of stress-induced local analgesia in the paw. METHODS: At 2, 6, and 96 h after Freund's complete adjuvant inoculation, cells were characterized by flow cytometry using a monoclonal pan-opioid antibody (3E7) and antibodies against cell surface antigens and by immunohistochemistry using a polyclonal antibody to beta-endorphin. After magnetic cell sorting, the beta-endorphin content was quantified by radioimmunoassay. Pain responses before and after cold water swim stress were evaluated by paw pressure thresholds. RESULTS: In early inflammation, 66% of opioid peptide-producing (3E7+) leukocytes were HIS48+ granulocytes. In contrast, at later stages (96 h), the majority of 3E7+ immune cells were ED1+ monocytes or macrophages (73%). During the 4 days after Freund's complete adjuvant inoculation, the number of 3E7+ cells increased 5.6-fold (P < 0.001, Kruskal-Wallis test) and the beta-endorphin content in the paw multiplied 3.9-fold (P < 0.05, Kruskal-Wallis test). In parallel, cold water swim stress-induced analgesia increased by 160% (P < 0.01, analysis of variance). CONCLUSIONS: The degree of endogenous pain inhibition is proportional to the number of opioid peptide-producing cells, and distinct leukocyte lineages contribute to this function at different stages of inflammation. These mechanisms may be important for understanding pain in immunosuppressed states such as cancer, diabetes, or AIDS and for the design of novel therapeutic strategies in inflammatory diseases.
2001
Rittner HL; Brack A; Machelska H; Mousa SA; Bauer M; Schafer M; Stein C
Anesthesiology
2001
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Journal Article
<a href="http://doi.org/10.1097/00000542-200108000-00036" target="_blank" rel="noreferrer">10.1097/00000542-200108000-00036</a>
Young Children's Ability To Report On Past, Future, And Hypothetical Pain States: A Cognitive-developmental Perspective
Declarative Memory; Randomized-trial; Mental Time-travel; Recall; Needle Pain; Child; Clinical Neurology; Age-children; Cognitive-development; Medical Procedures; Attention; Self-report; Memory; Pain Assessment; Intensity; Neurosciences; Anesthesiology; Self
Children are at times asked by clinicians or researchers to rate their pain associated with their past, future, or hypothetical experiences. However, little consideration is typically given to the cognitive-developmental requirements of such pain reports. Consequently, these pain assessment tasks may exceed the abilities of some children, potentially resulting in biased or random responses. This could lead to the over- or under-treatment of children's pain. This review provides an overview of factors, and specifically the cognitive-developmental prerequisites, that may affect a child's ability to report on nonpresent pain states, such as past, future, or hypothetical pain experiences. Children's ability to report on past pains may be influenced by developmental (age, cognitive ability), contextual (mood state, language used by significant others), affective and pain-related factors. The ability to mentally construct and report on future painful experiences may be shaped by memory of past experiences, information provision and learning, contextual factors, knowledge about oneself, cognitive coping style, and cognitive development. Hypothetical pain reports are sometimes used in the development and validation of pain assessment scales, as a tool in assessing cognitive-developmental and social-developmental aspects of children's reports of pain, and for the purposes of training children to use self-report scales. Rating pain associated with hypothetical pain scenarios requires the ability to recognize pain in another person and depends on the child's experience with pain. Enhanced understanding of cognitive-developmental requirements of young children's pain reports could lead to improved understanding, assessment, and treatment of pediatric pain.
Jaaniste T
Pain
2016
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DOI: 10.1097/j.pain.0000000000000666