RESUMEN
Two patients had a compartment syndrome after surgery at a remote site performed under a continuous lumbar infusion of a mixture of narcotic (fentanyl) and local anesthetic (bupivacaine 0.1%). Each patient had inadvertent excessive pressure applied to the limb distally and had no perception of pain in the presence of this analgesic combination. After the relief of this pressure from a sling or traction apparatus, each child had signs of a compartment syndrome, and this sensation of pathologic pain was not masked by the epidural infusion. A discussion of the literature questions the benefits of bupivacaine local anesthetic as a routine addition to epidural analgesia for orthopaedic surgery.
Asunto(s)
Analgesia Epidural/efectos adversos , Analgésicos Opioides/efectos adversos , Anestésicos Locales/efectos adversos , Bupivacaína/efectos adversos , Síndromes Compartimentales/etiología , Fentanilo/efectos adversos , Complicaciones Posoperatorias/etiología , Adolescente , Niño , Síndromes Compartimentales/diagnóstico , Humanos , Masculino , Complicaciones Posoperatorias/diagnóstico , Presión , Férulas (Fijadores)/efectos adversos , Tracción/efectos adversosRESUMEN
PURPOSE: The optimal dose of intravenous ketorolac tromethamine (ketorolac), a non-steroidal anti-inflammatory drug has not been determined in children. There are only limited published data on the use of intravenous ketorolac for paediatric analgesia. This study compares the analgesic and emetic effect of three different doses of ketorolac with morphine in paediatric dental surgical out-patients. METHODS: Following institutional approval and parental consent, 120 ASA I or II children, age 2-10 yr were randomized to four groups and received ketorolac 0.75, 1.0, and 1.5 mg.kg-1 or morphine 0.1 mg.kg-1 iv at induction of a standardized anaesthetic. At 15 and 30 min after arrival in the recovery room a blinded observer assessed pain using the Objective Pain Score (OPS). Twenty-four hours after surgery a telephone interview was carried out with a parent at home. RESULTS: There were no differences in demographic data, anaesthesia time, recovery and day-care unit time, OPS and postoperative analgesic requirements in the four groups. Postoperative vomiting in the first 24 hr occurred more frequently in the morphine group than in the other groups (P < 0.0166). No patient had excessive surgical bleeding. CONCLUSIONS: Ketorolac, in all doses studied (0.75, 1.0 and 1.5 mg.kg-1) was as effective an analgesic as morphine 0.1 mg.kg-1 given intravenously at induction to children having restorative dental surgery. Its use was associated with a significant reduction in the incidence of postoperative vomiting.
Asunto(s)
Analgesia , Analgésicos no Narcóticos/administración & dosificación , Analgésicos Opioides/administración & dosificación , Antiinflamatorios no Esteroideos/administración & dosificación , Antieméticos/administración & dosificación , Restauración Dental Permanente , Morfina/administración & dosificación , Dolor Postoperatorio/tratamiento farmacológico , Complicaciones Posoperatorias/prevención & control , Tolmetina/análogos & derivados , Trometamina/análogos & derivados , Vómitos/prevención & control , Niño , Preescolar , Femenino , Humanos , Lactante , Infusiones Intravenosas , Ketorolaco Trometamina , Masculino , Tolmetina/administración & dosificación , Trometamina/administración & dosificaciónRESUMEN
Although the recommended dose of rectal acetaminophen (25-30 mg.kg-1) is twice that for oral administration (10-15 mg.kg-1), the literature justifies the use of a higher dose when acetaminophen is administered via the rectal route. We measured venous plasma acetaminophen concentrations resulting from 45 mg.kg-1 of rectal acetaminophen in ten ASA 1, 15 kg paediatric patients undergoing minor surgery with a standardized anaesthetic. After induction of anaesthesia, a single 650 mg suppository (Abenol, SmithKline Beecham Pharma Inc.) was administered rectally. Plasma was sampled at t = 0, 15, 30, 45, 60, 90, 120, 180, 240 min in the first five patients and at t = 0, 30, 60, 90, 120, 180, 240, 300, 420 min in the subsequent five. Acetaminophen plasma concentrations were determined using a TDxFLx fluorescence polarization immunoassay (Abbott Laboratories, Toronto, Ontario). The maximum plasma concentration was 88 +/- 39 mumol.L-1 (13 +/- 6 micrograms.ml-1) and the time of peak plasma concentration was 198 +/- 70 min (mean +/- SD). At 420 min, the mean plasma concentration was 46 +/- 18 mumol.L-1 (7.0 +/- 0.9 micrograms.ml-1). No plasma concentrations associated with toxicity (> 800 mumol.L-1) were identified. A 45 mg.kg-1 rectal dose of acetaminophen resulted in peak plasma concentrations comparable with those resulting from 10-15 mg.kg-1 of oral acetaminophen at three hours after suppository insertion. It is concluded that the delayed and erratic absorption of acetaminophen after rectal administration leads to unpredictable plasma concentrations. Rectal acetaminophen will not be consistently effective for providing rapid onset of analgesia in children.