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Acupuncture management of pain and emergence agitation in children after bilateral myringotomy and tympanostomy tube insertion

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To further investigate the effect of acupuncture in postoperative pain and emergence agitation in children undergoing bilateral myringotomy and tympanostomy tube (BMT) placement. BMT insertion surgery in children is routinely performed under general anesthesia and is associated with a high incidence of postoperative pain and agitation upon emergence from anesthesia. Various medications have been investigated to alleviate the pain and agitation, which have been accompanied by high incidence of adverse effects. In children, anecdotal reports suggest that acupuncture may offer postoperative analgesia. This prospective randomized controlled trial is to evaluate the effectiveness of acupuncture to control pain and agitation after initial bilateral myringotomy tube placement in 60 nonpremedicated children. Acupuncture was applied at points LI-4 (he gu) and HT-7 (shen men) immediately after induction of anesthesia. A single-blinded assessor evaluated postoperative pain and agitation using CHEOPS and emergence agitation scale. Pain and agitation scores were significantly lower in the acupuncture group compared to those in the control group at the time of arrival in the post anesthesia care unit and during the subsequent 30 min. Acupuncture treatment provided significant benefit in pain and agitation reduction. The median time to first postoperative analgesic (acetaminophen) administration was significantly shorter in the control group. The number of patients who required analgesia was considerably fewer in the acupuncture group than that in the control. No adverse effects related to acupuncture treatment were observed. Our study suggests that acupuncture therapy may be effective in diminishing both pain and emergence agitation in children after BMT insertion without adverse effects.
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Acupuncture management of pain and emergence
agitation in children after bilateral myringotomy
and tympanostomy tube insertion
YUAN-CHI LIN MD MPHMD MPH*, ROSALIE F. TASSONE MD MPHMD MPH*,
STEFAN JAHNG MDMD*, REZA RAHBAR MDMD, ROBERT S.
HOLZMAN MDMD*, DAVID ZURAKOWSKI PPhDhD‡AND
NAVIL F. SETHNA MDMD*
Departments of *Anesthesiology, Perioperative and Pain Medicine and Otorhinolarngology and
Director of Biostatistics, Department of Anesthesiology, Perioperative and Pain Medicine,
Children’s Hospital Boston, Harvard Medical School, Boston, MA, USA
Summary
Aim: To further investigate the effect of acupuncture in postoperative
pain and emergence agitation in children undergoing bilateral
myringotomy and tympanostomy tube (BMT) placement.
Background: BMTinsertionsurgeryinchildrenisroutinely performed under
general anesthesia and is associated with a high incidence of postoperative
pain and agitation upon emergence from anesthesia. Various medications
have been investigated to alleviate the pain and agitation, which have been
accompanied by high incidence of adverse effects. In children, anecdotal
reports suggest that acupuncture may offer postoperative analgesia.
Methods Materials: This prospective randomized controlled trial is to
evaluate the effectiveness of acupuncture to control pain and agitation
after initial bilateral myringotomy tube placement in 60 nonpremed-
icated children. Acupuncture was applied at points LI-4 (he gu) and
HT-7 (shen men) immediately after induction of anesthesia. A single-
blinded assessor evaluated postoperative pain and agitation using
CHEOPS and emergence agitation scale. Pain and agitation scores
were significantly lower in the acupuncture group compared to those
in the control group at the time of arrival in the post anesthesia care
unit and during the subsequent 30 min.
Results: Acupuncture treatment provided significant benefit in pain
and agitation reduction. The median time to first postoperative
analgesic (acetaminophen) administration was significantly shorter in
the control group. The number of patients who required analgesia was
considerably fewer in the acupuncture group than that in the control.
No adverse effects related to acupuncture treatment were observed.
Conclusion: Our study suggests that acupuncture therapy may be
effective in diminishing both pain and emergence agitation in children
after BMT insertion without adverse effects.
Keywords: pediatric acupuncture; pediatric pain; emergence agitation
Correspondence to: Y.-C. Lin, Medical Acupuncture Service, Department of Anesthesiology, Perioperative and Pain Medicine, Children’s
Hospital Boston, Harvard Medical School, 300 Longwood Avenue, Boston, MA 02115, USA (email: Yuan-chi.lin@childrens.harvard.edu).
Pediatric Anesthesia 2009 19: 1096–1101 doi:10.1111/j.1460-9592.2009.03129.x
1096 2009 Blackwell Publishing Ltd
Introduction
Bilateral myringotomy and tympanostomy tube
(BMT) placement is one of the most frequently
performed pediatric surgical procedure (1). The
procedure is brief and is commonly performed in
outpatient surgical units under general anesthesia. It
may be associated with the high incidence of pain
and emergence agitation (18–80%), often requiring
opioids and sedatives that may cause undesirable
side effects (2–4). Pharmacological agents, such as
acetaminophen, fentanyl, butorphanol, midazolam,
ketamine clonidine, and ketorolac, have been used
for the management of pain and emergence agita-
tion, have resulted in variable analgesic effectiveness
(50–80%), and have been shown to cause excessive
sleepiness (75%) and nausea and vomiting (4–33%)
(4–10). Acupuncture is reported to reduce pain and
produce sedation without causing such side effects.
We undertook this randomized controlled trial to
evaluate the effectiveness of acupuncture in reduc-
ing pain and emergence agitation in children under-
going BMT insertion surgery.
Methods
This trial was approved by the Institutional Review
Board at Children’s Hospital Boston. The inclusion
criteria were children classified under American
Society of Anesthesiologists physical status 1 or 2
and between the ages of 1 and 6 years who were
scheduled for BMT insertion surgery for the first
time. Exclusion criteria included the presence of
neurological diseases, developmental delay, or chil-
dren who had received analgesics and sedatives
within 36 h prior to surgery. After obtaining paren-
tal consent, patients were randomized into either the
acupuncture or the control group. Premedication
was not used in any of the patients. A standard
general anesthetic technique and monitoring were
used in all patients. Parental presence was allowed
during inhalational induction by mask with 70%
nitrous oxide in oxygen followed by incremental
increase in inspired sevoflurane. The concentration
of sevoflurane was increased gradually by 0.2%to
0.5%to achieve effective general anesthesia. Spon-
taneous ventilation was maintained, and the anes-
thetic depth was adjusted to each patient’s response
to surgical stimulation. Standard monitoring
included precordial stethoscope, electrocardiogram,
blood pressure, and percutaneous pulse oximetry.
Immediately after the induction of anesthesia and
prior to surgical stimulation, the patients in the
acupuncture group received acupuncture treatment.
A stainless steel acupuncture needle, 30 mm in
length and 0.18 mm in diameter (Serin Co, Shizuoka,
Japan), was used for the acupuncture. Acupuncture
treatment was applied bilaterally at acupuncture LI-
4 (he gu) and HT-7 (shen men) points (Figure 1) (11).
Each acupuncture needle was manually manipu-
lated for 10 s and kept in situ for a total time of
10 min. No electrical stimulation was applied. The
surgical intervention commenced immediately fol-
lowing the acupuncture treatment. The control
group received similar anesthetic management but
no acupuncture treatment.
During the procedure, the surgeon evaluated the
condition of the middle ear on a scale of 1–4 points:
1 = no fluid; 2 = serous fluid; 3 = pus; and 4 = thick
tenacious mucus (8). In the post anesthesia care unit
(PACU), a single-blinded observer evaluated levels
LI-4 (he gu)
HT-7
(shen men)
Figure 1
Acupuncture points: LI-4 (he gu) and HT-7 (shen men).
ACUPUNCTURE FOR PAIN AND EMERGENCE AGITATION 1097
2009 Blackwell Publishing Ltd, Pediatric Anesthesia,19, 1096–1101
of pain and agitation every 5 min until the patients
fulfilled the discharge criteria. Postoperative pain
was the primary outcome measure and was assessed
by the CHEOPS (12). Emergence agitation was
assessed on a 4-point scale: 1 = asleep, calm;
2 = mildly agitated but easily consolable; 3 = mod-
erately agitated or restless and inconsolable; and
4 = hysterical, crying inconsolably, or thrashing
(5,13).
When simple comfort measures such as the
presence of parents, physically holding the child,
or offering oral fluids did not console the patient;
oral acetaminophen 15 mgÆkg
)1
was administered. If
the patient remained inconsolable, an additional
dose of acetaminophen was given 30 min later. The
criteria for discharge were based on the 10-point
modified Aldrete Post Anesthesia Recovery Score
scale (14).
Statistical analysis
Age, weight, and surgical and anesthesia times were
compared between patients in the control and
acupuncture groups using the two-sample Student’s
t-test. The Pearson chi-square test was used to
compare the groups with respect to gender and the
distribution of right and left middle ear conditions.
Agitation and pain scores were assessed for normal-
ity using the Kolmogorov–Smirnov goodness-of-fit
test and were found to show significant departures
from a normal curve because of skewness (15).
Therefore, CHEOP pain scores (4–13 points) and
agitation scores (4-point scale) were compared with
each of seven postoperative time points (arrival
PACU, every 5 min through 30 min) using the
nonparametric Wilcoxon rank sum test (16). Box
plots were used to graphically represent the pain
and agitation data for the two groups at 5, 15, and
30 min to show the medians and interquartile ranges
(i.e., length of the box). Multivariate analysis of
variance was used to control for confounders
including age, weight, gender, surgical, and anes-
thesia duration to determine whether the effect of
acupuncture was independent of these variables.
The proportion of patients requiring additional
postoperative analgesia medications was compared
between the acupuncture and control groups
using Fisher’s exact test, and median time to
additional medications was compared using the
Mann–Whitney U-test. Statistical analysis was per-
formed using SPSSSPSS version 14.0 (SPSS, Inc., Chicago,
IL, USA). A conservative two-tailed value P< 0.01
was used as the criterion for statistical significance to
protect against false positive (Type I errors) because
of comparing the groups at multiple time points. A
power analysis indicated that the sample size of 30
patients in each group provided 80%power to
detect a difference of two points in CHEOP pain
scores and one point in agitation scores between the
control and acupuncture groups (version 7.0, nQuery
Advisor, Statistical Solutions, Saugus, MA, USA).
Statistical analysis was performed using SPSSSPSS
software (version 16.0, SPSS, Inc.).
Results
Sixty patients, 38 boys and 22 girls, with a mean age
2.2 ± 1.4 years were enrolled. There was no differ-
ence with respect to gender, age, weight, surgical
and anesthesia time, or the degree of middle ear
condition between patients who received acupunc-
ture treatment vs control (all P> 0.10, Table 1).
There were no postoperative complications related
to surgery, anesthesia, or acupuncture therapy.
Differences in postoperative CHEOP pain scores
were observed at arrival in PACU (P< 0.001) and at
each 5 min time point (all P< 0.01, Table 2). In
general, median pain scores were between 2 and 4
Table 1
Demographic characteristics, duration of surgery and anesthesia,
and middle ear conditions
Variable
Control
group
(n=30)
Acupuncture
group
(n=30) Pvalue
Age, years 2.0 ± 1.3 2.4 ± 1.6 0.36
Weight, kg 12.7 ± 3.3 14.2 ± 4.9 0.18
Gender (M F) 19 11 19 11 1.00
Duration of surgery, min 8.7 ± 3.2 9.9 ± 4.4 0.24
Duration of anesthesia, min 24.7 ± 6.3 23.7 ± 8.1 0.58
Right middle ear, number (%) 0.83
1 7 (23) 9 (30)
2 13 (43) 12 (40)
3 5 (17) 3 (10)
4 5 (17) 6 (20)
Left middle ear, number (%) 0.86
1 6 (20) 5 (17)
2 12 (40) 15 (50)
3 5 (17) 5 (17)
4 7 (23) 5 (17)
Continuous data are mean ± SDSD.
1098 Y.-C. LIN ET AL.
2009 Blackwell Publishing Ltd, Pediatric Anesthesia,19, 1096–1101
points lower in the acupuncture group and showed
significantly lower distributions at the seven time
points. Figure 2 illustrates the differences in postop-
erative pain scores between the two groups using
box plots at 5, 15, and 30 min.
Differences in postoperative agitation scores were
observed at arrival in PACU (P< 0.001) and at each
5 min time point (all P< 0.01, Table 3). In general,
median agitation scores were between 1 and 2 points
lower in the acupuncture group and showed signif-
icantly lower distributions at the seven time points.
Figure 3 illustrates the differences in postoperative
agitation scores between the two groups using box
plots at 5, 15, and 30 min.
Multivariate analysis of variance revealed no
other significant predictors of postoperative pain or
agitation scores and confirmed that acupuncture
treatment provided significant benefit in pain and
agitation reduction independent of age, weight,
gender, surgical and anesthesia duration, or middle
ear condition.
None of the 60 patients experienced postoperative
nausea or vomiting. Although there was no difference
in the duration of PACU stay, the need for postoper-
ative oral acetaminophen was significantly lower in
the acupuncture group (57%) when compared to the
Table 2
Postoperative pain scores during recovery for control and acu-
puncture groups
Time point
CHEOPS pain score
Pvalue*
Control
group
(n=30)
Acupuncture
group
(n=30)
Arrival post
anesthesia care unit
11 (6–13) 7 (4–12) <0.001
5 min 11 (6–13) 7 (4–12) <0.001
10 min 10 (6–13) 7 (4–12) 0.002
15 min 9 (4–13) 6 (4–12) 0.002
20 min 9 (5–12) 6 (4–11) 0.005
25 min 8 (4–12) 6 (4–11) <0.001
30 min 8 (5–12) 6 (4–9) <0.001
Data are median score with ranges shown in parentheses.
CHEOPS, Children’s Hospital of Eastern Ontario Pain Scale (4–13
points).
*Significant difference between the groups at each time point
(Mann–Whitney U-tests).
13
10
11
12 Acupuncture
Control group
7
8
9
CHEOP pain score
5
6
7
*
**
Postoperative assessment (minutes)
4
515 30
Figure 2
The differences in postoperative pain scores between the two
groups using box plots at 5, 15, and 30 min.
Table 3
Postoperative agitation scores during recovery for control and
acupuncture groups
Time point
Agitation score
Pvalue*
Control
group
(n=30)
Acupuncture
group
(n=30)
Arrival post
anesthesia care unit
3 (1–4) 1 (1–3) <0.001
5 min 3 (1–4) 1 (1–3) <0.001
10 min 3 (1–4) 1.5 (1–4) 0.007
15 min 3 (1–4) 1 (1–4) 0.003
20 min 2.5 (1–4) 1 (1–3) 0.004
25 min 2 (1–4) 1 (1–2) <0.001
30 min 2 (1–4) 1 (1–2) <0.001
Data are median score with ranges shown in parentheses.
*Significant difference between the groups at each time point
(Mann–Whitney U-tests).
4
3
Control group
Acupuncture
2
Agitation score
1***
Postoperative assessment (minutes)
5 15 30
Figure 3
The differences in postoperative agitation scores between the two
groups using box plots at 5, 15, and 30 min.
ACUPUNCTURE FOR PAIN AND EMERGENCE AGITATION 1099
2009 Blackwell Publishing Ltd, Pediatric Anesthesia,19, 1096–1101
control group (87%)(P= 0.02, Fisher’s exact test).
Median time to postoperative oral acetaminophen
was significantly shorter in the control group (6 h vs
17 h, P< 0.01, Mann–Whitney U-test).
Discussion
Pain following BMT insertion is common; with
50-70%of children requiring analgesics in the
immediate postoperative period (9,13). Several phar-
macological agents have been studied to reduce
postoperative pain and emergence agitation after
BMT insertion in randomized blinded controlled
trials. While administration of intranasal fentanyl
2 mcgÆkg
)1
with various inhaled agents produced a
reduction in agitation scores relative to controls,
fentanyl was associated with an increased incidence
of postoperative vomiting (5,17). Administration of
transnasal butorphanol (25 mcgÆkg
)1
) also signifi-
cantly reduces postoperative pain and agitation
scores, decreases the frequency of occurrence com-
pared to controls, and does not delay discharge time.
However, increased sedation is associated with its
use (6). Administration of intravenous (8) or intra-
muscular (9) ketorolac 1 mgÆkg
)1
following midazo-
lam premedication also markedly diminishes
emergence agitation and or pain behavior. Postop-
erative analgesia following intramuscular ketorolac
was similar to nasal butorphanol (25 mcgÆkg
)1
),
produced significantly better analgesia than oral
acetaminophen with codeine (1 mgÆkg
)1
), and the
lowest rate of vomiting (3%) (9). The use of intra-
venous clonidine (2 mcgÆkg
)1
) after anesthetic
induction for minor otologic and laser procedures
diminished emergence agitation with significant
sedation and delayed time to discharge (4). Our
study demonstrates that acupuncture can effectively
reduce the pain and emergence agitation following
BMT insertion surgery in children without any
adverse effects.
Emergence agitation is a short-lived, but a trou-
blesome clinical event. There are no effective
preventive strategies (18). Emergence agitation can
burden health care providers, increase family dis-
tress, expose the child to potential injury, and delay
recovery after anesthesia (19). Emergence agitation
occurs after 18–80%of children undergoing general
anesthetics and may also follow brief inhaled
anesthesia and nonpainful procedures (2–4). The
mechanism of agitation following general anesthesia
is unclear. There is no universal scale to assess
postoperative agitation that is developmentally and
psychometrically valid for evaluation of the children
of different ages (19). Therefore, studies evaluating
postoperative agitation have used various agitation
scales, including pain or anxiety assessment scales,
making comparisons of therapeutic interventions
among the studies difficult.
In adults, stimulation of the acupuncture point,
LI-4 (he gu), is shown to increase activity in the
periaqueductal gray and somatosensory cortex dur-
ing functional MRI study (20), and to relieve head-
ache and facial and ear pain (11). The second
acupuncture point used in this study, HT-7 (shen
men), is reported to reduce stress and agitation in
adult subjects (11). In animal model, activation of
acupuncture point HT-7 (shen men) produced a
significant reduction in the behavioral hyperactivity
associated with morphine tolerance through inhibi-
tion of central release of GABA
B
modulating dopa-
mine (21). In a study of health care personnel,
utilizing bilateral HT-7 (shen men) acupuncture
treatment once a week for 4 weeks produced
marked reduction in workplace-related psychologi-
cal stress in 16 out of 17 (94%) subjects (22).
In conclusion, acupuncture therapy at bilateral LI-
4 (he gu) and HT-7 (shen men) markedly reduces the
severity of postoperative pain and emergence agita-
tion in children after sevoflurane and nitrous oxide
anesthesia for BMT insertion without adverse
events. Further studies are needed to evaluate the
long-term effect of acupuncture therapy beyond the
immediate recovery time and compare its efficacy
and adverse effects to analgesic regimens in current
use for management of pain and agitation in chil-
dren undergoing BMT insertion.
Acknowledgements
The authors thank Yue-Pang Mok, MD (Ohio Pain
Services, Inc.) for his advice on selection of utilized
acupuncture points. The authors also express sincere
gratitude to the staff in the Department of Anesthe-
siology, Perioperative and Pain Medicine, the
Department of Otolaryngology, and Post Anesthesia
Care Unit of Children’s Hospital, Boston, for the care
they provided to the patients who participated in
this study.
1100 Y.-C. LIN ET AL.
2009 Blackwell Publishing Ltd, Pediatric Anesthesia,19, 1096–1101
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ACUPUNCTURE FOR PAIN AND EMERGENCE AGITATION 1101
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... Acupuncture therapy is considered an effective solution without pharmacological therapy and is reported to prevent EA without causing adverse events [10,11]; however, its efficacy remains controversial [12]. Acupuncture therapy is aimed at reducing symptoms and curing diseases by inserting fine needles into the skin to a certain depth at acupoints and manipulating them. ...
... Several studies have reported that acupuncture therapy effectively prevents EA in children; however, its mechanism of action remains unclear [10,11]. Measures that prevent EA focus on the management of pain, opioid withdrawal, and its inhibitory effect on the central nervous system. ...
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Research on acupuncture-related techniques in the perioperative period has been increasing in the last 20 years. In this research, a bibliometric analysis was performed to review the application of acupuncture for perioperative medicine and to evaluate the trends in research on the perioperative use of acupuncture. CiteSpace was used to analyze published papers on the perioperative use of acupuncture in the Web of Science database from 2001 to 2021. The research trends were evaluated based on the number of publications, keywords, journals, countries, institutions, and authors. Moreover, collaborative networks and reference co-citation network maps were analyzed. A total of 719 related studies were included in the analyses. The number of annual publications has gradually been increasing. Evidence-Based Complementary and Alternative Medicine published the most (49 articles). Regarding the cited journals, Anesthesia & Analgesia ranked first in terms of frequency (361), while Pain ranked first in terms of centrality (0.71). China (284) and the China Medical University (26) published the most. Wang Yu (21 articles) was the most active author, while Lee A (116) was the most co-cited author. The most co-cited reference was a meta-analysis of acupuncture for post-operative pain (212). The “post-operative cognitive dysfunction” cluster was new research directions that had recently emerged. Pain-related keywords had the highest frequency in keywords about indications. Research on perioperative acupuncture is a promising field, and more cooperation in global scientific research is needed. Our results may help researchers in identifying potential collaborators, research frontiers, and hot topics.
... In the present study, the types of discomfort included EA, dizziness, headache, and PONV within 24 hours after postanesthesia care unit (PACU). EA was evaluated on a 4-point scale: 1 = asleep, calm; 2 = mildly agitated but easily consolable; 3 = moderately agitated or restless and inconsolable; and 4 = hysterical, crying inconsolably, or thrashing [23,24]. In this study, EA was considered when the score was the same ≥ 2. ...
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Introduction: Strabismus surgery is most commonly performed on children under general anesthesia. However, few studies have focused on the postoperative discomfort in children after strabismus surgery. Methods: A single-center prospective observational study including 300 children who underwent strabismus surgery after general anesthesia was conducted. Patients’ characteristics, preoperative anxiety, surgical and anesthesia data, discomfort within 24 hours after postanesthesia care unit were recorded. Results: Approximately 61.33% of the children complained of at least one of the following types of discomfort. Multivariate analysis indicated that history of PONV (P=0.999), history of motion sickness (P<0.001, odds ratio [OR]=3.72), and surgery in the dominant eye (P=0.010, OR=2.00) were independent predictors of postoperative discomfort; age was an independent predictor of EA (P<0.001, OR=0.33); prism diopter≥40 was an independent predictor of headache (P=0.005, OR=5.53); age (P=0.020, OR=1.12) and history of motion sickness (P=0.001, OR=2.80) were independent predictors of dizziness; history of PONV (P=0.999), history of motion sickness (P=0.001, OR=2.63), and surgery of inferior oblique anterior transposition (IOAT) (P=0.004, OR=3.10) were independent predictors of PONV. Conclusion: Younger age, larger angle of strabismus, history of motion sickness, history of PONV, surgery on the dominant eye, and IOAT may be risk factors for postoperative discomfort.
... They demonstrated that some medications or methods to relieve postoperative pain, such as ketamine, dexmedetomidine, acupuncture management, and intraoperative auditory stimulation, can reduce the occurrence of EA in children. [35][36][37][38] Interestingly, age was not a risk factor in the logistic regression model, possibly because most of the patients in this study were of preschool age, and according to previous studies, preschool age is a risk factor. Moreover, contrary to the results of Hino et al's study, 21 the duration of anesthesia was not a risk factor in our study. ...
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Background: Emergence agitation (EA) has a negative effect on the recovery from general anesthesia in children. This study aimed to evaluate the effectiveness of intravenous ibuprofen in reducing the incidence of EA in children. Methods: This randomized, double-blind, placebo-controlled, single-center study analyzed data from patients aged 3-9 years undergoing tonsillectomy under general anesthesia with propofol and remifentanil. These patients were randomly assigned to receive either the ibuprofen or the placebo intraoperatively. The primary endpoint was a between-group difference in the incidence of EA at 15 min following extubation. EA was defined as Pediatric Anesthesia Emergence Delirium score ≥10. The secondary endpoint included the associated factors of EA. Results: Eighty-nine patients were included in the study. Ibuprofen decreased the incidence of EA at 15 min following extubation (8.9% in the treatment group vs 34.1% in the control group; odds ratio [OR], 0.261; 95% confidence interval [CI], 0.094-0.724; P=0.004). Compared with the control group, there was a significant reduction in the number of rescue fentanyl doses (P=0.045), and fewer patients experienced moderate to severe pain at 15 min following extubation in the treatment group (P=0.048). Upon logistic regression analysis, high modified Pediatric Anesthesia Behavior and pain scores following surgery were considered the risk factors related to EA (OR, 8.07; 95% CI, 1.12-58.07, P=0.038 and OR, 2.78; 95% CI, 1.60-4.82, P<0.001, respectively). Ibuprofen administration was the protective factor related to EA (OR, 0.05; 95% CI, 0.01-0.67, P=0.023). Conclusion: Intraoperative ibuprofen infusion can significantly reduce the incidence of EA following general anesthesia with propofol and remifentanil in children. Trial registration: The study was registered with the Chinese Clinical Trial Registry on 7 April 2021 (number: ChiCTR2100045128; https://www.chictr.org.cn/edit.aspx?pid=124595&htm=4).
Article
Objective To examine the effect of acupuncture-like transcutaneous electrical nerve stimulation (ACUTENS) on labor pain in nulliparous women.Methods This randomized clinical trial was conducted at Razi Hospital in Qazvin, Iran between January and July 2018. After the screening process, 144 out of 184 pregnant women were selected by convenience sampling and assigned to an intervention group or a control group by the block randomization method. The intervention group received ACUTENS at Hegu (LI4), Shenmen (HT7), Sanyinjiao (SP6), and Neimadian (Extra) during various stages of delivery in addition to routine labor care at the delivery room. For the control group, the same routine labor care was performed alone. The severity of pain was assessed in the two groups using the visual analog scale (VAS). The data were analyzed using R software (ver. 4.0.2) and repeated measurement analysis of variance.ResultsACUTENS reduced the mean score of pain intensity in the first stage of labor in the intervention group more than that in the control group (P<0.001). Also, the mean scores of pain intensity in the second stage of labor, episiotomy, and one hour after delivery in the intervention group were significantly lower than those in the control group (P<0.001).ConclusionACUTENS at Hegu (LI4), Shenmen (HT7), Sanyinjiao (SP6), and Neimadian (Extra) can decrease the intensity of labor pain in nulliparous women. It can be used as a non-pharmacological method for reducing pain in and after labor.
Chapter
Pain management for children after otolaryngologic procedures is challenging and even controversial. The importance of adequate pain control for children after surgery is well understood, but debates about analgesia protocols center on the risks of opioids for children with obstructive sleep apnea as well as potential bleeding risk with the use of nonsteroidal antiinflammatory drugs. In this chapter, we review perioperative pain management for the two most common procedures in pediatric otolaryngology: tympanostomy tube placement and tonsillectomy. We focus on special considerations in pediatric patients, pharmacologic and nonpharmacologic interventions, and the evidence supporting their efficacy and possible adverse effects.
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Background Emergence delirium (ED) is a significant problem in the post anesthesia care unit (PACU), resulting in dislodgement of medical devices, patient and staff injury, prolonged recovery, and parent dissatisfaction. Parental requests for the use of weighted blankets in the hospital setting have increased. However, while weighted blankets have shown potential as treatment for anxiety in adults and children, no studies have demonstrated their safe use with children in the hospital setting. Purpose To explore the safety of weighted blanket use with children in the PACU as an intervention for ED, a feasibility study was conducted. Design and Methodology: A convenience sample of 93 participants, aged three to 10 years were recruited. Watcha scores, vital signs, length of wear time, and reason for blanket removal were recorded for all patients. Results Eighty-five patients completed the study. Four participants experienced vital signs outside the defined safety parameters, with only one experiencing an adverse event (1.2%). This was consistent with the historic adverse event rate of 1% for the study site. Staff did not report issues with the use or cleaning of the blankets. Of interest, there was significant correlation between ED and suspected pain. Conclusion The study demonstrated weighted blanket use is safe and feasible with children in the hospital setting, Additional studies are needed to determine the effectiveness of weighted blankets as an intervention for ED and the impact pain may have on the severity and prevalence of ED.
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Purpose: Acupuncture ameliorates several pain disorders including postoperative pain. This can help to decrease the need for postoperative analgesics. We aimed to evaluate the effectiveness of acupuncture as an adjuvant scheme reduce both intraoperative and postoperative analgesia needs in children undergoing adenotonsillectomy. Methods: This was a randomized controlled single-blinded trial that was performed over sixty children scheduled for adenotonsillectomy. They were randomly allocated to either an intervention group that received general anesthesia plus acupuncture or a control group which received general anesthesia alone. The primary outcome was the measurement of postoperative pain scores. Secondary outcomes included measurement of time to the first request of postoperative analgesia, the number of children requesting postoperative analgesics in the first 2 hours, the incidence of postoperative complications including postoperative nausea and/or vomiting (PONV), and emergence agitation (EA). Results: AThe Wong-Baker FACES pain scores at rest and on swallowing were significantly lower in the intervention group than in the control group postoperatively. The time to the first request of postoperative analgesia was delayed in the intervention group versus the control group, with less number of patients who have requested additional analgesia during the first 2 hours postoperatively. Postoperative agitation was lower in the intervention group versus the control group patients. However, the incidence of PONV was not statistically different between study groups. Conclusion: Combined acupuncture with general anesthesia in children undergoing adenotonsillectomy provided better postoperative pain control with no adverse effects.
Chapter
Perioperative pain management has been a major discussion topic as narcotic abuse and overdose deaths have dramatically increased over recent decades. Otolaryngologists have a duty to provide adequate postoperative pain relief in a responsible manner. Analgesic regimens are dependent on patient factors including age, gender, pre-procedural pain, and, most importantly, surgical site and type of procedure. A majority of procedures in otolaryngology are appropriately managed through non-opioid alternatives, and there are high levels of evidence supporting local anesthetics, acetaminophen, nonsteroidal anti-inflammatory drugs (NSAIDs), and gabapentin use. These multimodal regimens enable effective pain control and decrease the number of opioids prescribed to patients.
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Prophylactic administration of analgesics before surgery can decrease the intraoperative anaesthetic requirement and decrease pain during the early postoperative period. In a doubleblind, placebocontrolled study involving 90 healthy ASA physical status I or II children undergoing bilateral myringotomy, we compared the postoperative analgesic effects of oral acetaminophen and ketorolac, when administered 30 min before induction of anaesthesia. Patients were randomized to receive saline (0.1 ml · kg-1), acetaminophen (10 mg · kg-1) or ketorolac (1 mg · kg-1) diluted in cherry syrup to a total volume of 5 ml. Anaesthesia was induced and maintained with halothane and nitrous oxide via a face mask. Postoperative pain was assessed by a blinded observer using an objective pain scale. The three study groups were similar with respect to demographic data, duration of anaesthesia and surgery, induction behaviour, oxygen saturation, incidence of postoperative emesis and, recovery times. The ketorolac group had lower postoperative pain scores and required less frequent analgesic therapy in the early postoperative period compared with the acetaminophen and placebo groups. In contrast, there were no differences in pain scores or analgesic requirements between the acetaminophen and the placebo groups. We conclude that the preoperative administration of oral ketorolac, but not acetaminophen, provided better postoperative pain control than placebo in children undergoing bilateral myringotomy.
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This double-blinded study was undertaken to prospectively evaluate the role of halothane and sevoflurane and the use of IV ketorolac on the anesthetic emergence in a group of children undergoing bilateral myringotomy with pressure equalization tube procedures. Two-hundred ASA physical status I and II patients were premedicated with nasal midazolam (0.2 mg/kg) and randomized to one of four groups (Group 1 - halothane and ketorolac; Group 2 - halothane and placebo; Group 3 - sevoflurane and ketorolac; Group 4 - sevoflurane and placebo). A blinded nurse observer characterized the quality of the anesthetic emergence and recorded the incidence of emesis and the use of pain medications in the recovery room. There were no differences in age, weight, previous anesthetic experience, or duration of anesthesia among the four groups. There was no difference in the incidence of emergence agitation for patients anesthetized with sevoflurane compared with halothane, regardless of whether they received ketorolac or placebo. Regardless of the anesthetic, the incidence of emergence agitation was significantly less in patients who received ketorolac compared with patients who received placebo. The incidence of emesis in the recovery room, the total 24-h incidence of emesis, and the use of at-home pain medications were similar in all four groups. Implications: We conclude that the incidence of emergence agitation in children undergoing ultrashort anesthetic procedures is similar for sevoflurane and halothane and that ketorolac markedly diminishes emergence agitation and/or pain behavior. (Anesth Analg 1999;88:34-8)
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Myringotomy with tube placement (BMT) is the most frequent surgical procedure performed in children. The purpose of this prospective, double-blinded study was to determine if 15 mg.kg-1 of acetaminophen (paracetamol) provides analgesia similar to that provided by ketorolac, 1 mg.kg-1, at a lower cost. One-hundred-and-thirty-two children, ages six months to nine years, scheduled for elective BMT were randomized to receive oral acetaminophen or ketorolac 30 min preoperatively. An Objective Pain Scale score was assessed upon arrival to the PACU and at five, ten and 20 min. Time of awakening, time of PACU and day surgery discharge and incidence of vomiting were recorded. Groups were comparable in demographics, side effects and time to discharge. Median pain scores were lower in the ketorolac group at five and ten min but no differences were seen at discharge nor in postdischarge analgesic requirements. Is ten min of better analgesia worth the cost of ketorolac? We conclude that the slight analgesic benefit from ketorolac does not justify its cost in this setting.
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More than 70% of children require analgesics after bilateral myringotomy and tube placement (BMT). Because anesthesia for BMT is generally provided by face mask without placement of an intravenous catheter, an alternative route for analgesia administration is needed. Transnasal butorphanol is effective in relieving postoperative pain in adults and children. The effectiveness of transnasal butorphanol for postoperative pain management in children undergoing BMT was studied. This double-blinded, placebo-controlled study compared the postoperative analgesic effects of transnasal butorphanol administered after the induction of anesthesia. Sixty children classified as American Society of Anesthesiologists physical status 1 or 2 who were aged 6 months or older and scheduled for elective BMT were randomized to receive transnasal placebo or 5, 15, or 25 microg/kg butorphanol. Postoperative pain was assessed using the Children's Hospital of Eastern Ontario Pain Scale (CHEOPS) on arrival in the postanesthesia care unit and at 5, 10, 15, 30, 45, and 60 min. The CHEOP scores were significantly less in the 25 microg/kg transnasal butorphanol group compared with controls. Significantly fewer children received rescue analgesia in the 25 microg/kg transnasal butorphanol group compared with controls (n = 1 and 8, respectively; P = 0.02). Transnasal butorphanol given in a dose of 25 microg/kg after induction of anesthesia provided adequate postoperative pain relief in children undergoing BMT.