Pediatric procedural sedation in African clinical settings: A mixed methods study of African providers' sedation practices

Background: Little is known about the practice of pediatric procedural sedation in Africa, despite being incredibly useful to the emergency care of children. This study describes the clinical experiences of African medical providers who use pediatric proceduralsedation, including clinical indications, medications, adverse events, training, clinical guideline use, and comfort level. The goals of this study are to describe pediatric sedation practices in resource-limited settings in Africa and identify potential barriers to the provision of safe pediatric sedation. Methods: This mixed methods study describes the pediatric procedural sedation practices of African providers using semi-structured interviews. Purposive sampling was used to identify key informants working in African resource-limited settings across a broad geographic, economic, and professional range. Quantitative data about provider background and sedation practices were collected concurrently with qualitative data about perceived barriers to pediatric procedural sedation and suggestions to improve the practice of pediatric sedation in their settings. All interviews were transcribed, coded, and analyzed for major themes. Results: Thirty-eight key informants participated, representing 19 countries and the specialties of Anesthesia, Surgery, Pediatrics, Critical Care, Emergency Medicine, and General Practice. The most common indication for pediatric sedation was imaging (42%), the most common medication used was ketamine (92%), and hypoxia was the most common adverse event (61%). Despite 92% of key informants stating that pediatric procedural sedation was critical to their practice, only half reported feeling adequately trained. The three major qualitative themes regarding barriers to safe pediatric sedation in their settings were: lack of resources, lack of education, and lack of standardization across sites and providers. Conclusions: The results of this study suggest that training specialized pediatric sedation teams, creating portable "pediatric sedation kits," and producing locally relevant pediatric sedation guidelines may help reduce current barriers to the provision of safe pediatric sedation in resource-limited African settings.

Pentazocine versus tramadol-paracetamol combination as analgesia in labor: A randomized controlled trial

Objectives: Labor should be a satisfactory experience and effective pain management should be employed as recommended by the American Congress of Obstetricians and Gynaecologists. In developing countries, pain management in labor is still a big challenge and the search for the ultimate labor analgesia is still ongoing. The objectives of the study were to determine whether the synergistic analgesic effect of the combination of tramadol and paracetamol will produce analgesia comparable to pentazocine with a better side effect profile. Material and Methods: This was a randomized controlled, double-blinded trial of tramadol-paracetamol combination versus pentazocine as labor analgesia and was carried out at the University of Abuja Teaching Hospital, Abuja, between June 2018 and March 2019. A total of 218 eligible parturients recruited at term, were counseled on labor analgesia, its benefits, and the options made available to them and educated on the pain scoring system. Parturients were allocated into two groups using computer-generated numbers with the WINPEPI software. Group A was given tramadol-paracetamol combination, while Group B received pentazocine, both at standard doses. Hourly pain scores, APGAR scores, labor duration, patients' satisfaction, and side effects were collated. The level of significance was set at <0.05. Results: Tramadol-paracetamol was administered to 109 (50.9%) while pentazocine was administered to105 (49.1%) of the study participants. The mean age in the tramadol-paracetamol group was 29.6 ± 4.8 years, and in the pentazocine group, it was 28.8 ± 4.5 years. The difference in pain scores on the visual analog scale was statistically significant at the 3rd and 4th h (P = 0.02 and 0.004), but not significant in the 1st and 2nd h (P = 0.05 and 0.22) in the two groups. Overall, the average pain score in the tramadol-paracetamol group was significantly higher compared to the pentazocine group (5.27 ± 1.86 vs. 4.72 ± 1.54; P = 0.02). The 1st and 5th min APGAR scores (P = 0.44 and 0.67, respectively) of neonates in the tramadol-paracetamol and pentazocine groups were comparable. Nausea and drowsiness occurred more frequently in the pentazocine group at P-values of 0.047 and 0.0015, respectively. There was no statistically significant difference in the duration of labor between the tramadol-paracetamol and pentazocine groups. not statistically significant, a higher proportion of parturients in the pentazocine group was satisfied compared with the tramadol-paracetamol group (71.4% vs. 63.3%; P = 0.13).Conclusion: This study showed that intravenous pentazocine provides better pain relief in labor, but the tramadol-paracetamol combination has fewer side effects

Perception douloureuse et moyens de lutte en hystéroscopie au cabinet / Pain perception and management during office hysteroscopy

Contexte & objectif. L'hystéroscopie a connu des avancées majeures ces dernières à différents points de vue. Elle est passée d'une procédure nécessitant une hospitalisation à une procédure ambulatoire, de même elle a quitté la salle d'opération pour rejoindre le cabinet de consultation. Mais, un des problèmes à ces progrès, c'est la gestion de la douleur au cours et après la procédure. La présente revue passe en revue les différents moyens, tant pharmacologiques que non pharmacologiques utilisés pour la réduction de la perception de la douleur au cours d'une hystéroscopie au cabinet. Méthodes. Il s'agissait d'une revue exhaustive de la littérature (Pubmed, Medline, cochrane library) concernant les méta-analyses, revues de la littérature et essais randomisés publiés sur le sujet et en anglais de 2003 à 2021. Conclusion. Plusieurs moyens avec une efficacité très variable sont proposés pour réduire la douleur au cours de l'hystéroscopie au cabinet. Les auteurs s'accordent sur le fait que la bonne maitrise de l'anatomie de la filière génitale féminine vue en hystéroscopie, l'approche vaginoscopique et la psychothérapie permettent de diminuer significativement la douleur au cours de l'hystéroscopie et donc d'en améliorer la tolérance sans nécessité une quelconque anesthésie ou analgésie

Comparison of the duration and quality of epidural analgesia between plain bupivacaine alone and plain bupivacaine with tramadol in lower limb orthopaedic surgeries

Background: This study was aimed at comparing the duration and quality of epidural analgesia between plain bupivacaine alone with plain bupivacaine and tramadol in lower limb orthopaedic surgeries. Method: This was a prospective randomized double blinded control study involving 74 ASA I and II patients scheduled for elective lower limb orthopaedic surgeries. Group A (n=37) received 19mls of 0.5% epidural plain bupivacaine with 1 ml of water for injection, while group B received 19mls of 0.5% epidural plain bupivacaine with 1ml (50mg) of preservative freetramadol. The duration of analgesia was from the time of epidural block to the time of rescue analgesia. While, the quality of block was measured with Visual Analogue Scale (VAS) and Bromage scale. Results: Thestudy ages were between 16-60years,consisting of 22(60%) male and 15(40%) female in group A, while in group B 20 (54%) were male and 17(46%) female. It showed the mean duration of analgesia were 189.05±21.92min and 254.19±32.78min in group A and B respectively with p <0.01.The intra-operative VAS scores between the two groups did not show any significant difference between study groups (P> 0.05).The differences of grades of motor block and maximum sensory block height were not statistically significant (P=0.26) among the study groups. Conclusion: The addition of 50mg (1ml) of tramadol to plain bupivacaine epidurally prolonged the duration of analgesia and improved the quality of analgesia when compared to the use of bupivacaine alone

An overview of analgesics: NSAIDs, paracetamol, and topical analgesics

Pain is a complex and unique experience. It encompasses several pathways, involving nociceptive signal generation (transduction) and propagation (transmission), as well as perception and modulation of the nociceptive stimuli. Nonsteroidal anti-inflammatory drugs (NSAIDs) primarily exert their analgesic effects through inhibition of cyclooxygenase (COX) enzymes, thereby attenuating prostaglandin synthesis. The COX-2 selective NSAIDs (coxibs) and aspirin have also been shown to reduce colorectal cancers,presumably by prostaglandin-inhibition mechanisms. Paracetamol appears to have both peripheral and central effects. The postulated mechanism for its peripheral effects is indirect COX inhibition, while the central effects are thought to be mediated by modulation of descending pain inhibition pathways. Topical analgesics are available in various formulations. The topical NSAIDs have the same mechanism of action as the systemic formulations, but with less systemic absorption and effects. The local anaesthetics provide a dense sensory block via inhibition of nerve impulse transmission, and are available in percutaneous and transdermal preparations. Capsicum is effective forneuropathic pain, and acts by stimulating and then desensitising peripheral sensory nerves

Emergency Centre-based paediatric procedural sedation: current practice and challenges in Cape Town

Background: The aims and objectives of this survey of the current practice of doctors working in Emergency Centres (ECs) in the Cape Town metropole was to assess clinical practice and attempt to identify obstacles to the practice of paediatric procedural sedation and analgesia (PPSA). This was considered essential to establish a baseline for quality assurance purposes and improvement. Methods: After institutional ethics approval, a cross-sectional descriptive study was performed in 25 ECs in both private and government sectors in Cape Town. Specific aspects of PPSA practice were analysed after the anonymous completion of a specifically designed questionnaire, by full-time doctors working at each EC. The doctors' grade and training, practice preferences, medication and use of monitoring, and any perceived challenges to performing PPSA were assessed. Results: Sixteen ECs agreed to be part of the study and 62 questionnaires were completed (a 64% response rate). Procedural sedation and analgesia was performed at all the participating ECs, by medical practitioners of varying experience. Doctors' awareness of unit protocols was inconsistent. Common indications were orthopaedic interventions, radiological investigations and surgical procedures. Medications used were similar in the responding units, but dosages varied. Monitoring was poor compared with local and international standards. The obstacles reported predominantly related to a lack of training and formal protocols. Conclusions: This study was the first to evaluate the practice of Emergency Centre paediatric procedural sedation and analgesia practice in a South African setting. The lack of a formal system of training and accreditation, for both doctors and facilities, and the need for institutional and nationwide PPSA guidelines were highlighted

Intravenous paracetamol ­ waste not, want not: a retrospective audit on the appropriate use of intravenous paracetamol at Universitas Academic Hospital Complex­Bloemfontein

Background: Paracetamol can be given both orally and intravenously (IV) with similar clinical efficacy, but the IV formulation is 360 times more expensive. IV paracetamol is therefore only recommended when the oral route is not available. This study investigated whether IV paracetamol was being used appropriately and whether there had been a change in prescribing patterns between 2008 and 2015 after the introduction and update of a prescribing protocol at an academic hospital complex in Bloemfontein, South Africa. Methods: A retrospective comparative audit of patient files was undertaken. The prescribing and administration habits of IV paracetamol were compared for two consecutive months, seven years apart, including 88 and 83 patients, respectively, who had received IV paracetamol. Results: IV paracetamol was administered appropriately in 37.5% of patients in 2008 and in 43.4% of patients in 2015 (p = 0.43). There was an improvement in the duration that IV paracetamol was prescribed for, which decreased from a median two days in 2008 to one day (p < 0.01) in 2015. In total, 55 (32.4%) patients had a concomitant oral and IV paracetamol prescription, of which 37 (21.6%) patients also received concomitant paracetamol administration. Twenty patients exceeded the 24-hour maximum dose. Seventeen patients weighed less than 40 kg; six of these patients (three paediatric and three adult) did not receive the correct weight adjusted dose of paracetamol, 15 mg/kg, resulting in excessive doses of paracetamol being administered (21­ 32.3 mg/kg). Conclusions: Patients are receiving IV paracetamol when the oral route is available; this is an unnecessary waste of money. Excessive doses of paracetamol were administered due to concomitant oral and IV paracetamol prescription and administration, and a failure to calculate dose of paracetamol according to body weight in low body weight patients. Further remedial interventions are therefore required

Evaluation du dispositif transdermique d'administration de fentanyl (Ionsisr) dans l'analgesie apres chirurgie urologique

La voie intraveineuse a ete longtemps privilegiee pour l'administration d'analgesiques en post operatoire; du fait de son caractere non invasif; la voie transdermique semble etre une alternative interessante. Objectif: Le but de ce travail est d'evaluer l'analgesie procure par le dispositif transdermique d'administration de fentanyl Ionsisr apres une chirurgie urologique; ainsi que la satisfaction des patients et des paramedicaux par rapport au produit. Methode: Il s'agit d'une etude prospective realisee sur une periode de deux mois concernant des patients adultes ayant beneficie d'une intervention urologique sous coelioscopie ou a ciel ouvert. Resultats et conclusion: Ionsysr seul a suffit a assurer l'analgesie pour 67de nos malades. Pour les 33restants se pose l'indication d'une prise en charge multimodale de la douleur. Ionsysr est en general bien accepte par les patients et le personnel paramedical en termes de facilite d'utilisation pour les patients et pour le peu de contrainte qu'il engendre pour le personnel paramedical

Analgésie post-opératoire : essai comparatif du kétoprofène et de la buprénorphine en chirurgie abdominale

Abstract: Une étude prospective randomisée en double aveugle d'un anti-inflammatoire (le kétoprofène) et d'un morphinique (la Buprénorphine) a permis de comparer leur efficacité antalgique. Cette étude a été réalisée sur 128 patients dont 72 ayant re‡u la Buprénorphine et 54 le Kétoprofène. Ces patients ont subi une chirurgie abdominale pour appendicite, hernie de l'aine, péritonite occlusion ou lithiase vésiculaire. Au réveil du patient, la douleur a été évaluée aux moyens de l'échelle verbale simple (EVS) et de l'échelle visuelle analogique (EVA). La première évaluation s'est faite au temps T0 avant l'injection de l'analgésique tiré au hasard : Kétoprofène 110 mg en IV; Buprénorphine 0,3 ml en S/C. Les évaluations post thérapeutiques se sont faites aux temps T15 mn, T 30 mn, T1h, T2h puis toutes les 2h jusqu'à la 12ème heure ; ensuite toutes les 6h jusqu'à la 48ème heure. L'analyse a porté sur l'évolution de la douleur en fonction du temps. Les résultats ont montré une réduction de l'intensité douloureuse initiale de 30 pour cent à la 15ème mn d'injection du produit dans chaque groupe. Le soulagement complet a été observé après la 30 ème heure avec le Kétoprofène et après la 36èmc heure avec la Buprénorphine. Nous avons constaté 70,8 pour cent de cas de somnolence avec la Buprénorphine contre 39,3 pour cent avec le Kétoprofène, soit une différence assez significative. Il a été également observé 26,8 pour cent de cas de brûlures locales avec le kétoprofène. En ce qui concerne l'appréciation globale du personnel soignant, nous avons observé : 70,8 pour cent de résultats excellents avec la Buprénorphine; 69,6 pour cent de résultats excellents avec le Kétoprofène. Pour l'appréciation globale du malade, nous avons noté : 95,8 pour cent de résultats excellent dans le groupe Buprénorphine; 92,8 pour cent de résultats excellents dans le groupe de Kétoprofène. Ces différences ne sont pas statistiquement significatives