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1.
Curr Opin Anaesthesiol ; 36(3): 295-300, 2023 Jun 01.
Artigo em Inglês | MEDLINE | ID: mdl-36815521

RESUMO

PURPOSE OF REVIEW: In 1989, the United Nations passed the 'Convention on the Rights of the Child' (UNCRC) and, among others claimed the highest attainable standard of health for children and consequently the highest level of safety and quality in paediatric anaesthesia. SAFETOTS (Safe Anesthesia For Every Tot, www.safetots.org ), an initiative of international active paediatric anaesthetists, has derived 10 rights, the '10 R' of children undergoing anaesthesia care, which are critical for the well being of the child. RECENT FINDINGS: The current situation in paediatric anaesthesia care in Europe does not always meet the requirements demanded by the UNCRC. Anaesthesia-related complications in children are still persistent. Anaesthesiologists are frequently asked to provide care for newborns, infants and small children without having sufficient child-specific expertise, resulting in an increased morbidity and mortality. SUMMARY: This article will explain these statutes of children's rights and their implications for everyday paediatric anaesthesia. Furthermore, it will also express the institutional and political changes that are needed to guarantee children their right to enjoy the highest attainable standard of health.


Assuntos
Anestesia , Nações Unidas , Lactente , Criança , Recém-Nascido , Humanos , Anestesia/efeitos adversos , Europa (Continente)
3.
Anaesthesist ; 71(4): 255-263, 2022 04.
Artigo em Alemão | MEDLINE | ID: mdl-35347357

RESUMO

In 1989 the United Nations passed the "United Nations Convention on the Rights of the Child" (UNCRC) and, among others, demanded the highest attainable standard of health for children. Safe Anesthesia for Every Tot (SAFETOTS, www.safetots.org ), an association of internationally active pediatric anesthetists, has derived 10 rights, the 10 R's, which are of essential importance for the pediatric anesthetic practice. The first right (R1) postulates: "Children have the right to enjoy the highest possible standard of health. Children below the age of three years in particular should be treated by experienced anesthesiologists with profound and continuous training and regular activity in pediatric anesthesia. Children with significant comorbidities and those who need highly specialized or major interventions benefit from specialized pediatric anesthesia in pediatric centers". The current situation in pediatric anesthesia care in Germany, Austria and Switzerland does not always meet the requirements demanded by the UNCRC. Anesthesia-related complications are approximately 10 times more frequent in children than in adults. In contrast to adults, children who are injured during anesthesia are often healthy. Severe complications in pediatric anesthesia have a mortality that is several times higher than in adult anesthesia. There are hardly any statistics on this for German-speaking countries but corresponding cases frequently occur in the context of expert opinions in liability litigation and in the press. Anesthesiologists are often charged with the anesthetic care of newborns, infants and small children without having sufficient child-specific expertise, which results in morbidity and mortality. In some places, only a few babies per year undergo general anesthesia in clinics without a specialized pediatric anesthesia team or a small number of infant anesthesia cases are divided among a large number of anesthesiologists. These case numbers are not even sufficient to maintain a single pediatric anesthesiologist in training in this age group.Changes are needed to guarantee children the right to enjoy the highest attainable standard of health. We need decision-makers, politicians and professional representatives who rethink and who are willing to implement the UNCRC. This includes changing the current financing of hospitals in order that the quality actually provided is financed. The "pay for performance" must change to "pay for quality". In addition to broad basic pediatric care, all complex forms of pediatric treatment must be carried out in specialized pediatric centers, particularly for small and severely ill children.Significant improvement can be achieved at the local level by reorganization, bundling of pediatric surgical interventions within a clinical unit together with the concentration on a dedicated team.


Assuntos
Anestesia , Anestesiologia , Adulto , Anestesia/métodos , Anestesiologistas , Anestesiologia/educação , Anestesistas , Criança , Pré-Escolar , Alemanha , Humanos , Lactente , Recém-Nascido
4.
Eur J Anaesthesiol ; 38(9): 908-915, 2021 09 01.
Artigo em Inglês | MEDLINE | ID: mdl-33009187

RESUMO

BACKGROUND: Surgical craniosynostosis repair in children is associated with massive blood loss and significant transfusion of blood products. Fibrinogen concentrate is claimed to be useful in reducing blood loss and transfusion requirements. OBJECTIVE: We investigated whether prophylactic administration of fibrinogen concentrate will reduce blood loss and transfusion requirements during paediatric craniofacial surgery. DESIGN: Randomised, placebo-controlled, double-blind clinical trial. SETTING: University medical centre. PATIENTS: A total of 114 infants and children up to 25 months of age (median age 10 months). INTERVENTION: Surgical craniosynostosis repair by calvarial remodelling was performed in each patient. Patients were randomised to receive prophylactic fibrinogen concentrate (Haemocomplettan P) at a mean dose of 79 mg kg-1 body weight or placebo. MAIN OUTCOME MEASURES: Primary outcome was the volume of transfused blood products. Secondary outcomes were peri-operative blood loss, duration of surgery, length of stay in the paediatric ICU, length of hospital stay, postoperative complications and adverse effects of fibrinogen concentrate infusion. RESULTS: No significant differences (P < 0.05) were found in the volume of transfused blood products (median 29 ml kg-1 body weight vs. 29 ml kg-1 body weight), intra-operative estimated blood loss (45 vs. 46 ml kg-1), calculated blood loss (57 vs. 53 ml kg-1), or postoperative blood loss (24 vs. 24 ml kg-1) between the intervention and placebo groups. In addition, duration of surgery, length of stay in the paediatric ICU, hospital stay and complications were not significantly different between the two groups. CONCLUSION: During surgical craniosynostosis repair in young children, prophylactic administration of high-dose fibrinogen concentrate did not reduce the amount of transfused blood products or decrease peri-operative blood loss. TRIAL REGISTRATION: National Trial Register (NTR2975) and EudraCT (2011-002287-24).


Assuntos
Craniossinostoses , Hemostáticos , Perda Sanguínea Cirúrgica/prevenção & controle , Criança , Pré-Escolar , Craniossinostoses/cirurgia , Método Duplo-Cego , Fibrinogênio , Humanos , Lactente
5.
Paediatr Anaesth ; 28(7): 588-596, 2018 07.
Artigo em Inglês | MEDLINE | ID: mdl-29851190

RESUMO

Inspired by the Choosing Wisely initiative, a group of pediatric anesthesiologists representing the German Working Group on Paediatric Anaesthesia (WAKKA) coined and agreed upon 10 concise positive ("dos") or negative ("don'ts") evidence-based recommendations. (i) In infants and children with robust indications for surgical, interventional, or diagnostic procedures, anesthesia or sedation should not be avoided or delayed due to the potential neurotoxicity associated with the exposure to anesthetics. (ii) In children without relevant preexisting illnesses (ie, ASA status I/II) who are scheduled for elective minor or medium-risk surgical procedures, no routine blood tests should be performed. (iii) Parental presence during the induction of anesthesia should be an option for children whenever possible. (iv) Perioperative fasting should be safe and child-friendly with shorter real fasting times and more liberal postoperative drinking and enteral feeding. (v) Perioperative fluid therapy should be safe and effective with physiologically composed balanced electrolyte solutions to maintain a normal extracellular fluid volume; addition of 1%-2.5% glucose to avoid lipolysis, hypoglycemia, and hyperglycemia, and colloids as needed to maintain a normal blood volume. (vi) To achieve safe and successful airway management, the locally accepted airway algorithm and continued teaching and training of basic and alternative techniques of ventilation and endotracheal intubation are required. (vii) Ultrasound and imaging systems (eg, transillumination) should be available for achieving central venous access and challenging peripheral venous and arterial access. (viii) Perioperative disturbances of the patient's homeostasis, such as hypotension, hypocapnia, hypothermia, hypoglycemia, hyponatremia, and severe anemia, should not be ignored and should be prevented or treated immediately. (ix) Pediatric patients with an elevated perioperative risk, eg, preterm and term neonates, infants, and critically ill children, should be treated at institutions where all caregivers have sufficient expertise and continuous clinical exposure to such patients. (x) A strategy for preventing postoperative vomiting, emergence delirium, and acute pain should be a part of every anesthetic procedure.


Assuntos
Anestesia/métodos , Pediatria/métodos , Criança , Alemanha , Humanos , Lactente , Recém-Nascido , Sociedades Médicas
7.
BMC Med ; 14: 35, 2016 Feb 23.
Artigo em Inglês | MEDLINE | ID: mdl-26904977

RESUMO

Clinical pathways (CPWs) are a common component in the quest to improve the quality of health. CPWs are used to reduce variation, improve quality of care, and maximize the outcomes for specific groups of patients. An ongoing challenge is the operationalization of a definition of CPW in healthcare. This may be attributable to both the differences in definition and a lack of conceptualization in the field of clinical pathways. This correspondence article describes a process of refinement of an operational definition for CPW research and proposes an operational definition for the future syntheses of CPWs literature. Following the approach proposed by Kinsman et al. (BMC Medicine 8(1):31, 2010) and Wieland et al. (Alternative Therapies in Health and Medicine 17(2):50, 2011), we used a four-stage process to generate a five criteria checklist for the definition of CPWs. We refined the operational definition, through consensus, merging two of the checklist's criteria, leading to a more inclusive criterion for accommodating CPW studies conducted in various healthcare settings. The following four criteria for CPW operational definition, derived from the refinement process described above, are (1) the intervention was a structured multidisciplinary plan of care; (2) the intervention was used to translate guidelines or evidence into local structures; (3) the intervention detailed the steps in a course of treatment or care in a plan, pathway, algorithm, guideline, protocol or other 'inventory of actions' (i.e. the intervention had time-frames or criteria-based progression); and (4) the intervention aimed to standardize care for a specific population. An intervention meeting all four criteria was considered to be a CPW. The development of operational definitions for complex interventions is a useful approach to appraise and synthesize evidence for policy development and quality improvement.


Assuntos
Procedimentos Clínicos/normas , Atenção à Saúde/normas , Projetos de Pesquisa/normas , Viés , Medicina Baseada em Evidências , Humanos , Terminologia como Assunto
8.
BMC Med Res Methodol ; 12: 80, 2012 Jun 18.
Artigo em Inglês | MEDLINE | ID: mdl-22709274

RESUMO

BACKGROUND: The purpose of this article is to report on the quality of the existing evidence base regarding the effectiveness of clinical pathway (CPW) research in the hospital setting. The analysis is based on a recently published Cochrane review of the effectiveness of CPWs. METHODS: An integral component of the review process was a rigorous appraisal of the methodological quality of published CPW evaluations. This allowed the identification of strengths and limitations of the evidence base for CPW effectiveness. We followed the validated Cochrane Effective Practice and Organisation of Care Group (EPOC) criteria for randomized and non-randomized clinical pathway evaluations. In addition, we tested the hypotheses that simple pre-post studies tend to overestimate CPW effects reported. RESULTS: Out of the 260 primary studies meeting CPW content criteria, only 27 studies met the EPOC study design criteria, with the majority of CPW studies (more than 70 %) excluded from the review on the basis that they were simple pre-post evaluations, mostly comparing two or more annual patient cohorts. Methodologically poor study designs are often used to evaluate CPWs and this compromises the quality of the existing evidence base. CONCLUSIONS: Cochrane EPOC methodological criteria, including the selection of rigorous study designs along with detailed descriptions of CPW development and implementation processes, are recommended for quantitative evaluations to improve the evidence base for the use of CPWs in hospitals.


Assuntos
Procedimentos Clínicos/normas , Medicina Baseada em Evidências , Guias como Assunto , Avaliação de Processos e Resultados em Cuidados de Saúde , Projetos de Pesquisa/normas , Viés , Ensaios Clínicos como Assunto , Humanos , Tempo de Internação , Metanálise como Assunto , Ensaios Clínicos Controlados Aleatórios como Assunto , Reprodutibilidade dos Testes , Medição de Risco , Viés de Seleção
9.
Eval Health Prof ; 35(1): 3-27, 2012 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-21613244

RESUMO

This paper is a summary version of the previously published Cochrane review. It may increase the reach of the topic to health researchers and practitioners and encourage further discussion. The systematic review aims to summarize the evidence and assess the effect of clinical pathways on professional practice, patient outcomes, length of hospital stay, and hospital costs. The authors searched the Database of Abstracts of Reviews of Effectiveness, the Effective Practice and Organisation of Care Register, the Cochrane Central Register of Controlled Trials and bibliographic databases including MEDLINE, EMBASE, CINAHL, NHS EED, and Global Health. Twenty-seven studies considering a total of 11,398 participants were included for analysis. The main results were a reduction in in-hospital complications (odds ratio 0.58: 95% CI [0.36, 0.94] and improved documentation (odds ratio 11.95: 95% CI [4.72, 30.30]) associated with clinical pathways. Considerable variation in study design and settings prevented statistical pooling of results for length of stay (LOS) and hospital costs. The authors concluded that clinical pathways are associated with reduced in-hospital complications and improved documentation.

10.
Eval Health Prof ; 35(1): 43-6, 2012 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-21613246

RESUMO

The commentary provided by Vanhaecht et al. from the European Pathways Association (EPA) questions whether conclusions derived from the review of effects of clinical pathways in hospitals are appropriate. They provide some methodological discussion that indicates a poor appreciation of the detailed content of the review as published in the Cochrane Library and a lack of understanding of the methodological requirements for complex interventions of the Cochrane Effective Practice and Organisation of Care (EPOC) group. In addition, Vanhaecht et al. misrepresent some important points from the review relating to the intervention reviewed. The critical commentary offered by Vanhaecht et al. is a misrepresentation of the process and content of the review and suggests they have not taken the time and effort to thoroughly read and understand this comprehensive review.

11.
Artigo em Alemão | MEDLINE | ID: mdl-20539963

RESUMO

Induction of anesthesia can be very distressing for children. This may lead to a lack of cooperation and refusal. The knowledge about the reasons of this behaviour is important to develop strategies and techniques to minimize the preoperative stress. Adequate preparation and the use of anxiolytic premedication are important modules. Non-pharmacological interventions are interesting and could be an alternative to sedative drugs in the future.


Assuntos
Anestesia , Recusa do Paciente ao Tratamento , Ansiedade/terapia , Criança , Humanos , Hipnóticos e Sedativos , Pré-Medicação , Fatores de Risco , Estresse Psicológico/terapia
12.
Cochrane Database Syst Rev ; (3): CD006632, 2010 Mar 17.
Artigo em Inglês | MEDLINE | ID: mdl-20238347

RESUMO

BACKGROUND: Clinical pathways are structured multidisciplinary care plans used by health services to detail essential steps in the care of patients with a specific clinical problem. They aim to link evidence to practice and optimise clinical outcomes whilst maximising clinical efficiency. OBJECTIVES: To assess the effect of clinical pathways on professional practice, patient outcomes, length of stay and hospital costs. SEARCH STRATEGY: We searched the Database of Abstracts of Reviews of Effectiveness (DARE), the Effective Practice and Organisation of Care (EPOC) Register, the Cochrane Central Register of Controlled Trials (CENTRAL) and bibliographic databases including MEDLINE, EMBASE, CINAHL, NHS EED and Global Health. We also searched the reference lists of relevant articles and contacted relevant professional organisations. SELECTION CRITERIA: Randomised controlled trials, controlled clinical trials, controlled before and after studies and interrupted time series studies comparing stand alone clinical pathways with usual care as well as clinical pathways as part of a multifaceted intervention with usual care. DATA COLLECTION AND ANALYSIS: Two review authors independently screened all titles to assess eligibility and methodological quality. Studies were grouped into those comparing clinical pathways with usual care and those comparing clinical pathways as part of a multifaceted intervention with usual care. MAIN RESULTS: Twenty-seven studies involving 11,398 participants met the eligibility and study quality criteria for inclusion. Twenty studies compared stand alone clinical pathways with usual care. These studies indicated a reduction in in-hospital complications (odds ratio (OR) 0.58; 95% confidence interval (CI) 0.36 to 0.94) and improved documentation (OR 13.65: 95%CI 5.38 to 34.64). There was no evidence of differences in readmission to hospital or in-hospital mortality. Length of stay was the most commonly employed outcome measure with most studies reporting significant reductions. A decrease in hospital costs/ charges was also observed, ranging from WMD +261 US$ favouring usual care to WMD -4919 US$ favouring clinical pathways (in US$ dollar standardized to the year 2000). Considerable heterogeneity prevented meta-analysis of length of stay and hospital cost results. An assessment of whether lower hospital costs contributed to cost shifting to another health sector was not undertaken.Seven studies compared clinical pathways as part of a multifaceted intervention with usual care. No evidence of differences were found between intervention and control groups. AUTHORS' CONCLUSIONS: Clinical pathways are associated with reduced in-hospital complications and improved documentation without negatively impacting on length of stay and hospital costs.


Assuntos
Procedimentos Clínicos , Custos Hospitalares , Tempo de Internação , Avaliação de Processos e Resultados em Cuidados de Saúde , Prática Profissional , Procedimentos Clínicos/economia , Procedimentos Clínicos/organização & administração , Procedimentos Clínicos/normas , Humanos , Avaliação de Processos e Resultados em Cuidados de Saúde/organização & administração , Avaliação de Processos e Resultados em Cuidados de Saúde/normas , Prática Profissional/economia , Prática Profissional/organização & administração , Prática Profissional/normas
15.
Thromb Haemost ; 98(1): 172-7, 2007 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-17598010

RESUMO

The transfusion of fresh-frozen plasma (FFP) is suggested to minimize dilution coagulopathy when applied instead of colloids during paediatric craniofacial surgery (pCFS). We prospectively compared plasmatic haemostaseologic function between volume replacement with FFPs versus human albumin (HA) in a pilot study. Thirty infants with primary craniosynostosis were scheduled for pCFS. In 15 of those, FFPs were available from the identical donor as for packed red blood cells (pRBC), and were thus employed for intraoperative volume replacement. The remaining 15 infants were infused with HA-5% instead. Haemoglobin(Hb)-values, global coagulation parameters (activated partial thromboplastin time-aPTT; prothrombin time-PT), selected clotting factors (F) (VIII, XI, XIII), antithrombin-AT, fibrinolytic factors (fibrinogen; plasminogen; alpha2-antiplasmin-alpha2A), and activation parameters (thrombin-antithrombin-complex-TAT; plasmin-antiplasmin-complex-PAP; D-dimers) were assessed and compared between both groups after induction of anaesthesia, before transfusion of pRBC, and at the end of surgery. Patients and treatment characteristics were balanced between both groups. Prolongation of aPTT and decreases of PT, FXI, FXIII, AT3, and fibrinolytic factors were more pronounced in the HA-group. Increases in F VIII activity, activation parameters, and the course of Hb-values were similar among both groups. There was no difference regarding clinical endpoints (peri-/postoperative pRBC-transfusions, postoperative blood loss). In conclusion, the application of HA was associated with a more distinct dilution of procoagulant factors, AT3, and fibrinolytic factors than the use of FFPs. However, the course of activation markers suggested a similar extent of clotting and fibrinolytic activation with the use of both transfusion regimens, and there were no differences with regard to clinical endpoints.


Assuntos
Albuminas/administração & dosagem , Coagulação Sanguínea/efeitos dos fármacos , Craniossinostoses/cirurgia , Cuidados Intraoperatórios/métodos , Troca Plasmática , Biomarcadores/sangue , Anormalidades Craniofaciais/cirurgia , Transfusão de Eritrócitos , Feminino , Fibrinólise/efeitos dos fármacos , Humanos , Lactente , Masculino , Tempo de Tromboplastina Parcial , Projetos Piloto , Especialidades Cirúrgicas/métodos
17.
Paediatr Anaesth ; 15(4): 325-7, 2005 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-15787925

RESUMO

Percutaneous central venous cannulation of small infants is a challenging procedure. The use of ultrasound guidance has been shown to increase the success rate generally in children and to decrease the incidence of associated complications. To demonstrate that this technique is also suitable in very small infants we describe the case of a preterm neonate of 850 g body weight (BW), in which percutaneous central venous cannulation was performed successfully using ultrasound imaging for guidance.


Assuntos
Cateterismo Venoso Central/métodos , Recém-Nascido Prematuro , Peso Corporal , Gastrosquise/cirurgia , Humanos , Recém-Nascido , Veias Jugulares/diagnóstico por imagem , Masculino , Monitorização Intraoperatória , Ultrassonografia
18.
Anaesthesist ; 54(5): 455-66, 2005 May.
Artigo em Alemão | MEDLINE | ID: mdl-15765201

RESUMO

We have developed a modern strategy for the anesthetic management of pediatric cleft lip and cleft palate repair using anesthetic drugs such as sevoflurane, desflurane, acetaminophen, remifentanil, and pirtitramide together with new techniques. It provides best conditions for the surgeon and maximum safety for the pediatric patient. A team of pediatricians, neonatologists, pediatric surgeons, and pediatric anesthetists have tackled the problem of management of children with craniofacial abnormalities such as cleft lip and cleft palate. The best and safest anesthetic techniques are outlined and the most frequent complications are discussed, e.g. management of the difficult airway, the airway in patients with complex craniofacial abnormalities, fiberoptic endotracheal intubation through a laryngeal mask, intraoperative dislocation of the endotracheal tube, postoperative airway obstruction and perioperative bleeding.


Assuntos
Anestesia por Inalação/métodos , Fenda Labial/cirurgia , Fissura Palatina/cirurgia , Anormalidades Múltiplas/fisiopatologia , Analgésicos não Narcóticos , Analgésicos Opioides , Anestésicos Inalatórios/administração & dosagem , Humanos , Lactente , Recém-Nascido , Intubação Intratraqueal , Monitorização Intraoperatória , Dor Pós-Operatória/tratamento farmacológico
19.
Pediatr Int ; 46(2): 117-21, 2004 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-15056234

RESUMO

BACKGROUND: Bronchoscopies are performed in childhood for diagnostic reasons (e.g. evaluation of stridor, unexplained cough, possible malformations) and therapeutic reasons (e.g. foreign body removal, management of the difficult airway). METHODS: Various procedures of entering the pediatric airways are presented, based on an overview of the literature and the experience of the authors. RESULTS: The advantages and disadvantages of direct fibreoptic bronchoscopy, bronchoscopy via face mask, via laryngeal mask airway, via tracheal tube, and for combined flexible and rigid bronchoscopy are discussed. In addition, practical aspects of bronchoscopy are considered, including local anesthesia, oxygen supplementation, monitoring, antibiotic treatment. CONCLUSIONS: Although inspection of the pediatric airways has become a well-accepted routine procedure with a high diagnostic yield, and bronchoscopies are well tolerated, it is important that the most appropriate means of access to the airways is chosen according to the indications and the age of the child.


Assuntos
Broncoscopia/métodos , Fatores Etários , Criança , Pré-Escolar , Humanos , Lactente , Recém-Nascido
20.
Paediatr Anaesth ; 13(5): 397-402, 2003 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-12791112

RESUMO

BACKGROUND: In this study we compare the postoperative pain relief for inguinal herniotomy in children provided by instillation of bupivacaine into the wound with that provided by a caudal block. METHODS: Fifty-eight children aged 0-5 years having elective unilateral hernia repair were studied in this prospective, randomized, single-blind study. Anaesthesia was induced and maintained with oxygen, nitrous oxide, sevoflurane and propofol. Patients were randomly assigned to receive caudal analgesia with 1.0 ml.kg-1 body weight (BW) bupivacaine 0.25% or wound instillation with 0.2 ml.kg-1 BW bupivacaine 0.5% at the end of surgery. Pain was assessed over 24 h using a modified 10-point objective pain scale. During the first postoperative hour in the postanaesthesia care unit (PACU), intravenous (i.v.) piritramide (0.05 mg.kg-1) was administered to any child scoring 5 or more points on the pain scale. On the ward, rectal acetaminophen was administered by a staff nurse when considered necessary. RESULTS: Thirty children in the caudal group and 28 children in the wound instillation group were studied. There were no statistically significant differences between the groups regarding need for i.v. opioids, discharge time from the PACU and administration of acetaminophen. No statistically significant differences in postoperative pain score were observed in 16 of a total of 17 postoperative observations. No complications and no adverse effects were observed. CONCLUSION: Instillation of bupivacaine into a wound provides postoperative pain relief following hernia repair, which is as effective as that provided by a postoperative caudal block.


Assuntos
Anestesia Caudal , Anestésicos Locais/uso terapêutico , Bupivacaína/uso terapêutico , Procedimentos Cirúrgicos do Sistema Digestório , Hérnia Inguinal/cirurgia , Dor Pós-Operatória/tratamento farmacológico , Analgésicos Opioides/uso terapêutico , Anestésicos Locais/administração & dosagem , Bupivacaína/administração & dosagem , Pré-Escolar , Feminino , Humanos , Lactente , Masculino , Medição da Dor , Pirinitramida/uso terapêutico , Estudos Prospectivos , Método Simples-Cego
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