Opioid-Sparing Effect of Ketamine in Children: A Meta-Analysis and Trial Sequential Analysis of Published Studies.

INTRODUCTION: Reducing postoperative opioid consumption is a priority given its impact upon recovery, and the efficacy of ketamine as an opioid-sparing agent in children is debated. The goal of this study was to update a previous meta-analysis on the postoperative opioid-sparing effect of ketamine, adding trial sequential analysis (TSA) and four new studies. MATERIALS AND METHODS: A comprehensive literature search was conducted to identify clinical trials that examined ketamine as a perioperative opioid-sparing agent in children and infants. Outcomes measured were postoperative opioid consumption to 48 h (primary outcome: postoperative opioid consumption to 24 h), postoperative pain intensity, postoperative nausea and vomiting and psychotomimetic symptoms. The data were combined to calculate the pooled mean difference, odds ratios or standard mean differences. In addition to this classical meta-analysis approach, a TSA was performed. RESULTS: Eleven articles were identified, with four added to seven from the previous meta-analysis. Ketamine did not exhibit a global postoperative opioid-sparing effect to 48 postoperative hours, nor did it decrease postoperative pain intensity. This result was confirmed using TSA, which found a lack of power to draw any conclusion regarding the primary outcome of this meta-analysis (postoperative opioid consumption to 24 h). Ketamine did not increase the prevalence of either postoperative nausea and vomiting or psychotomimetic complications. CONCLUSIONS: This meta-analysis did not find a postoperative opioid-sparing effect of ketamine. According to the TSA, this negative result might involve a lack of power of this meta-analysis. Further studies are needed in order to assess the postoperative opioid-sparing effects of ketamine in children.

Factors affecting recovery of postoperative bowel function after pediatric laparoscopic surgery.

BACKGROUND AND AIMS: Laparoscopic pediatric surgery allows a rapid postoperative rehabilitation and hospital discharge. However, the optimal postoperative pain management preserving advantages of this surgical technique remains to be determined. This study aimed to identify factors affecting the postoperative recovery of bowel function after laparoscopic surgery in children. MATERIAL AND METHODS: A retrospective analysis of factors affecting recovery of bowel function in children and infants undergoing laparoscopic surgery between January 1, 2009 and September 30, 2009, was performed. Factors included were: Age, weight, extent of surgery (extensive, regional or local), chronic pain (sickle cell disease or chronic intestinal inflammatory disease), American Society of Anaesthesiologists status, postoperative analgesia (ketamine, morphine, nalbuphine, paracetamol, nonsteroidal anti-inflammatory drugs [NSAIDs], nefopam, regional analgesia) both in the Postanesthesia Care Unit and in the surgical ward; and surgical complications. Data analysis used classification and regression tree analysis (CART) with a 10-fold cross validation. RESULTS: One hundred and sixty six patients were included in the analysis. Recovery of bowel function depended upon: The extent of surgery, the occurrence of postoperative surgical complications, the administration of postoperative morphine in the surgical ward, the coadministration of paracetamol and NSAIDs and/or nefopam in the surgical ward and the emergency character of the surgery. The CART method generated a decision tree with eight terminal nodes. The percentage of explained variability of the model and the cross validation were 58% and 49%, respectively. CONCLUSION: Multimodal analgesia using nonopioid analgesia that allows decreasing postoperative morphine consumption should be considered for the speed of bowel function recovery after laparoscopic pediatric surgery.

Efficacy of Intraoperative Dexmedetomidine Compared with Placebo for Postoperative Pain Management: A Meta-Analysis of Published Studies.

INTRODUCTION: Dexmedetomidine (Dex) has sedative, analgesic, and anesthetic-sparing effects. This meta-analysis examines demonstrated intraoperative and postoperative effects of intraoperative Dex administration during pediatric surgery. METHODS: A search for randomized placebo-controlled trials was conducted to identify clinical trials examining intraoperative Dex use in children, infants, and neonates. Primary outcome was postoperative opioid consumption; secondary outcomes were: postoperative pain intensity and postoperative nausea and vomiting (PONV). RESULTS: Fourteen randomized controlled trials performed during painful procedures were analyzed. Intraoperative Dex administration was associated with significantly reduced postoperative opioid consumption in the postanesthesia care unit [PACU; risk ratio (RR) = 0.31 (0.17, 0.59), I (2) = 76%, p < 0.0001 and cumulative z score using trial sequential analysis], decreased pain intensity in PACU [standardized mean difference (SMD) = -1.18 (-1.88, -0.48), I (2) = 91%, p < 0.0001] but had no effect upon PONV incidence [RR = 0.67 (0.41, 1.08), I (2) = 0%, p = 0.48]. Subgroup analyses found administering Dex during adenotonsillectomy and using a bolus <0.5 µg/kg (irrespective to the use of a continuous administration) without effects on studies outcomes. Heterogeneity was high among results and a high suspicion of publication bias was present for all analyzed outcomes. CONCLUSIONS: This meta-analysis shows that intraoperative Dex administration in children reduces postoperative opioids consumption and postoperative pain in PACU. According to our results, optimal bolus dose was found to be ≥0.5 µg/kg. Future studies have to explore this particular point and the postoperative analgesic effects of Dex during longer periods.