Journal Watch Search

Journal Watch Search

92 Articles Found

Systematic Review and Meta-analysis of Virtual Reality in Paediatrics: Effects on Pain and Anxiety.

February 26, 2020

This is a systematic review and meta-analysis of the effectiveness of virtual reality (VR) in reducing pain and/or anxiety in paediatric patients.  Distraction is commonly used in paediatric patients for medical procedures and VR is a relatively new technique.  This review defined VR as a fully immersive three-dimensional environment displayed in surround stereoscopic vision on a head-mounted display.  This has promise in the paediatric population given the utility of imaginative play in these patients.

Seventeen studies met the inclusion criteria and reported on the effect of VR on reducing pain (14 studies) and/or anxiety (7 studies) in paediatric patients ( £21 years) undergoing a variety of medical procedures.  These included venous access, dental, burns (the most common procedure studied) and oncological care, while only one study considered use of VR prior to elective surgery and general anaesthesia.  VR intervention was compared to standard care conditions in all studies.  Outcome data from the studies was from behavioural observations, self-reports or questionnaires.

The meta-analysis concluded that VR may be an effective intervention to reduce patient-reported pain (SMD = 1.30) and anxiety (SMD = 1.32) during a variety of medical procedures.  Caregiver or professional observed reduction in pain was also noted (SMD = 3.02).  There was limited observer data for anxiety.

Comments

This paper highlights an apparent reduction in patient-reported and observed pain when using VR as a distraction technique for a variety of medical procedures.  The data on anxiety is less convincing with only seven studies reporting on this outcome, predominantly using patient-reporting and very limited observer data to correlate the effectiveness of the invention.  It should be noted that there was significant heterogeneity in the study findings, with some studies showing no meaningful benefit.

There are a number of limitations to the meta-analysis that emerge, including the difficulty in controlling factors such as using different kinds of VR software and including non-randomised controlled trials in the analysis.  Eijlers et al note that the studies themselves are of variable quality and several have relatively small numbers of patients.  The findings should therefore be interpreted with caution, although there is sufficient evidence to suggest that VR may be useful in some contexts.

In relation to paediatric anaesthetic practice, only one study was included that used VR as a preparation tool before entering the operating theatre.  There is therefore insufficient evidence to recommend use in the perioperative setting at this stage.  Given induction of anaesthesia is reported to be a period when patients experience high levels of anxiety, further research is required to determine the effectiveness of VR in reducing both pain and anxiety pre-operatively and at induction.

Reviewed by Dr Natasha Epari


Erector Spinae Plane Block vs Quadratus Lumborum Block for paediatric lower abdominal surgery.

February 26, 2020

This study is a double blinded, prospective, randomized trial. The study compared the  Erector Spinae Plane Block (ESPB) against the Quadratus Lumborum Block (QLB) in paediatric patients presenting for lower abdominal surgery.

Children aged 1 – 7 years, classified as ASA I-II and undergoing lower abdominal surgery were randomized to either an ESPB or QLB. An anaesthetist blinded to the intervention was assigned to manage the case and all blocks were performed by 2 anaesthetists that were blinded to the data collection. Bupivacaine 0.25% 0.5ml/ kg (max 20mL) was used for the blocks. Additional analgesia administered during the surgery included 1microg/ kg of fentanyl at induction, N2O maintenance and 15mg/ kg paracetamol IV at the end of surgery.

Post-operatively, FLACC scores were measured at 1, 3 and 6 hours, by a pain nurse blinded to the study. Rescue analgesia was in the form of Paracetamol (15mg/kg) if FLACC 2-4 & Tramadol (1mg/kg) if FLACC greater than 4. Discharge analgesia was paracetamol & Ibuprofen, although Ibuprofen was only at 7mg/kg and only if FLACC >4. Analgesic consumption was recorded by an author blinded to group allocation. Parental satisfaction was measured on a 1-10 scale, with 10 the highest level of satisfaction.

Findings:

There was no significant difference between the ESPB & QLB FLACC scores at any time point and parental satisfaction was 9.7 for the ESPB & 9.5 for the QLB. No block related complications were noted in either group. The authors commented that ESPB and QLB both provided effective analgesia for paediatric lower abdominal surgery with similar and low additional analgesic requirements immediately post-operatively. The authors conclude that both blocks are equally effective in the first 24hours and that clinicians should choose either block based on their clinical expertise.

Take home message:

Lower abdominal surgical procedures are common in children 1-7 years of age. Pain is generally worst in the first 24-36 hours and regional anaesthesia is useful to reduce the initial post-operative pain. Frequently caudal analgesia is used but there is some evidence in the literature to suggest that caudals do not have an insignificant failure rate. Similarly there is evidence to suggest that TAP blocks, while easy to perform, may not be as effective in controlling post-operative pain.

One of the weaknesses of this study is that it compares 2 regional techniques that are likely to be of interest to people that perform regular regional anaesthesia. The fact that these 2 blocks provide similar analgesic quality & that either can be performed is unlikely to change current practice. Had either block been shown to improve analgesia over a caudal then perhaps it would have had more of a practice changing effect. This study is however applicable to our general paediatric surgical population. With an increasing frequency of day case surgical procedures being performed regional techniques can add to our post-operative pain control armamentarium. This study increasies the knowledge base in paediatric regional anaesthesia and provides evidence for alternative strategies for pain control in our patients.

Reviewed by : Dr Neil Hauser


Perioperative Management of the Pediatric Patient of Medicinal Marijuana: What Anesthesiologists Should Know.

February 26, 2020

This article is a review of the history, known pharmacology, current evidence and anaesthetic considerations relating to medicinal marijuana in children. The context of the review is centred on the perspective of the American Academy of Pediatrics.

There are 2 synthetic cannabinoids and 2 purified extracts in production but the only product approved by the FDA for use in children is cannabidiol which is a plant derived oral solution primarily used for refractory seizures, chronic pain, multiple sclerosis and cancer related pain or nausea and vomiting. The review identifies 2 cannabinoid receptors: CB1 predominantly in the nervous system mediating psychoactive effects and CB2 in the immune system thought to have anti-inflammatory and antineoplastic actions. Cannabidiol is a cannabinoid with potentiating effects and possible antagonism at CB1 and CB2 with sedating, antiepileptic and antiemetic properties without psychotropic effects. Medical use in children is usually oral or topical.

Anaesthetic considerations include:

  1. Parental reassurance that the perioperative care team has a plan in place to minimise disruption of theory
  2. Dronabinol, nabilone or cannabidiol appear safe to continue their perioperative dosage on the day of surgery and throughout their hospital course
  3. Plant-derived cannabis products require individualised decisions about perioperative administration although in general most are safe to continue
  4. Monitor for medication interactions such as heart rate abnormalities with the use of sympathomimetic drugs. Titrate sedative medications and opioids carefully to avoid excess sedation. Due to CYP3A4/2C9 metabolism drug interactions with other medications is possible and unpredictable.

Assessment of article

Given the limited scientific evidence available (only 5 paediatric RCTs: 1 related to epilepsy, 4 related to chemotherapy induced nausea and vomiting) and no long term studies the review offers a reasonable attempt to address a growing pharmaceutic area and its pragmatic impact. A general reassuring message of safety is conveyed with some helpful tables summarising product comparison and possible drug interactions.

Take home message

Medicinal marijuana, in particular Cannabidiol has a growing profile as a supplemental treatment for a small number of conditions which are challenging or refractory to conventional management options. It appears safe to continue through hospital stay but vigilance for drug interactions is recommended.

Reviewed by: Dr Tom Flett