Paediatric drugs
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Postoperative nausea and vomiting (PONV), postoperative vomiting (POV), post-discharge nausea and vomiting (PDNV), and opioid-induced nausea and vomiting (OINV) continue to be causes of pediatric morbidity, delay in discharge, and unplanned hospital admission. Research on the pathophysiology, risk assessment, and therapy for PDNV, OINV and pain therapy options in children has received increased attention. Multimodal pain management with the use of perioperative regional and opioid-sparing analgesia has helped decrease nausea and vomiting. ⋯ Useful antiemetics include dexamethasone and serotonin 5-hydroxytryptamine-3 (5-HT3) receptor antagonists such as ondansetron. Multimodal combination prophylactic therapy using two or three antiemetics from different drug classes and propofol total intravenous anesthesia should be considered for children at high PONV risk. "Enhanced recovery after surgery" protocols include a multimodal approach with preoperative preparation, adequate intravenous fluid hydration, opioid-sparing analgesia, and prophylactic antiemetics. PONV guidelines and management algorithms help provide effective postoperative care for pediatric patients.
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Methadone is a synthetic opioid with unique pharmacodynamic and pharmacokinetic properties. It is effective in treating both nociceptive and neuropathic pain, which commonly co-exist in children with cancer. ⋯ Although the risk of life-threatening arrhythmia is commonly cited as an argument against the use of methadone, our review of the literature did not support this finding in children. Further evaluation with prospective studies is warranted to develop evidence-based recommendations for the use of methadone in pediatric oncology.
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Acute vaso-occlusive crisis (VOC) is a hallmark of sickle cell disease (SCD). Multiple complex pathophysiological processes can result in pain during a VOC. Despite significant improvements in the understanding and management of SCD, little progress has been made in the management of pain in SCD, although new treatments are being explored. ⋯ Advancements in the understanding of the pathophysiology of SCD and pain and the pharmacogenomics of opioids have yet to be effectively utilized in the management of VOC. Opioid tolerance and opioid-induced hyperalgesia are significant problems associated with the long-term use of opioids, and better strategies for chronic pain therapy are needed. This report reviews the mechanisms of pain associated with acute VOC, describes the current management of VOC, and describes some of the new therapies under evaluation for the management of acute VOC in SCD.
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Understanding the pharmacologic options for pediatric sedation outside the operating room will allow practitioners to formulate an ideal anesthetic plan, allaying anxiety and achieving optimal immobilization while ensuring rapid and efficient recovery. The authors identified relevant medical literature by searching PubMed, MEDLINE, Embase, Scopus, Web of Science, and Google Scholar databases for English language publications covering a period from 1984 to 2017. Search terms included pediatric anesthesia, pediatric sedation, non-operating room sedation, sedation safety, and pharmacology. ⋯ The use of nitrous oxide as a mild sedative, analgesic, and amnestic agent is gaining popularity, especially in the ambulatory setting. Utilizing a dedicated and experienced team to provide sedation enhances safety. Furthermore, limiting sedation plans to single-agent pharmacy appears to be safer than using multi-agent plans.
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Normal brain development in young children depends on a balance between excitation and inhibition of neurons, and alterations to this balance may cause apoptosis. During the perioperative period, both surgical stimuli and anesthetics can induce neurotoxicity. This article attempts to expand the perspective of a topical issue-anesthetic-induced neurotoxicity-by also considering the protective effect of general anesthetics against surgery-induced neurotoxicity, all of which may generate some controversy in the current literature. The "new" major factor influencing neurotoxicity-nociceptive stimulus-is discussed together with other factors to develop clinical and research strategies to obtain a balance between neurotoxicity and neuroprotection.