Multimodal Analgesia in Major Abdominal Pediatric Cancer Surgeries
Condition: Pediatric Cancer; Pain, Postoperative
MeSH terms: Pain, Postoperative
Study type: Interventional

Summary: 
      Surgical trauma initiates multiple physiological mechanisms that cause postoperative pain.
      Postoperative pain has nociceptive, inflammatory, and neuropathic components.Inadequate
      relief of postoperative pain leads to significant morbidity, delayed recovery, and
      mortality.Adverse reactions of medications used for postoperative pain management,
      particularly opioids, are common including pruritus and nausea and vomiting.Preemptive
      analgesia is defined as analgesic treatment that starts before surgical incision to prevent
      central sensitization caused by incisional and inflammatory injuries.Therefore, in this pilot
      study, the investigators are trying to evaluate safety and efficacy of preemptive multimodal
      analgesia compared with preemptive caudal analgesia and PCA morphine in pediatric cancer
      patient undergoing major abdominal surgery.
    

Detailed description: 
      Surgical trauma initiates multiple physiological mechanisms that cause postoperative pain.
      Postoperative pain has nociceptive, inflammatory, and neuropathic components.Inadequate
      relief of postoperative pain leads to significant morbidity, delayed recovery, and
      mortality.Despite the development of new drugs and analgesic techniques, up to 40% of
      hospitalized children - especially surgical patients - experiences moderate to severe pain.
      Adverse reactions of medications used for postoperative pain management, particularly
      opioids, are common including pruritus and nausea and vomiting.The incidence of
      opioid-related respiratory depression was reported to range from 0.11 to 0.41%.Regional
      anesthesia was suggested as an alternative to opioid-based analgesia in pediatric patients.
      Caudal epidural analgesia is a relatively safe and simple technique for postoperative pain
      management in children.However, there is a potential for adverse effects related to the
      technique of catheter placement or systemic toxicity of the local anesthetic.

      Preemptive analgesia is defined as analgesic treatment that starts before surgical incision
      to prevent central sensitization caused by incisional and inflammatory injuries.However,
      studies in animal models of incisional pain demonstrated that single analgesic treatment
      before the incision does not reduce postoperative pain. Once nociceptive afferent block
      subsides, the wound reinitiates central sensitization. Also, clinical trials reported similar
      results.Multimodal analgesia uses a combination of delivery routes administered at variable
      time points to optimize outcomes in the treatment of acute pain.

      Therefore, in this pilot study, the investigators are trying to evaluate safety and efficacy
      of preemptive multimodal analgesia compared with preemptive caudal analgesia and PCA morphine
      in pediatric cancer patient undergoing major abdominal surgery.
    

Intervention name(s): Paracetamol and ketamine; Caudal levobupivacaine; Morphine
Intervention type(s): Drug; Procedure; Drug
Intervention description(s): intravenous paracetamol and ketamine followed by ketorolac; an epidural injection of morphine and levobupivacaine through the caudal space; patient controlled analgesia by morphine
Other intervention name(s): Multimodal; Epidural; Patient controlled analgesia
Intervention MeSH terms: Acetaminophen; Ketamine; Morphine; Levobupivacaine
Allocation: Randomized
Intervention model: Parallel Assignment
Masking: Single (Outcomes Assessor)
Primary purpose: Prevention