In view of the increasing complexity of both cardiovascular implantable electronic devices (CIEDs) and patients in the current era, practice guidelines, by necessity, have become increasingly specific. This document is an expert consensus statement that has been developed to update and further delineate indications and management of CIEDs in pediatric patients, defined as ≤21 years of age, and is intended to focus primarily on the indications for CIEDs in the setting of specific disease categories. The document also highlights variations between previously published adult and pediatric CIED recommendations and provides rationale for underlying important differences. The document addresses some of the deterrents to CIED access in low- and middle-income countries and strategies to circumvent them. The document sections were divided up and drafted by the writing committee members according to their expertise. The recommendations represent the consensus opinion of the entire writing committee, graded by class of recommendation and level of evidence. Several questions addressed in this document either do not lend themselves to clinical trials or are rare disease entities, and in these instances recommendations are based on consensus expert opinion. Furthermore, specific recommendations, even when supported by substantial data, do not replace the need for clinical judgment and patient-specific decision-making. The recommendations were opened for public comment to Pediatric and Congenital Electrophysiology Society (PACES) members and underwent external review by the scientific and clinical document committee of the Heart Rhythm Society (HRS), the science advisory and coordinating committee of the American Heart Association (AHA), the American College of Cardiology (ACC), and the Association for European Paediatric and Congenital Cardiology (AEPC). The document received endorsement by all the collaborators and the Asia Pacific Heart Rhythm Society (APHRS), the Indian Heart Rhythm Society (IHRS), and the Latin American Heart Rhythm Society (LAHRS). This document is expected to provide support for clinicians and patients to allow for appropriate CIED use, appropriate CIED management, and appropriate CIED follow-up in pediatric patients.

Early postoperative arrhythmias are a known complication of cardiac surgery. It is unusual, however, to encounter postoperative junctional and ectopic atrial tachycardias in the same patient. We describe our experience with a 2-year-old girl who suffered both these tachycardias after repair of a ventricular septal defect, the abnormal rhythms being controlled solely with intravenous administration of amiodarone.

We reviewed retrospectively the clinical and surgical data from 9 children with postoperative chylothorax secondary to cardiac surgery for congenital heart disease seen over a 3 year period. Mean age was 26 months and 6 patients were female. The procedures performed were 2 Blalock-Taussig shunts, 6 Bidirectional Glenn anastomoses and 1 modified Fontan procedure. Diagnosis of chylothorax was made by classical means. The overall incidence of chylothorax was 0.8%, with the relative incidences being 2.5% for Blalock-Taussig, 2.7% for Fontan, and 11.7% for the Glenn procedures. All patients were initially treated conservatively with chest tube drainage and hypercaloric diet suplemented with medium chain triglycerides. Parenteral nutrition was needed in 2 patients, one because of sepsis and the other because of progressive malnourishment. High output fistulas and long periods of drainage were noted after cavo-pulmonary procedures. Up to 12% weight loss was observed in 6 patients, one patient was successfully treated of pneumonia and another died of Pseudomonas aeruginosa sepsis. Two patients required chemical pleurodesis because of unabated drainage, with the others being successfully treated conservatively. Chylothorax is a common complication after bidirectional Glenn procedures, and is associated with considerable morbidity and mortality. Earlier operative intervention may be required in these patients. Pleurodesis is a simple, safe, and effective procedure to stop chylous flow.

Background and objective: A critical factor that delays patient discharge following day-surgery is severe postoperative pain and the requirement for strong analgesics. Laparoscopic sterilization is a day case procedure and is associated with additional postoperative pain compared with diagnostic laparoscopy. This pain, associated with application of Filshie clips, may be ischaemic or spasmodic in aetiology. Papaverine relaxes smooth muscle, and the aim of the study was to investigate if papaverine would be effective in improving postoperative pain if administered directly to the Fallopian tubes. Bupivacaine is used commonly in day-surgery and so we compared the effect of this local anaesthetic with saline placebo.

Methods: Sixty-six ASA I-II females undergoing laparoscopic sterilization were entered into the prospective, randomized, double-blind, placebo-controlled clinical trial. They received intrauterine papaverine (30 mg) or bupivacaine (0.375% 30 mL) or normal saline (30 mL) via the transcervical route before application of Filshie clips.

Results: There were no significant differences in the postoperative period between the three groups in the number of patients needing analgesia in the first 60 min postoperatively, the time to first analgesia, the rescue analgesic or antiemetic consumption, the incidence of postoperative nausea and vomiting, and the sedation and visual analogue pain scores.

Conclusions: From the data presented, we would not recommend routine transcervical administration of papaverine or bupivacaine for pain following laparoscopic sterilization.

Background and objective: We assessed the analgesic efficacy of postoperative epidural infusions of ropivacaine 0.1 and 0.2% combined with sufentanil 1 μg mL−1 in a prospective, randomized, double-blinded study.

Methods: Twenty-two ASA I—III patients undergoing elective total-knee replacement were included. Lumbar epidural blockade using ropivacaine 0.75% was combined with either propofol sedation or general anaesthesia for surgery. After surgery, the epidural infusion was commenced. Eleven patients in each group received either an epidural infusion of ropivacaine 0.1% with 1 μg mL−1 sufentanil (Group 1) or ropivacaine 0.2% with 1 μg mL−1 sufentanil (Group 2) at a rate of 5–9 mL h−1. All patients had access to intravenous pirinatrimide (piritramide) via a patient-controlled analgesia (PCA) device.

Results: Motor block was negligible for the study duration in both groups. There was no significant difference with the 100 mm visual analogue scale (VAS) scores, with the consumption of rescue analgesia or with patient satisfaction. Patients in Group 1 experienced significantly less nausea (P < 0.05) than those in Group 2. Both treatment regimens provided effective postoperative analgesia with only a minimal use of supplemental opioid PCA.

Conclusions: We recommend the use of ropivacaine 0.1% with 1 μg mL−1 sufentanil for postoperative analgesia after total knee replacement as it provides efficient pain relief with no motor block of the lower limbs. In addition, compared with 0.2% ropivacaine with sufentanil, the mixture reduces local anaesthetic consumption without compromise in patient satisfaction or VAS scores. Patients even experience less nausea.

Background and objective: To investigate the interactions of postoperative pain and endocrine stress response, three groups of 21 patients each with total knee arthroplasty were compared in a randomized, prospective design. For postoperative pain management, a three-in-one block, an epidural catheter analgesia or an intravenous patient-controlled analgesia was used.

Methods: After standardized balanced anaesthesia, the pain intensity was measured by a visual analogue scale (VAS). For detection of epinephrine, norepinephrine, antidiuretic hormone, adrenocorticotropic hormone and cortisol in the plasma, blood samples were taken at six time points before and up to 180 min after the start of pain therapy. In addition, systolic arterial pressure, heart rate, partial arterial oxygen saturation, nausea, vomiting and satisfaction of the patients were recorded.

Results: Within 15 min after the start of pain therapy, VAS in all groups was similarly reduced from >40 mm to a range <10 mm (P < 0.001). Initially, all endocrine stress variables exceeded the normal range. Epidural anaesthesia led to a significant decrease of epinephrine and norepinephrine concentrations, while an increase was observed in the group with patient-controlled analgesia, and the decrease in patients with the three-in-one block was less than in patients receiving epidural anaesthesia (P = 0.001). Differences in antidiuretic hormone, adrenocorticotropic hormone and cortisol were less pronounced. Systolic arterial pressure decreased significantly in all groups, particularly in patients with epidural anaesthesia. Partial arterial oxygen saturation and the incidence of nausea and vomiting were comparable. All patients were satisfied with the methods used.

Conclusions: All methods of pain management led to sufficient analgesia, but they were not accompanied by an adequate reduction in endocrine stress response. Thus, postoperative pain is only a secondary stressor and sufficient analgesia with subjective well-being does not prove a stress-free state. With regard to the reduction of sympathoadrenergic stress response, epidural anaesthesia is superior to the three-in-one block and patientcontrolled analgesia. Epidural anaesthesia is recommended particularly for high-risk patients with hypertension, coronary heart disease and diabetes mellitus. In these patients, the reduction of a ‘hidden’ endocrine stress response in addition to prevention of pain is of special interest.

Background and objective: The α2-adrenoceptor agonist clonidine has potent central antinociceptive properties. The study was designed to investigate the effects of the combined subarachnoid administration of clonidine and prilocaine on spinal block and postoperative analgesia for the transurethral resection of tumours in the urinary bladder.

Methods: The controlled, prospective, double-blind study enrolled 40 patients scheduled for elective transurethral resection of bladder tumours under spinal anaesthesia with prilocaine. Patients were randomly assigned to receive an intrathecal injection of prilocaine 75 mg alone (control group) or in combination with clonidine 75 µg. We assessed haemodynamic changes (non-invasive arterial pressure, heart rate), pulse oximetry, the upper level of block, the onset and duration of sensory and motor block, postoperative analgesia and any adverse effects.

Results: There were no statistically significant differences in demographic data, heart rate, onset time or the levels of sensory or motor block. Analgesia lasted significantly longer in the clonidine group (498.4 ± 226.9 versus 187.2 ± 103.1 min; P < 0.05). The duration of motor block was longer in the clonidine group (165.5 ± 30.6 min) than in the control group (139.7 ± 40.4 min; P < 0.05) and the duration of sensory block was also longer in the clonidine group (157.3 ± 24.5 min) than in the control group (137.2 ± 31.2 min; P < 0.05). Fewer patients in the recovery room needed metamizol (dipyrone) in the clonidine group (5%) than in the control group (50%). Arterial pressure decreased significantly in the clonidine group 75-135 min after the block.

Conclusions: The addition of clonidine 75 µg to prilocaine 75 mg for subarachnoid anaesthesia increased the duration of sensory and motor block and reduced the need for additional postoperative analgesics by providing excellent analgesia for about 8 h during recovery from transurethral resection of bladder tumours.

Background and objective: Unilateral paravertebral nerve blockade has been reported to produce excellent afferent nerve block, reduce the incidence of postoperative nausea and vomiting, and reduce hospital stay following inguinal hernia repair. The aim was to compare the use of bilateral paravertebral blocks to regular general anaesthesia for ventral hernia repair.

Methods: Sixty patients were prospectively allocated to receive either bilateral paravertebral nerve blockade (midazolam for block; supplemented with light intraoperative sedation if needed) or general anaesthesia for ventral hernia repair. The end-points of the study were length of hospital stay, postoperative analgesia (visual analogue scale, supplemental opioid requirement) and incidence of postoperative nausea and vomiting.

Results: The duration of hospital stay was observed to be shorter in patients handled with bilateral paravertebral nerve blockade (2.3 [SD 1.3] days) compared with patients receiving general anaesthesia (4.1 (3.0) days). Paravertebral analgesia resulted in both lower visual analogue scores and a significantly reduced need for supplemental opioid administration during the first 48 h postoperatively compared with general anaesthesia (P < 0.001). The rate of postoperative nausea and vomiting in the paravertebral nerve blockade group was only 3.3%, while 26.7% of patients in the general anaesthesia group suffered from postoperative nausea and vomiting (P < 0.05). Paravertebral nerve blockade was associated with good patient acceptance in 90% of patients.

Conclusions: Bilateral paravertebral blockade combined with light intravenous sedation was superior to general anaesthesia for ventral hernia repair. Paravertebral blockade was associated with shorter hospital stay, improved analgesia and less postoperative nausea and vomiting. It is suggested that this technique deserves more widespread use in patients undergoing ventral hernia repair.

Background and objective Hypothermia may alter the disposition of opioids. Because opioids are commonly used as analgesics in the postoperative period, it is of clinical interest to clarify whether perioperatively developed hypothermia affects postoperative opioid requirements.

Methods Fifty-nine patients undergoing subtotal hysterectomy were prospectively randomized and either treated intraoperatively with forced air warming, or served as controls covered with conventional blankets without active warming. Both groups received postoperative patient-controlled analgesia with the opioid ketobemidone. Total analgesic requirements, demands, analgesic requirements over 6-h intervals and pain scores were measured for 48 h. Core temperature at the tympanic membrane and ambient room temperature were measured during the perioperative period.

Results There were no postoperative differences in analgesic requirements or pain intensity between normothermic and hypothermic patients. Patients treated with warm air had an up to 1°C higher core temperature from 0.5 h after anaesthesia induction until almost 2 h postoperatively. The actively warmed patients also had a lower intraoperative blood loss than the hypothermic patients (186 ± 27 mL vs. 308 ± 47 mL; P < 0.05).

Conclusion In a clinical setting, opioid requirements do not seem to be affected by mild postoperative hypothermia after lower abdominal surgery.

Background and objective The aim of the present study was to compare and assess the quality of analgesia, the safety and the side-effects after the use of a continuous, thoracic epidural infusion of sufentanil (5 μg h−1), 0.25% bupivacaine (10 mL h−1), 0.2% ropivacaine (10 mL h−1) alone or in combination in patients who had undergone major urological surgery. This prospective, randomized, double-blinded study investigated the efficacy of thoracic epidural infusions after major urological surgery.

Methods Patients received a 72-h continuous infusion␣(10 mL h−1) of 0.25% bupivacaine (B), 0.2% ropivacaine (R), 0.25% bupivacaine with 0.5 μg mL−1 sufentanil (BS), 0.2% ropivacaine with 0.5 μg mL−1 sufentanil (RS) or 0.5 μg mL−1 sufentanil only (S). The analysis included 109 patients.

Results The mean visual analogue scale (VAS) scores for pain were highest in the groups R and S (P < 0.001). The PaCO2 values were significantly higher in the groups RS and S (P = 0.003). Motor block occurred more frequently in the groups B and BS than in the other groups (P < 0.001). Sedation, nausea and pruritus were more common in the groups that received sufentanil.

Conclusions A continuous, epidural infusion with these drugs was safe and effective in our patients. The combination of 0.2% ropivacaine plus sufentanil appeared preferable because of the low incidence of motor block.

Background and objective Numerous drugs have been used to prevent or to treat opioid-induced pruritus in the surgical setting. Their relative efficacy is not well understood.

Methods The methods employed involved the systematic search (MEDLINE, EMBASE, Cochrane library, bibliographies, without language restriction, up to June 2000) for full reports of randomized comparisons of any intervention which is thought to be anti–pruritic (active) compared with placebo or no treatment (control) in surgical (including labour) patients receiving opioids. The number of patients who had no pruritus were analysed using relative risk and number–neededto– treat with 95% confidence interval.

Results Twenty-two trials (1477 patients) were analysed. Two trials (66 patients), both with low-dose propofol, were on treatment of established pruritus; propofol had no anti-pruritic effect compared with Intralipid. In prophylaxis trials, the average incidence of pruritus with control was 59% (range, 10% to 100%). Most mu–receptor antagonists were efficacious: intravenous naloxone 0.25–2.4 μgkg−1 h−1, relative risk 2.31 (95% confidence interval, 1.5 to 3.54), numberneeded– to–treat to prevent pruritus compared with control 3.5; oral naltrexone 9 mg, relative risk 2.80 (1.35–5.80), number-needed-to-treat 1.7; naltrexone 6mg was less effective and 3mg did not work; different intravenous and epidural nalbuphine regimens, relative risk 1.71 (1.12–2.62), number-needed-to-treat 4.2. Intravenous nalmefene 0.5 or 1mg was not antipruritic. Intravenous (but not epidural) droperidol 2.5mg was efficacious, relative risk, 1.71 (1.28–2.29), number-needed-to-treat 4.9. There was a lack of evidence for any anti–pruritic efficacy with prophylactic propofol, epidural or intrathecal epinephrine, epidural clonidine, epidural prednisone, intravenous ondansetron, or intramuscular hydroxyzine.

Conclusion Naloxone, naltrexone, nalbuphine and droperidol are efficacious in the prevention of opioidinduced pruritus; minimal effective doses remain unknown. There is a lack of valid data on the efficacy of interventions for the treatment of established pruritus.

Background and objective We have assessed the analgesic efficacy and side-effects of neostigmine when added to lidocaine for axillary brachial plexus block, in a prospective, randomized, double-blind, placebo-controlled study.

Methods We studied 34 ASA I or II patients undergoing elective ambulatory carpal tunnel release. Axillary brachial plexus block was performed using a peripheral nerve stimulator to locate the median nerve. All patients were administered 1.5% lidocaine 450 mg and epinephrine 5 μg mL−1. Patients were allocated randomly to one of two groups. Neostigmine 500|ig was added in group N, and saline 1 mL in group S.

Results The duration of analgesia did not significantly differ between groups [mean (SD)]: 812.5 (456.9) for group S vs. 746.7 (474.1) min for group N (P >0.05). The need for supplementary analgesia did not significantly differ between groups: 4.4 (1.5) extra doses for group S vs. 3.8 (2.2) extra doses for group N (P>0.05). Visual analogue pain scores and occurrence of side-effects did not significantly differ between groups.

Conclusion Neostigmine does not seem to be of clinical value for peripheral nerve blocks.

Background and objective Intravenous morphine titration is used to obtain postoperative pain relief, but few studies have assessed the appropriate regimen. In a quality programme, we performed a prospective non-randomized study of morphine titration in a postanaesthesia care unit (PACU).

Methods Four regimens of morphine titration were studied: every 10 (group 1, n = 400) or 5min (group 2, n = 400) with a maximum of five intravenous boluses; every 5min, without any limitation in the number of boluses (groups 3 and 4, n = 400 each); in groups 1, 2, and 3, subcutaneous morphine was administered 4 h after titration. In group 4, administration of subcutaneous morphine was allowed only 2h after titration. A visual analogue pain scale (VAPS) > 30 mm was required to administer morphine and pain relief was defined as a VAPS ≤ 30 mm.

Results After morphine titration, VAPS was lower and the number of patients with pain relief was greater in patients from groups 3 and 4. Patients from group 4 had the lowest VAPS (26±17mm) and the highest percentage of pain relief (73%) at the end of the PACU period. The number of sedated patients increased in groups 3 (62%) and 4 (61%) compared with group 1 (27%). No significant differences in morphine-related adverse effects were observed.

Conclusion Intravenous morphine titration every 5min with an unlimited number of boluses and early subcutaneous administration provided the best analgesic regimen.

Background and aim This study determines whether epidural fentanyl given before incision decreases the requirements for opioid analgesia postoperatively, compared with the same dose of epidural fentanyl given after the surgery.

Methods Forty patients scheduled to undergo elective abdominal surgery were randomly allocated between two groups according to the time of administered of fentanyl. None of the patients in either group received premedica-tion. Prior to induction of general anaesthesia an epidural catheter was inserted at the L2–3 interspace and flushed with 0.9% NaCI. Patients then received 100μg fentanyl in 10mL 0.9% NaCI through this catheter either 15min before awaking at the end of the operation (group I), or else the same dose given at an estimated time of 15 min before the start of surgery (group II). Postoperative analgesia consisted of patient-controlled intravenous fentanyl. The amount of fentanyl used by the patients was noted at 2, 4, 8, 12 and 24 h after surgery. Pain scores and sedation scores were assessed at 0, 2, 4, 8, 12 and 24 h postoperatively.

Results The consumption of fentanyl was similar in both groups in all studied periods postoperatively. The mean pain score was lower for patients in group I than group II immediately after operation. There were no statistically significant differences between the mean pain scores of groups at 2, 4, 8, 12 and 24 h after operation. Mean sedation scores were similar in both groups at all times postoperatively.

Conclusion This study showed that the dose of fentanyl administered epidurally prior to surgical incision did not produce any clinically useful pre-emptive analgesic effect.

In a randomized, prospective clinical study pain relief and pulmonary function were compared after upper abdominal surgery when thoracic epidural analgesia was instituted either before or after surgery. Twenty-six patients admitted for surgery to treat gastro-oesophageal reflux received thoracic epidural analgesia as an adjunct to general anaesthesia either before or after surgery. Twelve patients received epidural mepivacaine 20 mg mL−1 and morphine perioperatively. Another 14 patients received an epidural bolus of bupivacaine 2.5 mg mL−1 and morphine after skin closure. Bupivacaine 2.5 mg mL−1 with morphine was adminstered to all patients for three postoperative days. No intergroup differences were found regarding pain at rest and mobilization. The requirement for additional analgesics was similar in both groups as well as peak expiratory flow. Thoracic epidural analgesia that had already been induced before surgery, and was continued into the postoperative period, does not seem to add any advantage regarding pain relief and lung function compared with thoracic epidural analgesia instituted in the immediate postoperative period.