Scientific
Journal «ScienceRise
:
Medical Science» №5(50)2022
8
UDC 616-08
DOI: 10.15587/2519-4798.2022.265222
OPTIMISATION OF ACUTE PAIN TREATMENT IN CHILDREN IN ABDOMINAL
SURGERY AT THE STAGES OF THE PERIOPERATIVE PERIOD
Elmira Satvaldieva, Eldor Kuralov
The aim of the study.
To improve the quality of perioperative analgesia by combined multimodal use of paracetamol
and ketorolac tromethamine in children after abdominal surgery.
Materials and methods.
48 children (6–17 years old) with choledochal, pancreatic cysts, hepatic echinococcosis, and
abdominal trauma. The study period was from January 2021 to January 2022. Group 1 (main group, n=28): baseline
analgesia - 15 min before surgery, intravenous paracetamol administration at 25–30 mg/kg. In order to prevent postop-
erative pain syndrome 15 minutes before the end of the surgery, we administered ketorolac and tromethamine in a dose
of 0.5 mg/kg. Pain relief was repeated 6-8 h later with ketorolac at a dose of 0.5 mg/kg. Group 2 (comparison, n=20),
who received 0.2 – 0.3 mg/kg promedol (trimeperidin) in the postoperative period. Both groups received standard endo-
tracheal anaesthesia (propofol + fentanyl + arduan against the background of Low-flow anaesthesia with sevoflurane
MAK=1). Systemic haemodynamics, C-reactive protein, and glucose were investigated, and a visual analogue scale
was applied at the main stages of the study.
Results:
Analysis of the parameters of central hemodynamics, parameters of the operational stress response and clini-
cal data showed that in the postoperative period, sufficient analgesic effect was established only in children in group 1
with the preventive combined administration of paracetamol and ketorolac on the operating table, which allows rec-
ommending them in the practice of perioperative analgesia during abdominal surgical interventions.
Conclusions.
Optimised method of preventive (preoperative) use of paracetamol in children at a dose of 25–30 mg/kg
during abdominal surgery followed by administration of ketorolac tromethamine (15 minutes before the end of the sur-
gery) increases the degree of nociceptive protection. It ensures high efficiency of postoperative pain relief, which allows
to recommend it in the practice of perioperative analgesia for the above abdominal surgical interventions in children
Keywords:
perioperative analgesia, child on the operating table, surgical stress, multimodal anaesthesia, effectiveness
of analgesia
How to cite:
Satvaldieva, E., Kuralov, E. (2022). Optimisation of acute pain treatment in children in abdominal surgery at the stages of the perioperative period.
ScienceRise: Medical Science, 5 (50), 8–15. doi: http://doi.org/10.15587/2519-4798.2022.265222
© The Author(s) 2022
This is an open access article under the Creative Commons CC BY license hydrate
1. Introduction
Children are a particular category of surgical pa-
tients in terms of the choice and control of the effective-
ness of pain relief. In addition, many of them experience
fear and anxiety about the upcoming operation and have
a negative psycho-emotional background and discomfort
due to separation from their parents and being in a medi-
cal ward. All these factors can contribute to increased
pain after surgery [1, 2]. According to the literature,
despite using a wide range of drugs and non-drug pain
relief, 33–75 % of patients complain of moderate to se-
vere pain in the early postoperative period [3, 4].
Uncontrolled postoperative pain syndrome (PPS)
can cause cardiorespiratory and thromboembolic compli-
cations, accompanied by impaired gastrointestinal tract
motility and chronic pain development [5]. For this rea-
son, ensuring adequate postoperative pain relief (PPR) is
an urgent issue in modern anesthesiology.
Specific skills and special training are required
when providing surgical care to the pediatric population.
Lack of verbal contact, especially with preschool chil-
dren, shyness of the child, the need for simultaneous
psychological preparation of parents, and many other
factors determine the specificity of this problem in pae-
diatrics. Parents expect medical workers to reduce their
child's suffering to the greatest extent possible. Establish-
ing an appropriate level of patient and parental expecta-
tion that can be safely achieved prior to surgery will help
reduce anxiety and improve their understanding of mod-
ern pain management [6]. Apart from this, unreasonable
fear of respiratory depression, the development of de-
pendence when prescribing opioids, and the difficulty in
assessing the degree of pain, especially in young chil-
dren, partially explain the lack of pain relief in this cate-
gory of patients [7]
.
Therefore, the attitude towards pedi-
atric patients should be more personalised.
At the International Association for the Study of
Pain (IASP) initiative, 2017 was declared Global Year
Against Pain After Surgery [8]
.
This initiative pursued
the following objectives: dissemination of information
about the pain after surgery around the world, training of
medical personnel, researchers, medical administrators
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and the general public about the problems related the
pain after surgery, moreover encouraging healthcare
organisations and other entities which support policies
that lead to improved pain management after surgery [9,
10]. An important direction in improving the quality of
pain relief and reducing the severity of side effects is
developing and optimising methods for combining anal-
gesics with different mechanisms of action [11, 12].
Nowadays, interest in drugs that realise their analgesic
effect bypassing opioid receptors, which include NSAIDs
(ketorolac tromethamine) and paracetamol, has grown.
Paracetamol has a central action mechanism and has
almost no effect on the periphery. Ketorolac tro-
methamine and paracetamol have analgesic efficacy
comparable to opioids, quick onset of action, and their
combined use according to the multimodal principle
reduces undesirable effects and prolongs postoperative
pain relief [12, 13].
In the specialised literature, insufficient attention
is paid to the study of the after-surgery problem. Thus,
the works of foreign scientists confirm the unresolved
nature of this issue and the further need for large-scale
studies on the use of NSAIDs in children [14, 15].
The conducted literature analysis shows insuffi-
cient coverage of issues related to using the intravenous
form of Paracetamol and Ketorolac and its effectiveness
in the concept of proactive and multimodal analgesia in
children after abdominal surgery [16, 17]. Primarily
there is little information on this issue in the domestic
literature [18, 19]. Lack of investigation of this issue
and lack of consensus regarding the treatment methods
of PPS in children make this issue relevant in pediatric
anesthesiology.
In this regard, our study is devoted to developing
and implementing a pathogenetically substantiated meth-
od aimed at preventing the development of PPS or a
significant reduction in its intensity through the com-
bined multimodal use of Paracetamol and Ketorolac
tromethamine in the perioperative period in children in
abdominal surgery.
The aim of the study.
Improving the quality of
perioperative analgesia through the combined multimod-
al use of paracetamol and ketorolac tromethamine in
children after abdominal surgery.
2. Material and methods
We observed 48 pediatric patients (6–17 years
old - pupils) treated in the Children's National Medical
Center elective surgery department in Tashkent. The
observation period is January 2021 – January 2022. Of
them, 25 girls (52.1 %), 23 boys (47.9 %). This study
included patients (normotrophics) without premorbid
pathology. Anaesthesia risk according to ASA I – II. As
presented in Tab. 1, groups did not differ significantly in
age, div weight, and duration of surgery. The opera-
tions were planned, and standard preoperative prepara-
tion and examination were carried out.
Criteria for exclusion from the study:
1. Individual intolerance to the drugs used in the
study;
2. Patients at risk of ASA III-IV anaesthesia;
3. Conversion during the operation.
4. Non-consent of the patient or his relatives to
participate in the study.
5. Refusal to sign informed consent.
Abdominal surgical pathology was represented by
the following nosology: cysts of the choledochus, pan-
creas, spleen, liver echinococcosis, hernias and injuries
of the abdominal organs. According to the approval of
the ethics committee of the National Children's Medical
Center No. 1-08/491 from 22/08/2022 – the study was
approved, and informed consent was obtained from all
participants (or their relatives) to participate in the study.
In addition, written consent was obtained from the pa-
tient to publish relevant medical information and all
accompanying images within the manuscript.
The patients were divided into two groups:
The first group (main) – 28 patients who received
combined perioperative analgesia according to the fol-
lowing scheme: basic analgesia – before the surgery
(15 minutes before surgery), prophylactic intravenous
administration of paracetamol at a dose of 25–30 mg/kg.
In order to prevent early postoperative pain syndrome,
15 minutes before the end of the operation, an intrave-
nous injection of ketorolac tromethamine at a dose of
0.5 mg/kg. After 6-8 hours, ketorolac was re-
anaesthetised at a 0.5 mg/kg dose. On days 2 and 3,
0.5 mg/kg ketorolac was administered 2 and 1 times, respec-
tively. The following cases were contraindications to the
appointment of Paracetamol and NSAIDs: hypersensitivity
and allergic reactions to Paracetamol and NSAIDs, hemor-
rhagic diathesis, a disorder of the blood coagulation system
(coagulopathy), an active stomach or duodenal ulcer, ab-
normal liver, kidney function, haemophilia.
The second group (comparison) – 20 patients who
received 0.2–0.3 mg/kg of Promedol in the postoperative
period. Promedol was administered 3 times on the first
day, on the 2nd and 3rd days – 2 times a day (Table 1).
Table 1
Distribution of patients by the method of perioperative analgesia, age, div weight and surgery time (M±SD)
Indicators
The first group main, n=28
The second group comparison, n=20
Р
Perioperative analgesia
Paracetamol + Ketorolac
Promedol
Age (years)
9,5±2,54
10,1±3,02
>0,05
Body weight (kg)
26,7±7,11
31,0±8,41
>0,05
Surgery time (min)
112,8±29,06
99,3±21,76
>0,05
In both groups, standard endotracheal anaesthesia
was performed.
Anaesthesia was induced by administering
Propofol – 3 mg/kg, Fentanyl – 1–2 μg/kg, Arduan –
0.06–0.08 mg/kg, followed by tracheal intubation and
transfer to artificial ventilation (AV). Respiratory support
was performed at the anaesthesia station (GE Healthcare,
USA) using the forced ventilation mode by volume with
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an oxygen-air mixture with EtO2 – 30 % in the normoven-
tilation mode (EtСО2 at the level of 34–44 mm Hg). An-
aesthesia was maintained with Sevoflurane 1.0–1.2 MAC
according to the low-flow anaesthesia technique (LFA,
flow <1 liter). Analgesia was maintained by fractional
administration of Fentanyl at a dose of 0.5–
1 μg/kg every 30 minutes.
Infusion therapy was similar in both groups and
was represented by crystalloids: isotonic NaCl and/or
Ringer's solution, on average 4–6 ml/kg/h. In the case of
significant blood loss and long-term operations, compen-
sation for current losses was carried out individually (in
6.2 % of cases).
The study of systemic hemodynamics was per-
formed
by
transesophageal
echocardiography
(Transesophageal echocardiography, LOGIQ P7, 9T-RS
probe, D-7.2 mm, length 80 cm), invasive blood pressure
measurement method (radial artery). In transesophageal
echocardiography, the transducer was removed before
the patient was extubated on the operating table. Moni-
toring the depth of anaesthesia BIS + entropy (RE and
SE) and determining the pain index SPI (Surgical Ple-
thysmographic Index) with registration at the following
stages of the study: 1 – before surgery, 2 – traumatic
stage of surgery, 3 – 15 minutes before extubation, 4 –
during extubation, 5 – one hour after extubation (GE
Healthcare System). Continuous intraoperative monitor-
ing (CARESCAPE B650 GE, USA) of blood pressure,
heart rate, peripheral oxygen saturation (SpO2) with
plethysmogram, the concentrations of oxygen/carbon
dioxide/sevoflurane in inhaled (FiО
2
/FiCO
2
/FiSev) and
exhaled (EtO
2
/EtCO
2
/EtSev) mixtures with their registra-
tion at the main stages of the study: 1 – before the sur-
gery, 2 – traumatic stage of the surgery, 3 – end of the
surgery.
Laboratory research: determination of blood glu-
cose levels was carried out
by the glucose oxidase method
at the following three stages of the study: 1 – before sur-
gery (preoperative examination), 2 – traumatic stage of
surgery, 3 – 24 hours after the end of the surgery (Analyz-
er ABL 800 FLEX, Radiometer Medical Russia). Deter-
mination of C–reactive protein levels was carried out in
the following two stages: 1 – before surgery (preoperative
examination), 2–24 hours after the end of the surgery
(immunoturbidimetric test for the quantitative determina-
tion of C-reactive protein (CRP) in blood serum using
COBAS C systems, Roche Diagnostics GmbH).
The severity of postoperative pain syndrome was
analysed in study groups 2, 5, 24, 48 and 72 hours after
the end of the surgical intervention. For the assessment
of pain in the postoperative period, the Wong-Baker pain
rating scale was used (Fig. 1). Assessment of pain: ex-
treme pain (10 and 9 points), strong (8, 7, 6 points), me-
dium (5, 4, 3 points), weak (2, 1 point), no pain
(0 points). A survey on patient satisfaction with postop-
erative pain relief was conducted 24 hours after surgery
in two response options: negative and positive. The pres-
ence of nausea, vomiting, headache, as well as medica-
tion load in the early postoperative period, were taken
into account (Fig. 1).
Fig. 1. Wong-Baker pain rating scale
The received data was processed using the
StatSoft© STATISTICA ® 10 and Microsoft® Office
Excel 2016 application package. To compare groups,
non-parametric criteria were used: the significance of
differences was assessed using the Mann-Whitney test
(U-test). In addition, the Pearson test (χ2) was used to
compare the qualitative characteristics. Differences were
considered significant at p<0.05.
3. Results
Initial hemodynamic parameters in patients in the
studied groups were comparable and were within the
physiological norm. The intraoperative period in both
groups proceeded against the background of relatively
stable systemic hemodynamics, which can be explained
by using one type of anaesthesia in the study groups.
However, the following trends were noted: in pa-
tients of the leading group at the 2nd and 3rd stages of
the study, there was an unreliable decrease in the average
values of average arterial pressure by 4.5 % and 5 %
(Fig. 2). On the contrary, in the comparison group, an
increase in average arterial pressure and heart rate was
noted at the 2nd stage of the study concerning the initial
data by 7 % (p>0.05) and 10.9 % (p<0.05), respectively
(Fig. 3). At 3
rd
stage, there was a further increase in aver-
age arterial pressure and an increase in heart rate by
9.6 % (p>0.05) and 13.1 % (p<0.05) concerning the
outcome.
At the same time, at all stages of the study, the in-
dicators were within the reference values and age norms.
Intergroup comparison of hemodynamic parameters at
the stages of the study did not reveal statistically signifi-
cant differences.
These changes in hemodynamic parameters indi-
cated a sufficient degree of anaesthetic protection of the
above abdominal surgery in children.
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Fig. 2. Dynamics of mean arterial pressure at the stages of the study
Fig. 3. Dynamics of heart rate at the stages of the study
BIS+entropy (RE+SE), SPI data were registered
continuously; values in the range of 40–60 conventional
units were taken as adequate BIS+entropy (RE+SE)
values, which corresponds to the level of general anaes-
thesia on the sedation scale. SPI values ≤ 50 correspond
to clinically significant anaesthesia with a low probabil-
ity of response to painful stimulus [20].
When studying the BIS dynamics + entropy
(RE + SE), SPI in patients of both groups at the first
stage, the initial indicators corresponded to clear con-
sciousness and were within 98; at the second stage – the
traumatic stage of the operation – there was a significant
unidirectional decrease in both groups of values
(RE+SE), SPI by 54.1 %, 59.2 %, 61.3 % (57.2 %,
54.1 %, 61.3 %), respectively, which indicated the
achievement of a sufficient depth of sedation against the
background of combined general anaesthesia (Fig. 3, 4).
Furthermore, these BIS+entropy (RE+SE) SPI values
persisted throughout the entire period of anaesthesia and
corresponded to a sufficient depth of consciousness de-
pression. However, in the main group, there was a signif-
icant difference in the BIS+entropy (RE+SE) and SPI
values at the fifth stage from baseline by 18.4 %, 23.5 %,
and 39.8 %, indicating persistent sedation and incomplete
recovery of the level of consciousness after general an-
aesthesia.
Fig. 4. Bis+entropy (RE+SE), SPI indicators in patients of the first group
0
20
40
60
80
100
m
m
Hg
A
rt.
research stages
Dynamics of average arterial pressure at the
stages of the study
1 группа
2 группа
90
95
100
105
110
115
120
1st stage
2nd stage
3nd stage
Heart rate, min
1 group
2 group
0
50
100
150
1-STAGE
2-STAGE
3-STAGE
4-STAGE
5-STAGE
Dynamics of Bis+entropy(RE+SE), SPI in patients of the
first group
SE
RE
SPI
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The values of BIS+entropy (RE+SE) and SPI did
not have statistically significant differences in the inter-
group comparison but were statistically significantly
different from the outcome in the study groups.
Comparative analysis of blood glucose levels as a
marker of stress response at the stages of abdominal
interventions in the studied groups of patients demon-
strated unidirectional changes in glycemia characteristic
of the intraoperative period. However, their severity was
different (Fig. 5). There was a significant increase in
average blood glucose levels at the second stage of the
study in the comparison group by 47.8 % (p<0.05),
which was due to insufficient intraoperative anti-stress
protection.
Fig. 5. Bis+entropy(RE+SE), SPI indicators in patients of the second group
Fig. 6. Dynamics of glucose at the stages of the study
In the main group of patients, blood glucose dy-
namics at the study's second stage were within the ac-
ceptable operating stress norm. However, there was only
an upward trend of 10.8 % (Fig. 6). At the third stage of
the study, in the comparison group, the glucose index
remained elevated by 43.4 %. In the main group of pa-
tients, the increase in glucose was 6.5 %. The dynamics
of blood glucose levels showed the effectiveness of ke-
torolac tromethamine and paracetamol in the periopera-
tive period in preventing hormonal stress reactions dur-
ing abdominal surgeries in children.
Comparative analysis of the C-reactive protein
level (immunoturbidimetric test) in order to assess the
degree of activity of the proinflammatory cytokine cas-
cade and the adequacy of postoperative analgesia in
patients in selected groups at the first stage demonstrated
that the initial indicators in all groups corresponded to
the physiological norm, this fact shows the absence of
acute inflammation signs in the preoperative period.
However, after 24 hours, a significant increase (p<0.05)
of C-reactive protein in the blood was registered in all
the studied groups, which is associated with periopera-
tive tissue damage, activation of pathological inflamma-
tory reactions, and the release of mediators of pain sensi-
tivity. In a comparative assessment, the CRP increase in
the comparison group was 413.04 %, confirming the
well-known fact of the absence of suppressing proin-
flammatory reactions by narcotic analgesics. In the main
group of patients, changes in the CRP index were signifi-
cantly lower (p<0.05) than in the comparison group
(250 % of the initial level), so this confirmed the effec-
tiveness of PA and postoperative analgesia based on the
combined use of Paracetamol and Ketorolac trometham-
ine, due to the synergism of effects, the impact on differ-
ent levels of pain impulses, and the inflammatory re-
sponse to surgical trauma.
In the early postoperative period, differences were
found in the onset time of pain syndrome and its intensity
in patients of the studied groups. In both groups, postop-
erative pain was usually moderate or severe, accompa-
0
20
40
60
80
100
120
1-STAGE
2-STAGE
3-STAGE
4-STAGE
5-STAGE
Dynamics of Bis+entropy(RE+SE), SPI in patients of the
second group
SE
RE
SPI
0
1
2
3
4
5
6
7
8
1 stage
2 stage
3 stage
Glucose, mmol/l
comparison
group
main group
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nied by weakness, headache, malaise, anxiety, crying,
and apathy.
On the first day in patients of the first group,
2 hours after the operation, the pain was absent in 85.7 %
of patients. On average, 5 hours after surgery in patients
of the first group, severe pain (6–8 points) was detected
in 39.2 % and moderate pain (5 points) – in 60.8 % of the
subjects (Table 2). On average, 5 hours after surgery in
patients of the first group, severe pain (6-8 points) was
detected in 39.2 % and moderate pain (5 points) – in 60.8 %
of the examined patients (Table 2). Re-administration of
ketorolac after 6 hours led to a significant decrease in the
intensity of these pains and relative stabilization of he-
modynamic and respiratory parameters (blood pressure,
heart rate, respiratory rate). On the second day after sur-
gery, severe pain was detected in 21.4 % of patients, and
moderate pain (5–4 points) – in 78.6 %. On the 3rd day,
postoperative pain in this group of patients was moderate
(4.3 points) – in 17.8 %, weak (2.1 points) – in 71.4 %,
and no pain in 10.7 % of patients. Side effects (sleepi-
ness, sweating, anxiety) were observed in two
patients (7.1 %).
Table 2
Pain intensity assessment according to the Wong-Baker pain rating scale in patients of the first group (%/abs)
Days after
surgery
YOUR (points)
8
7
6
5
4
3
2
1
0
1
17,8 %
(5)
14,2 %
(4)
7,1 %
(2)
60,7 %
(17)
2
21,4 %
(6)
50 %
(14)
28,5 %
(8)
3
10,7 %
(3)
7,1 %
(2)
46,4 %
(13)
25 %
(7)
10,7 %
(3)
On the first day, in patients of the second group,
PPS resumed on average 2.5–3 hours after the surgery:
extreme and severe pain (9–6 points) was detected in
75 %, moderate (5 points) pain – in 25 % of patients
(Table 3). Approximately 30–40 minutes after the intra-
muscular injection of Promedol, there was a moderate
decrease in the intensity of these pains, and the alignment
of hemodynamic and respiratory parameters (BP, heart
rate, respiratory rate). On the 2nd day after the surgery,
severe pain was detected in 45 % of patients and moder-
ate pain (5.4 points) in 55 % of patients. On the 3rd day,
severe pain (7.6 points) was detected in 20 % of the sub-
jects, and moderate (5.4 points) in 80 %. Side effects
(excessive sleepiness, nausea, vomiting, urinary reten-
tion, intestinal paresis) were observed in three patients
(15 %). Side effects disappeared on their own after the
abolition of Promedol.
Analysis of the results of assessing satisfaction
with pain relief in the early postoperative period of ab-
dominal operations (Table 4) showed that in the first
and second groups, the number of patients satisfied with
the level of pain relief was 78.5 % and 55 %, respec-
tively. The above statistics proved the high efficiency
of multimodal PA in preventing PBS. The above statis-
tics proved the high efficiency of multimodal PA in
PPS prevention.
Table 3
Pain intensity assessment according to the Wong-Baker pain rating scale in patients of the second group (%/abs)
Days after
surgery
YOUR (points)
9
8
7
6
5
4
3
2
1
0
1
35 %
(7)
20 %
(4)
15 %
(3)
5 %
(1)
25 %
(5)
2
20 %
(4)
15 %
(3)
10 %
(2)
50 %
(10)
5 %
(1)
3
5 %
(1)
15 %
(3)
35 %
(7)
25 %
(5)
20 %
(4)
Table 4
Comparative assessment of patient satisfaction with postoperative pain relief (%/abs)
Satisfaction score
Study groups
χ2
Main, n=28
Comparison, n=20
Positive
78.5 % (22)
55.0 % (11)
Р<0.01
Negative
21.4 % (6)
45.0 % (9)
Р<0.01
4. Discussion
Nowadays, postoperative opioid analgesia is char-
acterized by a high frequency of use (up to 60 % of pa-
tients in the ICU) and high efficiency, mainly if it is
carried out according to the Western method of patient-
controlled intravenous bolus administration of morphine
(patient-controlled analgesia). However, during the last
15–20 years, enough negative information has accumu-
lated about an increase in the frequency of postoperative
complications related to the appointment of opioids and
even an increase in mortality [21, 22]. According to a
study performed on orthopaedic patients, the frequency
of complications of opioid analgesia reached 54.2 %
[23]. At the same time, 25.6 % of patients had two or
more side effects, and 7.2 % had three or more. Side
effects of opioid analgesia increased the length of stay of
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patients in the clinic by 18–80 % (depending on their
number and severity) and treatment costs by 7.4 % [24].
Furthermore, the concept of accelerated postoperative
rehabilitation of patients «Enhanced Recovery After
Surgery (ERAS)» recommends using short-term drugs
and techniques in anaesthesia schemes, with rapid post-
operative rehabilitation and the absence of complications
such as uncontrolled PBS, nausea, vomiting and exces-
sive sedation.
As a result of the research, we have established
the features of shifts in systemic hemodynamics, BIS+
entropy data (RE and SE), SPI, stress response reactions
of the div and the intensity of postoperative pain syn-
drome in patients of the main group in abdominal sur-
gery. The use of multimodal preventive analgesia with
Paracetamol and Ketorolac tromethamine avoids exces-
sive stress response of the div and reduces the intensity
of postoperative pain in patients after abdominal surgery.
While in patients of the comparison group at the 2nd and
3rd stages of anesthesia, there was an increase in the
average heart rate (10.9 % and 13.1 %) and blood glu-
cose (47.8 % and 43.4 %), which indicated insufficient
intraoperative anti-stress protection. C-reactive protein
(stage 2) remained significantly elevated (41.3 %) in the
early postoperative period, confirming the absence of
suppression of the inflammatory response to surgical
trauma in patients of the comparison group. C-reactive
protein (stage 2) remained significantly elevated (41.3 %)
in the early postoperative period, confirming the absence
of suppression of the inflammatory response to surgical
trauma in patients of the comparison group.
Our results align with the works of various au-
thors, in which the effect of opioids is considered to a
greater extent symptomatic, and non-steroidal anti-
inflammatory drugs are classified as pathogenetic drugs.
Their use does not lead to impaired consciousness and
breathing or cognitive dysfunctions. The safety of using
NSAIDs is determined by an adequate assessment of
the patient's condition, taking into account the existing
contraindications and the short duration of the appoint-
ment [25].
Thus, the advantages of the combined multimodal
method with the preventive administration of Paracetamol
and Ketorolac tromethamine at the recommended doses in
patients of the first group are apparent: the intensity of post-
operative pain syndrome decreases almost 2 times, and the
time of PPS development lengthens 2 times. Ketorolac
administration frequency decreases in the next 2 and 3 days
and improves patients' quality of life in the early postopera-
tive period without serious side effects.
Study limitations
The results of this study should be viewed in light
of some limitations. First, given the insufficient sample
size (48 patients), we pooled children from all age groups
for statistical analysis. As a result, anatomical and physi-
ological parameters and laboratory
indicators
have slight
age-related deviations. However, it should be noted that
the study was prospective; both groups were homogene-
ous in terms of age, div weight, duration of surgery,
and inclusion and exclusion criteria from the study. In
the future, we will conduct a study in different age
groups: younger, middle and older to obtain guaranteed
reasonable conclusions.
In order to assess the degree of activity of the pro-
inflammatory cytokine cascade, the adequacy of postop-
erative pain relief in patients, interleukin 6 or tumour
necrosis factor as early markers are most often studied in
world studies. However, for us the possibility of studying
cytokines in the blood became another limitation due to
the lack of reagents in the clinic at the time of the study.
Therefore, we limited ourselves to studying C-reactive
protein, which rises later than the early markers of cyto-
kines and studied it at 2 stages of outcome and 24 hours
after surgery.
Prospects for further research.
We plan to con-
duct similar studies to assess the quality of postoperative
pain relief in pediatric cardiac surgery.
5. Conclusion
1. Optimised method of preventive (preoperative)
use of paracetamol in children at a dose of 25–30 mg/kg
during abdominal surgery followed by administration of
ketorolac tromethamine (15 minutes before the end of the
surgery) increases the degree of nociceptive protection. It
ensures high efficiency of postoperative pain relief,
which allows to recommend it in the practice of periop-
erative analgesia for the above abdominal surgical inter-
ventions in children.
2. The use of multimodal preventive analgesia
with paracetamol and ketorolac tromethamine signifi-
cantly reduces the severity of stress response reactions in
the perioperative period. Reliable dynamics of C-reactive
protein levels reflect a clinically significant anti-
inflammatory effect and an expressed decrease in pain
impulses in patients of the main group.
3. The transition from the intraoperative to the
postoperative stage proceeded smoothly in 60.9 % of
patients in the main group. On average, 5 hours after
surgery, 39.1 % of patients had moderate-severe pain (8–
6 points). In the comparison group, very severe and se-
vere pain (9–6 points) resumed 2.5 hours after surgery in
75 % of patients.
4. Applying the Wong-Baker pain rating scale
makes it possible to evaluate the effectiveness of postop-
erative analgesia with the possibility of correcting anal-
gesic therapy for PPS in children after the above ab-
dominal surgical interventions.
Conflict of interests
The authors declare that they have no conflict of
interest concerning this research, whether financial, per-
sonal, authorship or otherwise, that could affect the re-
search and its results presented in this paper.
Financing
The study was performed without financial support.
Scientific
Journal «ScienceRise
:
Medical Science» №5(50)2022
15
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Received date 04.08.2022
Accepted date 27.09.2022
Published date 30.09.2022
Elmira Satvaldieva
*
,
Professor, Scientific Adviser, National Children's Medical Center, Parkent str., 294,
Tashkent, Uzbekistan, 100207, Professor, Head of Department, Children's Anaesthesiology and Resuscitation
Department, Tashkent Pediatric Medical Institute, Bagishamal str., 223, Tashkent, Uzbekistan, 100140
Eldor Turgun ugli Kuralov,
Anesthesiologist
,
National Children's Medical Center
,
Parkent str., 294, Tashkent,
Uzbekistan, 100207
*Corresponding author:
Satvaldieva Elmira, e-mail: elsatanest@mail.ru
