INFILTRATIVE ANALGESIA OF THE SKIN FLAP IN CHILDREN WITH CRANIOSYNOSTOSIS AFTER RECONSTRUCTIVE SURGERY ON SKULL BONES

The objective of the study is to evaluate the effectiveness of analgesia by infiltration of the skin flap with local anesthetic in children with craniosynostosis after reconstructive surgery� Materials and subjects. 50 children with craniosynostosis, who underwent reconstructive surgery on skull bones, were divided into two groups based on the method of postoperative anesthesia: in Group 1(experimental), the infiltration of the skin flap was used within multimodal anesthesia, while in Group 2, it was standard parenteral use of analgesic drugs� In the postoperative period, pain severity was assessed by FLACC scales, the amount of opioid and non-opioid analgesics consumed was assessed by the formalized Analgesiс Assessment Scale (FSA), and non-invasive hemodynamic monitoring (BP, HR) was performed� Results. The statistical analysis of the results revealed significant differences between groups in the assessment results of FSA and FLACC scales� In Group 1, the level of postoperative pain was significantly lower compared to Group 2� The amount of opioid and non-opioid analgesics consumed was also significantly lower in Group 1� Conclusion. The use of the infiltration of the skin flap as part of multimodal analgesia in children with craniosynostosis, after reconstructive surgery on skull bones significantly reduces the intensity of pain and the amount of opioid analgesics consumed in the postoperative period�


Материалы и методы
Дизайн: проспективное когортное исследование� Критерии включения: реконструктивные оперативные вмешательства на костях черепа, единая тактика оперативного лечения и единая хирургическая бригада� Период набора материала 01�10�2017 -01�10�2018 гг� Критерии исключения: малоинвазивные, эндоскопические оперативные вмешательства, аллергия на местный анестетик ропивакаин� Проанализированы данные о 50 последовательно оперированных больных в указанный период� Всем пациентам выполняли фронтоорбитальную реконструкцию, заключающуюся в ремоделировании костей черепа до получения нормоцефалии и вос-treatment� In addition, surgical treatment is indicated in the case of significant cosmetic defects since they provide a negative impact on the psycho-emotional state of the child [2,8,11,12]� Radical-reconstructive surgery of craniosynostosis is of long continuance and highly traumatic and it causes massive blood loss [2,9]� The surgeon affects numerous reflexogenic zones, which contributes to the development of high-intensity pain in the postoperative period� Due to the young age of the patients (from 1 month up to 3 years old), the intensity of pain may be inaccurately assessed and consequently lead to inadequate therapy [4,6]� Very often, in the early postoperative period, the medical staff ignores the anxiety and crying of the child, although these important signs may indicate the suffering and pain in young patients [6]� The use of opioid analgesics often leads to excessive sedation, nausea, vomiting and refusal to eat, which negatively affects the overall condition and postoperative recovery� Therefore, it is promising to use different regional methods in this group of pa-tients� Numerous studies report the effectiveness of various methods of regional analgesia in neurosurgical operations in children, including the treatment of craniosynostosis [7,10]� These facts led us to our own prospective study�

Рис. 3. Почасовое изменение интенсивности боли, измеренной по шкале FLACC в группах 1 и 2
Время после операции (часы) Оценка по шкале FLACC (баллы) 2) Consumption of analgesics as per formalized Analgesiс Assessment Scale (FSA) [3], 3) Non-invasive hemodynamic monitoring: systolic, diastolic, mean blood pressure, and HR� The investigated parameters were assessed by a duty intensive care specialist, who did not take part in this study� Assessment of pain intensity, hemodynamic monitoring and parameters of the acid-base state were assessed in 2, 6, 8 hours after extubation� The first measurement of pain intensity was performed 2 hours after extubation, this time coincided with a complete cessation of sedation� The amount of consumed analgesics was estimated every 4 hours� All investigated parameters were entered into the database� Statistical processing was performed using the Statistica 10�0 package� The following methods were used in the analysis: estimation of parameters of descriptive statistics, check of normality of distribution (Shapiro-Wilk test)� For comparison of variables between groups, nonparametric tests (Whitney-Mann Test) were used; for intergroup comparison, graphical results were presented as Mean±SD (mean + mean square deviation)� The results were considered statistically significant at the critical level of statistical significance p<0�05�

Вывод
Использование инфильтрации кожного лоскута в составе мультимодальной анальгезии у детей с краниосиностозом после реконструктивных операций на костях черепа значительно снижает интенсивность боли и количество потребляемых наркотических анальгетиков в послеоперационном периоде� sociated with the action of sedative drugs� Intergroup differences were significant (BP systolic: Z -criterion 3�6; BP diast� Z -criterion of 4�0; HR Z -criterion 4�2, p=0�000)� When comparing the mean BP during the observation time in Group 1, the mean values were higher� Figure 4 demonstrates the change in the average BP during the observation time� Lower values in Group 2 were directly associated with high consumption of opioid analgesics and sedation� The results demonstrated that hemodynamic parameters were not always significantly correlated with the intensity of pain� Thus for effective analgesic therapy it is necessary to use pain scales corresponding to the patient's age�

Conclusion
The use of the infiltration of the skin flap as part of multimodal analgesia in children with craniosynostosis, after reconstructive surgery on skull bones significantly reduces the intensity of pain and amount of opioid analgesics consumed in the postoperative period�

Fig. 3 .
Fig. 3. Hourly change in pain intensity measured by FLAC scale in Groups 1 and 2Time after surgery (hours)