Regional anesthesia for children undergoing orthopedic ambulatory surgeries in the United States, 1996-2006

Severity and associated factors of postoperative pain in paediatric surgical patients aged 2 months-7 years at selected Addis Ababa Public Hospitals: a multicenter prospective longitudinal study

Background

Postoperative pain is a common and distressing consequence of surgery in children. It can lead to suffering, prolonged recovery, impaired physical functioning, and even chronic pain. Effective postoperative pain management is crucial for improving patient outcomes. However, several factors hinder the accurate assessment and management of pain in children, particularly in low-income countries. This study aims to evaluate the severity of postoperative pain in paediatric patients and identify its predictors.

Materials and methods

A longitudinal study was conducted on 235 paediatric surgical patients aged 2 months-7 years in Public Hospitals of Addis Ababa from January to April 2023. The primary outcome, pain severity, was assessed at three different times using a pain assessment tool. Cochran's q-test was used to compare postoperative pain incidences. The Generalized Estimating Equation was used to determine predictor variables' effects on pain severity over time. The study demonstrated the direction of association and significance using an AOR with a 95% CI at a P value of 0.05.

Result

The incidence of moderate to severe postoperative pain was 36.6% at 12 h, 20% at 24 h, and 10% at 36 h. Patients with preoperative pain and preoperative anxiety were more likely to experience moderate to severe postoperative pain [adjusted odds ratio (AOR)=3.41, CI=1.15, 10.00 and AOR=2.28, CI=1.219, 4.277, respectively). Intraoperative predictors of postoperative pain severity included longer duration of surgery (AOR=6.62, CI=1.90, 23.00) and major surgery (AOR=5.2, CI=2.11, 12.88). Postoperative pain severity was reduced in patients receiving multimodal analgesia (AOR=0.24; CI=0.091, 0.652) and in patients assessed frequently in the postoperative period (AOR=0.09; CI=0.022, 0.393).

Conclusion

A significant portion of paediatric surgical patients in this study experienced high levels of postoperative pain, particularly within the first 24 h. The most influential factors affecting pain severity were postoperative pain management strategies and assessment practices.

Variability in Pain Management Practices for Pediatric Anterior Cruciate Ligament Reconstruction

BACKGROUND

The opioid epidemic in the United States is a public health crisis. Pediatric orthopaedic surgeons must balance adequate pain management with minimizing the risk of opioid misuse or dependence. There is limited data available to guide pain management for anterior cruciate ligament reconstruction (ACLR) in the pediatric population. The purpose of this study was to survey current pain management practices for ACLR among pediatric orthopaedic surgeons.

METHODS

A cross-sectional survey study was conducted, in which orthopaedic surgeons were asked about their pain management practices for pediatric ACLR. The voluntary survey was sent to members of the Pediatric Orthopaedic Society of North America. Inclusion criteria required that the surgeon perform anterior cruciate ligament repair or reconstruction on patients under age 18. Responses were anonymous and consisted of surgeon demographics, training, practice, and pain management strategies. Survey data were assessed using descriptive statistics.

RESULTS

Of 64 included responses, the average age of the survey respondent was 48.9 years, 84.4% were males, and 31.3% practiced in the southern region of the United States. Preoperative analgesia was utilized by 39.1%, 90.6% utilized perioperative blocks, and 89.1% prescribed opioid medication postoperatively. For scheduled non-narcotic medications postoperatively 82.8% routinely advocated and 93.8% recommended cryotherapy postoperatively.Acetaminophen was the most used preoperative medication (31.3%), the most common perioperative block was an adductor canal block (81.0%), and the most common postoperative analgesic medication was ibuprofen (60.9%). Prior training or experience was more frequently reported than published research as a primary factor influencing pain management protocols.

CONCLUSIONS

Substantial variability exists in pain management practices in pediatric ACLR. There is a need for more evidence-based practice guidelines regarding pain management.

LEVEL OF EVIDENCE

Level V.

Pediatric lower limb peripheral nerve blocks: Indications, effectiveness, and the incidence of adverse events

AIM

While the proportion of pediatric anesthetics with regional anesthesia in pediatric patients has steadily increased, there are only a few series that describe the use of lower limb peripheral nerve blocks in children. Our aim was to describe the indications, anesthetic approach, and complications associated with lower limb blocks in children undergoing orthopedic surgery in a center with a large caseload of complex patients.

METHODS

In a retrospective analysis of prospectively collected data, we reviewed children who had a peripheral nerve block for orthopedic surgery placed between January 2016 and January 2021 at the Royal Children's Hospital Melbourne. Block data were sourced from the electronic medical record and departmental regional anesthesia database. Data collected included demographics, the site of catheter placement and technique of nerve block, presence of sensory/motor blockade, the use of perioperative opioids, and any complications related to peripheral nerve block.

RESULTS

A total of 1438 blocks were performed in 1058 patients. Four patients had clinical features of perioperative neurological injury giving an incidence of 3 per 1000 blocks (95% CI 1.1-8:1000). Only one patient had a sensory deficit persisting longer than 6 months for an incidence of 0.8 per 1000 blocks (95% CI 0.1-5:1000). All four peripheral nerve injury followed tibial osteotomy for lengthening procedures or correction of tibial torsion. The etiology of the injury could not be determined despite imaging and surgical exploration and the contribution of popliteal sciatic nerve block to the subsequent PNI could not be confirmed. There were no cases of local anesthetic systemic toxicity.

CONCLUSION

An increased risk of perioperative peripheral nerve injury is associated with pediatric tibial osteotomy for congenital deformity. While popliteal sciatic nerve block was not directly implicated in the nerve injury the presence of a prolonged sensory block can delay early recognition and treatment of peripheral nerve injury.

Ambulatory Pain Management in the Pediatric Patient Population

PURPOSE OF REVIEW

Outpatient surgery in the pediatric population has become increasingly common. However, many patients still experience moderate to severe postoperative pain. A poor understanding of the extent of pain after pediatric ambulatory surgery and the lack of randomized control studies of pain management of the outpatient necessitate this review of scientific evidence and multimodal analgesia.

RECENT FINDINGS

A multimodal approach to pain management should be applied to the ambulatory setting to decrease postoperative pain. These include non-pharmacological techniques, multimodal pharmacologics, and neuraxial and peripheral nerve blocks. Postoperative pain management in pediatric ambulatory surgical patients remains suboptimal at most centers due to limited evidence-based approach to postoperative pain control. Pediatric ambulatory pain management requires a multipronged approach to address this inadequacy.

Decreased Prescribing of Postoperative Opioids in Pediatric ACL Reconstruction: Treatment Trends at a Single Center

Background:

Anterior cruciate ligament (ACL) injury is common in the pediatric population. Pain control after ACL reconstruction (ACLR) presents a unique challenge due to age and early rehabilitation needs. Pain management practices are believed to have evolved in recent years to limit unnecessary exposure to risks associated with opioid use in this vulnerable population.

Purpose:

To describe trends in postoperative opioid prescribing and assess factors including obtaining consent for opioid prescribing for minors that may have mitigated excessive prescription of opioids.

Study Design:

Cohort study; Level of evidence, 3.

Methods:

This is a retrospective review of a consecutive series of pediatric patients (<18 years) undergoing primary ACLR within an urban academic hospital system over a 5-year period (2014-2018). The study period included the gradual introduction of preoperative consenting for opioid use in minors as mandated by state law in 2016. Patient characteristics, surgical details, presence of a signed consent form to prescribe opioid medications, prescribed postoperative medications, prescriber, and indicators of inadequate pain control were collected. Univariate and multivariate analyses were performed to determine factors associated with reduced postoperative opioid prescribing.

Results:

This study included 687 patients with a mean age of 15.1 ± 1.9 years, with less than one-third of patients having preoperative consent forms to prescribe opioid medications. Postoperative prescribing trends demonstrated a decline in the number of opioid doses provided and increased utilization of nonopioid medications. Patients who received preoperative opioid counseling and signed a consent form were prescribed fewer opioids and had a smaller number of unscheduled contacts for poorly controlled pain. Univariate analyses identified multiple predictors of the number of opioid doses prescribed postoperatively. Obtaining preoperative consent to prescribe opioids and ambulatory surgery center location were found to be independent predictors of prescribed doses in the multivariate analysis.

Conclusion:

The quantity of opioid medication prescribed for pain management after pediatric ACLR at our institution has declined in recent years. This appears to be, in part, related to state-mandated preoperative counseling about opioid use, signing of a consent form by the parent(s) or guardian(s) to prescribe opioids to minors, and encouragement toward the use of nonopioid medications when possible. Preoperative opioid use discussions in the pediatric population may be useful in reducing opioid overprescription and utilization in this population.

Risk of Postdural Puncture Headache in Adolescents and Adults

BACKGROUND

Spinal anesthesia is known to have numerous benefits, including reductions in nausea and opioid consumption; however, postdural puncture headache (PDPH) remains a significant risk associated with this technique. The literature specifically examining this complication in adolescents is scarce. Our primary objective was therefore (1) to estimate the incidence of PDPH with a 27G pencil-point needle in patients between the ages of 12 and 19 undergoing ambulatory lower extremity procedures and (2) to compare it to the incidence in adults aged 20-45 years.

METHODS

After institutional review board (IRB) approval, patients aged 12-45 years undergoing ambulatory lower extremity surgery were approached. Patients undergoing the procedure under combined spinal-epidural (CSE) or spinal anesthesia with a 27G pencil-point needle were eligible for enrollment. Patients were consented before surgery and received a survey via e-mail on postoperative day (POD) 4 inquiring about the presence of a headache. Each headache was described by the participant and assessed for severity, time of onset, duration, location, and whether it was of a postural nature. All patients reporting a postural headache were contacted by a physician author to confirm a diagnosis of PDPH using the International Headache Society diagnostic criteria.

RESULTS

A total of 656 patients were included in the analysis. Overall, 3.4% of patients developed PDPH. The percentage developing PDPH was 4.9% (3.0-7.8) among those aged 12-19 years and 1.8% (0.8-3.9) in the 20- to 45-year-old group. After adjusting for covariates, the age group between 12 and 19 years was associated with an almost 3-fold increase in the odds (2.8 [95% confidence interval {CI}, 1.1-7.3]) for the development of PDPH compared to that in the 20-45 age group. One patient in the adult group required an epidural blood patch.

CONCLUSIONS

The overall incidence for the development of PDPH in ambulatory patients <45 years of age is low. However, the odds for developing PDPH is significantly higher in teenagers compared to those aged 20-45 years. This increase was not associated with an increase in the need for an epidural blood patch. Providers may incorporate these data in their consent process and have a higher index of suspicion for PDPH in teenagers who report headaches after neuraxial anesthesia.

General anesthesia risk across pediatric surgical specialties: Low in otolaryngology

PURPOSE

To determine the relevance of the Food and Drug Administration (FDA) warning regarding general anesthesia (GA) in children under 3 years of age for procedures lasting longer than 3 h, by surgical specialty and for otolaryngology specifically.

METHODS

A one-year retrospective review was conducted at a tertiary-care medical center for all children younger than 3 years undergoing surgical procedures with durations greater than 3 h. De-identified data related to age, surgical service, procedure types, American Society of Anesthesiologists (ASA) physical status classification, and general anesthesia time were collected and examined.

RESULTS

During 2017, 430 of 11,757 patients (3.7%) met the age and duration of anesthesia criteria. Procedures performed by the cardiothoracic surgery service were mostly likely to result in duration of surgery greater than 3 h (46.6%), followed by neurosurgery (12.9%), cardiology (9.3%), plastic surgery (7.1%), general surgery (6.6%), and urology (5.1%). Less than 2% of patients undergoing ophthalmology (1.9%), orthopedic surgery (1.7%), and otolaryngology (0.5%) procedures required anesthesia greater than 3 h.

CONCLUSION

Less than 4% of patients younger than 3 years undergoing surgery required general anesthesia for longer than 3 h. The theoretical risks of general anesthesia per the FDA warning are discussed and must be balanced against the known functional and neurodevelopmental consequences of not performing critical and time-sensitive surgery on children in this age group. A strategy for addressing parental and provider concerns is discussed.

Postoperative Pain and Opioid Use in Children with Supracondylar Humeral Fractures: Balancing Analgesia and Opioid Stewardship

BACKGROUND

Effective postoperative analgesia remains a priority in orthopaedic surgery, but concerns with regard to opioid diversion and misuse have brought overdue attention to improving opioid stewardship. Normative data for postoperative pain and opioid use are needed to guide and balance these dual priorities. We aimed to characterize postoperative pain and opioid use for an archetypal pediatric orthopaedic procedure: closed reduction and percutaneous pinning of a supracondylar humeral fracture.

METHODS

Children at a single pediatric trauma center who underwent closed reduction and percutaneous pinning of a supracondylar humeral fracture were enrolled and were prospectively followed. Validated pain scores (Wong-Baker FACES Pain Rating Scale) and opioid utilization data were collected using an automated text message-based protocol on postoperative days 1 to 7, 10, 14, and 21. Data were analyzed with descriptive and univariate statistics.

RESULTS

Eighty-one patients with a mean age (and standard deviation) of 6.1 ± 2.1 years (62% of whom were male) were enrolled, including 53.1% who had Type-II fractures and 46.9% who had Type-III fractures. The mean pain ratings were highest on arrival to the emergency department (3.5 ± 3.5 points) and the morning of postoperative day 1 (3.5 ± 2.4 points). By postoperative day 3, the mean pain rating decreased to <2 (1.8 ± 1.8 points) and the mean opioid doses decreased to <1 dose (0.8 ± 1.2 doses). Postoperative opioid use decreased in parallel to reported pain (r = 0.972; p < 0.001). The interquartile range of opioid use was 1 to 7 doses, and patients used only 24.1% of the prescribed opioids (mean, 4.8 ± 5.6 doses used and 19.8 ± 7.1 doses prescribed). There was no significant difference (p > 0.05) in pain ratings or opioid use by fracture classification, age, or sex.

CONCLUSIONS

Following closed reduction and percutaneous pinning for supracondylar humeral fracture, pain levels and opioid usage decrease to a clinically unimportant level by postoperative day 3. Patients who report pain scores of ≥6 points following discharge are outliers and should be screened for compartment syndrome or ischemia. Patients used <25% of prescribed opioid medication, suggesting the potential for overprescription and opioid diversion. A prescription for 7 opioid doses after discharge should allow adequate postoperative analgesia in the majority of patients while improving narcotic stewardship.

LEVEL OF EVIDENCE

Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Short-term Outcomes in Pediatric Patients Managed with Peripheral Nerve Blockade for Arthroscopic Anterior Cruciate Ligament Reconstruction and/or Meniscus Surgeries

Introduction

Peripheral nerve blockade (PNB) can be a useful component of a multimodal analgesia approach in managing pain after knee arthroscopy. However, the impact of PNB and short-term recovery in pediatric patients, particularly adolescents, who underwent knee arthroscopy for anterior cruciate ligament (ACL) reconstruction and/or meniscus surgery (repair or resection) has not been well characterized. This prospective study presents observational data on short-term patient outcomes and side effects for 72 hours following discharging home of pediatric patients who underwent arthroscopic ACL and/or meniscus procedures with PNB.

Methods

This is a single-center, single-surgeon prospective observational study conducted over a three-year period. We characterized 72-hour postoperative outcomes including pain scores, return of sensation to the affected limb, analgesic use [nonsteroidal anti-inflammatory drugs (NSAIDs) and opioids], readmission rate, and activities of daily living (ADL) via telephone survey. In addition, retrospective chart review was conducted to obtain perioperative and anesthesia details. Results for surgery groups were analyzed using descriptive and Pearson correlations using the SPSS version 24 (IBM Corp. Released 2016. IBM SPSS Statistics for Mac, Version 24.0. Armonk, NY, USA).

Results

We collected data on 47 patients undergoing ACL reconstruction with or without meniscus surgery (18/47, 38.3%) or meniscus surgery only (29/47, 61.7%). At 72 hours postsurgery, there were no readmissions or complications related to pain. Median-reported pain scores were 2.5 and 5.0 for the ACL and meniscus groups, respectively. A majority of patients continued to require opioids (45/47, 95.7%) and NSAIDs (46/47, 97.9%) at 72 hours postsurgery, but the number of daily opioid doses taken decreased with each day postoperatively. Over 93% of the patients could ambulate and shower at 72 hours postsurgery.

Conclusions

Regional nerve block appears to be an effective and safe analgesic strategy for pediatric arthroscopic ACL and meniscus procedures, with no short-term complications or readmissions related to pain in our cohort. Future prospective investigation is needed to characterize long-term pain outcomes in this surgical population.

Combined Femoral-Sciatic Nerve Block is Superior to Continuous Femoral Nerve Block During Anterior Cruciate Ligament Reconstruction in the Pediatric Population

BACKGROUND

Despite advancements in minimally invasive arthroscopic surgical techniques, post-operative pain management following ACL reconstruction remains a concern. This study compares the effectiveness of two common intraoperative pain management strategies - a femoral nerve catheter (FC) versus a combined femoral nerve catheter and single injection sciatic nerve block (FSB) - in pediatric patients undergoing ACL reconstruction.

METHODS

The medical records of patients age 8 to 18 who underwent ACL reconstruction at our institution were reviewed retrospectively. All subjects underwent general anesthesia with either FC or FSB. Multivariable linear regression, or modified Poisson regression were used to compare outcome variables across groups. Propensity scores were used to minimize bias due to the non-randomized allocation of the regional anesthesia protocol.

RESULTS

The study population included 18 subjects in the FC group and 32 subjects in the FSB group. There was no difference in incidence of nausea or opioid prescription refill requests between groups. Total intravenous (IV) morphine equivalent dose, maximum numerical rating scale (NRS) pain score, and percentage of subjects requiring one or more opioid doses in the PACU were significantly greater in the FC group relative to the FSB group. PACU length of stay (LOS) was also significantly greater in the FC group than the FSB group.

CONCLUSION

This study suggests that FSB may be a more effective pain management technique for reducing the total IV morphine equivalent dose, maximum NRS pain scores, number of PACU postoperative opioid doses, and PACU LOS following ACL reconstruction in the pediatric population.Level of Evidence: III.

Outpatient Pediatric Orthopedic Surgery

Outpatient surgery refers to a surgical procedure that is performed without an overnight stay in a hospital. Outpatient surgery is associated with decreased individual and societal costs while achieving equivalent health outcomes and excellent patient satisfaction. Successful outpatient pediatric surgery is predicated on appropriate patient selection, adequate pain control, thorough preoperative education, and close clinical follow-up. Continuous research in quality, value, and patient safety are needed to ensure that this practice continues in as safe and efficient a manner as possible.

Pediatric Perioperative Pain Management

Effective perioperative pain control in pediatric patients undergoing orthopedic surgery remains a challenge. Developing a successful pain control regimen begins preoperatively with assessment of the patient and discussion with the patient and family regarding expectations. Perioperative pain control regimens are customized based on the type of surgery, patient characteristics, and anticipated severity and duration of the postoperative pain. Recent study focuses on multimodal strategies and regional anesthesia options, allowing for decreased opioid use. This article provides an evidence-based overview of preoperative, intraoperative, and postoperative pain control for the pediatric orthopedic patient.

Post-Dural Puncture Headache is Uncommon in Young Ambulatory Surgery Patients

BACKGROUND

The incidence of post-dural puncture headache (PDPH) arising from spinal anesthesia in the general population is low. However, patients under 45 years have been shown to exhibit a higher incidence of PDPH, even with small needles.

QUESTIONS/PURPOSES

This study aimed to estimate the incidence of PDPH from a 27G pencil-point needle in ambulatory surgery patients between the ages of 15-45 years and compare incidence of PDPH by age group, sex, and history of headache.

METHODS

In this prospective cohort study, 300 patients (15-45 years old) who underwent simple knee arthroscopy under spinal anesthesia with a 27G pencil-point needle were enrolled. Verbal consent was obtained during the initial phone conversation between post-operative days (PODs) 2-5. A PDPH questionnaire was administered during this conversation and between PODs 7-10. Patients who reported a positional headache were contacted by a physician co-investigator, who determined PDPH diagnosis.

RESULTS

Five patients were excluded from analysis due to complicated operative procedures or spinal needle size. The overall PDPH incidence was 2.0% (95% CI 0.9-4.4; 6/295). PDPH incidence in 15-19-year-old patients was 16.7% (95% CI 4.7-44.8; 2/12). The crude relative risk of PDPH was 15.4 (95% CI 2.8-114.4) for patients with and without history of headache and 2.5 (95% CI 0.5-14.8) for females vs. males. Overall, 16.3% (95% CI 12.5-20.9) of patients reported post-operative, non-positional headaches.

CONCLUSIONS

There was a low overall incidence of PDPH among patients aged 15-45. Pre-planned subgroup analyses of PDPH incidence by age group revealed a high risk of PDPH among a small sample of 15-19-year-olds.

Regional anesthesia in pediatrics: marching forward

PURPOSE OF REVIEW

This review highlights new data and current trends of well tolerated and effective paediatric regional anesthesia. Historically, the practice of paediatric regional anesthesia was based largely on information from adult studies, but recent literature contains information on paediatric specific risks and benefits of old and new techniques as well as the impact of new ideas and technologies.

RECENT FINDINGS

Excellent pain relief with regional anesthesia is well demonstrated in children. Several databases of paediatric regional anesthesia (over 46,000 regional anesthetics) demonstrate overall safety and lack of major complications. Detailed analysis demonstrates additional safety and decreased failure rates of peripheral compared with neuraxial nerve blocks. Ultrasound technology confers additional safety and efficacy benefits.Increasingly, data support the safety and efficacy of novel peripheral nerve blocks, transversus abdominis plane and ultrasound-guided paravertebral, and the use of perineural catheters for both inpatients and outpatients. Regional anesthesia as a sole agent for surgical anesthesia and the use of regional anesthesia for pain in nonsurgical pain patients remains underutilized.

SUMMARY

Paediatric specific data for regional anesthesia are available to help guide optimal pain management. The paediatric regional anesthesia literature lags behind literature available for adult populations and increased studies are needed for additional information for informed decision-making.

Pediatric pain management: a review

Although the occurrence of pain in hospitalized children is common, assessment and treatment of pain presents unique challenges to practitioners who care for pediatric patients. Knowledge of drug mechanisms as well as metabolic differences in infants and children compared with adults is necessary for the successful treatment of acute and chronic pain syndromes. Recent reports of adverse events in children receiving both opioid and non-opioid analgesics have prompted re-examination of some long standing pain medication regimens and prescribing practices. We review advances in diagnosis and management of pain in pediatric populations.