Fentanyl sparing effects of combined ketorolac and acetaminophen for outpatient inguinal hernia repair in children

Impact of Ketorolac on Reoperation for Hemorrhage After Pediatric Tonsillectomy: A Single-Center Retrospective Propensity-Matched Study

OBJECTIVE

To determine if perioperative ketorolac is associated with an increased rate of reoperation for hemorrhage after pediatric tonsillectomy at 30 days and 48 hours.

STUDY DESIGN

Single-center retrospective propensity-matched study.

SETTING

Quaternary pediatric hospital and ambulatory surgery center.

METHODS

Patients less than 18 years old undergoing tonsillectomy or adenotonsillectomy between January 1, 2015 and October 1, 2020 were included. Hemorrhage rates between exposed (K+) and unexposed (K-) patients were calculated for the total cohort and a 1:1 propensity-matched cohort. Additional analyses included: multivariable logistic regression, subgroup analysis of ASA 1 and 2 patients, subgroup analysis comparing children with teenagers.

RESULTS

There were 5873 patients (42.1% K+) in the full cohort and 4694 patients in the propensity-matched cohort. Reoperation for hemorrhage within 30 days occurred in 1.9% of K+ patients and 1.6% of K- patients (P = 0.455) in the full cohort and 1.9% of K+ patients and 1.7% of K- patients (odds ratio [OR] 1.10, 95% confidence interval [CI] 0.72-1.69, P = 0.662) in the propensity-matched cohort. Reoperation within 48 hours occurred in 0.65% of K+ patients and 0.53% of K- patients (P = 0.679) in the full cohort and 0.68% of K+ patients and 0.51% of K- patients (OR 1.33, 95% CI 0.63-2.81, P = 0.451) in the propensity-matched cohort. There was no association between perioperative ketorolac administration and reoperation for hemorrhage in any of the other analyses.

CONCLUSION

Ketorolac at end of surgery should be considered as part of the nonopioid analgesic regimen for pediatric tonsillectomy.

Pain-related hospitalization and emergency room visit following initial analgesic prescription after outpatient surgery

PURPOSE

Our study examined the association between outpatient postsurgical analgesic prescription and risk of insufficiently managed pain characterized by pain-associated hospital admission and emergency room (ER) visit.

METHODS

Eligible individuals were children 1-17 years of age who filled an incident analgesic following an outpatient surgery during 2013-2018. Pain-associated hospital admission or ER visit were measured within 30 days following the outpatient surgical procedure. A hierarchical multivariable logistic regression model with patients nested under prescribers was fitted to test the association between incident analgesic prescription and risk of having pain-associated hospital admission or ER visit.

RESULTS

Of 14 277 children meeting the inclusion criteria, 6224 (43.6%) received an incident opioid and 8053 (56.4%) received an incident non-opioid analgesic prescription respectively. There were a total of 523 (3.7%) children undergoing surgical procedures that had pain-related hospital admissions or ER visits with 5.1% initiated on non-opioid analgesics and 1.8% on opioid analgesics. The multilevel model indicated that initial opioid analgesic recipients were 32% less likely of having a pain-associated hospital admission or ER visit [aOR: 0.68 (95% CI: 0.3-0.8)].

CONCLUSION

Majority of postsurgical patients do not require additional pain management strategies. In the 3.7% of patients requiring additional pain management strategies, those initiated on non-opioid analgesics are more likely to have a pain-associated hospital admission or ER visit compared with their opioid recipient counterparts.

Intravenous acetaminophen for postoperative pain control after open abdominal and thoracic surgery in pediatric patients: a systematic review and meta-analysis

Pediatric opioid exposure increases short- and long-term adverse events (AE). The addition of intravenous acetaminophen (IVA) to pediatric pain regimes to may reduce opioids but is not well studied postoperatively. Our objective was to quantify the impact of IVA on postoperative pain, opioid use, and AEs in pediatric patients after major abdominal and thoracic surgery. Medline, Embase, CINAHL, Web of Science, and Cochrane Library were searched systematically for randomized controlled trials (RCTs) comparing IVA to other modalities. Five RCTs enrolling 443 patients with an average age of 2.12 years (± 2.81) were included. Trials comparing IVA with opioids to opioids alone were meta-analyzed. Low to very low-quality evidence demonstrated equivalent pain scores between the groups (-0.23, 95% CI -0.88 to 0.40, p 0.47) and a reduction in opioid consumption (-1.95 morphine equivalents/kg/48 h, 95% CI -3.95 to 0.05, p 0.06) and minor AEs (relative risk 0.39, 95% CI 0.11 to 1.43, p 0.15). We conclude that the addition of IVA to opioid-based regimes in pediatric patients may reduce opioid use and minor AEs without increasing postoperative pain. Given the certainty of evidence, further research featuring patient-important outcomes and prolonged follow-up is necessary to confirm these findings.

Perioperative opioid use in paediatric inguinal hernia patients: A systematic review and retrospective audit of practice

BACKGROUND

Opioids play a major role in postoperative pain management in children, but their administration remains an under investigated topic. This study aimed to describe perioperative opioid prescribing practices for paediatric inguinal hernia patients in the literature and at The Royal Children's Hospital (RCH) in Melbourne, Australia.

MATERIAL/METHOD

A systematic review of English articles (published from 2009 to 2019) was conducted on paediatric (0-18y) inguinal hernia patients who received a postoperative or discharge opioid prescription, or both. The review was combined with a retrospective audit of RCH patients. Demographic, surgical, and analgesic details were collected from the electronic medical records.

RESULTS

Fifteen studies (n = 1166; combined mean age 4.93y) met the systematic review criteria. The percentage of patients receiving opioids postoperatively overall ranged from 3.33-100%, and doses ranged from 0.07 to 0.35 mg/kg oMEDD. At the RCH, perioperative opioid use was analyzed from 150 inguinal hernia patients (male - 113, median age - 3 months old). Postoperatively, 26 (17.3%) patients received opioids. The most commonly administered opioids were fentanyl (0.04-0.60 mg/kg oMEDD) in the post anaesthesia care unit and oxycodone (0.14-0.40 mg/kg oMEDD) in the first 24 h postoperatively. Older age at surgery, female sex and absence of regional anaesthesia were significantly associated with higher risk of total opioid use. No patients received an opioid prescription at discharge.

CONCLUSION

There is demonstratable variability in opioid prescribing practices for paediatric inguinal hernia patients as described in the literature. At our institution opioids were not used frequently in postoperative period.

Opioid reduction and elimination in pediatric surgical patients

INTRODUCTION

Opioid overuse is a national concern. Mitigation strategies include judicious prescribing and encouragement of non-opioid therapies. This quality improvement project aimed to identify physician opioid prescribing and patient usage patterns at a pediatric academic center.

METHODS

Patients who underwent same-day general, orthopedic, or plastic surgery procedures were contacted 7 - 28 days post-operatively. Inquiries were made about opioid usage, non-opioid strategies, and overall pain management satisfaction. A subset of general surgery patients not prescribed opioids was compared to those prescribed opioids.

RESULTS

Between August 2017 - May 2020, 558 surveys were obtained. There was a significant increase in the use of non-opioid therapies between 2017 and 2020 (83.5% vs 97%, p=0.04). Almost all patients' opioid prescriptions were filled; however, 78-98% had leftover opioids. Only 20-25% disposed the excess opioids. In subset analysis of general surgery patients, no inguinal hernia or orchiopexy patient who was discharged without opioids required opioids later. More non-opioid patients used other therapies (acetaminophen, heat (p=0.03)); however, pain management satisfaction was higher in the opioid group (99% vs 94%, p=0.01).

CONCLUSION

While our opioid prescribing has decreased, physicians are still prescribing more opioids than patients require. Further education on non-opioid pain therapies and proper disposal of opioids are needed.

LEVEL OF EVIDENCE

III TYPE OF STUDY: prospective quality improvement study.

Does Intravenous Acetaminophen Reduce Opioid Requirement in Pediatric Emergency Department Patients With Acute Sickle Cell Crises?

OBJECTIVE

We evaluated the ability of intravenous (IV) acetaminophen to reduce the amount of opioid medication administered in pediatric patients with sickle cell disease (SCD) having vasoocclusive crisis (VOC) in an emergency department (ED) setting.

METHODS

This was a prospective, randomized, double-blind placebo-controlled trial at an academic urban pediatric ED. Participants included patients with SCD, aged 4 to 16 years, with VOC pain. All patients received a 0.1 mg/kg dose of IV morphine, 0.5 mg/kg ketorolac, or both. Patients were randomized to receive either 15 mg/kg IV acetaminophen or placebo. Patients were reassessed every 30 minutes to see whether additional opioid doses were indicated to a maximum of three doses. The total morphine given, pain scores, rates of admissions, 72-hour return visits, and adverse events were assessed for each group.

RESULTS

Of 71 subjects randomized, 35 patients in the acetaminophen group and 36 patients in the control group were analyzed. Baseline characteristics and initial pain scores were similar in both groups. The mean total amount of morphine given was 8.6 mg (95% confidence interval [CI] = 6.5 to 10.8) in the acetaminophen group and 8.0 mg (95% CI = 5.9 to 10.2) in the placebo group. The mean total cumulative morphine dosing was 0.2 mg/kg (95% CI = 0.1 to 0.2 mg/kg) in the acetaminophen group and 0.2 mg/kg (95% CI = 0.1 to 0.2 mg/kg) in the control group. The mean pain score at time of disposition was 5.5 (95% CI = 4.3 to 6.6) in the acetaminophen group and 5.2 (95% CI = 4.2 to 6.3) in the placebo group. There were no clinical or statistically significant differences between the rates of admission, 72-hour return visits, or adverse events.

CONCLUSION

In this study, patients who received IV acetaminophen did not receive less morphine than patients in the placebo group. Disposition pain scores for the two groups were also equivalent. We conclude that IV acetaminophen, when used in addition to morphine for pediatric sickle cell VOC pain, does not provide an opioid-sparing effect. Further searches for adjunctive nonaddictive pain medicines are indicated.

Current State of Analgesia and Sedation in the Pediatric Intensive Care Unit

Critically ill pediatric patients often require complex medical procedures as well as invasive testing and monitoring which tend to be painful and anxiety-provoking, necessitating the provision of analgesia and sedation to reduce stress response. Achieving the optimal combination of adequate analgesia and appropriate sedation can be quite challenging in a patient population with a wide spectrum of ages, sizes, and developmental stages. The added complexities of critical illness in the pediatric population such as evolving pathophysiology, impaired organ function, as well as altered pharmacodynamics and pharmacokinetics must be considered. Undersedation leaves patients at risk of physical and psychological stress which may have significant long term consequences. Oversedation, on the other hand, leaves the patient at risk of needing prolonged respiratory, specifically mechanical ventilator, support, prolonged ICU stay and hospital admission, and higher risk of untoward effects of analgosedative agents. Both undersedation and oversedation put critically ill pediatric patients at high risk of developing PICU-acquired complications (PACs) like delirium, withdrawal syndrome, neuromuscular atrophy and weakness, post-traumatic stress disorder, and poor rehabilitation. Optimal analgesia and sedation is dependent on continuous patient assessment with appropriately validated tools that help guide the titration of analgosedative agents to effect. Bundled interventions that emphasize minimizing benzodiazepines, screening for delirium frequently, avoiding physical and chemical restraints thereby allowing for greater mobility, and promoting adequate and proper sleep will disrupt the PICU culture of immobility and reduce the incidence of PACs.

Guidelines for Opioid Prescribing in Children and Adolescents After Surgery: An Expert Panel Opinion

IMPORTANCE

Opioids are frequently prescribed to children and adolescents after surgery. Prescription opioid misuse is associated with high-risk behavior in youth. Evidence-based guidelines for opioid prescribing practices in children are lacking.

OBJECTIVE

To assemble a multidisciplinary team of health care experts and leaders in opioid stewardship, review current literature regarding opioid use and risks unique to pediatric populations, and develop a broad framework for evidence-based opioid prescribing guidelines for children who require surgery.

EVIDENCE REVIEW

Reviews of relevant literature were performed including all English-language articles published from January 1, 1988, to February 28, 2019, found via searches of the PubMed (MEDLINE), CINAHL, Embase, and Cochrane databases. Pediatric was defined as children younger than 18 years. Animal and experimental studies, case reports, review articles, and editorials were excluded. Selected articles were graded using tools from the Oxford Centre for Evidence-based Medicine 2011 levels of evidence. The Appraisal of Guidelines for Research & Evaluation (AGREE) II instrument was applied throughout guideline creation. Consensus was determined using a modified Delphi technique.

FINDINGS

Overall, 14 574 articles were screened for inclusion, with 217 unique articles included for qualitative synthesis. Twenty guideline statements were generated from a 2-day in-person meeting and subsequently reviewed, edited, and endorsed externally by pediatric surgical specialists, the American Pediatric Surgery Association Board of Governors, the American Academy of Pediatrics Section on Surgery Executive Committee, and the American College of Surgeons Board of Regents. Review of the literature and guideline statements underscored 3 primary themes: (1) health care professionals caring for children who require surgery must recognize the risks of opioid misuse associated with prescription opioids, (2) nonopioid analgesic use should be optimized in the perioperative period, and (3) patient and family education regarding perioperative pain management and safe opioid use practices must occur both before and after surgery.

CONCLUSIONS AND RELEVANCE

These are the first opioid-prescribing guidelines to address the unique needs of children who require surgery. Health care professionals caring for children and adolescents in the perioperative period should optimize pain management and minimize risks associated with opioid use by engaging patients and families in opioid stewardship efforts.

Utility of a Team-Based Multimodal Opioid Reduction Protocol for the Pediatric Plastic Surgery Population

Opioid use can cause significant adverse side effects with increased propensity toward both short- and long-term complications in the pediatric population. We present a multifaceted opioid reduction protocol based on physician and care team member education. The strategy was designed to alter prescribing practices, improve preoperative and postoperative patient education, increase the use of nonnarcotic pain control modalities, and improve coordination of opiate reduction strategies for all team members participating in patient care. We present the utility of this strategy in limiting postoperative narcotic use in the pediatric plastic surgery population.A prospective study with historical controls was conducted to evaluate pediatric patients undergoing elective pediatric plastic surgery procedures at 3-month intervals in 2016, 2017, and 2018. In the final year, the dedicated opiate reduction protocol was implemented before the data collection period, and results were compared with the prior 2 collection periods. The primary outcomes were total days and doses of outpatient narcotics prescribed after surgery.The median days (quartiles) of opioids prescribed in 2016, 2017, and 2018 cohorts were 1.5 (1.1, 2.5) days, 1.5 (1.4, 2.5) days, and 0.8 (0, 1.6) days, respectively. The median doses (quartiles) of opioids prescribed in 2016, 2017, and 2018 cohorts were 6.3 (6, 10), 6.0 (5.7, 15.0), and 4.2 (0, 6.2) doses, respectively. There were statistically significantly less days and doses of opioids prescribed in the 2018 cohort when compared with the 2016 (P < 0.0001) and 2017 (P < 0.0001) cohorts.A multimodal opioid reduction protocol was successfully implemented for the pediatric plastic surgery population. Patients were able to shorten the duration of narcotic prescription upon discharge with the use of a multidisciplinary team approach.

Intravenous Paracetamol in Adjunct to Intravenous Ketoprofen for Postoperative Pain in Children Undergoing General Surgery: A Double-Blinded Randomized Study

Background and objectives: The combination of non-steroidal anti-inflammatory drugs and paracetamol is widely used for pediatric postoperative pain management, although the evidence of superiority of a combination over either drug alone is insufficient. We aimed to find out if intravenous (i.v.) paracetamol in a dose of 60 mg kg^-1 24 h^-¹, given in addition to i.v. ketoprofen (4.5 mg kg^-1 24 h^-¹), improves analgesia, physical recovery, and satisfaction with postoperative well-being in children and adolescents following moderate and major general surgery. Materials and Methods: Fifty-four patients were randomized to receive either i.v. paracetamol or normal saline as a placebo in adjunct to i.v. ketoprofen. For rescue analgesia in patients after moderate surgery, i.v. tramadol (2 mg kg^-¹ up two doses in 24 h), and for children after major surgery, i.v. morphine-patient-controlled analgesia (PCA) were available. The main outcome measure was the amount of opioid consumed during the first 24 h after surgery. Pain level at 1 and over 24 h, time until the resumption of normal oral fluid intake, spontaneous urination after surgery, and satisfaction with postoperative well-being were also assessed. Results: Fifty-one patients (26 in the placebo group and 25 in the paracetamol group) were studied. There was no difference in required rescue tramadol doses (n = 11 in each group) or 24-h morphine consumption (mean difference (95% CI): 0.06 (⁻0.17; 0.29) or pain scores between placebo and paracetamol groups. In patients given morphine-PCA, time to normal fluid intake was faster in the paracetamol than the placebo subgroup: median difference (95% CI): 7.5 (1.3; 13.7) h, p = 0.02. Parental satisfaction score was higher in the paracetamol than the placebo group (mean difference: ⁻1.3 (⁻2.5; ⁻0.06), p = 0.04). Conclusions: There were no obvious benefits to opioid requirement or analgesia of adding regular intravenous paracetamol to intravenous ketoprofen in used doses. However, intravenous paracetamol may contribute to faster recovery of normal functions and higher satisfaction with postoperative well-being.

Perioperative Ketorolac Use and Postoperative Hematoma Formation in Reduction Mammaplasty: A Single-Surgeon Experience of 500 Consecutive Cases

BACKGROUND

In light of the escalating opioid crisis, surgeons are increasingly focused on minimizing opioid use. Ketorolac has well-documented opioid-sparing effects in the postoperative period; however, its use is limited because of concerns of postoperative bleeding and hematoma formation. This study explores the relationship between hematoma formation and administration of perioperative ketorolac in adolescent female patients and young adult women undergoing reduction mammaplasty. It also aims to determine the effect of perioperative ketorolac administration on the requirement for opioid analgesia.

METHODS

The authors reviewed the medical records of 500 consecutive female patients who underwent reduction mammaplasty for bilateral macromastia from 2007 to 2017. The authors collected data pertaining to perioperative analgesia use and postoperative hematoma formation.

RESULTS

Five-hundred patients were included in analyses. The average age of the patients was 18.1 ± 2.2 years. Three hundred eighty-nine patients (77.8 percent) received intravenous ketorolac during the perioperative period. Seven patients (1.4 percent) developed a postoperative hematoma. Hematoma was not associated with intraoperative, postoperative, and perioperative ketorolac use (p > 0.43, all). Intraoperative ketorolac use was associated with lower total intraoperative dosing of fentanyl and morphine, and postoperative ketorolac use was associated with lower total postoperative doses of oxycodone and morphine (p < 0.001, all).

CONCLUSIONS

Ketorolac use was largely associated with decreased perioperative opioid use, but not with hematoma formation. Ketorolac may be a safe alternative to opioids in adolescents and young women undergoing reduction mammaplasty without increasing the risk of hematoma formation.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.

Use of Intravenous Acetaminophen in Children for Analgesia After Spinal Fusion Surgery: A Randomized Clinical Trial

OBJECTIVES

Opioid pharmacotherapy is the cornerstone of postoperative analgesia. Despite its effectiveness, it has a variety of potential adverse effects. Therefore, a multimodal approach with non-opioid analgesics would be optimal. The aim of this study was to determine if intravenous (IV) acetaminophen would reduce opioid requirements and improve clinical outcomes in children after surgery.

METHODS

A single-center, randomized, double-blind study was conducted in 57 children (10-18 years old) undergoing posterior spine fusion surgery between July 2011 to May 2014. All subjects received either acetaminophen or placebo at the end of surgery, followed by repeated doses every 6 hours for a total of 8 doses.

RESULTS

In the first 24 postoperative hours, the average opioid consumption was lower for the active group compared with the placebo group (p = 0.02). The total unadjusted time to patient controlled analgesia (PCA) discontinuation was also longer in the placebo group than the active group (90 hours vs. 73 hours, p = 0.02); however, this was not statistically significant after normalizing for body weight. Additionally, time to first solid intake was longer without the use of acetaminophen (69 hours vs. 49 hours, p = 0.01).

CONCLUSIONS

Postoperative use of IV acetaminophen was associated with earlier time to diet advancement and discontinuation of IV analgesics and may result in lower opioid consumption.

Effect of Pre-Emptive Paracetamol Infusion on Postoperative Analgesic Consumption in Children Undergoing Elective Herniorrhaphy

Objective

Studies have suggested that pre-emptive analgesia may decrease postoperative pain and opioid consumption. This study was undertaken to determine whether pre-emptive analgesia reduces postoperative pain and total paracetamol and opioid consumption in children undergoing herniorrhaphy.

Methods

In this retrospective study, medical records were analysed before and after the pre-emptive analgesia regimen was introduced. Demographic data, perioperative drug consumption and discharge time were recorded. In the first group, no pre-emptive analgesia (NA; year, 2011; n=60) was given and in the second group, the pre-emptive analgesia (PA) paracetamol 10-15 mg kg^-1 was given intravenously in the surgical ward at least 1 h before the surgical procedure (year 2013; n=60). Postoperative pain determining supplemental pain medications was scored using a Faces Pain Scale or visual analogue scale. Total paracetamol and opioid consumption during 24 perioperative hours was registered for all patients. The statistical analysis was performed using t test and Chi-square test.

Results

The mean age of children was 69.6±49.9 and 58.7±32.4 months (p=0.157), and the mean body mass index (BMI) was 18.3±8.8 kg m^-2 and 16.4±3.7 kg m^-2 (p=0.125) in the NA and PA groups, respectively. Total paracetamol consumption was 1157.8±908.8 mg vs. 983.0±536.4 mg (p=0.202), and the total opioid consumption was 5.8±4.7 in the NA group and 7.0±4.6 morphine equivalents in the PA group (p=0.160). No differences in the discharge time between the groups were observed (2.1±0.3 vs. 2.0±0.3 days, p=0.13).

Conclusion

PA was proven to be efficient in the terms of postoperative pain control but did not reduce the overall analgesic drug consumption in the children undergoing elective herniorrhaphy. Multimodal pain treatment may decrease the consumption of analgesic drugs.

Postoperative pain management in children: Guidance from the pain committee of the European Society for Paediatric Anaesthesiology (ESPA Pain Management Ladder Initiative)

The main remit of the European Society for Paediatric Anaesthesiology (ESPA) Pain Committee is to improve the quality of pain management in children. The ESPA Pain Management Ladder is a clinical practice advisory based upon expert consensus to help to ensure a basic standard of perioperative pain management for all children. Further steps are suggested to improve pain management once a basic standard has been achieved. The guidance is grouped by the type of surgical procedure and layered to suggest basic, intermediate, and advanced pain management methods. The committee members are aware that there are marked differences in financial and personal resources in different institutions and countries and also considerable variations in the availability of analgesic drugs across Europe. We recommend that the guidance should be used as a framework to guide best practice.

Intermittent Versus Continuous and Intermittent Medications for Pain and Sedation After Pediatric Cardiothoracic Surgery; A Randomized Controlled Trial

OBJECTIVES

Compare continuous infusions of morphine and midazolam in addition to intermittent doses with an intermittent only strategy for pain and sedation after pediatric cardiac surgery.

DESIGN

Randomized controlled trial.

SETTING

Advocate Children's Hospital, Oak Lawn, IL.

PATIENTS

Sixty patients 3 months to 4 years old with early extubation after pediatric cardiac surgery.

INTERVENTIONS

Patients received a continuous infusion of morphine and midazolam or placebo for 24 hours. Both groups received intermittent morphine and midazolam doses as needed.

MEASUREMENTS AND MAIN RESULTS

Gender, age, bypass time, and surgical complexity were not different between groups. Scheduled ketorolac and acetaminophen were used in both groups and were not associated with adverse events. The mean, median, and maximum Faces, Legs, Activity, Cry, And Consolability score were not different between groups. There was no significant difference in number of intermittent doses received between groups. The total morphine dose was higher in the continuous/intermittent group (0.90 vs 0.23 mg/kg; p < 0.01). The total midazolam dose was also higher in the continuous/intermittent group (0.90 vs 0.18 mg/kg; p < 0.01). The hospital length of stay was longer in the continuous/intermittent group (8.4 vs 4.9 d; p = 0.04).

CONCLUSIONS

Pain was not better controlled with the addition of continuous infusions of morphine and midazolam when compared with intermittent dosing only. Use of continuous infusions resulted in a significantly higher total dosage of these medications and a longer length of stay.

Neonatal pain management

Pain management in the neonatal ICU remains challenging for many clinicians and in many complex care circumstances. The authors review general pain management principles and address the use of pain scales, non-pharmacologic management, and various agents that may be useful in general neonatal practice, procedurally, or at the end of life. Chronic pain and neonatal abstinence are also noted.

Perioperative management in children with chronic pain

Children with chronic pain often undergo surgery and effective perioperative management of their pain can be challenging. Identification of the pediatric chronic pain patient preoperatively and development of a perioperative pain plan may help ensure a safer and more comfortable perioperative course. Successful management usually requires multiple different classes of analgesics, regional anesthesia, and adjunctive nonpharmacological therapies. Neuropathic and oncological pain can be especially difficult to treat and usually requires an individualized approach.

Preemptive, preventive, multimodal analgesia: what do they really mean?

SUMMARY

To improve postoperative pain management, several concepts have been developed, including preemptive analgesia, preventive analgesia, and multimodal analgesia. This article will discuss the role of these concepts in improving perioperative pain management. Preemptive analgesia refers to the administration of an analgesic treatment before the surgical insult or tissue injury. Several randomized clinical trials have, however, provided equivocal evidence regarding the benefits of preincisional compared with postincisional analgesic administration. Current general consensus, therefore, indicates that use of preemptive analgesia does not translate into consistent clinical benefits after surgery. Preventive analgesia is a wider concept where the timing of analgesic administration in relation to the surgical incision is not critical. The aim of preventive analgesia is to minimize sensitization induced by noxious stimuli arising throughout the perioperative period. Multimodal analgesia consists of the administration of 2 or more drugs that act by different mechanisms for providing analgesia. These drugs may be administered via the same route or by different routes. Thus, the aim of multimodal analgesia is to improve pain relief while reducing opioid requirements and opioid-related adverse effects. Analgesic modalities currently available for postoperative pain control include opioids, local anesthetic techniques [local anesthetic infiltration, peripheral nerve blocks, and neuraxial blocks (epidural and paravertebral)], acetaminophen, nonsteroidal anti-inflammatory drugs, and cyclooxygenase-2-specific inhibitors as well as analgesic adjuncts such as steroids, ketamine, α-2 agonists, and anticonvulsants.

Variability in Pancreatitis Care in Pediatrics: A Single Institution's Survey Report

OBJECTIVE

The incidence of acute pancreatitis (AP) in childhood has increased in the last 2 decades, yet management has been largely extrapolated from adult studies. We sought to determine whether there is a consensus for treatment of AP among different pediatric subspecialists.

METHODS

Providers from subspecialties seeing most patients admitted for AP were surveyed on their practice patterns in managing a first attack of uncomplicated AP.

RESULTS

From November 2009 to August 2013, there were 284 admissions for patients with AP to our center. Patients were primarily admitted to the gastroenterology or hospitalist service (39% and 26%, respectively). Survey results found practice patterns for diagnostic evaluation, fluid resuscitation, pain management, and introduction of nutrition were variable between practitioners belonging to different subspecialties as well as within the same subspecialty group.

CONCLUSIONS

There is a lack of consensus on management of acute uncomplicated pancreatitis among pediatric providers, which may be improved through development of evidence-based pediatric guidelines.

Intravenous non-opioid analgesia for peri- and postoperative pain management: a scientific review of intravenous acetaminophen and ibuprofen

Pain is a predictable consequence following operations, but the management of postoperative pain is another challenge for anesthesiologists and inappropriately controlled pain may lead to unwanted outcomes in the postoperative period. Opioids are indeed still at the mainstream of postoperative pain control, but solely using only opioids for postoperative pain management may be connected with risks of complications and adverse effects. As a consequence, the concept of multimodal analgesia has been proposed and is recommended whenever possible. Acetaminophen is one of the most commonly used analgesic and antipyretic drug for its good tolerance and high safety profiles. The introduction of intravenous form of acetaminophen has led to a wider flexibility of its use during peri- and postoperative periods, allowing the early initiation of multimodal analgesia. Many studies have revealed the efficacy, safety and opioid sparing effects of intravenous acetaminophen. Intravenous ibuprofen has also shown to be well tolerated and demonstrated to have significant opioid sparing effects during the postoperative period. However, the number of randomized controlled trials confirming the efficacy and safety is small and should be used in caution in certain group of patients. Intravenous acetaminophen and ibuprofen are important options for multimodal postoperative analgesia, improving pain and patient satisfaction.

Effects of COX inhibition and LPS on formalin induced pain in the infant rat

In the adult, immune and neural processes jointly modulate pain. During development, both are in transition and little is known about the role that the immune system plays in pain processing in infants and children. The objective of this study was to determine if inhibition or augmentation of the immune system would alter pain processing in the infant rat, as it does in the adult. In Experiment 1, rat pups aged 3, 10, or 21 (PN3, PN10, and PN21) days of age were pretreated with NS398 (selective cyclooxygenase (COX)-2 inhibitor) or SC560 (selective COX-1 inhibitor) and tested in the intraplantar formalin test to assess effects of COX inhibition on nociception. Neither drug had an effect on the behavioral response at PN3 or PN10 pups but both drugs attenuated nociceptive scores in PN21 pups. cFos expression in the spinal cord likewise was reduced only at PN21. In Experiment 2, pups were injected with lipopolysaccharide (LPS) prior to the formalin test at PN3 or PN21. LPS increased the nociceptive response more robustly at PN21 than at PN3, while increasing cytokine mRNA equally at both ages. The augmentation of pain responding at PN21 was largely during the late stages of the formalin test, as reported in the adult. These data support previous findings demonstrating late maturing immune modulation of nociceptive behaviors.

Update to the management of pediatric acute pancreatitis: highlighting areas in need of research

Acute pancreatitis is an emerging problem in pediatrics, with an incidence that is rising in the last 2 decades. Data regarding the optimal management and physician practice patterns are lacking. We present a literature review and updates on the management of pediatric pancreatitis. Prospective multicenter studies defining optimal management of pediatric pancreatitis are needed to guide care and improve outcomes for this patient population.

Intravenous acetaminophen: a review of pharmacoeconomic science for perioperative use

Hospitals are subject to more economic pressures than ever before. On the one hand, cost containment or cost reduction is paramount, particularly in relation to costly branded pharmaceuticals. On the other hand, quality measures and value-based reimbursement penalizes poor patient care. Multimodal analgesia sits squarely in this quandary, since its very nature requires use of multiple drugs with their associated costs, though this approach has the potential to improve quality of care. We undertook a comprehensive review of the pharmacoeconomics of IV acetaminophen, a new drug useful as part of a multimodal analgesic approach. While this new branded drug adds to direct drug costs, there is clear potential for IV acetaminophen to reduce the incidence of opioid-related adverse events and, in so doing, result in net hospital savings. This review describes many clinical studies showing significant improvements in postoperative nausea and vomiting, excessive sedation and pruritus. In addition, we describe studies demonstrating faster recovery times in the post-anesthesia care unit, intensive care unit and total hospital length of stay. Lastly, we summarize many studies demonstrating the robust effect of IV acetaminophen on patient satisfaction. A holistic view of total hospital performance should be adopted when reviewing drugs rather than a silo mentality within the pharmacy. While IV acetaminophen adds to drug costs, the body of evidence indicates this drug has the potential to improve outcomes and hospital efficiency.

Opioid-sparing effects of perioperative paracetamol and nonsteroidal anti-inflammatory drugs (NSAIDs) in children

BACKGROUND AND OBJECTIVES

Perioperative pain in children can be effectively managed with systemic opioids, but addition of paracetamol or nonsteroidal anti-inflammatory drugs (NSAIDs) may reduce opioid requirements and potentially improve analgesia and/or reduce adverse effects.

METHODS

A systematic literature search was conducted to identify trials evaluating postoperative opioid requirements in children and comparing NSAID and/or paracetamol with placebo. Studies were stratified according to design: continuous availability of intravenous opioid (PCA/NCA) vs intermittent 'as needed' bolus; and single vs multiple dose paracetamol/NSAIDs. Primary outcome data were extracted, and the percentage decrease in mean opioid consumption was calculated for statistically significant reductions compared with placebo. Secondary outcomes included differences in pain intensity, adverse effects (sedation, respiratory depression, postoperative nausea and vomiting, pruritus, urinary retention, bleeding), and patient/parent satisfaction.

RESULTS

Thirty-one randomized controlled studies, with 48 active treatment arms compared with placebo, were included. Significant opioid sparing was reported in 38 of 48 active treatment arms, across 21 of the 31 studies. Benefit was most consistently reported when multiple doses of study drug were administered, and 24 h PCA or NCA opioid requirements were assessed. The proportion of positive studies was less with paracetamol, but was influenced by dose and route of administration. Despite availability of opioid for titration, a reduction in pain intensity by NSAIDs and/or paracetamol was reported in 16 of 29 studies. Evidence for clinically significant reductions in opioid-related adverse effects was less robust.

CONCLUSION

This systematic review supports addition of NSAIDs and/or paracetamol to systemic opioid for perioperative pain management in children.

Evidence-based comfort care for neonates towards the end of life

The provision of care to the newborn or young infant at the end of life is primarily motivated by concern and compassion. When examining the evidence base for most interventions, it is lacking - but this is not unique to this aspect of neonatal care. Nevertheless, a redirection of care from cure-oriented and life-extending measures to comfort and limitations of life-sustaining technologic interventions requires the neonatologist to apply practical knowledge skillfully and with prudence. Clinicians can acknowledge that patient needs require managing their end-of-life symptoms now; neither these patients nor their families should have to wait for research to catch up to their current needs.

Prevalence of moderate-severe pain in hospitalized children

BACKGROUND

  Acute pain management in children is often inadequate. The prevalence of pain in hospitalized children in the US is unknown.

METHODS

  We reviewed clinical characteristics of all pediatric patients admitted to Mayo Eugenio Litta Children's hospital during July 2009. Patients with moderate-severe pain were identified. For patients identified as having moderate-severe pain risk factors, analgesia regimens, and pain outcomes were reviewed.

RESULTS

  The prevalence of moderate-severe in-hospital pain was 27% (95% C.I. 23% to 32%). Teenagers and infants experienced higher prevalence rates of moderate-severe pain (38% and 32% respectively) than children (17%, P < 0.001). In addition, patients admitted to medical services had much lower rates of moderate-severe pain (13%) than those admitted to surgical services (44%, P < 0.001). Regional anesthesia was used in eleven (7.2%) of the patients on surgical services. Acetaminophen was administered to 75% of patients with moderate-severe pain. Only 21% of these patients had nonsteroidal anti-inflammatory drugs (NSAIDS) available. Opioids were given scheduled to 36% of patients with moderate-severe pain and as needed to another 40%. Fifty-five percent of patients still had one or more episode of moderate-severe pain on the day following an initial diagnosis; however, this number decreased steadily over subsequent days. Eleven patients (13% of those diagnosed with moderate-severe pain) still had one or more episodes of daily moderate-severe pain by day four.

CONCLUSIONS

  The prevalence of moderate-severe pain in hospitalized children remains high. Analgesia regimens may not be optimal. Underutilization of regional anesthesia techniques may have contributed to increased pain scores. A large proportion of children diagnosed with moderate-severe pain may have persistent clinically significant pain in subsequent days.

Pain prevalence, intensity, assessment and management in a hospitalized pediatric population

New research, regulatory guidelines, and practice initiatives have improved pain management in infants, children, and adolescents, but obstacles remain. The aim of this study was to identify the prevalence and demographics of pain, as well as pain management practice patterns in hospitalized children in a tertiary-care university hospital. We prospectively collected data including patient demographics, presence/absence and location of pain, pain intensity, pain assessment documentation, analgesic use, side effects of analgesic therapy, and patient/family satisfaction. Two hundred male (58%) and female, medical and surgical (61%) patients, averaging 9 ± 6.2 years were studied. Pain was common (86%) and often moderate to severe (40%). Surgical patients reported pain more frequently when enrolled than did medical patients (99% vs. 65%). Female gender, age ≥ 5 years, and Caucasian race were all associated with higher mean pain scores. Furthermore, females and Caucasian children consumed more opioids than males and non-Caucasians. Identified obstacles to optimal analgesic management include lack of documented physician pain assessment (<5%), a high prevalence of "as needed" analgesic dosing, frequent opioid-induced side effects (44% nausea and vomiting, 27% pruritus), and patient/family dissatisfaction with pain management (2%-7%). The data demonstrated that despite a concentrated focus on improving pain management over the past decade, pain remains common in hospitalized children. Identification of patient populations and characteristics that predispose to increased pain (e.g., female, Caucasian, postoperative patient) as well as obstacles to analgesic management provide a focus for the development of targeted interventions and research to further improve care.

Retrospective evaluation of inpatient celecoxib use after total hip and knee arthroplasty at a Veterans Affairs Medical Center

A retrospective cohort study (1.5 years) was performed to investigate the efficacy of celecoxib vs non-celecoxib use in patient who underwent total knee arthroplasty (TKA) and total hip arthroplasty (THA). Study time frame encompassed a pre and post period of a local policy decision opening access to short-term celecoxib use after TKA/THA. Primary end point was the amount of opioid use during their inpatient stay postprocedure. The TKA (n = 81) and THA (n = 60) groups were analyzed independently. Both celecoxib groups used significantly less opioids during their inpatient stay vs noncelecoxib groups, given in oral morphine milligram equivalents (TKA: 203 vs 337 mg, P = .002; THA: 214 vs 336 mg, P = .005). Other secondary outcome measures showed that the celecoxib groups also reported reduction in pain scores, total as needed (PRN) opioid doses, PRN opioid doses per day, average dose of PRN opioids, total PRN opioids, use of intravenous opioids, and rehabilitation facility admissions (in the TKA group only). Linear regression analysis showed a statistically significant inverse relationship between opioid consumption and age. Short-term celecoxib use after TKA/THA may lead to a reduction in overall opioid use and improved pain scores; however, further studies will be required to validate the results of this study.

Preventing Chronic Pain following Acute Pain: Risk Factors, Preventive Strategies, and their Efficacy

Chronic pain is the leading cause of disability in the United States. The transition from acute to persistent pain is thought to arise from maladaptive neuroplastic mechanisms involving three intertwined processes, peripheral sensitization, central sensitization, and descending modulation. Strategies aimed at preventing persistent pain may target such processes. Models for studying preventive strategies include persistent post-surgical pain (PPP), persistent post-trauma pain (PTP) and post-herpetic neuralgia (PHN). Such entities allow a more defined acute onset of tissue injury after which study of the long-term effects is more easily examined. In this review, we examine the pathophysiology, epidemiology, risk factors, and treatment strategies for the prevention of chronic pain using these models. Both pharmacological and interventional approaches are described, as well as a discussion of preventive strategies on the horizon.

The role of multimodal analgesia in pain management after ambulatory surgery

PURPOSE OF REVIEW

As outpatient (day-case) surgery had continued to grow throughout the world, many more complex and potentially painful procedures are being routinely performed in the ambulatory setting. Opioid analgesics, once considered the standard approach to preventing acute postoperative pain, are being replaced by a combination of nonopioid analgesic drugs with diverse modes of action as part of a multimodal approach to preventing pain after ambulatory surgery. This review will provide an update on the topic of multimodal pain management for ambulatory (day-case) surgery.

RECENT FINDINGS

Efficacy of multimodal analgesic regimens continues to improve; opioid analgesics are increasingly taking on the role of 'rescue analgesics' for acute pain after day-case surgery. The use of multimodal analgesia is rapidly becoming the 'standard of care' for preventing pain after ambulatory procedures at most surgery centers throughout the world.

SUMMARY

This article discusses recent evidence from the peer-reviewed literature regarding the role of local anesthetics, NSAIDs, gabapentinoids, and acetaminophen, as well as alpha-2 agonists, ketamine, esmolol, and nonpharmacologic approaches (e.g., transcutaneous electrical stimulation) as parts of multimodal pain management strategies in day-case surgery.

Pharmacotherapy for acute pain in children: current practice and recent advances

INTRODUCTION

Acute pain in children may be undertreated. Improved understanding of developmental neurobiology and paediatric pharmacokinetics should facilitate better management of pharmacotherapy. The objective of this review is to discuss current paediatric practice and recent advances with these analgesic agents by using an evidence-based approach.

AREAS COVERED

Using PubMed an extensive literature review was conducted on the commonly used analgesic agents in children from 2000 to April 2010.

EXPERT OPINION

A multimodal analgesic regimen provides better pain control and functional outcome in children. The choice of pharmacological treatment is determined by the severity and type of pain. However, more research and evidence is required to determine the optimal drug combinations.