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

Automatic diagnosis of pediatric supracondylar humerus fractures using radiomics-based machine learning

The aim of this study was to construct a classification model for the automatic diagnosis of pediatric supracondylar humerus fractures using radiomics-based machine learning. We retrospectively collected elbow joint Radiographs of children aged 3 to 14 years and manually delineated regions of interest (ROI) using ITK-SNAP. Radiomics features were extracted using pyradiomics, a python-based feature extraction tool. T-tests and the least absolute shrinkage and selection operator (LASSO) algorithm were used to further select the most valuable radiomics features. A logistic regression (LR) model was trained, with an 8:2 split into training and testing sets, and 5-fold cross-validation was performed on the training set. The diagnostic performance of the model was evaluated using receiver operating characteristic curves (ROC) on the testing set. A total of 411 fracture samples and 190 normal samples were included. 1561 features were extracted from each ROI. After dimensionality reduction screening, 40 and 94 features with the most diagnostic value were selected for further classification modeling in anteroposterior and lateral elbow radiographs. The area under the curve (AUC) of anteroposterior and lateral elbow radiographs is 0.65 and 0.72. Radiomics can extract and select the most valuable features from a large number of image features. Supervised machine-learning models built using these features can be used for the diagnosis of pediatric supracondylar humerus fractures.

Opioids and Youth Athletes

CONTEXT

The ongoing opioid epidemic and associated adverse effects impart a large burden on our current healthcare system. The annual economic and noneconomic cost of opioid use disorder and fatal opioid overdose is currently estimated at $1 trillion.

OBJECTIVE

This review presents the prevalence, frequency of use, need, and effectiveness of opioid analgesia in the youth and adolescent athlete population. It identifies current indications for opioid versus nonopioid analgesic use in the setting of acute orthopaedic injuries, postoperative management, concussion, and chronic pain. Current knowledge of youth athlete opioid use, risks related to use, misuse, diversion, and addiction are reviewed.

DATA SOURCES

A PubMed, Medline, and Cochrane Library search was conducted in February 2023 to review opioid pain management strategies in the pediatric athlete population from 2000 to present.

STUDY SELECTION

Searches were restricted to English language articles and human subjects. Initial reviews of titles and abstracts were performed by all authors and relevant full-text articles were selected. Priority was given to systematic and narrative reviews, meta-analyses, and prospective studies.

STUDY DESIGN

Narrative review.

LEVEL OF EVIDENCE

Level 3.

DATA EXTRACTION

First author name, publication year, study design, study country, subject demographics, and data on the frequency, type, and duration of analgesic treatments for musculoskeletal injuries, postsurgical care, chronic pain disorders, and concussion were extracted.

RESULTS

Pediatric athletes comprise a high-risk population seeking analgesic relief for injury-related pain. Participation in high school sports is associated with increased risk of opioid use. An average of 28% to 46% of high school athletes have used opioids in their lifetime. Participation in ≥1 high school sport puts adolescents at 30% greater odds of future opioid misuse.

CONCLUSION

The use of opioids in the pediatric athlete population is common and associated with both short- and long-term risks of misuse and addiction.

Use of Peripheral Nerve Blocks Is Not Associated With Decreased Postoperative Opioid Prescription After ACL Reconstruction in Adolescents

The rate of anterior cruciate ligament (ACL) injuries and reconstruction in pediatric patients is increasing. Perioperative peripheral nerve blocks (PNBs) are widely used for pain management in this population. We used a multi-state administrative claims database to describe the effect of PNB after ACL reconstruction on postoperative opioid consumption. We identified patients 10 to 18 years old undergoing primary ACL reconstruction between 2014 and 2016 in an administrative claims database. Patients filling an outpatient perioperative prescription for opioids with at least 1 year of follow-up were included. We stratified patients based on PNB. Our primary outcome was opioid prescription patterns (in morphine milligram equivalents [MMEs]) and incidence of opioid represcription. Of the 4459 cases, 2432 (54.5%) of the patients were given a PNB during ACL reconstruction while 2027 (45.5%) were not. Patients with PNB were prescribed more MMEs per day (76.1±41.7 vs 62.7±35.7 MMEs, P<.001), more pills (63.6±53.1 vs 54.4±40.6 pills, P<.001), higher MMEs per pill (10.0±9.5 vs 8.3±5.0 MMEs, P<.001), and more total MMEs (460.6±259.4 vs 355.7±215.1 MMEs, P<.001) than patients without PNB. Adjusting for prescription patterns and demographic variables with logistic regression, PNBs were associated with a 60% increase in the odds of opioid represcription within 30 days and a 32% increase in the odds of opioid represcription within 90 days. We demonstrated an increase in postoperative opioid prescription rates with PNB after ACL reconstruction. [Orthopedics. 2024;47(2):83-88.].

Postoperative Opioid Prescribing Practices and Patient Opioid Utilization in Pediatric Orthopaedic Surgery Patients

INTRODUCTION

Amid a national opioid epidemic, it is essential to review the necessity of opioid prescriptions. Research in adults has demonstrated patients often do not use their entire postoperative opioid prescription. Limited data suggest that the trend is similar in children. This study investigated the prescription volume and postoperative utilization rate of opioids among pediatric orthopaedic surgery patients at our institution.

METHODS

We identified pediatric patients (ages below 18 y old) who presented to our institution for operating room intervention from May 24, 2021, to December 13, 2021. Patient demographics and opioid prescription volume were recorded. Parents and guardians were surveyed by paper "opioid diary" or phone interview between postoperative days 10 to 15, assessing pain level, opioid use, and plans for remaining opioid doses. Wilcoxon rank-sum test, Independent t test, and Pearson correlation were used for the analysis of continuous variables. Multivariable logistic regression was used to control for patient demographic variables while analyzing opioid usage relationships.

RESULTS

Prescription volume information was collected for 280 patients during the study period. We were able to collect utilization information for 102 patients (Group 1), whereas the remaining 178 patients contributed only prescription volume data (Group 2). Patients with upper extremity fractures received significantly fewer opioid doses at discharge compared with other procedure types ( P =0.036). Higher BMI was positively correlated with more prescribed opioid doses ( R2 =0.647, P <0.001). The mean opioid utilization rate was 22.37%. A total of 50.6% of patients prescribed opioids at discharge used zero doses. A total of 96.2% of patients used opioids for 5 days or less. Most families had not disposed of excess medication by postoperative day 10.

CONCLUSIONS

We found significant differences in opioid prescribing practices based on patient and procedure-specific variables. In addition, although our pediatric orthopaedic surgery patients had low overall rates of postoperative opioid utilization, there was significant variation in opioid use among procedure types. These results provide insights that can guide opioid prescribing practices for pediatric orthopaedic patients and promote patient education to ensure safe opioid disposal.

Research: Construction and validation of elbow function prediction model after supracondylar humerus fracture in children

This article's objectives are to develop a model to predict children's recovery of elbow function following supracondylar fracture, analyze the risk factors affecting those children's elbow function after surgery, and propose a individualized treatment strategy for elbow function in various children. We retrospectively analyzed clinical data from 410 children with supracondylar humerus fracture. A modeling set and a validation set of kids in the included studies were arbitrarily split into 2 groups on a 7:3 basis. To identify statistically significant risk factors, univariate logistic regression analysis was used. Then, multivariate logistic regression was used with the risk factors, and the best logistic regression model was chosen based on sensitivity and accuracy to create a nomogram; A total of 410 children were included in the study according to the inclusion criteria. Among them, there were 248 males and 162 females, and the fracture type: 147 cases of type IIb and 263 cases of type III. There were no significant changes in the afflicted limb's lateral difference, surgical method, onset season, and number of K-wires, according to univariate logistic regression analysis. Age (P < .001), weight (P < .001), height (P < .001), preoperative elbow soft tissue injury (OR = 1.724, 95% CI: 1.040-2.859, P = .035), sex (OR = 2.220, 95% CI: 1.299-3.794, P = .004), fracture classification (Gartland IIb) (OR = 0.252, 95% CI: 0.149-0.426, P < .001), no nerve injury before surgery (OR = 0.304, 95% CI: 0.155-0.596, P = .001), prying technique (OR = 0.464, 95% CI: 0.234-0.920, P = .028), postoperative daily light time > 2 hours (OR = 0.488, 95% CI: 0.249-0.955, P = .036) has a significant difference in univariate analysis; Multivariate regression analysis yielded independent risk factors: fracture classification; No nerve injury before surgery; The daily light duration after surgery was > 2 hours; soft tissue injury; Age, postoperative cast fixation time. The establishment of predictive model is of significance for pediatric orthopedic clinicians in the daily diagnosis and treatment of supracondylar humerus fracture.

Opioid Analgesia Compared with Non-Opioid Analgesia After Operative Treatment for Pediatric Supracondylar Humeral Fractures: Results from a Prospective Multicenter Trial

BACKGROUND

Minimal pain and opioid use after operative treatment for pediatric supracondylar humeral fractures have been previously described; however, opioid-prescribing practices in the United States remain variable. We hypothesized that children without an opioid prescription would report similar postoperative pain compared with children prescribed opioids following closed reduction and percutaneous pinning (CRPP) of supracondylar humeral fractures.

METHODS

Children who were 3 to 12 years of age and were undergoing CRPP for a closed supracondylar humeral fracture were prospectively enrolled in a multicenter, comparative study. Following a standardized dosing protocol, oxycodone, ibuprofen, and acetaminophen were prescribed at 2 hospitals (opioid cohort), and 2 other hospitals prescribed ibuprofen and acetaminophen alone (non-opioid cohort). The children's medication use and the daily pain that they experienced (scored on the Wong-Baker FACES Scale) were recorded at postoperative days 1 to 7, 10, 14, and 21, using validated text-message protocols. Based on an a priori power analysis, at least 64 evaluable subjects were recruited per cohort.

RESULTS

A total of 157 patients were evaluated (81 [52%] in the opioid cohort and 76 [48%] in the non-opioid cohort). The median age at the time of the surgical procedure was 6.2 years, and 50% of the subjects were male. The mean postoperative pain scores were low overall (<4 of 10), and there were no significant differences in pain ratings between cohorts at any time point. No patient demographic or injury characteristics were correlated with increased pain or medication use. Notably, of the 81 patients in the opioid cohort, 28 (35%) took no oxycodone and 40 (49%) took 1 to 3 total doses across the postoperative period. Patients rarely took opioids after postoperative day 2. A single patient in the non-opioid cohort (1 [1%] of 76) received a rescue prescription of opioids after presenting to the emergency department with postoperative cast discomfort.

CONCLUSIONS

Non-opioid analgesia following CRPP for pediatric supracondylar humeral fractures was equally effective as opioid analgesia. When oxycodone was prescribed, 84% of children took 0 to 3 total doses, and opioid use fell precipitously after postoperative day 2. To improve opioid stewardship, providers and institutions can consider discontinuing the routine prescription of opioids following this procedure.

LEVEL OF EVIDENCE

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

Parental Postoperative Pain Management Perceptions, Attitudes, and Practices in Pediatric Limb Fractures

BACKGROUND

Post-surgical pain in children is common, severe, and inadequately controlled. An effective model should involve the participation of parents.

AIMS

To investigate parental perceptions, attitudes, and practices in postoperative pain management in children with limb fractures and analyze the factors affecting parental practices.

DESIGN

This was a descriptive cross-sectional study.

SETTINGS

Research was conducted at a tertiary Children's Hospital Affiliated with Soochow University.

PARTICIPANTS

Parents whose children (age, 6-18 years) underwent orthopedic fracture surgery between January 1, 2020, and August 31, 2020, were recruited using purposive sampling.

METHODS

The parents were asked to complete self-report questionnaires: "Pain Management Knowledge and Attitudes Questionnaire" and "Parents' Use of Pain Relief Strategies Questionnaire." The Wong-Baker Faces Scale was used to measure pain intensity in children. The Mann-Whitney U test, Kruskal-Wallis H test, and correlation and regression analyses were used for statistical analyses.

RESULTS

Data of 180 parents were collected. Of the participants, 80.6%, 78.3%, and 71.7% had low-to-moderate scores for knowledge, general attitudes, and use of pain relief strategies, respectively. Moreover, 93.9% of parents had moderate-to-high scores for negative attitudes toward medication, despite 89.5% of them reporting moderate-to-high pain intensities in their children (median proxy-report of pain intensity, 7.0 [3.00]). Multivariate linear stepwise regression showed that parents' use of pain-relief strategies was related to their general attitudes, knowledge, and sex.

CONCLUSIONS

Most parents had low-to-moderate scores for perceptions and general attitudes toward children's postoperative pain management, and use of pain relief strategies. Moreover, they lacked knowledge of and had negative attitudes toward pain assessment and analgesics, which significantly impacted their practices.

CLINICAL IMPLICATIONS

Clinical pediatric nurses should provide appropriate support for the entire family of the child. Moreover, to enhance parental practices, they should develop targeted parental education programs for pain management, particularly regarding pain assessment tools and pain medications.

Do kids with forearm fractures need opioids at discharge from the emergency department? Analgesic prescribing and pain control following closed reduction of pediatric forearm fractures

Objective

The purpose of this 2-part study is to determine opioid prescribing patterns and opioid use and pain control after discharge following closed reduction of pediatric forearm fractures.

Methods

A retrospective study was conducted from December 2016 to January 2018 at a level 1 trauma center to determine opioid prescribing habits for patients 1-17 years old with forearm fractures treated with closed reduction. A prospective study was then conducted from August 2019 to October 2020 to determine pain control and opioid use after discharge. Data were collected through chart review and with telephone surveys on post-discharge days 1, 3, and 5 to collect pain scores and opioid use.

Results

Fifty patients with a median age of 8 (interquartile range [IQR], 5-11) years old and 51 patients with a mean age of 9 (IQR, 6-11) years old were included in the retrospective and prospective cohorts, respectively. From the retrospective study, 21 patients (42%) were prescribed a median of 10 opioid doses (IQR, 8-12) at discharge. From the prospective study, 12 patients (24%) were discharged with a median of 8 opioid doses (IQR, 5.5-10), for a total of 98 total doses. Of those, only 7 doses (7%) were used by 3 patients. Higher weight and initial pain score were associated with increased rates of opioid prescription.

Conclusions

Pediatric patients who undergo closed reduction of a forearm fracture under procedural sedation in the emergency department are prescribed approximately 14 times the amount of opioid that is used. We propose that prescribing only non-opioid analgesics to these patients would afford equivalent pain control without the side-effects and abuse potential of opioid use at an early age.

A Psycholgical Intervention Delivered by Automated Mobile Phone Messaging Stabilized Hip and Knee Function During the COVID-19 Pandemic: A Randomized Controlled Trial

BACKGROUND

We conducted a randomized controlled trial to evaluate the effectiveness of acceptance and commitment therapy (ACT) delivered via a mobile phone messaging robot to patients who had their total hip arthroplasty or total knee arthroplasty procedures postponed due to the COVID-19 pandemic.

METHODS

Ninety patients scheduled for total hip arthroplasty or total knee arthroplasty who experienced surgical delay due to the COVID-19 pandemic were randomized to the ACT group, receiving 14 days of twice daily automated mobile phone messages, or the control group, who received no messages. Minimal clinically important differences (MCIDs) in preintervention and postintervention patient-reported outcome measures were utilized to evaluate the intervention.

RESULTS

Thirty-eight percent of ACT group participants improved and achieved MCID on the Patient-Reported Outcome Measure Information System Physical Health compared to 17.5% in the control group (P = .038; number needed to treat [NNT] 5). For the joint-specific Hip Disability and Osteoarthritis Outcome Score Joint Replacement and Knee Disability and Osteoarthritis Outcome Score Joint Replacement (KOOS JR), 24% of the ACT group achieved MCID compared to 2.5% in the control group (P = .004; NNT 5). An improvement in the KOOS JR was found in 29% of the ACT group compared to 4.2% in the control group (P = .028; NNT 5). Fourteen percent of the ACT group participants experienced a clinical important decline in the KOOS JR compared to 41.7% in the control group (P = .027; NNT 4).

CONCLUSION

A psychological intervention delivered via a text messaging robot improved physical function and prevented decline in patient-reported outcome measures in patients who experienced an unexpected surgical delay during the COVID-19 pandemic.

LEVEL OF EVIDENCE

1.

Preoperative Opioid Informed Consent and Prescribing Practices in Children Undergoing Orthopaedic Trauma Surgery

This study sought to examine prescribing practices for pediatric patients undergoing orthopaedic trauma surgery and assess the effect of state-mandated preoperative informed consent for opioids.

Tiered Guidelines in a Pediatric Orthopaedic Practice Reduce Opioids Prescribed at Discharge

BACKGROUND

Data regarding opioid prescribing patterns following pediatric orthopaedic procedures is limited. The aim of this work was to evaluate the effects of tiered guidelines for discharge opioid prescriptions following common pediatric orthopaedic procedures.

METHODS

Quality improvement project conducted at a single academic institution. Guidelines for discharge opioid prescriptions were implemented January 2018 and established 4 tiers of increasing invasiveness for 28 common pediatric orthopaedic procedures. Patients who underwent these procedures in 2017 comprised the preguideline cohort (N=258), while patients treated in 2019 comprised the postguideline cohort (N=212). Opioid prescriptions were reported as oral morphine equivalents (OMEs). Univariate tests were performed to assess statistically significant differences before and after implementation of the guidelines.

RESULTS

There was a significant decrease in OME prescribed between preguideline and postguideline cohorts (median OME 97.5 vs. 37.5). When analyzed according to procedure tiers, tiers 1, 2, and 4 showed significant decreases in OME prescribed between 2017 and 2019. The rate of no opioids prescribed at discharge increased from 13% to 23% between preguideline and postguideline cohorts. The 30-day refill rate did not significantly change. After implementation of guidelines, 91% of all prescriptions were within the guideline parameters, and there was a significant reduction in prescription variability. In tier 4 procedures, median OME prescribed decreased from 375 preguideline to 188 postguideline, but was associated with greater opioid refills within 30 days of discharge (10.2% preguideline vs. 28.8% postguideline).

CONCLUSIONS

Tiered guidelines for discharge opioid prescriptions following pediatric orthopaedic procedures can significantly decrease the quantity of opioids prescribed. Furthermore, we noted excellent adherence and no overall increase in the rates of narcotic refills. Such guidelines may improve pediatric orthopaedists' ability to responsibly treat postoperative pain while limiting the distribution of unneeded opioids.

LEVEL OF EVIDENCE

Level IV-quality improvement project.

Variability in discharge opioid prescribing practices for children: a historical cohort study

PURPOSE

Legitimate opioid prescriptions can increase the risk of misuse, addiction, and overdose of opioids in children and adolescents. This study aimed to describe the prescribing patterns of discharge opioid analgesics following inpatient visits and to determine patient and prescriber characteristics that are associated with prolonged opioid prescription.

METHODS

In a historical cohort study, we identified patients discharged from hospital with an opioid analgesic prescription in a tertiary pediatric hospital from 1 January 2016 to 30 June 2017. The primary outcome was the duration of opioid prescription in number of days. We assessed the association between patient and prescriber characteristics and an opioid prescription duration > five days using a generalized estimating equation to account for clustering due to repeated admissions of the same patient.

RESULTS

During the 18-month study period, 15.4% of all admitted patients (3,787/24,571) were given a total of 3,870 opioid prescriptions at discharge. The median [interquartile range] prescribed duration of outpatient opioid therapy was 3.75 [3.00-5.00] days. Seventy-seven percent of the opioid prescriptions were for five days or less. Generalized estimating equation analysis revealed that hospital stay > four days, oxycodone prescription, and prescription by clinical fellows and the orthopedics service were all independently associated with a discharge opioid prescription of > five days.

CONCLUSIONS

Most discharge opioids for children were prescribed for less than five days, consistent with current guidelines for adults. Nevertheless, the dosage and duration of opioids prescribed at discharge varied widely.

Older, Male Orthopaedic Surgeons From Southern Geographies Prescribe Higher Doses of Post-Operative Narcotics Than do their Counterparts: A Medicare Population Study

Purpose

Methods

Results

Conclusion

Level of Evidence

Medications Reconciled at Discharge Versus Admission Among Inpatients at a Children's Hospital

BACKGROUND AND OBJECTIVES

Discharge prescription practices may contribute to medication overuse and polypharmacy. We aimed to estimate changes in the number and types of medications reported at inpatient discharge (versus admission) at a tertiary care pediatric hospital.

METHODS

Electronic medication reconciliation data were extracted for inpatient admissions at The Hospital for Sick Children from January 1, 2016, to December 31, 2017 (n = 22 058). Relative changes in the number of medications and relative risks (RRs) of specific types and subclasses of medications at discharge (versus admission) were estimated overall and stratified by the following: sex, age group, diagnosis of a complex chronic condition, surgery, or ICU (PICU) admission. Micronutrient supplements, nonopioid analgesics, cathartics, laxatives, and antibiotics were excluded in primary analyses.

RESULTS

Medication counts at discharge were 1.27-fold (95% confidence interval [CI]: 1.25-1.29) greater than admission. The change in medications at discharge (versus admission) was increased by younger age, absence of a complex chronic condition, surgery, PICU admission, and discharge from a surgical service. The most common drug subclasses at discharge were opioids (22% of discharges), proton pump inhibitors (18%), bronchodilators (10%), antiemetics (9%), and corticosteroids (9%). Postsurgical patients had higher RRs of opioid prescriptions at discharge (versus admission; RR: 13.3 [95% CI: 11.5-15.3]) compared with nonsurgical patients (RR: 2.38 [95% CI: 2.22-2.56]).

CONCLUSIONS

Pediatric inpatients were discharged from the hospital with more medications than admission, frequently with drugs that may be discretionary rather than essential. The high frequency of opioid prescriptions in postsurgical patients is a priority target for educational and clinical decision support interventions.

Comparing Email, SMS, and Concurrent Mixed Modes Approaches to Capture Quality of Recovery in the Perioperative Period: Retrospective Longitudinal Cohort Study

Background

As patients are discharged from the hospital more quickly, the ability to monitor patient recovery between hospital discharge and the first follow-up clinic visit is becoming increasingly important. Despite substantial increase in both internet use and smartphone ownership over the past 5 years, clinicians have been slow to embrace the use of these devices to capture patient recovery information in the period between hospital discharge and the first clinical follow-up appointment.

Objective

This study aims to investigate the generalizability of using a web-based platform to capture patient recovery in a broad surgical patient population and compare response rates for 3 different web-based strategies for delivering recovery surveys over the perioperative period: email, SMS text messaging, and a concurrent mixed approach of using both email and SMS text messaging.

Methods

Patients undergoing surgeries managed with an enhanced recovery after surgery pathway were asked to participate in a web-based quality assurance monitoring program at the time of their preoperative surgery appointment. Different follow-up methods were implemented over 3 sequential phases. Patients received Health Insurance Portability and Accountability Act–compliant web-based survey links via email (phase 1), SMS text messaging (phase 2), or concurrently using both email and SMS text messaging (phase 3) using REDCap and Twilio software. Recovery assessments using the established Quality of Recovery-9 instrument were performed 4 days before surgery and at 7 and 30 days postoperatively. Generalizability of the web-based system was examined by comparing characteristics of those who participated versus those who did not. Differences in response rates by the web-based collection method were analyzed using adjusted models.

Results

A total of 615 patients were asked to participate, with 526 (85.5%) opting for the follow-up program. Those who opted in were younger, slightly healthier, and more likely to be in a partnership. The concurrent mixed modes method was the most successful for obtaining responses at each time point compared with text or email alone (pre: 119/160, 74.4% vs 116/173, 67.1% vs 56/130, 43.1%, P<.001; 7 days: 115/172, 66.9% vs 82/164, 50.0% vs 59/126, 46.8%, P=.001; 30 days: 152/234, 65.0% vs 52/105, 49.5% vs 53/123, 43.1%, P=.001, respectively). In the adjusted model, the concurrent mixed modes method significantly predicted response compared with using email alone (odds ratio 3.4; P<.001) and SMS text messaging alone (odds ratio 1.9; P<.001). Additional significant predictors of response were race, partnership, and time.

Conclusions

For internet users and smartphone owners, electronic capture of recovery surveys appear to be possible through this mechanism. Discrepancies in both inclusion and response rates still exist among certain subgroups of patients, but the concurrent approach of using both email and text messages was the most effective approach to reach the largest number of patients across all subgroups.

What's New in Pain Management for Pediatric Orthopaedic Surgery

BACKGROUND

Improving pain control and decreasing opioid prescription and usage continue to be emphasized across both pediatric and adult populations. The purpose of this review is to provide a comprehensive assessment of recent literature and highlight new advancements pertaining to pain control in pediatric orthopaedic surgery.

METHODS

An electronic search of the PubMed database was performed for keywords relating to perioperative pain management of pediatric orthopaedic surgery. Search results were filtered by publication date for articles published between January 1, 2015 and December 1, 2020 and yielded 404 papers.

RESULTS

A total of 32 papers were selected for review based upon new findings and significant contributions in the following categories: risk factors for increased opioid usage, opioid overprescribing and disposal, nonpharmacologic interventions, nonsteroidal anti-inflammatory drugs, peripheral nerve blocks, spine surgery specific considerations, surgical pathway modifications, and future directions.

CONCLUSIONS

There have been many advances in pain management for pediatric patients following orthopaedic surgery. Rapid recovery surgical care pathways are associated with shorter length of stay and improved pain control in pediatric spine surgery. Opioid overprescribing continues to be common and information regarding safe opioid disposal practices should be routinely provided for pediatric patients undergoing surgery.

LEVEL OF EVIDENCE

Level IV-literature review.

How Much Opioid Do Kids Actually Need? A Prospective Study of Analgesic Prescribing and Postdischarge Opioid Use Among Pediatric Patients With Operative Fractures

BACKGROUND

Analgesic guidelines are lacking for most operative pediatric fractures, and little is known about postdischarge opioid use or pain control. We hypothesized that opioid/acetaminophen/non-steroidal anti-inflammatory drugs (NSAID) prescribing would vary, pain would be well controlled, and postdischarge opioid use would be low.

METHODS

This prospective cohort study included nonpolytraumatized patients aged 17 years and below with operative fractures at a level 1 trauma center from August 1, 2019 to March 31, 2021. Supracondylar humerus fractures were excluded since they have been studied extensively. Information regarding injury/surgery/analgesics were collected. Discharged patients were called on postoperative days (POD) 1/3/5. Parents/guardians were asked about analgesic use and pain over the preceding 2 days. Complications, pain control, and opioid refills were recorded after first follow-up.

RESULTS

All 100 eligible patients were included. Mean age was 10.1 years (range: 1.8 to 17.8 y). Common fracture types were humeral condyle/epicondyle (28%), radius/ulna (15%), and femoral shaft (13%). Opioids were prescribed to 95% of patients with mean 14 doses (range: 2 to 45). Acetaminophen/NSAIDs were prescribed to 74% and 60% of patients, respectively. Eleven patients were excluded from telephone follow-up (7 non-English speaking, 3 prohibitive social situations, 1 inpatient POD1 to 5). Telephone follow-up was completed for 87/89 eligible patients (98%). Mean pain scores declined from 3.7/10 POD1 to 2.4/10 POD5. Opioids were taken by 50% POD1, 20% POD5. Acetaminophen/NSAID was given before opioid 82% of the time. By POD5, mean total doses of opioid taken postdischarge was 2.3; mean proportion of prescribed opioid doses taken was 22%; and 97% of patients took ≤8 opioid doses postdischarge. Two patients were evaluated early due to poor pain control which improved with cast changes. Pain was well controlled or absent at follow-up in 97% of patients.

CONCLUSIONS

Pain is consistently well controlled after operative pediatric fractures. Nearly all were prescribed opioids, while acetaminophen/NSAIDs were inconsistently prescribed and used. Opioid prescriptions are written for 4 to 5 times the amount needed. Prescribing ≤8 doses of opioid is adequate for acute pain through POD5 in 97% of patients. Poorly controlled pain should prompt early evaluation for possible complications.

LEVEL OF EVIDENCE

Level II-prospective comparative study.

Early Opiate Analgesic Requirements Following Nonsurgically Managed Tibial Fractures in Children

BACKGROUND

Many children with tibial fractures are currently being managed as outpatients. It is unclear how much opiates should be prescribed to ensure adequate analgesia at home without overprescription. This study aimed to evaluate the risk factors for requiring opiates following admission for tibial fractures and to estimate opiate requirements for children being discharged directly from the emergency department (ED).

METHODS

All children aged 4 to 16 years admitted with closed tibial fractures being treated in a molded circumferential above-knee plaster cast between October 2015 and April 2020 were included. Case notes were reviewed to identify demographics, analgesic prescriptions, and complications. Risk factors were analyzed using logistic regression.

RESULTS

A total of 75 children were included, of which 64% were males. The mean age was 9.5 (SD 3.4) years. Opiates were required by 36 (48%) children in the first 24 hours following admission. The median number of opiate doses in the first 48 hours was 0 (range: 0 to 5), with 93% of children receiving ≤3 doses. The odds of requiring opiates in the first 24 hours were unchanged for age above 10 years [odds ratio (OR)=0.85, 95% confidence interval (CI): 0.33-2.23], male sex (OR=1.58, 95% CI: 0.59-4.19), high-energy injury (OR=1.65, 95% CI: 0.45-6.04), presence of a fibula fracture (OR=2.21, 95% CI: 0.72-6.76), or need for fracture reduction in the ED (OR=0.57, 95% CI: 0.20-1.65). No children developed compartment syndrome, and the mean length of stay was 1.4 (SD 1.2) days. No children were readmitted following discharge.

CONCLUSIONS

We have found no cases of compartment syndrome or extensive requirement for opiates following closed tibial fractures treated in plaster cast. These children are candidates to be discharged directly from the ED. We have not identified any specific risk factors for the targeting of opiate analgesics. We recommend a guideline prescription of 6 doses of opiates for direct discharge from the ED to ensure adequate analgesia without overprescription.

LEVEL OF EVIDENCE

Level IV-case series.

A Standardized Order-Set Improves Variability in Opioid Discharge Prescribing Patterns After Surgical Fixation of Pediatric Supracondylar Humerus Fractures

OBJECTIVE

To evaluate institutional opioid prescribing patterns following percutaneous fixation of pediatric supracondylar humerus fractures before and after implementation of a standardized discharge order set.

DESIGN

A retrospective review of patients who underwent closed reduction and percutaneous skeletal fixation of a Type II or III supracondylar humerus fracture in 2017 (prior to pain protocol implementation) and again in 2019 (after pain protocol implementation) SETTING: Single Tertiary Care Children's Hospital PARTICIPANTS: In total, 106 patients met inclusion criteria between years 2017 (n = 49) and 2019 (n = 57). Exclusion criteria included miscoded patients, open fractures, patients who presented with vascular injury or nerve palsy, polytrauma patients with multiple fractures in the same upper extremity, and supracondylar humerus fractures that underwent an open procedure.

RESULTS

There were no significant differences between inpatient pain scores (p = 0.91) and MDE prescribed (p = 0.75) between the 2 cohorts. In 2017, large variability was noted in day supply of opioids (0-11.4 days) and MDE (0-8.45 mg/kg), with significant differences between prescribing patterns of junior and senior level residents (mean day supply of opioids (p = 0.045), mean MDE prescribed on discharge (p = 0.001)). After implementation of a standardized opioid discharge order set, there was a tenfold increase in the number of patients discharged without an opioid prescription (2017: 4%, 2019: 44%). Additionally, any discrepancies between prescribing practices of junior and senior level residents were eliminated (mean day supply of opioids (p = 0.65), mean MDE prescribed on discharge (p = 0.69)).

CONCLUSIONS

The introduction of a standardized post-operative opioid discharge order set led to a 10-fold increase in the number of patients discharged without an opioid prescription. Additionally, the order set decreased the variability in the prescribing patterns of discharge opioid medications without change in pain control. The resident prescribing variability based upon level of experience resolved with the use of the order set.

Patient-reported opioid analgesic use after discharge from surgical procedures: a systematic review

OBJECTIVE

This systematic review synthesizes evidence on patient-reported outpatient opioid analgesic use post-surgery.

METHODS

We searched Pubmed (February 2019), Web of Science and Embase (June 2019) for U.S. studies describing patient-reported outpatient opioid analgesic use. Two reviewers extracted data on opioid analgesic use, standardized use, and performed independent quality appraisals based on the Cochrane Risk of Bias Tool and an adapted Newcastle-Ottawa scale.

RESULTS

Ninety-six studies met eligibility criteria; 56 had sufficient information to standardize use in oxycodone 5 mg tablets. Patient-reported opioid analgesic use varied widely by procedure type; knee and hip arthroplasty had the highest postoperative opioid use, and use after many procedures was reported as < 5 tablets. In studies that examined excess tablets, 25%-98% of the total tablets prescribed were reported to be excess, with most studies reporting that 50%-70% of tablets went unused. Factors commonly associated with higher opioid analgesic use included preoperative opioid analgesic use, higher inpatient opioid analgesic use, higher postoperative pain scores, and chronic medical conditions, among others. Estimates also varied across studies due to heterogeneity in study design, including length of follow-up and inclusion/exclusion criteria.

CONCLUSION

Self-reported post-surgery outpatient opioid analgesic use varies widely both across procedures and within a given procedure type. Contributors to within-procedure variation included patient characteristics, prior opioid use, intraoperative and perioperative factors, and differences in timing of opioid use data collection. We provide recommendations to help minimize variation caused by study design factors and maximize interpretability of forthcoming studies for use in clinical guidelines and decision-making.

Efficacy of Short Message Service Text Messaging Interventions for Postoperative Pain Management: Systematic Review

Background

Addiction to opiates and synthetic opioids poses a major threat to public health worldwide, with pharmaceutical opioids prescribed to manage pain constituting the main problem. To counteract this threat, suitable pain management strategies should be implemented in health care. Monitoring pain management seems to be feasible using telemedicine with a certain degree of resource intensity and digitization. As a communication channel for this type of monitoring, SMS appears to be a valid alternative.

Objective

The aim of this systematic literature review was to (1) provide information on the state of research regarding postoperative pain management via SMS, (2) establish a basic understanding of SMS-based pain management, and (3) provide insight into the feasibility of these management strategies. The research question was as follows: Is postoperative pain management feasible and effective utilizing SMS?

Methods

A systematic literature review was performed mainly following the PRISMA guidelines and another guide on performing a systematic literature review for information systems–related research. A search string was developed based on the objectives and research question, and eight databases were searched.

Results

The initial search resulted in 2083 records, which could be narrowed down by applying various exclusion criteria. Thereby, 11 articles were identified as relevant, which were accordingly analyzed and evaluated by full-text screening. In all articles, pain management interventions were performed using SMS communication between health care professionals and patients or their legal guardians. A prospective approach was predominantly chosen as the study design (91%) with the leading research objective of determining the intervention’s feasibility (73%). The primary reason for sending SMS messages was to monitor patients (64%). Overall, the use of SMS improved adherence, acceptance, and satisfaction regarding postoperative pain management. With an average response rate of approximately 89.5% (SD 3.8%), the reliability of SMS as a communication and monitoring tool was further emphasized. This response rate is significantly higher than that for email interventions (66.63%, P<.001).

Conclusions

This study provides a comprehensive picture of the current status on postoperative pain management by SMS. Communication via SMS was beneficial in all interventions, even preoperative. Six SMS interventions could be certified by the respective institutional review board and three were Health Insurance Portability and Accountability Act–compliant. Therefore, the results of this study could be leveraged to address the opioid epidemic. Overall, the research question could be confirmed. Future research should extend this systematic literature review regarding preoperative pain management. Based on these findings, a pre- and postoperative communication model should be developed to address the opioid epidemic effectively.

Ballistic trauma patients have decreased early narcotic demand relative to blunt trauma patients: Blunt ballistic injury opioid use

OBJECTIVES

Blunt and ballistic injuries are two common injury mechanisms encountered by orthopaedic traumatologists. However the intrinsic nature of these injures may necessitate differences in operative and post-operative care. Given the evolving opioid crisis in the medical community, considerable attention has been given to appropriate management of pain; particularly in orthopaedic patients. We sought to evaluate relative postoperative narcotic use in blunt injuries and ballistic injuries.

DESIGN

Retrospective Cohort Study.

SETTING

Academic Level-1 Trauma Center.

PATIENTS

96 Patients with blunt or ballistic fractures.

INTERVENTION

Inpatient narcotic pain management after orthopaedic fracture management.

MAIN OUTCOME MEASUREMENTS

Morphine equivalent units (MEU).

RESULTS

Patients with blunt injuries had a higher MEU compared to ballistic injuries in the first 24 hours postoperatively (35.0 vs 29.5 MEU, p=0.02). There were no differences in opiate consumption 24-48 hours (34.8 vs 28.0 MEU), 48 hours - 7 days post op (28.4 vs 30.4 MEU) or the 24 hours before discharge (30.0 vs 28.6 MEU). On multivariate analysis, during the 24-48 hours and 24 hours before discharge timepoints total EBL was associated with increased opioid usage. During days 3-7 (p<0.001) and in the final 24 hours prior to discharge (p=0.012), the number of orthopaedic procedures was a predictor of opioid consumption.

CONCLUSION

Blunt injuries required an increased postoperative narcotic consumption during the first 24 hours of inpatient stay following orthopedic fracture fixation. However, there was no difference at other time points. Immediate post-operative pain regimens may be decreased for patients with ballistic injuries.

LEVEL OF EVIDENCE

III.

Opioid prescribing to preteen children undergoing ambulatory surgery in the United States

BACKGROUND

Overuse and misuse of opioids is a continuing crisis. The most common reason for children to receive opioids is postoperative pain, and they are often prescribed more than needed. The amount of opioids prescribed varies widely, even for minor ambulatory procedures. This study uses a large national sample to describe filled opioid prescriptions to preteen patients after all ambulatory surgical procedures and common standard procedures.

METHODS

We analyzed Truven Health MarketScan data for July 2012 through December 2016 to perform descriptive analyses of opioid fills by age and geographic area, change over time, second opioid fills in opioid-naïve patients, and variation in the types and amount of medication prescribed for 18 common and standard procedures in otolaryngology, urology, general surgery, ophthalmology, and orthopedics.

RESULTS

Over 10% of preteen children filled perioperative opioid prescriptions for ambulatory surgery in the period 2012 to 2016. The amount prescribed varied widely (median 5 days' supply, IQR 3-8, range 1-90), even for the most minor procedures, for example, frenotomy (median 4 days' supply, IQR 2-5, range 1-60). Codeine fills were common despite safety concerns. Second opioid prescriptions were filled by opioid-naïve patients after almost all procedures studied. The rate of prescribing declined significantly over time and varied substantially by age and across census regions.

CONCLUSIONS

We identified opioid prescribing outside of the norms of standard practice in all of the specialties studied. Standardizing perioperative opioid prescribing and developing guidelines on appropriate prescribing for children may reduce the opioids available for misuse and diversion.

Pain Control and Medication Use in Children Following Closed Reduction and Percutaneous Pinning of Supracondylar Humerus Fractures: Are We Still Overprescribing Opioids?

BACKGROUND

The purpose of this 2-part study is to determine opioid prescribing patterns and characterize actual opioid use and postoperative pain control in children following discharge after closed reduction and percutaneous pinning of a supracondylar humerus fracture.

METHODS

A retrospective study was conducted from 2014 to 2016 to determine pain medication prescribing patterns at a single level 1 trauma center. Next, a prospective, observational study was conducted from 2017 to 2018 to determine actual pain medication use and pain scores in the acute postoperative period. Data were collected through telephone surveys performed on postoperative day 1, 3, and 5. Pain scores were collected using a parental proxy numerical rating scale (0 to 10) and opioid use was recorded as the number of doses taken.

RESULTS

From 2014 to 2016, there were 126 patients who were prescribed a mean of 47 doses of opioid medication at discharge. From 2017 to 2018, telephone questionnaires were completed in 63 patients. There was no significant difference (P>0.05) in pain ratings or opioid use by fracture type (Gartland), age, or sex. Children required a mean of 4 doses of oxycodone postoperatively. There were 18 (28%) patients who did not require any oxycodone. On average, pain scores were highest on postoperative day 1 (average 5/10) and decreased to clinically unimportant levels (<1) by postoperative day 5. Acetaminophen and ibuprofen were utilized as first-line pain medications in only 25% and 9% of patients, respectively. Two of 3 patients who used >15 oxycodone doses experienced a minor postoperative complication.

CONCLUSIONS

Pediatric patients have been overprescribed opioids after operative treatment of supracondylar humerus fractures at our institution. Families who report pain scores >5 of 10 and/or persistent opioid use beyond postoperative day 5 warrant further clinical evaluation. Two of 3 pain outliers in this study experienced a minor postoperative complication. With appropriate parental counseling, satisfactory pain control can likely be achieved with acetaminophen and ibuprofen for most patients. If oxycodone is prescribed for breakthrough pain, then the authors recommend limiting to <6 doses.

LEVEL OF EVIDENCE

Level IV-observational, cohort study.

Refilling Opioid Prescriptions After Pediatric Orthopaedic Surgery: An Analysis of Incidence and Risk Factors

BACKGROUND

Understanding which pediatric patients seek opioid refills is crucial as prescription opioid use in childhood is associated with an increased risk of future opioid misuse. Orthopaedic surgeons are optimally positioned to lead the charge in addressing the opioid epidemic. The aim of this study was to describe the incidence of and risk factors associated with requiring opioid refills after pediatric orthopaedic surgery in children.

METHODS

This retrospective case-control study included 1413 patients aged 0 to 18 years that underwent orthopaedic surgery at a single tertiary care children's hospital and were prescribed opioids at discharge. Using the state Prescription Drug Monitoring Program (PDMP) database, we determined which patients filled additional opioid prescriptions within 6 months following an orthopaedic procedure. Comparisons were made between patients that sought additional opioids and those that did not use bivariate analysis and binomial logistic regression.

RESULTS

In total, 31 (2.2%) patients sought additional opioid prescriptions a median 41 days postoperatively (range, 2 to 184). Nearly half of these patients obtained refills from providers outside of our institution, suggesting that previous reports using hospital records may underestimate its prevalence. Factors associated with requiring opioid refills included receiving hydromorphone [odds ratio (OR)=3.04, P=0.04] or methadone (OR=38.14, P<0.01) while inpatient, surgery on the axial skeleton (OR=5.42, P=0.01) or lower extremity (OR=2.49, P=0.04), and nonfracture surgery (OR=3.27, P=0.01). Patients who obtained additional opioids received significantly more opioids during their inpatient recovery (32.9 vs. 11.1 morphine equivalents, P<0.01).

CONCLUSIONS

Approximately 2% of children and families obtain additional opioids within 6 months of orthopaedic surgery. The volume of opioids during inpatient hospitalization may predict the need for opioid prescription refills after discharge. Clinicians should maximize efforts to achieve pain control with multimodal analgesia and opioid alternatives, and use caution when administering high-dose opioids during postoperative hospitalization.

LEVEL OF EVIDENCE

Level III-prognostic.

Structured opioid-free protocol following outpatient hypospadias repair - A prospective SQUIRE 2.0-compliant quality improvement initiative

BACKGROUND

Prescription opioids have been extensively to manage postoperative pain in children. A growing body of evidence from the adult literature, suggests however, that healthcare providers may be prescribing far more opioids than required, with some studies demonstrating equivalent post-operative pain and clinical outcomes with their omission.

OBJECTIVE

The objectives of this prospective study were to assess the current heterogeneity of practice in post-operative opioids prescription following day case hypospadias surgery, to establish a streamlined discharge protocol, and to reduce the use of post-operative opioid prescription by 30% within a 4 month period through the use of systemic forcing functions and education.

STUDY DESIGN

This prospective study was approved by the Quality Improvement (QI) sub-committee of the hospital's Research and Ethics Board (REB) and was compliant with the Standards for Quality Improvement Reporting Excellence (SQUIRE 2.0) guidelines. Recruited parents (n = 84) were contacted for telephone interview following a combined intervention of education and omission of post-operative opioids from the discharge prescription. A mixture of qualitative and quantitative techniques were employed including an initial process analysis to assess current opioid use, the creation of balancing measures, and the creation of Plan-Do-Study-Act cycles. Age, procedure, post-operative outcomes and opioid prescription data were recorded over a period of 6 months in 2019.

RESULTS

Initial measures in our process analysis demonstrated significant institutional practice variation amongst our 84 post-intervention patients. Our process and fidelity measures confirmed 100% information provision. Following the point of intervention, there was a significant and sustained drop in opioid prescription, with an absolute reduction of 35%, and a relative reduction of 56%. There was no significant difference in patient age, pain scores, or outcomes pre- and post-intervention.

DISCUSSION

We have shown in this study that a sustainable decrease in post-operative opioid prescriptions following hypospadias surgery is possible. We managed to achieve a relative reduction 56% which is comparable to other specialties, however, did it within a quality improvement framework to ensure fidelity and no adverse balancing measures. We also managed to reduce the number of doses prescribed in those receiving opioids post-intervention at week 9.

CONCLUSION

Our study demonstrates opioids can be safely omitted in hypospadias cohorts without any adverse clinical outcomes or balancing measures. We recommend that opioids be used extremely judiciously in this population in order to minimize exposure in children.

Acceptance and Commitment Therapy Delivered via a Mobile Phone Messaging Robot to Decrease Postoperative Opioid Use in Patients With Orthopedic Trauma: Randomized Controlled Trial

BACKGROUND

Acceptance and commitment therapy (ACT) is a pragmatic approach to help individuals decrease avoidable pain.

OBJECTIVE

This study aims to evaluate the effects of ACT delivered via an automated mobile messaging robot on postoperative opioid use and patient-reported outcomes (PROs) in patients with orthopedic trauma who underwent operative intervention for their injuries.

METHODS

Adult patients presenting to a level 1 trauma center who underwent operative fixation of a traumatic upper or lower extremity fracture and who used mobile phone text messaging were eligible for the study. Patients were randomized in a 1:1 ratio to either the intervention group, who received twice-daily mobile phone messages communicating an ACT-based intervention for the first 2 weeks after surgery, or the control group, who received no messages. Baseline PROs were completed. Two weeks after the operative intervention, follow-up was performed in the form of an opioid medication pill count and postoperative administration of PROs. The mean number of opioid tablets used by patients was calculated and compared between groups. The mean PRO scores were also compared between the groups.

RESULTS

A total of 82 subjects were enrolled in the study. Of the 82 participants, 76 (38 ACT and 38 controls) completed the study. No differences between groups in demographic factors were identified. The intervention group used an average of 26.1 (SD 21.4) opioid tablets, whereas the control group used 41.1 (SD 22.0) tablets, resulting in 36.5% ([41.1-26.1]/41.1) less tablets used by subjects receiving the mobile phone-based ACT intervention (P=.004). The intervention group subjects reported a lower postoperative Patient-Reported Outcome Measure Information System Pain Intensity score (mean 45.9, SD 7.2) than control group subjects (mean 49.7, SD 8.8; P=.04).

CONCLUSIONS

In this study, the delivery of an ACT-based intervention via an automated mobile messaging robot in the acute postoperative period decreased opioid use in selected patients with orthopedic trauma. Participants receiving the ACT-based intervention also reported lower pain intensity after 2 weeks, although this may not represent a clinically important difference.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03991546; https://clinicaltrials.gov/ct2/show/NCT03991546.

The Cost and Educational Experience of Treating Supracondylar Humerus Fractures: A Pilot Analysis on Standardizing Surgical Care

Closed reduction and percutaneous pinning (CRPP) for supracondylar humeral fractures (SCHF) comprised considerable surgical volume in pediatric orthopaedics. Limited reports are available on how standardization of the surgical care affects the cost and trainee's learning experience.

[Supracondylar humeral fractures in childhood]

The classification of supracondylar humeral fractures in German-speaking areas is carried out according to von Laer, which has been appropriated from the AO system and has the advantage that it can be used to derive the treatment. When indicated immediate surgery is given preference over a delayed treatment. The result is controlled by functional tests directly during the operation. Instability of the fracture and correct placement of the Kirschner (K) wires are challenging. Alternatives are an external fixator and elastically stable intramedullary nailing (ESIN). Concomitant injuries initially affect the median nerve and the brachial artery and secondarily the radial nerve. Lesions of the ulnar nerve are mostly a postoperative complication. The bony consolidation is achieved after 3-4 weeks and afterwards implant removal can be safely carried out. Embedded K‑wires and ESIN are removed after 3-6 months, depending on the surgical capacity and complaints of the patient.

Detailing postoperative pain and opioid utilization after periacetabular osteotomy with automated mobile messaging

In the setting of periacetabular osteotomy (PAO), this investigation sought to (i) describe patient-reported pain scores and opioid utilization in the first 6 weeks following surgery and (ii) evaluate the effectiveness of postoperative communication using a robotic mobile messaging platform. Subjects indicated for PAO were enrolled from a young adult hip clinic. For the first 2 weeks after surgery, subjects received daily mobile messages inquiring about pain level on a 0–10 scale and the number of opioid pain medication tablets they consumed in the previous 24 h. Messaging frequency decreased to 3 per week in Weeks 3–6. Pain scores, opioid utilization and response rates with our mobile messaging platform were quantified for the 6-week postoperative period. Twenty-nine subjects underwent PAO. Twenty-one had concurrent hip arthroscopy. Average daily pain scores decreased over the first four postoperative days. Average pain scores reported were 5.9 ± 1.9, 4.1 ± 3.3 and 3.0 ± 3.5 on Day 1, Day 14 and Week 6, respectively. Reported opioid tablet utilization was 5.0 ± 3.2, 2.2 ± 2.0 and 0.0 ± 0.0 on Days 1 and 14 and at 6 weeks. Response rate for participants completing the 6-week messaging protocol was 84.1%. Patient-reported pain scores decreased over the first two postoperative weeks following PAO before plateauing in weeks 3–6. Opioid pain medication utilization increased in the first postoperative week before gradually declining to no tabs consumed at 6 weeks after PAO. Automated mobile messaging is an effective method of perioperative communication for the collection of pain scores and opioid utilization in patients undergoing PAO.

Who Hurts More? A Multicenter Prospective Study of In-Hospital Opioid Use in Pediatric Trauma Patients in the Midwest

BACKGROUND

Despite increased national attention on misuse of prescription and nonprescription opioids for adolescents and children, little is known about opioid use in a pediatric population during hospitalization for injury. The purpose of this investigation is to describe opioid administration and magnitude of opioid exposure in the first 48 hours of hospitalization in a pediatric trauma population.

STUDY DESIGN

This is a secondary analysis of data collected for a randomized, prospective intervention study at 4 Midwestern children's trauma centers. Participants included children ages 10 to 17 years old, admitted to the hospital for unintentional injury. Descriptive statistics and multivariable modeling were used to characterize demographic factors and measure prevalence and magnitude of opioid use within the first 48 hours of hospitalization.

RESULTS

Among 299 participants, 82% received at least 1 opioid administration. Children had increased odds of receiving an opioid (odds ratio [OR] 4.25; 95% CI 2.16 to 8.35) for every log increase of Injury Severity Scores (ISS), yet the majority of children with minor injury (61%) also received an opioid. Children with fractures and older children had higher odds of receiving an opioid. Amount of opioid, expressed as morphine milligrams equivalent (MME), significantly increased with child age, ISS, and fracture.

CONCLUSIONS

Most pediatric trauma patients received an opioid in the first 48 hours of hospitalization, although prevalence and exposure varied by age, injury, and acuity. Aggressive pain management can be appropriate for injured pediatric patients; however, study results indicate areas for improvement, specifically for children with minor injuries and those receiving excessive opioid amounts.