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Lin EE, Fazal FZ, Pearsall MF, Talwar D, Chang H, Shah AS. Local Anesthetic Injection Before Incision Decreases General Anesthesia Requirements in Pediatric Trigger Thumb Release: A Randomized Controlled Trial. J Pediatr Orthop 2022; 42:e285-e289. [PMID: 34967805 DOI: 10.1097/bpo.0000000000002042] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Animal studies have shown evidence of neurotoxicity from inhalational anesthesia, yet clinical studies have been less conclusive. While ongoing studies investigate the clinical significance of anesthesia-associated neurodevelopmental changes in young children, reducing anesthetic exposure in pediatric orthopaedic surgery is prudent. The primary objective of this study is to determine if local anesthetic injection before surgical incision versus after surgical release decreased inhalational anesthetic exposure in children undergoing unilateral trigger thumb release. The secondary objectives were to determine if the timing of local anesthetic injection affected postoperative pain or length of stay. METHODS This was a single-center randomized controlled trial of pediatric patients (4 y and below) undergoing unilateral trigger thumb release. Subjects were randomized into preincision or postrelease local anesthesia injection groups. The surgeon was aware of the treatment group, while the anesthesiologist was blinded. Patient demographics, operative times, cumulative sevoflurane dose, and postoperative anesthesia care unit recovery characteristics were collected. The χ2, Fisher exact, and Mann-Whitney U tests were conducted. RESULTS A total of 24 subjects were enrolled, with 13 randomized to the preincision injection group and 11 to the postprocedure injection group. There was no significant difference in age, sex, operative time, or tourniquet time between groups. There was a significant difference in the cumulative sevoflurane dose between the preincision injection group (23.2 vol%; interquartile range: 21.7 to 27.6) and the postprocedure injection group (28.1 vol%; interquartile range: 27 to 30) (P=0.03), with a 21% reduction in cumulative dose. There were no significant differences in postoperative pain scores, use of rescue pain medications, the incidence of nausea, or time to discharge between groups. CONCLUSIONS Administering local anesthesia before incision versus at the end of the procedure significantly decreased cumulative sevoflurane dose for unilateral trigger thumb release. The results of this study suggest that local anesthetic injection before the incision is a low risk, easy method to reduce general anesthesia requirements during trigger thumb release and could decrease sevoflurane exposure more substantially in longer procedures and mitigate risks of neurotoxicity. Preincision injection with local anesthetic should be incorporated into routine clinical practice. LEVEL OF EVIDENCE Level I.
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Affiliation(s)
- Elaina E Lin
- Department of Anesthesiology and Critical Care Medicine
- Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Faris Z Fazal
- Division of Orthopaedics, Children's Hospital of Philadelphia
| | - Matthew F Pearsall
- Department of Anesthesiology and Critical Care Medicine
- Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Divya Talwar
- Division of Orthopaedics, Children's Hospital of Philadelphia
| | - Hannah Chang
- Division of Orthopaedics, Children's Hospital of Philadelphia
| | - Apurva S Shah
- Division of Orthopaedics, Children's Hospital of Philadelphia
- Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
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Kim K, Armstrong D, Hennrikus W. Methods to reduce opioid use during surgical treatment of pediatric supracondylar fractures - a pilot study. Injury 2021; 52:1331-1335. [PMID: 33213865 DOI: 10.1016/j.injury.2020.10.092] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2020] [Revised: 10/19/2020] [Accepted: 10/20/2020] [Indexed: 02/02/2023]
Abstract
BACKGROUND The current opioid epidemic is a national problem and an increasing concern for pediatric orthopedic patients. The utilization of non-opioid pain methods may help improve the over-prescribing and overuse of opioid medications. The present study is a pain medication usage study that aims to investigate the effects of an intraoperative bupivacaine (BP) fracture injection and IV paracetamol on postoperative opioid consumption when treating supracondylar fractures of the humerus in children. METHODS The study was approved by the college of medicine's institutional review board (IRB). Forty-two patients treated for a type-III supracondylar extension-type fracture of the humerus by 2 surgeons were reviewed. Two cohorts (n = 21) were compared based on whether patients received an intraoperative fracture injection of BP. A sub-analysis was performed among the BP cohort by stratifying patients who received only BP and patients who received BP and intraoperative IV paracetamol. Data variables evaluated included baseline patient characteristics and postoperative inpatient analgesic use. RESULTS The BP cohort received a lesser number of opioid doses during the total postoperative hospital stay (2.1 ± 1.8 versus 3.6 ± 2.5; p = 0.031) as well as average morphine-milligram equivalents (MME) (11.8 ± 15.9 versus 4.2 ± 5.2; p = 0.044). When the BP cohort was stratified by patients who did and did not receive intraoperative IV paracetamol, during their total postoperative hospital stay, the paracetamolgroup consumed analgesic medication less frequently (p = 0.005), consumed less opioid doses (p = 0.011), and consumed less morphine-milligram-equivalents of opioids (p = 0.043). DISCUSSION Opioid abuse and overuse in children is part of a national healthcare crisis. The use of BP injected into the fracture at the time of surgery is safe, effective, and reduces the need for opioids. Furthermore, the combination of intraoperative BP and IV paracetamol demonstrated less utilization of opioids than BP alone.
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Affiliation(s)
- Kelvin Kim
- Univerity of Las Vegas, Nevada, Department of Orthopedic Surgery, 2040 W Charleston Blvd. Las Vegas, NV 89102, United States
| | - Douglas Armstrong
- Penn State Hershey Medical Center, 30 Hope Drive, Building A, Hershey, PA 17033, United States
| | - William Hennrikus
- Penn State Hershey Medical Center, 30 Hope Drive, Building A, Hershey, PA 17033, United States.
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Astacio E, Echegaray G, Rivera L, Otero-Delgado JM, Olivella G, Ramírez N, Ramos-Alconini N, Foy C. Local Hematoma Block as Postoperative Analgesia in Pediatric Supracondylar Humerus Fractures. JOURNAL OF HAND SURGERY GLOBAL ONLINE 2020; 2:155-158. [PMID: 35415488 PMCID: PMC8991413 DOI: 10.1016/j.jhsg.2020.02.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2019] [Accepted: 02/20/2020] [Indexed: 11/29/2022] Open
Abstract
Purpose Supracondylar humerus fracture (SHF) is the most common type of fracture in children. The aim of this study was to evaluate the efficacy of local hematoma block with 0.25% bupivacaine as postoperative pain control in patients with pediatric SHF who underwent closed reduction pin fixation. Methods We performed an institutional review board–approved, prospective cohort study of 65 patients with SHF treated with closed reduction percutaneous pin fixation. For 6 months, all patients were randomly divided into 2 groups. The treatment group (35 patients) received an intraoperative local hematoma block using 0.25% bupivacaine whereas the control group (30 patients) did not receive a local hematoma block as postoperative pain management adjuvant. After surgery, all patients were prescribed opioid pain medication. To evaluate the efficacy of the hematoma block, postoperative morphine equivalent consumption and the Faces Pain Scale–Revised (FPS-R) survey were blindly recorded during postoperative day 1. Demographic data, surgical details, clinical neurovascular examination during the hospital stay, and complications were also evaluated. Results Comparison of the control group with the treatment group showed similar morphine equivalent consumption and Face Pain Scale–Revised Survey results. No hematoma block-associated complications were reported. Conclusions The result of this study do not favor the use of local hematoma block to improve pain control and decrease the need for opioid use on postoperative day 1 in pediatric SHF after patients undergo closed reduction percutaneous pin fixation. These results can lay the foundation for future studies while suggesting new, novel opioid-free pain control strategies in patients with SHF. Type of study/level of evidence Therapeutic II.
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Affiliation(s)
- Eric Astacio
- Orthopedic Department, University of Puerto Rico Medical Sciences Campus, San Juan, PR
| | - Gabriel Echegaray
- Orthopedic Department, University of Puerto Rico Medical Sciences Campus, San Juan, PR
| | - Lenny Rivera
- Orthopedic Department, University of Puerto Rico Medical Sciences Campus, San Juan, PR
- Corresponding author: Lenny Rivera, MD, Orthopedic Department, University of Puerto Rico Medical Sciences Campus, PO Box 365067, San Juan, PR 00936-5067.
| | | | - Gerardo Olivella
- Transitional Year Residency Program, St. Lukes Episcopal Hospital, Ponce, PR
| | - Norman Ramírez
- Pediatric Orthopedic Department, Hospital de la Concepción, San German, PR
| | - Nestor Ramos-Alconini
- Orthopedic Department, University of Puerto Rico Medical Sciences Campus, San Juan, PR
| | - Christian Foy
- Orthopedic Department, University of Puerto Rico Medical Sciences Campus, San Juan, PR
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Current Evidence for Acute Pain Management of Musculoskeletal Injuries and Postoperative Pain in Pediatric and Adolescent Athletes. Clin J Sport Med 2019; 29:430-438. [PMID: 31460958 DOI: 10.1097/jsm.0000000000000690] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVE Sports-related injuries in young athletes are increasingly prevalent with an estimated 2.6 million children and adolescents sustaining a sports-related injury annually. Acute sports-related injuries and surgical correction of sports-related injuries cause physical pain and psychological burdens on pediatric athletes and their families. This article aims to evaluate current acute pain management options in pediatric athletes and acute pain management strategies for postoperative pain after sports-related injuries. This article will also elucidate which areas of pain management for pediatric athletes are lacking evidence and help direct future clinical trials. DATA SOURCES We conducted a literature search through PubMed and the Cochrane Central Register of Controlled Trials to provide an extensive review of initial and postoperative pain management strategies for pediatric sports-related musculoskeletal injuries. MAIN RESULTS The current knowledge of acute pain management for initial sports-related injuries, postoperative pain management for orthopedic surgeries, as well as complementary and alternative medical therapies in pediatric sports-related injuries is presented. Studies evaluating conservative management, enteral and nonenteral medications, regional anesthesia, and complementary medical therapies are included. CONCLUSIONS Adequate pain management is important for sports injuries in children and adolescents for emotional as well as physical healing, but a balance must be achieved to provide acceptable pain relief while minimizing opioid use and side effects from analgesic medications. More studies are needed to evaluate the efficacy of nonopioid analgesic medications and complementary therapies in pediatric patients with acute sports-related injuries.
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Perioperative Ketorolac for Supracondylar Humerus Fracture in Children Decreases Postoperative Pain, Opioid Usage, Hospitalization Cost, and Length-of-Stay. J Pediatr Orthop 2019; 39:e447-e451. [PMID: 30720556 DOI: 10.1097/bpo.0000000000001345] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND There is a need for improved opioid stewardship in orthopedic surgery through multimodal analgesia strategies. Perioperative administration of ketorolac in children undergoing closed reduction and percutaneous pinning (CRPP) for displaced supracondylar humerus (SCH) fracture may decrease pain, reduce opioid requirements, and decrease hospitalization costs. METHODS Retrospective case-control investigation of children (aged, 1 to 14) treated with CRPP for closed, modified Gartland type III extension-type SCH fractures at a single children's hospital between 2011 and 2017. Patients that received ketorolac perioperatively (cases) were randomly matched 1:2 by sex and age (±1 y) with patients that did not receive ketorolac (controls). Data abstraction included demographic and perioperative details including inpatient Wong-Baker FACES pain ratings and analgesic requirements. Analysis included 2-tailed Mann-Whitney U and χ tests. RESULTS In total, 342 patients were studied including 114 cases and 228 controls. Age (mean, 6.2±2.4 y), sex ratio (M:F, 1.28:1), operative time, and number of pins used were equivalent between groups. Mean pain rating at 0 to 29 minutes postoperatively was lower in the ketorolac group (0.7±1.9) than in controls (1.4±2.6, P=0.017), as well as at 30 to 120 minutes postoperatively (1.1±2.3 and 1.7±2.8, respectively, P=0.036), as seen in Figure 1. Patients in the ketorolac group received a lower number of inpatient oxycodone doses (1.0±0.6) than control patients (1.2±0.5, P=0.003). Mean postoperative length-of-stay (LOS) was 50.0% longer for control patients (20.4±11.3 h) than the ketorolac patients (13.6±8.8 h, P<0.001). Ketorolac administration was associated with 40.4% lower inpatient hospitalization cost compared to control patients, providing a 33.8 times return on investment. There was no difference in the 90-day complication rate between patient groups (P=0.905). CONCLUSIONS The complementary administration of ketorolac reduces postoperative pain and opioid use in children with displaced supracondylar humerus fractures. Perioperative ketorolac is also associated with reduced LOS following CRPP for supracondylar humerus fractures and offers significant cost savings opportunities. LEVEL OF EVIDENCE Level 3-Therapeutic: Case-Control Study.
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Abstract
Effective perioperative pain control in pediatric patients undergoing orthopedic surgery remains a challenge. Developing a successful pain control regimen begins preoperatively with assessment of the patient and discussion with the patient and family regarding expectations. Perioperative pain control regimens are customized based on the type of surgery, patient characteristics, and anticipated severity and duration of the postoperative pain. Recent study focuses on multimodal strategies and regional anesthesia options, allowing for decreased opioid use. This article provides an evidence-based overview of preoperative, intraoperative, and postoperative pain control for the pediatric orthopedic patient.
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Gupta B, Banerjee S, Prasad A, Farooque K, Sharma V, Trikha V. Analgesic efficacy of three different dosages of intra-articular morphine in arthroscopic knee surgeries: Randomised double-blind trial. Indian J Anaesth 2015; 59:642-7. [PMID: 26644611 PMCID: PMC4645352 DOI: 10.4103/0019-5049.167479] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND AND AIMS Arthroscopic knee surgery is a common procedure and may cause enough pain to delay rehabilitation. Intra-articular (IA) morphine is a known modality for post-operative pain relief. However, the optimal dose of IA morphine has not been studied. The current study has been conducted to find out the optimal dosage of IA morphine when administered with 0.25% bupivacaine. METHODS Sixty adult patients of either sex, aged between 18 and 60 years, undergoing diagnostic/therapeutic knee arthroscopic surgery were included in the study and randomised into three groups. All patients underwent surgery under subarachnoid block. After the surgical closure, 20 ml of 0.25% bupivacaine with 1 mg, 3 mg and 5 mg of morphine as additive was injected intra-articularly in Group A, B and C patients, respectively. Post-operative pain assessment was performed with visual analogue scale score in the 1(st), 2(nd), 6(th), 12(th) and 24(th) post-operative hour. The common complications were also recorded. RESULTS There was statistically significant analgesia in Group B and C than Group A in the 1(st) and 2(nd) post-operative hour; while at the 24(th) post-operative hour, Group C had statistically significant analgesia than the other two groups. Time to first rescue analgesia was statistically significantly less and consumption of supplemental analgesia was significantly higher in Group A than the other two groups. CONCLUSION IA dose of 3 mg and 5 mg morphine with 20 ml of 0.25% bupivacaine provided adequate analgesia. However, 3 mg morphine group patients had fewer side effects than 5 mg group patients although the difference was not statistically significant.
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Affiliation(s)
- Babita Gupta
- Department of Anaesthesiology, JPNATC, AIIMS, New Delhi, India
| | | | - Arunima Prasad
- Department of Anaesthesiology, JPNATC, AIIMS, New Delhi, India
| | | | - Vijay Sharma
- Department of Orthopaedics, JPNATC, AIIMS, New Delhi, India
| | - Vivek Trikha
- Department of Orthopaedics, JPNATC, AIIMS, New Delhi, India
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Somford MP, van Deurzen DFP, Ostendorf M, Eygendaal D, van den Bekerom MPJ. Quality of research and quality of reporting in elbow surgery trials. J Shoulder Elbow Surg 2015; 24:1619-26. [PMID: 25958211 DOI: 10.1016/j.jse.2015.03.031] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2014] [Revised: 03/12/2015] [Accepted: 03/18/2015] [Indexed: 02/01/2023]
Abstract
BACKGROUND Randomized controlled trials (RCTs) are high in the hierarchy of scientific evidence, but possible sources of bias should be identified or even excluded. This systematic review assessed the methodologic quality and the quality of reporting of the RCTs on the treatment of elbow pathology. METHODS A systematic review of RCTs was performed on the treatment of elbow pathology. PubMed/MEDLINE, Embase, and the Cochrane Library were searched for relevant trials. Thirty-five of the initial 540 articles being an (pseudo) RCT on invasive treatment of elbow pathology in humans were included. These were scored with the use of an adapted Checklists to Evaluate A Report of a Nonpharmacologic Trial (CLEAR-NPT). To assess quality of reporting, points were administered to the articles based on the results from CLEAR-NPT list. The highest possible score for quality is 26 points. RESULTS The average quality score was 18.1 points (range, 10-25 points). The mean scores were 19.5 for trials published in the American Journal of Sports Medicine, 19.8 for those published in the Journal of Bone and Joint Surgery, and 20.3 for those published in the Journal of Shoulder and Elbow Surgery. CONCLUSIONS The most important finding was that the overall quality and the quality of reporting has not improved over the years and that the overall quality of the selected studies and the quality of reporting in these trials is not related to the journal they are published in.
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Affiliation(s)
- Matthijs P Somford
- Department of Orthopedic Surgery, Medisch Spectrum Twente, Enschede, The Netherlands.
| | - Derek F P van Deurzen
- Department of Orthopedic Surgery, Onze Lieve Vrouwe Gasthuis, Amsterdam, The Netherlands
| | - Marieke Ostendorf
- Department of Orthopedic Surgery, St Maartenskliniek Woerden, Woerden, The Netherlands
| | - Denise Eygendaal
- Upper Limb Unit, Department of Orthopedic Surgery, Amphia Hospital, Breda, The Netherlands
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Yin B, Levy D, Meadows M, Moen T, Gorroochurn P, Cadet ER, Levine WN, Ahmad CS. How does external rotation bracing influence motion and functional scores after arthroscopic shoulder stabilization? Clin Orthop Relat Res 2014; 472:2389-96. [PMID: 24158541 PMCID: PMC4079886 DOI: 10.1007/s11999-013-3343-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND After arthroscopic shoulder stabilization, the loss of motion or delayed recovery of motion remains a clinical problem and may lead to poor patient satisfaction. There remains no consensus regarding the optimal position for postoperative immobilization and it is not known whether the position for shoulder immobilization has an effect on motion and functional recovery. QUESTIONS/PURPOSES We asked: (1) Do patients treated with external rotation (ER) bracing after arthroscopic anterior shoulder stabilization reliably regain ROM and shoulder function? And (2) what is the frequency of recurrent instability and brace-related complications associated with the use of ER bracing? METHODS Forty consecutive patients with a primary diagnosis of anterior shoulder instability underwent arthroscopic stabilization and received postoperative ER bracing; 33 patients (83%; mean age, 23 years; range, 13-44 years) were followed for at least 1 year postoperatively and seven patients were lost to followup. Shoulder ROM and functional scores were recorded preoperatively and at 2 weeks, 12 weeks, 6 months, and greater than 1 year (mean, 16 months) after surgery. RESULTS All patients recovered their preoperative ROM and most patients achieved normal ROM by 3 months after surgery. Significant improvements in American Shoulder and Elbow Surgeons (ASES) and Western Ontario Shoulder Instability (WOSI) scores were observed at each postoperative time point. The mean (± SD) final scores were 95 ± 9 for the ASES and 87% ± 17% for the WOSI (p < 0.001 compared to preoperative scores). One patient (3%) developed recurrent instability. No patients underwent reoperation for the injured shoulder for any reason during the followup period. CONCLUSIONS ER bracing after arthroscopic shoulder stabilization is associated with a predictable recovery of ROM and functional score improvement. Future studies comparing ER bracing to traditional sling use should be conducted to determine the optimal method of postoperative immobilization. LEVEL OF EVIDENCE Level IV, therapeutic study. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Bob Yin
- />Department of Orthopedic Surgery, Columbia University Medical Center, 622 West 168 Street, PH11-Center, New York, NY 10032 USA
| | - David Levy
- />Department of Orthopedic Surgery, Rush University Medical Center, Chicago, IL USA
| | - Molly Meadows
- />Department of Orthopedic Surgery, Columbia University Medical Center, 622 West 168 Street, PH11-Center, New York, NY 10032 USA
| | - Todd Moen
- />W. B. Carrell Memorial Clinic, Dallas, TX USA
| | - Prakash Gorroochurn
- />Department of Orthopedic Surgery, Columbia University Medical Center, 622 West 168 Street, PH11-Center, New York, NY 10032 USA
| | - Edwin R. Cadet
- />Department of Orthopedic Surgery, Columbia University Medical Center, 622 West 168 Street, PH11-Center, New York, NY 10032 USA
| | - William N. Levine
- />Department of Orthopedic Surgery, Columbia University Medical Center, 622 West 168 Street, PH11-Center, New York, NY 10032 USA
| | - Christopher S. Ahmad
- />Department of Orthopedic Surgery, Columbia University Medical Center, 622 West 168 Street, PH11-Center, New York, NY 10032 USA
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Pandya NK, Otsuka NY, Sanders JO. What's new in pediatric orthopaedics. J Bone Joint Surg Am 2014; 96:345-50. [PMID: 24553894 DOI: 10.2106/jbjs.m.01367] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Affiliation(s)
- Nirav K Pandya
- Department of Orthopedic Surgery, Children's Hospital of Oakland and Research Center/University of California, San Francisco, 747 52nd Street, Oakland, CA 94609. E-mail address:
| | - Norman Y Otsuka
- Center for Children, NYU Langone Hospital for Joint Diseases, 301 East 17th Street, New York, NY 10003
| | - James O Sanders
- Department of Orthopaedics, University of Rochester, 601 Elmwood Avenue, Rochester, NY 14642
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