SLR - June 2022 - Hannah R. Schneiders, DPM
Reference: Johnson MA, Andras LM, Andras LE, Ellington MD, Upasani VV, Shah AS. What’s New in Pain Management for Pediatric Orthopaedic Surgery, J pediatr Orthop.2021 Nov-Dec 01;41(10):e923-e928.Level of Evidence: Level IV
Scientific Literature Review
Reviewed By: Hannah R. Schneiders, DPM
Residency Program: Emory University School of Medicine - Decatur, GA
Podiatric Relevance: The opioid crisis has brought attention to prescription opioids across all medical fields due to the high rate of opioid misuse and overdose in the past few years. Although the majority of overdoses occur in adults there has been a significant increase in pediatric opioid related intensive care unit admissions. The purpose of this review article is to provide a comprehensive assessment of recent literature and highlight the new advancements pertaining to pain control in pediatrics orthopedic surgery.
Methods: An electronic search of PubMed database was used to identify 32 papers that met inclusion criteria. The articles were reviewed based upon new findings and significant contributions in the following eight categories: risk factors for increased opioid usage, opioid overprescribing and disposal, nonpharmacological interventions, nonsteroidal anti-inflammatory drugs, peripheral nerve blocks, spine surgery specific consideration, surgical pathway modifications and future direction.
Results:
Risk Factors for Increased Opioid Usage: Older age, higher body mass index and higher peri-operative pain score are associated with increased post-operative opioid usage.
Opioid Overprescribing and Disposal: There is a need for evidence based clinical practice guidelines for post-operative prescribing. Also a need for readily available and convenient opioid disposal options.
Nonpharmacological Interventions: Decrease in post-operative pain associated with comfortable positions in bed and believing pain status. Infant sucrose water is better than milk and water in decreasing pain during casting.
Nonsteroidal Anti-inflammatory Drugs: No association between NSAIDs and delayed or nonunion in pediatrics. Ketorolac leads to lower odds of moderate to severe post-operative pain rating and shorter hospital stays.
Peripheral Nerve Blocks: Perineural catheters used to administer continuous analgesic infusions are more effective in controlling pain compared with both epidural and intravenous patient controlled analgesia and provided shorter hospital stays.
Liposomal preparations of analgesics, like Exparel, reduces post-operative pain although more studies are needed.
Combing local anesthetic with adjunct molecules, like dexamethasone, provide an additional 2.5 hours of motor and sensory block.
Spine Surgery Specific Consideration” Gamma-aminobutyric acid analogs, like gabapentin and pregabalin, showed significant decrease in both post-operative pain and total opioid use.
Surgical Pathway Modifications: Includes preoperative gabapentin and acetaminophen, intraoperative IV methadone and acetaminophen, postoperatively hydromorphone PCA and diazepam supplemented with 3 additional doses of IV acetaminophen, gabapentin and ketorolac on POD 1 showed to improved daily pain scores. Additional studies needed on post-operative pain management.
Future Direction: Virtual reality for both acute and chronic pain have potentially greater benefits than watching a movie or no distractions.
Conclusions: Although medications such as gabapentin, transdermal clonidine and dexamethasone have led to improvements in postoperative pain management, further research still needs to be performed, especially in pediatrics. Surgical pathway modification with multimodal analgesia still remains an important research topic to improve post-operative daily pain score and standardize protocols. A future promising direction of pain control therapy could be virtual reality.