Clinical Progress Note: Perioperative Pain Control in Hospitalized Pediatric Patients

Acetaminophen

Acetaminophen has central-acting analgesic and antipyretic properties and readily crosses the blood brain barrier, which makes it particularly useful in spine and neurological surgeries. Oral administration is preferred when feasible. The AAP recommends refraining from rectal administration of acetaminophen as analgesia in children because of concerns about toxic effects and erratic, variable absorption.¹⁰ A systematic review of six studies found no benefit in pain control between intravenous (IV) and oral (PO) administration of acetaminophen in adults.¹¹ There is a paucity of studies in children comparing PO with IV acetaminophen perioperative efficacy. Children may benefit from IV formulations in the early postoperative period, in cases with frequent nausea and vomiting, and in those with oral medication intolerance. Since infants have greater risk of respiratory depression from opioids, IV acetaminophen may have utility in this age group. Because of the cost associated with IV formulation, some institutions restrict IV acetaminophen. However, rapidly well-controlled pain and minimization of opioid-related side effects with shorter hospital stays may lower healthcare costs despite the cost of acetaminophen itself.

NSAIDs

NSAIDs possess anti-inflammatory properties through the inhibition of cyclooxygenase and blockade of prostaglandin production. NSAID risks include bleeding, renal and gastrointestinal toxicities, and potentially delayed wound and bone healing. Ketorolac is an NSAID that continues to be widely used with demonstrated opioid-sparing effects. Many retrospective studies including large numbers of pediatric patients have not demonstrated increased risks of bleeding nor poor wound healing with short postoperative use. A Cochrane review, however, concluded that there is insufficient data to either support or reject the efficacy or safety of ketorolac for postoperative pain treatment in children, mostly because of the very low quality of evidence.12

Regional Anesthesia

Regional anesthesia, which includes central (spinal/epidural/caudal) and peripheral blocks, decreases postoperative pain and opioid-associated side effects. Blocks typically consist of local anesthetic with or without the addition of adjuncts (eg, clonidine, dexamethasone). Regional anesthesia may also improve pulmonary function, compared with that of nonregional MMA use, in patients who have thoracic or upper abdominal surgeries. While having broad applications, the utility of regional anesthesia is greatest in preterm infants/neonates and in those with underlying respiratory pathology. A systematic review of randomized controlled trials demonstrated that regional anesthesia decreased opioid consumption and minimized postoperative pain with no significant complications attributed to its use.¹³ Additional studies are needed to better delineate specific surgical procedures and subpopulations of pediatric patients in which regional anesthesia may provide the most benefit.

Gabapentinoids

Children receiving gabapentinoids perioperatively have been shown to have fewer adverse reactions, decreased opioid consumption, and less anxiety, as well as improved pain scores. Gabapentin is increasingly being utilized for children with idiopathic scoliosis undergoing posterior spinal fusion, and there is some evidence for improving pain control and reducing opioid use. However, a recent systematic review found a paucity of data supporting its clinical use.¹⁴ Both gabapentin and pregabalin may further increase risks of respiratory depression, especially in synergy with opioids and benzodiazepines.

Opioids