Clinical Progress Note: Perioperative Pain Control in Hospitalized Pediatric Patients

Opioids should be used with caution in pediatric patients and are reserved primarily for the management of severe acute pain. The shortest duration of the lowest effective dose of opioids should be encouraged. Patient-controlled opioid analgesia (PCA) offers benefits when parenteral postoperative analgesia is indicated: It maximizes pain relief, minimizes risk of overdose, and improves psychological well-being through self-­administration of pain medicines. Basal-infusion PCA should not be routinely used because it is associated with nausea, vomiting, and respiratory depression without having superior analgesia compared with demand use only. Monitoring of side stream end-tidal capnography can readily detect respiratory depression, especially if opioids, benzodiazepines, gabapentinoids, and diphenhydramine are used concomitantly. Patient education regarding opioid use, side effects, safe storage, and disposal practices is imperative because significant amounts of opioids remain in households after completion of treatment for pain and because opioid diversion and accidental ingestions account for significant morbidity. Providers need to balance efficient pain management with opioid stewardship, complying with state and federal policies to limit harm related to opioid diversion.¹⁵

Nonpharmacological Modalities

The use of nonpharmacologic therapies, along with pharmacologic modalities, for perioperative pain management has been shown to decrease opioid use and opioid-related side effects. Trials of acupressure have demonstrated improvement in nausea and vomiting, sleep quality, and pain and anxiety scores. Nonpharmacologic treatments currently serve as a complementary approach for pain and anxiety management in the perioperative setting including acupuncture, acupressure, osteopathic manipulative treatment, massage, meditation, biofeedback, hypnotherapy, and physical/occupational, relaxation, cognitive-behavioral, chiropractic, music, and art therapies. The Joint Commission suggests consideration of such modalities by hospitals.

Combining multimodal pharmacologic and integrative nonpharmacologic modalities can decrease opioid use and related side effects and improve the perioperative care of hospitalized children. Pediatric hospitalists have an opportunity to optimize care preoperatively, practice multimodal analgesia, and contribute to reducing risk of opioid diversion post operatively.