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Procedural Pain Management During Tenotomy for Congenital Talipes Equinovarus
Kate N Moss1,2, Pamela A Hennessy1, Marianne McCormick1,3
1Department of Physiotherapy, Sydney Children's Hospital, Randwick, Randwick, NSW, Australia.
Insights
Achilles tenotomy for congenital talipes equinovarus (CTEV) in infants causes significant pain, even with multimodal pain management. This study highlights the need for improved pain control strategies during this common pediatric orthopedic procedure.
Area of Science:
- Pediatric Orthopedics
- Pain Management
- Neonatal Care
Background:
- Congenital talipes equinovarus (CTEV) is a common birth defect requiring surgical intervention.
- Tenotomy of the tendoachilles is a frequent procedure for CTEV, often performed on awake infants.
- The pain experienced by infants during awake Achilles tenotomy has not been well-documented.
Purpose of the Study:
- To assess the pain response in infants undergoing awake Achilles tenotomy for CTEV.
- To evaluate the effectiveness of multimodal pain management strategies during this procedure.
- To provide objective data on infant pain levels and recovery time.
Main Methods:
- Observational study of 91 infants undergoing Achilles tenotomy for CTEV.
- Multimodal pain management included sucrose, paracetamol, topical/local anesthetics, pacifier, and swaddling.
- Pain assessed using the Face, Legs, Activity, Cry, and Consolability (FLACC) scale; physiological parameters (HR, SpO2) recorded.
Main Results:
- Infants experienced high pain levels, with peak median FLACC scores of 9 and heart rate (HR) of 200 bpm.
- Oxygen saturation (SpO2) dropped to a median of 92% during the procedure.
- Pain, measured by FLACC, returned to a score of 3 or less within a median of 2 minutes.
Conclusions:
- Achilles tenotomy for CTEV in awake infants is associated with substantial pain, despite comprehensive multimodal analgesia.
- Current pain management strategies may be insufficient to fully mitigate discomfort during this procedure.
- Further research into optimizing pain relief for infant tenotomy is warranted.
Abstract:
The majority of infants with congenital talipes equinovarus (CTEV) require tenotomy of the tendoachilles. The pain response of this procedure in the awake infant has not been previously reported. In this observational study, multimodal pain management strategies, including oral sucrose, oral paracetamol, topical anesthetic, local anesthetic, a pacifier (dummy), and swaddling, were used. Physiological responses and pain were recorded. Pain was rated out of 10 at regular intervals, using the Face, Legs, Activity, Cry, and Consolability (FLACC) scale. Ninety-one infants (65 men, mean age = 53 days, range = 19-217 days) were observed. At baseline, median FLACC, heart rate (HR), and oxygen saturation (Spo2) were 1, 159, and 97% respectively. Peak median FLACC and HR were 9 and 200, respectively, and lowest median Spo2 was 92%. The median (interquartile range) time for FLACC to return to 3 or less was 2 (2-5) minutes. Achilles tenotomy for CTEV in the awake infant is associated with high pain levels despite provision of multimodal pain relief measures.
