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Pre-Emptive Opioid-Sparing Medication Protocol Decreases Pain and Length of Hospital Stay in Children Undergoing
Selina Poon1, De-An Zhang1,2, Frederic Bushnell1,2
1Department of Orthopedics, Shriners Children's Southern California, Pasadena, California, USA.
Insights
A new pre-emptive, opioid-sparing pain protocol for pediatric Posterior Spinal Instrumented Fusion (PSIF) significantly reduced pain scores and hospital stays. This multimodal approach improved patient recovery without increasing overall opioid consumption.
Area of Science:
- Pediatric Orthopedic Surgery
- Pain Management
- Pharmacokinetics
Background:
- Poorly controlled post-operative pain after Posterior Spinal Instrumented Fusion (PSIF) for scoliosis can delay patient mobilization and prolong hospital stays.
- Multimodal analgesia is effective in other orthopedic procedures but lacks description in pediatric spinal surgery.
- Optimizing post-operative pain management is crucial for improving recovery outcomes in pediatric scoliosis patients.
Purpose of the Study:
- To evaluate a novel, pre-emptive, opioid-sparing pediatric pain management protocol for PSIF surgery.
- To assess the protocol's impact on post-operative pain, early mobilization, and hospital length of stay.
- To implement a pain management strategy based on first-order pharmacokinetics to improve patient outcomes.
Main Methods:
- A retrospective review of 116 pediatric PSIF cases was conducted, comparing standard analgesia (n=52) with a pre-emptive multimodal protocol (n=64) initiated two days before surgery.
- The pre-emptive protocol included acetaminophen, celecoxib, and gabapentin, continued throughout the inpatient stay.
- Outcomes analyzed included length of stay, total opioid consumption (morphine equivalents), and daily maximum pain scores.
Main Results:
- The pre-emptive group experienced a significantly shorter mean length of hospital stay (3.9 days) compared to the standard group (4.5 days, p<0.05).
- Patients on the pre-emptive protocol reported significantly lower maximum pain scores on post-operative days 1, 3, and 4.
- There was no significant difference in total post-operative opioid consumption between the two groups.
Conclusions:
- A novel pre-emptive, opioid-sparing multimodal pain protocol significantly reduced maximal pain scores and length of stay in pediatric patients undergoing PSIF.
- The protocol, based on first-order pharmacokinetics, demonstrates potential for improved post-operative recovery in pediatric spinal surgery.
- Further research is warranted to investigate mobilization and long-term pain control post-discharge.
Background:
Poorly controlled post-operative pain following Posterior Spinal Instrumented Fusion (PSIF) for scoliosis may be associated with delayed ambulation and longer hospital stays. Multimodal analgesia use has been shown to provide superior analgesia with improved recovery and reduction of post-operative morbidity in other orthopedic subspecialties, but has not been described with pediatric patients undergoing spinal surgery.
Objective:
We describe a novel, pre-emptive, opioid-sparing pediatric pain medication protocol that is started two days prior to surgery, in accordance with first-order pharmacokinetics, and continued post-operatively until discharge with the goal of decreasing post-operative pain, improving early mobilization, and ultimately decreasing the patient's length of hospital stay.
Methods:
We retrospectively reviewed 116 PSIF cases from March 2014 to November 2017. Fifty-two patients received standard analgesia before August 2016, and 64 patients after August 2016 received the pre-emptive protocol consisting of a standardized combination of acetaminophen, celecoxib, and gabapentin two days prior to surgery and continued during their inpatient stay. Scheduled oxycodone and intravenous hydromorphone via patient controlled analgesia (PCA) were given to both groups equally during the post-operative hospital stay. We analyzed length of stay, total opioid consumption, and maximum pain scores per day from surgical to discharge date.
Results:
116 patients were included: 64 patients in the pre-emptive group and 52 patients in the standard group. Length of hospital stay significantly differed, with means of 3.9 days in the pre-emptive group and 4.5 days in the standard analgesia group (p<0.05). Patients in the pre-emptive group recorded significantly lower maximal pain levels than those in the standard analgesia group on post-operative days #1 (4.9 vs. 5.8, p=0.0196), #3 (4.4 vs. 6.1, p=0.0006), and #4 (4.2 vs. 5.4, p=0.0393). Total post-operative morphine equivalents taken did not significantly differ between the two groups.
Conclusion:
This is a preliminary report demonstrating a significant decrease in maximal pain score and length of stay following PSIF on a cohort of patients receiving a novel pre-emptive opioid-sparing pain medication protocol based on first order pharmacokinetics. Future studies should investigate degree of mobilization and opioid consumption and maximal pain level after discharge from the hospital. Level of Evidence: III.
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