Clinical Progress Note: Perioperative Pain Control in Hospitalized Pediatric Patients

Pediatric hospitalists play an increasingly significant role in perioperative pain management.¹ Advances in pediatric surgical comanagement may improve quality of care and reduce the length of hospitalization.² This review is based on queries of the PubMed and Cochrane databases between January 1, 2014, and July 15, 2019, using the search terms “perioperative pain management,” “postoperative pain,” “pediatric,” and “children.” In addition, the authors reviewed key position statements from the American Academy of Pediatrics (AAP), the American Pain Society (APS), the Centers for Disease Control and Prevention (CDC), and the Society of Hospital Medicine (SHM) regarding pain management.³ This update is intended to be relevant for practicing pediatric hospitalists, with a focus on recently expanded options for pain management and judicious opioid use in hospitalized children.

Postoperative pain management begins preoperatively according to the concept of the perioperative surgical home (PSH).⁴ The preoperative history should identify the patient’s previous positive (eg, good pain control) and negative (eg, adverse reactions) experiences with pain medications. Family and patient expectations should be discussed regarding types and sources of pain, pain duration, exacerbating/alleviating factors, and modalities available for realistic pain control because preoperative information can limit anxiety and improve outcomes. Pain specialists can perform risk assessments preoperatively and develop plans to address pharmacologic tolerance, withdrawal, and opioid-induced hyperalgesia after surgery.⁵ Children with chronic pain and on preoperative opioids may require more analgesia for a longer duration postoperatively. Early recognition of variability of patient’s pain perception and differences in responses to pain need to be clearly communicated across the disciplines in a collaborative model of care.

Children with medical complexity and/or cognitive, emotional, or behavioral impairments may benefit from preoperative psychosocial treatments and utilization of pain self-­management training and strategies that could further reduce anxiety and optimize postoperative care because patient and parental preoperative anxiety may be associated with adverse outcomes. Validated pain assessment tools like Revised FLACC (Face, Leg, Activity, Cry, and Consolability) Scale and Individualized Numeric Rating Scale could be particularly useful in children with limitations in communication or altered pain perception; therefore, medical teams and family members should discuss their utilization preoperatively.

Multimodal analgesia (MMA) is a strategy that synergistically uses pharmacologic and nonpharmacologic modalities to target pain at multiple points of the pain processing pathway (Table).⁶ MMA can optimize pain control by addressing different types of pain (eg, incisional pain, muscle spasm, or neuropathic pain), expedite recovery, reduce potential pharmacologic side effects, and decrease opioid consumption. Patients taking opioids are at an increased risk of developing opioid-related side effects such as respiratory depression, medication tolerance, and anxiety, with resultant longer hospital stay, increased readmissions, and higher costs of care.⁷ Treatment for postoperative pain should prioritize appropriately dosed and precisely scheduled MMA before opioid-focused analgesia with the goals of decreasing opioid-related adverse effects, intentional misuse, diversion, and accidental ingestions. The AAP, APS, CDC, and SHM endorse the use of MMA and recommend nonpharmacologic measures and regional anesthesia.^8,9 The most used modalities in MMA are discussed below.