Improved pain management in pediatric postoperative liver transplant patients using parental education and non‐pharmacologic interventions

Abstract

A pain management intervention, consisting of pretransplant parental education and support, pre- and postoperative behavioral pediatrics consultation, postoperative physical and occupational therapy consultation, and implementation of non-pharmacologic pain management strategies, was introduced to all pediatrics patients receiving liver transplants at Lucile Packard Children's Hospital beginning August 2001. Children receiving transplants pre-intervention (May, 2000 to February, 2001) and post-intervention (August, 2001 to March, 2002) were compared using pain scores, parent perception of pain ratings, length of stay, ventilator days, total cost, and opioid use. A total of 27 children were evaluated (13 historical control, 14 intervention). The two populations did not differ on age at transplant (mean age 53.8 vs. 63.6 months), sex (46.1% vs. 50% male), ethnicity (53.8% vs. 57.1% white, non-Hispanic) weight at transplant (17.5 vs. 24.7 kg), percent with biliary atresia as the primary reason for transplant (42.9% vs. 69.2%), percent with status 1 transplant listing score (38.5% vs. 50.0%), or public insurance status (30.8 vs. 57.2% with Medicaid). No differences were found in mean pediatric intensive care unit (PICU) postoperative length of stay (6.7 vs. 5.3 days), total postoperative length of stay (17.5 vs. 17.5 days), total inpatient length of stay (27.0 vs. 24.4 days), time to extubation (30 vs. 24.3 h), total cost (dollar 147,983 vs. dollar 157,882) or opioid use through postoperative day (POD) 6 (0.24 vs. 0.25 mg/kg/day morphine equivalent). A decrease in mean pain score between POD 0 and 6 (2.82 vs. 2.12; p = 0.047), a decrease in mean parental pain perception score (3.1 vs. 2.1; p = 0.001), and an increase in number of pain assessments per 12 h shift (3.43 vs. 6.79; p < 0.005) were seen. A comprehensive non-pharmacologic postoperative pain management program in children receiving a liver transplant was associated with decreased pain scores, improved parent perception of pain, and an increased number of pain assessments per 12 h shift. No increases in lengths of stay (PICU, postoperative, total), time to extubation, or total cost were found.

Implementation of a Multimodal Pain Management Order Set Reduces Perioperative Opioid Use after Liver Transplantation

“…Surprisingly, although numerous studies exist on the use of opioids for pain management in liver recipients, research is lacking on nonopioid strategies to optimize pain management after liver transplantation . One previous study examined the usefulness of a nonpharmacologic approach in the context of a comprehensive pain management program; however, this intervention did not result in a significant reduction in opioid use . Nonopioid analgesics are often used in a myriad of pain management settings to reduce opioid burden.…”

“…4,10 One previous study examined the usefulness of a nonpharmacologic approach in the context of a comprehensive pain management program; however, this intervention did not result in a significant reduction in opioid use. 11 Nonopioid analgesics are often used in a myriad of pain management settings to reduce opioid burden. Such multimodal analgesia strategies were found to be efficacious in other postsurgical populations including orthopedic, gastric bypass, gynecologic, and cardiothoracic surgery.…”

Early experiences with the use of continuous erector spinae plane blockade for the provision of perioperative analgesia for pediatric liver transplant recipients

“…The postoperative opioid-sparing effect is further highlighted by comparison with consumption reported for the first six postoperative days among 27 patients as part of the evaluation of a non-pharmacologic pain intervention following pediatric liver transplant 13. In the study, patients consumed 0.24 mg/kg/day and 0.25 mg/kg/day of morphine equivalent over the first six postoperative days.…”

Family experience of waiting for living donor liver transplantation: from parental donor perspective

“…Transplantation research in Taiwan and overseas has focused on the postoperative impact of the operation on the individual and the family, including risk assessment for the child with biliary atresia (Saito et al. 2007), postoperative symptom management after liver transplantation (Sharek et al. 2006), the recipients’ psychological functioning (Sundaram et al.…”

“…Waiting for a child to undergo surgery has a strong impact on family interactions, no matter how long the waiting period. Transplantation research in Taiwan and overseas has focused on the postoperative impact of the operation on the individual and the family, including risk assessment for the child with biliary atresia (Saito et al 2007), postoperative symptom management after liver transplantation (Sharek et al 2006), the recipients' psychological functioning (Sundaram et al 2007, Wu et al 2008 and the impact of surgery on the family (Yoshino et al 2008). Few studies have investigated the impact on families before liver transplantation (Simons et al 2007) and studies looking at donors during the preoperative period and their experiences while waiting are lacking (Otte 2004).…”