Pain and Hemodynamic Status Assessment in Children Undergoing Orthopaedic Trauma Surgeries Amid Perioperative Multimodal Analgesia

Abstract

Stable hemodynamic parameters are used as one of the criteria for adequacy of analgesia during the surgery. In order to provide reliable antinociceptive protection, it is necessary to reduce the flow of nociceptive stimuli from the peripheral to central receptors.
 Hence, pain and hemodynamic assessment is crucial for adequate perioperative analgesia and the choice of anesthetic technique in children undergoing orthopaedic trauma surgeries. 
 Purpose. This study aims to assess pain intensity and changes of hemodynamic parameters in orthopaedic trauma pediatric patients under perioperative multimodal analgesia.
 Materials and methods. A total of 61 patients with orthopaedic trauma were included in this study. Mean age was 9.3±4.5 years (range: 8-17). Open reduction was performed in 43 cases (70.5%), and 18 children (29.5%) underwent closed reduction. Mean duration of the surgery was 102.1±20.4 min. All patients have the premedication (atropine sulfate, diazepam, acetaminophen, intravenously) done 30-40 min. before the surgery in the surgical ward. Surgical procedures were performed under general anesthesia. Postoperative pain intensity was assessed by Individualized Numeric Rating Scale – NRS. Perioperative monitoring included peripheral pulse oximetry (SpO2), non-invasive blood pressure measurement (SBP, DBP, MAP), vital signs and blood glucose level control. Postoperative analgesia was maintained by IV acetaminophen, if necessary – by administration of divided dose of morphine. Results and conclusions. Mean pain intensity was 2.32±0.28 (6 hrs postop.), 12.06±0.16 (12 hrs postop.),
 2.78±0.24 (24 hrs postop.), 2.04±0.6 (48 hrs postop.) based on NRS, respectively (p<0.05). 26% patients required single dose administration of morphine during the first 24 hrs after the surgery.
 Significant decrease in blood glucose 12 hrs (4.3 mmol/l) and 24 hrs (4.6 mmol/l) after the surgery in comparison to the preoperative level (6.2 mmol/l) suggests of the severe stress resolution in the majority of the patients and adequate pain management. Preoperative stress is mainly caused by underlying disease and the surgical procedure itself.
 Heart rate (HR) monitoring shows that the vast majority of the patients (n=55, 86.5%) had mean pulse less than 110 bpm after IV Acetaminophen administration (20 mg/kg). 
 Minimal mean HR throughout the study was 87.3±5.3 bpm, maximal mean HR was 120±5.3 bpm. Mean SBP throughout the study was 100.2±5.3 mm Hg and mean DBP – 66.4±1.8 mm Hg, respectively. Oxygen saturation was within normal limits in all children. Hemodynamic parameters were within physiological surgical stressrelated limits, which suggests of the fluctuant course of postoperative pain syndrome.
 A traditional approach to perioperative pain management in children is associated with a moderate pain syndrome according to the results obtained with pain scales, hyperkinetic type of hemodynamics 6.24 hrs after the surgery, and the fluctuant course of postoperative pain.