Pain management following major intracranial surgery in pediatric patients: a prospective cohort study in three academic children's hospitals

Abstract

Introduction Pain management following major intracranial surgery is often limited by a presumed lack of need and a concern that opioids will adversely affect postoperative outcome and interfere with the neurologic examination. Nevertheless, evidence in adults is accumulating that these patients suffer moderate to severe pain and this pain is often under-treated. The purpose of this prospective, clinical observational cohort study was to assess the incidence of pain, prescribed analgesics, methods of analgesic delivery, and patient/parent satisfaction in pediatric patients undergoing cranial surgery at 3 major university children’s hospitals. Methods After obtaining IRB and parental consent (and when applicable, patient assent), children who underwent cranial surgery for cancer, epilepsy, vascular malformations, and craniofacial reconstruction were studied. Neither intraoperative anesthetic management nor postoperative pain management was standardized, but were based on institutional routine. Patients were evaluated daily by a study investigator and by chart review for pain scores using age appropriate, validated tools (FLACC, Faces Pain Scale-Revised, Wong Baker Faces Scale or Self-Report on a 0–10 scale), for patient/parent satisfaction using a subset of the NRC Picker satisfaction tool and in adolescents a modified QoR-40, and for the frequency, mode of administration, and type of analgesic provided. Finally, the incidence of opioid-induced side effects, specifically nausea, vomiting, pruritus, altered level of consciousness, and need for emergency diagnostic radiologic studies for altered neurologic examination were recorded. Data are provided as mean ± SD. Results Two hundred children (98:102 M:F), averaging 7.8 ± 5.8 years old (range 2 mos to 18.5 yr) and 32.2 ± 23.0 kg (range 4.5 to 111.6 kg) undergoing craniectomy (51), craniotomy (96), and craniofacial reconstruction (53) were studied. Despite considerable variation in mode and route of analgesic administration, there were no differences in average pain score, length of hospital stay, or parental satisfaction with care. Interestingly, opioid induced side effects were not related to total daily opioid consumption, site of surgery, or method of opioid delivery. The most common side effect was vomiting. No patient developed respiratory depression or altered mental status secondary to analgesic therapy. Regardless of age or procedure, once eating, most patients were treated with oral oxycodone and/or acetaminophen. Conclusions Despite considerable variation in modality and route of analgesic administration, there were no differences in average pain score, length of stay, or parental satisfaction with care. Pain scores were low, side effects were minimal, and parental satisfaction was high, providing equipoise for future blinded prospective randomized trials in this patient population.

Options for perioperative pain management in neurosurgery

“… 10 Therefore, it has been historically reasoned that patients’ exposure to the risks of opioid administration should be minimized given the widely presumed idea that intense pain is not experienced following intracranial procedures, a belief reinforced by the fact that surgical procedures on the brain parenchyma in itself do not cause pain. 11 …”

Postoperative Analgesia for Pediatric Craniotomy Patients: A Randomized Controlled Trial

“…The main analgesic methods advocated in current studies are multimodal analgesia and PCIA or NCIA analgesia 5,7 . Maxwell et al 7 have demonstrated that PCIA or NCIA analgesia is an effective analgesia with a low incidence of opioid-related side effects; although it should be noted that the analgesic pump settings in their study were not standardized. Chiaretti 21 found PCIA with fentanyl plus midazolam could effectively relieve postoperative pain in pediatric neurosurgery.…”

Postoperative analgesia of scalp nerve block with ropivacaine in pediatric craniotomy patients: a protocol for a prospective, randomized, placebo-controlled, double-blinded trial

“…A decrease of 20% will be considered a minimal clinically important difference. According to Maxwell's article [30] and our experience, 54 subjects per group will be necessary with a two-sided α level of 0.017 (0.05/3) and 80% power. Considering a 10% rate of loss to follow-up, it would be necessary to include 60 participants per group (total: 180 participants).…”