Evaluation of Gabapentin and Clonidine Use in Children Following Spinal Fusion Surgery for Idiopathic Scoliosis: A Retrospective Review

Gabapentin as a novel adjunct for postoperative irritability after superior cavopulmonary connection operation in children

OBJECTIVES

Describing our institution's off-label use of gabapentin to treat irritability after superior cavopulmonary connection surgery and its impact on subsequent opiate and benzodiazepine requirements.

METHODS

This is a single-center retrospective cohort study including infants who underwent superior cavopulmonary connection operation between 2011 and 2019.

RESULTS

Gabapentin was administered in 74 subjects (74/323, 22.9%) during the observation period, with a median (IQR) starting dose of 5.7 (3.3, 15.0) mg/kg/day and a maximum dose of 10.7 (5.5, 23.4) mg/kg/day. Infants who underwent surgery in 2015-19 were more likely to receive gabapentin compared with those who underwent surgery in 2011-14 (p < 0.0001). Infants prescribed gabapentin were younger at surgery (137 versus 146 days, p = 0.007) and had longer chest tube durations (1.8 versus 0.9 days, p < 0.001), as well as longer postoperative intensive care (5.8 versus 3.1 days, p < 0.0001) and hospital (11.5 versus 7.0 days, p < 0.0001) lengths of stays. The year of surgery was the only predisposing factor associated with gabapentin administration in multivariate analysis. In adjusted linear regression, infants prescribed gabapentin on postoperative day 0-4 (n = 64) had reduced benzodiazepine exposure in the following 3 days (-0.29 mg/kg, 95% CI -0.52 - -0.06, p = 0.01) compared with those not prescribed gabapentin, while no difference was seen in opioid exposure (p = 0.59).

CONCLUSIONS

Gabapentin was used with increasing frequency during the study period. There was a modest reduction in benzodiazepine requirements associated with gabapentin administration and no reduction in opioid requirements. A randomised controlled trial could better assess gabapentin's benefits postoperatively in children with congenital heart disease.

Perioperative role of oral gabapentin as an analgesic in paediatric patients: A randomised controlled trial

Background and Aims

Surgical procedure commonly performed in the advanced pediatric age group includes urogenital surgery, adenotonsillectomy, etc., Aim: The aim of this study is to determine the effect of single-dose gabapentin 15 mg/kg on acute pain in the immediate postoperative period in patients aged 8-14 years undergoing surgeries under general anesthesia.

Material and Methods

After the approval from the institutional ethical committee, 60 American Society of Anesthesiologists (ASA) I and II patients aged 8-14 years undergoing urogenital surgeries (orchidopexy/urethroplasty) under general anesthesia were included in this study. The patients were assigned into one of the two treatment groups. Patients in group I received oral gabapentin 15 mg/kg dissolved in 5 mL of honey 2 h before surgery, while patients in group II received 5 mL honey orally 2 h before surgery.

Results

A total of 60 patients participated. Patients in group I had lower consumption of fentanyl perioperatively (intraoperatively: 1.36 ± 0.70 mcg/kg; postoperatively: 2.36 ± 0.795 mcg/kg) than group II (intraoperatively: 1.8 ± 0.6 mcg/kg; postoperatively: 2.9 ± 0.47 mcg/kg). The differences in the two groups were significant. The time to first rescue analgesia was greater in group I (3.03 ± 0.60 h) than in group II (2.26 ± 0.57 h). There was an increase in sedation score in the treatment group.

Conclusion

Our clinical study demonstrates that a 15 mg/kg single preemptive oral dose of gabapentin might reduce the requirement of analgesics perioperatively in pediatric urogenital surgery but might also be associated with undesirable effects such as increased sedation.

Perioperative gabapentin usage in pediatric patients: A scoping review

BACKGROUND

There has been a recent focus among anesthesiologists on reducing the use of perioperative opioids in favor of multimodal analgesic regimens. Gabapentin has played an integral role in this evolution of practice. This comprehensive review assesses the current clinical evidence on the efficacy of perioperative gabapentin regarding postoperative pain and opioid requirements among the pediatric surgery population.

DATA SOURCES

Pubmed, CINAHL, Embase, Scopus, and Web of Science Review.

METHODS

This scoping review of the above databases includes all studies examining the use of gabapentin perioperatively in pediatric patients and its association with postoperative pain intensity and postoperative opioid consumption through July 2021. The inclusion criteria encompassed all studies evaluating gabapentin in the perioperative pediatric population through randomized controlled trials (RCTs) and retrospective studies. Relevant metadata from each study were abstracted and descriptive statistics were used to summarize the results.

RESULTS

Fifteen papers met the inclusion criteria for this review, including 11 RCTs and 4 retrospective studies. Sample sizes ranged from 20 to 144 patients. Administered doses varied widely, mainly between 5 and 20 mg/kg. The studies included primarily orthopedic (10) and neck surgery cases (3). Seven papers had gabapentin provided preoperatively only, two postoperative only, and six both pre- and postoperatively. Of the studies assessing postoperative pain, 6/11 studies saw a decrease in postoperative pain in at least one period for the gabapentin group. Of the studies considering opioid requirements, 6/10 reported a reduction, 1/10 an increase, and 3/10 no difference in opioid requirements for the gabapentin groups. Yet, most of these pain and opioid requirement findings were only significant at one to two time points in the study follow-up periods, and the actual decreases had minimal clinical significance.

CONCLUSIONS

The current data on perioperative gabapentin in pediatric patients are insufficient to support the routine use of gabapentin in pediatric patients. Additional high-quality RCTs with more standardized protocols for gabapentin administration and outcome measures are necessary to provide more definitive conclusions.

Efficacy of perioperative gabapentin use in patients with idiopathic scoliosis undergoing fusion surgery: a systematic review and meta-analysis

PURPOSE

This study aimed to assess whether the perioperative use of gabapentin was associated with decreased opioid use.

METHODS

A meta-analysis was performed using PubMed, Embase, Scopus, and Cochrane Library. The randomized clinical trials included were focused on patients with adolescent idiopathic scoliosis who underwent posterior fusion surgery and were treated with gabapentin versus placebo medicine. The primary outcomes were opioid consumption at 24, 48, 72, and 96 h; time to introduction of oral medication, length of hospital stay, and period of urinary catheterization were also recorded. Data were combined using the Review Manager 5.4 software.

RESULTS

Four randomized clinical trials with a pool of 196 adolescent patients (mean age: 14.8 ± 2.0 years) were included. At 24 and 48 h after surgery, opioid consumption was significantly lower in the gabapentin group: (standardized mean difference [SMD]: -0.50; 95% confidence interval [CI] - 0.79 to - 0.22) and (SMD: - 0.59; 95% CI - 0.88 to - 0.30), respectively. At 72 and 96 h, there were no significant differences between studies: (SMD: - 0.19; 95% CI - 0.52 to 0.13) and (SMD: 0.12; 95% CI - 0.25 to 0.50), respectively. Regarding the administration type, there were significant differences in favor of the 15 mg/kg subgroup with 600 mg at 48 h (SMD: - 0.69; 95% CI - 1.08 to - 0.30). There were no significant differences concerning the time to introduction of oral medication (MD: - 0.08; 95% CI - 0.39 to 0.23), hospitalization time (MD: - 0.12; 95% CI - 0.40 to 0.16), or period of urinary catheterization (SMD: - 0.27; 95% CI - 0.58 to 0.05).

CONCLUSIONS

Gabapentin decreased opioid consumption during the first 48 h. Doses of 15 mg/kg showed superiority in reducing opioid consumption in the first 48 h.

LEVEL OF EVIDENCE I

Diagnostic: individual cross-sectional studies with consistently applied reference standard and blinding.

Prospective analysis of home narcotic consumption and management of excess narcotic prescription following adolescent idiopathic scoliosis surgery

PURPOSE

The aim of this study was to identify factors associated with the outpatient narcotic intake of patients following posterior spinal fusion (PSF) for adolescent idiopathic scoliosis (AIS) and to introduce a safe and effective method of disposing of unused narcotics.

METHODS

Following Institutional Review Board approval, retrospective review of prospectively collected data from patients undergoing PSF for AIS took place. Pain scores, narcotic use, patient demographic data, pre-, intra-, and postoperative parameters, and discharge data were gathered via chart review. Patients were divided into two groups according to home narcotic use, high use (top 25th percentiles) and low use (bottom 75th percentiles), and multivariate statistical analysis was conducted. Narcotic surplus was collected during postoperative clinic visits and disposed of using biodegradable bags.

RESULTS

Statistical analysis of 27 patients included in the study showed that patients with a higher home narcotic use correlated with increased length of hospitalization with an average of 3.4 days compared to the lower-use group of 2.8 day (p = 0.03). Higher-use group also showed increased inpatient morphine milligram equivalent than the lower-use group. There was no significant difference of home narcotic use when looking at patient age, height, weight, BMI, levels fused, intraoperative blood loss, or length of surgery. A total of 502 narcotic doses were disposed of in the clinic.

CONCLUSION

Our study suggests that there are not a significant number of patient- or surgical-level factors predisposing patients to increased home narcotic usage following spinal fusion for adolescent idiopathic scoliosis.

LEVEL OF EVIDENCE

Level I, prospective study.

Effect of gabapentin on length of stay, opioid use, and pain scores in posterior spinal fusion for adolescent idiopathic scoliosis: a retrospective review across a multi-hospital system

BACKGROUND

Gabapentin has been adopted in Enhanced Recovery After Surgery protocols as a means to reduce opioid consumption while maintaining adequate post-operative analgesia. The purpose of our study was to review and compare changes in length of stay, opioid use, and patient reported pain scores after the addition of gabapentin into five, distinct pain protocols for posterior spinal fusion in adolescent idiopathic scoliosis.

METHODS

A retrospective review was completed using a database of electronic medical data from a single pediatric orthopedic healthcare system that was queried for patients with adolescent idiopathic scoliosis who underwent first-time posterior spinal fusion. Perioperative data including demographics, hospital length of stay, surgical details, opioid use, patient reported pain scores, and non-opioid analgesic use were collected.

RESULTS

From December 2012 to February 2019, 682 hospitalizations for posterior spinal fusion in adolescent idiopathic scoliosis were identified with complete inpatient data; 49% were administered gabapentin. For the gabapentin cohort, the system saw no statistically significant effect on length of stay or pain averaged over POD#0-3. Opioid use was statistically lower averaged over POD#0-3. Individual sites saw variation on length of stay and opioid use compared to the system.

CONCLUSION

In conclusion, system-wide data showed gabapentin containing protocols reduced opioid use while maintaining clinically equivalent analgesia. However, variations of individual site results make it difficult to conclude the degree to which gabapentin were responsible for this effect.

Perioperative Indications for Gabapentinoids in Pediatrics: A Narrative Review

In recent years, there has been increased interest in using gabapentinoids (gabapentin and pregabalin) as part of multimodal medication plans or enhanced recovery after surgery protocols to mitigate several perioperative clinical challenges. Outcomes explored in the context of using gabapentinoids perioperatively in children are variable and include acute complications of pain, anxiety, nausea and vomiting, and emergence agitation, as well as the long-term postoperative outcome of chronic postsurgical pain. This narrative review describes the current literature regarding perioperative use of gabapentinoids in pediatric patients and aims to describe the role of gabapentinoids in the perioperative setting for each specific indication.

Gabapentin and intrathecal morphine combination therapy results in decreased oral narcotic use and more consistent pain scores after posterior spinal fusion for adolescent idiopathic scoliosis

Background

Gabapentin and intravenous patient-controlled analgesia (PCA) can reduce postoperative pain scores, postoperative opioid use, and time to completing physical therapy compared to PCA alone after posterior spinal fusion (PSF) for adolescent idiopathic scoliosis (AIS). Gabapentin combined with intrathecal morphine has not been studied. The primary purpose of this retrospective study was to evaluate whether perioperative gabapentin and intrathecal morphine provide more effective pain control than intrathecal morphine alone after PSF for AIS.

Methods

Patients aged 11 to 18 years who underwent PSF for AIS were identified. Patients who received intrathecal morphine only (ITM group) were matched by age and sex to patients who received intrathecal morphine and perioperative gabapentin (ITM+GABA group). The ITM+GABA group received gabapentin preoperatively and for up to 2 days postoperatively. Both groups received oxycodone and the same non-narcotic adjuvant medications.

Results

Our final study group consisted of 50 patients (25 ITM, 25 ITM+GABA). The ITM+GABA group had significantly lower mean total oxycodone consumption during the hospitalization (0.798 vs 1.036 mg/kg, P<0.015). While the ITM group had a lower mean pain score between midnight and 8 am on POD 1 (2.4 vs 3.7, P=0.026), pain scores were significantly more consistent throughout the postoperative period in ITM+GABA group. The ITM+GABA group experienced less nausea/vomiting (52% vs 84%, P=0.032) and pruritus (44% vs 72%, P=0.045). Time to physical therapy discharge and length of hospital stay were similar.

Conclusion

Addition of gabapentin resulted in reduced oral opioid consumption and more consistent postoperative pain scores after PSF for AIS. The patients who received intrathecal morphine and gabapentin also experienced a lower rate of nausea/vomiting and pruritus.

Trial registration

All data was collected retrospectively from chart review, with institutional IRB approval. Trial registration is not applicable.

What's New in Pain Management for Pediatric Orthopaedic Surgery

BACKGROUND

Improving pain control and decreasing opioid prescription and usage continue to be emphasized across both pediatric and adult populations. The purpose of this review is to provide a comprehensive assessment of recent literature and highlight new advancements pertaining to pain control in pediatric orthopaedic surgery.

METHODS

An electronic search of the PubMed database was performed for keywords relating to perioperative pain management of pediatric orthopaedic surgery. Search results were filtered by publication date for articles published between January 1, 2015 and December 1, 2020 and yielded 404 papers.

RESULTS

A total of 32 papers were selected for review based upon new findings and significant contributions in the following categories: risk factors for increased opioid usage, opioid overprescribing and disposal, nonpharmacologic interventions, nonsteroidal anti-inflammatory drugs, peripheral nerve blocks, spine surgery specific considerations, surgical pathway modifications, and future directions.

CONCLUSIONS

There have been many advances in pain management for pediatric patients following orthopaedic surgery. Rapid recovery surgical care pathways are associated with shorter length of stay and improved pain control in pediatric spine surgery. Opioid overprescribing continues to be common and information regarding safe opioid disposal practices should be routinely provided for pediatric patients undergoing surgery.

LEVEL OF EVIDENCE

Level IV-literature review.

Gabapentin reduces postoperative pain and opioid consumption in patients who underwent lumbar laminectomy

BACKGROUND

Postoperative pain management solely with opioids elevates the risk of opioid-related adverse events during hospitalization and after discharge from the hospital. Clinical trials have demonstrated gabapentinoids as viable adjunctive treatments for spinal surgeries. However, only a few practice-based studies have examined the efficacy of gabapentin as an opioid-sparing agent for patients undergoing lumbar laminectomy in rural hospital settings.

OBJECTIVE

To determine the effects of gabapentin on opioid consumption and pain perception in patients who underwent lumbar laminectomy at a rural community hospital.

METHODS

Data were collected by retrospective chart reviews of 99 patients who underwent lumbar laminectomy at Yavapai Regional Medical Center from January 1, 2017, to July 1, 2019. The patients were stratified into 2 groups: those who were taking gabapentin as outpatients before surgery and were continued on the same dose postoperatively (n = 50, gabapentin group) and those who were not taking gabapentin preoperatively or postoperatively (n = 49, usual-treatment group). The primary end points were opioid consumption in morphine milligram equivalents (MME) and pain for 24 hours postsurgery.

RESULTS

Outcomes from the mixed-model analysis of variance showed significant main effects of group and time for opioid consumption in MME (F_1,97 = 4.3, P < 0.05 and F_3,291 = 133.9, P < 0.001, respectively) and numerical pain scale scores (F_1,99 = 4.0, P < 0.05 and F_3,241 = 21.4, P < 0.001, respectively) and group-time interaction for opioid consumption in MME (F_3,291 = 2.6, P = 0.05). Post hoc analyses showed that opioid consumption in MME was significantly lower in the gabapentin group than in the usual-treatment group for the first 6 hours postoperatively. The pain scores were significantly lower in the gabapentin group than in the usual-treatment group across all time periods.

CONCLUSION

Patients on gabapentin showed reductions in pain perception and postoperative opioid consumption. The results extend the findings from randomized trials to a real-world clinical setting. These data support using gabapentin in conjunction with opioids for pain management of patients undergoing lumbar laminectomy.

Postoperative Pain Management in Pediatric Spinal Fusion Surgery for Idiopathic Scoliosis

This article reviews and summarizes current evidence and knowledge gaps regarding postoperative analgesia after pediatric posterior spine fusion for adolescent idiopathic scoliosis, a common procedure that results in severe acute postoperative pain. Inadequate analgesia may delay recovery, cause patient dissatisfaction, and increase chronic pain risk. Despite significant adverse effects, opioids are the analgesic mainstay after scoliosis surgery. However, growing emphasis on opioid minimization and enhanced recovery has increased adoption of multimodal analgesia (MMA) regimens. While opioid adverse effects remain a concern, MMA protocols must also consider risks and benefits of adjunct medications. We discuss use of opioids via different administration routes and elaborate on the effect of MMA components on opioid/pain and recovery outcomes including upcoming regional analgesia. We also discuss risk for prolonged opioid use after surgery and chronic post-surgical pain risk in this population. Evidence supports use of neuraxial opioids at safe doses, low-dose ketorolac, and methadone for postoperative analgesia. There may be a role for low-dose ketamine in those who are opioid-tolerant or have chronic pain, but the evidence for preoperative gabapentinoids and intravenous lidocaine is currently insufficient. There is a need for further studies to evaluate pediatric-specific optimal MMA dosing regimens after scoliosis surgery. Questions remain regarding how best to prevent acute opioid tolerance, opioid-induced hyperalgesia, and chronic postsurgical pain. We anticipate that this timely update will enable clinicians to develop efficient pain regimens and provide impetus for future research to optimize recovery outcomes after spine fusion.

Enhanced Recovery After Pediatric Scoliosis Surgery: Key Components and Current Practice

With the goal of safety and efficiency in health care delivery, enhanced recovery protocols (ERPs) continue to gain traction throughout various surgical disciplines, including in pediatric scoliosis surgery. The growing body of literature reporting decreased length of stay and cost with no change in readmissions or complications has brought these protocols to the forefront. The key components of ERPs include preoperative patient counseling, perioperative pain management, and early patient mobilization. In this review, the authors aim to describe the foundational history and major components of ERPs following pediatric spine deformity surgery. [Orthopedics. 2020;43(5):e338-e344.].

An analysis of the safety and efficacy of dexmedetomidine in posterior spinal fusion surgery for adolescent idiopathic scoliosis: a prospective randomized study

PURPOSE

To evaluate whether use of dexmedetomidine, a centrally acting α2 adrenergic agonist, reduces opioid consumption in PSF.

METHODS

Adolescent idiopathic scoliosis patients who underwent PSF were randomized into morphine (M) and dexmedetomidine (D) group. M group received a 10 μg/kg/h IV infusion of morphine for 24 h post-surgery, while the D group received a 0.4 μg/kg/h IV infusion of dexmedetomidine. Trained nursing staffs recorded hourly vital parameters (blood pressure, pulse rate, respiratory rate, and oxygen saturation). Pain, postoperative nausea/vomiting (PONV), and sedation were rated using: the numerical rating scale (NRS), the PONV scale, and sedation status scale (SS). Preemptive analgesia with gabapentin and postoperative analgesia with ketorolac and paracetamol were used in both the groups. Any complications in the study groups were recorded.

RESULTS

No significant difference was noted between the groups (M vs D) with respect to NRS (3.1 ± 0.8 vs 2.7 ± 0.5) (p = 0.07) and breakthrough analgesia requirements (0.78 vs 0.45) (p = 0.17). A significant difference was noted between the groups with respect to the secondary outcome measures of time to ambulation (56.6 ± 12.7 h vs 45.2 ± 7.7 h), time to oral analgesics (84.3 ± 20 h vs 64.0 ± 15.4 h), and time to liquid intake (8.3 ± 1.3 h vs 7.2 ± 1.2 h). The M group had a higher PONV score (0.46 ± 0.3 vs 0.16 ± 0.1) (p < 0.001) and mean time to bowel opening (112.7 ± 28.4 h vs 90.1 ± 20.5 h) (p < 0.001). Additionally, the enema or suppository requirements for bowel opening were significantly more (0.59 ± 0.6 vs 0.26 ± 0.4) (p = 0.01) in the M group.

CONCLUSION

Dexmedetomidine provided analgesia comparable to morphine with lower PONV scores. It also reduced the opioid requirements in the PSF patients without additional complications and can therefore be incorporated in pain management protocols.

Quality improvement in post-operative opioid and benzodiazepine regimen in adolescent patients after posterior spinal fusion

STUDY DESIGN

Prospective, quality-improvement.

OBJECTIVES

To evaluate pain management following posterior spinal fusion (PSF) for adolescent idiopathic scoliosis (AIS) and Scheuermann's Kyphosis (SK) determine the optimal opioid and benzodiazepine prescription amounts, and implement a multimodal post-operative pain regimen. The incidence of prescription opioid abuse is increasing in the United States. Orthopedic spine surgeons often prescribe large quantities of opioids post-operatively for pain control. Previous efforts on pain control have focused on in-patient post-operative regimens after PSF.

METHODS

Between 2/1/17 and 5/30/18 patients with AIS or SK were sent home with pain diaries after discharge to document daily narcotic, benzodiazepine, non-steroidal anti-inflammatory drugs (NSAIDs), acetaminophen and gabapentin use following PSF. Diaries were collected at the 4 week post-operative visit. Data from two cohorts were reviewed: pre-intervention and post-intervention. Our prescription intervention went into effect 9/1/17.

RESULTS

Twenty-four (30%) patients returned pain diaries. The pre-intervention cohort consisted of 12 patients (7 female; 5 males; 14.9 years (range 12-19)). Patients were prescribed on average 80 × 5 mg tabs (26-140) of oxycodone but used on average 45 tabs (12-129) over an average of 17.5 days (9-33). They were prescribed an average of 30 × 2 mg tabs (0-150) of diazepam, used on average 4.8 (0-105) tabs over 12.5 (5-25) days. The post-intervention cohort consists of 12 patients (9 female; 3 male; 14.8 years (12-19)). They were prescribed on average 50 × 5 mg tabs (35-80) of oxycodone, used 20.5 (0-39.5) tabs over 8.5 days (3-16). They were prescribed on average 18 × 2 mg tabs of diazepam (0-43), used 5.4 tabs (0-19) over 10 days (5-14).

CONCLUSIONS

This analysis has directly impacted clinical practice. Prescribed opioid and benzodiazepine doses have been decreased by over 50%, and more resources are being directed towards determining the disparity between the amount of medications prescribed and consumed in our post-operative patients.

Current Trends in Pediatric Spine Deformity Surgery: Multimodal Pain Management and Rapid Recovery

STUDY DESIGN

Narrative review.

OBJECTIVES

The purpose of this article is to perform a review of the literature assessing the efficacy of opioid alternatives, multimodal pain regimens, and rapid recovery in pediatric spine surgery.

METHODS

A literature search utilizing PubMed database was performed. Relevant studies from all the evidence levels have been included. Recommendations to decrease postoperative pain and expedite recovery after posterior spinal fusion in adolescent idiopathic scoliosis patients have been provided based on results of studies with the highest level of evidence.

RESULTS

Refining perioperative pain management to lessen opioid consumption with multimodal regimens may be useful to decrease recovery time, pain, and complications. Nonsteroidal anti-inflammatory drugs, acetaminophen, gabapentin, neuraxial blockades, and local anesthesia alone offer benefits for postoperative pain management, but their combination in multimodal regimens and rapid recovery pathways may contribute to faster recovery time, improved pain levels, and lower reduction in total opioid consumption.

CONCLUSION

A rapid recovery pathway using the multimodal approach for pediatric scoliosis correction may offer superior postoperative pain management and faster recovery than traditional opioid only pain protocols.

Lidocaine as an element of multimodal analgesic therapy in major spine surgical procedures in children: a prospective, randomized, double-blind study

Background

Introducing the principles of multimodal analgesic therapy is necessary to provide appropriate comfort for the patient after surgery. The main objective of the study was evaluating the influence of perioperative intravenous (i.v.) lidocaine infusion on postoperative morphine requirements during the first 48 h postoperatively in children undergoing major spine surgery.

Materials and methods

Prospective, randomized, double-blind study: 41 children, qualified to multilevel spine surgery, were randomly divided into two treatment groups: lidocaine and placebo (control). The lidocaine group received lidocaine as a bolus of 1.5 mg/kg over 30 minutes, followed by a continuous infusion at 1 mg/kg/h to 6 hours after surgery. The protocol of perioperative management was identical for all patients. Measurements: morphine demand, intensity of postoperative pain (the Numerical Rating Scale), oral feeding initiation time, first attempts at assuming erect position, postoperative quality of life (the Acute Short-form /SF-12/ health survey).

Results

Patient data did not differ demographically. Compared to the control group, lidocaine treatment reduced the demand for morphine during the first 24h [95% CI 0.13 (0.11-0.28) mg/kg, p = 0.0122], 48h [95% CI 0.46 (0.22-0.52) mg/kg, p = 0.0299] after surgery and entire hospitalization [95% CI 0.58 (0.19-0.78) mg/kg, p = 0.04]; postoperative pain intensity; nutritional withdrawal period [introduction of liquid diet (p = 0.024) and solid diet (p = 0.012)], and accelerated the adoption of an upright position [sitting (p = 0.048); walking (p = 0.049)]. The SF-12 generic health survey did not differ between groups before operation, 2 months and 4 years after surgery.

Conclusions

Perioperative lidocaine administration, as a part of the applied analgesic therapy regimen, may decrease postoperative opioid demand and accelerates convalescence of children undergoing major surgery.

Postoperative pain management in patients undergoing posterior spinal fusion for adolescent idiopathic scoliosis: a narrative review

Posterior spinal fusion for adolescent idiopathic scoliosis is one of the most invasive surgical procedures performed in children and adolescents. Because of the extensive surgical incision and massive tissue trauma, posterior spinal fusion causes severe postoperative pain. Intravenous patient-controlled analgesia with opioids has been the mainstay of postoperative pain management in these patients. However, the use of systemic opioids is sometimes limited by opioid-related side effects, resulting in poor analgesia. To improve pain management while reducing opioid consumption and opioid-related complications, concurrent use of analgesics and analgesic modalities with different mechanisms of action seems to be rational. The efficacy of intrathecal opioids and nonsteroidal anti-inflammatory drugs as components of multimodal analgesia in scoliosis surgery has been well established. However, there is either controversy or insufficient evidence regarding the use of other analgesic methods, such as continuous ketamine infusion, perioperative oral gabapentin, acetaminophen, continuous wound infiltration of local anesthetics, a single dose of systemic dexamethasone, and lidocaine infusion in this patient population. Moreover, appropriate combinations of analgesics have not been established. The aim of this literature review is to provide detailed information of each analgesic technique so that clinicians can make appropriate choices regarding pain management in patients with adolescent idiopathic scoliosis undergoing posterior spinal fusion.

Effectiveness of gabapentin as a postoperative analgesic in children undergoing appendectomy

PURPOSE

Though gabapentin is increasingly used as a perioperative analgesic, data regarding effectiveness in children are limited. The purpose of this study was to evaluate gabapentin as a postoperative analgesic in children undergoing appendectomy.

METHODS

A 12-month retrospective review of children undergoing appendectomy was performed at a two-hospital children's institution. Patients receiving gabapentin (GP) were matched (1:2) with patients who did not receive gabapentin (NG) based on age, sex and appendicitis severity. Outcome measures included postoperative opioid use, pain scores, and revisits/readmissions.

RESULTS

We matched 29 (33.3%) GP patients with 58 (66.6%) NG patients (n = 87). The GP group required significantly less postoperative opioids than the NG group (0.034 mg morphine equivalents/kg (ME/kg) vs. 0.106 ME/kg, p < 0.01). Groups had similar lengths of time from operation to pain scores ≤ 3 (GP 12.21 vs. NG 17.01 h, p = 0.23). GP and NG had similar rates of revisit to the emergency department (13.8 vs. 10.3%, p = 0.73), readmission (6.9 vs. 1.7%, p = 0.26), and revisits secondary to surgical pain (3.4 vs. 3.4%, p = 1.00).

CONCLUSION

In this single-center, retrospective cohort study, gabapentin is associated with a reduction in total postoperative opioid use in children with appendicitis. While promising, further prospective validation of clinical effectiveness is needed.

Update in the Treatment of Chronic Pain within Pediatric Patients

Pediatric chronic pain is a challenging entity to evaluate and treat as it encompasses a wide variety of presentations often with overlapping psychosocial implications. Chronic pain may have significant effects upon a child's involvement in academic, athletic, and social participation. If unrecognized, it may have deleterious effects upon family interactions and stability. The treatment of pediatric chronic pain is focused on not only providing analgesia, but also on assisting the child and family with reintegrating into a more functional lifestyle. Given the complex multifactorial causes of pain, a comprehensive multidisciplinary treatment plan is often the most effective way to achieve remission. This paper will discuss two examples of pediatric pain that have shown the good response to treatment with a multidisciplinary team approach: complex regional pain syndrome (CRPS) and amplified pain due to Ehlers-Danlos syndrome-hypermobility type (EDS-HT). Treatment of these patients often encompasses a multimodal approach that incorporates physical therapy (PT), occupational therapy (OT), medication(s), pain psychology, procedure(s), sleep hygiene, education, and encouragement of overall physiologic wellness. Management principles are to reduce pain and help prevent future occurrences.