Perioperative Pain Control in Pediatric Patients Undergoing Orthopaedic Surgery
ABSTRACT Management of perioperative pain is critical in the pediatric patient undergoing orthopaedic surgery. A variety of modalities can be used to manage pain and optimize recovery and patient satisfaction, including nonopioid and opioid analgesia; local anesthetic injection; and regional analgesia such as intrathecal morphine, epidural therapy, and peripheral nerve blocks. Acute pain management can be tailored based on the needs of the patient, the surgical site, and the anticipated level of postoperative pain. A preoperative discussion of the plan for perioperative pain control with the patient, his or her parents, and the anesthesiologist can help manage expectations and maximize patient satisfaction.
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ABSTRACT: Clinicians are now appreciating that the perception of pain is a multifaceted, biopsychosocial construct. Expectation of postsurgical pain is part of this construct and should be considered preoperatively. It is our belief that by establishing reasonable expectations with preoperative teaching, we can minimize narcotic use and lessen untoward issues that can potentially follow. With this goal in mind, we have been using a comprehensive pre- and postoperative program for our outpatient orthopedic surgery patients for the last 5 years, which includes physical, pharmacologic, and simple sport psychological techniques. We reviewed postoperative prescription narcotic purchases in 133 consecutive surgical patients during the last year (2013). All patients were given a prescription postoperatively for 10 hydrocodone 5-mg/acetaminophen 500-mg tablets, with 1 refill. We then contacted the patients' pharmacies to assess the actual amount purchased. Data were available for 100 patients. Of these, 62 patients had undergone "simple" arthroscopies and 38 had had "open" procedures, including 25 anterior cruciate ligament reconstructions, 4 tibial tubercle osteotomies, and various other surgeries. Of the 62 arthroscopies, 24 patients (39%) refilled their prescriptions, with 4 patients (6%) needing > 1 refill. Of the 38 open procedures, 16 patients (42%) refilled their medications, 2 (5%), more than once. Thus, 89% of patients required ≤ 20 narcotic tablets after undergoing common orthopedic operations. No patient needed chronic narcotic medication. Pain is a complex issue and patient expectation of postoperative pain is one aspect that can potentially affect the amount of narcotics used. By preparing the patient both physically and psychologically, we believe the amount of narcotics used postoperatively can be decreased without affecting pain control. As a result, the multiple possible detriments of having more narcotics available than actually necessary would be lessened. By limiting the overall number of narcotic tablets prescribed, decreased use by the patient when such a medication may no longer be appropriate, and minimized use by others in the household who might have access to it would decrease.The Physician and sportsmedicine 11/2014; 42(4):100-5. DOI:10.3810/psm.2014.11.2096 · 1.49 Impact Factor
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ABSTRACT: Ultrasonography is an excellent adjunct to other musculoskeletal imaging tools utilized in the pediatric population and in some instances offers advantages over CT and MRI. It permits dynamic examination of anatomic structures and assists in guiding minimally invasive procedures. In the lower extremity, ultrasonography assists in screening for such disorders as developmental dysplasia of the hip and in detecting slipped capital femoral epiphysis and femoral acetabular impingement. In the neonatal spine, ultrasonography can identify unossified vertebral arches. Among other applications in the upper extremity, ultrasonography may be used in the evaluation and examination of peripheral nerve injuries and is a preferred modality for imaging the shoulder in infants with neonatal brachial plexus palsy. It is also considered an optimal adjunct for administration of botulinum toxin-A in children with cerebral palsy. The portability, relative low cost, lack of radiation, and absence of known contraindications enhances the utility of ultrasonography in pediatric orthopaedics.The Journal of the American Academy of Orthopaedic Surgeons 11/2014; 22(11):691-698. DOI:10.5435/JAAOS-22-11-691 · 2.40 Impact Factor