Management of routine postoperative pain for children undergoing cardiac surgery: a Paediatric Acute Care Cardiology Collaborative Clinical Practice Guideline

Abstract

Background: Pain following surgery for cardiac disease is ubiquitous, and optimal management is important. Despite this, there is large practice variation. To address this, the Paediatric Acute Care Cardiology Collaborative undertook the effort to create this clinical practice guideline. Methods: A panel of experts consisting of paediatric cardiologists, advanced practice practitioners, pharmacists, a paediatric cardiothoracic surgeon, and a paediatric cardiac anaesthesiologist was convened. The literature was searched for relevant articles and Collaborative sites submitted centre-specific protocols for postoperative pain management. Using the modified Delphi technique, recommendations were generated and put through iterative Delphi rounds to achieve consensus Results: 60 recommendations achieved consensus and are included in this guideline. They address guideline use, pain assessment, general considerations, preoperative considerations, intraoperative considerations, regional anaesthesia, opioids, opioid-sparing, non-opioid medications, non-pharmaceutical pain management, and discharge considerations. Conclusions: Postoperative pain among children following cardiac surgery is currently an area of significant practice variability despite a large body of literature and the presence of centre-specific protocols. Central to the recommendations included in this guideline is the concept that ideal pain management begins with preoperative counselling and continues through to patient discharge. Overall, the quality of evidence supporting recommendations is low. There is ongoing need for research in this area, particularly in paediatric populations.

The Year in Review: Anesthesia for Congenital Heart Disease 2022

“…In 2022, the Pediatric Acute Care Cardiology Collaborative published a guideline on the management of postoperative pain after pediatric cardiac surgery, which included 60 consensus recommendations for postoperative management. 17 The authors highlight a recent survey of heart centers that reported only 6 of 34 respondents had an institutional written policy regarding pain management, 3 reported standardized practice among providers but no written policy, and the remaining 25 reported no standardization in their institution. Given the variability in analgesic, sedation, and delirium management across heart centers; the heterogeneity of pediatric cardiac surgical patients; and the lack of consensus regarding meaningful endpoints in study design, the Pediatric Acute Care Cardiology Collaborative authors sought to provide clinical practice guidelines on the management of routine postoperative pain based on the best available evidence at that time.…”

“…Given the variability in analgesic, sedation, and delirium management across heart centers; the heterogeneity of pediatric cardiac surgical patients; and the lack of consensus regarding meaningful endpoints in study design, the Pediatric Acute Care Cardiology Collaborative authors sought to provide clinical practice guidelines on the management of routine postoperative pain based on the best available evidence at that time. The recommendations and supporting literature are too numerous to relate in this article, and the interested anesthesiologist is encouraged to review the guidelines 17 and assess opportunities to design studies that will add high-quality data to enhance perioperative management of these pediatric patients.…”