Opioid Use After Cardiac Surgery in Children With Down Syndrome*

Abstract

OBJECTIVES To determine the cumulative opioid doses administered to patients with Down syndrome (DS) after cardiac surgery and compare them to patients without DS. DESIGN Retrospective, observational, comparative study. SETTING PICU in a university-affiliated, freestanding pediatric teaching hospital. PATIENTS Infants and children who presented to our institution for heart surgery after July 1, 2008, and met the following criteria: 1) no opioid medications for 48 hours prior to surgery, 2) sternotomy approach with primary closure, 3) no additional operative procedures in the 5 days after surgery. All patients with DS were included, and patients without DS with similar age, type of cardiac lesion, and length of surgical procedure were selected in a ~2:1 ratio, blinded to opioid exposure. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Clinical and demographic data were extracted from electronic medical record data. Univariate analyses and mulitvariate linear regression modeling were performed to determine the influence of DS, patient characteristics, and clinical covariates on weight-adjusted opioid dose. The differences in median cumulative opioid doses between those with DS (n=44) and those without (n=77) were not significant in the first 24 hours [+0.39 mg/kg (95% CI −0.45 to +1.39 mg/kg)] or 96 hours [+0.54 mg/kg (−0.59 to +2.07 mg/kg)] after surgery. Age, cardiac bypass time, benzodiazepines, and neuromuscular blocking agents were significantly correlated with opioid dose, but DS, gender, pain score, creatinine, acetaminophen, NSAIDs, and steroid medications were not. Patients with DS had longer hospital stays; in multivariate analysis, higher opioid exposures in the first 96 hours after surgery and higher peak serum creatinine values correlated with longer hospitalization. CONCLUSIONS This cohort did not provide evidence for opioid resistance in patients with DS. Younger age, longer cardiac bypass time, exposure to benzodiazepines, and neuromuscular blockade did correlate with increased opioid doses after cardiac surgery.

Defining Adequate Pain Control in the Child With Down Syndrome

“…The findings of Van Driest et al (12) are consistent with the aforementioned study by Valkenburg et al (11). Both studies found no significant different between analgesia requirements between Down syndrome patients and their non-Down syndrome counterpart.…”

“…Nonetheless, the findings of Van Driest et al (12) are important in two fundamental aspects. First, they offer new input to a sound question which had conflicting data.…”

“…Bartlett and coworkers (2, 3) went on to publish groundbreaking studies that demonstrated the efficacy of However, the study by Van Driest et al (12) is not without its limitations. Perhaps, most importantly, the cardiac diagnoses between the two study groups were different.…”

“…In this issue of Pediatric Critical Care Medicine, Van Driest et al (12) compared the cumulative opioid doses in the postoperative period of Down syndrome patients who underwent cardiac surgery with a matched cohort of patients without Down syndrome who also underwent cardiac surgery. Their nest retrospective study found that the median cumulative opioid doses between the Down syndrome group and non-Down syndrome group were not different in the first 24 hours or 94 hours.…”

Supportive care utilization and treatment toxicity in children with Down syndrome and acute lymphoid leukaemia at free‐standing paediatric hospitals in the United States

“…A previous small, single-centre study found no increased use of opiate analgesia or parenteral nutrition in patients with DS-ALL (Shah et al , 2009). Studies of post-operative pain management of children with DS suggest either an increased or similar need of post-operative pain analgesia as compared to non-DS patients (Gakhal et al , 1998; Valkenburg et al , 2012; Van Driest et al , 2013). Recent studies quantitatively comparing pain thresholds in children with and without DS have demonstrated that children with DS experience pain at the same frequency as children without DS, with delays in acute pain expression and magnified pain response (McGuire & Defrin, 2015; Valkenburg et al , 2015).…”