Pain Management for Nonsyndromic Craniosynostosis: Adequate Analgesia in a Pediatric Cohort?

Kattail, Deepa; Macmillan, Alexandra; Musavi, Leila; Pedreira, Rachel; Faateh, Muhammad; Cho, Regina; Lopez, Joseph; Dorafshar, Amir H.

doi:10.1097/scs.0000000000004406

Cited by 11 publications

(12 citation statements)

References 23 publications

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“…4 A follow-up retrospective study from the same institution demonstrated that 57 percent of their cranial vault patients experience moderate to severe pain on postoperative day 0, and 61 percent experienced moderate to severe pain on postoperative day 1. 3 Although we recognize the importance of pain control, it is of equal importance to consider the consequences of overadministration of narcotics. Efforts are needed to minimize the risk of these medications, including side effects and potential for opioid abuse.…”

Section: Discussionmentioning

confidence: 99%

“…They also advocate for the use of multimodal pain control, including scheduled ketorolac and acetaminophen in addition to intravenous and enteral narcotics. 3 To date, there are no studies that directly evaluate outcomes with use of multimodal pain control following cranial vault surgery, but this research is certainly warranted.…”

Section: Discussionmentioning

confidence: 99%

“…2 Surgery is usually indicated in the first year of life to prevent intracranial hypertension and improve the appearance of the shape of the head. 3…”

mentioning

confidence: 99%

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Pediatric Outcomes following Cranial Vault Remodeling with Restricted Use of Postoperative Narcotics: A Retrospective Review

Smith

Cimaroli

Loo

et al. 2022

Plastic &Amp; Reconstructive Surgery

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Background: The appropriate use of narcotics for postoperative pain control is controversial because of potential medication-induced complications. The authors sought to determine the effects of narcotics in the pediatric population following cranial vault remodeling operations. Methods: A retrospective review was performed on 160 consecutive patients who underwent cranial vault remodeling for craniosynostosis. Results: There was a statistically significant difference in total morphine equivalents in the group that experienced no emesis and those with at least one episode of emesis (0.97 morphine equivalents/kg versus 1.44 morphine equivalents/kg; p = 0.05). There was a statistically significant difference in hospital morphine equivalents in the group with documented respiratory events (average, 2.3 morphine equivalents/kg versus 1.3 morphine equivalents/kg in the nonevent group; p = 0.006). The patients who received dexmedetomidine had a trend toward a decrease in hospital narcotic administration with equivalent pain control (1.2 morphine equivalents/kg versus 1.9 morphine equivalents/kg; p = 0.09). There was a statistically significant positive correlation between total morphine equivalents for the hospitalization and hospital stay (r = 0.27, p = 0.001). The amount of morphine equivalents used in the first 24 hours was also found to be an independent predictor of a respiratory event (p = 0.002 by multivariate logistic regression). Independent positive predictors of hospital stay were age (p < 0.001), intensive care unit time (p < 0.001), and total morphine equivalents for the hospitalization (p = 0.001) by multivariate analysis with linear regression. Conclusion: The authors’ study demonstrates improvement in outcomes with decreased use of narcotics, which establishes that there is a need to further explore postsurgical recovery outcomes with multimodal pain control. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

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Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

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Pediatric Outcomes following Cranial Vault Remodeling with Restricted Use of Postoperative Narcotics: A Retrospective Review

Smith

Cimaroli

Loo

et al. 2022

Plastic &Amp; Reconstructive Surgery

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“…We conducted this systematic review using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, in accordance with Cochrane review methods [ 19 , 20 ]. The published literature was searched on MEDLINE, Cochrane, EMBASE, and Google Scholar from inception until May 2022 without specifying a timeframe.…”

Section: Methodsmentioning

confidence: 99%

The management of perioperative pain in craniosynostosis repair: a systematic literature review of the current practices and guidelines for the future

Mortada

AlKhashan

Alhindi

et al. 2022

Maxillofac Plast Reconstr Surg

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Background Craniosynostosis is a condition characterized by a premature fusion of one or more cranial sutures. The surgical repair of craniosynostosis causes significant pain for the child. A key focus of craniosynostosis repair is developing effective strategies to manage perioperative pain. This study aimed to review perioperative pain control strategies for craniosynostosis repair systematically. Methods Guidelines for reporting systematic reviews and meta-analyses were used in the design of this review. In May 2022, the following databases were used to conduct the literature search: MEDLINE, Cochrane, EMBASE, and Google Scholar. A search was performed using MeSH terms “craniosynostosis,” “pain management,” and “cranioplasty.” Results The literature review yielded 718 publications. After applying our inclusion criteria, 17 articles were included, accounting for a total of 893 patients. During the postoperative period, most studies used multimodal analgesia, primarily opioids, and acetaminophen. In the postoperative period, oral ibuprofen was the most commonly used NSAID, rectal codeine, and acetaminophen were the most commonly used weak opioids, and continuous remifentanil infusion was the most commonly used potent opioid. Conclusion The authors determined the best pain management options for pediatric patients undergoing cranioplasty by analyzing the most commonly used analgesics. A high-quality clinical trial comparing different types of analgesic combinations would be a valuable addition to the present literature.

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“…Ketorolac is an NSAID with an analgesic efficacy and safety similar to commonly used opioids and has been validated in cardiac, abdominal, orthopedic, urologic, neurologic, and plastic surgical procedures involving adult and pediatric populations (Watcha et al, 1992; Marín-Bertolín et al, 1997; Lieh-Lai et al, 1999; Beiter et al, 2001; Shin et al, 2001; Dsida et al, 2002; Forrest et al, 2002; Gupta et al, 2004; Cepeda et al, 2005; Lynn et al, 2007; Torgerson et al, 2008; Yassen & Sayed, 2012; Carr et al, 2018; Howard et al, 2018; Kattail et al, 2018). The analgesic effect is provided by the blockade of the cyclooxygenase (COX) system, which decreases prostaglandin synthesis.…”

Section: Introductionmentioning

confidence: 99%

Safety and Efficacy of Single-Dose Ketorolac for Postoperative Pain Management After Primary Palatoplasty: A Prospective Cohort Study With Historical Controls

Stein

Mantilla-Rivas

Aivaz

et al. 2021

The Cleft Palate-Craniofacial Journal

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Objective: To analyze safety and efficacy of single-dose ketorolac after primary palatoplasty (PP). Design: Consecutive cohort of patients undergoing PP, comparing to historical controls. Setting: A large academic children’s hospital. Patients, Participants: A consecutive cohort of 111 patients undergoing PP (study n = 47) compared to historical controls (n = 64). Interventions: All patients received intraoperative acetaminophen, dexmedetomidine, and opioids while the study group received an additional single dose of ketorolac (0.5 mg/kg) at the conclusion of PP. Main Outcome Measures: Safety of ketorolac was measured by significant bleeding complications and need for supplementary oxygen. Efficacy was assessed through bleeding, Face Legs Activity Cry Consolability (FLACC) scale, and opioid dose. Results: Length of stay was similar for both groups (control group 38.5 hours [95% CI: 3.6-43.3] versus study group 37.6 hours [95% CI: 31.3-44.0], P = .84). There were no significant differences in all postoperative FLACC scales. The mean dose of opioid rescue medication measured as morphine milligram equivalents did not differ between groups ( P = .56). Significant postoperative hemorrhage was not observed. Conclusions: This is the first prospective study to evaluate the safety and efficacy of single-dose ketorolac after PP. Although lack of standardization between study and historical control groups may have precluded observation of an analgesic benefit, analysis demonstrated a single dose of ketorolac after PP is safe. Further investigations with more patients and different postoperative regimens may clarify the role of ketorolac in improving pain after PP.

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Pain Management for Nonsyndromic Craniosynostosis: Adequate Analgesia in a Pediatric Cohort?

Cited by 11 publications

References 23 publications

Pediatric Outcomes following Cranial Vault Remodeling with Restricted Use of Postoperative Narcotics: A Retrospective Review

Pediatric Outcomes following Cranial Vault Remodeling with Restricted Use of Postoperative Narcotics: A Retrospective Review

The management of perioperative pain in craniosynostosis repair: a systematic literature review of the current practices and guidelines for the future

Safety and Efficacy of Single-Dose Ketorolac for Postoperative Pain Management After Primary Palatoplasty: A Prospective Cohort Study With Historical Controls

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