Postoperative Pain Management in Pediatric Patients Undergoing Cardiac Surgery: Where Are We Heading?

Pollak, Uri; Bronicki, Ronald A.; Achuff, Barbara-Jo; Checchia, Paul A.

doi:10.1177/0885066619871432

Cited by 8 publications

(11 citation statements)

References 56 publications

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“…4 It is suggested that arterial hypotension in patients undergoing ESPB is due to a sympathetic block by diffusion of the local anesthetic towards the anterior region through the costotransverse foramen, penetrating the thoracic paravertebral space generating blockage of the spinal branches and sympathetic fibers. 17 However, studies such as Kaushal et al 12 and our study did not report hemodynamic changes in patients with ESPB during the first 24 hours ( Table S1 ).…”

Section: Discussioncontrasting

confidence: 54%

Postoperative Outcomes of Analgesic Management with Erector Spine Plane Block at T5 Level in Pediatric Patients Undergoing Cardiac Surgery with Sternotomy: A Cohort Study

Cruz¹,

Rebellón-Sánchez²,

Torres-Salazar³

et al. 2023

LRA

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Introduction There is limited evidence on the impact of erector spinae plane block (ESPB) as part of multimodal analgesia in pediatric population undergoing cardiac surgery. Methods A retrospective cohort study was conducted in patients under 18 years of age, who underwent cardiac surgery Risk Adjusted classification for Congenital Heart Surgery (RACHS-1) ≤3 by sternotomy. The study aims to evaluate the effect of ESPB as part of multimodal analgesia in pediatric patients undergoing cardiac surgery compared to conventional analgesia (CA) on relevant clinical outcomes: length of hospital stay, length of ICU stay, opioid consumption, time to extubation, mortality, and postoperative complications. The participants included were treated in a reference hospital in Colombia from July 2019 to June 2022. Results Eighty participants were included, 40 in the ESPB group and 40 in the CA group. There was a significant decrease (Log rank test p = 0.007) in days to length of hospital stay in ESPB group (median 6.5 days (IQR: 4–11)) compared to the CA group (median 10.5 days (IQR: 6–25)). Likewise, there was a higher probability of discharge from the ICU in the ESPB group (HR 1.71 (95% CI: 1.05–2.79)). The ESPB group had lower opioid consumption (p < 0.05). There were no differences in time to extubation, mortality, and postoperative complications. Conclusion ESPB as part of multimodal analgesia in pediatric patients undergoing cardiac surgery is feasible and associated with shorter hospital length of stay, faster ICU discharge and lower opioid consumption.

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Section: Discussioncontrasting

confidence: 54%

Postoperative Outcomes of Analgesic Management with Erector Spine Plane Block at T5 Level in Pediatric Patients Undergoing Cardiac Surgery with Sternotomy: A Cohort Study

Cruz¹,

Rebellón-Sánchez²,

Torres-Salazar³

et al. 2023

LRA

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“…Strategies should also be considered for development of less costly objective pain assessment tools. 5…”

Section: Moderate Strongmentioning

confidence: 99%

“…Pain management should be adjusted for individual experience of pain and reaction to interventions including undertreatment and overtreatment. 5…”

Section: Very Low Strongmentioning

confidence: 99%

“…While numerous review articles have been published on pharmacotherapy strategies, they do not provide actionable guidance for practitioners. [2][3][4][5][6][7][8][9] An international survey of 15 centres found significant practice variation in choice of analgesics and dosing. 10 Furthermore, a national survey of heart centres conducted by the Paediatric Acute Care Cardiology Collaborative in 2021 revealed only 6 of 34 respondents reported having an institutional written policy regarding pain management, three reported standardised practice among providers but no written policy, and the remaining 25 said there was no standardisation among providers within their institution.…”

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confidence: 99%

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

et al. 2022

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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.

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“…2,6 Additionally, the use of opioids in neonates and infants has been associated with long-term neurodevelopmental effects. 7,8 Following cardiac surgery and in response to validated pain and sedation scores, additional morphine doses may often be required. 2,9 An important question is whether a morphine concentration can be identified above which the probability of side effects (eg, oversedation) increases.…”

mentioning

confidence: 99%

Exploring the Relationship Between Morphine Concentration and Oversedation in Children After Cardiac Surgery

Valkenburg

Goulooze

et al. 2020

The Journal of Clinical Pharma

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Titrating analgesic and sedative drugs in pediatric intensive care remains a challenge for caregivers due to the lack of pharmacodynamic knowledge in this population. The aim of the current study is to explore the concentration‐effect relationship for morphine‐associated oversedation after cardiac surgery in children aged 3 months to 3 years. Data on morphine dosing, as well as morphine plasma concentrations, were available from a previous study on the pharmacokinetics of morphine after cardiac surgery in children. Oversedation was defined as scores below 11 on the validated COMFORT–behavioral scale. Population pharmacokinetic‐pharmacodynamic modeling was performed in NONMEM 7.3. The probability of oversedation as a function of morphine concentration was best described using a step function in which the EC 50 was 46.3 ng/mL. At morphine concentrations below the EC 50 , the probability of oversedation was 2.9% (0.4& to 18%), whereas above the EC 50 percentages were 13% (1.9% to 52%) (median value [95% prediction interval from interindividual variability]). Additionally, the risk of oversedation was found to be increased during the first hours after surgery ( P < .001) and was significantly lower during mechanical ventilation ( P < .005). We conclude that morphine concentrations above approximately 45 ng/mL may increase the probability of oversedation in children after cardiac surgery. The clinician must evaluate, on a case‐by‐case basis, whether the analgesic benefits arising from dosing regimen associated with such concentrations outweigh the risks.

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Postoperative Pain Management in Pediatric Patients Undergoing Cardiac Surgery: Where Are We Heading?

Cited by 8 publications

References 56 publications

Postoperative Outcomes of Analgesic Management with Erector Spine Plane Block at T5 Level in Pediatric Patients Undergoing Cardiac Surgery with Sternotomy: A Cohort Study

Postoperative Outcomes of Analgesic Management with Erector Spine Plane Block at T5 Level in Pediatric Patients Undergoing Cardiac Surgery with Sternotomy: A Cohort Study

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

Exploring the Relationship Between Morphine Concentration and Oversedation in Children After Cardiac Surgery

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