The postoperative management of pain from intracranial surgery in pediatric neurosurgical patients

Abstract

Pain following intracranial surgery has historically been undertreated because of the concern that opioids, the analgesics most commonly used to treat moderate-to-severe pain, will interfere with the neurologic examination and adversely affect postoperative outcome. Over the past decade, accumulating evidence, primarily in adult patients, has revealed that moderate-to-severe pain is common in neurosurgical patients following surgery. Using the neurophysiology of pain as a blueprint, we have highlighted some of the drugs and drug families used in multimodal pain management. This analgesic method minimizes opioid-induced adverse side effects by maximizing pain control with smaller doses of opioids supplemented with neural blockade and nonopioid analgesics, such nonsteroidal antiinflammatory drugs, local anesthetics, corticosteroids, N-methyl-D-aspartate (NMDA) antagonists, α2 -adrenergic agonists, and/or anticonvulsants (gabapentin and pregabalin).

Review in The Management of Post-Craniotomy Pain

“…Showing the dosage of non opioidal analgesics that are commonly used for PCP relief. 34 2 inhibitor (COX) and can cause platelet dysfunction and increase bleeding (COX-1 isomer) and analgesia by (COX-2 isomer). Selective COX-2 inhibitor does not have anti-platelet effects and therefore do not cause bleeding.…”

“…Showing the common opioidal drugs and their dosage. 34 Tramadol: the classical side effects of opioids like sedation, dizziness, vomiting, dry mouth, nausea, vomiting, miosis can hide the true signs of neurological deterioration and hence the use of opioids was not common in neurosurgery. Tramadol is a weak analgesic acting as the Mu-receptor agonist or serotonin/ norepinephrine reuptake inhibition.…”

“…Nausea and itching can also be severe in some cases.The dosage guidelines of the common opioids are given in Figure 3. 34 Management of chronic PCP: these are a subtype of patients that complain of persistent headache or pain after craniotomy. Other causes like cervical spondylosis, psychiatric illness, fi bromyalgia, migraines and tension headaches must be ruled out.…”

Review of the enhanced recovery pathway for children: perioperative anesthetic considerations

“…Its analgesic efficacy is similar to that of morphine, and it can help reduce the incidence of opioid-associated postoperative nausea and vomiting. 53 Other options for intravenous nonopiate analgesia include low-dose ketamine infusions, intermittent diazepam, 54,55 and butorphanol 56 injections.…”

Post-craniotomy pain: A neglected entity

“…Similar to adult patients, in children too, multimodal analgesia has been recommended maximising pain control with smaller dose of opioids. [23] With the available literature, the healthcare workers are now realising that the traditional justification for avoiding morphine or other strong opioids in the treatment of post-craniotomy pain is largely based on weak evidence. Although it is emerging that opioids are safe and provide effective analgesia following craniotomy, many regimens have been investigated aiming to reduce their dose in acute pain of craniotomy.…”