Preemptive analgesia comparable to standard protocol for pain after pediatric osteotomy

Study Type: Therapy
OE Level of Evidence: 2
Journal Level of Evidence: N/A
Synopsis
51 pediatric patients scheduled for corrective osteotomy were randomized to undergo the procedure with an analgesia regimen initiated either 5 minutes prior to or 5 minutes after skin incision. The purpose of this study was to determine if significant improvements in postoperative pain, rescue analgesic use, the frequency of intravenous patient-controlled analgesia (IV-PCA) button use, and incidence of nausea and vomiting were associated with preemptive analgesia when compared to standard analgesia throughout a 48-hour post-surgery period. A significantly higher Please login to view the rest of this report. Please login to view the rest of this report.
Funding: Non-funded
Conflicts: None disclosed
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Why was this study needed now?
Several challenging factors involved in postoperative pain management for pediatric patients can contribute to inadequate pain relief, including patient variability, quantifying pain, pain perception, and varying pharmacodynamics and pharmacokinetics between infants and children. Several long-term and debilitating symptoms can arise due to improper postoperative pain control, and as such, the need for comprehensive and effective pediatric analgesia is imperative. Preemptive analgesia is commonly defined as analgesia established prior to surgical treatment that aims to prevent the formation of central sensitization due to incisional injury and inflammatory response. Since its first introduction, preemptive analgesia has been associated with decreased pain and longer duration of pain relief, however, evidence analyzing its efficacy in comparison to standard analgesia and other modes of pain relief have been conflicting.
What was the principal research question?
For pediatric patients aged 3 to 7 years undergoing corrective osteotomy, was the administration of preemptive intravenous analgesia associated with significantly reduced postoperative pain when compared to a standard postoperative analgesic regimen up to 48 hours post-surgery?
Population: 51 patients aged 3 to 7 years scheduled to undergo corrective osteotomy and receive intravenous patient-controlled analgesia (IV-PCA) were included in this study. A standardized general anesthetic regimen was administered to all patients; protocol included 0.02 mg/kg atropine and 2 mg/kg propofol, a neuromuscular blockade with 0.6 mg/kg rocuronium, and maintenance with desflurane and an air-oxygen mixture. Additionally, the same IV-PCA protocol was provided for all patients, including 25 mcg/kg fentanyl with a loading dose of 1 mcg/kg, a basal infusion dose of 2 mcg/kg/h, a bolus dose of 0.5 mcg/kg per demand, and ‘lock-out’ interval of 15 min.
Intervention: Preemptive group: IV-PCA regimen was administered five minutes prior to skin incision during corrective osteotomy (n=25, 21 completed follow-up; mean age= 5.2+/-1.3, 15M/6F).
Comparison: Control group: IV-PCA regimen was administered five minutes after skin incision during corrective osteotomy (n=26, 20 completed follow-up; mean age= 5.2+/-1.3, 10M/10F).
Outcomes: The primary outcome of interest was pain score measured with a verbal rating scale (VRS; where 0 indicates no pain and 4 indicates worst pain imaginable), the Wong-Baker FACES pain rating scale (WFBS; where 0 indicates no pain and 5 indicates worst pain). Secondary outcomes of interest included IV-PCA start time, postoperative rescue analgesics, and postoperative nausea or vomiting. Emergence agitation score (EAS) was evaluated with the Pediatric Anesthesia Emergence Delirium (PAED) scale.
Methods: RCT: prospective, assessor-blinded
Time: Outcomes of interest were evaluated 1, 2, 4, 8, 12, 24, and 48 hours post-surgery.
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The authors responsible for this critical appraisal and ACE Report indicate no potential conflicts of interest relating to the content in the original publication.