Race and unequal burden of perioperative pain and opioid related adverse effects in children

Abstract

Background: Interindividual variability in pain perception and analgesic response is a major problem in perioperative practice. Adult studies suggest pain management is influenced by patient's race. The objective of this study is to evaluate the influence of race on perioperative pain treatment in children.

Methods: Prospective observational study evaluating effect of race on analgesia and opioid related adverse effects after tonsillectomy in African American and Caucasian children. A sample of 194 healthy children between 6 and 15 years of age were included. Race was self-identified by parents. All participants received standard perioperative care with a standard anesthetic and an intraoperative dose of morphine. Analgesia outcomes included maximum postoperative pain scores, postoperative opioid requirement, and analgesic interventions. Safety outcomes included incidences of opioid related adverse effects.

Results: African American children experienced significantly more postoperative pain than Caucasian children as measured by postoperative opioid requirement (P = .0011), maximum postoperative pain scores (P < .0001), and analgesic interventions (P < .0001) in the recovery room. Although Caucasian children received relatively less opioids perioperatively, they had significantly higher opioid related adverse effects (P = .039). African American children with obstructive sleep apnea were more likely to have prolonged post anesthesia recovery unit stay due to inadequate pain control.

Conclusions: After similar uses of intraoperative morphine for tonsillectomy, there was an unequal burden of increased pain in African American children and increased opioid adverse effects in Caucasian children in the recovery room. Though Caucasian children received relatively less opioids perioperatively, they had higher incidences of opioid related adverse effects than African American children.

Trial registration: ClinicalTrials.gov NCT01140724.

Figures

FIGURE 1

The consort diagram illustrates the flow of study participants through this clinical trial. Eligible participants, reasons for exclusions, and enrolled patients are reported. IRB, institutional review board.

FIGURE 2

Racial differences in morphine related adverse events and perioperative morphine use; total morphine dose is plotted in the x axis and the probabilities of morphine related adverse effects are plotted in the y axis for African American and Caucasian children. The red dots and blue stars represent raw opioid side effect data (yes side effect as 1, and no side effect as 0). Overall incidences of opioid related side effects in the PACU were relatively higher in Caucasian children compared with African American children, despite a relatively lower mean total perioperative opioid use in Caucasian children (0.24 mg/kg) compared with African American children (0.3 mg/kg).