Pain management following major intracranial surgery in pediatric patients: a prospective cohort study in three academic children's hospitals

Abstract

Introduction: Pain management following major intracranial surgery is often limited by a presumed lack of need and a concern that opioids will adversely affect postoperative outcome and interfere with the neurologic examination. Nevertheless, evidence in adults is accumulating that these patients suffer moderate to severe pain, and this pain is often under-treated. The purpose of this prospective, clinical observational cohort study was to assess the incidence of pain, prescribed analgesics, methods of analgesic delivery, and patient/parent satisfaction in pediatric patients undergoing cranial surgery at three major university children's hospitals.

Methods: After obtaining IRB and parental consent (and when applicable, patient assent), children who underwent cranial surgery for cancer, epilepsy, vascular malformations, and craniofacial reconstruction were studied. Neither intraoperative anesthetic management nor postoperative pain management was standardized, but were based on institutional routine. Patients were evaluated daily by a study investigator and by chart review for pain scores using age appropriate, validated tools (FLACC, Faces Pain Scale-Revised, Wong-Baker Faces Scale or Self-Report on a 0-10 scale), for patient/parent satisfaction using a subset of the NRC Picker satisfaction tool and in adolescents a modified QoR-40, and for the frequency, mode of administration, and type of analgesic provided. Finally, the incidence of opioid-induced side effects, specifically nausea, vomiting, pruritus, altered level of consciousness, and need for emergency diagnostic radiologic studies for altered neurologic examination were recorded. Data are provided as mean ± SD.

Results: Two hundred children (98:102 M:F), averaging 7.8 ± 5.8 years old (range 2 months-18.5 years) and 32.2 ± 23.0 kg (range 4.5-111.6 kg) undergoing craniectomy (51), craniotomy (96), and craniofacial reconstruction (53) were studied. Despite considerable variation in mode and route of analgesic administration, there were no differences in average pain score, length of hospital stay, or parental satisfaction with care. Interestingly, opioid-induced side effects were not related to total daily opioid consumption, site of surgery, or method of opioid delivery. The most common side effect was vomiting. No patient developed respiratory depression or altered mental status secondary to analgesic therapy. Regardless of age or procedure, once eating, most patients were treated with oral oxycodone and/or acetaminophen.

Conclusions: Despite considerable variation in modality and route of analgesic administration, there were no differences in average pain score, length of stay, or parental satisfaction with care. Pain scores were low, side effects were minimal, and parental satisfaction was high, providing equipoise for future blinded prospective randomized trials in this patient population.

Trial registration: ClinicalTrials.gov NCT01576601.

Keywords: analgesia; craniotomy; opioid; pain control; pediatric pain.

Conflict of interest statement

No conflicts of interest declared.

© 2014 John Wiley & Sons Ltd.

Figures

Figure 1

CONSORT (Consolidated Standards of Reporting Trials) flow chart of patient enrollment. BCH: Boston Children’s Hospital; CHOP: Children’s Hospital of Philadelphia; JHH: Charlotte R. Bloomberg Children’s Center of the Johns Hopkins Hospital. M:F: Male to female ratio.

Figure 2

Frequency distribution by surgery type and institution. BCH: Boston Children’s Hospital; CHOP: Children’s Hospital of Philadelphia; JHH: Charlotte R. Bloomberg Children’s Center of the Johns Hopkins Hospital.

Figure 3

Comparison of total intravenous morphine equivalents (mcg/kg/day) by surgery type, postoperative day, and institution. Data are represented by box plot. BCH: Boston Children’s Hospital; CHOP: Children’s Hospital of Philadelphia; JHH: Charlotte R. Bloomberg Children’s Center of the Johns Hopkins Hospital.

Figure 4

Comparison of total oral analgesics (opioid and acetaminophen) by surgery type, postoperative day, and institution. Data are represented by box plot. BCH: Boston Children’s Hospital; CHOP: Children’s Hospital of Philadelphia; JHH: Charlotte R. Bloomberg Children’s Center of the Johns Hopkins Hospital.

Figure 5

Parental perception of the amount of pain medication given to their child to control pain. BCH: Boston Children’s Hospital; CHOP: Children’s Hospital of Philadelphia; JHH: Charlotte R. Bloomberg Children’s Center of the Johns Hopkins Hospital.