Best Practices
Major Orthopedic Surgery (Femoral/Pelvic Osteotomy; Spinal Fusion)(Pediatrics)
All best practices are subject to change and may require modifications depending on a patient’s history and status. Healthcare practitioners should always defer to their clinical judgement and, whenever appropriate, consult with additional resources for further guidance.
Avoid prodrugs such as codeine and tramadol in paediatric patients given the variability in CYP2D6 enzyme in children and the risk of over-metabolizing to morphine, a recommendation supported by Health Canada.
| Preoperative | Intraoperative | Postoperative (Inpatient) | Discharge Strategies |
|---|---|---|---|
| •Acetaminophen •NSAIDs (consider selective COX-2 for fewer side effects) | •IV acetaminophen if not given preop •IV NSAIDs if not given preop •Consider IV ketamine bolus plus infusion 0.1-0.3mg/kg/hr •Consider IV lidocaine bolus (1-1.5mg/kg) plus infusion at 0.5-1.5mg/kg/hr if no epidural •If appropriate, consider epidural analgesia | •Continue epidural infusion 24-72 hours until tolerating diet •If no regional anesthesia, +/- IV PCA, transition to PO in 24-48 hours •Ketamine infusion 3-4 mcg/kg/min •Acetaminophen scheduled dosing •NSAIDs scheduled dosing •Consider diazepam as needed if patient reporting spasmodic pain | MANAGEMENT OF PAIN W/O MEDICATION: •Heat/cold packs •Massage therapy •Physiotherapy (per surgeon) CO-ANALGESICS: •Acetaminophen •NSAIDs OPIOID PRESCRIPTION*: 15-20 tabs |
*Preferred opioid: Morphine immediate release, available as elixir or 5mg tabs. To convert this dosage, please visit this page. We encourage prescribers to consider discharge prescriptions of short-acting opioids at the lowest effective dose, with the lowest potency, for the shortest duration.
Before surgery, and at the surgical safety checklist time, the surgical and anesthesia team should work together to develop a multimodal pain management plan with active strategies to optimize perioperative pain management.
Healthcare practitioners are also encouraged to help patients set realistic expectations around pain management, including the use of prescription medications.
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References
Cravero JP, Agarwal R, Berde C, Birmingham P, Coté CJ, Galinkin J, et al. The Society for Pediatric Anesthesia recommendations for the use of opioids in children during the perioperative period. Paediatr Anaesth. 2019 06;29(6):547-71.
Felix MMDS, Ferreira MBG, da Cruz LF, Barbosa MH. Relaxation therapy with guided imagery for postoperative pain management: An integrative review. Pain Manag Nurs. 2019 02;20(1):3-9.
Gai N, Naser B, Hanley J, Peliowski A, Hayes J, Aoyama K. A practical guide to acute pain management in children. J Anesth. 2020 06;34(3):421-33.
Health Canada. Health Canada’s review recommends codeine only be used in patients aged 12 and over [Internet]. Ottawa: Health Canada; 2013 [cited 2020 Aug 01]. Available from: www.healthycanadians.gc.ca/recall-alert-rappel-avis/hc-sc/2013/33915a-eng.php
Michigan OPEN. Pediatric Opioid Prescribing Recommendations [Internet]. Ann Arbor, MI: Michigan Opioid Prescribing Engagement Network; 2017 [cited 2020 Aug 10]. Available from: https://michigan-open.org/wp-content/uploads/2020/06/Pediatric-Prescribing-Recommendations_.pdf
Monitto CL, Hsu A, Gao S, Vozzo PT, Park PS, Roter D, et al. Opioid prescribing for the treatment of acute pain in children on hospital discharge. Anesth Analg. 2017 12;125(6):2113-22.
Zeidan F, Emerson NM, Farris SR, Ray JN, Jung Y, McHaffie JG, et al. Mindfulness meditation-based pain relief employs different neural mechanisms than placebo and sham mindfulness meditation-induced analgesia. J Neurosci. 2015 Nov 18;35(46):15307-25.
Zeidan F, Martucci KT, Kraft RA, Gordon NS, McHaffie JG, Coghill RC. Brain mechanisms supporting the modulation of pain by mindfulness meditation. J Neurosci. 2011 Apr 6;31(14):5540-8.
Treatment Altering Factors
Below are a few of the more common and/or impactful health factors that may result in deviation from the above best practices. Please note that the following list is not exhaustive and that the remarks for each factor are not surgery-specific. Healthcare practitioners should always defer to their clinical judgement and, if appropriate, consult with additional resources for further guidance. See our full disclaimer here.
Organ Dysfunction
Hepatic dysfunction/Excessive alcohol intake
| •In general: Limit or avoid acetaminophen altogether, depending on degree of hepatic dysfunction •Preoperative: Avoid or reduce dose of acetaminophen •Intraoperative: Decrease dose of opioids, benzodiazepines, meperdine •Postoperative: Reduce dose of acetaminophen •Discharge: Lower daily maximum dose of tramadol and increase dosing interval; avoid codeine |
Renal dysfunction
| •In general: Limit or avoid NSAIDs altogether, depending on degree of renal dysfunction •Preoperative: Avoid NSAIDs and use gabapentinoids cautiously •Intraoperative: Avoid morphine and meperidine •Postoperative: Avoid NSAIDs and use lower dose of gabapentin •Discharge: Lower daily maximum dose of tramadol and increase dosing interval; avoid codeine |
Patient Specific Factors
Chronic pain and/or long-term opiate use
| •In general: May attempt to wean chronic opioids if surgery is to treat issues contributing to the chronic pain but otherwise continue chronic pain medication perioperatively if patient uses it •Preoperative: Anesthesia consult where indicated; continue preop opioids on day of surgery and give preemptive analgesia •Intraoperative: Regional anesthesia and peripheral nerve blocks preferable where indicated; use a multi-modal opioid sparing approach; may require higher doses of opioids to account for tolerance •Postoperative: Use a multi-modal opioid sparing approach; may require higher doses of opioids to account for tolerance; regular dose acetaminophen and oral NSAIDs where indicated •Discharge: Consider minimum amount of opiates based on the surgical procedure, age and comorbidities and avoid opioid dose escalation from preop, if possible |
History of difficulty with postop pain management
| •Consider regional anesthetic techniques, if feasible for specific surgical procedure |
Uncontrolled anxiety/depressive symptoms
| •Preoperative: Consider anxiolytics prior to administration of anesthetic •Discharge: While reviewing expected duration of opioid use, as well as opioid safety strategies including the appropriate storage and disposal of unused pills, should be standard practice, it is of paticular importance with patients who have uncontrolled anxiety/depressive symptoms Special note for paediatric surgeries: Given the risk of opioid misuse in youth with depressive symptoms, consider heightened opioid safety factors including reviewing with caregivers at discharge |
System Disorders
Coagulopathy
| •Avoid neuraxial techniques if any abnormal coagulation; consider following ASRA guidelines |
Obstructive sleep apnea
| •Preoperative: Use multi-modal analgesia; reduce or avoid use of gabapentinoids •Intraoperative: Reduce or avoid benzodiazepines; reduce doses of opioid medications •Postoperative: Use multi-modal analgesia; reduce use of opioids and gabapentinoids •Discharge: Reduce opioid dosing |