1. PAIN MANAGEMENT IN PEDIATRIC ORTHOPAEDIC SURGERY JUSTIN LUCAS – T4

2. TREATMENT GOALS  Return of normal function  Respiration  Mental status  Mobility  Adverse effects to a minimum  Dynamic Regimen

3. PATIENT ASSESSMENT  Patient’s self assessment  Fifth vital sign  0-5 scale with faces  Mentally challenged require physiologic and behavioral signs

4. TIMELINE OF INTERVENTION  Pain can be addressed at all stages of surgery  Preoperative anxiety  Education and anxiolytics  During surgery  Local and regional blocks  Epidural anesthetics  NSAIDS or narcotics  Postoperative scheduled pain regimen  Change to PO once pain improves

5. NONPHARMOCOLOGIC TREATMENTS  Education  Relaxation techniques  Distractions  Allowing patient to participate in procedures  Mechanical modalities  RICE  Transcutaneous electrical nerve stimulation

6. MEDICATIONS  Acetaminophen  Antipyretic and analgesic  Inhibits prostaglandin H synthase  Used in conjunction with narcotic medications  Adverse effects include rash and hypothermia  Overdose  fatal hepatic necrosis  NSAIDS  Antipyretic, analgesic, anti-inflammatory  Peripheral inhibition of cyclo-oxygenase  Renal impairment – Na retention and edema

7. NSAIDS  DELAYED BONE HEALING?  COX-2 shown to be essential for bone healing in animal studies  Indomethacin given to rats for 14 or 29 days compared with placebo inhibited fracture healing  Gerstfeld et al: Compared ketorolac vs placebo given for up to 21 and 35 days post op  reduced mechanical strength and stiffness  Brown et al: Compared adult rat femoral fracture healing in groups given indomethacin, celecoxib, no drug.  At 4 wks indomethacin group had radiographic and biomechanical evidence of delayed bone healing. Celecoxib group ahd fibrous tissue formation.  No differences among 3 groups at 12 wks.   COX-2 may have less effect on delaying fracture union than traditional NSAIDS  Eberson et al: Ketorolac use resulted in decreased need for morphine

8. OPIOIDS  Raise pain threshold centrally and peripherally and alter brain’s perception of pain  Many adverse effects  Respiratory depression  Decreased smooth muscle contraction  Histamine release from mast cells  Urinary retention from increase in ADH  Morphine  Meperidine  Fentanyl  Orals: Codeine, oxycodone, hydrocodone

9. REGIONAL BLOCKS  Epidural anesthesia  Caudal blocks at sacral hiatus in younger children  Lumbar blocks in older children  Plexus and peripheral nerve blocks  Brachial plexus  Interscalene  Infra/supraclavicular  Lumbar plexus  Femoral/sciatic nerve

10. CONCLUSIONS  Kids are challenging!  Incorporation of newer strategies in adult care  Multimodal approach  Psychological  Mechanical  Medical  Frequent reassessment with a dynamic treatment plan

11. REFERENCES  McCann HL, Stanitski, DF: Pediatric orthopaedic surgery pain management. J Pediatr Orthop 2004; 24: 581-585.