Mirna Giordano (left), Assistant Professor of Pediatrics Columbia University Medical Center; Belinda Shao (middle), Research Assistant, Rutgers University; Richard C.E. Anderson (right), MD, FACS, FAAP, Associate Professor of Neurological Surgery Columbia University Medical Center.
Beyond the anxiety associated with any neurosurgical procedure in our pediatric population, most children and their families are also concerned with the aftermath. Will my child be in pain? Will they have to take opioids? Thankfully, parents can be reassured to hear that the majority of children’s hospitals have an entire team of doctors and nurses who work together to take care of their children and make sure they are comfortable after surgery. Over the years, many innovations in patient care have allowed these teams to improve the recovery experience so that patients can get better and faster pain relief, take less or possibly no opioids, and feel ready to leave the hospital faster.
The latest consensus guidelines by expert physicians on pain control recommend using multimodal analgesia for pain control after surgery. This method combines different types of pain medications synergistically for pain relief, while avoiding the side effects of a larger quantity of a single type of medication. The specific medications used depends on the individual patient as well as the type of surgery. Most commonly, doctors will use local anesthetics along the incision, small doses of opioid medications, anti-inflammatories (NSAIDs such as ibuprofen — Advil® or MOTRIN®), acetaminophen (TYLENOL®) and benzodiazepines (such as diazepam/Valium). When combined, these medications address different types of pain such as incisional pain, bone pain, and pain associated with muscle spasms.
Multimodal pain management enables a transition away from opioid-heavy strategies traditionally used after surgery. High-dose opioids can make patients feel sleepy, constipated, nauseous, itchy and even confused. They may also impair breathing. All of these side effects can slow down the recovery process, as it becomes difficult to get out of bed, walk, and eat if the child is feeling nauseous, constipated, vomiting or sleepy. In fact, an overwhelming number of studies have found that moderating opioid use after different kinds of surgery can help enhance recovery and allow patients to get home from the hospital sooner. This growing movement, called Enhanced Recovery After Surgery (ERAS), may even translate into cost savings for both patients and hospitals.
Another potential side effect of opioid use in the hospital is the risk of longer-term opioid use by the patient or abuse of available opioids by those around them. Currently, our nation faces an opioid epidemic that has become more prominent over the past few decades. Daily, 175 Americans die of opioid-related causes, and there are some projections that this number could reach 250 soon. Surveys have shown that 55 percent of opioid drug abusers obtain opiates from family and friends. To reduce the non-prescription supply doctors are trying to reduce unnecessary opioids prescriptions. Some studies show that adults receiving opioids to recover from surgery were more likely than a control group of adults to become chronic opioid users one year later. Even for children, around-the-clock use of opioids for just 3-5 days places them at higher risk for opioid dependence. Reducing postoperative opiate usage can help address the epidemic by reducing the amount of opioids that a child is exposed to, and also by reducing the amount of opioids that go home with the patient.
Surgeons, anesthesiologists, pediatricians, nurses and all healthcare professionals play a critical role in combating the opioid epidemic in minimizing post-operative opioid use when possible. It is also our responsibility in the pediatric neurosurgery community to establish the evidence for best practices for our patients. Leading the way, our multidisciplinary pediatric neurosurgery research team at the Morgan Stanley Children’s Hospital of New York (Columbia University Irving Medical Center) believes that a specifically-timed and dosed combination of Ketorolac, ibuprofen, acetaminophen, and diazepam works well for many neurosurgical procedures and reduces the use of opioids and their most common side effects: nausea and vomiting, constipation, sedation and decreased mobility. In our first study of a small subset of patients, we found that these medications in combination were associated with less opioid use in the hospital, fewer opioids prescribed at discharge and fewer hospital charges. Before we can draw any conclusions, however, we need to see these results in a larger sample and are currently conducting more analysis.
Each patient care team employs an evidence-based approach to identify the optimal multimodal analgesia regimen for their pediatric patients. Policies vary by hospital, but patients and parents are always encouraged to be vocal regarding medications used after surgery and to advocate for opioid-sparing multimodal analgesia to be used for their children after undergoing neurological surgery. Together, we can make sure your child is comfortable after surgery, as well as combat the opioid epidemic.
Editor’s Note: We encourage everyone to join the conversation online by using the hashtag #PedsNeurosurgery.