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Pediatric Surgical Pain Management toolkit for healthcare professionals

Nearly half of the opioids prescribed to patients under 21 years old could be classified as high risk, based on pharmacy data from 2019.7 More than half of these prescriptions were written by dentists and surgeons.

To begin to combat the opioid epidemic, we need to:

  • Review our prescribing patterns
  • Consider the amount of opioid being prescribed and consumed
  • Rethink patients’ pain management
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BEST PRACTICES FOR PEDIATRIC POSTOPERATIVE PAIN MANAGEMENT

We convened a multidisciplinary working group at Michigan Medicine with representatives from Surgery, Anesthesiology, Nursing, Pharmacy, Child Life, and Psychology, who provide care for patients and families after surgery. Together, we discussed concerns about postoperative pain and formulated a common message about how to best manage it. We encourage you to consider doing the same at your institution.

Michigan Medicine’s multidisciplinary working group has developed the following:

Provide a consistent message about pain management and medication use, risks, storage, and disposal. Make sure that verbal and written instructions from all providers are consistent, from preoperative evaluation to postoperative follow-up. Coordinate transitions between all clinicians to establish shared expectations for postoperative recovery and pain management needs.

As early as possible before surgery, discuss expectations regarding the experience of pain, length of recovery, and functional pain management goals with the patient and family in an age-appropriate manner. Do not routinely provide opioid prescriptions intended for postoperative use prior to surgery.

Discuss with the anesthesia team how to best manage the patient’s pain in the operating room so postoperative pain is minimized. Think about using a nerve block, local anesthetic catheter, or epidural when appropriate. Administer intravenous non-opioid medications (e.g., ketorolac, acetaminophen) for management of pain before arrival in the postanesthesia care unit unless contraindicated.

In the recovery area, use nonpharmacologic techniques such as distraction, Child Life services, and parental presence to address pain and anxiety as soon as it is safe to do so. When appropriate, give enteral non-opioid medications if not already administered pre- or intraoperatively. If opioids are used in the recovery area, oral administration is preferred over IV administration. Consider obtaining a consult from the Pain Service if the patient’s pain is poorly relieved despite standard therapy or from the Pediatric Psychiatry Service if a new history of substance use disorder is identified in a patient.

Use non-opioid therapies as a primary method for pain management and include dosing of over-the-counter (OTC) medications and instructions for their use. Discuss and encourage non-pharmacologic therapies, including distraction, heat or ice, and physical therapy

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First-line Medications for Pain Control

Acetaminophen (Tylenol®) and ibuprofen (Motrin®) can provide similar pain management to opioids. Specifically, a randomized study on pediatric patients undergoing tonsillectomy and adenoidectomy, a procedure associated with significant postoperative pain, showed that ibuprofen and acetaminophen in combination provided similar analgesia to morphine without risk of respiratory depression.8

Patient-reported outcome data collection by OPEN also show that for procedures such as circumcision, herniorrhaphy, appendectomy and adenoidectomy, patients have adequate pain management with acetaminophen and ibuprofen alone.9 Even if opioids are prescribed, using medications such as acetaminophen and ibuprofen can decrease opioid use.

Prescribe Acetaminophen and Ibuprofen

Since acetaminophen and ibuprofen are available over the counter and don’t require a prescription for patients to use, patients and caregivers often do not receive instructions on how to use them after surgery. The packaging instructions for acetaminophen and ibuprofen provide dosing for an age and weight range and recommend as-needed use. If families follow these instructions, they may be under-dosing their children and inadequately addressing their pain. And if they were prescribed an opioid, they may think this is the first medication they should use for their child’s pain, not understanding that acetaminophen and ibuprofen often provide adequate pain relief when dosed and administered correctly and that an opioid may not be needed.

Your Guidance Can Make a Difference

At Michigan Medicine, acetaminophen and ibuprofen are sent electronically as prescriptions to a patient’s pharmacy. When acetaminophen and ibuprofen are written as prescriptions and instructions on how to use them are provided, families then have clear information regarding dosing and understand these are the first-line medications for pain management. Some insurance companies may cover the cost of these medications when they are written as a prescription.

How to Dose

Acetaminophen

Tylenol®

15 mg/kg every 6 hours, with a maximum of 650 mg per dose

Ibuprofen

Motrin®

10 mg/kg every 6 hours +, with a maximum of 600 mg per dose

For mild pain, these are used either individually or together on an as-needed basis.

For moderate pain, they are given on a schedule together every 6 hours during the day, and at night as needed (if the patient wakes) for 1-2 days after surgery, and then as needed.

For severe pain, they are given on a schedule together around the clock for 2 days after surgery and then as needed.

Notes:

  • Avoid ibuprofen and other non-steroidal anti-inflammatory drugs (NSAIDs) in patients with bleeding disorders, renal disease, peptic ulcer disease, and for specific operations at surgeon discretion. Do not use ibuprofen in children under 6 months of age. Use only one NSAID at a time (do not combine NSAIDs).
  • Use caution when prescribing acetaminophen in patients with hepatic impairment or active liver disease.

 

Give Acetaminophen and Ibuprofen Together

Many families are familiar with using acetaminophen and ibuprofen on an alternating basis as-needed for fever and assume they should use them for pain control in the same way. However, from a pain management standpoint, the half-life of both of these medications is long enough that they can be given together.

Giving these two different medications at the same time has benefits:

  • Much simpler for families
  • Decreases the likelihood of missing or duplicating a dose
  • Less disruptive to both sleep and daytime schedules

Simultaneous administration may also allow for longer-lasting pain management.10 For this reason, we strongly recommend administering acetaminophen and ibuprofen together for pain management. Provide caregivers with information about how to administer these two medications together for pain relief after surgery.

  • Use weight-based dosing for acetaminophen and ibuprofen.
  • Recommend several days of around-the-clock use for severe pain.
  • Give acetaminophen and ibuprofen at the same time.
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Streamline Prescribing and Education by Using Order Sets

At Michigan Medicine, they use the Epic electronic medical record system. When patients are discharged after surgery, providers use a discharge order set that contains instructions on postoperative care. Standard orders for acetaminophen and ibuprofen and instructions on their use have been added to the postoperative order sets. This simplifies the process of prescribing for providers and removes the barrier of additional work.

It also allows for standard weight-based dosing and instructions, and offers the opportunity for families to receive the medication at a pharmacy (where it may be covered by insurance). Providing the medications as a prescription validates these over-the-counter medications as the first-line choice for pain management and ensures patients receive the appropriate dose for their size.

Michigan Medicine Order Set Example Discharge Medications

Acetaminophen

Acetaminophen 160 mg/5 mL suspension – 15 mg/kg Q6H PRN
• Disp-354 mL, R-0

Acetaminophen 80 mg chewable tablet
• Disp-60 tablet, R-0

Acetaminophen 325 mg tablet – 15 mg/kg Q6H PRN
• Disp-60 tablet, R-0

Contraindicated
• no prescription provided

Ibuprofen

Ibuprofen 100 mg/5 mL suspension – 10 mg/kg Q6H PRN
• Disp-360 mL, R-0

Ibuprofen 200 mg tablet – 10mg/kg Q6H PRN
• Disp-60 tablet, R-0

Ibuprofen 400 mg tablet
• Disp-60 tablet, R-0

Ibuprofen 600 mg tablet
• Disp-60 tablet, R-0

Contraindicated
• no prescription provided