ms th shrader pain - aacpdm · 2017-09-01 · shrader mw, et al jco, 2015 hip reconstruction is...

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•  Similar groups in terms of amount of pain

•  Questions raised: •  Did the CP group really have

“zero” pain? •  Did the CP group have that

much better pain control than the Controls?

•  Why were there gaps in pain assessment in the CP group?

Assessment of Post-Operative Pain in Children with Cerebral Palsy

Are We Under-Medicating Patients with Neuromuscular Scoliosis after Posterior Spine Fusion?

•  How well are we treating pain after PSF?

•  Concern: pt’s undergoing PSF for NM scoliosis may be under-medicated due to inaccurate pain assessment and and risk of respiratory depression

•  Goal: Compare pain management in patients with NM patients to a cohort of patients with adolescent idiopathic scoliosis following PSF

•  Published in J Spine Def 2015


•  Institutional Review Board (IRB) approval •  Retrospective case control study •  30 pts with NM scoliosis matched for age,

gender, and weight with a group of patients with AIS

•  Patients with AIS also matched - minimum of 10 vertebral levels instrumented / fused

•  Additional data collected: length of stay, daily opioid use, and standard pain scores during the first 24 hours and the entire post-operative period

Shrader MW, et al J Spine Def, 2014


•  Total opioid used (TOU) - measure used to determine relative pain management between the two groups

•  TOU - determined by summing all of the opioids (narcotics) given during the hospital stay (oral / IV), then converted to morphine equivalent units (mg of morphine-equivalents, normalized by body weight).

•  nTOU/LOS – normalized total opioid used / kg/ per day length of stay (LOS)

•  2 pain assessment tools used (VAS, FLACC/non-verbal) •  Paired Student T-tests used to compare the two groups (p <

0.05)


TOU • NM group - 1.2 mg morphine/kg (range, 0.28 to 4.31)

• AIS group - 3.52 mg morphine/kg (range, 0.71 to 15.51)

• (p = 0.0006) 0

0.5

1

1.5

2

2.5

3

3.5

4

NM AIS

TNU



nTOU / LOS •  normalized TOU for

LOS for the NM group was 0.23, and was 0.69 for the AIS group (p < 0.00005)

• LOS for the NM group was 5.38 days, and 4.6 days for the AIS group (p = 0.043)

0

0.1

0.2

0.3

0.4

0.5

0.6

0.7

NM AIS

nTNU



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• Discussion: •  Patients with AIS undergoing PSF

received more than 2x the amount of narcotic compared to an age and weight matched group of patients with NM scoliosis

•  This data suggests that these NM patients’ pain may be under-treated compared to our AIS patients



•  Concerns about postoperative pain control in patients with Cerebral Palsy (CP) are anxiety provoking for patients and families, especially Hip surgery!

• A better understanding of the magnitude and quality of postoperative pain would better prepare patients and families.

•  Cohort of pts w/ CP undergoing Hip reconstruction compared to cohort undergoing PSF

•  Published in JCO 2015

Hip Reconstruction is More Painful than Spine Fusion in Patients with Cerebral Palsy

Shrader MW, et al JCO, 2015


0

0.05

0.1

0.15

0.2

0.25

0.3

0.35

0.4

0.45

0.5

Hip vs Spine

0.49

0.24

TNU

(mg

MSO

4/kg

/DLO

S)

Hip Spine

p = 0.014



0

0.5

1

1.5

2

2.5

Hip vs Spine

1.52

0.72

Mea

n Pa

in S

core

Hip Spine

p = 0.013


• Discussion: • Our data suggests that for patients with CP, hip

reconstruction is MORE painful than PSF, when comparing pain scores and total narcotics used

•  This data supports our clinical assumption •  This is the first study, to our knowledge, that has

documented this finding •  This knowledge will better prepare families about what to

expect in the postoperative period.



•  Do Epidurals help with postoperative pain control?

•  Pedersen reported as part of a tiered RCT, comparing local infiltrate vs placebo, with a 3rd arm for epidural for unilat hip reconstruction

•  r-FLACC/VAS and nTOU was lower in the epidural group at 4 hr postop

•  At 9 and 21 hr po, TOU was less w/ epidural but NS p-value for difference in pain scores

•  Only 6 in each group

Clinical Aspects of Acute Pain in Children with CP

Pedersen LK et al, Acta Orthopaedica, 2016

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•  Chalkiadis et al reported on RCT with epidural w/ fentanyl or clonidine for SEMLS

•  24, 26 in each group • No change in primary

outcomes: pain scores, valium use, or muscle spasm (with low pain scores in each group)

• More vomitting and O2 desaturation with Fentanyl group; Clonidine resulted in lower SBP and HR


Chalkiadis GA, et al DMCN, 2015

• What about epidurals after SDR?

• Moore et al reported on a group of 31 pts undergoing SDR with an epidural compared to 41 with IV analgesia

•  Epidural resulted in lower pain scores in first 24o, and less O2 desaturations


Moore RP, et al Pediatric Anesthesia, 2013

•  Can Epidural Baclofen help with postoperative pain control?

•  44 pts with CP undergoing SEMLS, 19 received baclofen in their epidural

• No changes in pain scores, opioid or benzo use, or LOS


Nemeth BA, et al JPO, 2015

• Conclusion: • Pain assessment in children with CP is difficult

•  Need better tools/instruments •  Need concerted training programs for our RNs

• CP pts undergoing PSF receive less narcotics than those with AIS – likely we’re undertreating their pain

• Hip reconstruction is more painful than PSF in children with CP •  Helps counsel parents not to postpone PSF!

• Adjunctive Pain Modalities (Epidural) may be key to help better control postop pain

Assessment of Post-Operative Pain in Children with Cerebral Palsy

Thank You

ms th shrader pain - aacpdm · 2017-09-01 · shrader mw, et al jco, 2015 hip reconstruction is...

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