Post-Operative Pain Management

There is so many stories and discussions about adult opioid crisis and addiction that often children are lost in this important rhetoric. In our 6th Episode of SURGUCATION, I sat down with one of my anesthesiology colleagues, Dr. Elisha Peterson, the Director of Chronic Pain Program at Children's National Hospital to discuss post-operative pain management in children as well address concerns of many parents about prescription pain medication addiction.  

Transcript

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This is SURGUCATION, surgical education for parents. We are here to inform, Inspire, Connect and Heal Welcome To SURGUCATION this is Dr. Mikael Petrosyan, as many of you know, a surgery and anesthesiology work together in unison. To be anesthesiologist Is not just being in the operating room in my opinion. I think the one of the most important and critical role of anesthesiologist is managing pain for those kids who had operation afterwards and especially in pediatric field. I think it's more important because you know kids don't communicate well. Infants and neonates and you know different ages it's hard to ascertain. Well, what is this child's level of pain is and what should I give. And given the fact that now there's opioid crisis an epidemic. I have with us Dr. Elisha Peterson here with us. She is a director of chronic pain clinic. She has a crucial role in managing patients in the the operating room as well as postoperatively or after the operation and for those parents who want to know what happens to my kids. She's the right person to ask the questions. So welcome to SURGUCATION. Thanks for being with us today. Thank you. I'm absolutely thrilled to be here. This is such an incredible endeavor that you have undertaken and it is an absolute pleasure to be invited to speak to your audience. Thank you very much. So, Dr. Peterson. Well, how do you define your role after the operation how do you figure out well how much pain medications do I give this child and how do you know the child's in pain if they don't communicate with you . Right, so let's take a step back because a lot of what we do surrounding developing pain plans really comes off of a combination of a few factors one is we first wanted meet the family, the child get a sense of what their needs have been prior to procedure so some kids who have let's say they're fresh they're healthy they've never had any surgery before what we like to do is get to know well does your child have any issues with anxiety for example, parents often times know if this is a kid that let's say they fell and skinned their knee and if Little Johnny is crying for hours after skidding their knee then we know that when it comes to their pain plan we have to be a bit more aggressive in utilizing distractions and all different types of techniques with the help of our child life team and really just point-by-point instructions for the family. Let's say though. However, you have a child who does not have that kind of concern and skins their knee and doesn't even recognize it and has really good pain coping mechanisms. The plan would look a little different for that child. So it really does depend. Also we have to take into account the invasiveness of the procedure if it's a procedure that involves a major surgery than we anticipate that you all would be admitted in which case we would walk you through what that pain plan looks like and follow with the family every day while they're here during their procedure. So there is a multiple factors that we have to consider when coming up with a pain strategy. So you would say it's a multidisciplinary approach meaning you have child life involved you guys involve surgeons and type of the operation. So ahead of time. Do you meet with family? I think one of the most common approach questions I've been asked as a surgeon is not how's my operation is done is what pain medications are you giving me a lot of times. I don't have the answer for that. I tell them well, you know will involve paint him and they'll figure that out. So I think this for me it's educational to find out what you guys do. And what kind of pain medication how do you determine what pain medications to use to prevent the abuse, right? Okay. So let's get let's address that topic straightaway. Many people are so concerned. Oh, my goodness is my child going to be addicted to pain medication following this procedure. Is that something I'm going to have to be concerned about. Often times in our pediatric population. The child have not received any medications really prior to the surgery. And so the development of an addiction within the context of for post-operative pain is not a concern, addiction will not develop. In a child receiving pain medications or surgery. So I would strongly encourage that the pain medications that are instructed to be given are given because what can happen when we have families who express that you know, I really don't want to give my child any pain medications. They're poisonous. I'm concerned about whether the long-term consequences. I will say that like everything we give in medicine the response is Dose dependent and that is why families are given instructions. They're given dosing exact dosing based off of the child's weight to minimize sort of the dose-related side effects that can occur the consequence of untreated post-operative pain is pretty huge, untreated severe post-operative pain can lead to that child not really taking deep breaths and breathing. So then that can lead to pneumonia, to the child not sleeping at all. It can cause a great deal of anxiety and stress it can impair wound healing which then opens the door for infections and potentially additional surgical procedures. And then finally it can decrease quality of life after the procedure. So we definitely want to treat post-operative pain the most common medications. We recommend giving around-the-clock post-surgery provided that the surgeon, provided that the child doesn't Have medical conditions that would be contraindications. We would recommend something like Tylenol Ibuprofen, around the clock ensuring that either Tylenol or Ibuprofen is given every three hours in an alternating fashion to ensure that there is medication around the clock that we don't fall behind. And then if the surgery is one in which stronger pain medications are required By mouth medication that we look at is like an oxycodone. And so it's a very good pain medication given by mouth. And for that medication, if the child is admitted oftentimes schedule that like every six hours and so that's something that can be looked at at home to provide for the first two post-operative days. It's very important when it comes to post-operative pain for the first two days that there is medication scheduled around the clock, by the time they let you know that they have pain it's already excruciating and it takes about 15 minutes at least for the pain medications to work and that can feel like an eternity If the child is bowled over, you know in tears so we certainly want to prevent that and that is why we have at least a baseline level of medications given around the clock and then if pain persists breaks through that. We have an as-needed medication. Is there any type of other pain treatment that you recommend besides to medications? Absolutely. So using techniques such as distraction, it helps prior to procedure having board games lined up their favorite movies. Let's say they had a tonsil and tonsillectomy and adenoidectomy and all they can have like tmechanical soft. So having their favorite yogurt and ice cream All ready to go so that you have a plan in place for when the child comes home because depending on the kind of procedure they get they might have activity restrictions and you don't want them feeling left out. If the rest of the family has something going on and then they can't participate so bringing the family in and having it centered around activities that they can do can certainly make that recovery period a little less cumbersome How do cognitive behavior or psychological therapies help with reducing the pain? So some people think think that cognitive therapies are like alternative and absolutely not we know that pain is actually mediated by the brain as well. And so kids who particularly children who we know have anxiety or depression, you know, we want to be sure to have them what we call optimized have that anxiety and depression under control as much as possible prior to surgery because what can happen is that if those conditions are not under Some kind of control that can actually cause pain to persist and cause pain intensities to be escalated and certainly in the light of us talking about addiction. I would say that the child wouldn't become addicted but it certainly opens the door for misuse. If now instead of the child taking the pain medication for their surgical pain, they end up taking it because of emotional pain, so that's why we want to be Sure to have the right Therapies in place for the right condition. Are there any other ways to help to ease the pain besides, you know giving medication especially off the immediately after surgery you talked about having yogurt and ice cream. Is there any other behavioral therapy or anything else that you recommend? Yes, so part of what we want to look at when we employ our pain strategies is for example, if the child did have cognitive behavioral therapy or therapy prior to their procedure after their procedure employing the strategies that they learned which could look like deep breathing relaxation strategies visualization. And also we want to be sure that the parents are on board with this as well because we know that when it comes to vulnerabilities when developing post-surgical pain that is persistent parental anxiety can also play a role. So if the parents are nervous and anxious that can also color the child and the child would be nervous and anxious and it can cause their pain to persist longer than it ordinarily would so we also have to make sure that the parents are in check. Catastrophizing is as it relates to pain is when pain is being described in the worst terms possible the person starts to ruminate about pain and they just can't think of anything else besides. It's pain or when they feel helpless like my pain will never get better. You know that catastrophizing is a piece that if the person is prone to and usually you get a sense of this if the child and other aspects of Life tends to describe stuff in the worst terms ever then that's a piece that we need to address prior to surgery because that kind of way of thinking will also cause pain to persist longer than it needs to . Acute pain post-surgical pain is that once the tissue heals, we expect the pain to go away. So what we're doing right now is just supporting the body allowing the body to heal post-surgery and we're using these tools to support the child what can parents do to avoid addiction at home? If this is a child who does not have a history of substance abuse or substance misuse and they don't have that kind of exposure. substances in that way to develop a craving they're not going to be addicted but I can certainly see your point too well we don't want them to misuse so what can we do to mitigate that well one is we have to do our homework and see okay does this teenager have any risk factors so risk factors being a history of substance use and I include marijuana in that I know it's legal but Studies have came out to demonstrate that smoking marijuana or vaping can make pain difficult to treat post-surgery, other risk factors such as you know anxiety and depression this comes up again because usually misuse occurs when okay the surgical pain has healed but now the teenager is still taking those pain medications to address their emotional pain and so we want to be sure that we have the right medication the right therapy for the right condition and we don't want to miss apply Taking an opioid for emotional pain. So we have to make sure that there is a stable family structure in place so that the child's needs are met any other advice for parents whose children are undergoing surgery or about to have surgery or in the hospital had the surgery. Yes. I would say for parents make sure that you have a plan if you're feeling anxious or uncomfortable know that your child is also going to pick up on that. So do a deep dive is your anxiety or discomfort due to the fact that you really don't know what this course is going to look like or what this what's going to happen. Let us walk you through it. I think that some parents have the conception that oh, I don't want to ask questions. I don't want to look silly. I don't want to look foolish. They're going to think I'm ignorant. No, we're here to serve you. We want to be able to address all your concerns and walk you through this process. So meeting Child Life Services meeting the anesthesiologist and walking through what a plan looks like and in concert with what scripts the surgeon will write postoperatively. Also in route The Recovery Unit the nurse will walk you through what those discharge medications are and if you need additional help, there's an anesthesiologist that covers the recovery unit that can walk you through. Through what that looks like . One of the things I've learned today is that pain medications that contain opioids are okay to give postoperatively. They're not going to get addicted or be addictive. So parents shouldn't worry about that stuff. So you should always make sure that a child is free of pain because that can lead a whole host of problems down the line or I would say have tolerable pain tolerance of pain. Yes. Okay. Yes. Good. Please do not look up ways to treat post-operative pain. on the internet, often times what comes up in the Google search like the first few searches are all just the train wrecks. And I would encourage if there's questions talk to your team to provide the most targeted instruction to you. And so that's what you want. You want personalized tailored instruction. And that is what you would get from Consulting your team and not doing a Google Search and secondly, I would also like for you, please, please do not pull pain medications that you've gotten from cousin Jack's old surgery or you know, dad had a hernia repair long time ago and your child still in pain and please do not give your child your teenager medications from other people. Well, thank you very much. Thanks for coming and visiting us and educating us about chronic pain control as well as post-operative pain control. Thanks for being here. Thank you. I appreciate it.