Perioperative Pain
Overview
When a child or youth needs surgery, they will almost always be administered opioids during the surgery to manage the pain associated with their procedure. Almost 80% of these patients experience postoperative pain, with 80% of them reporting moderate to severe pain*.
*Boric et al. 2017. https://doi.org/10.1111/pan.13203
As such, children and youth may require opioids after surgery for their postoperative pain. Judicious use of opioids can help reduce discomfort, shorten time of hospitalization, lower hospital costs, and increase patient satisfaction. In contrast, inadequate postoperative pain treatment is associated with delayed wound healing and the development of chronic pain in the future. This toolkit section includes resources for safely and responsibly prescribing and administering opioids for perioperative pain in children and youth.
When opioids are prescribed and administered for postoperative pain, there are several considerations to ensure safer therapeutic use:
- Inadequate management of postoperative pain may lead to development of complications and prolonged recovery time, with increased morbidity and mortality
- Physical (e.g., ice, splinting) and psychological (e.g., music therapy, child life specialist involvement) treatments should be used for all children and youth with post-operative pain
- Non-opioid medications (e.g., ketorolac, diclofenac, other NSAIDs) should be used as first-line pharmacologic therapies
- Systemic opioid prescribing can be decreased with judicious use of regional anesthesia, for certain procedures and surgeries
- Opioid analgesia (both oral and parenteral) should be combined with non-opioid medications such as ketorolac or acetaminophen to ensure that only the lowest dose of opioids is used
- Opioid analgesia should be used for as short of a time as possible. As soon as a child’s pain is better managed, they should be transitioned to an alternative non-opioid pharmacologic treatment
- Children and their families should always be counselled about the potential side effects of opioid medications
- Potential risks for higher-risk opioid use should be assessed using a validated risk assessment tool before prescribing or administering opioid analgesia
Opioids should be prescribed and administered in a culturally safe way. Also consider risks for opioid use disorder, higher-risk opioid use, child age, and preexisting mental health diagnoses.
However, even when these risks are present, children with severe pain have the right to adequate pain management, which may include the use of opioids. Children and their families should share the decision making about whether opioid analgesia is appropriate for them with their healthcare provider.
Definition of perioperative pain:
Pain related to or that occurs around the time of a surgical procedure. Effectively managing perioperative pain is essential for optimizing pediatric surgical health outcomes and preventing the development of chronic pain after surgery.
Birnie et al. 2022. https://www.tandfonline.com/doi/full/10.1080/24740527.2022.20 38031
“Acute pain after surgery is common, ranging from moderate to severe, and often goes undertreated. This can lead to delayed recovery, longer hospital stays, and is linked to chronic post-surgical pain, a devastating and expensive public health concern. Post-surgical pain should be treated with non-opioid medications, alongside physical and psychological strategies – but when these approaches fall short in providing comfort, children should receive opioids as a critical component of pain care. Hopefully this toolkit will help in the quest to provide proper pain management for children. It doesn’t have to hurt!”
~ Dr. Fiona Campbell, Physician
Have feedback? Visit linktr.ee/youthinpain or kidsinpain.ca/youth-in-pain to learn more about this toolkit. For content suggestions please e-mail contact@kidsinpain.ca
References
Statements and Guidelines
Clinical practice guidelines for pain management after tonsillectomy: Systematic quality appraisal using the AGREE II instrument
Barrette L-X, et al. International Journal of Pediatric Otorhinolaryngology. 2022
View guideline *subscription-based access
Guidelines for Opioid Prescribing in Children and Adolescents After Surgery: An Expert Panel
Opinion Kelley-Quon LI, et al. JAMA Surgery. 2021
View guideline *subscription-based access
PROSPECT guideline for tonsillectomy: systematic review and procedurespecific postoperative pain management recommendations
Aldamluji N, et al. Anaesthesia. 2020
View guideline
Revision of expert panel’s guidelines on postoperative pain management
Aubrun F, et al. Anaesthesia Critical Care & Pain Medicine. 2019
View recommendations
Postoperative pain management in children: Guidance from the pain committee of the European Society for Paediatric Anaesthesiology (ESPA Pain Management Ladder Initiative)
Vittinghof M, et al. Pediatric Anesthesia. 2018.
View recommendations
Review Articles
Assessment and management of pain in pediatric otolaryngology
Rodriguez M. International Journal of Pediatric Otorhinolaryngology. 2016
Access article *subscription-based access
Strategies for preventing side effects of systemic opioid in postoperative pediatric patients
Jitpakdee T & Mandee S. Pediatric Anesthesia. 2014
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Opioid-sparing effects of perioperative paracetamol and nonsteroidal antiinflammatory drugs (NSAIDs) in children
Wong I, et al. Pediatric Anesthesia. 2013
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Youth and Family Resources
L’analgésie contrôlée par le patient (ACP) pour le soulagement de la douleur
CHU Sainte-Justine. 2019 Découvrez comment l’analgésie contrôlée par le patient (ACP) et l’analgésie contrôlée par le personnel infirmier (ACPI) peuvent soulager votre enfant de douleurs graves de courte durée à l’hôpital.
View PDF
Opioids for Pain after Surgery
Institute For Safe Medication Practices. 2018 Answers to common questions about opioids for pain after surgery.
View PDF
Les opioïdes pour la douleur après la chirurgie : réponses à vos questions
L’Institut pour la sécurité des medicaments. 2018 Answers to common questions about opioids for pain after surgery.
View PDF
Additional Resources
Prescription Patterns, Associated Factors, and Outcomes of Opioids for Operative Foot and Ankle Fractures: A Systematic Review
Badin D, et al. Clinical Orthopaedics and Related Research. 2022
Access article *subscription-based access
Opioid Prescription and Usage in Adolescents Undergoing Orthopaedic Surgery in the United States: A Systematic Review
Dautremont E, et al. JB&JS Reviews. 2017
Access article *subscription-based access
How to replace codeine after tonsillectomy in children under 12 years of age? Guidelines of the French Oto-Rhino-Laryngology – Head and Neck Surgery Society (SFORL)
Constant I, et al. European Annals of Otorhinolaryngology, Head and Neck Diseases. 2014
Access article
A Meta-Analysis of the Use of Nonsteroidal Antiinflammatory Drugs for Pediatric Postoperative Pain
Michelet D, et al. Anesthesia & Analgesia. 2012
Access article
Production of this document has been made possible through a financial contribution from Health Canada. The views expressed herein do not necessarily represent the views of Health Canada.