Background & Aims

Background: Perioperative pain management following complex surgeries is a vital component in preventing chronic post surgical pain. We designed a Qualitive improvement (QI) project to address the gap in pediatric Perioperative pain management using the Adolescent Idiopathic Scoliosis (AIS) population as a study group. Corrective surgery for AIS presents numerous perioperative challenges such as patient and caregiver counselling, preoperative optimization of the patient, adequate analgesia with effective management of their side-effects and early mobilization1. Failure to address these effectively may lead to delayed functional recovery, extended hospitalization, increased costs, and increased risk of development of chronic post-surgical pain.
Aim: The aim of this QI initiative was to a) Create, implement, and assess an innovative Integrated Pediatric Perioperative Pain Pathway, with the goal of enhancing perioperative pain management for children undergoing major orthopedic surgery.

Methods

An interdisciplinary team was formed with the aim of creating a perioperative pain pathway, utilizing the 3P’s approach to pain management. This pathway integrated innovative components like preoperative psychological interventions, education for patients and caregivers, standardized medication order sets, and early detection of increased pain levels. To assess its effectiveness, significant metrics such as duration of hospital stay, opioid usage, and achievement of physiotherapy objectives were evaluated before and after the pathway’s introduction. Although the study encompassed children undergoing various major orthopedic procedures, particular emphasis was placed on those undergoing posterior spinal instrumentation and fusion (PSIF) for adolescent idiopathic scoliosis (AIS). Input from hospital management and other funding sources was obtained in regard to cost and benefits of the pathway. Various education programs were conducted for knowledge translation.

Results

In the first two years following pathway implementation, 35 children undergoing PSIF for AIS were enrolled. Comparison of metrics were made following chart review of 34 children similarly undergoing PSIF for AIS in the two years before pathway rollout. The two groups were well matched for age (pre 14.1 years & post 14.7 years, p=0.10) and weight (pre 55.0 kg & post 57.0 kg, p=0.28). Length of stay in the Intensive Care Unit (pre 1.06 days & post 0.73 days, p < 0.01) and length of hospital stay (pre 6.23 days & post 5.01 days, p < 0.01) significantly decreased.

The pathway was initially funded by grants received by local academic and hospital foundations. The numbers from the study were shared with the Ministry funding source to receive permanent funding for the personnel to successfully deliver the service. Educational activities included grand rounds, conference workshops and peer to peer teaching.

Conclusions

A novel Integrated Pediatric Perioperative Pain Pathway, rooted in the 3P’s methodology for pain management and placing a strong emphasis on perioperative pain education, holds the promise of significantly improving pain management for children undergoing major surgery. It also demonstrated the feasibility of a pathway for the hospital funding and practice of healthcare providers.

References

1. Blanco, J. S., Perlman, S. L., Cha, H. S., & Delpizzo, K. (2013). Multimodal pain management after spinal surgery for adolescent idiopathic scoliosis. Orthopedics, 36(2 Suppl), 33–35. https://doi.org/10.3928/01477447-20130122-55.
2. Gadiya, A. D., Koch, J. E. J., Patel, M. S., Shafafy, M., Grevitt, M. P., & Quraishi, N. A. (2021). Enhanced recovery after surgery (ERAS) in adolescent idiopathic scoliosis (AIS): a meta-analysis and systematic review. Spine deformity, 9(4), 893–904. https://doi.org/10.1007/s43390-021-00310-w.
3. Shah SA, Guidry R, Kumar A, White T, King A, Heffernan MJ. Current Trends in Pediatric Spine Deformity Surgery: Multimodal Pain Management and Rapid Recovery. Global Spine Journal. 2020;10(3):346-352. doi:10.1177/2192568219858308.

Presenting Author

Vivek Patil

Poster Authors

Dr. N Karuppiah

Lead Author

Vivek Patil

Lead Author

Dr. Abi Kandasamy

Lead Author

Ms. Susan Cater

Lead Author

Raju Poolacherla

MD FRCA

Childrens Hospital LHSC, Western University

Lead Author

E-mail

Topics

  • Access to Care