Management of pain is a critical aspect of postoperative care in pediatric urology. Currently, clinicians who aim to control postoperative pain in children use a combination of both opioids and anti-inflammatory drugs. Regional anesthesia with a caudal block is another effective pain management technique that is used in pediatric urology, but these blocks only last 6 to 8 hours unless an indwelling caudal catheter is used. Having an indwelling caudal catheter in place often limits patients’ mobility and requires a hospital admission after surgery.
An Evolution in Care
Continuous infusion of site-specific analgesia is a more evolved way to provide prolonged pain management. Continuous infusion has been found to result in fewer side effects and better postoperative recovery. This treatment approach has been shown to lead to earlier mobilization and earlier discharge than standard therapy.
One FDA-approved device that currently is used to provide continuous infusion of analgesia is the ON-Q® pump (I-Flow/Kimberly-Clark). The device is an elastomeric pump that delivers 0.25% bupivacaine at the incision site via a flexible silver-coated catheter. The catheter, which is tunneled subcutaneously at the completion of a patient’s surgery, is attached to the elastomeric pump, which has a flow-limiting valve. The local anesthetic is delivered at a constant flow rate (0.4mg/kg) for the entire duration of use. The pump functions automatically and doesn’t require any manipulation by patients or their families. The pump is carried in a small pouch, which allows patients to maintain mobility and be discharged home.
In a recent prospective randomized controlled trial conducted at Children’s Hospital of Orange County, my colleagues and I confirmed the efficacy of the ON-Q® pump. Our data demonstrated that the device improved postoperative pain scores, reduced narcotic usage, and shortened recovery time after major pediatric urological surgery. Patients who were randomized to receive the device had significantly lower maximal daily pain scores as assessed with the Visual Analog Scale or the Face, Legs, Activity, Cry, Consolability Scale, depending on the age of the child. The significant reduction in pain score evaluation occurred on the day of surgery and the first postoperative day. Additionally, the pump reduced the average number of narcotic doses needed after surgery starting on the day of the operation and the first day after it.
Our data support the notion that continuous infusion of site-specific analgesia is a feasible option for managing postoperative pain in pediatric urology patients. The ON-Q® pump is roughly $150 per device, but may help to reduce costs of narcotics and extended hospital stays for pain management. With continued improvement in pain control, we may achieve long-term benefits for patients, families, providers, and the healthcare system.
Readings & Resources (click to view)
Liu SS, Richman JM, Thirlby RC, et al. Efficacy of continuous wound catheters delivering local anesthetic for postoperative analgesia: a quantitative and qualitative systematic review of randomized controlled trials. J Am Coll Surg. 2006; 203:914-932.
Ganesh A, Rose JB, Wells L, et al. Continuous peripheral nerve blockade for inpatient and outpatient postoperative analgesia in children. Anesth Analg. 2007;105:1234-1242.
Tirotta CF, Munro HM, Salvaggio J, et al. Continuous incisional infusion of local anesthetic in pediatric patients following open heart surgery. Pediatric Anesthesia. 2009;19:571-577.
Nottingham J, Gregorie D, Zink J. Indications and benefits of continuous peripheral local anesthesia. J Surg Educ. 2008; 65:254-258.
Hidas G, Lee HJ, Watts B, et al: Application of continuous incisional infusion of local anesthetic after major pediatric urological surgery. J Pediatr Urol. 2013;9:927-931.
McGrath PA. Pain in the pediatric patient: practical aspects of assessment. Pediatr Ann. 1995;24:37-38,126-133.