Pain Management
Perioperative Pain Management

What is Perioperative Pain Management?

A multi-professional group including physicians, nurse practitioners, and registered nurses, will help manage pain after some surgical procedures. While the anesthesia and the surgical teams manage pain for procedures that are less painful, some surgeries that are more painful need the expertise of the perioperative pain management team.

We consult children before undergoing surgery, formulate pain management plans, and help manage their pain in the postoperative period. We work closely with integrative care, surgical services, nursing and occupational/physical therapy to aid in comprehensive postoperative recovery.

It is important to remember that pain coping starts way before surgery. Good sleep habits, healthy nutrition, physical fitness and anxiety reducing strategies like deep breathing exercises help prepare for pain coping and quicker return to normal activity after surgery.

A Culture of Managed Pain

Pain is unpleasant. But worse, it can interfere with recovery from surgery or illness, prevent normal activity and affect a child’s quality of life. One of the hardest things about pain is that even the best treatments do not guarantee that pain will be eliminated.

Patients and medical personnel may want there to be no pain after surgery, but trying to get rid of all pain can cause complications. Over-treating pain can be as bad as under-treating it. We strive to manage pain, keeping it at the lowest level that is safely possible, even if that means there is still a little pain left over.

We treat each patient’s pain according to her unique situation. The condition, patient’s quality of life and physicians’ plans all factor into our pain management plan. We work with physicians, your child and your family to ensure that we plan the most appropriate pain management strategy.

Perioperative Pain Management FAQ's

Depending on the surgery, the child's condition and medical illness, and surgeon requests, we will usually see you before surgery to formulate our plan and discuss the risks/benefits of medications/procedures we can offer to help with your child's pain.

Intravenous "I.V.": Pain-relieving medications that are injected into a vein which help decrease pain, for example, IV opioids – these medicines help with pain, but may have other side effects like nausea, itching, drowsiness and can affect breathing.

Oral Medications: Pain-relieving medications taken by mouth help to decrease pain. They are usually taken every 4-6 hours. The pain relief usually lasts longer than with IV medications. These medications are prescribed once one can tolerate eating and drinking regularly.

Local Anesthesia: Other pain-relieving medications may be injected into the surgical incision by their surgeon. These medications are local anesthetics. They provide numbness or loss of sensation in a small area.

Regional Blocks: Regional blocks can reduce the pain after surgery and can provide either analgesia or anesthesia. Local anesthetics and other drugs are used for these procedures to reduce or "block" pain and other sensation over a wider region of the body.

This means using different medications which tackle pain in different ways. This is because pain after surgery can have different reasons. It is believed that pain has not only a sensation component, but also a “worry” component. In general, stress and pain coping may be different depending on whether the child is a “worrier” or anxious. Another aim of our pain management is to minimize need for opioids without compromising pain control. The different kinds of medications and approaches we use for helping with pain after surgery are summarized below:

  1. muscle relaxants to help with muscle cramps
  2. medications that help with inflammation and reduce the need for stronger medicines like narcotics
  3. opioids to treat severe pain
  4. nerve-soothing agents
  5. medications for anxiety
  6. For some procedures, we offer nerve blocks and epidurals, which helps reduce pain by numbing the nerves that supply the painful area, and thus help recovery and decrease the need for sedating medications.
  7. Integrative care and holistic health are our partners in helping with pain coping. They provide relaxation techniques which help your child cope with pain. The surgical/pain team will consult them if they think their services will help your child. Please ask your providers about this if you want to have them involved.
  8. Physical therapy and occupational therapy also play an important role after some surgeries to help your child regain their function after surgery
  9. We sometimes also ask for behavioral medicine to help assess and manage anxiety symptoms as they play an important role in worsening pain.

A PCA is a computerized pump that can be set to deliver a specific amount of medication when your child pushes a button. Children as young as 7 years old can use PCAs effectively. For younger children, parents or nurses can help push the button to relieve pain.

Safety settings limit how often the pump will deliver the medication, how much is given at a time, and how much can be given over a four-hour period. Several medications can be used this way. Only the patient is allowed to press the button; pressing the button while a patient is asleep is dangerous (no matter how old the patient is) and we prohibit it in a policy we strictly enforce.

In specific cases, we may allow a parent or nurse to use the button on behalf of the child. Because this carries extra risk, we reserve the right to limit who receives this treatment. We will discuss the options with you, and decide if your child is a candidate for this treatment. Our primary focus is safety, and all decisions are based on what is the safest way to care for your child. We will provide educational sheet about safe PCA practices.

Epidural and caudal blocks are used to help with pain after some procedures. They may be placed either awake/sedated in older children or asleep in younger children who cannot cooperate. Pain / anesthesia team will discuss the risks and benefits of epidural/caudal blocks and get consent from you/your child after answering all your questions.

Nerve blocks are sometimes used as a part of a pain treatment plan and are a way to help reduce pain and discomfort after surgery. Nerve blocks are performed by injecting numbing medication around the nerves that carry painful sensation from an arm or leg. The exact place where numbing medication is injected depends on where the surgical procedure is performed.  An ultrasound camera is often used to visualize the nerves underneath the skin.

Nerve blocks often substantially reduce the need for pain medications as well as pain medication-related adverse effects, such as vomiting, drowsiness and slow breathing. A nerve block may help your child to get up in a chair or walk around after surgery without being very uncomfortable. One time injection (single shot) nerve blocks typically provide pain relief for eight to 24 hours.

In general, complications are extremely rare with the sort of nerve blocks used at Cincinnati Children's. However, possible complications include:

  • Less than perfect pain relief
  • Bruises
  • Discomfort where the needle was inserted
  • Prolonged "pins-and-needles" sensation after the block wears off

Any type of long-lasting or permanent damage to nerves is extremely rare. Your anesthesiologist will discuss any potential problems and risks with you in detail.

For major and painful surgeries such as knee reconstruction or shoulder surgeries, a continuous nerve catheter (thin plastic tube) is often needed to provide extended pain relief. Sometimes, children are discharged home with a nerve catheter and a numbing medication infusion pump to provide pain control at home for two to three days. Removal of the nerve catheter is easy and can be done at home by the child’s parents.

The Acute Pain Service will actively manage children with nerve catheters. There is a member of the Acute Pain Service available 24 hours a day in case there are questions or concerns about the nerve catheter or about pain management.

Pain is not just physical. It causes stress and suffering, and depression and anxiety can result from pain or make it worse.

The entire family is affected by this stress, and addressing this issue is important to your child’s recovery.

In addition, there are pathways in the brain and spinal cord whose job it is to suppress pain.

Sometimes, we or the surgical service places referrals to integrative care and/or behavioral medicine (pain psychology) to help with coping skills for the entire family to improve pain management. Integrative care group consists of a team of healthcare professionals, including child life specialists and assistants, creative arts therapies (art and music therapy), holistic health specialists, media specialists, and recreation therapists, who provide outstanding patient and family-centered holistic care to optimize healing and wellness for patients and families. The techniques they use include massage, breathing techniques, etc. In addition, our psychologists can help your child harness these neurologic defenses to reduce and manage his pain.

We use opioid (narcotic) pain medicines for certain pain conditions after surgery. The number of children who become addicted to these medications is extraordinarily small.

People of any age can become tolerant to opioid medications. They may need more and more to get the same effect, and may have withdrawal if they stop the medicine suddenly (withdrawal can be avoided by following a medication schedule provided by the pain service). This is a physical phenomenon that happens to almost everyone,and is different from addiction. However, by rule, we always use non-opioid adjunct medications to minimize opioids and their side effects.

Cincinnati Children’s is a leader in pediatric pain research. We work with other leading institutions to develop clinical trials that advance the understanding of pain and pain management therapies.

Current research initiatives include:

  1. Evaluation of psychosocial, genetic and epigenetic factors influencing acute post-surgical pain and chronic postsurgical pain after surgery
  2. Pharmacogenomics of opioids – optimizing the dosing of opioids.
  3. Evaluation of preoperative mindfulness interventions for pain coping and anxiety in children undergoing major surgery

In addition, the Pain Management Center is one of only two ACGME-accredited pediatric pain fellowship programs in the country and is a major training site for pediatric pain psychologists. Lectures for pediatric residents, observerships for practicing physicians, and multidisciplinary pain seminars are also conducted routinely.