Strategies in Trauma and Limb Reconstruction

Register      Login

VOLUME 18 , ISSUE 3 ( September-December, 2023 ) > List of Articles


Multimodal Analgesia for Paediatric Patients Undergoing Lower Limb Reconstruction with External Fixators: A Prospective Case Series of Post-operative Pain and Functional Goals

Alice Wei Ting Wang, Harpreet Chhina, Anthony Cooper

Keywords : Analgesia, External fixation, Lower limb, Pain, Paediatric, Post-operative

Citation Information : Wang AW, Chhina H, Cooper A. Multimodal Analgesia for Paediatric Patients Undergoing Lower Limb Reconstruction with External Fixators: A Prospective Case Series of Post-operative Pain and Functional Goals. 2023; 18 (3):140-147.

DOI: 10.5005/jp-journals-10080-1601

License: CC BY-NC-SA 4.0

Published Online: 18-01-2024

Copyright Statement:  Copyright © 2023; The Author(s).


Aim: Limb reconstruction with external fixators requires appropriate pain management to promote effective analgesia and healing while minimising adverse events of the analgesic technique used. The objective of this prospective case series was to evaluate a multimodal analgesia regimen designed to reduce opioid requirements and hence reduce the opioid-related side effect profile. Materials and methods: A prospective cohort of patients undergoing lower limb reconstruction surgery (LRS) were managed through an evidence-informed multimodal analgesia guideline (MMAG), including acetaminophen, pregabalin, dexmedetomidine, IV lidocaine, and opioids. Outcome measures included intraoperative and post-operative opioid administration, post-operative pain scores, time to achieve mobilisation milestones, and post-operative complications. Surveys were conducted to obtain patient reported experiences. Results: 26 patients were included in this prospective case series. 110.59 (84.29, 162.13) (median, interquartile range) µg/kg/hr intraoperative IV morphine equivalent opioids were administered. In the first 48 hours post-operatively, patients received 11.49 (6.41, 19.35) µg/kg/hr of IV morphine equivalent dose. Median level of pain (0–10) in the first 48 post-operative hours was 2 (1, 2). Patients achieved mobilisation. And 19/20 patients surveyed reported ‘yes’ to having effective pain management; 17/20 patients had no unwanted side effects associated with analgesia medications. There were no cases of compartment syndrome. Conclusion: This multimodal analgesia regime applied to patients undergoing lower LRS with external fixators demonstrates the feasibility of this analgesic regimen which revealed effective pain control, early mobilisation, with minimal side effects, but warrants further study. Clinical significance: This study provides valuable evidence that this standardised multimodal anaesthesia and analgesia regimen is feasible, offers adequate post-operative comfort and encourages early mobilization while minimising opioid use and adverse events in a paediatric LRS population at our institution.

  1. Young N, Bell D, Anthony A, et al. Pediatric pain patterns during Ilizarov treatment of limb length discrepancy and angular deformity. J Pediatr Orthop 1994;14(3):352–357. DOI: 10.1097/01241398-199405000-00015.
  2. Savedra MC, Holzemer WL, Tesler MD, et al. Assessment of postoperation pain in children and adolescents using the adolescent pediatric pain tool. Nurs Res 1993;42(1):5–9. PMID: 8424069.
  3. Hamdy RC, Montpetit K, Raney EM, et al. Botulinum toxin type A injection in alleviating postoperative pain and improving quality of life in lower extremity limb lengthening and deformity correction: A pilot study. J Pediatr Orthop 2009;29(5):427–434. DOI: 10.1097/BPO.0b013e3181aad628.
  4. Wells N, Pasero C, McCaffery M. Improving the quality of care through pain assessment and management. In: Hughes RG (Ed), Patient Safety and Quality: An Evidence-Based Handbook for Nurses. Rockville (MD): Agency for Healthcare Research and Quality (US); 2008 Apr. Chapter 17.
  5. Frink, M, Hildebrand F, Krettek C, et al. Compartment syndrome of the lower leg and foot. Clin Orthop Relat Res 2010;468(4):940–950. DOI: 10.1007/s11999-009-0891-x.
  6. Azam MQ, Ali MS, Al Ruwaili M, et al. Compartment syndrome obscured by post-operative epidural analgesia. Clin Pract 2012;2(1):e19.
  7. Khademi H, Kamangar F, Brennan P, et al. Opioid Therapy and its Side Effects: A Review. Arch Iran Med 2016;19(12):870–876. PMID: 27998163.
  8. Neuman MD, Bateman BT, Wunsch H. Inappropriate opioid prescription after surgery. Lancet 2019;393(10180):1547–1557. DOI: 10.1016/S0140-6736(19)30428-3.
  9. Clarke H, Soneji N, Ko DT, et al. Rates and risk factors for prolonged opioid use after major surgery: Population based cohort study. BMJ 2014;348:g1251.
  10. Brummett CM, Waljee JF, Goesling J, et al. New persistent opioid use after minor and major surgical procedures in US adults. JAMA Surg 2017;152(6):e170504. DOI: 10.1001/jamasurg.2017.0504.
  11. Kain ZN, Mayes LC, Caldwell-Andrews AA, et al. Preoperative anxiety, postoperative pain, and behavioral recovery in young children undergoing surgery. Pediatrics 2006;118(2):651–658. DOI: 10.1542/peds.2005-2920.
  12. Birnie K, Hundert A, Lalloo C, et al. Recommendations for selection of self-report pain intensity measures in children and adolescents: A systematic review and quality assessment of measurement properties. Pain 2019;160(1):5–18. DOI: 10.1097/j.pain.0000000000001377.
  13. Zhang J, Ho KY, Wang Y. Efficacy of pregabalin in acute postoperative pain: A meta-analysis. Br J Anaesth 2011;106(4):454–462. DOI: 10.1093/bja/aer027.
  14. Schnabel A, Meyer-Friebem CH, Reichl SU, et al. Is intraoperative dexmedetomidine a new option for postoperative pain treatment? A meta-analysis of randomized controlled trials. Pain 2013;154(7): 1140–1149. DOI: 10.1016/j.pain.2013.03.029.
  15. Sun Y, Li T, Wang N, et al. Perioperative systemic lidocaine for postoperative analgesia and recovery after abdominal surgery: A meta-analysis of randomized controlled trials. Dis Colon Rectum 2012;55(11):1183–1194. DOI: 10.1097/DCR.0b013e318259bcd8.
  16. Zengin SU, Saracoglu A, Eti Z, et al. The effects of preoperative pregabalin and perioperative intravenous lidocaine infusion on postoperative morphine requirement in patients undergoing laparatomy. Pain Res Manag 2015;20(4):179–182. DOI: 10.1155/2015/509474.
  17. Kang JG, Kim MH, Kim EH, et al. Intraoperative intravenous lidocaine reduces hospital length of stay following open gastrectomy for stomach cancer in men. J Clin Anesth 2012;24(6):465–470. DOI: 10.1016/j.jclinane.2012.02.006.
  18. Farag E, Ghobrial M, Sessler DI, et al. Effect of perioperative intravenous lidocaine administration on pain, opioid consumption, and quality of life after complex spine surgery. Anesthesiology 2013;119(4):932–940. DOI: 10.1097/ALN.0b013e318297d4a5.
  19. Kim KT, Cho DC, Sung JK, et al. Intraoperative systemic infusion of lidocaine reduces postoperative pain after lumbar surgery: A double-blinded, randomized, placebo-controlled clinical trial. Spine J 2014;14(8):1559–1566. DOI: 10.1016/j.spinee.2013. 09.031.
  20. Peng Y, Zhang W, Kass IS, et al. Lidocaine reduces acute postoperative pain after supratentorial tumor surgery in the PACU: A secondary finding from a randomized, controlled trial. J Neurosurg Anesthesiol 2016;28(4):309–315. DOI: 10.1097/ANA.0000000000000230.
  21. Batko I, Kościelniak-Merak B, Tomasik PJ, et al. Lidocaine as an element of multimodal analgesic therapy in major spine surgical procedures in children: A prospective, randomized, double-blind study. Pharmacol Rep 2020;72(3):744–755. DOI: 10.1007/s43440-020-00100-7.
  22. Frattarelli DA, Galinkin JL, Green TP, et al. American Academy of Pediatrics Committee on Drugs. Off-label use of drugs in children. Pediatrics 2014;133(3):563–567. DOI: 10.1542/peds.2013-4060.
  23. Kranke P, Jokinen J, Pace NL, et al. Continuous intravenous perioperative lidocaine infusion for postoperative pain and recovery. Cochrane Database Syst Rev 2015;(7):CD009642. DOI: 10.1002/14651858.CD009642.pub2.
  24. Nuelle JAV, Coe KM, Oliver HA, et al. Effect of NSAID use on bone healing in pediatric fractures: A preliminary, prospective, randomized, blinded study. J Pediatr Orthop 2020;40(8):e683–e689. DOI: 10.1097/BPO.0000000000001603.
  25. Rudd RA, Aleshire N, Zibbell JE, et al. Increases in drug and opioid overdose deaths–United States, 2000–2014. Morb Mortal Wkly Rep 2016;64(50–51):1378–1382. DOI: 10.15585/mmwr.mm6450a3.
  26. Elzey MJ, Barden SM, Edwards ES. Patient characteristics and outcomes in unintentional, non-fatal prescription opioid overdoses: A systematic review. Pain Physician 2016;19(4):215–228. PMID: 27228510.
  27. Brat GA, Agniel D, Beam A, et al. Postsurgical prescriptions for opioid naive patients and association with overdose and misuse: Retrospective cohort study. BMJ 2018;360:j5790. DOI: 10.1136/bmj.j5790.
  28. Volkow ND, McLellan TA, Cotto JH, et al. Characteristics of opioid prescriptions in 2009. JAMA 2011;305(13):1299–1301. DOI: 10.1001/jama.2011.401.
  29. El-Deeb A, El-Morsy GZ, Ghanem AAA, et al. The effects of intravenous lidocaine infusion on hospital stay after major abdominal pediatric surgery. A randomized double-blinded study. Egypt J Anaesth 2013;29(3):225–230. DOI: 10.1016/j.egja.2013.02.005.
PDF Share
PDF Share

© Jaypee Brothers Medical Publishers (P) LTD.