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Prospective Cohort Study Comparing A Single Narcotic Based Post-Operative Pain Treatment Regimen To A Standing Alternating Ibuprofen And Acetaminophen Multidrug Regimen In Children Who Have Outpatient Pediatric Urologic Surgery
Daniel B. Herz, MD1, Paul A. Merguerian, MD2, Leslie T. McQuiston, MD3, Alyssa Malcolm, MS4, Lynn Brenfleck, RN5.
1Nationwide Children's Hospital, Colmbus, OH, USA, 2Seattle Children's Hospital, Seattle, WA, USA, 3Dell Children's Hospital, Austin, TX, USA, 4The Dartmouth Institute For Health Policy and Clinical Practice, Lebanon, NH, USA, 5The Children's Hospital at Dartmouth, Lebanon, NH, USA.

BACKGROUND: Children experience significant post-operative pain after pediatric urologic surgery. There is widespread variation in the management of post-operative pain with some advocating single drug regimens and others advocating for alternating or multi-drug regimens. There is also sparse objective data on how intense and how long children have pain even after the most routine of outpatient procedures. Our main goal was to compare the efficacy of a single as needed narcotic based drug regimen to a standing alternating Ibuprofen and Acetaminophen regimen with narcotic supplementation as needed in children who had routine ambulatory pediatric urologic surgery. Our secondary goal was to record the duration and intensity of post-op pain after a variety of outpatient urologic surgeries.
METHODS: Study design was a prospective cohort of consecutive ambulatory pediatric urologic surgeries. There were 2 similar cohorts. Children in cohort A were managed by alternating Ibuprofen (10 mg/kg/dose) and Acetaminophen (15 mg/kg/dose) given every 3 hours for 48-72 hours. Parents were instructed to give Acetaminophen/Hydrocodone (0.2 mL/kg/dose) instead of Acetaminophen if they deemed it necessary. Parents were instructed NOT to awaken their child for medication but to administer medication if the child awakened spontaneously. Children in cohort B were managed by the standard as needed (PRN) regimen of Acetaminophen/Hydrocodone (0.2 mL/kg/dose) every 4-6 hours. A nurse administered questionnaire was filled out by phone interview at 96 hours and 4-6 weeks after surgery. Pain scale was recorded by the Wong-Baker verbal pain scale.
RESULTS: Cohort A and B were similar in average age at surgery, type and duration of urologic surgery, complication rate, and gender distribution. There were 96 children in cohort A and 84 children in cohort B. In cohort A the average pain level in the first 96 hours was 4.9 with a median of 4.4 (range from 3-7) and average maximum pain recorded was 7.2 with a median of 5.6 (range 5-8). In cohort B the average pain in the first 96 hours was 6.1 with a median of 5.9 (range from 4-8) and average maximum pain recorded was 7.5 with a median of 6.3 (range 5-8). Cohort A had significantly lower average and median pain scores in the first 96 hours (p=0.02). Cohort A had overall shorter duration of pain with 95% of parents reporting stopping pain medication at 48 hours, while in cohort B 95% of parents stopped pain medication at 72 hours. In cohort A, 90% of parents for children less than 2 years of age reported giving no narcotic supplementation. In children 2 to 7 years of age, 61% of parents reported no narcotic supplementation. In children older than 8 years of age only 26% reported no narcotic supplementation.
CONCLUSIONS: Alternating Ibuprofen and Acetaminophen with narcotic supplementation is superior to narcotic alone in the children having a variety of routine ambulatory pediatric urologic surgery. Pain interval and average intensity was blunted in in Cohort A compared to Cohort B.


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