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Post-operative pain and analgesia requirements in children undergoing urological outpatient procedures
Annette Schröder, MD, PhD, Fiona Campbell, MD, Eli Bator, BScN, Rodney AuYeoung, BS, Daniel Stocki, MD, Walid A. Farhat, MD, Armando J. Lorenzo, MD, Darius J. Bägli, MD, Martin A. Koyle, MD.
Hospital for Sick Children, Toronto, ON, Canada.

Background: The majority of minor urological operations are nowadays performed as an outpatient procedure. As a consequence, the responsibility for assessment of post-operative pain and the administration of pain medication lies with the parents. It now widely recognized that “around-the-clock” (ATC) administration of pain medication is superior to “as needed” (PRN). However, as a consequence of the known difficulty that parents experience with the administration of pain medication, the recommendations are frequently not followed.
There is a also paucity of information about pain patterns, analgesic requirements and predictors of requiring opioid medications, in particular in the field of pediatric urology. This prospective study aims to assess recovery profiles and pain medication requirements of children undergoing outpatient urologic surgery.
Methods: Patients between 6 months and 12 years of age undergoing urological outpatient procedures were recruited for a prospective study. Demographic and operative characteristics were collected. Following discharge home, the parents were asked to administer both acetaminophen and ibuprofen Q6H at a weight-adjusted dose, following a provided schedule, until the end of POD#2, and to administer the medication PRN on POD#3. They were asked to record their child’s pain, using age appropriate, validated pain scores (FLACC and PPPM). For break-through pain a prescription for morphine PO was provided. A Likert-scale was used to assess parent’s satisfaction with the pain management. Significant pain was defined as PPPM score ≥ 6 or FLACC score ≥ 4.
Results: A total of 249 patients were recruited into the study. Of those, 111 patients returned correctly completed surveys and were included in the final analysis (response rate 44.6%). Mean age was 44.1 months (SD = 37.3) and 26 patients (23.4%) were under 1 year of age.
The performed procedure were orchidopexy (18 scrotally, 13 inguinally), hypospadias repair (TIP procedure (20 distal, 2 mid-shaft) and 4 others), inguinal hernia or hydrocele repair (15), Fowler-Stephens procedure (13, 7 first stage, 6 second stage), meatoplasty (7), phalloplasty (4), scrotoplasty (1), circumcision (7), and diagnostic laparoscopy (5). Twentyeight (25.2%) patients had secondary procedures performed at the same time.
Adjuvant analgesia was given in the form of regional blocks in 60 patients and skin infiltration of local anaesthetic in 41 patients.
At home, 16 patients (14.4%) required morphine. The median dose required was 1 dose (range 1-30). Mean utilization of non-opioid analgesia was 79% on post-operative day 1, 67% on day 2, 36% on day 3 and 2% on day 4. Seventy-nine percent of patients had no significant pain (using evening age-appropriate pain score) at day 1, 91.0% on day 2 and 96.4% on day 3. Parental satisfaction with post-operative analgesia was high (92.0% either satisfied or very satisfied). No pre-operative, anaesthetic or operative factors were associated with opioid use or prolonged need for analgesia post-operatively.
Conclusion: Combination of non-opioid medications for maintenance and opioids for break-through pain is adequate to achieve appropriate pain control after outpatient urologic surgery in children. No patient or operative factors were identified as predictors of requiring opioid analgesia post-operatively.


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