Why Do I Still Hurt? A Primer on Chronic Post-Surgical Pain
Rita Agarwal MD, FAAP, FASA
Today’s PAAD by Rita Agarwal reviews several original pain articles by Dr. Jennifer Rabbitts of the Seattle Children’s Hospital. As promised, we’ve expanded our reviewers and executive council for the PAAD and Rita is one of our primary pain article reviewers. So, you’ll be hearing from her regularly in the months to come. For those of you who were registered and attended the recent Society for Pediatric Anesthesia’s annual meeting in San Diego, Jennifer Rabbitts should be familiar to you. Jennifer’s lecture, entitled “Impact of sleep on adolescents’ pain and recovery after surgery” was one of the highlights of the meeting. This has been a long term interest of mine and I was rivetted to my seat. I would urge anyone who was registered for the meeting to go to the meeting mobile guide at SPA’s website and (re)listen to her fantastic lecture. For those of you weren’t registered, you may not be out of luck. I believe that these lectures will become available to all SPA members sometime in the next year. Myron Yaster MD
Original articles
Rabitts JA, Palermo TM, Zhou C, Mangione-Smith R: Pain and Health-Related Quality of Life After Pediatric Inpatient Surgery. Pain. 2015 Dec;16(12):1334-1341. PMID: 26416163
Rabbitts JA, Aaron RV, Fisher E, Lang EA, Bridgwater C, Tai GG, Palermo TM. Long-Term Pain and Recovery After Major Pediatric Surgery: A Qualitative Study With Teens, Parents, and Perioperative Care Providers. J Pain. 2017 Jul;18(7):778-786. PMID: 28232147
Rabbitts JA, Fisher E, Rosenbloom BN, Palermo TM. Prevalence and Predictors of Chronic Postsurgical Pain in Children: A Systematic Review and Meta-Analysis. J Pain. 2017 Jun;18(6):605-614. PMID: 28363861
At a Society for Pediatric Anesthesia meeting awhile back, Myron Yaster asked the audience the following questions:
“How many of you did an anesthetic in the last week?”
Most hands go up
“How many of you know how the patient did after the anesthetic?”
Hands mostly stay up
“How many of you know if that patient is still alive?”
Nervous laughter follows this question. While again most hands stay up, many start to drop and people look around at each other with questioning looks.
“Really? How? How do you know?”
I have never forgotten the questions and the sudden realization that I, like I’m sure many of you, didn’t know whether or not my patients were actually still alive, particularly if they had gone home. We assumed that at least all the healthy children were alive, particularly if they had had an uncomplicated recovery, but the truth is unless we are calling these patients days after a surgery, we have no idea what has happened to them. The same is true about pain. We all assume that children will NOT have persistent or new pain after surgery, but the truth is we do not actually know.
In the first of several ground-breaking studies, Jennifer Rabbitts MBChB and her Seattle Children’s Hospital team looked at Health Related Quality of Life Outcomes (HRQoL) and pain, starting pre-operatively and for the first month after surgery. They chose to study children aged 2-18, undergoing a variety of surgical procedures, who were admitted post-operatively to a surgical service, and were fluent in English or Spanish. Children were categorized into 3 levels of medical complexity based on the Pediatric Medical Complexity Algorithm (PMCA). Questionnaires, available in both English and Spanish and were administered prior to the start of surgery and one month later to the parents of the children. Surgical procedures included general surgery (37%) orthopedics (21%), otolaryngology (16%) neurosurgery (10%), and others. The average length of stay was 2.7 days, and the incidence of unplanned readmission was 9%. In this study they found that at one month 8% of children were still suffering from moderate to severe pain, and 13% had pain that occurred for 4 or more days. Twelve percent had worsened pain compared to their baseline, and 22% reported having more frequent pain than at baseline. A multivariate analysis of factors associated with a deterioration in HRQOL was significant for age (older children had a greater chance of worsening HRQOL) and not surprisingly for the presence of pain.
A follow-up study of 15 teenagers, their parents and members of the perioperative teen looked more deeply at qualitative factors. Several themes emerged from these semi-structured interviews. Most families and patients described significant anxiety, fear, emotional challenges and the belief that they lacked the psychosocial coping strategies related to the surgery and its outcomes. Families felt unprepared for the surgery and the degree of post-operative pain. They specifically desired more information about pain medications, side effects, weaning and addiction risk. They also stated that no amount of information could have adequately prepared them for the challenge of surgery. Recovery and function at home were frustrating and challenging. Patients and their parents did not expect the significant limitations to their activities of daily living, ability to return to school and increased reliance on family members. They did think that discussion with people who had previously experienced these surgeries would have been the most helpful. Medical Professionals for the most part felt that families would have benefited from more detailed preparatory information, enhanced and flexible exposure to coping skills and psychosocial interventions.
The last article is a systematic review of the prevalence and predictors of chronic postsurgical pain in children by the team from Seattle Children’s Hospital. Most of these studies either looked at or commented on the incidence of chronic post-surgical pain (CSPS) 3, 6 or 12 months after the original operation. The median prevalence of CSPS was 20% with a range from 11-54%. In this systematic review which was admittedly of low quality, presurgical pain intensity, child anxiety, child pain coping efficacy, and parent al pain catastrophizing were associated with chronic post-surgical pain.
This series of studies, among others both by Dr Rabbits and her team at Seattle Children’s Hospital and other authors recognize the significant role of chronic post-surgical pain in recovery and health related quality of life. And yet until recently, despite a relatively high incidence, little research has been dedicated to recognizing, preventing, and treating this challenging and distressing problem.
Rita Agarwal MD, FAAP, FASA