Pre-Emptive Opioid-Sparing Medication Protocol Decreases Pain and Length of Hospital Stay in Children Undergoing Posterior Spinal Instrumented Fusion for Scoliosis.

Background: Poorly controlled post-operative pain following Posterior Spinal Instrumented Fusion (PSIF) for scoliosis may be associated with delayed ambulation and longer hospital stays. Multimodal analgesia use has been shown to provide superior analgesia with improved recovery and reduction of post-operative morbidity in other orthopedic subspecialties, but has not been described with pediatric patients undergoing spinal surgery. Objective: We describe a novel, pre-emptive, opioid-sparing pediatric pain medication protocol that is started two days prior to surgery, in accordance with first-order pharmacokinetics, and continued post-operatively until discharge with the goal of decreasing post-operative pain, improving early mobilization, and ultimately decreasing the patient's length of hospital stay. Methods: We retrospectively reviewed 116 PSIF cases from March 2014 to November 2017. Fifty-two patients received standard analgesia before August 2016, and 64 patients after August 2016 received the pre-emptive protocol consisting of a standardized combination of acetaminophen, celecoxib, and gabapentin two days prior to surgery and continued during their inpatient stay. Scheduled oxycodone and intravenous hydromorphone via patient controlled analgesia (PCA) were given to both groups equally during the post-operative hospital stay. We analyzed length of stay, total opioid consumption, and maximum pain scores per day from surgical to discharge date. Results: 116 patients were included: 64 patients in the pre-emptive group and 52 patients in the standard group. Length of hospital stay significantly differed, with means of 3.9 days in the pre-emptive group and 4.5 days in the standard analgesia group (p<0.05). Patients in the pre-emptive group recorded significantly lower maximal pain levels than those in the standard analgesia group on post-operative days #1 (4.9 vs. 5.8, p=0.0196), #3 (4.4 vs. 6.1, p=0.0006), and #4 (4.2 vs. 5.4, p=0.0393). Total post-operative morphine equivalents taken did not significantly differ between the two groups. Conclusion: This is a preliminary report demonstrating a significant decrease in maximal pain score and length of stay following PSIF on a cohort of patients receiving a novel pre-emptive opioid-sparing pain medication protocol based on first order pharmacokinetics. Future studies should investigate degree of mobilization and opioid consumption and maximal pain level after discharge from the hospital. Level of Evidence: III.

Continuous Epidural Analgesia (CEA) via Single Catheter Providing Profound Analgesia for Pediatric Patients Following Posterior Spinal Fusion (PSF) in Adolescent Idiopathic Scoliosis (AIS).

INTRODUCTION: Posterior spinal fusion (PSF) is a commonly performed orthopedic procedure to correct scoliosis in children. Continuous epidural analgesia (CEA) is a proposed means of providing analgesia following PSF. Whether a single epidural catheter with the tip in the upper thorax can provide adequate analgesia for PSF, which often spans the upper thoracic to lower lumbar regions, is unresolved in the literature. METHOD: In this single-center, retrospective study, we reviewed 69 consecutive patients undergoing PSF for adolescent idiopathic scoliosis (AIS) with CEA at our institution from October 1, 2020 to May 26, 2022. Data for the entire cohort was divided into two time intervals before and after epidural removal, group epidural (Epi) and group no epidural (No Epi). Daily intravenous and oral opioid morphine equivalents per kilogram (OME/kg) plus mean and maximal visual analogue pain scores (VAS 0-10) were recorded from post-anesthesia care unit (PACU) discharge to the end of postoperative day (POD) three.  Results: 57 patients were included in the study. Opioid usage was 4.5 times greater in the 19 hours following removal of the epidural catheter when compared to the entire period (mean 65 hours) the epidural was in place (Group Epi 0.154 OME/kg vs Group No Epi 0.690 OME/kg, p<0.001). 51% (29/57) of patients did not require opioids (intravenous or oral) while the epidural was in place, all patients required opioids after epidural removal. Mean opioid usage while the epidural was in place was 9.3 OME, equivalent to approximately 6 mg of oxycodone. Mean and maximum pain scores increased significantly after removal of the epidural on POD 3 (mean pain score: Epi 3.4 (1.8) vs No Epi 4.1 (1.7); p<0.001) (max pain score: Epi 4.9 (2.5) vs No Epi 6.3 (2.1); p<0.001).  Conclusions: This is the first study we are aware of to report pain scores and cumulative opioid requirements for PSF patients receiving CEA with a single epidural catheter before and after epidural removal. Opioid usage increased over four times in the 19 hours after epidural removal compared to the total opioid requirements while the epidural was infusing. Mean and maximum pain scores increased significantly after removal of the epidural on POD 3. This study firmly establishes that CEA with a single epidural catheter can provide profound analgesia for patients having PSF for AIS.

Effect of gabapentin on length of stay, opioid use, and pain scores in posterior spinal fusion for adolescent idiopathic scoliosis: a retrospective review across a multi-hospital system.

BACKGROUND: Gabapentin has been adopted in Enhanced Recovery After Surgery protocols as a means to reduce opioid consumption while maintaining adequate post-operative analgesia. The purpose of our study was to review and compare changes in length of stay, opioid use, and patient reported pain scores after the addition of gabapentin into five, distinct pain protocols for posterior spinal fusion in adolescent idiopathic scoliosis. METHODS: A retrospective review was completed using a database of electronic medical data from a single pediatric orthopedic healthcare system that was queried for patients with adolescent idiopathic scoliosis who underwent first-time posterior spinal fusion. Perioperative data including demographics, hospital length of stay, surgical details, opioid use, patient reported pain scores, and non-opioid analgesic use were collected. RESULTS: From December 2012 to February 2019, 682 hospitalizations for posterior spinal fusion in adolescent idiopathic scoliosis were identified with complete inpatient data; 49% were administered gabapentin. For the gabapentin cohort, the system saw no statistically significant effect on length of stay or pain averaged over POD#0-3. Opioid use was statistically lower averaged over POD#0-3. Individual sites saw variation on length of stay and opioid use compared to the system. CONCLUSION: In conclusion, system-wide data showed gabapentin containing protocols reduced opioid use while maintaining clinically equivalent analgesia. However, variations of individual site results make it difficult to conclude the degree to which gabapentin were responsible for this effect.

Survey Response Rates to a Self-Initiated Longitudinal Survey Accessed by a Quick Response Code in Six Different Regions of the United States.

Background A quick response (QR) code allows rapid access to an online survey via a smartphone and may improve response rates for web-based surveys. We report the response rates for a QR code-based, self-initiated, longitudinal survey of opioid use and pain scores following hospital discharge in pediatric surgical patients. Methodology All parents of pediatric patients who underwent surgery at one of six pediatric medical facilities were asked to participate in the study from October 5, 2020, until July 15, 2021. Those who chose to participate accessed the initial enrollment survey using a QR code on a handout provided. The next day they received an emailed link to a daily survey until their child was not requiring opioids and had pain scores of less than 4 for the previous 48 hours. Results A total of 1,759 families were asked to participate in the study. The parents of 44 patients completed the initial enrollment survey by accessing the QR code (response rate of 2.5%). Of those who completed the initial survey, 67% were lost to follow-up during the survey series. Conclusions We found an extremely low response rate for a self-initiated survey accessed by QR code. Additionally, we found a drop in the response rate with each successive daily email-based survey. At the end of the survey series, the majority of the initial participants had dropped out. We recommend using alternative modalities (informed consent, telephone call, weekly surveys) for initiating and delivering surveys to improve response rates for similarly designed studies.

Prolonged Use of a Continuous Peripheral Nerve Block Catheter for Analgesia after Pediatric Foot and Ankle Surgery.

Continuous peripheral nerve blocks (CPNB) have a variety of indications and have been shown to be a safe and effective means of minimizing pain postoperatively. Early studies have indicated duration of catheter use greater than 48 hours as a main contributor to infection risk in CPNBs. Recent studies, though, have suggested that the risk of infection does not increase until 4 days after insertion. In the following case report, we recount our experience in using a continuous popliteal-sciatic peripheral nerve block for postoperative pain control in a pediatric patient following calcaneal and first metatarsal osteotomy. The catheter remained in place for 65 hours postoperatively without signs of local inflammation or infection. The prolonged CPNB use resulted in a significant decrease in postoperative opioid use and pain and increase in patient satisfaction when compared to the same procedure done one year prior on the opposite foot.

Core-shell α-Fe2O3@α-MoO3 nanorods as lithium-ion battery anodes with extremely high capacity and cyclability.

α-Fe2O3 nanoparticles are uniformly coated on the surface of α-MoO3 nanorods through a two-step hydrothermal synthesis method. As the anode of a lithium-ion battery, α-Fe2O3@α-MoO3 core-shell nanorods exhibit extremely high lithium-storage performance. At a rate of 0.1 C (10 h per half cycle), the reversible capacity of α-Fe2O3@α-MoO3 core-shell nanorods is 1481 mA h g(-1) and a value of 1281 mA h g(-1) is retained after 50 cycles, which is much higher than that retained by bare α-MoO3 and α-Fe2O3 and higher than traditional theoretical results. Such a good performance can be attributed to the synergistic effect between α-Fe2O3 and α-MoO3 , the small size effect, one-dimensional nanostructures, short paths for lithium diffusion, and interface spaces. Our results reveal that core-shell nanocomposites have potential applications as high-performance lithium-ion batteries.