Postoperative Pain in Children: A Real Emergency

Abstract

The topic of acute pain, especially post-operative pain, risks being unfairly relegated to the background. Although significant progress has been made in pediatric anesthesia, with a drastic reduction in perioperative mortality and morbidity, much remains to be done in terms of organization and training. Artificial intelligence can potentially help here. Combining data from large, well-structured datasets can provide predictive models that guide patients at higher risk of developing pain. Having reliable alerts would allow resources to be used not only more effectively, but also more rationally. Furthermore, artificial intelligence could help us diagnose and measure the pain of all those patients with cognitive barriers, exploiting nonverbal communication.

Introduction

The scientific debate is often focused on the treatment of chronic pain in children, and rightly so, given the lack of solid literature. ¹ However, the topic of acute pain, especially post-operative pain, risks being unfairly relegated to the background. First of all, in pediatrics, medical conditions that cause chronic pain often expose patients to surgical interventions. Consider, for example, patients with severe cognitive disabilities, who often undergo invasive diagnostic procedures, PEG (percutaneous endoscopic gastrostomy) placement and other procedures necessary to improve their quality of life. ² These patients suffer from pain that we could define as total, since they experience, very often simultaneously, all types of acute and chronic pain. ² Not only that, but they come to the attention of the algologist several months after their onset. In fact, these patients, precisely because of their conditions, have communication difficulties that make it very difficult to effectively measure and characterize the pain and therefore treat it. ³ Unfortunately, this creates a vicious cycle in which chronic pain is compounded by acute, inadequately managed pain. However, in literature there is evidence that the prevalence of pain is similar between patients with cognitive impairment and patients with intact cognitive systems.^2,4 That is, 1 in 2 patients hospitalized for surgical procedures experiences uncontrolled pain.

A True Epidemic

Indeed, if we consider that approximately half of the patients admitted to surgical wards have pain, and that this pain is not treated adequately, we are unfortunately faced with frightening numbers.^{4 -8}

But what does uncontrolled pain mean? First of all, it is pain that is not measured.^7,9 Very often, timing is incorrect, with no measurements taken at crucial moments, such as when moving to and from hospital wards. ⁵ Or pain scales appropriate for the patient’s age and characteristics aren’t used. No less insidious is the choice of medication, and here too the issue often hinges on timing. ¹⁰ Indeed, prescriptions given on demand rather than at fixed times make the patient more vulnerable to experiencing unnecessary pain flare-ups. And finally, the choice of analgesic strategy. As some authors have reported, not using opioids at the risk of not controlling pain is simply ethically unacceptable. ¹¹ There’s a strong temptation to use opioid-free anesthesia across the board, simply ignoring the patient’s perioperative perspective, that is, with a timeframe that’s too limited. Instead, it would be necessary to wisely combine regional anesthesia with systemic therapy to prevent undertreatment of pain. And here, the choice of molecules is crucial. Without detracting from the importance of paracetamol, it’s unthinkable to treat severe pain with a drug for a different purpose, avoiding opioids, even more so if we consider that children deserve the gold standard treatment. ¹² The risk is that undertreated pain may become chronic. While we have evidence that the type of surgery and the type of anesthesia used are among the primary determinants of chronic postoperative pain in adult patients, the situation is completely different in children. ¹³ What really matters is not whether we choose opioid-free anesthesia or whether we use 1 molecule over another; what matters is adequate pain control. We’re not sure why: pediatric surgeons are probably more anatomically conscious and respectful of structures, the procedures are less invasive, and young patients have a natural protective neuroplasticity. But we do know that poorly managing post-operative pain exposes patients to chronic pain. ¹⁴ In this scenario, parental attitudes undoubtedly play an active role. Indeed, parental pain catastrophizing has been identified as one of the factors that most influence postoperative pain.^15,16 In fact, parents with catastrophic thinking adopt behaviors that limit their children’s social life, and transmit incorrect coping strategies in overcoming difficulties and processing the mourning of the surgery. ¹⁷ This topic is so important that it should consider not only treating acute and chronic pain in children, but also providing support measures for parents so that the whole family can benefit.

However, the factor that has the greatest impact on the incidence of chronic post-surgical pain is the presence of preoperative pain. ¹⁶ Too often, preoperative pain goes unmeasured and untreated. ¹⁸

The organization of the anesthesia service generally does not foster a healthy doctor-patient relationship, as those responsible for the preoperative assessment are often not the same people who administer anesthesia in the operating room. ¹⁹ The lack of a point of reference makes the therapeutic alliance more difficult and, in fact, encourages the onset of anxiety. Educational materials, even in the most immediate forms such as videos, regarding the anesthesiologist’s work could help reduce anxiety levels and, in turn, increase compliance among patients and, above all, parents. ²⁰ Using techniques borrowed from cognitive behavioral therapy such as normalization and reframing can eliminate false beliefs and automatic thoughts that can negatively impact the entire family.

This is even more true when parents represent the acute pain service. In outpatient surgery procedures, the patient is discharged from the hospital after a very short hospital stay. This brief experience hasn’t allowed for the establishment of a solid human relationship with the medical and nursing staff, and consequently, a solid bond of mutual trust. Furthermore, patients undergoing outpatient procedures (such as circumcision) have not exhausted their painful experience, but after discharge, they require monitoring and medication administration. This is why parents are the true acute pain service: they are responsible for assessing the pain and deciding whether to administer analgesics. ²⁰ Not only that, but they are also responsible for determining whether their pain management is insufficient. It’s no coincidence that the leading cause of unplanned admissions after day surgery is pain. If we consider the economic and emotional impact of such an event, we realize how delicate postoperative pain management is in outpatient surgery.

Postoperative pain therefore represents a true emergency, as it affects not only the health of young patients but also their families. Unfortunately, the responses we currently have available are inadequate. The production of clinical guidance documents, such as guidelines, is patchy, with significant differences between the various realities. And the situation is no better when considering the healthcare aspect. Very few anesthesia services have a dedicated team for perioperative medicine and another for pain management. ²¹ And here another big mistake is made: confusing perioperative medicine with pain medicine. Indeed, the management of uncomplicated postoperative pain can and should be the prerogative of perioperative medicine, but when cases are complex, different expertise is required.^{22 -24} Let’s take the case of a patient with a history of addiction. ²⁵ This undoubtedly requires the expertise of a physician capable of managing not only the pain but also the potential for recurrence of abuse and addiction. Therefore, the organizational model cannot be one in which the algologist is one of the perioperative medicine physicians: this means providing a poor-quality service that functions intermittently. A virtuous model should include 2 distinct and hierarchically independent services that can collaborate, continuously requesting mutual consultations (including through teleconsultation).^18,26 Indeed, not only the pain therapy service provides consultations, but also the perioperative medicine service provides support for all invasive or diagnostic procedures requiring anesthesia/sedation.

Clearly, addressing this crisis requires resources, training, and research. Although significant progress has been made in pediatric anesthesia, with a drastic reduction in perioperative mortality and morbidity, much remains to be done in terms of organization and training. Artificial intelligence can potentially help here. Combining data from large, well-structured datasets can provide predictive models that guide patients at higher risk of developing pain. Having reliable alerts would allow resources to be used not only more effectively, but also more rationally. Obviously, the driving force must come from the nations with the greatest resources and which must take charge of research, providing clinical assistance (perhaps with the aid of telemedicine, understood in its broadest sense of telehealthcare) to less developed nations.

Furthermore, artificial intelligence (ie, facial recognition algorithms, physiological pattern analysis, or analysis based on machine learning) could help us diagnose and measure the pain of all those patients with cognitive barriers, exploiting nonverbal communication.^{27 -29} However, all of these tools present enormous challenges in implementation related to privacy, data collection, resources, and sample size issues. The primary barrier to using this technology is the resources required to purchase the necessary equipment and software. Additional resources must be allocated to staff training and ongoing refresher courses. Finally, resources are also needed for a repository that guarantees patient privacy, protecting them from potential data leaks. The issue of privacy is part of a larger debate about ethics and regulation. Recently, the Artificial Intelligence Act established stringent guidelines on the use of AI on vulnerable patients. The possibility, not entirely remote, of creating databases that could fall into malicious hands represents a real problem that must be addressed with utmost care.

Indeed, obtaining homogeneous datasets of pediatric patients is extremely difficult, since patients aged 3, 8, and 15 years have markedly different clinical and therapeutic needs yet fall within the pediatric patient category.

This is one of the main problems for anyone undertaking pediatric research, but it’s exaggerated when we’re talking about large datasets, which can be used by AI. The risk of bias is real and could lead to misleading and counterproductive results.

However, the use of AI, despite its limitations, can be a valuable aid in managing pediatric postoperative pain, a significant and too often overlooked problem.