PM1059: Synergistic Effect of Multimodal Pain Control Approach on Patient Reported Outcomes in Children Undergoing Surgery

Background: Multimodal pain management strategies have been endorsed to improve perioperative pain and anxiety. However, the optimal combinations of modalities including preoperative and postoperative non-opioid analgesics, regional anesthetic blocks, and use of biobehavioral interventions such as relaxation, distraction, or mindfulness meditation exercises have not been well characterized in children. Our aims were to evaluate the effect of multimodal pain management strategies on pediatric patient reported outcomes (PROs) and determine optimal combinations of modalities.

Methods: Data were collected as part of the ongoing 18-hospital ENhanced Recovery In CHildren Undergoing Surgery (ENRICH-US) clinical trial for children, ages 10-18 years, undergoing elective gastrointestinal surgery. We assessed the association of multimodal pain management strategies collected via the electronic health record with PROs including perioperative nervousness, pain-related functional disability, and health-related quality of life (HRQoL) from preoperative and postoperative patient/caregiver surveys. Analyses included chi-squared tests and multivariable logistic regression models with linear combination of multimodal pain management strategies.

Results: Of 186 patients, 62 (33.33%) received preoperative non-opioid analgesics, 81 (43.55%) a regional anesthetic block, and 135 (72.58%) reported use of a biobehavioral intervention. The most common treatments from each modality, respectively, were acetaminophen (n=58; 31.18%), epidural (n=36; 19.35%), and distraction (n=85; 45.70%; Figure). All patients received postoperative non-opioid analgesics. Among patients who reported worsened postoperative nervousness, a higher proportion did not receive a regional anesthetic block (n=23; 74.19% vs. n=8; 25.81%; p<.01). Among patients who reported improved/stable postoperative nervousness, a higher proportion reported use of a biobehavioral technique (n=99; 74.44% vs n=34; 25.56%; p=0.01). Use of preoperative non-opioid analgesics was not associated with nervousness. After adjustment for demographic and clinical characteristics, patients who received a regional block alone were 3.10 times more likely to report improved/stable postoperative nervousness (95% confidence interval [CI]:1.19-8.08; p=0.02), and those who used a biobehavioral intervention alone were 3.02 times more likely to report improved/stable postoperative nervousness (95% CI:1.22-7.52; p=0.02; Table). When regional block and biobehavioral techniques were used in combination, patients were 9.38 times more likely to report improved/stable nervousness postoperatively (95% CI:2.51-34.99; p<.01). There was no significant effect of multimodal pain management strategies on other evaluated PROs.

Conclusion: Multimodal pain management strategies may lead to improvements in postoperative PROs in children. Regional anesthetic blocks and use of biobehavioral interventions may be effective alone and have a greater synergistic effect. Adoption of these strategies should be considered in the development and implementation of perioperative pain management protocols.