Postoperative Management for Adolescent Trauma Surgery
For a teenage boy recovering from trauma surgery, prioritize opioid-free or opioid-minimizing pain management using scheduled NSAIDs and acetaminophen, provide comprehensive preoperative education about pain expectations and medication use, ensure secure storage and disposal plans for any prescribed opioids, and minimize follow-up imaging unless it will change management. 1
Pain Management Strategy
First-Line Approach: Opioid-Free or Opioid-Sparing Regimen
Nonopioid medications should be the foundation of postoperative analgesia for most pediatric trauma procedures. 1 The evidence strongly supports that many operations can be managed entirely without opioids, and when opioids are necessary, they should be minimized through multimodal approaches. 1
Scheduled (not PRN) administration is critical - timed analgesics prevent pain establishment rather than chasing it after it develops. 2
Recommended Medication Regimen:
NSAIDs (oral or IV): Ketorolac is the most well-studied and effective option for reducing both pain and opioid requirements in pediatric orthopedic procedures. 1 Oral NSAIDs should be continued throughout the postoperative period. 1
Acetaminophen (oral, rectal, or IV): Use throughout the entire postoperative period. 1 The optimal rectal dosing is 40 mg/kg after induction, then 20 mg/kg every 6 hours for the first 24 hours. 2
Combination therapy: Using both NSAIDs and acetaminophen together reduces opioid consumption more effectively than either alone. 1
Regional Anesthesia Considerations:
Regional or neuraxial anesthesia techniques should be employed when appropriate as part of an opioid-sparing strategy, requiring coordination between surgeons and anesthesiologists for proper patient selection. 1
If Opioids Are Prescribed:
Avoid codeine and tramadol entirely - the FDA restricts their use in patients under 18 years due to serious risks. 1, 3
Prescribe the minimum necessary quantity - adolescents who receive opioid prescriptions after surgery have 2.7 times higher odds of persistent opioid use within the following year. 1
Patient and Family Education
Timing and Content:
Education must begin before the day of surgery, not just perioperatively. 1 Parents spend less than 6 minutes receiving pain education on surgery day when anxiety is already high, making preoperative counseling essential. 1
Key Educational Components:
Pain expectations: Explain what level of pain is normal, how long it should last, and when to seek help. 1
Medication instructions: Provide both written and verbal instructions in plain, non-medical language in the family's preferred language. 1
Adverse effects: If opioids are prescribed, specifically educate about oversedation risks and instruct caregivers to hold medication if the child is overly sleepy or sedated. 1 Only 3 parents in one study received written instructions about this critical safety measure. 1
Non-pharmacologic strategies: Include positioning, ice application, distraction techniques, and activity modification. 4, 5
All team members must provide consistent messaging - conflicting information from different providers increases confusion and reduces satisfaction. 1
Opioid Safety Measures (If Prescribed):
Storage and Disposal:
Educate families to store opioids in a secure, locked location immediately. 1 Only 11.7% of families with adolescents report safe storage practices. 1
Provide specific disposal instructions before discharge - the top reasons families dispose of unused opioids are awareness of risks and direct instructions from healthcare providers. 1
Diversion Risk:
Recognize that 94% of adolescents will divert medication once approached, and 66.4% of adolescents who misuse opioids obtain them from friends/relatives who received prescriptions from healthcare professionals. 1 This makes prescribing decisions particularly consequential in this age group.
Follow-Up Management:
Minimize postoperative imaging unless it will change management - a 2018 systematic review found immediate postoperative imaging identified complications in only 0.22% of cases. 1
Consider telehealth for follow-up visits when clinically appropriate to reduce unnecessary healthcare contacts while ensuring patients aren't lost to follow-up. 1
Use removable casts and splints when possible for orthopedic injuries, accepting more initial deformity than traditionally tolerated given the high remodeling potential in adolescents. 1
Common Pitfalls to Avoid:
PRN-only analgesic orders: Always use scheduled dosing to prevent pain rather than treat established pain. 2
Inadequate preoperative education: Waiting until surgery day leaves families unprepared and anxious. 1
Overprescribing opioids "just in case": The most common reason families retain unused opioids is wanting them available for future use. 1
Failing to address storage and disposal: 30% of caregivers don't dispose of opioids because they "never got around to it" or didn't know how. 1
Inconsistent team messaging: Ensure all providers give the same pain management instructions. 1