Is day surgery failing our children?

Advances in paediatric surgery, including less invasive surgical techniques and more refined anaesthetic methods, have resulted in increasing numbers of surgical day cases/short stay procedures. In the United States, an estimated 84% of paediatric surgery is performed as a day stay procedure, facilitating an increasing trend towards early discharge. While short stay cases curtail costs, reduce disruption to families and minimise risk of nosocomial infection; very often, the responsibility for postoperative pain management rests with parents. Pain is common in the post-operative period with procedures such as tonsillectomy, resetting of fractures, hernia repair and orchidopexy – especially early on, but in many cases also for a number of days after the procedure. One study focusing on tonsillectomy and adenoidectomy found that 86% of parents rated their children’s pain as significant day one postoperatively, 67% significant at day 3, with a further study reporting significant pain up to 1 week in over 50% of patients. There is increasing evidence from several studies suggesting pain is inadequately managed in the home environment and can potentially delay recovery with long-term consequences including alterations in the development and function of the nervous system and pain perception. Furthermore, re-presentations to health-care professionals and emergency departments because of inadequate pain relief represent an increasingly common cause for readmission to hospital. Managing pain at home places significant demands on parents as they engage with accurate assessment and correct analgesic dosing in addition to non-pharmacological strategies for pain. Consequently, problems facing parents can be divided broadly into issues of inadequate prescription, inadequate administration or a combination of both, as well as difficulties with the early recognition and appropriate response to pain. While the provisions of assessment tools and self-reporting scales have been shown to improve accuracy of pain recognition, they have little effect on provision of analgesia. Simple tools such as alarm reminders can potentially increase analgesia usage, while the provision of parent-centred education has had varying results in terms of outcome. This may reflect the heterogeneity and quality of the educational techniques employed, with an algorithm combining assessment tools and criteria-specific responses suggested by some as the most appropriate modality. Unfortunately, in the current clinical environment, these educational strategies are not frequently employed as discharges occur with little parental instruction in relation to pain. Medication factors are also pertinent as the recommendations on effective analgesia have become more restrictive. The World Health Organization recently reduced the three-step analgesic ladder to a two-step model with the removal of codeine. This, albeit appropriate restriction, has left many centres in difficulty, with options limited to non-steroidal anti-inflammatory drugs, paracetamol and morphine analogues in younger children. The step up to oral morphine is daunting for many physicians and may, in fact, act to further intensify parental concerns. Effective pain management requires a multimodal approach, targeting prescription and administration factors to reduce the burden on parents. It is vital that barriers to effective pain relief such as parental misconceptions are addressed and medication with appropriate potency made available. Further research is needed to establish the best combination of interventions to maximise pain control in the home setting. In the interim, surgeons are left with a difficult problem: if pain control cannot be achieved at home (‘Primum non nocere’), should these children be discharged?