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Management of routine postoperative pain for children undergoing cardiac surgery: a Paediatric Acute Care Cardiology Collaborative Clinical Practice Guideline

Published online by Cambridge University Press:  16 November 2022

Dana B. Gal*
The Heart Institute, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA
Caitlin O. Clyde
UT Southwestern Medical Center, Heart Center at Children’s Health, Dallas, TX, USA
Erin L. Colvin
Heart Institute, Division of Pediatric Cardiothoracic Surgery, UPMC Children’s Hospital of Pittsburgh, Pittsburgh, PA, USA
Jessica Colyer
Heart Center, Seattle Children’s Hospital, Seattle, WA, Division of Pediatrics, University of Washington, Seattle, WA, USA
Anne M. Ferris
Department of Pediatrics, Columbia University Vagelos College of Physicians and Surgeons and New York-Presbyterian Morgan Stanley Children’s Hospital, New York, NY, USA
Mayte I. Figueroa
Division of Pediatric Cardiology, Washington University School of Medicine, St. Louis, MO, USA
Brittney K. Hills
The Heart Institute, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA
Sarah M. Lagergren
Heart Center, Children’s Mercy Hospital, Kansas City, MO, USA
Jordan Mangum
Children’s National Heart Institute, Children’s National Hospital, Washington, DC, USA
Jessica L. Mann
Division of Pediatric Cardiology, Washington University School of Medicine, St. Louis, MO, USA
Angela S. McKeta
Pediatric Cardiology, Medical University of South Carolina, Charleston, SC, USA
Sonali S. Patel
Pediatric Cardiology, University of Colorado School of Medicine, Aurora, CO, USA
Jennifer F. Reeves
Division of Pediatric Cardiac Surgery, Shawn Jenkins Children’s Hospital at Medical University of South Carolina, Charleston, SC, USA
Molly Richter
Heart Center, Seattle Children’s Hospital, Seattle, WA, USA
Lisa M. Ring
Children’s National Heart Institute, Children’s National Hospital, Washington, DC, USA
Joshua M. Rosenblum
Division of Cardiac Surgery, Children’s Healthcare of Atlanta and Emory University School of Medicine, Atlanta, GA, USA
Kaitlin Tindel
UT Southwestern Medical Center, Heart Center at Children’s Health, Dallas, TX, USA
Jeffrey G. Weiner
Thomas P. Graham Jr. Division of Pediatric Cardiology, Monroe Carell Jr. Children’s Hospital at Vanderbilt, Nashville, TN, USA
Kimberly G. Williams
Division of Cardiology, Lucile Packard Children’s Hospital Stanford, Palo Alto, CA, USA
Luis M. Zabala
UT Southwestern Medical Center, Heart Center at Children’s Health, Dallas, TX, USA
Nicolas L. Madsen
UT Southwestern Medical Center, Heart Center at Children’s Health, Dallas, TX, USA
Author for correspondence: Dana B. Gal, 3333 Burnett Ave., Cincinnati, OH 45229, USA. Tel: +1 513 803 4574; Fax: +1 513 803 4493. E-mail:



Pain following surgery for cardiac disease is ubiquitous, and optimal management is important. Despite this, there is large practice variation. To address this, the Paediatric Acute Care Cardiology Collaborative undertook the effort to create this clinical practice guideline.


A panel of experts consisting of paediatric cardiologists, advanced practice practitioners, pharmacists, a paediatric cardiothoracic surgeon, and a paediatric cardiac anaesthesiologist was convened. The literature was searched for relevant articles and Collaborative sites submitted centre-specific protocols for postoperative pain management. Using the modified Delphi technique, recommendations were generated and put through iterative Delphi rounds to achieve consensus


60 recommendations achieved consensus and are included in this guideline. They address guideline use, pain assessment, general considerations, preoperative considerations, intraoperative considerations, regional anaesthesia, opioids, opioid-sparing, non-opioid medications, non-pharmaceutical pain management, and discharge considerations.


Postoperative pain among children following cardiac surgery is currently an area of significant practice variability despite a large body of literature and the presence of centre-specific protocols. Central to the recommendations included in this guideline is the concept that ideal pain management begins with preoperative counselling and continues through to patient discharge. Overall, the quality of evidence supporting recommendations is low. There is ongoing need for research in this area, particularly in paediatric populations.

© The Author(s), 2022. Published by Cambridge University Press

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