acute pain in children
TRANSCRIPT
![Page 1: Acute pain in children](https://reader033.vdocument.in/reader033/viewer/2022042514/55a75b011a28ab71458b4829/html5/thumbnails/1.jpg)
Acute Pain Management in Children
Presenter : Ranjith Nelluri( 2nd yr MD)
Moderator : Dr.Govardhani
(Asst.Professor)
![Page 2: Acute pain in children](https://reader033.vdocument.in/reader033/viewer/2022042514/55a75b011a28ab71458b4829/html5/thumbnails/2.jpg)
• International Association for the Study of Pain
– An unpleasant sensory and emotional experience
arising from actual or potential tissue damage or
described in terms of such damage
– Sensory, emotional, cognitive, and behavioral
components that are interrelated with environmental,
developmental, socio-cultural, and contextual factors
![Page 3: Acute pain in children](https://reader033.vdocument.in/reader033/viewer/2022042514/55a75b011a28ab71458b4829/html5/thumbnails/3.jpg)
DIFFICULTIES• Belief that children, especially infants, do not feel pain the
way adults do
• Lack of routine pain assessment
• Lack of knowledge in pain treatment
• Fear of adverse effects of analgesics, especially respiratory depression and addiction
• Belief that preventing pain in children takes too much time and effort
• Parental understanding of pain
• Personal values and beliefs; i.e. pain builds character
• AAP 2001 Task Force on Pain in Infants, Children and Adolescents
![Page 4: Acute pain in children](https://reader033.vdocument.in/reader033/viewer/2022042514/55a75b011a28ab71458b4829/html5/thumbnails/4.jpg)
• Historically children and infants received less post-
operative analgesia than adults
• Well documented that children are often undertreated for
pain
• Specifically in neonates:
– Recent studies show that neonates can experience pain by 26
weeks of gestation
• Mature afferent pain transmission
– Untreated pain in neonates lead to increased distress and altered
pain response in the future
![Page 5: Acute pain in children](https://reader033.vdocument.in/reader033/viewer/2022042514/55a75b011a28ab71458b4829/html5/thumbnails/5.jpg)
Acute Pain in Children
• Acute illness
• Procedural pain
• Surgical pain
• Postoperative pain
• Exacerbation of chronic pain
![Page 6: Acute pain in children](https://reader033.vdocument.in/reader033/viewer/2022042514/55a75b011a28ab71458b4829/html5/thumbnails/6.jpg)
Effects of Acute Pain
• Physiologic
• Metabolic
• Behavioral
![Page 7: Acute pain in children](https://reader033.vdocument.in/reader033/viewer/2022042514/55a75b011a28ab71458b4829/html5/thumbnails/7.jpg)
Physiologic Response
• Increased heart rate
• Increased respiratory rate
• Increased blood pressure
• Decrease in oxygen saturation
![Page 8: Acute pain in children](https://reader033.vdocument.in/reader033/viewer/2022042514/55a75b011a28ab71458b4829/html5/thumbnails/8.jpg)
Metabolic Response
• Increased secretion of catecholamine, glucagon, and corticosteroids.
• Delayed wound healing
• Poor intake
• Impaired mobility
• Sleep disturbances
• Irritability
![Page 9: Acute pain in children](https://reader033.vdocument.in/reader033/viewer/2022042514/55a75b011a28ab71458b4829/html5/thumbnails/9.jpg)
General Principles ofPain Management
• Anticipate & prevent pain
• Adequately assess pain
• Use multi-modal approach
• Involve parents
• Use non-noxious routes
![Page 10: Acute pain in children](https://reader033.vdocument.in/reader033/viewer/2022042514/55a75b011a28ab71458b4829/html5/thumbnails/10.jpg)
Anticipate & Prevent Pain
• Prepare patient and parent on what to expect
• Guide them on ways to minimize pain and anxiety
• Utilize quiet environment
• Distraction , parental presence
• Treat pain prophylactically when anticipated
– E.g. Following surgery or local anesthetic for lumbar puncture
– Takes more medication to treat pain than to prevent its
occurrence
![Page 11: Acute pain in children](https://reader033.vdocument.in/reader033/viewer/2022042514/55a75b011a28ab71458b4829/html5/thumbnails/11.jpg)
Pain Assessment
• Obtain a detailed assessment of pain
– description of pain, experience with pain medications, use of non-
pharmacologic techniques, parent experience with pain
– Quality, location, duration, intensity, radiation, relieving & exacerbating
factors, & associated symptoms
• Use age appropriate tool
– Scales for neonate, infant, children ages 3-8, >8 years, and children with
cognitive impairments
• Directly ask child when possible
• Pain can be multi-dimensional and therefore, tools can be limited
![Page 12: Acute pain in children](https://reader033.vdocument.in/reader033/viewer/2022042514/55a75b011a28ab71458b4829/html5/thumbnails/12.jpg)
PQRSTU mnemonic
• Provocative/Palliative factors (For example, "What makes your pain better or
worse?")
• Quality (For example, use open-ended questions such as "Tell me what your
pain feels like," or "Tell me about your 'boo-boo'.")
• Region/Radiation (For example, "Show me where your pain is," or "Show me
where your teddy hurts.")
• Severity: Ask child to rate pain, using a pain intensity scale that is appropriate
for child's age, developmental level, and comprehension. Consistently use the
same pain intensity tool with the same child.
• Timing: Using developmentally appropriate vocabulary, ask child (and family) if
pain is constant, intermittent, continuous, or a combination. Also ask if pain
increases during specific times of the day, with particular activities, or in specific
locations.
• How is the pain affecting you (U) in regard to activities of daily living (ADLs),
play, school, relationships, and enjoyment of life?
![Page 13: Acute pain in children](https://reader033.vdocument.in/reader033/viewer/2022042514/55a75b011a28ab71458b4829/html5/thumbnails/13.jpg)
Goal of Pain Rating Scale
Identify characteristics of pain
Establish a baseline assessment
Evaluate pain status
Effects of intervention
![Page 14: Acute pain in children](https://reader033.vdocument.in/reader033/viewer/2022042514/55a75b011a28ab71458b4829/html5/thumbnails/14.jpg)
Assessment in Neonates & Infants
• Challenging
• Combines physiologic and behavioral parameters
• Many scales available
– NIPS (Neonatal Infant Pain Scale)
– FLACC scale (Face, Legs, Activity, Cry ,Consolability)
![Page 15: Acute pain in children](https://reader033.vdocument.in/reader033/viewer/2022042514/55a75b011a28ab71458b4829/html5/thumbnails/15.jpg)
CRIES scale
![Page 16: Acute pain in children](https://reader033.vdocument.in/reader033/viewer/2022042514/55a75b011a28ab71458b4829/html5/thumbnails/16.jpg)
FLACC scale
![Page 17: Acute pain in children](https://reader033.vdocument.in/reader033/viewer/2022042514/55a75b011a28ab71458b4829/html5/thumbnails/17.jpg)
Neonatal Infant Pain Scale (NIPS)
![Page 18: Acute pain in children](https://reader033.vdocument.in/reader033/viewer/2022042514/55a75b011a28ab71458b4829/html5/thumbnails/18.jpg)
Children between 3-8 years
• Usually have a word for pain
• Can articulate more detail about the presence and location of pain; less able to comment on quality or intensity
• Examples:– Color scales
– Faces scales
![Page 19: Acute pain in children](https://reader033.vdocument.in/reader033/viewer/2022042514/55a75b011a28ab71458b4829/html5/thumbnails/19.jpg)
Children older than 8 years
• Use the standard visual analog scale
• Same used in adults
![Page 20: Acute pain in children](https://reader033.vdocument.in/reader033/viewer/2022042514/55a75b011a28ab71458b4829/html5/thumbnails/20.jpg)
Children with Cognitive Impairment
• Often unable to describe pain
• Altered nervous system and experience pain differently
• Use behavioral observation scales
– e.g. FLACC
• Can apply to intubated patients
![Page 21: Acute pain in children](https://reader033.vdocument.in/reader033/viewer/2022042514/55a75b011a28ab71458b4829/html5/thumbnails/21.jpg)
4: Patient & Parental Involvement
• Parent– Excellent sources of information on child
– Learn techniques to help coach through pain
– Reduces anxiety
• Patient– Age & developmentally appropriate
– Gives them control in their pain experience
– Learn techniques to help with pain control
– Reduces anxiety
![Page 22: Acute pain in children](https://reader033.vdocument.in/reader033/viewer/2022042514/55a75b011a28ab71458b4829/html5/thumbnails/22.jpg)
Multi-modal Approach
• Pharmacological therapy
• Interventional therapy
• Non pharmacological therapy
![Page 23: Acute pain in children](https://reader033.vdocument.in/reader033/viewer/2022042514/55a75b011a28ab71458b4829/html5/thumbnails/23.jpg)
Non-pharmacologic Therapy
• Physical
– Massage
– Heat and cold
– Acupuncture
• Behavioral
– Relaxation
– Art and play therapy
– Biofeedback
• Cognitive
– Distraction
– Imagery and Hypnosis
![Page 24: Acute pain in children](https://reader033.vdocument.in/reader033/viewer/2022042514/55a75b011a28ab71458b4829/html5/thumbnails/24.jpg)
![Page 25: Acute pain in children](https://reader033.vdocument.in/reader033/viewer/2022042514/55a75b011a28ab71458b4829/html5/thumbnails/25.jpg)
![Page 26: Acute pain in children](https://reader033.vdocument.in/reader033/viewer/2022042514/55a75b011a28ab71458b4829/html5/thumbnails/26.jpg)
World Health Organization (WHO)
Principles of
Pediatric Acute Pain Management
• By the clock
• With the child
• By the appropriate route
• WHO Ladder of Pain Management
![Page 27: Acute pain in children](https://reader033.vdocument.in/reader033/viewer/2022042514/55a75b011a28ab71458b4829/html5/thumbnails/27.jpg)
By the Clock
• Regular scheduling ensures a steady blood level
• Reduces the peaks and troughs of PRN dosing
• PRN = as little as possible???
![Page 28: Acute pain in children](https://reader033.vdocument.in/reader033/viewer/2022042514/55a75b011a28ab71458b4829/html5/thumbnails/28.jpg)
With the Child
Analgesic treatment should be
individualized according to:
• The child’s pain
• Response to treatment
• Frequent reassessment
• Modification of plan as required
![Page 29: Acute pain in children](https://reader033.vdocument.in/reader033/viewer/2022042514/55a75b011a28ab71458b4829/html5/thumbnails/29.jpg)
Correct Route
Oral
Nebulized
Buccal
Transdermal
Sublingual
Intranasal
IM
IV / SC
Rectal
![Page 30: Acute pain in children](https://reader033.vdocument.in/reader033/viewer/2022042514/55a75b011a28ab71458b4829/html5/thumbnails/30.jpg)
![Page 31: Acute pain in children](https://reader033.vdocument.in/reader033/viewer/2022042514/55a75b011a28ab71458b4829/html5/thumbnails/31.jpg)
Pharmacological intervention
![Page 32: Acute pain in children](https://reader033.vdocument.in/reader033/viewer/2022042514/55a75b011a28ab71458b4829/html5/thumbnails/32.jpg)
![Page 33: Acute pain in children](https://reader033.vdocument.in/reader033/viewer/2022042514/55a75b011a28ab71458b4829/html5/thumbnails/33.jpg)
Non-opioid Analgesics
• Mild to moderate pain
• No effects of respiratory depression
• Highly effective when combined with opioids
• Acetaminophen
• NSAIDs
• COX-2 inhibitors
• Aspirin
– No longer used in pediatrics
![Page 34: Acute pain in children](https://reader033.vdocument.in/reader033/viewer/2022042514/55a75b011a28ab71458b4829/html5/thumbnails/34.jpg)
Acetaminophen
• Antipyretic
• Mild analgesic
• Administer PO or PR
• Pediatric Oral dose 10-15 mg/kg/dose every 4 hr
– Infant dose is 10-15 mg/kg/dose every 6-8 hr
• Onset 30 minutes
![Page 35: Acute pain in children](https://reader033.vdocument.in/reader033/viewer/2022042514/55a75b011a28ab71458b4829/html5/thumbnails/35.jpg)
Acetaminophen
• Per rectum dose
• 35-50mg/kg once followed by 20 mg/kg/dose every 6 hours– Uptake is delayed and variable
– Peak absorption is 60-120 minutes
– Unreliable to cut suppositories
• Maximum daily dosing– <2yrs : 60-75 mg/kg/day
– >2yrs kg : 90-100 mg/kg/day
![Page 36: Acute pain in children](https://reader033.vdocument.in/reader033/viewer/2022042514/55a75b011a28ab71458b4829/html5/thumbnails/36.jpg)
Side Effects of Acetaminophen
• Generally a good safety profile
– Do not use in hepatic failure
• Causes hepatic failure in overdose
– Infant drops are MORE concentrated than the
children’s suspension
• Infant’s Acetaminophen 80 mg/0.8 mL
• Children’s Acetaminophen 160 mg/5 mL
![Page 37: Acute pain in children](https://reader033.vdocument.in/reader033/viewer/2022042514/55a75b011a28ab71458b4829/html5/thumbnails/37.jpg)
NSAIDs
• Antipyretic
• Analgesic for mild to moderate pain
• Anti-inflammatory
– COX inhibitor Prostaglandin inhibitor
• Platelet aggregation inhibitor
![Page 38: Acute pain in children](https://reader033.vdocument.in/reader033/viewer/2022042514/55a75b011a28ab71458b4829/html5/thumbnails/38.jpg)
NSAIDs: Ibuprofen
• Dose 5-10 mg/kg/dose every 6 hours
– Adult dose 400-600 mg/dose every 6 hours
• Onset 30-45 minutes
• Maximum daily dosing
– <60 kg: 40 mg/kg
– >60 kg: 2400 mg
• May use higher doses in rheumatologic disease
![Page 39: Acute pain in children](https://reader033.vdocument.in/reader033/viewer/2022042514/55a75b011a28ab71458b4829/html5/thumbnails/39.jpg)
NSAIDs: Ketorolac
• Intravenous NSAID (also available P.O.)
• Dose every 6 hours
• < 2 years: 0.25 mg/kg i.v.
• > 2 years: 0.5 mg/kg i.v., max. 30mg, max of 5 days)
• Onset 10 minutes
• Maximum I.V. dose 30 mg every 6 hours
• Monitor renal function
• Do not use more than 5 days– Significant increase in side effects after 5 days
![Page 40: Acute pain in children](https://reader033.vdocument.in/reader033/viewer/2022042514/55a75b011a28ab71458b4829/html5/thumbnails/40.jpg)
Side Effects of NSAIDs
• Gastritis
– Prolonged use increases risk of GI bleed
– Still rare in pediatric patients compared to adults
– NSAID use contraindicated in ulcer disease
• Nephropathy (ATN)
• Bleeding from platelet anti-aggregation
– Increased risk versus benefit post-tonsillectomy
– NSAID use contraindicated in active bleeding
• Delayed bone healing?
![Page 41: Acute pain in children](https://reader033.vdocument.in/reader033/viewer/2022042514/55a75b011a28ab71458b4829/html5/thumbnails/41.jpg)
COX-2 inhibitors
• Selectively inhibits Cyclooxygenase-2 which reduces risk of gastric irritation and bleeding
• Same risk for nephropathy as non-selective COX inhibitors
• Shown to have increased cardiovascular events in adults
• More studies needed in pediatric patients
– COX-2 inhibitors used in rheumatologic diseases
![Page 42: Acute pain in children](https://reader033.vdocument.in/reader033/viewer/2022042514/55a75b011a28ab71458b4829/html5/thumbnails/42.jpg)
Opioids
• Codeine
• Oxycodone
• Morphine
• Fentanyl
• Hydromorphone
• Methadone
![Page 43: Acute pain in children](https://reader033.vdocument.in/reader033/viewer/2022042514/55a75b011a28ab71458b4829/html5/thumbnails/43.jpg)
Opioids Analgesics
• Moderate to severe pain
• Various routes of administration
• Different pharmacokinetics for different age
groups
– Infants younger than 3 months have increased risk of
hypoventilation and respiratory depression
• Low risk of addiction among children
![Page 44: Acute pain in children](https://reader033.vdocument.in/reader033/viewer/2022042514/55a75b011a28ab71458b4829/html5/thumbnails/44.jpg)
Codeine
• Oral analgesic (also anti-tussive)
• Weak opioid
– Used often in conjunction with acetaminophen to increase analgesic effect
• Metabolized in the liver and demethylated to morphine
– Some patients ineffectively convert codeine to morphine so no analgesia is achieved
• Dose 0.5-1 mg/kg every 4-6 hours
![Page 45: Acute pain in children](https://reader033.vdocument.in/reader033/viewer/2022042514/55a75b011a28ab71458b4829/html5/thumbnails/45.jpg)
Oxycodone
• Oral analgesic
• Mild to moderate pain
• Hepatic metabolism to noroxycodone and oxymorphone
• Can be given alone or in combination with acetaminophen
• Dose 0.05-0.15 mg/kg every 4-6 hours
• Maximum 5-10 mg every 4-6 hours
![Page 46: Acute pain in children](https://reader033.vdocument.in/reader033/viewer/2022042514/55a75b011a28ab71458b4829/html5/thumbnails/46.jpg)
Morphine• Available orally, sublingually, subcutaneously, intravenous, rectally,
intrathecally
• Moderate to severe pain
• Hepatic conversion with renally excreted metabolites
– Use in caution with renal failure
• Duration of I.V. analgesia 2-4 hours
– Oral form comes in an immediate and sustained release
• Dose dependent on formulation
• I.V. Dose 0.05-0.2 mg/kg/dose every 2-4 hours
• Onset 5-10 minutes
• Side effect of significant histamine release
![Page 47: Acute pain in children](https://reader033.vdocument.in/reader033/viewer/2022042514/55a75b011a28ab71458b4829/html5/thumbnails/47.jpg)
Fentanyl
• Available intravenous, buccal tab, lozenge and transdermal
patch
• Severe pain
• Rapid onset, brief duration of action
– With continuous infusion, longer duration of action
• I.V. Dose 1 mcg/kg/dose every 30-60 minutes
• Side effect of rapid administration may produce glottic and
chest wall rigidity
• Careful observation, CRM and immediate availability of airway
equipment
![Page 48: Acute pain in children](https://reader033.vdocument.in/reader033/viewer/2022042514/55a75b011a28ab71458b4829/html5/thumbnails/48.jpg)
![Page 49: Acute pain in children](https://reader033.vdocument.in/reader033/viewer/2022042514/55a75b011a28ab71458b4829/html5/thumbnails/49.jpg)
![Page 50: Acute pain in children](https://reader033.vdocument.in/reader033/viewer/2022042514/55a75b011a28ab71458b4829/html5/thumbnails/50.jpg)
Ketamine
Analgesic dose : 0.1-0.5mg/kginfusion - 4µg/kg/min
![Page 51: Acute pain in children](https://reader033.vdocument.in/reader033/viewer/2022042514/55a75b011a28ab71458b4829/html5/thumbnails/51.jpg)
Patient/Parent Controlled Analgesia (PCA)
• Programmable pump that allows patient control of
intravenous analgesia
• Patient can choose when to deliver a dose of opioid and
achieve relief quickly
• Inherent safety in the PCA: patient will fall asleep when
over sedated and is unlikely to administer too much
drug
• Teaching is integral and essential
![Page 52: Acute pain in children](https://reader033.vdocument.in/reader033/viewer/2022042514/55a75b011a28ab71458b4829/html5/thumbnails/52.jpg)
PCA
• Useful for sickle cell vaso-occlusive episodes,
postoperative pain, cancer pain, palliative care
• Take patient’s age, maturity, and medical condition into
the decision
![Page 53: Acute pain in children](https://reader033.vdocument.in/reader033/viewer/2022042514/55a75b011a28ab71458b4829/html5/thumbnails/53.jpg)
PCA• Loading dose if patient is in pain so that there is a therapeutic serum level to start
• Basal infusion rate can deliver continuous background dose of opioid to maintain
therapeutic level
• Patient demand dose is the dose administered with each patient activation of the
pump (usually small)
• Lockout interval (5-10 min) prevents a second PCA dose before the previous bolus
has taken effect (important to prevent overdosing)
• Maximum hourly limit can be set based on the average hourly use of morphine
• Sedation and vital sign assessment is mandatory
![Page 54: Acute pain in children](https://reader033.vdocument.in/reader033/viewer/2022042514/55a75b011a28ab71458b4829/html5/thumbnails/54.jpg)
Naloxone
• Opioid antagonist
• 1 ampule = 0.4 mg/mL
• Use when unresponsive to physical stimulation, shallow respirations
(<8 breaths/min), pinpoint pupils
• Stop Opioid
– For <40 kgs: Naloxone ¼ ampule with NS 9 mL = 10 mcg/mL
• Administer slowly and observe response
– 1-2 mcg/kg/min
• Discontinue naloxone as soon as patient responds
• Duration 30-45 minutes
– Monitor the patient; repeat doses may be needed
![Page 55: Acute pain in children](https://reader033.vdocument.in/reader033/viewer/2022042514/55a75b011a28ab71458b4829/html5/thumbnails/55.jpg)
Local Anesthetics
• For IV cannulation, suturing, lumbar puncture, etc.
• Topical or infiltration
• Acts by blocking nerve conduction at Na-channels
• If administered in excessive doses, can cause systemic effects
– CNS effects of perioral numbness, dizziness, muscular twitching, seizures &
cardiac toxicity
– Aspirate back before injecting to avoid direct injection into blood vessels
– Calculate maximum mg/kg dose to avoid overdose
![Page 56: Acute pain in children](https://reader033.vdocument.in/reader033/viewer/2022042514/55a75b011a28ab71458b4829/html5/thumbnails/56.jpg)
Anesthesia
• Regional
– Blocks afferent pathways to CNS
– Good for post-operative pain relief
– Epidural and caudal anesthesia
– Peripheral nerve blocks
• General
![Page 57: Acute pain in children](https://reader033.vdocument.in/reader033/viewer/2022042514/55a75b011a28ab71458b4829/html5/thumbnails/57.jpg)
Caudal anaesthesia The armitage regime:
• O.5 ml/kg- all sacral dermatomes blocked
• 1 ml/kg- sacral and lumbar dermatomes blocked
• 1.25 ml/kg- upto midthoracic levels blocked
Bupivacaine in Concentration Dose Possible additives
Single dose caudal
0.175%- 0.5% 0.75- 1.25 ml/kg (max. 3 ml/kg)
Epinephrine 2.5- 5 µg/kgClonidine 1- 2 µg/kgMorphine 30- 70 µg/kg
Continuous caudal
0.1%- 0.25% 0.4 ml/kg Fentanyl 2- 5 µg/kg
![Page 58: Acute pain in children](https://reader033.vdocument.in/reader033/viewer/2022042514/55a75b011a28ab71458b4829/html5/thumbnails/58.jpg)
Epidural Block
• Epidural space more superficial in children than
adults
• Guideline for determining epidural depth:
– 1mm/kg of body weight
– Depth (cm) = 1 + 0.15 X age (years)
– Depth (cm) = 0.8 + 0.05 X weight (kg)
• Use shorter needles and extreme care
![Page 59: Acute pain in children](https://reader033.vdocument.in/reader033/viewer/2022042514/55a75b011a28ab71458b4829/html5/thumbnails/59.jpg)
Epidural Block
• Dosing:
– Depends on upper level of analgesia required
– > 10 years of age:
• Volume to block one spinal segment
– V (in ml) = 1/10 X (age in years)
– < 10 years old:
• 0.04ml/kg/segment
![Page 60: Acute pain in children](https://reader033.vdocument.in/reader033/viewer/2022042514/55a75b011a28ab71458b4829/html5/thumbnails/60.jpg)
Maximum dosage
![Page 61: Acute pain in children](https://reader033.vdocument.in/reader033/viewer/2022042514/55a75b011a28ab71458b4829/html5/thumbnails/61.jpg)
Sucrose for Infants
• Sucrose 24% oral solution
• Can be used for procedures such as heel stick,
venipuncture, catheterization, etc.
• Effective analgesic in preterm and term infants
– Not effective beyond 3 months old
• Dip pacifier in sucrose solution or give 0.2 mL to buccal
area
– May repeat but be cautious with many doses to younger infants
![Page 62: Acute pain in children](https://reader033.vdocument.in/reader033/viewer/2022042514/55a75b011a28ab71458b4829/html5/thumbnails/62.jpg)
• Anesthesiologists are like no other physicians: we are experts at controlling the
airway and at emergency resuscitation;
• we are real-time cardio pulmonologists achieving hemodynamic and
respiratory stability for the anesthetized patient;
• we are pharmacologists and physiologists, calculating appropriate doses
and desired responses;
• we are gurus of postoperative care and patient safety;
• we are internists performing perianesthetic medical evaluations;
• we are the pain experts across all medical disciplines and apply specialized
techniques in pain clinics and labor wards;
• we manage the severely sick and injured in critical care units;
• we are neurologists, selectively blocking sympathetic, sensory, or motor functions
with our regional techniques
![Page 63: Acute pain in children](https://reader033.vdocument.in/reader033/viewer/2022042514/55a75b011a28ab71458b4829/html5/thumbnails/63.jpg)
THANK YOU
![Page 64: Acute pain in children](https://reader033.vdocument.in/reader033/viewer/2022042514/55a75b011a28ab71458b4829/html5/thumbnails/64.jpg)