-
8/3/2019 Perioperative Pain Management in Paediatric Patients-08.07.09
1/23
Perioperative painPerioperative painmanagement in paediatricmanagement in paediatric
patients.patients.
OBAIDOBAID
-
8/3/2019 Perioperative Pain Management in Paediatric Patients-08.07.09
2/23
It is defined by the international association forIt is defined by the international association forstudy of pain as an unpleasant sensory and emotionalstudy of pain as an unpleasant sensory and emotional
experience associated with actual or potential tissueexperience associated with actual or potential tissue
damage or described in terms of such phenpmenon.damage or described in terms of such phenpmenon.
Children are special in this regard because, in them it is a veryChildren are special in this regard because, in them it is a verycomplex phenomenon. It is also very difficult to differentiatecomplex phenomenon. It is also very difficult to differentiate
restlessness or crying due to pain from that of hunger orrestlessness or crying due to pain from that of hunger or
fear in the children. An effective pain therapy to block orfear in the children. An effective pain therapy to block or
modify the myriad physiologic responses to stress has becomemodify the myriad physiologic responses to stress has become
an essential component of modern pediatric anaesthesia andan essential component of modern pediatric anaesthesia and
surgical practice.surgical practice.
-
8/3/2019 Perioperative Pain Management in Paediatric Patients-08.07.09
3/23
Paediatric pain reliefPaediatric pain reliefThe society of Paediatric Anaesthesia, at its
15th annual meeting at New Orleans, Louisiana (2001)clearly defined the alleviation of pain as a basic human
right, irrespective of age, medical condition, treatment,
primary service response for the patient care or medical
institution.
-
8/3/2019 Perioperative Pain Management in Paediatric Patients-08.07.09
4/23
Assesment of painAssesment of pain
One such standard approach of
assessment of
pain is QUESTT which is asfollows-
Q Question the child
U Use pain rating scales
E Evaluate childs behavior
S Secure parents involvement
TTake cause of pain into account
TTake earliest action
-
8/3/2019 Perioperative Pain Management in Paediatric Patients-08.07.09
5/23
a. Question the child
Self Report : The childs verbal statement and
description of pain are important factors in assessment of
pain. Children up to 2 years can report and locate the pain,although, at this age they will not be able to quantify the
intensity.
-
8/3/2019 Perioperative Pain Management in Paediatric Patients-08.07.09
6/23
b. Use a pain rating scale
Faces scale : Children up to 4-5 years old can use standardizedmeasuring scales. One must introduce anddiscuss the detailedaspects of the scale to the child and hisparents, before usingthem. Some of the methods available for self report areHesters poker chip tool,16 Faces scale of Bieri et al,17 facesscale of Kutner and Le Page,18 Elands colour scale,7 VisualAnalog Scale (VAS), Smiley Analog Scale, Oucher Scale ofBeyer and Wells,19 and Work Graphic Scale ofTesler et al.
-
8/3/2019 Perioperative Pain Management in Paediatric Patients-08.07.09
7/23
c. Evaluate behavior and physiologic changes
Behavioral and physiologic changes : Specific
distress behaviors eg. cry, ouch, facial expression (grimace),
posture (guarding) and body movements are typically
associated with pain and are useful in evaluating pain inchildren with limited communication skills. However, it is
difficult to discriminate between behavior due to pain and
other types of distress eg. hunger, fear or anxiety.
-
8/3/2019 Perioperative Pain Management in Paediatric Patients-08.07.09
8/23
d. Secure parents involvementParents should be questioned about
the early
recognition and childs behavior
during pain. They should
be also encouraged to get actively
involved in assessment,
progress as well as treatment
strategies of pain in their
-
8/3/2019 Perioperative Pain Management in Paediatric Patients-08.07.09
9/23
Take cause of pain in to accountEtiology and or procedure may give clues to the
expected intensity and type of pain.
f. Take a quickaction to relieve the pain
Establish the acceptable pain level in the child and
use appropriate methods to relieve it.
-
8/3/2019 Perioperative Pain Management in Paediatric Patients-08.07.09
10/23
Pain ManagementPain Management
Evaluate the relative risks or benefits, its analgesic efficacy,safety, side effects, costs and the course of recovery.
The child should be prepared properly for that particularmethod of pain relief.
A good psychological preparation of the child as well asparents, proper premedication and smooth anaesthesia coursealways helps in reducing the anxiety and needs of painmedications in the post-operative period.
The treatment modalities include general measures,systemicdrug therapy, regional techniques and nonpharmacologic
merthods.
-
8/3/2019 Perioperative Pain Management in Paediatric Patients-08.07.09
11/23
A. General measures
Child should be made comfortable and less distressed, before
surgery as well as during hospital stay. These measures
include presence of parent with the child, nursing in acomfortable environment, allowing the child to adopt most
comfortable position.
-
8/3/2019 Perioperative Pain Management in Paediatric Patients-08.07.09
12/23
B. Systemic drug therapy
I. Non-narcotic analgesics This group of drugs has become
extremely popular for treating pain in children as they are
effective with few side effects and produce an opioid sparingaction through decreasing the inflammatory mediators
generated at the site of tissue injury.
-
8/3/2019 Perioperative Pain Management in Paediatric Patients-08.07.09
13/23
a) Paracetamol (Acetaminophen) : This is the most commonanalgesic used in the children. It is very useful as a analgesicspecially if used with Ibuprofen. Though dose response inchildren is not known, 15-20 mgkg-1 can be used safely.
a) Ibuprofen : This is a better analgesic than acetaminophen.Safety of Ibuprofen for use in children less than 6 months ofage is yet to be established. However, the pharmacokineticsin infants over 3 months is similar to adults. Oralformulations are available and 4-10 mgkg-1dose-1every 6-8hours is quite effective.
-
8/3/2019 Perioperative Pain Management in Paediatric Patients-08.07.09
14/23
c) Diclofenac : This is more powerful antiinflammatory drug
than acetaminophen and ibuprofen. It is available in tablet,
syrup as well as suppository form. The oral dose is 1-1.5
mgkg-1 12 hourly.
d) Ketorolac : Ketorolac is a very useful analgesic in children
and its opioid sparing effect has been confirmed. Being a non-
narcotic and with a duration of action for 4-6 hours, it is
routinely prescribed even for children in empirical doses.
Recently, IV route has also been declared safe in children. The
IV or IM dose of ketorolac is 0.2-0.5 mgkg-1 every 6 hours for
48 hours. Maximum permitted total dose per day is 120 mg.
-
8/3/2019 Perioperative Pain Management in Paediatric Patients-08.07.09
15/23
The commonly seen side effects with NSAIDs are increased
chances of bleeding, thrombocytopenia, precipitation of
asthma attacks, increase in heart rate, retension of sodium and
water, GI ulcerations, bleeding, hepatotoxicity, nephrotoxicity,
nausea, vomiting, and dyspepsia etc.
-
8/3/2019 Perioperative Pain Management in Paediatric Patients-08.07.09
16/23
e) Ketamine : It can be administered alone or in conjunction withother agents via the oral, rectal, intramuscular, subcutaneous,intravenous and intraspinal routes. There are evidences aboutthe efficacy of low dose ketamine (of less than 2 mgkg-1intramuscularly or less than 1 mgkg-1 intravenously orepidurally) in the management of acute pain.
-
8/3/2019 Perioperative Pain Management in Paediatric Patients-08.07.09
17/23
Narcotic analgesics
Opioids are the mainstay in the management of pain.
a) Morphine : Morphine still remains the standard opioid forpain relief in infants and children of all age groups. It is
considered safest in a dose of 0.1 mgkg-1 intramuscularly in aspontaneously breathing child.
b) Codeine : This drug is used mainly as a powerful antitussive,than analgesic. A single oral dose of 1 mgkg-1 is good enough
as both antitussive and analgesic.
c)Pethidine : Pethidine is not very popular forc)Pethidine : Pethidine is not very popular forpostpost--operativeoperativepain management in children because practically it offers nopain management in children because practically it offers noadvantages over morphine. Injection pethidine in a dose of 1.5advantages over morphine. Injection pethidine in a dose of 1.5--2 mgkg2 mgkg--1 IM is a useful premedicant and in a dose of 1 mgkg1 IM is a useful premedicant and in a dose of 1 mgkg--1 I.V. is used for intraoperative and postoperative analgesia1 I.V. is used for intraoperative and postoperative analgesia
-
8/3/2019 Perioperative Pain Management in Paediatric Patients-08.07.09
18/23
d) Fentanyl : Though fentanyl has been tried in doses of 1-2mgkg-1, it is not a popular systemic analgesic for conventional
analgesia in children.e)Buprenorphine : In a dose of 3-5 mgkg-1 is a useful analgesic
for intra-operative and post-operative analgesia. A tablet form
for sublingual administration is suitable for use in older
children who do not like injections.
f)Pentazocine : A partial agonist, can also be used in a dose of 1
mgkg-1 IM or 0.5-0.75 mgkg-1 I.V.
Common side effects encountered with opioids are nausea,
vomiting, dyspepsia, constipation, urinary retension,
respiratory depression, drowsiness, euphoria etc.
-
8/3/2019 Perioperative Pain Management in Paediatric Patients-08.07.09
19/23
Various regional techniques which have been used in childrenVarious regional techniques which have been used in children
are lumbar epidural, caudal epidural, intercostal, ilio inguinalare lumbar epidural, caudal epidural, intercostal, ilio inguinal
and ilio hypogastric, 3 in l block, sciatic nerve block, fasciaand ilio hypogastric, 3 in l block, sciatic nerve block, fascia
iliaca block, brachial plexus block, wrist block, penile block,iliaca block, brachial plexus block, wrist block, penile block,
infiltration block and topical analgesia.infiltration block and topical analgesia.
Before a regional or nerve block is done, considerations mustBefore a regional or nerve block is done, considerations must
be given regarding NPO statusbe given regarding NPO status,,emergency airway accesses,emergency airway accesses,intravenous access, standard monitoring of cardiorespiratoryintravenous access, standard monitoring of cardiorespiratory
function and resuscitative measures like oxygen, suction,function and resuscitative measures like oxygen, suction,
equipment for ventilation and intubation, and emergency drugsequipment for ventilation and intubation, and emergency drugs
etc.etc.
-
8/3/2019 Perioperative Pain Management in Paediatric Patients-08.07.09
20/23
Epidural injectionEpidural injection
Epidural injection can be done at thoracic, lumbar and caudalEpidural injection can be done at thoracic, lumbar and caudal
levels in children. Single shot caudal blocks are quite popularlevels in children. Single shot caudal blocks are quite popular
in the routine clinical practice in the children.T
he child almostin the routine clinical practice in the children.T
he child almostalways requires another method of pain relief after 3always requires another method of pain relief after 3--4 hours4 hours
in case of bupivacaine and 8in case of bupivacaine and 8--16 hours in case of morphine16 hours in case of morphine
injectioninjection given caudally.given caudally.
-
8/3/2019 Perioperative Pain Management in Paediatric Patients-08.07.09
21/23
Sacral epidural (caudal)analgesiaSacral epidural (caudal)analgesia
This is the most popular and useful regional block inThis is the most popular and useful regional block in
paediatrics. It is simple to perform and easily adaptable to daypaediatrics. It is simple to perform and easily adaptable to day--
care surgery. Common indications of caudal block arecare surgery. Common indications of caudal block arecircumcision, hypospadias repair, cystoscopy, anal surgery andcircumcision, hypospadias repair, cystoscopy, anal surgery and
club foot repair and Inguinal surgeryclub foot repair and Inguinal surgery like hernia repair.like hernia repair.
-
8/3/2019 Perioperative Pain Management in Paediatric Patients-08.07.09
22/23
Infiltration blockand topical analgesia
Subcutaneous infiltration of skin and the underlying
tissues at the site of surgical incision is one of the easiestmethods of making the patient reasonably pain free after incision.
Topical analgesia with lignocaine patch 5% or atopicallocalanaesthetic mixture EMLA (Eutectic Mixture of
Local Anaesthetics), can penetrate the skin for 5 mm depth,when covered with an occlusive dressing and left undisturbedfor 60-90 minutes. A routine perioperative use of topical, localor regional analgesia, alone or as a component of a multimodalapproach with NSAIDs or acetaminophen is particularlyuseful.
-
8/3/2019 Perioperative Pain Management in Paediatric Patients-08.07.09
23/23
D. Non-pharmacological approaches
Various non-pharmacological approaches eg.,psychological interventions like hypnosis, behavioral
therapy,Acupuncture, Transcutaneous electrical nervestimulation (TENS) have been described for post-operativeanalgesia. As all these techniques need a co-operation from the
child, its usefulness is limited only in a select group ofchildren. TENS have been seen to reduce postoperativenarcotic requirement after thoracotomies.