Perioperative Pain Management in Paediatric Patients-08.07.09

8/3/2019 Perioperative Pain Management in Paediatric Patients-08.07.09

1/23

Perioperative painPerioperative painmanagement in paediatricmanagement in paediatric

patients.patients.

OBAIDOBAID


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.


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.


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


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.


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.


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.


8/23

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


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.


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.


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.


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.


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.


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.


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.


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.


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


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.


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.


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.


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.


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.


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.

Perioperative Pain Management in Paediatric Patients-08.07.09

Documents