ميحرلا نمحرلا للها مسب · regional anesthesia and analgesia •regional...

اهلل الرحمن الرحيمبسم

POSTOPERATIVE PAIN

MANAGEMENT IN PEDIATRIC

PATIENTS

Ezz El-Din Fikri Ismail, MD, DHPE

Prof. of Anesthesia & Pain Medicine

Al-Azhar University, Cairo, Egypt

[email protected]

mailto:[email protected]

Disclosure

• I have no relevant financial or non-financial

relationships to disclose.

Outline

• Causes of under-treatment of pain in children.

• Management of Acute Pain in Children:

• Non- pharmacological.

• Pharmacological

• Post-operative pain control in children.

• Recommendations from American Pain Society and

American Academy of Pediatrics.

Introduction

• Pain is both a sensory and emotional personal

experience, making assessment complex

(Melzack & Wall, 1965).

• Despite many research in recent years, pediatric pain is

often underestimated and undertreated

(Craig & Pillai Riddell, 2003).

Introduction

• The nervous system is sufficiently developed to process

nociception before birth.

• Children must be assumed to experience pain from birth

onward.

• Infants and young children may experience a greater

neural response following a noxious stimulus than do

adults due to:

• a more robust inflammatory response &

• the lack of a central inhibitory influence,.

Misconceptions that lead to Under-

treatment of Pain in Children

1. False belief that infants & children do not feel pain, or

suffer less from it than adults.

2. Lack of routine pain assessment in children.

3. Lack of knowledge regarding newer modalities & proper

dosing strategies for the use of analgesics in children.

4. Fears of respiratory depression or other adverse effects

of analgesic medications.

5. The belief that preventing pain in children takes too

much time and effort.

Committee on Psychosocial Aspects of Child and Family Health, American Academy of

Pediatrics; Task Force on Pain in Infants, Children and Adolescents, American Pain Society

Management of Acute Pain in Children


• Acute pain is more common than chronic pain in children.

• Pain from injury or illness is transient:

• can be easily managed by parents and caretakers.

• Iatrogenic acute pain is common & ranges from:

• needle stick procedures (immunizations, screening blood tests)

• acute severe pain e.g. surgery.

• Management include:

• Non-pharmacological

• Pharmacological

Non-pharmacologic Pain Management

• These include psychological strategies, education and

parental support.

• For children undergoing repeated painful procedures:

• Cognitive-Behavioral Therapy (CBT) interventions, which

decrease anxiety and distress, can be quite effective.

• They are not adequate as the sole means of pain relief for

most painful procedures.

Walco GA, Halpern SL, Conte PM. Pain in Infants and Children. In: Tollison CD,

Satterthwaithe JR, Tollison JW, eds. Practical Pain Management. Philadelphia; 2002


Non-pharmacologic Pain Management

• CBT techniques take

time to learn:

• simple distraction

techniques that divert

attention away from painful

stimuli, or

• positive incentive

techniques which provide a

small reward (e.g., stickers

or prizes).

• Not adequate alone.


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Pharmacologic Pain Management

• Most of the major organ systems are anatomically well

developed at birth,

• their functional maturity is often delayed.

• These systems rapidly mature approaching a functional

level similar to adults before 3 months of age.


Physiology & Pharmacology, 1

• Most analgesics (including opioids and local anesthetics)

are conjugated in the liver.

• Newborns (premature infants) have delayed maturation of

enzyme systems involved in drug conjugation.

• Many of these hepatic enzyme systems mature over the

first 1 – 6 months of life.



• Glomerular filtration rates are diminished in the first week

of life, esp. in premature infants,

• sufficiently mature to clear medications & metabolites by 2 weeks

of age.

• Newborns have a higher % of body weight as water &

less fat compared with older patients.

• Therefore, water soluble drugs have larger volumes of

distribution.



• Newborns have reduced plasma conc. of both albumin

and alpha-1 acid-glycoprotein than older children.

• This may lead to higher conc. of unbound drug (active)

• greater drug effect or drug toxicity.

• Newborns, esp. premature infants, have diminished

ventilatory responses to hypoxemia and hypercarbia.

• These ventilatory responses can be further impaired by

CNS depressant drugs e.g. opioids & benzodiazepines.


Paracetamol or Acetaminophen

Pediatric Pain: Pharmacological Management

Paracetamol, 1

• It is the most commonly used analgesic agent due to:

• excellent safety profile

• lack of significant side effects

• It is the mainstay for mild to moderate pain.

• It is often combined with opioid analgesics for severe pain

• Infants and children produce high levels of glutathione

(GSH) as a part of hepatic growth:

• this may provide some protection against overdose hepatotoxicity.


Paracetamol, 2

• It inhibits prostaglandin synthesis in the hypothalamus.

• It reduces hyperalgesia mediated by substance P.

• It reduces nitric oxide generation involved in spinal

hyperalgesia induced by substance P or NMDA.

• It has an opioid sparing effect.

Paracetamol, 3

• Recommended oral dose: 10 -15 mg/kg.

• Daily maximum oral dose should not to exceed:

• 75 mg/kg for children,

• 60 mg/kg for term neonates <10 days of age, and

• 45 mg/ kg for premature infants > 34 weeks gestational age.

• Single rectal dose of 30 - 45 mg/kg:

• produced plasma conc. in the effective range.

• subsequent doses of 20 mg/kg, at 6 hours interval.


Paracetamol: IV Dose Guide

Age/ weight Dose Max. daily dose

1 month – 50 Kg 15 mg/kg

up to 6 hourly

60 mg/kg/day

> 50 Kg 1 g up to 6 hourly 4 g/ day

Perioperative Analgesic Pharmacology in Children

http://www.anaesthesiauk.com/documents/perioperative_analgesic_pharm_for_children.pdf

Nonsteroidal Anti-inflammatory Drugs

Nonsteroidal Anti-inflammatory Drugs

• Pharmacodynamics and pharmacokinetics of NSAIDs in

children are not much different than in adults.

• The half-life is significantly longer in the newborn period,

• The incidence of GI & renal problems in children may be

less than that encountered in adults.

• Rectal and oral bioavailability are both good

• So, for short cases they are best given orally preoperatively.


NSAIDs

• Ibuprofen is used for

• mild to moderate pain,

• it is available in a liquid form.

• It has a better safety profile

than ketorolac.


NSAIDs

• Ketorolac (parenteral)

has been used for the

treatment of postop.

pain in children:

• as a single agent.

• as an adjuvant to opioid

analgesia.

• 0.5 mg/kg IV every 6

hours for up to 48 hrs.


Pediatric Pharmacotherapy (17) 2011

NSAIDs

• COX-2 inhibitor

(celecoxib) is available for

oral administration:

• In patients with juvenile

arthritis, celecoxib 6

mg/kg twice daily was as

effective as naproxen

7.5mg/kg twice daily.

Foeldvari I et al. A prospective study comparing celecoxib with naproxen in

children with juvenile rheumatoid arthritis. J Rheumatol. 2009


Dose Guidelines for Non-opioid Analgesics

Pediatric pain management. (2010). Journal of American Medical Association

http://www.amacmeonline.com/pain_mgmt/printversion/ama_painmgmt_m6.pdf


NSAIDs Dose Guide

Drug Route Dose

Ibuprofen Oral < 20 kg

> 20 kg

5 – 10 mg/kg up to 6 hourly

200 mg 6 hourly

Diclofenac Oral/ Rectal 1 – 3

mg/kg

Up to 3 mg/kg in divided doses



Opioids

Codeine

• Codeine is a poor opioid analgesic:

• causing more nausea and constipation than other opioids.

• It is available as an oral solution:

• the most commonly administered in young children.

• It is often given in combination with acetaminophen (10:1)

• Codeine’s analgesic effects derive from its metabolic

conversion to morphine via

• the enzyme O-demethylates


Methadone

• Methadone is available as an oral solution.

• It can provide excellent analgesia with TID dosing:

• because of its long half-life.

• Oral and intravenous doses are similar:

• oral bioavailability of 60% to 90%.

• It requires careful titration to prevent delayed sedation.

• Fatal respiratory depression may occur:

• with highest risk at initiation and with dose increases.

• QT interval prolongation & serious arrhythmia

• torsades de pointes.


Intravenous Opioids

• Opioids should be administered to children via

• oral or intravenous route.

• IM injections should be avoided.

• Intermittent IV boluses of morphine, hydromorphone or

fentanyl can provide rapid pain relief but for short duration:

• dosing interval should be every 2 to 4 hours.

• PCA or NCA used to avoid fluctuations in plasma conc.

• Meperidine is generally not recommended when other

opioids are available (toxic normeperidine: seizures).


Continuous Opioid Infusions

• For toddlers and children:

• initial morphine infusion rates are roughly: 1.25 mg/kg/hr.

• In newborns the initial infusion rates are much lower and

• range from 0.005 to 0.01 mg/kg/hr.

• Cardiorespiratory monitoring is required for infants less

than 3 months of age.

• Adjustment of these rates should be based on clinical

signs of either inadequate pain relief or increased

somnolence.


Patient Controlled Analgesia (PCA)

• With appropriate preop. teaching and encouragement,

children as young as 6 to7 y can use PCA pump.

• Children between 4 & 6 y, require encouragement from

their parents & nurses to push button before anticipated

painful movements or procedures.

• For infants and children unable to use PCA button, nurse

controlled analgesia (NCA) permit small titrated dosing of

opioids.


Starting Parameters for PCA


PCA

• Morphine is the most extensively studied in children.

• Basal infusions improve sleep quality:

• hypoxemia when used for postoperative pain management.

• One solution for this is to combine:

• PCA in bolus-only mode with

• round-the-clock adm. of NSAIDs and/or acetaminophen.

• For children with acute pain associated with chronic

illness, most developed some tolerance to opioids:

• larger basal infusion is preferred to control disease-related pain.


Local Anesthetics and Regional Anesthesia


Topical Anesthetics

• Local anesthetics should be injected into the skin to be

effective.

• Topical anesthetics are available to provide pain relief

prior to needle-stick procedures that children must

undergo in the first 6 years of life.


Eutectic Mixture of Local Anesthetics (EMLA)

• Eutectic mixtures of LAs are effective in reducing pain

from dermatologic procedures, venipuncture etc.

• lidocaine/prilocaine and lidocaine/tetracaine

• EMLA cream must be applied in a thick layer.

• It requires 30 to 60 minutes to become fully effective.

• New topical approaches to improve outcomes with EMLA:

• patch delivery,

• heat enhanced delivery.


Infiltration of Local Anesthetics

• In urgent or emergent situations:

• infiltration of 1% lidocaine can reduce the pain associated with

venous or arterial cannulation.

• Intradermal injection pain can be lessened by:

• use of a smaller needle &

• buffering of LA with the addition of NaHCO3 (ratio 4:1).

• A bio-injector uses compressed CO2 to inject lidocaine

rapidly beneath the skin.


Regional Anesthesia and Analgesia

• Regional anesthetic techniques are used in children to:

• decrease GA requirements

• aid in postop. pain management.

• Multimodal analgesia provide optimal analgesia:

• LAs, NSAIDs and opioids.

• Single-shot caudal injections of LAs are

• easy to perform for outpatient surgeries.

• Continuous epidural analgesia via catheters:

• provide excellent postop. analgesia for extensive abdominal and

lower extremity procedures.


Dosing guide for bupivacaine,

levobupivacaine and ropivacaine

Single bolus

injection

Maximum

dosage

Continuous

Infusion

Maximum

infusion rate

Neonates 2 mg/kg Neonates 0.25 mg/kg/hr

Children 2.5 mg/kg Children 0.5 mg/kg/hr



Postoperative Pain Control in Children

http://ether.stanford.edu/library/pediatric_anesthesia/pediatric%20pain%20manage

ment%20and%20regional%20anesthesia/PostoperativePainControlInChildren.pdf

http://ether.stanford.edu/library/pediatric_anesthesia/pediatric pain management and regional anesthesia/PostoperativePainControlInChildren.pdf

http://ether.stanford.edu/library/pediatric_anesthesia/pediatric pain management and regional anesthesia/PostoperativePainControlInChildren.pdf

Recommended doses of paracetamol for

postoperative pain relief in children

Route of

administration

Loading

dose

(mg/kg)

Short term

maintenance

(mg/kg/day)

Long term

maintenance

(mg/kg/day)

Oral 25 – 30 80 60

rectal 35 – 40 80 Not

recommended

Oral route is preferable because of wide variations in bioavailability of rectal route.

Postoperative Pain Control in Children. Pediatr Drugs 2003; 5 (11)


Postoperative Pediatric Dosages of NSAIDs

Route of

administration

Single dose

(mg/kg)

Number of

daily doses

Maximum

Doses

(mg/kg/day)

Diclofenac

(po or pr)

1 – 2 1 – 3 2 – 4

Ibuprofen

(po or pr)

5 – 10 3 – 4 40

Ketorolac

(po)

0.2 – 0.5 3 – 4 1

Ketoprofen

(po)

1 – 2.5 2 – 3 5



Management of Postoperative Pain

• Minor surgery

• Major surgery

Management of postoperative pain, 1

Minor surgery

Acetaminophen

+

Peripheral NB, caudal block, or wound infiltration

+

IV opioids in single doses, when needed.



Management of postoperative pain, 2

Major Surgery

(abdominal, thoracic, orthopedic, urogenital)

Acetaminophen and NSAID

+

Opioids

(continuous IV in children < 6 years &

PCA in children > 6 years)

OR

Regional Anesthesia

(continuous epidural or continuous paravertebral analgesia)



Recommendations

Recommendations from the American Pain

Society and the American Academy of Pediatrics, 1

1. Expand knowledge about pediatric pain & pediatric pain

management principles and techniques.

2. Provide a calm environment for procedures that reduce

distress-producing stimulation.

3. Use appropriate pain assessment tools and techniques.

4. Anticipate predictable painful experiences, intervene,

and monitor accordingly.



Recommendations from the American Pain

Society and the American Academy of Pediatrics, 2

5. Use a multimodal approach to pain management:

• (pharmacologic, cognitive, behavioral, and physical)

6. Use a multidisciplinary approach when possible.

7. Involve families and tailor interventions to individual

child.

8. Advocate for the effective use of pain medication for

children to ensure compassionate and competent

management of their pain.



ميحرلا نمحرلا للها مسب · regional anesthesia and analgesia •regional...

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