Acute Postoperative Pediatric Pain Management. Gamal Fouad S Zaki, MD Professor of Anesthesiology Ain Shams University firstname.lastname@example.org. Problems in the management of pediatric acute postoperative pain .
Gamal Fouad S Zaki, MD
Professor of Anesthesiology
Ain Shams University
Intrauterine Development of the Pain Pathways
20 wks Dendrites
30 wks wake/sleep
Anand et al. Measuring the severity of surgical stress in neonates. J PediatrSurg 1988; 23: 297–305
Anand et al. Randomized trial of fentanyl anesthesia in preterm neonates undergoing surgery: effects on stress response. Lancet 1987; i: 243–8
Wolf et al. Effect of extradural analgesia on stress responses to abdominal surgery in infants. Br J Anaesth 1993; 70: 654–60
Myelination 3rd Trimester
Descending Inhibition: mid infancy
Opioid receptors: fetus /neoborn
241 children aged 5 to 12 yrs to undergo elective outpatient tonsillectomy and adenoidectomy
Children’s self-reported postoperative pain.
Preoperative anxiety in young children undergoing surgery is associated with a more painful postoperative recovery & higher incidence of sleep problems
Local and Regional Analgesia / Anesthesia:
Giaufre et al. Epidemiology and morbidity of regional anesthesia in children: a one-year prospective survey of the French-Language Society of Pediatric Anesthesiologists. AnesthAnalg 1996; 83: 904–12
A prospective study of 24 409 paediatric regional anaesthetics found an incidence of complications of 0.9 in 1000 blocks, with no complications of peripheral techniques. Central blocks (15,013), most of which were caudals, accounted for more than 60% of all regional anesthetics
Dalens B. Complications in paediatric regional anaesthesia. In: Proceedings of the 4th European Congress of PaediatricAnaesthesia, Paris, 1997
Common complications are technical: block failure. Rare Complications: Infection, pressure area problems, peripheral nerve injury, local anaesthetic toxicity, and serious adverse effects of opioids
Simple Local techniques are effective:
Caudal Epidural Block:
Penetrate S Hiatus
Inject LA solution
Suggested maximum dosages of bupivacaine, levo-bupivacaine, and ropivacaine in infants and children (racemicbupivacaine being replaced by levobupivacaine and ropivacaine)Morton. Management of postoperative pain in children. Arch Dis Child EducPract Ed 2007 92: ep14-ep19
For continuous epidural levobupivacaine, a 0.0625% solution is effective
For single shot caudal: levobupivacaine and ropivacaine give similar analgesia but less motor block than racemicbupivacaine
Radio-opaque dye injected through epidural catheter in infants (1.8-4.5kg) after major surgery
Wider spread with 1ml/kg vs. 0.5ml/kg (11.5 vs. 9.3 segments), fewer skipped segments & greater density
Vas et al. Spread of radioopaque dye in the epidural space in infants. PaediatrAnaesth 2003; 13: 233–43
Bosenberg et al. Thoracic epidural anesthesia via caudal route in infants. Anesthesiology 1988
Tsui BCH, Seal R, Koller J. Thoracic epidural catheter placement via the caudal approach in infants by using electrocardiographic guidance. AnesthAnalg 2002; 95: 326–30
Tsui et al. Thoracic epidural analgesia via the caudal approach in pediatric patients undergoing fundoplication using nerve stimulation guidance. AnesthAnalg 2001; 93: 1152–5
Advantages in pediatric practice:
Oral Neonates 10-15mg/kg/dose q 6-8 hrs
Onset 30 min, sometimes used in premed
Erratic absorption: subtherapeutic plasma levels?
183 ASA I or II in-patients, aged 1–12 years, admitted for unilateral inguinal hernia repair were randomized to receive in a double-blind design either i.v. paracetamol 15 mg·kg−1 (n = 95) or propacetamol 30 mg·kg−1 (n = 88) for postoperative pain relief as soon as pain intensity was greater than 30 on a 100 mm visual analog scale
A single infusion of i.v. paracetamol 15 mg·kg−1 produced analgesia similar to a single infusion of propacetamol 30 mg·kg−1 following inguinal hernia repair in children. Paracetamol i.v. 15 mg·kg−1 was better tolerated at the injection site than propacetamol.
IV Paracetamol pharmacokinetics similar to oral or rectal with clearance reduced in neonates & infants reaching adult levels at approximately 2 years of age.
Safety of IV paracetamol in Neonates: good, but slow clearance calls for wider dose spacing
Allegaert et al. Hepatic tolerance of repeated intravenous paracetamol administration in neonates. PedAnesth 2008; 18:388-92.
Palmer et al. IV acetaminophen pharmacokinetics in neonates after multiple doses. Br J Anaesth 2008; 101:523-30.
Moiniche et al. Nonsteroidalantiinflammatory drugs and the risk of operative site bleeding after tonsillectomy: a quantitative systematic review. AnesthAnalg 2003
Krishna et al. Postoperative hemorrhage with nonsteroidal anti-inflammatory drug use after tonsillectomy. Arch Otolaryngol Head Neck Surg 2003; 129: 1086 may increase risk of reoperation for bleeding by 2%, but with better pain control & reduced PONV
Meta-analysis of 25 randomized controlled trials reporting incidence of perioperative bleeding attributable to NSAIDs in tonsillectomy patients
0.5 mg/kg diluted in 5% glucose to 1.0 mg/ml IV infusion. T1/2β=78 min (57-111min), Clearance 7.7ml/kg/min, 2x adults
Elimination of diclofenac appears to be at least as fast in children as in adults. There are no pharmacokinetic contraindications to its use as an analgesic in children.
Common to all opioids. Anticipate & manage: