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Acute Postoperative Pediatric Pain Management. Gamal Fouad S Zaki, MD Professor of Anesthesiology Ain Shams University Problems in the management of pediatric acute postoperative pain .

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acute postoperative pediatric pain management

Acute Postoperative Pediatric Pain Management

Gamal Fouad S Zaki, MD

Professor of Anesthesiology

Ain Shams University

problems in the management of pediatric acute postoperative pain
Problems in the management of pediatric acute postoperative pain
  • Wrong conceptions: pain sensation in children (esp. neonates and premies) is less than adults
  • Lack of routine assessment for pain
  • Insufficient pain-related knowledge
  • Complexity of pain assessment in the absence of verbal communication (infans = voiceless)
  • Concern regarding adverse effects of pain management and lack of protocols/facilities to deal with them (respiratory depression, nausea and vomiting, sedation)
developmental pediatric neurobiology
Developmental Pediatric Neurobiology

Intrauterine Development of the Pain Pathways


20 wks Dendrites

30 wks wake/sleep

  • Neonates & even premis: have anatomic & functional requirements for pain perception and ?memory
  • Neonates /infants exhibit a graded hormonal stress response to surgical interventions
  • Adequate intra- & postoperative analgesia: modifies the stress response & reduces morbidity and mortality
  • Inadequate control results in altered response to subsequent pain

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

37 wks


30 wks


Myelination 3rd Trimester

20 wks

Sensory receptors

30 wks

Dorsal horn

Descending Inhibition: mid infancy

Opioid receptors: fetus /neoborn

effective acute postoperative pain management aims
Effective Acute Postoperative Pain Management: Aims
  • Recognize Pain and importance of control
  • Safely control Pain in all pediatric patients
  • Employ comprehensive care of emotional and physical aspects of pain
  • Anticipate pain and prevent it when predictable
  • Continue pain management after discharge
effective acute postoperative pain management tools
Effective Acute Postoperative Pain Management: Tools
  • Individualized management plan according to:
  • An algorithm of linked assessment/documentation/intervention and
  • A plan for managing breakthrough pain, adverse effects, and equipment-related issues
  • Pain prevention using multi-modal or Co-analgesia with 4 classes of drugs: LA, Opioids, NSAIDs, Paracetamol
  • Opioids are better omitted in day-case surgery
  • A Dedicated acute pain service
anticipate and prevent pain
Anticipate and Prevent Pain
  • Educate patient and parents on expected pain
  • Discuss measures to reduce anxiety and pain
  • Treat anticipated pain prophylactically: give paracetamol supp after induction of Anesth
  • Prevention of pain requires less medication than treating established pain

241 children aged 5 to 12 yrs to undergo elective outpatient tonsillectomy and adenoidectomy

  • Preop: child and parental situational anxiety
  • Postop pain and analgesic consumption assessed every 3 hrs. After 24 hrs in hospital, children were discharged & followed up at home for 14 days

Parental assessment of the children’s postoperative pain

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

pain assessment
Pain Assessment
  • Obtain detailed assessment
    • 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
assessment in neonates infants
Assessment in Neonates & Infants
  • Challenging
  • Combines physiologic and behavioral parameters
  • Scales available
    • NIPS (Neonatal Infant Pain Scale)
    • FLACC scale (Face, Legs, Activity, Cry Consolability)
children between 3 8 years
Children between 3-8 years
  • Usually have a word for pain
  • Tells more detail about the presence and location of pain; less on quality, intensity
  • Examples:
    • Color scales
    • Faces scales
children older than 8 years
Children older than 8 years
  • Standard visual analog scale, Same as used in adults
effective acute postoperative pain management techniques
Effective Acute Postoperative Pain Management: Techniques

Local and Regional Analgesia / Anesthesia:

  • Excellent analgesia, attenuate stress response
  • Good safety profile: few, mainly minor complications:

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

effective acute postoperative pain management techniques1
Effective Acute Postoperative Pain Management: Techniques

Simple Local techniques are effective:

  • Local wound infiltration
  • Local anesthetic creams: EMLA cream
  • Wound perfusion
effective acute postoperative pain management techniques2
Effective Acute Postoperative Pain Management: Techniques

Caudal Epidural Block:

  • Simple, effective, low cost
  • Safe when properly done: sterile technique, proper solution, aspirate for blood and CSF
  • Volume: 0.1-0.2% Bupivacaine

Caudal Block

Identify Landmarks

Skin Prep

Penetrate S Hiatus

Change direction

Aspirate!! check

Inject LA solution

kinetics of la in neonates and children
Kinetics of LA in neonates and children
  • Most Amide LAs are highly protein bound by α1-acid glycoprotein:
  • Significantly lower levels in neonates and infants, reaching adult levels by 6-12 months resulting in higher unbound active levels
  • Increased risk of toxicity may be counterbalanced by a greater volume of distribution?
  • Max safe dose not established in neonates
  • Caution is important to ensure safety

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

effective acute postoperative pain management techniques3
Effective Acute Postoperative Pain Management: Techniques
  • Epidural Spread:

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

effective acute postoperative pain management techniques4
Effective Acute Postoperative Pain Management: Techniques
  • Thoracic or lumbar Catheters inserted via caudal route are 85-93% successful in small children

Bosenberg et al. Thoracic epidural anesthesia via caudal route in infants. Anesthesiology 1988

  • Verification of position:
    • Radiological
    • ECG recording from tip of catheter compared to reference cutaneous electrode placed at desired dermatomal level

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

ultrasound guided regional blocks
Ultrasound guided regional blocks

Advantages in pediatric practice:

  • Visualization of anatomy, spread of LA
  • More rapid onset, block usually in anesthetized subject
  • Reduced volume of LA
  • Less ossification allows for caudal and epidural U/S guided block
adjuncts to local anesthetics
Adjuncts to Local Anesthetics
  • Combined with LA for caudal block to prolong duration of analgesia without increasing side effects (motor block) Anserminoet al. Nonopioid additives to local anaesthetics for caudal blockade in children: a systematic review. PaediatrAnaesth 2003;13:561–73.
  • ketamine, clonidine, fentanyl and diamorphine, S(+)-ketamine more potent, reduces neuro-psychiatric side effects (NMDA receptor block) Koinig, Marhofer . S(+)-Ketamine in paediatricanaesthesia. Paediatr Anaesth2003;13:185–7.
  • Neuraxialopioids: major surgery: Spine, Liver Transplant (caudal morphine)
systemic analgesics
Systemic Analgesics
  • Opioids
  • Nonopioids:
    • Paracetemol
    • NSAIDs: ketorolac, diclofenac, iboprufen
    • COX2 inhibitors
    • Aspirin (not used in pediatrics)
  • Routes: IV, IM, SC, Rectal, Oral
  • Mild analgesic, Antipyertic
  • Mild to moderate pain, morphine sparing effect in pediatric outpatients Korpela et al. Anesthesiology 1999
  • IV 15mg/kg (1.5ml/kg) over 15 min q 4-6 hrs. Peak analgesic effect of IV paracetamol occurs in 1 hour, duration 4-6 hrs
  • Rectal 40mg/kg first dose (commonly given after induction of anesthesia) and 20 mg/kg q 4-6 hrs. Peak after 60-120 min, formulations vary in bioavailability: lipophilic are better
  • Oral Children10-15 mg/kg/dose q 4 hrs

Oral Neonates 10-15mg/kg/dose q 6-8 hrs

Onset 30 min, sometimes used in premed

Erratic absorption: subtherapeutic plasma levels?

  • Good safety profile
  • Containdicated with severe liver impairement
  • Reduce dose if GFR<30ml/min, young infants, sick children, and preterm neonates
  • May cause liver failure with large overdose
  • Hepatotoxicity mediated by reactive metabolite (N-acetyl- p-benzoquinone-imine ), is a function of total dose, & develops when rate of production of reactive metabolite exceeds rate of supply of reduced glutathione
  • Maximum daily dosing
    • Infants: 60-75 mg/kg/day
    • <60 kg: 100 mg/kg/day
    • >60 kg: 4 grams/day

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.

  • Analgesic, Antipyretic , mild to moderate pain
  • Anti-inflammatory: COX inhibitor: Prostaglandin inhibitor
  • Inhibit platelet aggregation
  • Effective when used with regional blocks
  • Combination with opioids: opioid-sparing effects (30-40% in adults) with reduced side-effects
  • Combination with paracetamol: analgesia better than with either drug alone
  • Adverse reactions: most common are bleeding, gastrointestinal, skin, central nervous system, pulmonary, hepatic and nephrotoxicity

Avoided in:

  • infants less than 6 months?
  • children with aspirin or NSAID allergy
  • dehydration, hypovolaemia
  • renal or hepatic failure
  • coagulation disorders
  • peptic ulcer disease
  • significant risk of haemorrhage
  • Concurrent administration of anticoagulants, steroids, and nephrotoxic agents (aminoglycosides)
nsaids asthma tonsillectomy and orthopedics
NSAIDs: Asthma, Tonsillectomy, and Orthopedics
  • Caution in asthma, multiple allergies, check previous exposure, use if no advrse effect. Short et al. Use of diclofenac in children with asthma. Anaesthesia 2000; 55: 334–7
  • Use in Tonsillectomy is controvrsial:

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

  • Animal studies show impaired bone healing, limitation recommended in fusion surgery, difficult bone healing & limb lengthening procedures

Meta-analysis of 25 randomized controlled trials reporting incidence of perioperative bleeding attributable to NSAIDs in tonsillectomy patients

  • Of 4 bleeding end points (intraop blood loss, postop bleeding, readmission, & reoperation), only reoperation happened significantly more often with NSAIDs
  • Compared with opioids, NSAIDs were equianalgesic, and the risk of emesis was significantly decreased
nsaids ketorolac
NSAIDs: Ketorolac
  • IV NSAID (available P.O.)
  • Dose 0.5 mg/kg/dose q 6 hours
  • Onset after 10 minutes
  • Maximum I.V. dose 30 mg q 6 hours
  • Do not use more than 5 days
    • Significant increase in side effects after 5 days
  • Monitor renal function
nsaids diclofenac
NSAIDs: Diclofenac
  • IV, IM, Rectal and oral
  • Dose 1mg/kg/dose q 8-12 hours
  • Potent antipyeretic, analgesic
  • Onset after
  • Monitor renal function

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.

  • Potent action with binding to CNS opioid receptors
  • Moderate to severe pain
  • Addiction rare in pediatrics
  • Pharmacodynamic profile of different opioids vary with opioid receptor affinity
  • Increased risk of respiratory depression in neonates (pharmacokinetics vary with age)
opioids side effects
Opioids: Side Effects

Common to all opioids. Anticipate & manage:

  • Nausea and vomiting
  • Pruritis: esp. with neuraxial
  • Respiratory depression
  • Urinary retention
  • Constipation
  • Drug of choice for severe pain, various routes
  • Dose: 0.05-0.2mg/kg dose q 2-4 hrs
  • Metabolism: Hepatic Glucoronidation: morphine-3-glucuronide (M3G) & -6-glucuronide (M6G),plasma concentrations significantly greater than morphine

12 children, 9 premis, continuous infusion 10-360μg/kg/hr

  • Clearance higher in children than neonates: 25.7 vs. 4.7 ml/kg/min
  • Morphine glucoronidationenhanced after neonatal period (M3G/Morphine ratio higher in children)
  • No difference in M3G/M6G ratio in children and neonates, indicating parallel development of both glucuronidation pathways

Br J Anaesth 2004; 92: 208–17

  • M3G is the predominant metabolite in young children and total body morphine clearance is 80% that of adult values by 6 months
  • A mean steady‐state serum concentration of 10 ng/ml can be achieved in children after non‐cardiac surgery in ICU with an infusion of 5 µg/kg/hr at birth (term neonates), 8.5 µg/kg/hr at 1 month, 13.5 µg/kg/hr at 3 months and 18 µg/kg/hr at 1 year and 16 µg/kg/hr for 1‐3‐yr‐old children
  • IV use, 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
  • I.V. Infusion: 1-5 µg/kg/hour
  • Side effect of rapid administration may produce glottic and chest wall rigidity
  • Careful observation, immediate availability of airway equipment and skilled personnel
opioids monitoring
Opioids: Monitoring
  • Close observation of all patients receiving opioids
    • Respiratory rate: watch for trends
    • Routine vital signs
    • Sedation scales
  • Special Considerations:
    • History of Obstructive Sleep Apnea
    • Ex-prematures
    • Craniofacial anomalies
    • Infants who are younger than 6 months
    • Opioid-naïve patients with continuous infusions
general points
General points
  • Holistic care of emotional & physical components of pain
  • Inform parent & child about benefits & side effects
  • Use least invasive effective technique for anticipated pain
  • Match technique to complexity of surgery/procedure
  • Consider age, medical status and co-morbidity
  • Appropriate monitoring & safety measures are essential
  • The treatment of pain is not only ethically, but also physiologically essential