Perioperative pain managenent in infants and children

1. Pharmacologic management of acute
perioperative pain in infants and children.
Dr. ABHINAV CHAUDHARY ;JUNIOR RESIDENT.

2. 
INTRODUCTION
PAIN DEFINITION AND PATHOPHYSIOLOGY
PAIN MANAGEMENT
• PAIN ASSESSMENT SCORES
• NON PHARCOLOGICAL MANAGEMENT
• PHARMACOLOGICAL MANAGEMENT
• PREUMPTIVE ANALGESIA
• MULTIMODAL ANALGESIA
SUMMARY AND CONCLUSION
CONTEND

3. 
• Infants and children present unique challenges that
necessitate consideration of the child’s age,
developmental level, cognitive and communication
skills, previous pain experiences, and associated
beliefs.
• Painful experiences can imprint themselves indelibly
on the nervous system.
• Pain in infants, children, and adolescent is often
underestimated and under treated .
INTRODUCTION

4. • Perioperative pain control is an essential component
of the anesthetic plan for infants and children.
• Difficult to assess , led to the creation of numerous
age specific pain management tools and scores.
• Difference in Pharcokinetics and Dynamics of the
drugs.

6. • Unpleasant sensation localised to a part of the body.
• Duality of pain : both a sensation and emotion.
• Acute associated with stress response.
• PERIPHERAL MECHANISMS
The Primary Afferent Nocioceptor
• Peripheral nerve consists of axons of three different
neurons
1. Primary sensory afferent
2. Motor neurons
3. Sympathetic postganglionic neurons
• Cell bodies located in dorsal root ganglion
• Classified : diameter, conduction velocity, myelination.

7. A-beta
Light touch and or moving stimuli
Does not produce pain
A-delta and C fibers
Skin, deep somatic and visceral structures
Produce subjective experience of pain.
Noxious stimuli
Heat, intense cold, mechanical distortion, changes in pH
chemical irritants, serotonin, bradykinin ,histamine.
Vanilloid receptor
TrpV1,mediates perception of some noxious stimuli
Capsaicin

8. Inflammatory mediators
BK,Nerve growth factor,
Prostaglandins ,Leukotrines

9. NOCICEPTOR
Induced inflammation

11. Spinal cord and reffered pain
• Axons of primary afferent nociceptors enter the spinal cord
via the dorsal root.
• In presence of noxious stimuli these release
neurotransmitters that excite the spinal cord neurons.
• Glutamate rapidly excite the second order dorsal horn
neurons.
• Peptides Substance P and Calcitonin related peptide-
produce a slower and longer lasting excitation of dorsal
root neurons.
• Axon of each primary afferent contacts many spinal
neurons and each spinal neuron receives convergent input
from many primary afferents.

12. • All spinal neurons that receive inputs from viscera and deep
musculoskeletal structure also receive input from the skin.
• Afferents supplying the diaphragm are derived from third
and fourth cervical dorsal root ganglia, primary afferents with
the cell bodies in the same ganglia supply the skin of the
shoulder and lower neck.
• Mislocalized to a place which roughly corresponds to region of
the skin innervated by same spinal segment.
• Spatial displacement of the pain sensation from the site of injury
that produces it is REFRRED PAIN.

14. 
Pain assessment scores
Accurate pain measurements in children are difficult to
achieve.
Three main methods are currently used to measure
pain intensity: self report, behavioral, and physiological
measures.
Numerous scales available ,the most common being the
Neonatal Facial Coding System (NFCS) and the
Neonatal Infant Pain Scale (NIPS).

15. Neonatal Facial Coding System (NFCS).
It is used to monitor facial actions in newborns.
The system looks at eight indicators to measure pain intensity
brow bulge, eye squeeze, nasolabial furrow, open lips,
stretched mouth (horizontal or vertical), lip purse, tout
tongue, and chin quiver .
It has been proven reliable for short duration, acute pain in
infants and neonates.
NFCS is able to discriminate between degrees of distress, but
not between pain-related and non pain-related distress .
The system is also difficult to assess in intubated neonates.

16. Neonatal Infant Pain Scale (NIPS).
The scale takes into account pain measurement before, during and after
a painful procedure, scored in one-minute intervals.
The indicators include: face, cry, breathing pattern, arms, legs, and
state of arousal.
The Premature Infant Pain Profile (PIPP) .
Crying Requires Increased Vital Signs Expression Sleeplessness(CRIES).
Maximally Discriminate Facial Movement Coding System(MAX).
The COMFORT Scale.
The Child Facial Coding System (CFCS).
Poker Chip Tool.
Visual Analogue Scale (VAS).
Paediatric Pain Questionnaire.

19. Surgical stress

21. 
Nonpharmacological
management

22. 
REGIONAL
LOCAL
NEURAXIAL
Open thoracotomy or large subcostal incisions (for improved
pulmonary toilet and to allow for early extubation)
Amputations or limb-salvage procedures (eg, tumor surgery)
with risk of developing phantom limb sensations.
Knee surgery that requires continuous range of motion devices
or intensive early physical activity.
Pharcological methods

23. Major osteotomy (eg, pelvic /femoral osteotomy for congenital
hip dislocation)
Procedures that predispose to bladder, ureteral, or muscle
spasm (eg, genitourinarysurgery, tendon transfers, or tendon
lengthening procedures)
CAUDAL EPIDURAL

24. EPIDURAL SPACE

31. Efficacy of regional anesthesia.
Safety of regional anesthesia in children.
Awakeversus asleep block or catheter placement.
Local anesthetic dosing in children.
Increased risk of LAST with regional anesthesia techniques.
Low serum levels of alpha-1 acid glycoprotein (AAG), which binds
amide LAs
Immature hepatic clearance of these LAs

32. Multimodal approach
Combination of drugs with different MOA
Reduce side effects
Opiod sparing effect
Preumptive analgesia
Introduction of an analgesic regimen before the onset of
noxious stimuli.
Emphasis on preventing sensitization of the nervous
system.
Started before the surgery continued througout the post
surgical period

36. Acetaminophen—
Perioperative acetaminophen for postoperative analgesia.
Continue postoperative, regularly scheduled acetaminophen
for up to 72 hours, depending on the procedure.
Administer acetaminophen 15 mg/kg orally or intravenously
30 minutes before the procedure, and postoperatively every six
hours, maximum dose 3.25 g per day.
Avoid rectal administration.
Avoid fixed dose combination with steroids.
Rectal dosing is never used in the neutropenic child because of
the risk of bacteremia.

37. Nonsteroidal anti inflammatory drugs
Moderate to severe post opereative pain.

38. NSAIDs may be associated with renal injury, platelet
dysfunction, gastrointestinal toxicity, and possibly poor bone
healing.
Reduced dosing or avoid
Age <6 months
Renal dysfunction, or those taking potentially nephrotoxic
medications
Hypoperfused states (eg, hypovolemia, cardiac dysfunction)
Coagulopathy, intrinsic or caused by medications
History of gastrointestinal hemorrhage or inflammatory bowel
disease

39. Non opioid adjunctive medication
Gabapentin –
Administer a single dose of gabapentin 15 to 20 mg/kg orally
(maximum dose 600 mg) two hours prior to induction for
children who undergo major surgical procedures (eg, scoliosis
repair, pectus excavatum repair)
Associated with significant postoperative inflammatory pain
and additional neuropathic pain component.
Limit the dose to 600 mg to avoid delayed emergence from
anesthesia and excessive immediate postoperative sedation.
Do not continue gabapentin postoperatively, due to the risk of
respiratory depression when combined with opioids.

40. Ketamine
NMDA Receptors
Dissociative anaesthesia ;Emergence delirium
Raised intracranial , intraocular pressure ,hypertension.
Analgesic adjuvant at "ultra-low" dose ranges
of 0.025 to 0.05mg/kg/hour up to 0.1 mg/kg/hour IV
Opiod sparing

41. Dexmedetomidine –
Single dose of dexmedetomidine 0.5 to 1 mcg/kg
IV for a wide variety of patients primarily for prophylaxis for
emergence delirium.
Dexmedetomidine is a selective presynaptic alpha
adrenoreceptor agonist with sedative and possible analgesic
properties.
Multimodal opioid-sparing strategy .
ICU sedation.

42. Opioids—
Indicated for moderate to severe postoperative pain.
Safe use of systemic opioids requires modification of doses
for high-risk patients and monitoring for respiratory
depression and side effects.
Start with low doses, and increased in small incremental
amounts as necessary based on patient response.
Prematurity, age, history of apnea, and other underlying
disease.

43. Avoid opioid infusion.
Avoid other respiratory depressants.
High-risk patients.
Regularly scheduled versus as needed dosing.

44. Monitoring for sedation
Modified Pasero Opioid Induced Sedation Scale (m-POSS),
and attempt to maintain a score of 1or 2 (either awake and
alert or slightly drowsy but easily aroused by voice or light
touch).
S – Sleep, easy to arouse: • No action necessary
1 – Awake and alert: No action necessary
2 – Slightly drowsy, easily aroused: No action necessary
3 – Frequently drowsy, arousable, drifts off to sleep during conversation:
monitor respiratory status and sedation level closely until sedation level is
stable at <3; consider reducing opioid dose.
4 – Somnolent, minimal or no response to verbal or physical stimulation: stop
opioid; consider administering naloxone; notify prescriber or anesthesiologist;
monitorrespiratory status and sedation level closely until sedation level is stable
at <3 and respiratory status is satisfactory.

45. Monitoring for respiratory depression
Clinical assessment
Oxygen saturation
Importantly, oxygen administration may improve peripheral
arterial oxygen saturation while masking signs of
hypoventilation.
Intensified monitoring should be utilized in all infants (whose respiratory
control mechanisms may be immature) and any child who has significant
central nervous system or cardiorespiratory comorbidity,
obstructive/central sleep apnea, or who requires supplemental oxygen to
maintain oxygen saturation while receiving IV opioids postoperatively.
End tidal Co2 monitoring
.

47. Patient-controlled analgesia in children
PCA is a widely used modality of IV opioid administration
in children who are capable of understanding and
controlling the PCA pump, usually children over seven or
eight years of age.
Programmed to allow the patient to self-administer small
doses of opioid with a fixed lockout interval.
Reduces delay in patient access to pain medication.
Sense of control over pain.
Lower total dose of opioid compared with as needed or
around the clock bolus opioid administration

48. PCA settings –
The use of a continuous background infusion for PCA is not
routinely recommended.
Limited to patients who are opioid tolerant and/or receiving
care in a properly monitored unit.
If the demand dose alone provides inadequate relief, allow
several supplemental clinician-administered (usually nurse-
administered) bolus doses that are based on strict limits and
clinical evaluation criteria.
Set the patient-activated demand dose lockout interval to at
least 10 minutes and the minimum time period between
clinician boluses set at 15 to 20 minutes.

49. Dose adjustments
Review of the pump history.
Patients who press the button in a staccato fashion are
either highly anxious or need additional education about
the pump's functionality. The same may be true for
patients who rarely use the button and are yet in apparent
pain.
The PCA usage pattern history, the patient's pain intensity,
and underlying medical/surgical condition should be
evaluated within several hours of initiating PCA.

50. If the one hour demand dose total approaches the amount
allowed by the lockout interval, we increase the demand
dose by approximately 20 percent.
An increase in demand dose may also be indicated if
frequent clinician boluses have been required.
If the patient cannot sleep or obtain relief because of the
need for frequent self administered doses, consider a night-
basal infusion (with intensified monitoring required).
If conventional dosing does not relieve pain adequately, the
patient should be evaluated for underlying pathology,
especially for patients who cannot effectively communicate.

55. 
References
 HARRISON Principles of internal Medicine 20th edition.
 Pain in Children: Assessment and Nonpharmacological Management
Rasha Srouji et al.
 Pharmacologic management of acute perioperative pain in infants and
children. William Schechter, MD
 New Concepts in Acute Pain Therapy: Preemptive AnalgesiaALLAN
GOTTSCHALK, M.D., PH.D.

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