Improving postoperative pain

outcomes for children

Muhammed Muhsin Ahmed Damudi

Dept.Of Anaesthesia and ICU
Sohar Hospital
In the name of Allah, the most
merciful and beneficent
Preamble
o Despite substantial evidence to guide
practice, children continue to have
significant pain after surgery
o The challenge is to implement
knowledge to provide safe effective
pain management to all children in the
right place at the right time
!!!
Objectives
After this presentation you will be able to:
Explain the importance of optimizing pain
outcomes after surgery
Describe what is known about pain outcomes after
surgery
Apply evidence to prevent and manage surgical
pain in children more effectively
 OUTLINE
Context
Why is good postoperative pain prevention &
management important?
How well is surgical pain managed in children?
Pain Management Strategies:evidence&controversies
General principles Pharmacology, Physical,
Psychological .the 3Ps
Whats Trending
How can we do better?
Postoperative pain is risky
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PAIN MANAGEMENT INTERVENTIONS
PAIN ALGORITHM
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PHYSICAL STRATEGIES
Acknowledgements

INTERNET
Background
Historically, children and infants received less
post-operative and procedural analgesia than
adults
Well documented that children are often
undertreated for pain
Kids were half as likely as adults to receive pain
medications in the ED for painful conditions (i.e.
fractures, burns, sickle cell pain crises)
30% kids vs. 60% adults got pain meds
Selbst & Clark, Ann Emerg Med, 1990
 What distinguishes pain in childhood
from adult pain?
IASP: An unpleasant sensory or emotional experience
associated with actual or potential tissue damage, or
described in terms of such damage.
The inability to communicate pain verbally in no way negates the
possibility that an individual is experiencing pain and in need of
treatment.
In pediatrics, pain is an inherent quality of life that
appears early in development and serves as a signaling
system for tissue damage.
Pain may be modulated by developmental stage, affective
state, cognitive state, prior pain experiences, distress or
suffering.
Cassell. NEJM 306:639,1994
Anand KJS and Craig KD Pain 67: 3, 1996
Barriers to Pediatric Pain Control

Belief that children, especially infants, do

not feel pain the way adults do
Lack of routine pain assessment
Lack of knowledge in pain treatment
Fear of adverse effects of analgesics,
especially respiratory depression and
addiction
Belief that preventing pain in children
takes too much time and effort
Pediatrics, 18 (3) 2001
Jeffrey Lawson, 1985
Landmark seminar paper
Pain and its effects in the human
neonate and fetus, 1987, NEJM.
Anand & Hickey.
Called into question the widely held belief that
neonates do not have the neurophysiologic
apparatus required to experience pain
Developmental Anatomy of Pain
Cutaneous nociception: sensory
terminals are present in the perioral area
at 7 wks GA, with spread to all body areas
by 20 wks GA
Dorsal horn: A fibers enter the spinal cord
prior to C fibers at 8-12 wks; A and C fiber
territories overlap at birth in the
developing substantia gelatinosa
Developmental Anatomy of Pain
Ascending pain pathways: completely
myelinated in the spine and brainstem
between 22 and 30 wks GA; myelination
extends to thalamus at 30 wks; to cortex at
37 wks-term
Descending inhibition: develops post term
Pain sensitivity may be more profound Nervous system less
effective at blocking painful stimuli
Pain in children is still undertreated
By health care professionals
Fear of adverse effects - inadequate knowledge of drug
dosing and safety across the spectrum of ages
Legal concerns about diversion or abuse
Inadequate assessment and patient disbelief
Costs and availability of medication
By parents
Lack of adequate instruction by health care
professionals
Fear of addiction and tolerance
By patients themselves
Suffer in silence
Pediatric Pain Assessment
Pain assessment = the crucial first step in
managing pain
Pain is multidimensional
Includes sensory, affective, cognitive,
behavioral, sociocultural, and physiologic
dimensions
Interactions of above components explain
variations that exist in patients response to pain
and perception of pain
Frequent reassessment just as important
Pain Scoring Tools

Health care providers need to use age-

appropriate validated pain scoring tools
Child self-report = gold standard
Must use an age-appropriate, reliable, and valid pain
tool
Infant or young child
May be assessed with behavioral pain tools coupled
with a parent report
The lower age limit for successful use of a self-
report pain scale is generally 3-4 years old
(Hicks et al., 2001; Wong & Baker, 1988)
Physiologic measures
Provide information about general
distress levels but are not sensitive or
specific indicators of a childs pain
Should only be used as adjuncts to self-
report and behavior parental report
Pain in the ED
Injuries: contusions, strains,
sprains, and fracture
Rest and splinting
Oral analgesics
Acetaminophen
NSAIDs
Aspirin
Opioids (i.e. Hydrocodone / Oxycodone)
Intravenous analgesics for moderate to
severe pain as with displaced fractures
Acetaminophen
Most commonly used analgesic drug in pediatric practice
Centrally-acting prostaglandin synthetase inhibitor
Antipyretic and analgesic activity but minimal anti-
inflammatory effects
Highly effective as sole analgesic for mild to moderate
pain
Synergistic when used in combination with NSAIDs and
opioids for moderate to severe pain
Oral dosing: 15 mg/kg q 4 hours
Rectal dosing: 30-40 mg/kg, followed by 20 mg/kg 6
hours later
Daily max: 90 mg/kg children, 80 mg/kg neonates, 60
mg/kg premature infants
Non-steroidal anti-inflammatory
drugs (NSAIDs)
Nonselective inhibitors of peripheral cyclooxygenase (COX)
Provide excellent analgesia with good safety margin
Children appear to have lower incidence of renal and GI side
effects than adults even with chronic administration
Except in newborn period, when t1/2 after administration is
significantly longer, the pharmacodynamics and
pharmacokinetics in children similar to that of adults
Dosing guidelines:
Ibuprofen PO 6-10 mg/kg q6h
Naproxen PO 5-6 mg/kg q12h
Ketorolac IV 0.5 mg/kg q6h
Comparable with opiates for treatment of postoperative pain
and orthopedic injuries with less sedation and fewer side
effects
Opioids
Most commonly used analgesic for moderate to
severe acute pain
Marked individual variation in opioid dose
requirements; therefore doses must be titrated
to effect
Come in different levels of potency and efficacy
Combined with acetaminophen for synergistic
effect
Oral dosing guidelines:
Hydrocodone: 0.1-0.2 mg/kg/dose q4h
Oxycodone 0.05-0.1 mg/kg/dose q4h
Codeine
Codeine
Phenanthrene alkaloid derived from morphine
Change in the methyl group on 3 position (substituted for the hydroxyl group)
One tenth the potency (analgesic properties) of morphine
Prodrug has very little to no analgesic properties in and
of itself
Metabolized in liver by CYP2D6 to become an active morphine metabolite
Commonly administered orally in combination with acetaminophen
At least 10% of American population does not have enzyme
necessary for conversion (genetic polymorphisms)
Not all enzyme systems are turned on at birth
Newborns do not have CYP2D6; therefore, no analgesic properties with
codeine, only vomiting
Very narrow therapeutic window, so genetic variability in
metabolism is more likely to have a relevant clinical effect
Morphine
Gold standard
Widely studied in infants and children
Metabolized by liver, excreted by kidney
Histamine release can lead to decreased peripheral
vascular resistance and hypotension
Only of concern if child has severe injury and showing signs of
hypovolemia
Full term infants < 3 months have decreased morphine
clearance (reduce starting dose by 25-50%)
10-20 hrs in preterm infants and 1-2 hrs in young children
Continuous pulse oximetry recommended
Children < 11 yrs have higher clearance and larger
volume of distribution for morphine and and its
glucoronides
Dosing: 0.05-0.1 mg/kg IV/SQ q3h
Fentanyl
Synthetic opioid which is 50-100 times more potent than
morphine
Highly lipid-soluble with rapid entry into the brain very rapid
onset (2-5 minutes) and short duration of action (30-45
minutes)
Ideal choice for ED
Eliminated almost entirely by hepatic metabolism
Rarely causes hypotension
Excellent choice for injured children with severe pain
Can rarely cause chest wall rigidity at high doses (>15
micrograms/kg)
Reversible with naloxone, but succinylcholine may be required
Dosing: 2-3 micrograms/kg IV q1h
Procedural Pain
Patients seldom
remember how great
a clinician you are,
but they DO
remember how much
or how little they hurt
when you were
treating them.
Procedural Pain
Consider the type of procedure, expected
duration of pain, the patient and parents
involved, and childs pain history
Educate the parents and patients on what to
expect
Utilize combination of non-pharmacologic
and pharmacologic methods maximizing
topical/local anesthetics
Calm environment
Consider anxiolytic/sedation
Topical Analgesics
Widely used for pain
associated with
needle pricks, IV
placements, lumbar
punctures, laceration LET

repairs, and
procedures on
superficial skin
lesions
Lidocaine Infiltration
Decreasing Pain
Buffer with bicarbonate (9:1 mixture)
Decreases pain of injection by neutralizing
acidic pH of lidocaine
Warm to body temperature
Inject slowly!
Use smallest gauge needle (30-gauge)
Inject directly into wound rather than
through intact dermis
Anxiolytic + Analgesic Combination
Benzodiazepine (Midazolam) + Opiate
(Fentanyl or Morphine)
Amnesia, sedation and muscle relaxation
Safe and effective in children
Likelihood of respiratory depression
increases with use of a sedative
Proper precautions to protect the airway must
be taken
Nitrous Oxide-Oxygen Analgesia
Advantages
Disadvantages
Fail-safe delivery
Painless system required
Odorless, tasteless
Equipment expensive
Rapid onset,
Scavenger device
short needed
duration of action
Produces patient
Requires sedation,
cooperation
amnesia and dissociation
May be used
Increased incidence
in youngof children
vomiting
Safe when
Greater personnel
mixed with
demands
oxygen
N2O Self-Administration by a
3-year-old
Ketamine hydrochloride
PCP derivative; NMDA receptor antagonist
Analgesic, amnesic, and sedative properties
without loss of protective airway reflexes
Causes dissociative amnesia
Rapid onset (IV: 1 min, IM: 5-10 min)
Dosing: 0.5-2 mg/kg IV or 4-5 mg/kg IM
Adverse reactions: Laryngospasm, emergence
reactions (less common in children than
adults)
Atropine (0.01 mg/kg) or Glycopyrrolate (0.005 mg/kg)
to prevent excess salivation
Benzodiazepine may decrease likelihood of
emergence reaction
Propofol
Non-opioid, nonbarbiturate sedative-hypnotic given
intravenously for sedation during short procedures
Potent sedative with amnesic properties; no analgesic
properties
Rapid onset of action (3 sec - 1 min) and rapid recovery
phase (5-10 minutes)
Use outside of OR by non-anesthesiologists controversial
Low complication rate comparable to midazolam in one
pediatric ED study, but advantage of shorter recovery
time with propofol (small sample size)1
Dosing: Initial bolus 1-2 mg/kg, followed by maintenance
infusion of 60-100 microgram/kg/min

1
Havel et al. Acad Emerg Med 1999
 Propofol for ED PSA - Concerns

Difficult to titrate to desired sedation endpoints

without overshooting to apnea and hypotension

Loss of protective airway reflexes during apneic

periods likely places patients at increased risk of
pulmonary aspiration, especially if positive
pressure ventilation administered
Gastric insufflation likely induces passive regurgitation
 Propofol for ED PSA Concerns
(continued)

Patients must be carefully screened for full

stomachs and difficult airways.
Propofol should only be used by providers with
in-depth knowledge of its adverse effects and
skilled in airway assessments and positive
pressure ventilation.
When propofol is administered, an experienced
provider must be dedicated to administering the
sedation, managing the airway and
cardiorespiratory status of the patient, and not
involved with the procedure being performed.
Propofol in ED future research
Prospective, randomized studies of pediatric
patients undergoing procedural sedation with
propofol in the ED needed to better clarify:
Risks of adverse events
Effectiveness of distress reduction, amnesia
Recovery and post-recovery experiences
Etomidate
Rapidly-acting intravenous sedative-hypnotic; no analgesic
properties
Fast onset (15-45 seconds), short duration of action (5-10
minutes)
Advantage of maintaining cardiovascular stability
Minimal effects on ventilation when used alone, although rapid
administration can lead to transient apnea
Common side effects: nausea, vomiting, myoclonus
Dosing: 0.1-0.2 mg/kg IV

Three reports of use in pediatric ED for procedural sedation:

Dickinson: Acad Emerg Med,2001
Ruth: Acad Emerg Med, 2001
Vinson: Ann Emerg Med, 2002
Etomidate future research
Prospective, randomized studies of
pediatric patients undergoing procedural
sedation with etomidate in the ED needed
to better clarify:
Standardized protocol
Dose (titrated to effect?)
Analgesic adjunct
Procedure specific
Impact of myoclonus on CT scans, suturing?
Elucidation of risk of apnea, aspiration
Dexmedetomidine
Selective alpha-2-agonist with analgesic and
sedative properties and minimal effect on
respiratory drive or cardiac function
Preliminary studies in pediatric patients
demonstrate it is a safe and effective
alternative for children undergoing diagnostic
imaging
Associated with a much shorter recovery time and less
need for adjuvant sedatives
Nonpharmacologic Techniques
Effect of environment itself must be
considered
Presence of child life therapists who are
trained in nonpharmacologic techniques for
reducing pain is vital
Three broad categories:
Cognitive
Behavioral
Physical
General Principles of
Pediatric Pain Management
Anticipate & prevent pain
Assessment is a continuous process
Reverse the reversible: treat the underlying
cause
Use multi-modal approach
Nonpharmacologic
Pharmacologic
Involve parents
Use non-noxious routes
Address associated psychosocial distress

Pediatrics in Review 2003; 24 (10)

Questions??