Practical Postoperative Pain Management for Children

1. Practical Postoperative Pain Management for Children R3 정준영

2. Do Children Experience Pain Differently? • Needle • painful symbol of all the evil of disease • Important variables • Cognitive and emotional development • Previous painful experiences • Ability to communicate • Family interactions • Psychological defense mechanisms • Withdrawing rather than crying or asking for medication

3. Do Child Express Pain Differently? • Emotional component of pain is very strong in children • Nonpharmacologic methods are very important • Minimal separation from parents : Most important • Reassurance, cudding, stroking, distraction • Assessment, intervention, reassessment : keys to good pain management • Pain assessment tools - older children : visual analog pain scale or scales with differing facial expressions - < 4 years : physiologic behavioral scale

4. Aren’t Patients Likely to Overmedicate? • Parents are more likely to undermedicate than overmedicate • Parents education increase home analgesic administration • All instruction should be written, and specific questions regarding administered analgesics should be asked during routine follow-up phone calls • Optimum home analgesic treatment - around the clock (not as needed) administration of minor analgesics - nonpharmacologic treatment

5. What Are My Pharmacologic Options? Nonopioid analgesics • AAP or NSAID : mild to moderate discomfort, reducing need for opioid • AAP • Traditionally used in same dose for oral or rectal administration : based on fever Tx rather than pain Tx - Oral adm : peak plasma conc. After 50min 10~15mg/kg every 5hours max adult dose 2.5g/24hrs - Recral adm : max blood conc. After 90mins loading dose 45mg/kg 25mg/kg rectal or 10~15mg/kg oral every 6~8 hours Max dose 90mg/kg/24hrs

6. Ibuprofen • 10mg/kg • Superior to AAP in child suffering Severe pharyngitis • Ketorolac • IM 0.75mg/kg or IV 0.5mg/kg every 6hours • Useful in orthopedic surgery or ureteral reimplantation • Cx : gastritis, impaired PLT function, renal function - well hydration is important • All of these NSAIDS can reduce the amount of opioid nessary to provide analgesia • Excessive amount of AAP or Ibuprofen can cause lethal organ damage

7. Opioid analgesics • Usually given to treat rather than prevent pain • M/c postop modality of opioid adm is as needed injection • Intermittent IV opioid - Fentanyl : 0.5~1μg/kg rapid onset, short duration combination with rectal AAP or regional analgesic technique - Morphine : 0.05 ~ 0.2 mg/kg in older children • Oral opioid - Codeine (0.5~1mg/kg). Often combined with AAP(10~15 mg/kg) • Oxycodon (0.2mg/kg) availabe only as tablet also combined with AAP or NSAID • Nasal opioid - Butorphanol ( 25μg/kg), Fentanyl (2μg/kg) - for children undergoing myringotomy and insertion of tubes

8. Regional Anesthetic Techniques Topical blocks • EMLA - 2.5% lidocaine + 2.5% prolocaine in an oil-in-water emulsion penetrate intact skin to a depth of 5mm • Iontophoresis of lidocaine - cause tingly sensation for about 10 min • To view vocal cord movement in patient who require direct laryngoscopy - Topical intratracheal licocaine(1~2mg/kg) • circumcision - Topical 0.5% lidocaine or 0.25~0.5% bupicvacaine - repeated every 6hours for 2days provide effective postop analgesia • Hernia or hydrocele repair - Bupivacaine 0.25~0.5% or ropivacaine 0.5%

9. Ilioinguinal-Iliohypogastric Nerve Block • Inguinal herniorrhaphy, hydroceletomy, orchiopexy • Three technique • Wound edge infiltration below the fascia by surgeon • Instillation of local anesthetics at end of dissection before closure 3. bupivacaine 0.25~0.5% with or without epinephrine in dose if as much as 10 ml ( large child)

10. Penile Nerve Block • Penile surgery : circumcision, hypospadia repair, simple retraction of foreskin • Little space between the fascia, neurovascular bundle, and the corpora - easy to inject local anesthetic into an unintended highly vascular area • 3 techniques • Topical anethetics apply : lidocain jelly or bupivacaine • Ring the base of the penis with a raised supf.wheal of local anesthetic • Retract pennis toward the feet and insert needle 90˚to the skin, just below symphysis pubis into the shaft of pennis. Feel the “pop” as the needle cross the Buck’s fascia. Inject half dose at 11 o’clock and half at 1 o’clock. AVOID EPINEPHRINE

11. Fasia Iliacus Compartment Block • Useful for surgery in Upper lumbar dermatome : femoral shaft fracture or osteotomy, skin graft fron front thigh, quadriceps m. biopsy

12. Single-shot Caudal Block • Easier than placing IV line in many chubby toddler • Useful for surgery below the diaphragm, especially in sacral and lower lubmar area • 15% failure rate for children > 7 years old • Bupivacaine 0.25% cause no delay in discharge • Epinephrine does not prolong the duration of block • Doses of 0.75~1 ml/kg are commonly employed for lumbar dermatomal surgery

13. Special Problems and Specific Procedures Tonsillectomy(Adenoidectomy) • High incidence of nausea and vomiting • Opioid lead to inc. N/V → aggressive use of AAP is important • IV dexamethason : reduce emesis in tonsillectomy pts. • Vigorous IV hydration and avoidance of early oral hydration will dec. N/V • The Use of local anesthetics is controversal

14. Myringotomy and Tubes • Nasal opioid : less behavior disturbance • Oral adm. Of AAP or ibuprofen sholud take place at least 1hr before surgery to achive therapeutic blood conc. By the end of surgery • Topical lidocaine • Rapid return to parental presence and nonpharmacologic measures

15. Orchidopexy • High risk for N/V • Avoidance of opioid • Antiemetics • Use of NSAIDs, AAP, regional blocks may be helpful

16. Bilateral Ureteral Reimplant • Combination of NSAIDs, AAP, and regional blocks is very helpful • Surgical pain is enough to require opioid • Bladder spasm can be real issue • Ketorolac has been specially shown to be efficacious

17. Strabismus • High risk for N/V • Avoid opioid • Use of NSAIDs, AAP, Ketorolac are helpful • Topical local anesthetics may be useful

18. Conclusions • Provide proactive analgesia for children both in the hospital and through the instructions for parents • Education is first step • Parents tend to undermedicate children - repeated education of parents with written instructions to administer NSAIDs, AAP, or even combinations including minor opioid by the clock rather than as needed • Topical agents can be used at home by parents in the postoperative period • Local anesthetics that can penetrate the skin are the boon the needle hating child - decrease the fear when coming hospital or see doctor • Recognize Assessment, intervention, reassessment are key to good pain management • It is an adult responsibility to provide proactive analgesia to children, not the child’s responsibility to request it