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Ch31. Pediatric Postoperative Pain

Ch31. Pediatric Postoperative Pain. R2 김용일. ANATOMIC AND PHYSIOLOGIC DIFFERENCES. Body composition 과 core organ function 의 성숙정도 확인 필요 Full-term newborn 에서는 total body water 가 체중의 약 80% 2 세경까지 60% 로 감소  water-soluble drug 의 volume of distribution 이 큼

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Ch31. Pediatric Postoperative Pain

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  1. Ch31. PediatricPostoperative Pain R2 김용일

  2. ANATOMIC AND PHYSIOLOGIC DIFFERENCES • Body composition과 core organ function의 성숙정도 확인 필요 • Full-term newborn에서는 total body water가 체중의 약 80% • 2세경까지 60%로 감소  water-soluble drug의 volume of distribution이 큼 • Newborn은 skeletal muscle mass와 fat store 적음  muscle & fat의 inactive site에 binding하는 양도 적음

  3. ANATOMIC AND PHYSIOLOGIC DIFFERENCES (2) • More side effects at a lower plasma concentration • Higher CNS drug concentrations 때문 • Cardiac output is higher • Rapid equilibration of drug concentrations • Immaturity of BBB • Increased passage of more water-soluble medications • Increased drug metabolism and excretion  Renal & hepatic blood flow is increased • Greater drug effect & toxicity  Decreased quantity & binding ability of serum albumin & AAG(alpha-1 acid glycoprotein)  이러한 성인과의 차이는 6세경 사라짐

  4. ANATOMIC AND PHYSIOLOGIC DIFFERENCES (3) • Spinal cord & dura mater • 신생아에서 L3, S3 level까지 닿음 • 1세경 L1, S1-2 level로 • Post. Sup. Iliac crest를 연결하는 intercristal line • 성인에서는 L4 or L5 level • Neonate에서는 S1 level • Base of sacrum에서의 epidural cath. Insertion이 비교적 쉬움  Less and more loosely connected fat in epidural spaces in infants

  5. PAIN ASSESSMENT • Specialized self-reporting scales • 3세 까지도 사용 가능 • 더 어린 경우 behavioral or physiologic measure

  6. NONOPIOID ANALGESICS • Acetaminophen • Rectal administration • 어린이에서 periop. Period에 사용 가능 • At least initially, higher dosing in needed • Surgical insicion 전에 사용시 more timely analgesia in early postop. Period 가능 • Higher dose는 significant opioid-sparing effect • Overall elimination is similar • Between neonates, children, and adults • Dose-dependent hepatotoxicity • 어린이에서 less common, less likely to be fatal

  7. NONOPIOID ANALGESICS (2) • Nonsteroidal anti-inflammatory drugs (NSAIDs) • IV ketorolac • Generally good safety record • Effects on bleeding • Controversial • Inhibitory effects on osteogenesis following bone surgery • Unclear • Combination of acetaminophen & NSAIDs • Toxicity does not appear to be additive • Aspirin (Acetylsalicylic Acid) • Not used • Reye syndrome • Acute, fulminant, potentially fatal hepatoencephalopathy • Children with influenza-like illness or varicella, who ingest aspirin-containing medications

  8. OPIOID ANALGESIA • Oral opioids • Codeine • 0.5-1mg/kg • Often combination with acetaminophen • Patient-controlled analgesia(PCA) • 5-6 years of age • Morphine (m/c), hydromorphone, fentanyl • Safe in children, more effective analgesia with greater patient satisfaction

  9. OPIOID ANALGESIA (2) • Parent/Nurse-assisted analgesia • Unwilling or unable to operate PCA button • Because of age, developmental delay, physical disability • More commonly used in cancer treatment-related pain • Such as oral mucositis with bone marow transplantation • Continuous intravenous infusions • Morphine의 경우 성인에 비해 • Longer elimination half-life • Lower plasma clearance • Marked interindividual variability in plasma morphine concentration • Kinetics of morphine & fentanyl • 6-12months of age 정도에서 성인에 근접

  10. OPIOID ANALGESIA (3)

  11. REGIONAL ANALGESIA • “Single-Shot” caudals (SSC) • In infants and children vs adults • Readily palpable landmarks • Relative ease of caudal block insertion • 10-12세까지 lumbosacral to mid-thoracic dermatome level의 수술시 적용 • Bupivacaine • Concentration : 0.125%-0.25% • Injection volumes : 0.5-1.5 ml/kg • Provide analgesia for upper lumbar to mid-thoracic levels • Upper volume limit : 20ml • Maximum recommended dose : 2.5-3.0 mg/kg • 4개월 이하 유아에서는 upper limit of 1.25 mg/kg • Combined epidurally with 1-2ug/kg fentanyl, 20-50ug/kg morphine, or 1-2ug/kg clonidine (alpha-2-adrenergic agonist) • Delayed respiratory depression : epidural morphine 주입 22시간 후 까지 나타날 수 있음 • 1세이하 유아에서 특히 위험 • Test dose of 0.1ml/kg(maximum 3ml) of local anesthetic with 1:200,000 epinephrine (5ug/kg) • Increase in T wave, heart rate (>10bpm), systolic BP (>10%), within 60 seconds  positive test dose

  12. REGIONAL ANALGESIA (2) • Continuous epidural infusions • 4-6개월 이하의 유아에서는 lower infusion rates가 권장됨 • Lower protein binding으로 인한 higher free fractions • Pharmacokinetic differences에 의한 higher plasma levels & prolonged drug half-life • Catheter tip은 block시킬 dermatome 주위에 위치시켜야 함 • Infants나 작은 아이에서는 catheter를 caudal로 삽입하여 lumbar or thoracic level까지 올릴 수 있음 • 어린 아이는 cooperation이 어려우므로 전신마취가 유도된 후에 시행 • Patient-controlled epidural analgesia는 5세 이상 어린이에서 사용 가능

  13. REGIONAL ANALGESIA (3) • Peripheral nerve blocks • Ilioinguinal / iliohypogastric block • Penile block • Femoral block • Digital block • Head and neck blocks

  14. Ch32. Pain managementduring Pregnancy and Lactation R2 김용일

  15. 거의 모든 약물은 placenta 또는 모유를 통해 아기에게 전달됨 • Umbilical v.이나 모유에서의 농도 결정 인자 • Concentration gradient • Lipid solubility of drug • Degree of ionization • Protein binding • Diffusion capacity of membrane • 아기에 대한 effect는 다음에 따름 • Gestational age or age • Amount and duration of drug exposure • Specific drug • 약물에 대한 maternal exposure를 최소화하고 nonpharmacologic therapies를 이용하기 위해 최선을 다해야 함 • 약물이 필요할 경우, benefit과 risk를 잘 따져보아야 함 • Minimum effective dose 사용할 것

  16. DRUGS DURING PREGNANCY • Pharmacokinetic changes during pregnancy • G-I function의 변화는 oral drug absorption을 변화시킴 • GFR 증가로 renal elimination은 증대됨 • Total body water 증가로 drug distribution과 peak concentration도 변함 • Protein binding은 대개 감소 • Drug clearance는 증가되어 있으므로 free drug concentration은 대개 변화 없음

  17. DRUGS DURING PREGNANCY (2) • Transfer of drugs across the placenta • Amount of drug that crosses placenta depends on • Maternal cardiac output • Fetal cardiac output • Placental binding • Placental metabolism • Factors that influence passive diffusion across the placenta • Amount of fetal exposed drugs depends on • Fetal metabolism • Fetal protein binding • Distribution of fetal cardiac output

  18. DRUGS DURING PREGNANCY (3) • Teratogenicity • Possible adverse effects • Structural malformations • Acute neonatal intoxication or neonatal abstinence syndromes • Intrauterine fetal death • Altered fetal browth • Neurobehavioral teratogenicity • Teratogenesis는 critical period of organogenesis와 연관 • LMP 31일 후부터 71일 후 까지 • 31일 전에는 all-or-none effect • 특히 CNS는 2nd & 3rd trimester에도 계속 발달하므로 이 시기의 fetal drug exposure 또한 위험

  19. DRUGS DURING PREGNANCY (4) • Food and drug administration risk classification • Category A에서 X로 갈수록 반드시 위험이 커지는 것은 아님 • 단지 20-30가지 약물만 teratogen으로 알려져 있지만 category X에는 70가지 이상이 올라가 있음 • 모든 신약들은 category C로 분류되어 있음

  20. DRUGS DURING PREGNANCY (5) • Specific drugs • Aspirin & NSAIDs • Aspirin은 gastroschisis 위험 증가시킴 • 임산부는 150mg/day 이상 정기적으로 복용하지 말아야 함 • Ibuprofen & naproxen은 1st trimester때 teratogenic하지 않음 • Prostaglandin inhibitor는 ductus arteriosus를 narrowing • 약물 투여 중지시 reversible • Fetal urine output 감소시켜 amniotic fluid volume 감소시킴 • May prolong pregnancy and labor • 출산에 임박하여 aspirin 복용 시 neonatal intracranial hemorrhage 발생 증가 • 3rd trimester시에는 full-dose aspirin & NSAIDs 피할 것 • 임신중 mild analgesic 필요시 acetaminophen 사용 • Opioids • Teratogenic evidence는 없음 • Chronic in utero exposure to opioids • Neonatal abstinence syndrome 유발 • 임신중 mild or moderate pain 치료 • Acetaminophen combined with hydrocodone or oxycodone 사용

  21. DRUGS DURING PREGNANCY (5) • Bupivacaine & lidocaine • Not associated with risk of terotogenicity • Mepivacaine은 fetal anomaly를 2배 발생시킴 • 실험규모가 작아서 결론내리기는 어려움 • Steroid • Orofacial clefts와의 연관성은 controversial • Epidural steroid therapy는 minimal fetal risk • Placenta가 prednisolone을 inactivation 시킴 • Other adjuvant medications • SSRIs, tricyclic antidpressant drugs • Not teratogenic • Anticonvulsants • Phenytoin, carbamazepine, valproic acid • Fetal dysmorphic syndrome과 연관 • Ergotamine • Contraindicated in pregnancy • Teratogenic & causes uterine contractions • Beta-blockers • Not teratogenic • May be associated with intrauterine growth retardation

  22. DRUGS DURING LACTATION • Milk to plasma (M:P) ratio • Index of amount of drug that is excreted into breast milk • Breask milk is slightly more acidic than plasma • Weak bases, lipid soluble, low protein bindiong drug에서 passive diffusion이 쉬움 • Infant plasma concentraion은 대개 milk concentration의 1%-2% 정도 • M:P ratiork 1 이더라도 infant plasma concentration이 therapeutic level에 이르는 경우는 드물다 • Postpartum period • Colostrum은 소량이므로 영향 적음 • 대부분의 모유는 수유동안 또는 직후에 만들어짐 • 수유 후 잠시 시간이 지난 후에 약물을 복용 • Long-acting drug 피할 것

  23. DRUGS DURING LACTATION (2) • American academy of pediatrics • 수유부에 약 처방시 고려할 점 • 약물치료가 정말로 필요한가? • 가장 안전한 약물을 선택 • Mild analgesia에서 aspirin보다는 acetaminophen • 유아에게 위험성이 있을 경우 infant serum drug level을 monitoring 할 것을 고려 • 수유 직후나 아이가 잠들려 할 때에 약물을 복용

  24. DRUGS DURING LACTATION (3) • Specific drugs • Acetaminophen & NSAIDs • Acetaminophen • Safest analgesic for nursing mothers • Aspirin • Intermittent use는 위험성 증가시키지 않음 • Chronic aspirin therapy 시에는 adverse side effects 관찰해야 함 • Opioids • Cross freely into breast milk • Americal academy of pediatrcians에서는 모유수유시의 opioid사용이 가능하다고 간주 • 유아에서 부작용 발현 가능한 혈중농도까지 올라갈 수 있음 • Opioids (특히 meperidine) 사용시 adverse effects 발생 여부를 monitor 하여야 함 • Steroid • Prednisone or prednisolone은 maternal dose의 1% 이하만 모유로 분비됨

  25. DRUGS DURING LACTATION (4) • Anticonvulsants • Carbamazepine, phenytoin, valproic acid • May be used safely during lactation • Tricyclic antidepressants • 아직 확실치 않음 • Beta-blockers • 유아에서 subtherapeutic level만 초래 • Ergotamine • Neonatal convulsions, GI disturbances • Sumatriptan • Injection 후 8시간 동안 pumping & discarding milk로 infant exposure 피할 수 있음 • Propranolol • 유아의 serum concentrations은 therapeutic dose의 1% 미만

  26. IMAGING DURING PREGNANCY • 임신 15주까지는 ionizing radiation 피할 것 • Gestational age와 흡수된 방사선의 fetal dose가 방사선의 영향을 결정하는 factor • 착상 전에는 embryo에 치명적이지만 teratogenic effect는 없음 • MRI도 1st trimester에는 가능하면 피할 것 • 초음파 등으로 충분치 않고 다른 방사선 검사가 필요할 경우에는 MRI가 indication

  27. PAIN SYNDROMES DURING PREGNANCY AND LACTATION • Musculoskeletal pain • Back pain • Very common : about 50% • Widening of sacroiliac synchondroses and pubic symphysis • Hormonal change에 의해 • Located lat. to lumbosacral junction • May radiate to post. thigh (not leg or foot) • 임신중 back pain은 lumber lordosis에 의해 악화됨 • 임신중 disc herniation은 증가하지 않음 • Lumbosacral plexus에 대한 fetus의 direct pr.가 lower ext. Sx.의 원인

  28. PAIN SYNDROMES DURING PREGNANCY AND LACTATION (2) • Musculoskeletal pain (continued) • Treatment • Traditional conservative techniques이 우선적으로 고려되어야 함 • Instruction on proper body mechanics • Back exercises • Relaxation training • Special pillows to support the pregnant abdomen • Referral to a physical therapist • Acetaminophen • Drug of choice for minor back pain • 임신 1,2기 때 NSAIDs의 short-term use는 무방함 • Severe back pain 때는 opioid therapy가 필요할 수 있음 • Epidural steroid injection • Lumbar nerve root compression과 동반된 acute radicular pain

  29. PAIN SYNDROMES DURING PREGNANCY AND LACTATION (3) • Headache • Migraine headaches • 임신중엔 드물다 • 임신 중에 새로 생긴 migraine-like headache는 다른 중요한 원인을 찾아보아야 함

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