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Practical Postoperative Pain Management for Children

Practical Postoperative Pain Management for Children. R3 정준영. 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

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Practical Postoperative Pain Management for Children

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  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

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