PAIN MANAGEMENT/ANESTHESIA
| ACUTE PEDIATRIC PAIN MANAGEMENT IN THE OFFICE —Maurice S. Zwass, MD, Professor of Anesthesia
and Pediatrics, and Associate Director, Pediatric Critical Care Medicine, University of California, San Francisco, School
of Medicine
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| Pain: International Association for the Study of Pain (IASP) definition—unpleasant sensory and emotional experience
arising from actual or potential damage to tissue; physiologic and psychologic components contribute to experience
of pain; transduction—nociceptors detect painful stimuli; under normal conditions, patient experiences pain proportionate
to stimulus; disproportionate or chronic pain considered pathologic; types of acute pain—somatic (described
as sharp, aching, or throbbing); visceral (more diffuse; described as gnawing or cramping)
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| Definitions: allodynia—pain elicited by non-noxious stimulus (mechanical or thermal); hyperalgesia—
exaggerated pain response; hyperpathia—delayed explosive pain response to noxious stimulus
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| Acute vs chronic pain: acute—functions as “warning system”; associated with anxiety; controlled by analgesics;
amenable to scoring and assessment; chronic—has no apparent purpose; associated with depression; rarely controlled
by analgesics alone; difficult to assess
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| Pain relief vs comfort: discomfort multifactorial; when analgesia sufficient, but (preverbal) child remains upset,
consider adverse effects of medications (eg, nausea) before increasing pain medication
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| Factors that affect response to pain: personality characteristics; coping mechanisms; attitudes of family and
culture; past pain experiences; presence of chronic pain; reinforcement of behavior; threshold and tolerance to pain
(changes with age and situation); ability to report symptoms
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| Prioritizing pain management: Agency for Healthcare Research and Quality (AHRQ; formerly Agency for
Health Care Policy and Research [AHCPR]) began creating guidelines for clinical practice in 1990; guidelines for
infants, children, and adolescents available online through National Library of Medicine (http://text.nlm.gov); material
available in different languages; Joint Commission on Accreditation of Healthcare Organizations (JCAHO)
now emphasizes assessment and management of pain; some states require education in pain management and palliative
care for renewal of medical license
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| Barriers to adequate pain management: health care professionals—inadequate knowledge; poor assessment of
pain; concerns about controlled substances (regulations, addiction, tolerance, adverse effects); health care system—
low priority given to treatment of pain; inadequate reimbursement; restrictive regulation; problems of availability and
access; patients and families—reluctance to report pain (child may fear consequences); fear of implications of pain
(eg, disease); concern that reporting pain may distract clinicians from treating underlying problem; misconceptions
about physician expectations; reluctance to take pain medication; fears of addiction, tolerance, adverse effects, and
cost
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| Pain assessment: pain history—important part of assessment, includes mechanism of injury, description of pain, and
patient’s experience of past practices for managing pain; examination must use pain scales appropriate to age of patient
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 | Pain assessment tools: Linear (Visual) Analog Scale—patient marks 10-cm line, ranging from “no pain” to “pain as
severe as possible” to indicate current level of pain; Wong-Baker Faces Pain Rating Scale—“smiley” faces indicate
progressively worse pain (2 versions, with 6 or 11 faces); FLACC pain scale—observational assessment;
categories include Face, Legs, Activity, Cry, and Consolability, each scored 0, 1, or 2 points (for total score of
0-10); age-appropriateness—numeric scales good for children ≥6 yr of age; faces scale appropriate for children
≥3 yr of age; FLACC validated in full-term newborns through 4 yr of age (also used in other nonverbal patients);
pain scales for premature and full-term infants include Premature Infant Pain Profile (PIPP), CRIES assessment
(Crying, Requires O2 for O2 saturation >95%, Increased vital signs, Expression, and Sleeplessness), and Neonatal
Infant Pain Scale (NIPS)
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| Opioids: tolerance—patient requires increased amount of drug to achieve same analgesic effect; dependence—abrupt
cessation of drug leads to uncomfortable (sometimes severe) effects; subsequent administration of drug relieves
symptoms; addiction—drug-seeking behavior; almost never seen in younger children and rare in adolescents
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| Misconceptions: belief that nervous systems of infants too immature to experience or remember pain (untrue); unsafe
to use opioids (although true that metabolic pathways in premature and full-term infants not fully developed,
cautious use of opioids acceptable)
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| Pain management: goals—avoid or minimize pain; avoid negative experience for patient; optimize safety (primary);
techniques—pharmacologic management typically emphasized, but speaker also encourages use of nonpharmacologic
approaches (eg, hypnosis, biofeedback, transcutaneous electrical nerve stimulation [TENS],
massage); asking about patient experience (ie, what has worked and what has not) important for guiding management
plan
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| World Health Organization (WHO) analgesic ladder: step 1—for mild pain, use non-narcotic medications
(eg, aspirin, acetaminophen, nonsteroidal anti-inflammatory drugs [NSAIDs], adjuvants); step 2—for moderate
pain, add weak narcotic (eg, codeine, hydrocodone, oxycodone, tramadol); because tramadol competes for opioid
receptors, do not administer with opioid; step 3—for severe pain, use opioids (eg, morphine, hydromorphone,
methadone, fentanyl) plus nonopioid analgesic and adjuvants; use of nonopioid analgesics decreases amount of
opioid required
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| Nonopioid analgesics: acetaminophen—mode of administration (oral or rectal) affects dose and schedule (rectal absorption
lower); lengthwise splitting of suppositories acceptable; ibuprofen—good safety profile, but typical risks associated
with NSAIDs; maximum daily dose 50 mg/kg
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| Opioids: charts list equivalent doses of various medications as compared to oral morphine; pediatric dosing for
elixir preparations not well studied (15 mL similar to 1 standard adult-dose tablet); anticipatory guidance—
analgesic effect easier to maintain than to achieve; parents need information about dosing regimen to optimize
analgesic effect
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| Examples: bone pain—options include opiates, NSAIDs, and other nonopiate drugs; regional anesthetic techniques
may help; sickle cell anemia—acute and chronic pain; opiate and nonopiate medications good for acute pain crises;
headaches—careful examination and history important; multifactorial etiology; cancer—chronic pain and acute
exacerbations; recurrent abdominal pain—work-up important (especially gastrointestinal [GI]); psychologic and
behavioral components important for managing pain
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| Final comments: critical evaluation required when assessing studies of pain management in children; some studies
have no control or do not evaluate adverse effects
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| COMMON POSTOPERATIVE PROBLEMS: WHAT THE PEDIATRICIAN NEEDS TO KNOW —Myron Yaster,
MD, Richard J. Traystman Professor, Departments of Anesthesiology, Critical Care Medicine, and Pediatrics and
Clinical Director, Pediatric Anesthesiology and Pain Management, Johns Hopkins Medical School, Baltimore, MD
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| Outpatient surgery: increasingly common option; pediatricians now frequently deal with problems formerly handled
by surgeon or anesthesiologist; criteria—relatively uncomplicated surgery, without excessive bleeding or involvement
of body cavities; responsible parent (with phone) available to care for child at home; mild to moderate
postoperative pain; American Society of Anesthesiologists (ASA) physical status—level 1, healthy individual; level 5,
imminent death; patients at ASA level 4 inappropriate for outpatient surgery
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| Postoperative hospitalization: preterm infants (born at <37 wk) have increased risk for postoperative apnea until
≈60 wk of age (postconceptional); postoperative admission recommended (even for healthy infants); all infants <60
wk of age (postconceptional) at increased risk for respiratory depression with exposure to opioids for postoperative
pain management (admission required)
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| Therapeutic index: difference between effective dose and toxic dose; wide therapeutic index indicates minimal
adverse effects, even at large doses (eg, penicillin); many drugs used for analgesia (eg, morphine) have narrow
therapeutic index; effective dose in 1 patient may be toxic in another
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| Anesthesia: general anesthetics have virtually no therapeutic index; death may occur if intubation not achieved;
safety and standardization—anesthetic agents tightly controlled; delivery machines standardized; speed of
action—although agents that have fast onset and fast clearance beneficial in many ways, waking up too quickly
can cause delirium and nightmares; all these agents associated with nausea and vomiting
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| Nausea and vomiting: affects ≈30% of all patients (up to 80% after ear or eye surgery); frequently causes delayed
discharge from recovery room or unanticipated admission to hospital after outpatient surgery
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| Causes: surgical procedure; patient predisposition; anesthetic agent (opioids especially problematic); skill of anesthesiologist;
motion; forcing oral intake
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| Prevention: avoiding triggering agents (eg, opioids; consider ketorolac, but problems with postoperative bleeding);
prophylaxis; limiting oral intake (intravenous [IV] fluids during surgery limit need for postoperative intake)
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| Treatment: serotonin antagonists (eg, ondansetron, dolasetron, granisetron); phenothiazines (eg, prochlorperazine,
chlorpromazine) no longer recommended; agents with sedating effects (eg, antihistamines) may help; speaker
recommends prophylactic treatment with serotonin antagonist for all patients; dilution with dexamethasone helps
reduce cost
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| Oral intake: only patients who express hunger or thirst should take fluids before leaving hospital; forcing oral intake
postoperatively greatly increases risk for vomiting (and subsequent readmission to hospital)
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| Experience of pain: perception and individual experience of pain affected by age, personal and cultural values,
and previous experience of pain; sleep disturbances, anxiety, and anger exacerbate pain; therefore, listening to
and treating postoperative issues important
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| Misconceptions: age extremes—some clinicians think that infants and elderly patients do not experience or remember
painful events, but studies clearly disprove this; ability to recognize pain—although many clinicians trust
their ability to recognize patients in pain, studies show poor accuracy
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| Pain management: although WHO therapeutic ladder recommends increasing strength of pain medications in
steps, speaker uses multimodal approach, immediately using cognitive therapy, weak analgesics, and potent analgesics
as required
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| Medications: most antipyretics with weak analgesic properties (eg, acetaminophen, ibuprofen) work by blocking cyclooxygenase
(COX) receptors; acetaminophen acts centrally, while ibuprofen acts peripherally (increased analgesic
effect with simultaneous administration); acetaminophen very effective if given rectally at right dose (30 mg/
kg), with maximum daily dose of 90 mg/kg tid; although ibuprofen superior to acetaminophen for analgesia, it increases
risk for postoperative bleeding and interferes with bone healing; ketorolac—good alternative to IV opioids
for inpatients; opioid agonists—most important drugs for managing postoperative pain; contrary to popular belief,
meperidine (Demerol) associated with same degree of respiratory depression and biliary spasm as morphine, when
given at equianalgesic doses; analgesic effect of codeine occurs only after metabolism to morphine in liver; no
therapeutic effect in patients who lack conversion enzyme (all neonates and 10% of all patients)
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| Behavioral disturbances: after undergoing surgery, many children experience nightmares, separation anxiety,
problems eating or sleeping, and increased fear of physicians; risk affected by age, baseline anxiety (of child and of
parents), and previous experience; programs directed at children and parents seek to minimize behavioral effects;
parental presence in operating room at time of induction of anesthesia benefits parents more than children; administering
benzodiazepine (eg, midazolam, diazepam) preoperatively may help
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Educational Objectives
| The goal of this program is to educate the listener about pain management and postoperative issues in pediatric patients.
After hearing and assimilating this program, the clinician will be better able to:
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| 1. Choose the appropriate pain assessment scale, based on age of patient.
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| 2. Discuss the use of opioids and nonopioids for management of pain in children.
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| 3. Establish and assess management plans for postoperative pain in children.
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| 4. Educate patients and families about common postoperative problems.
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| 5. Prevent and treat postoperative nausea and vomiting in children.
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Discussed on This Program
Acetaminophen (several formulations and trade names)
Chlorpromazine HCl [Thorazine]
Codeine (several formulations and trade names)
Diphenhydramine HCl (Benadryl, others)
Dolasetron mesylate [Anzemet]
Droperidol [Inapsine]
Fentanyl (several formulations and trade names)
Granisetron HCl [Kytril]
Hydrocodone (several trade names)
Hydrocodone bitartrate and acetaminophen (Lortab, others)
Hydromorphone HCl [Dilaudid, Dilaudid-5, Dilaudid-HP, Palladone]
Ibuprofen (several trade names)
Ketorolac tromethamine [Acular, Acular LS, Acular PF, Toradol
Methadone HCl [Dolophine HCl, Methadone HCl Diskets, Methadone HCl Intensol, Methadose]
Morphine sulfate (several trade names)
Ondansetron HCl [Zofran, Zofran ODT]
Oxycodone HCl [ETH-Oxydose, M-oxy, OxyContin, Oxydose, OxyFAST, OxyIR, Roxicodone, Roxicodone
Intensol]
Penicillin (several formulations and trade names)
Prochlorperazine [Compazine, Compro]
Promethazine HCl [Phenadoz, Phenergan]
Tramadol HCl [Ultram]
Suggested Reading
Anderson BJ, Palmer, GM: Recent developments in the pharmacological management of pain in children. Curr Opin
Anaesthesiol 19:285, 2006; Badina L, et al: Procedural sedation and analgesia in children. Lancet 367:1900, 2006;
Board T, Board R: The role of 5-HT3 receptor antagonists in preventing postoperative nausea and vomiting. AORN J
83:209, 2006; Cucchiaro G, et al: What postoperative outcomes matter to pediatric patients? Anesth Analg 102:1376,
2006; Dalens B: Some current controversies in paediatric regional anaesthesia. Curr Opin Anaesthesiol 19:301, 2006;
Drendel AL, et al: Pain assessment for pediatric patients in the emergency department. Pediatrics 117:1511, 2006;
Ewah BN, et al: Postoperative pain, nausea and vomiting following paediatric day-case tonxillectomy. Anaesthesia
61:116, 2006; Gan TJ: Risk factors for postoperative nausea and vomiting. Anesth Analg 102:1884, 2006; Goodarzi
M, et al: A prospective randomized blinded study of the effect of intravenous fluid therapy on postoperative nausea
and vomiting in children undergoing strabismus surgery. Paediatr Anaesth 16:49, 2006; Kolarik RC, et al: Pediatric
resident education in palliative care: a needs assessment. Pediatrics 117:1949, 2006; Mattila K, et al: Postdischarge
symptoms after ambulatory surgery: first-week incidence, intensity, and risk factors. Anesth Analg 101:1643, 2005;
Paut O, Lacroix F: Recent developments in the perioperative fluid management for the paediatric patient. Curr Opin
Anaesthesiol 19:268, 2006; Simons J, Macdonald LM: Changing practice: implementing validated paediatric pain assessment
tools. J Child Health Care 10:160, 2006.
Faculty Disclosure
In adherence with ACCME guidelines, the Audio-Digest Foundation requests all lecturers to disclose any significant
financial relationship with the manufacturer or provider of any commercial product or service discussed. For this issue,
the faculty reported nothing to disclose.
Dr. Zwass was recorded in San Francisco at the 39th Annual Advances and Controversies in Clinical Pediatrics, sponsored
by the University of California, San Francisco, School of Medicine, Department of Pediatrics, and held June 1-
3, 2006; Dr. Yaster was recorded in Bal Harbour, FL at Masters of Pediatrics/Contemporary and Future Pediatrics,
sponsored by the University of Miami Miller School of Medicine, Department of Pediatrics and Department of Dermatology
and Cutaneous Surgery, and held January 25-30, 2006. The Audio-Digest Foundation thanks the speakers
and the sponsors for their cooperation in the production of this program.
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