Postoperative pain management in infants and children: new developments

The elimination of pain should be of outstanding importance for all people caring for children. A concept of balanced analgesia including non-steroidal anti-inflammatory drugs, opioids and local anaesthetics is widely accepted. This review focuses on extending analgesia beyond the immediate postoperative period, the understanding of pharmacokinetic-pharmacodynamic interactions of paracetamol, the side-effects of opioids during patient-controlled administration, and the position of ropivacaine in paediatric pain management. For the majority of clinical situations, however, we already have established and functioning concepts for analgesia; we only have to use them!     

Postoperative analgesia: opioid infusions in infants and children

The purpose of this review is to emphasise the ineffectiveness of traditional analgesic therapy in paediatric patients after surgery, to examine the sensation of pain in infants and children, and to describe the use of intravenous opioids for postoperative analgesia. The management of acute postoperative pain in the paediatric surgical population has been poor. This is despite the knowledge that infants and children have sufficient neurological development at birth to sense pain, and that the same hormonal and metabolic responses to nociceptive stimuli that occur in adult also occur in the neonate. Physicians frequently order analgesics in inappropriate doses, nurses are reluctant to administer opioids, and children themselves frequently compound the problem by refusing injections. The sophisticated techniques for providing postoperative analgesia which have been used so successfully in adults can also be used in paediatric patients. Two of these, continuous intravenous opioid infusion and patient-controlled analgesia, have proved to be very successful. Children older than six months can receive either modality safely with regular monitoring by qualified nursing staff. Infants younger than six months receiving continuous opioid infusions should be monitored in high-dependency units.     

Postoperative analgesia after spinal blockade in infants and children undergoing cardiac surgery

The aim of this prospective, randomized, controlled clinical trial was to define the opioid analgesic requirement after a remifentanil (REMI)-based anesthetic with spinal anesthetic blockade (SAB+REMI) or without (REMI) spinal blockade for open-heart surgery in children. We enrolled 45 patients who were candidates for tracheal extubation in the operating room after cardiac surgery. Exclusion criteria included age <3 mo and >6 yr, pulmonary hypertension, congestive heart failure, contraindication to SAB, and failure to obtain informed consent. All patients had an inhaled induction with sevoflurane and maintenance of anesthesia with REMI and isoflurane (0.3% end-tidal). In addition, patients assigned to the SAB+REMI group received SAB with tetracaine (0.5-2.0 mg/kg) and morphine (7 mug/kg). After tracheal extubation in the operating room, patients received fentanyl 0.3 mug/kg IV every 10 min by patient-controlled analgesia for pain score = 4. Pain scores and fentanyl doses were recorded every hour for 24 h or until the patient was ready for discharge from the intensive care unit. Patients in the SAB+REMI group had significantly lower pain scores (P = 0.046 for the first 8 h; P =0.05 for 24 h) and received less IV fentanyl (P = 0.003 for the first 8 h; P = 0.004 for 24 h) than those in the REMI group. There were no intergroup differences in adverse effects, including hypotension, bradycardia, highest PaCO(2), lowest pH, episodes of oxygen desaturation, pruritus, and vomiting.     

Postoperative extradural analgesia in children: comparison of morphine with fentanyl

We have compared the efficacy and side effects of extraduralmorphine with extradural fentanyl for postoperative pain relief.Thirty children (ages 1–16 yr) were allocated randomlyto receive, after extradural administration of 0.5% bupivacaine0.75 ml kg^–1 and before surgical incision, extreduralmorphine 0.75 µg kg^–1 (group M), with an additionaldose administered 24 h later or extradural fentanyl 2 µgkg^–1 (group F) followed by a continuous extradural infusion(during 48 h). There was no major complication (respiratorydepression). Pain scores were satisfactory in both groups for48 h. Ventilatory frequency was greater in group M 20, 21, 22,23 and 25 h after the beginning of analgesia (P < 0.05).Pruritus, nausea and vomiting were less common with extraduralfentanyl (20% vs 53%, P < 0.05 and 0% vs 33%, P < 0.05)than with morphine. Urinary retention occurred with equal frequency(25%) in the two groups. After a bolus of 2 µg kg^–1,continuous extradural infusion of fentanyl 5 µg kg^–1day^–1 provided analgesia comparable to that from a dailybolus of extradural morphine 0.75 mg kg^–1 and producedfewer side effects.      

Postoperative small bowel obstruction in infants and children.

In the Pediatric Surgical Department of The St Radboud Hospital, Nijmegen, The Netherlands, between January 1970 and December 1980, 1476 laparotomies were performed on neonates, infants, and children. In 33 of these patient the abdominal surgery was complicated by a postoperative small bowel obstruction (SBO), for which a second laparotomy had to be performed. In 80% of patients this SBO developed within three months of the prior operation. The risk of developing an adhesive SBO was greater when there was more than one prior peritoneal procedure, and when, during this prior procedure, there was already a peritonitis. There was no obvious relation with the nature of the original operation. In more than 70% of patients a single adhesion caused the obstruction, while in many of these cases there were already circulatory disturbances, even by early reintervention. The mortality was 6%.     

Postoperative analgesia in children day surgery circumcision: Comparison of three methods

Objective: To compare three methods of postoperative analgesia in children who underwent day surgery circumcision. Methods: One hundred and eighty‐five boys who were admitted for day surgery circumcision were randomly allocated to one of three groups. Group 1 received caudal block, group 2 received dorsal penile nerve block and group 3 received a combination of rectal diclofenac and intravenous fentanyl (RD/IVFENT). Oral paracetamol was given to relieve postoperative pain; its requirement and postoperative complications were recorded. Results: There were no significant differences found among the three groups regarding post‐circumcision paracetamol requirements in the first 2 h and day of operation, and duration of analgesia. There was no increased wound bleeding and vomiting seen for group 3. Conclusion: RD/IVFENT is a useful alternative to caudal block and dorsal penile nerve block for providing post‐circumcision pain relief. Also, it is easier to administer and appears safe.     

Postoperative analgesia

Postoperative analgesia both by drugs and regional techniques is reviewed. In the United Kingdom in the last 25 years or more there has been little advance on either front. Some marginal improvement in regard to drugs might be brought about by better education of both doctors and nurses and better patient contact. Extradural analgesia and intercostal block do not offer a complete solution, though a judicious increase in the use certainly of the former might be beneficial. The problem awaits a radical new approach.     

Postoperative analgesia

Pain is a complex experience consisting of sensory, affective, behavioural and physiological components. Pain management is therefore best achieved through an approach which acknowledges the complex interaction between biological, psychological and sociocultural factors. Effective pain management requires preoperative patient engagement and education in order to manage expectations and a structured inpatient service to facilitate evidence-based postoperative pain management and continuous staff education. Multimodal postoperative analgesia, built on an opioid-sparing ethos, is an essential component of perioperative pain management. Effective pain management facilitates early mobilization and a reduction in respiratory and cardiac complications and reduces the stress response to surgery which in turn improves wound healing and recovery. Inadequate pain control can lead to morbidity and mortality including prolonged hospital stays and the development of chronic postoperative pain.     

Postoperative analgesia

Pain is a complex experience consisting of sensory, affective, behavioural and physiological components. Pain management is therefore best achieved through an approach which acknowledges the complex interaction between biological, psychological and sociocultural factors. Effective pain management requires preoperative patient engagement and education in order to manage expectations and a structured inpatient service to facilitate evidence-based postoperative pain management and continuous staff education. Multimodal postoperative analgesia, built on an opioid-sparing ethos, is one component of postoperative pain management and is essential for achieving patient satisfaction and enhanced recovery. Effective pain management facilitates early mobilization and a reduction in respiratory and cardiac complications, reducing the stress response to surgery in turn improving wound healing and recovery. Inadequate pain control can lead to higher morbidity and mortality, prolonged hospital stays and the development of chronic postoperative pain.