CURRICULUM VITAE

Name : Dr. Arie Utariani, dr. SpAn. KAPDosen/Staff Pengajar Anestesiologi Fakultas Kedokteran

Universitas Airlangga

Posisi / Jabatan :•Ketua Program Studi Anestesiologi & Terapi Intensif

Fakultas Kedokteran Universitas Airlangga

•Ketua Program Studi Anestesi Pediatrik Fakultas

Kedokteran Universitas Airlangga

POSTOPERATIVE PAIN MANAGEMENT FOR PEDIATRIC

PATIENT

Arie UtarianiDept. of Anaesthesiology & Reanimation

Dr. Soetomo Hospital – University of Airlangga Surabaya

The aim of effective post-operative pain management is to:

•Improve the comfort and satisfaction of the patient •Facilitate recovery and functional ability •Reduce morbidity •Promote rapid discharge from hospital

Recommendation

Post-operative pain should be treated adequately, to avoid post-operative complications and the development of chronic pain (Grade of Recommendation: B)

Clinical definition of pain

“An unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage...

1. IASP Pain Terminology. In Merskey H & Bogduk N eds. Classification of Chronic Pain, Second Edition, IASP Task Force on Taxonomy. IASP Press, Seattle 1994:209-14.

Pain Pathway

Pain: Clinical Types Nociceptive pain

Transient pain in response to noxious stimuli

Inflammatory pain Spontaneous pain and hypersensitivity to pain in response to tissue damage and inflammation

Neuropathic painSpontaneous pain and hypersensitivity to pain in association with damage to or a lesion of the nervous system

Functional pain spontaneous pain results from a dysfunction in central processing of

pain in dorsal horn or other regions of the spinal cord.

Woolf. Ann Intern Med. 2004;140:441-451.

Postoperative pain is nociceptive

Transmission

Transduction

Reuben et al. J Bone Joint Surg. 2000;82:1754-1766.

Key sites of developmental transition in infant pain pathways

Nature Clinical Practice Neurology (2009) 5, 35-50doi:10.1038/ncpneuro0984

(1) Peripheral innervation is vulnerable and sensitive to tissue injury. (2) Dorsal horn sensory pathways undergo considerable postnatal reorganization. (3) Nociceptive reflex pathways are diffuse and poorly tuned. (4) Primary hyperalgesia develops before secondary hyperalgesia. (5) Endogenous descending controls via the brainstem are unbalanced. (6) Extensive cortical development begins postnatally, but little is known of the development of intracortical network connections in infancy. (7) The somatosensory cortex is activated by noxious stimulation from an early age, but little is known of activation in other cortical regions.

Fitzgerald M. The birth of pain. MRC News (London) 1998; Summer: 20-23.

Fitzgerald M. The birth of pain. MRC News (London) 1998; Summer: 20-23.

Fitzgerald M. The birth of pain. MRC News (London) 1998; Summer: 20-23.

Lingering pain: For weeks after injury at birth damaged skin can stay more touch sensitive than uninjured skin.

Fitzgerald M. The birth of pain. MRC News (London) 1998; Summer: 20-23.

0 1 2 3

normal

neonatally injured area

Postnatal age in weeks

Touc

h th

resh

old

Fitzgerald M and Walker SM (2008) Infant pain management: a developmental neurobiological approachNat Clin Pract Neurol doi:10.1038/ncpneuro0984

Methods of assessing infant pain

•The neurophysiological techniques EMG, EEG and NIRS are not used for routine

pain assessment but are increasingly being used in research studies of infant pain.

•Abbreviations: EMG, electromyogram; NIRS, near-infrared spectroscopy; pO2,

partial pressure of oxygen.

Pain Mechanisms in Newborns Complete myelination of nerve pathways not required for

pain transmission

Pain impulse transmission in neonates Occur along nonmyelinated C-fibers

C-fibers are unmyelinated and A-delta fibers are thinly myelinated

Incomplete myelination results in slower conduction velocity but offset by shorter distances

Complete myelination of pain pathways to brainstem and thalamus by 30 weeks gestation; thalamus to cortex by 37 weeks

Nociceptive nerve endings in cutaneous and mucous surfaces by 20 weeks of gestation

Inhibitory pathways do not develop until after birth

Threshold for responding to cutaneous stimulation is lowest in youngest neonates

Pain Mechanisms in Newborns,cont.

What does it mean ?

Young infants may perceive pain more intensively than older children or adults because their descending control mechanisms are immature

This limits their ability to modulate the pain experience

Physiologic Response to pain

Stress Responses to Postoperative Pain in Neonate

Biochemical Changes: stress hormones corticosterone adrenaline, noradrenaline glucagon aldosterone

metabolites glucose lactate pyruvate

Pain Responses•Tachycardia•Tchypnea•Increase blood pressure

•Tissue trauma results in release of mediators of inflammation and stress hormons•Activation of this stress response leads to:

-Retention of water and sodium-Increase in metabolic rate

Complications•Respiretory•Cardiovascular •Thromboembolic •Gastrointestinal•Musculoskeletal•Psychological

Post-operative pain management. In: Guidelines on pain management. Arnhem, The Netherlands: European Association of Urology (EAU); 2009 Mar. p. 62-82. [79 references]

Facts about Pain in Infants and Children

Infants, regardless of age, feel pain.

The youngest premature infant has the anatomic and physiologic components to perceive pain or “nociception” and demonstrates a severe stress response to painful stimuli.

Unrelieved pain in infants can permanently change their nervous system and may “prime” them for having chronic pain.

Postoperative pain can be divided into acute pain and chronic pain:

Acute pain is experienced immediately after

surgery (up to 7 days)

Pain which lasts more than 3 months after the injury is considered tobe chronic pain

Pain evaluation & assessment

Pain Assessment•Careful pain assessment by the anesthetist, surgeon or the acute pain team can lead to more efficient pain control, adequate doses of the correct drugs, and diminished morbidity and mortality (Level of evidence: 2a). •Pain should be assessed before and after treatment.

•In the post-anaesthesia care unit (PACU), pain should be evaluated, treated and re-evaluated initially every 15 minutes and then every 1-2 hours.

• After discharge from the PACU to the surgical ward, pain should be assessed every 4-8 hours before and after treatment.

RecommendationAdequate post-operative pain assessment can lead to more effective pain control and fewer post-operative complications (Grade of recommendation: B).Guidelines on pain management. Arnhem, The Netherlands: European Association of Urology (EAU); 2009 Mar. p. 62-82. [79 references]

Q – Question the childU – Use pain rating scalesE – Evaluate child’s behaviorS – Secure parent’s involvementT – Take cause of pain into accountT – Take earliest action

QUESTT(One such standard approach of

assessment of pain) QUEST principles of pain assessment

Baker, Wong. Orthop Nurs 6,1987;11-21

PHYSIOLOGICVital signO2 ChangesHormonal changesSweating Palmar

VOCALSpecific : Self reportNon specifik : Cry, Scream, groan

BEHAVIORFacial ExpressionPosturActivityBehavior stateResponse to intervention

PAIN ASSESSMEN

T

QU

E E

ST

CONTEXTUALPain Stimulus / HistoryTemperamentAge, SexCulturSignificant Other input

Multidimensional Model of Pain AssessmentPAIN ASSESSMENT

PAIN SCALESINFANTS TODDLERS

AND PRESCHOOLER

S

SCHOOL AGE AND

ADOLESCENTS

CRIES CHEOPS

FLACC FLACC FACES

NIPS OUCHER SCALE NUMERIC

SUNCRIES : Crying, Require s O2 for saturation > 95%, Increased VS, Expression, Sleeplessness.FLACC : Faces, Legs, Activity, Cry, ConsolabilityNIPS : Neonatal Infant Pain ScaleSUN : Scale for Use in NewbornsCHEOPS : Children’s Hospital of Eastern Ontario Pain ScoreOUCHER SCALE : Combaines pictures with a Visual Analog Scale (VAS)

CRIES scales(Crying, Require s O2 for saturation > 95%, Increased VS, Expression, Sleeplessness.)

ITEM Score 0 Score 1 Score 2Crying No Higgh Pitched InconsolableRequires O2For saturation > 95%

No < 30% O2 > 30% O2

Increased Vital signs

HR and BP= or < preop

Increase in HR or BP< 20% preop

Increase in HR or BP> 20% preop

Expression None Grimace Grimace / Grunt

Sleepless No Wakes atfrequent

Constantlyawake

Preop= Preoperative

PARAMETER FINDING : characteristic

POINTS

Cry 4 8Facial 3 3Child verbal 3 6Torse 6 11Touch 5 9

Legs 5 9

Children's Hospital of Eastern Ontario Pain Scale (CHEOPS) in Young Children

The initial study was done on children 1 to 5 years of age. According to Mitchell (1999) it is intended for ages 0-4. Interpretation: minimum score: 4 maximum score: 13

FLACC Behavior Pain Assessment

Children and Infants Postoperative Pain Scale (ChIPPS)

Item Score 0 Score 1

Score 2

Crying None Moaning ScreamingFacial expression

Relaxed smiling Wry mouth Grimacing

Posture of the trunk Neutral Variable Rear up

Posture of the legs Neutral Kicking Tightened

Motor restlessness None Moderate RestlessTotal score indicates how the baby should be managed according to the scale

•0 - 3 No requirement for treating pain,•4 – 10 Progressively greater need for analgesia.

Behavior scale and /or Physiological stress parameter

Buttner W, Finke W: Paediatr Anaesth 2000;10(3):303-18.

Faces pain

assessment scale

VRS painassessment scale

NRSassessment scale

VASassessment scale

PatientAble to

Communicate well ?

No

Yes

Choice of assessment tool

Wong-Baker Faces Scale (0-10)

For children over the age of three, for adults who are cognitively or developmentally delayed, and for the use with geriatric patients who are unable to use the numeric scale The care provider is to explain to the patient that the "0" represents "NO PAIN" and "10" represents the "WORST" pain.

How is Your Pain Today?

NoPain

Worst Pain

Numeric Scale = NRS

0 21 43 8 7

5 6 10

9

Moderate pain

No pain Littlepain

Medium pain

Large pain

Worst pain

Verbal Ranting Scale = VRS

No Pain Worst Pain

Pain Intensity Ranting Scales

Visual-Analogue Scale = VAS

Usually 0-10 cm long line.Placed either vertical or horizontal.

VAS or Face scale can be used from 5-6 year of age

INFANTS (gold Standard – FACIAL expression)

•Eyes Forcibly closed•Brows lowered and furrowed•Nasal roots broadened and

bulged•Deepened nasolabial furrow•Square mouth•Cupped tongue

CHILDREN WITH COGNITIVE IMPAIRMENT

VOCAL BEHAVIOR Moaning, crying, screaming

SOCIAL BEHAVIOR Not cooperating, withdrawn,Difficult to distract

FASCIAL EXPRESSION Furrowed brow, changes in eyes,Clenches or grinds teesth, thrusts tongue out

ACTIVITY Not moving, quiet, agitated, fidgety

PHYSICAL SIGNS Changes in color perspiring, sharp intakes of breath, gasping

BODY AND LIMBS Stiff, spastic, tense, rigid

Concept of “Total Pain Management”

Four aspects must be addressed:1. Physical2. Psychological3. Social4. Spiritual

Last 3 can be met only after pain and related symptoms (e.g., N/V, anxiety) are controlled.

Pain management & monitoring

Is responsive to NSAID’s, coxibs, paracetamol and opiates

Postoperative pain is nociceptive

Transmission

Transduction

Reuben et al. J Bone Joint Surg. 2000;82:1754-1766.

Procedure-related pain managementIntervention: The first & most essential intervention:

prepare the child & family for painful procedure parents may benefit from written information

Pharmacologic management: Analgesia Sedation

Nonpharmacologic management: Effective for children Distraction, guided imagery, muscle relaxation

Texas Cancer Council Booklet, 1999

Non-pharmacologic Interventions

Neonate/infant

Toddler Preschooler School Age Adolescent

Sensory Sensory Sensory/Behavior

Sensory/Behavior/ Cognitive

Sensory/Behavior/ Cognitive

•Positioning•Swaddling•Rocking/Cuddling•Touch/massage•Dim

Lighting•Visual Distraction•Sucking•Sucrose/

Water solution on pacifier

•Positioning•Play therapy •Hugging/ Holding•Touch/ massage •Security object (blanket, toy, stuffed animal)•Distraction devices (toys/music/videos)•Heat/cold application•Imagery•Pacifier

•Positioning•Play therapy •Hugging/ Holding•Touch/ massage•Distraction devices (toys/music/videos/ games, books)•Heat/cold application•Imagery

•Positioning•Play therapy •Hugging/ Holding•Touch/ massage•Distraction devices (toys/music/videos/ breathing techniques)•Heat/cold application•Imagery•Humor•Exercise

•Positioning•Heat/cold application•Imagery•Humor•Prayers• breathing techniques•Relaxation techniques•Distraction devices (especially music/videos)

Pharmacologic Interventions Mild Pain :

•Acetaminophen •NSAIDs

Moderate to Severe Pain•Opioid•Non-Opioid•Local/Topical anaesthetics

Analgesic drugs Nonsteroidal Anti-inflammatory Drugs

(acetaminophen, aspirin, ibuprofen, diclofenac sodium, naproxen, cox-2 inhibitor)

Opioids (codein, oxycodone, pethidine, morphine, fentanyl)

Adjuvants (co-analgesic drugs) (amitriptyline, gabapentin, carbamazepine,

lorazepam, diazepam, corticosteroid)

The doses and routes of administration of drugs described above are general examples and each patient should be assessed individually before prescribing.

Texas Cancer Council Booklet, 1999

Drug DoseDiclofenac Oral, Rectal 1 mg/kg/8h

Ibuprofen Oral 10 mg/kg/8h

Ketorolac IV, IM, PODo not use with other NSAIDs

0,5 mg/kg/8h orContinuous infustion

Paracetamol Rectal 40 mg /kg; followed by 30 mg/kg/8h

Oral 20 mg/kg and 30 mg/kg/12h

Newborn, rectal 20 mg/kg and 30 mg/kg/12 jam

Newborn , oral 30 mg/kg and 20 mg/kg/8h

NSAIDs and Paracetamol

Drug DoseMorphin Newborn 0,02 mg/kg/8h

Newborn (for continuous infustion) 5-15 μg/kg/h

Children 0,05-0,1 mg/kg/h

Children (for continuous infustion) 0-30 μg/kg/h

Fentanyl According to surgery 2-10 μg/kg

In ICU 2-5 μg/kg/h

Oral transmucosal FentanylCitrate lollipop

15-20 μg/kg

Remifentanil Surgery 0,5-1 μg/kg/min

In ICU 0,1-0,05 μg/kg/min

Codein Mainly used in combination with Paracetamol (suppositories or syrup)(not recommended for children under < 2 year)

0,5-1 mg /kg/4h

OPIOID

Local Anaesthetic

Caudal block

Lumbarblock

Thoracicblock

Bupivacaine 0,25% 2,5 mg/kg 2 mg/kg 1-1,2 mg/kg

Levobupivacaine 0,2-0,25%

2-2,5 mg/kg 1,4-2 mg/kg 0,8-1 mg/kg

Ropivacaine 0,2% 2 mg/kg 1,4 mg/kg 0,8-1 mg/kg

Examples of local anaesthetics and mean doses for single shot

epidural

Local Anaesthetic

Newborn and Infants (up to 1 year)

Older Children(>1 year)

Bupivacaine 0,125%Levobupivacaine 0,1%Ropivacain 0,1%

0,2 mg/kg/h 0,3-0,4 mg/kg/h

Ropivacaine is not licenced for use in infants under the age of 1 year

Examples of local anaesthetics and mean doses for continuous infusion via catheter

Drug DoseMorphine 0,02-0,05 mg/kg

Fentanyl 1,2 μg/kg or 0,5–1 μg/kg/h

Sufentanyl 0,2-0,3 μg/kg

Clonidine 1-2 μg/kg single shot or 3 μg/kg/24h in epidural infusion

Ketamine 0,5 mg/kg

Adjuvant drugs for epidural use

Local anaesthetic/adjuvant

Newborns and infants (up to 1 year)

Older Children (>1 year)

Ropivacaine 0,2% or Levobupivacaine 0,25%

0,2 mg/kg/h 0,4 mg/kg/h

Clonidine can be added as adjuvant

3 μg/kg/h

Examples of local anaesthetics and mean doses for continuouse peripheral nerve block

in children

Ropivacaine is not licenced for use in infants under the age of 1 year

Multimodal Analgesia Attacks Different Points Along the Pain

Pathway

Analgesic ladder:The plan of anaesthesia should always include postoperative analgesia and should be safe, effective and convenient.This will have been discussed as part of the pre-operative visit.

Each child will return from theatre with an appropriate regime of post-operative analgesia prescribed.Those children who are receiving intravenous opioids will reviewed by the Pain Control Service. They are also available for advice on all apsects of pain management.

Slight Paracetamol

Mild

Paracetamol+

NSID

Moderate Paracetamol

NSID +Weak opioidEq: codeine,

tramadol

Severe Paracetamol

NSID +Poten opioid

Eq: morphine,pehtidine

Increasing pain

Observe for Improvement in Behavior Following an Analgesic

Complication

Positive role of painAcute pain plays a useful "positive" physiological role by:

Providing a warning of tissue damage Inducing immobilisation to allow appropriate healing

Negative effects of painShort term negative effects of acute pain include:

1. Emotional and physical suffering for the patient2. Sleep disturbance3. Cardiovascular side effects4. Increased oxygen consumption5. Impaired bowel6. respiratory function7. Delays mobilisation and promotes thromboembolism

Long term negative effects of acute pain:

Severe acute pain is a risk factor for the development of chronic pain

There is a risk of behavioural changes in children for a prolonged period (up to 1 year) after surgical pain

Conclution

Awareness and assessment of the pain in

postoperative children is important

Remember the different pharmacology in neonates, infants and children

Multi-modal approach to preventing and treating

pain to minimize adverse effects

Regional analgesia must be considered unless

contraindicated

The Golden RuleWhat is painful to an adult is painful to an infant and child

unless proven otherwise.

THANK YOU