pain

1. Post operative pain assessment
and management in pediatrics
Nure (NTM)
Nov. 2021
4/7/2023 1
UoG, Department of Anesthesia.

2. Outlines
 Introduction
 Pain in pediatrics
 Assessment of pain in children
 Pain control
4/7/2023 2
UoG, Department of Anesthesia.

3. Introduction
Consider Physiologic and Anatomic
Differences
Pain Assessment and Communication
Pain and Anxiety Associated with Minor
Procedures or Unfamiliar Situations
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UoG, Department of Anesthesia.

4. Cont…
The most important barriers to pain control in
pediatric patients are the myths that
1. Children and infants do not feel pain,
2. Pain mg’t is not remembered, and
3. There are no bad consequences
These incorrect assumptions may hinder
management of pediatric pain.
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UoG, Department of Anesthesia.

5. Intro…
 Complete myelination of nerve pathways
is 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.
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UoG, Department of Anesthesia.

6. Cont…
 Complete myelination of pain pathways to
brainstem and thalamus occur by 30 weeks of
gestation; thalamus to cortex by 37 weeks
 Nociceptive nerve endings in cutaneous and
mucous surfaces develop by 20 weeks of
gestation
 Inhibitory pathways do not develop until after
birth
 Threshold for responding to cutaneous
stimulation is lowest in young neonates
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UoG, Department of Anesthesia.

7.  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
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UoG, Department of Anesthesia.

8.  Unrelieved pain in infants can
permanently change their nervous
system and may “prime” them for
having chronic pain.
 Sleep deprivation
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UoG, Department of Anesthesia.

9. How neonates express pain?
 Flexion and adduction of affected limb
 Distinct facial expressions
 Specific features of a pain “cry” that
has unique spectrographic
characteristics to distinguish it from
other types of cry (pain cry vs hunger
cry)
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UoG, Department of Anesthesia.

10.  Pediatric patients may have difficulty
conceptualizing and quantifying pain.
 The lack of routine assessment and
reassessment of pain may interfere with
effective acute pain management.
 Special scales are available to assist
young children in self-reporting of pain;
 However, interpretation of behavior and
physiologic parameters may be used to
estimate pain intensity in preverbal
children or those who cannot self-report
their pain. 4/7/2023 10
UoG, Department of Anesthesia.

11. Assessment of pain
 Concomitantly with the vital signs,
assessment of neonatal pain must be
done every 4-6 hrs or as indicated by the
clinical condition of the neonate.
 Pain is the 5th V/S
 Pain assessment tools
◦ sensitive and specific for infants
 pain assessment should be
comprehensive
Multidimesional including
• contextual,
• behavioral and
• physiological indicators.
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UoG, Department of Anesthesia.

12. How to assess pain in
neonates ?
 Acute procedural pain/post operative
pain
◦ Intensity – Many pain scales
 PIPP(Premature Infant Pain Profile) (27
wks – term)
 NIPS(Neonatal Infant Pain Scale) (28-38
wks)
 NPASS(Neonatal Pain, Agitation and
Sedation Scale)
 CRIES score (32-60 wks)
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UoG, Department of Anesthesia.

13. Scale Variables Type of pain
PIPP (Premature Infant
Pain Profile)
(27 wks – term)
HR, SpO2, Facial expression,
takes state and GA into account
Procedural,
Postoperative (minor)
NIPS(Neonatal Infant Pain
Scale) (28-38 wks)
Facial expression, crying,
breathing pattern, arm and leg
movements, state of arousal
Procedural
NFCS (Neonatal Facial
Coding System)
Facial actions Procedural
N-PASS (Neonatal Pain,
Agitation, and Sedation
Scale)
Crying, irritability, behavioral state,
facial expression, extremity tone,
vital signs
Postoperative
Procedural
CRIES (Cry, Requires O2,
Increased vital signs,
Expression,
Sleeplessness)
Cry, Requires O2, Increased vital
signs, Expression, Sleeplessness
Postoperative
COMFORT Scale (0-3 yr
old)
Movement, Calmness, facial
tension, alertness, RR, HR, BP
Postoperative, critical
care, sedated,
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UoG, Department of Anesthesia.

14. The NIPS:
1.Facial expression
Relaxed – restful
face/neutral
expression
score - 0
Grimace – Tight facial muscles
furrowed brow, chin & jaw
Score - 1
4/7/2023 UoG, Department of Anesthesia. 14

15. 2. CRY
 No Cry –Quiet, not crying – 0
 Whimper – Mild moaning, intermittent – 1
 Vigorous cry – Loud cry, shrill (penetratingly high-
pitched), continuous - 2
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16. 3. Breathing patterns
 Relaxed – Usual pattern for that baby
- 0
 Change in breathing - Indrawing
,irregular, fast than usual, gagging,
breath holding - 1
• Relaxed – No muscular rigidity, occasional
random movements – 0
• Flexed/Extended – Tense straight
arms/legs, rigid, rapid flexion/extension - 1
4. ARMS & 5. LEGS
4/7/2023 UoG, Department of Anesthesia. 16

17. 6. State of arousal
 Sleeping/awake – Quiet, peaceful
sleeping, occasional random legs/arm
movements – 0
 Fussy(irritated) – Alert restless and
trashing - 1
4/7/2023 UoG, Department of Anesthesia. 17

18. NIPS Score
 Neonatal Infant Pain Scale =
SUM(points for the 6 parameters)
 Interpretation:
• minimum score: 0
• maximum score: 7
Pain Level Intervention
0-2 = mild to no pain None
3-4 = mild to
moderate pain
Non-pharmacological intervention
with a reassessment in 30 minutes
>4 = severe pain Non-pharmacological intervention
and possibly a pharmacological
intervention with reassessment in 30
minutes
4/7/2023 UoG, Department of Anesthesia. 18

19. CRIES : Crying, Requires O2 for saturation > 95%, Increased VS,
Expression, Sleeplessness.
FLACC : Faces, Legs, Activity, Cry, Consolability
NIPS : Neonatal Infant Pain Scale
SUN : Scale for Use in Newborns
CHEOPS : Children’s Hospital of Eastern Ontario Pain Score
OUCHER SCALE : Combines pictures with a Visual Analog Scale
(VAS)
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UoG, Department of Anesthesia.

20. Oucher Pain Scale
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UoG, Department of Anesthesia.

21. Infants FACIAL expression
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UoG, Department of Anesthesia.

22. • Eyes Forcibly closed
• Brows lowered and furrowed
• Nasal roots broadened and bulged
• Deepened nasolabial furrow
• Square mouth
• Cupped tongue
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UoG, Department of Anesthesia.

23. There are three ways to assess pain:
1. What the children do (Behaviour )? -
Observational assessment
2. How their bodies react (Measure the
physiological response)?
3. What children say ? - Self-report
(best)
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UoG, Department of Anesthesia.

24. 4/7/2023 24
UoG, Department of Anesthesia.

25. Cont…
FLACC Tool – observational assessment of
pain in pre-verbal children and in children
unable to communicate
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UoG, Department of Anesthesia.

26.  The revised FLACC includes
emotional displays (eg, “appearing
sad or worried”)
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UoG, Department of Anesthesia.

27.  Wong-Baker Faces Pain Rating Scale 6 - Self-
report faces scale for acute pain
 Six line-drawn faces range from no pain to worst
pain. It assigns a numerical value to each face
 The Wong-Baker Scale also adds word descriptors
to each face (no hurt, hurts a little, hurts a whole
lot, etc.)
 Age group 3-18 years
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UoG, Department of Anesthesia.

28. 4/7/2023 28
UoG, Department of Anesthesia.

29. Interpretation of Observational
Tools
• The observational pain scores should be
interpreted in context of the child and the
behaviour shown.
• Observational tools are used to assess pain in
pre-verbal children and in children who are
unable to communicate.
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UoG, Department of Anesthesia.

30. Faces pain
assessmen
t scale
VRS pain
assessmen
t scale
NRS
assessmen
t scale
VAS
assessmen
t scale
Patient
Able to
Communicate
well ?
No
Yes
Choice of assessment tool
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UoG, Department of Anesthesia.

31.  Use the pain scales algorithm to choose a suitable pain
assessment tool
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UoG, Department of Anesthesia.

32. Pharmacological treatment of pain
in children
Opioids
 Opioids appear to be more potent in neonates
than in older children and adults.
easier entry across the BBB
decreased metabolic capability
 increased sensitivity of the respiratory
centers.
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UoG, Department of Anesthesia.

33.  Morphine sulfate, particularly in
repeated doses, should be used with
caution in neonates
 Because of toxicity from its metabolite,
meperidine is not an opioid of choice.
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UoG, Department of Anesthesia.

34. Cont…
 Children as young as 6 yrs can use
intravenous PCA.
 Nurse- or PCA is also effective
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UoG, Department of Anesthesia.

35.  When unable to use PCA, continuous
infusions or intermittent IV administration of
opioids is effective in providing
postoperative analgesia.
4/7/2023 35
Fentanyl - 0.01 to 0.05 μg/kg/minute
Sufentanil - 0.0015 to 0.01 μg/kg/minute
Alfentanil - 0.25 to 0.75 μg/kg/minute
Remifentanil - 0.05 to 0.25 μg/kg/minute
UoG, Department of Anesthesia.

36. Commonly used parenteral opioids
include
Fentanyl (1–2 mcg/ kg)
Morphine (0.05–0.1 mg/kg)
Hydromorphone (15 mcg/kg)
4/7/2023 36
UoG, Department of Anesthesia.

37. PCM
 Paracetamol has a mainly central mode of action
producing both antipyretic and analgesic effects.
 MOA
 Inhibit prostaglandin synthesis in the hypothalamus,
 Reduce hyperalgesia mediated by substance P and
 Reduce nitric oxide generation involved in spinal
hyperalgesia induced by substance P or NMDA.
Dose
Child <10kg 7.5mg/kg qid
10kg -50kg 15mg/kg qid
Maximum per day 60 mg/kg
4/7/2023 37
UoG, Department of Anesthesia.

38. NSAID’s
MOA : Act mainly
peripherally by inhibiting prostaglandin
synthesis and
thus reducing inflammation though central
effects
have also been postulated involving the
opioid, serotonin and nitric oxide pathways.
They are highly efficacious in the treatment
of mild to moderate pain in children.
4/7/2023 38
UoG, Department of Anesthesia.

39.  Advantage
◦ Reported opioid-sparing effect by 30 – 40 %
◦ Reduce opioid-related adverse effects as well as
facilitating more rapid weaning of opioid
infusions.
◦ They have also been shown to be highly effective
in combination with local or regional nerve block.
◦ In combination with PCM produce better
analgesia than either drug alone
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UoG, Department of Anesthesia.

40.  There are limitations to their use in
paediatric populations.
 Generally, their use is not recommended for
children less than 6 months of age .
Precaution
 Care should be taken in those
 Patients who are asthmatic,
 Have a known asprin or NSAID allergy,
 Coagulopathic or
 Where there is a significant risk of
haemorrhage
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UoG, Department of Anesthesia.

41. Local Anesthetics
MOA
 blocking the conduction of nociceptive stimuli along the
pain pathway.(AP)
 This can be achieved by many different routes, the
commonest ones are:
central/regional blocks, plexus blocks,
peripheral nerve blocks,
infiltration at the site of injury and topical application
 Regional analgesia produces excellent
perioperative analgesia for major surgery at all age
groups, even preterm neonates, and has been
shown to decrease postoperative complications.
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UoG, Department of Anesthesia.

42. Caudal epidural block
Anatomic considerations
 Caudal epidural space is the lowest portion of
the epidural system and is entered through
the sacral hiatus.
 The sacrum is a triangular bone that consists
of the five fused sacral vertebrae (s1- s5).
 It articulates with the fifth lumber vertebra and
the coccyx.
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UoG, Department of Anesthesia.

43. 4/7/2023 43
UoG, Department of Anesthesia.

44.  The lack of fusion or absence of the S4 and S5
laminae gives rise to the sacral hiatus b/n the
sacral cornua.
 Covered
◦ Posteriorly by sarcococcygeal ligament
◦ Sarcococcygeal ligament is formed from the
supraspinous and infraspinous ligaments as
well as the ligamentum flavum
 Penetration of the SCL by a needle provides
direct access to the sacral canal.
4/7/2023 44
UoG, Department of Anesthesia.

45.  Sacral canal is a continuation of the lumbar
spinal canal which terminates at the sacral
hiatus.
 The sacral canal contains:
◦ Terminal part of the dural sac,
◦ Cauda equine
◦ Filum terminale
◦ Epidural fat
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UoG, Department of Anesthesia.

46.  Cauda equinae- made up of the 5
sacral & coccygeal nerves
 Filum terminale- final part of the
spinal cord w/c does not contain
nerves
 Epidural fat- loose texture in children,
fibrous close-meshed texture in adults
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UoG, Department of Anesthesia.

47.  Indications: Anaesthesia and
analgesia below the umbilicus including ;
Inguinal hernia repair,
Urinary and digestive tract surgery,
Orthopedic procedures on the pelvic girdle and
lower extremities
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UoG, Department of Anesthesia.

48.  Contraindications
◦ Major malformations of the sacrum
(myelomeningocele, open spina bifida),
◦ Meningitis,
◦ Intracranial hypertension.
◦ Infection near the site of the needle insertion.
◦ Coagulopathy or anti coagulation.
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UoG, Department of Anesthesia.

49.  Choice and dose of LA’s
Use the drug with longest duration of action and the
fewest side effects.
 Commonly used
◦ Lignocaine 1% and
◦ Bupivacaine 0.25%
 Preferably preservative free
 Commonly used regimen:- bupivacaine;
◦ 0.5ml/kg  lumbosacral
◦ 1ml/kg  thoraco-lumbar, and
◦ 1.25ml/kg  mid-thoracic block
4/7/2023 49
UoG, Department of Anesthesia.

50. Techniques of caudal epidural
1. Pt prepared as for GA
◦ Fasted, equipment for resuscitation and
intubation as well as drugs for fitting and IV
access
◦ for fitting: - Thiopentone 2-4mg/kg, diazepam
0.2-0.4mg/kg
2. Aseptic technique mandatory
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UoG, Department of Anesthesia.

51.  Landmarks : As there can be a considerable
degree of anatomical variation in this region and
confirmation of bony landmarks is the key to
success
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UoG, Department of Anesthesia.

52.  The sacral hiatus and the posterior superior iliac spines
form an equilateral triangle pointing inferiorly
 First palpate the coccyx, and then sliding the palpating
finger in a cephalad direction until a depression is felt.
 22 gauge short bevelled cannula or needle is directed
at about 450 to skin and inserted till a “click” is felt as
the sacro-coccygeal ligament is pierced  advance
needle cephalad.
◦ The distance from skin to the epidural space is hardly
influenced by the age and weight of the patient.
◦ 25-mm-long needles are long enough to reach the sacral
epidural space and short enough to prevent inadvertent dural
puncture in most patients.
The needle should be aspirated looking for either CSF or blood.
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UoG, Department of Anesthesia.

53.  A negative aspiration test does not exclude intravascular or
intrathecal placement.
 Care should always be taken to look for signs of acute toxicity
during the injection.
 The injection should never be more than 10 ml/30 seconds.
 Tests to confirm correct placement
 Gently moving the tip of the needle from side to
side the needle will feel firmly held
 Introduction of a small amount of air will not
produce subcutaneous emphysema
 There should be no local pain during injection.
 Test dose (2-4mls) 
◦ No swelling in the subcutaneous tissues
◦ No feeling of resistance to the injection or
◦ No systemic side effects (arrhythmias, peri-oral
tingling, numbness or hypotension)
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UoG, Department of Anesthesia.

54. 4/7/2023 54
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55. 4/7/2023 55
UoG, Department of Anesthesia.

56. Non pharmacological interventions
 facilitated tucking (holding the infant’s
extremities close to the body, promoting
flexion), swaddling, nesting, use of
nonnutritive sucking ???
 minimal handling protocols
 lowering noise levels in the NICU
 avoiding exposure to bright lights
 promoting day/night light cycles.
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UoG, Department of Anesthesia.

57. 4/7/2023 57
UoG, Department of Anesthesia.