2. Objectives
Defining and classifying pain
Neurophysiology of pain conduction and modulation
Pain assessment in pediatric patients
Different methods for management of perioperative pain
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3. Introduction
An unpleasant sensory and emotional experience associated with actual or potential
tissue damage, or described in terms of such damage.(IASP= InternationalAssociation
of study of pain)
“Pain is a more terrible lord of mankind than even death itself.”
-Albert Schweitzer
Pain affects various system of our body
Nowadays pain is also considered as 5th vital sign
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23. Remember In Pediatrics
■ Not all of the essential nerve pathways are present and functioning by
24 weeks gestation
■ Myelination is incomplete at birth
■ Inhibitory mechanisms in dorsal horn of spinal cord are immature and
inhibition of nociceptive input in dorsal horn is less than adults
■ Dorsal horn neurons in newborns have wider receptive fields and lower
excitatory threshold
■ Exaggerated reflex response to pain
■ Failure to provide analgesia results in re-wiring responsible for increased
pain perception for future painful insults
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24. CONSEQUENCES OF INADEQUATE PAIN
CONTROL
■ Cardiovascular: Tachycardia, HTN and increased cardiac workload
■ Pulmonary: Respiratory muscle spasm (splinting), decrease in vital
capacity, atelectasis, hypoxia, and increased risk of pulmonary infection
■ Gastrointestinal: Postoperative ileus
■ Renal: Increased risk of oliguria and urinary retention
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25. CONTD
■ Coagulation: Increased risk of thromboembolism
■ Muscular: Muscle weakness and fatigue
■ Psychological: Anxiety, fear and frustration
■ Poor patient satisfaction, delayed wound healing, increase hospital stay
and cost
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34. Pre-emptive Analgesia
-Treatment that is initiated before surgical procedure
- Reduces sensitization
Goal: To prevent NMDA receptor activation in the dorsal horn. NMDA receptor activation-
– causes “wind-up”, facilitation, central sensitization expansion of receptive fields
and long-term potentiation
– lead to a chronic pain state
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35. Pre-emptive Analgesia
Three critical principles
1. Adequate depth of analgesia to block all nociceptive input during
surgery
2. Extensive analgesic technique to include the entire surgical field
3. Duration of analgesia must include both the surgical and postsurgical
periods
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36. Pre-emptive Analgesia
Activation of peripheral nociceptors:
NSAIDs, anti-histaminics, 5-HT antagonists and local
anesthetics.
Within dorsal horn: Nociceptive transmission and processing
can be affected by local anesthetic, neuraxial opiods,alpha-2
adrenergic agonist (clonidine, dexmedetomidine),
transcutaneous nerve stimulation.
Within CNS: Systemic opioids, alpha 2 agonist, anticonvulsants,
hypnosis, acupuncture, biofeedback, distraction, relaxation
technique.
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37. MANAGEMENT OF PERIOPERATIVE
PAINR=Recognize
A=Assessment
T=Treatment
MultimodalAnalgesia:
Different drugs and technique with different mechanisms/sites of action
along pain pathway
Each with a lower dose than if used alone
Can provide additive or synergistic effects
Provides better analgesia with less side effects
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38. DRUGS
■ Opioids: Morphine, Fentanyl, Pethidine etc.
■ NSAIDS: Ketorolac, Declofenac, PCM?? Etc.
■ Anti-depressants: TCA (Amitriptyline)
■ Anti-convulsants : Carbamazepine,
■ Delta 2 Calcium channel ligand mediated: Pregabaline and gabapentine
etc.
■ NMDA blockers: Ketamine
■ Alfa 2 agonist: Clonidine and dexmedetomidine
■ Local Anesthetics: Lignocaine, Bupivacaine, Ropivacaine etc.
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46. REGIONALANESTHESIA FOR
PERIOPERATIVE PAIN MANAGEMENT
Central Neuro-axial block
a) Intra-thecal Injection of drug
b)Epidural analgesia, caudal analgesia
Commonly used drugs are- 0.5%bupivacaine, Lignocaine,
Fentanyl, Morphine, Clonidine, dexmedetomidine etc
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106. SUMMARY
■ Pain affects various system of our body
■ Careful assessment of pain is necessary
■ Multiple approach of pain management should be considered while managing pain
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107. REFERENCES
■ Miller’sAnesthesia, 8th edition
■ MorganAnesthesia 6th edition
■ Smith pediatric anesthesia, 8th edition
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