The document discusses peri-operative pain management. It covers defining and classifying pain, the neurophysiology of pain conduction and modulation, pain assessment in pediatric patients, and different methods for managing peri-operative pain. These include pre-emptive analgesia, multimodal analgesia using various drug classes and techniques, and the WHO pain ladder. Regional anesthesia techniques like central neuroaxial blocks, peripheral nerve blocks, and neuraxial adjuncts are also outlined.

1. PERI-OPERATIVE PAIN MANAGEMENT
Presenter:
Dr.Tirtha Raj Bhandari
2nd year Resident
Department of Aesthesia , KCH,
NAMS
2/8/2019 Department of PediatricAnesthesia, KCH 1

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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6. PAIN PATHWAY
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17. MODULATIONOF PAIN
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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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26. ASSESSMENT OF PAIN
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33. MANAGEMENT OF PERIOPERATIVE
PAIN
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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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41. WHO PAIN LADDER
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FOR ADULT

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44. ■THANKYOU
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45. PERIOPERATIVE PAIN MANAGEMENT
PART-II
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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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48. CAUDAL ANALGESIA
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49. CAUDALANALGESIA
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50. CAUDAL ANALGESIA
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51. Armitage Regimen For CaudalAnalgesia
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52. Peripheral Nerve Block
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53. PERIPHERAL NERVE BLOCK
1) Brachial Plexus block
2) Lumber plexus block
3) QL block
4) Paravertebral block
5) TAP block
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54. CONTD
1) Rectus sheath block
2) Ilio-inguinal nerve block
3) Penile Block
4) Femoral nerve block, Sciatic nerve block
5) Lateral femoral cutaeous block
Others- four point block, ankle block, popliteal block, radial, ulnar, medial ,pudendal block
etc.
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56. Brachial Plexus
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60. Lumber Plexus
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68. Interscalene
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70. Supraclavicular
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72. Infraclavicular
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74. Axillary
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77. Femoral
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79. Saphenous
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81. Subgluteal Sciatic
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83. Popliteal Sciatic
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88. SPINAL NERVE
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89. TAP BLOCK
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90. TAP BLOCK
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91. TAP BLOCK
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92. TAP-Types
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93. TAP BLOCK
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94. PARAVERTEBRAL BLOCK
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95. PARAVERTEBRAL BLOCK
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96. QL BLOCK
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97. QL BLOCK
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98. QL BLOCK
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99. QL BLOCK
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100. Ili-inguinal and Ilio-hypogastric nerve
block
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101. Ili-inguinal and Ilio-hypogastric nerve
block
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102. Ili-inguinal and Ilio-hypogastric nerve block
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103. PENILE BLOCK
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104. PENILE BLOCK
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105. ANY QUESTIONS???
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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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108. THANKYOU
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