post operative pain relief in children

Home Page Contact Page hospital Staff About Page Whats New Page Favorite Links Page Event of the week Guest Book Page Patient and Family Education

Paul H.Ting,MD E.mailed DR.Dina N.S.Baroudi and thanked her about the review article

Breast Cancer
At a glance:
Breast cancer is one of the commonest female malignancy. Screening of breast cancer is very important, because early diagnosis always means good prognosis. This facilitates the era of the conservative breast surgery rather than the disturbing radical breast amputation surgery. The most important first step is the breast self examination (BSE), which is the examination of the breast by the patient herself once a month in a fixed date preferably in the last day of her menstrual period. Any abnormalities should be reported without delay to the experienced and qualified doctor in order to do the proper management.

Breast Cancer

Post operative pain management in Pediatrics

Post operative pain management in Pediatrics
Dr.Dina N.S.Baroudi
Consultant Anaesthesia
M.S.Basharahil Hospital
Mekkah -KSA

Pain is defined by the International Association for the Study of Pain as an unpleasant sensory and emotional experience associated with actual or Potential tissue damage It is now accepted that pain should be anticipated, safely and effectively controlled, in all children, whatever their age, maturity or severity of illness .Unfortunately the postoperative pain in pediatric patient is not adequately managed despite of it's cause of morbidity and even some reported mortality (1)
Pain evaluation
Pain measurement in children is difficult , this has led
to the proliferation of a multiplicity of pain measurement for neonates, infants and children. Most scores try to assign a numerical value to one of these dimensions: cognitive, physiological, sensory, behavioral, and even facial expression, the anesthetist must be adequately trained and sensitive to the manifestations of acute pain in the various age groups and must be experienced in intervening safely, effectively and appropriately to control the pain.(2)
Consideration points in postoperative pain management:
1.well organized plan .
The post operative pain treatment must be included in the anesthetic planing even before induction of anesthesia , adopting the idea
of " managing pain before it occurs ", (3)
2. Medical attitudes and patient education :
Adequate time must be invested in the preoperative visit to the parent and child ,to assure and explain that the immediate post operative period is going to be pain free ,In a questionnaire done in our institute we include in our pre-operative evaluation visit to all pediatric patient the question of what is the most fearful event -the child or guardian - are afraid from ,and we found that about 64% of all parents as well as most children age >6 year were afraid from having uncontrolled pain ,this concern came ahead from other causes as separation from parents and strange surrounding ( 4)
3. Clinical protocols:
All children in the post surgical recovery room should be regularly assessed for the presence of pain, its intensity and its cause. Titration of analgesia to control pain and documentation of the efficacy and adverse effects of pain management should be routine in all age groups. Regardless of the adopted scoring system , the assessments should be repeated regularly, appropriate interventions should be prescribed and their effectiveness in reducing the pain severity should be regularly documented.
4. Disciplinary involvement:
Although the immediate postoperative pain care is the responsibility of the anesthetist the pediatric surgeon must be involved in the planning of the pain regimen control especially in cases where regional techniques are performed or combined regional-general anesthesia is planed.
The past decade has brought about an explosion of knowledge the pathophysiology of acute pain and analgesic pharmacology.
Many new techniques and methods applicable for pain management in pediatric patient in the post operative period depend on the patient, underlying medical conditions, the type of surgery, the patient's disposition following surgery (inpatient vs. outpatient), and the physician's comfort level with a particular analgesic regimen. (5)
The most important role in postoperative pain management is still played by opoids administered through various modes. However, non-opioid analgesics, i.e.non-steroid anti-inflammatory drugs and paracetamol(6) are more and more frequently used in the management of postoperative pain. The appearance on the market of intravenous forms of these drugs could make them play more important role in the post operative period .
In our protocol of Post -operative pain management we should remember always :
1. use two analgesics, one narcotic and one non narcotics.
2. use timed analgesics and avoid PRN.
3. start the post operative pain management intra-operatively.
A..Non-opioid analgesics
Paracetamol (acetaminophen) owing to its safe therapeutically profile, should be the primary postoperative pain management tool in a majority of surgical procedures (7)( we give a suppository of Tylenol 100 mg or 20 drops of Adol 20 minutes before conclusion of surgery ) noting that the calculated dose of acetaminophen at which 50% of the children not requiring a rescue opioid was 35 mg/kg. The rectal bioavilability in the very young is higher than older children,this require proper calculation of the dose since clearance is reduced in neonates , and neonates are capable of forming the reactive intermediate metabolites that cause hepatocellular damage particulary after multiple doses.(8)
NSAIDS - this group of drugs has become extremely popular for treating postoperative pain in children as they are effective with few side effects and produce an opioid sparing action through decreasing the inflamatory mediatores generated at the site of tissue injury . They should be avoided in patients with coagulopathy ,nephropathy, gastropathy and asthma. Diclofenac 1-3 mg/kg per day in divided doses is widely used. It is also available as a suppository.Ketrolac intravenously 0,5-1.0mg/kg the maximum daily dosage is 90 mg, is as effective analgesic as morphine ,Ketrolac is not recommended for use in infant aged <1 year. (9,10)
Aspirin( Acetylsalisylic acid )This should not be used for children under 12 years because of the association with Reye's syndrome.
3..combination of NSAIDs and paracetamol in order to relieve pain allows both for a significant reduction in the dosage of respective drugs, fewer side effects and an improved pain relief. Regular administration of paracetamol and nonsteroidal anti-inflammatory drugs decreased morphine requirement .(11)
4..Ketamine in the management of postoperative Relief of pain,
Ketamine is in use for almost 3 decades. The role of the (NMDA)
N-methyl-D-aspartate receptor in the processing of nociceptive input has led naturally to renewed clinical interest (NMDA) receptor antagonists such as ketamine. There are evidences about the efficacy of low-dose ketamine in the management of acute postoperative pain when administered alone or in conjunction with other agents via the oral,rectal , intramuscular, subcutaneous,intravenous and intraspinal routes.Low-dose ketamine is defined as a bolus dose of less than 2 mg/kg when given intramuscularly or less than 1 mg/kg when administered via the intravenous or epidural route.Low-dose ketamine may play an important role in postoperative pain management in the furture , some more study may be needed as regards the associated side effects(12,13,14)
5. Tramadol is interesting because it has nonopioid and opioid actions that can be attributed to the two isomers found in the racemic mixture. With low affinity for opioid receptors. iT is used extensively in postoperative management.The postoperative analgesic potency roughly similar to morphine but without relevant cardiovascular or respiratory depressant , and a very low dependency liability. It appears to be well tolerated, oral ( 2,5 mg/kg), intramuscular and intravenous analgesic(2mg/kg) (15)
6. Spinal neostigmine and the use of adenosine represent completely different mechanisms of nonopiod analgesia and it is still under investigation(16).
Opioids may be administered by IM, IV tranmucosal and transdermal or oral routes(17). Children are sensitive to opioids and doses should be reduced accordingly. This should not be given to children <5kg.
The intrasnasal adminstration of sufentanyl1,5 mic/kg 10 minutes before the end of sevoflarene anesthesia will give you very satisfactory results The transdermal administration of fentanyl provide steady-state plasma concentration , The acceptance of oralet fentanyl in children is very good(18) , Inspite it's assosiation with increased incidence of nausea and vomiting.
C.Local anaesthetic :
1.Local wound infiltration with bupivacaine 0.25% at the conclusion of surgery is very effective and is extremely simple and safe. It reduces the need for additional measures(19)
2. Regional Blocks :
Many pediatric anesthesiologists and surgeons have excellent success with the utilization of regional anesthetic techniques as treatment for postoperative pain.These include intercostal blocks following thoracotomy, ilio-inguinal and ilio-hypogastric nerve blocks following hernia repair ,orchidopexy, dorsal nerve blocks of the penis or caudal blocks following circumcision. These blocks not only provide excellent postoperativ analgesia, but are great adjuncts to general anesthesia, Additionally, the use of epidural opioids is extremely useful in patients following major abdominal, thoracic, and orthopedic surgeries. (20,21,22)
The usual Guidelines for local anesthetics use must be obeyed and
Proper doses of local anesthetics considering the maximum safe doses. The recommended maximum dose of Bupivicaine is 2 mg/kg or Lignocaine 4 mg/kg. These dosages are the maximum for a correctly injected dose. If the drug is mistakenly injected intravenously very small dosages may cause serious toxicity.
Contraindications of regional techniques.
1. Unfamiliarity with the technique" do not experiment " Always perform the technique you are familiare with.
2. Infections near the site of the needle insertion.
3. Coagulopathy or anti coagulation therapy
4 Pilonidal cyst (caudal block)
5.Congenital abnormalities of the lower spine or menings because
of the unclear or impalpable anatomy.
D.Patient controlled Analgesia:
PCA in a pediatric patient is modified to become a nurse or parent controlled analgesia (PNCA) however a special education for parents are prerequisites(23)
children are defenseless and are depending upon our care , the first thing we must do is to believe the child pain Is real if the child says that it hurts ,it hurts, Unrelieved pain increases the patient's anxiety and apprehension, which in turn increase the intensity of pain the current situation in postoperative pain management indicates more room availability for improvement, especially in the area of patient education .Optimizing postoperative pain control is the key to further advancement in the field of ambulatory anesthesia Preoperative administration of analgesia would decrease the intraoperative analgesic requirement, which may lead to a smooth and rapid recovery (24)

1. Fisher SM. Postoperative pain management in paediatrics.
Br J Perioper Nurs. 2000 Feb;10(2):80-4.
2. CL von Baeyer ,CL Hicks Echelle de la douleur chez les
enfants: en faveur d'un systeme commun , pain research&
management Summer 2000 ,volume 5, number 2: 157-160.
3. Langlade A, Kriegel I Treatment of acute postoperative pain.
Ann Chir. 1997;51(9):1013-21.
4. Dweiri M, Premedication and fluid management in paediatrics
Saudi Anaesthetic Association newsletter ,volume 10 No .2 May
5. Golianu B, Krane EJ ,Galloway KS , Yaster M , pediatric acute
pain management , pediatr Clin North Am 2000 jun ;
47(3):559- 87.
6.Korpela R, Korvenoja P, Meretoja OA. Morphine-sparing
effect of acetaminophen in pediatric day-case surgery.
Anesthesiology. 1999 Aug;91(2):442-7.
7. Korpela R, Korvenoja P, Meretoga OA , Comment IN :
Anaesthesiology 2000 Apr ;92(4) : 1202-3.
8. Arna A, Morton NS, Hansen TG : Treatment with paracetamol
in infants Acta Anaesthesiology Scand.2001 Jan ;45(1):20-9.
9. Forrest JB ,Heitlinger EL,Revell S Ketrolec for postoperative
pain management in children. : Drug Saf 1997 May 16(5):309-
29 .
10.Purday JP,Reichert CC,Merrick PM Comparative effects of
three doses of intravenous Ketrolac or Morhine on emesis and
analgesia Can J Anaesth 1996 Mar;43(3):221-5.
11.Berkowitz RA,McDoland TB , Post-operative pain
management Indian J Pediatr 1997 May-Jun ;64(3): 351-67.
12. Schmid RL, Sandler AN, Katz J.Use and efficacy of low-dose
ketamine in the management of acute postoperative pain: a
review of current techniques and outcomes. Pain. 1999
13.Levanen J "Ketamine and oxycodone of postoperative pain
Ann Chir 1997; 51(9): 1013-12.
14.Markus RJ, Victoria BA, Rushman SC, Thompson JP
Comparison of Ketamine and morphine for analgesia after
tonsillectomy in children ,Br J Anaesthesia 2000 Jun ;48: 739-426. 15.Naguib M, Seraj M, Attia M, Samarkandi AH, Seet M, Jaroudi R.
Perioperative antinociceptive effects of tramadol. A prospective,
randomized, double-blind comparison with morphine.
Can J Anaesth. 1998 Dec;45(12):1168-75.
16. Power I,Barratt S Analgesic agents for the postoperative period.
Nonopioids.Surg Clin North Am 1999 Apr;79(2):275-95
17.Engelhardt T, Crawford M.Sublingual morphine may be a suitable
alternative for pain control in children in the postoperative period.
Paediatr Anaesth. 2001 Jan 26;11(1):81-83.
18. Aboelmaged E, Saudi Anaesthesia and the 21ST Century Anaesthetic
Association newsletter ,volume 10 No .2 May 1999.
19.Gozal Y, Shapira SC, Gozal D, Magora F.Bupivacaine wound infiltration
in thyroid surgery reduces postoperative pain and opioid demand. Acta
Anaesthesiol Scand. 1994 Nov;38(8):813-5.
20. Kundra P, Deepalakshmi K, Ravishankar M.
Preemptive caudal bupivacaine and morphine for postoperative
analgesia in children. Anesth Analg. 1998 Jul;87(1):52-6.
21.Goodarzi M. The effect of preoperative and postoperative caudal
block on pain control in children. Paediatr Anaesth. 1996;6(6):475-
22. Mayhew JF, Brodsky RC, Blakey D, Peters Low-dose caudal
morphine for postoperative analgesia in infants and children: a
report of 500 cases.J Clin Anesth. 1995 Dec;7(8):640-2.
23. Monitto cl, Greenber RS ,Kost-byerly S, Wetzel R ,Billet C, Lebert RM ,Yaster M The safety and efficacy of partent-/nurse-controlled analgesia in patient less than six years of age .Anesth Analg 2000 sep;91(3):573-9.
24.Tong D, Chung F , Postoperative pain control in ambulatory surgery.
Surg Clin North Am. 1999 Apr;79(2):401-30.


The first C-Shape MRI in the west region

On Monday 26 of May 2003 the general manager of the hospital Eng.Turky M.Basharahil and Dr. Anwar Obeidat sign the contract , the hospital purchased the up to date C-Shape MRI , to replace the close MRI available now in the hospital , the Al-Faisaliah Medical group will install the new Siemens C-Shape MRI in September 2003 .
The Hospital as well purchased the HDI4000 ultrasound 3D with real D.

This is some descriptive text.

This is some descriptive text.