Indian J. Anaesth.

406 PG ISSUE2004; 48 (5)ANAESTH

: PAED : 406-414 INDIAN JOURNAL OF ANAESTHESIA, OCTOBER 2004
406

POST OPERATIVE PAIN MANAGEMENT

IN PAEDIATRIC PATIENTS
Dr. R. P. Gehdoo

Introduction Swaford and Allen6 had stated that “Paediatric patients

Pain is perhaps the most feared symptom of disease, seldom need medication for relief of pain. They tolerate
which a man is always trying to alleviate and conquer discomfort well…”. Eland 7 identified significant
since ages. It is defined by the international association for discrepancies in the treatment of pain in the children and
study of pain as an “unpleasant sensory and emotional adults. A few years after this, the clinical reports on
experience associated with actual or potential tissue incidents of pain and analgesic administration in children
damage or described in terms of such damage”.1 Children started emerging.8,9 Anand et al10 described the effects of
are special in this regard because, in them it is a very pain on infants due to minimal anaesthesia surgery in his
complex phenomenon. It is also very difficult to differentiate articles. Similar articles appeared in the editorials of the
restlessness or crying due to pain from that of hunger or major medical journals.11 Soon after these articles, various
fear in the children. An effective pain therapy to block or committees were formed to give recommendations on this
modify the myriad physiologic responses to stress has become subject.12 The society of Paediatric Anaesthesia,13 at its
an essential component of modern pediatric anaesthesia and 15th annual meeting at New Orleans, Louisiana (2001)
surgical practice. clearly defined the alleviation of pain as a “basic human
right”, irrespective of age, medical condition, treatment,
Historically, children have been under treated for primary service response for the patient care or medical
pain and for painful procedures because of the wrong notion institution. Langlade et al14 suggested that the post operative
that they neither, suffer or feel pain, nor responded to or pain treatment must be included in the anaesthetic planning
remembered the painful experiences to the same degree even before induction of anesthesia, adopting the idea of
that adult did. An unproved safety and efficacy of the ‘managing pain before it occurs’. Now, post-operative pain
analgesics and worries about the risk of opioid induced management is an integral part of practice of paediatric
respiratory depression, added more reasons for the under anaesthesia in all major hospitals.
treatment of pain in children. Popular dogma had suggested
that the human child does not feel pain, and that it is Acute pain is the pain associated with a brief episode
dangerous to give him powerful analgesia because of the of tissue injury or inflammation, such as that caused by
risk of addiction2. Under treatment of post-operative pain surgery, burns, or trauma. In most of such cases, the intensity
even in the children and newborns may trigger biochemical of pain diminishes steadily over a period of time.
and physiologic stress response and cause impairments in
Pain assessment in children
pulmonary, cardiovascular, neuro endocrinal, gastrointestinal,
immunological, and metabolic functions.3 Finely et al4 Pain assessment is the most important and critical
have recently reported that many types of the so called component of pain management. Assessing pain in children
“minor” surgery can cause significant pain in children and is an ever challenging as well as a difficult task, mainly
that, parents have a number of misconceptions concerning because so far no reliable method of assessing and measuring
pain treatment. child’s pain is available.

In spite of all these reports, the postoperative pain However, the child’s self report is the single most
in paediatric patient is not adequately managed despite of reliable indicator of the existence and intensity of pain.
it’s cause of morbidity and even some reported mortality.5 Cognitive and emotional developments together with
psychological defense mechanisms are important variables
to be considered with paediatric pain.15 Unfortunately, this
Professor in Anaesthesiology
is possible only in youngsters with sufficient cognitive and
Tata Memorial Hospital, Mumbai
Correspond to : communicative abilities. In the infants, or children with
Dr. R. P. Ghedoo cognitive or physical impairments, self-report is not always
E-mail : [email protected] possible and observational assessment in the form of
GEHDOO : POST OPERATIVE PAIN MANAGEMENT 407

behavioral or biological methods are the only options c. Evaluate behavior and physiologic changes
available. One such standard approach of assessment of Behavioral and physiologic changes : Specific
pain is QUESTT which is as follows- distress behaviors eg. cry, ouch, facial expression (grimace),
Q – Question the child posture (guarding) and body movements are typically
associated with pain and are useful in evaluating pain in
U – Use pain rating scales
children with limited communication skills. However, it is
E – Evaluate child’s behavior difficult to discriminate between behavior due to pain and
S – Secure parent’s involvement other types of distress eg. hunger, fear or anxiety.
T – Take cause of pain into account
Facial expression scale of Wong
T – Take earliest action

a. Question the child

Self Report : The child’s verbal statement and
description of pain are important factors in assessment of
pain. Children up to 2 years can report and locate the pain,
although, at this age they will not be able to quantify the
intensity. Questioning should be patient and in the words
familiar to the child should be used. It is the best to talk
to the parents before asking the child and the words that
CRIES scale
are used to describe the pain in the family should be used.
Children, at any age can deny pain if the questioner is a
stranger, or are afraid of receiving injections for pain.

Faces scale

b. Use a pain rating scale Many scales for behavioral assessment have
Faces scale : Children up to 4-5 years old can use been described, namely, Directly Observed Behaviors,
standardized measuring scales. One must introduce and Children’s Hospital of Eastern Ontario Pain Scale
discuss the detailed aspects of the scale to the child and his (CHEOPS),21 Toddler Preschool Post operative Pain Scale,22
parents, before using them. Some of the methods available Ten Item Post operative Pain Score,23 CRIES scale, facial
for self report are Hester’s poker chip tool,16 Faces scale expression scale of Wong et al24 and Nurse or Parent rating
of Bieri et al,17 faces scale of Kutner and Le Page,18 Eland’s of pain.
colour scale,7 Visual Analog Scale (VAS), Smiley Analog
Scale, Oucher Scale of Beyer and Wells,19 and Work Graphic Physiologic changes : As like the behavioral
Scale of Tesler et al.20 Ideally speaking, no one scale is measures, the physiologic changes do not discriminate
better than the others. between physical responses to pain and other forms of stress.
Most studies of physiologic measures have assessed to the
Children older than 7-8 years can use a zero to ten acute pain but are unreliable indicators of persistent pain.
numeric scale or even VAS scale. Using the above scales, Examples of physiologic changes to pain are increase in
pain is measured for the treatment plan as well as to gauze heart rate, respiration and blood pressure, crying, sweating,
the success of the therapy instituted in the child.
408 PG ISSUE : PAED ANAESTH INDIAN JOURNAL OF ANAESTHESIA, OCTOBER 2004

decrease in oxygen saturation, dilation of pupils, flushing B. Systemic drug therapy

or pallor, nausea and muscle tension. Heart rate is probably I. Non-narcotic analgesics
the simplest and therefore the most appropriate. Vagal
This group of drugs has become extremely popular
tone25 and heart rate variability26 such as during breathing for treating postoperative pain in children as they are
have been used as indices of pain and distress. Heart rate effective with few side effects and produce an opioid sparing
initially decreases and then increases in response to short action through decreasing the inflammatory mediators
sharp pain. generated at the site of tissue injury. These drugs act
Surgery also triggers the release of stress hormones peripherally by inhibiting prostaglandin (PGs) and thereby,
(corticosteroids, catecholamines, glucagon and growth blocking the afferent pain mediators and impulses. These
hormone). Except in laboratories and researches, these drugs have a ceiling effect in the higher doses, though this
measurements are not been found to be useful clinically to may increase the side effects. These are useful for mild to
assess and treat the pain. moderate pain or as adjuncts with narcotics to decrease the
side effects of narcotics.
d. Secure parent’s involvement
a) Paracetamol (Acetaminophen) : This is the
Parent’s should be questioned about the early most common analgesic used in the children. It is very
recognition and child’s behavior during pain. They should useful as a postoperative analgesic specially if used with
be also encouraged to get actively involved in assessment, Ibuprofen. Owing to its safe therapeutic profile, it should
progress as well as treatment strategies of pain in their be the primary postoperative pain management tool
child. in a majority of surgical procedures.27 Though dose
response in children is not known, 15-20 mgkg-1 can be
e. Take cause of pain in to account
used safely orally every 4 hours. An injectable formulation
Etiology and or procedure may give clues to the of paracetamol also exists as pro-drug paracetamol.28
expected intensity and type of pain. Nephrotoxicity and hepatotoxicity are the commonly
f. Take a quick action to relieve the pain encountered complications but, are not seen with short
term use.
Establish the acceptable pain level in the child and
use appropriate methods to relieve it. b) Ibuprofen : This is a better analgesic than
acetaminophen. Safety of Ibuprofen for use in children
Pain Management in paediatrics less than 6 months of age is yet to be established. However,
There are many different modalities to treat the the pharmacokinetics in infants over 3 months is similar to
paediatric pain. But before opting for an appropriate adults.29 Oral formulations are available and 4-10 mgkg-1dose-1
modality of pain relief, one must evaluate the relative risks every 6-8 hours is quite effective.
or benefits, it’s analgesic efficacy, safety, side effects, c) Diclofenac : This is more powerful anti-
costs and the course of recovery. The child should be inflammatory drug than acetaminophen and ibuprofen.
prepared properly for that particular method of pain However, the incidence of nephrotoxicity and GI
relief. A good psychological preparation of the child complications are also higher with this drug. It is available
as well as parents, proper premedication and smooth in tablet, syrup as well as suppository form. The oral dose
anaesthesia course always helps in reducing the anxiety and is 1-1.5 mgkg-1 12 hourly.
needs of pain medications in the post-operative period.
d) Ketorolac : Ketorolac is a very useful analgesic
The treatment modalities include general measures, in children30 and it’s opioid sparing effect has been
systemic drug therapy, regional techniques and non- confirmed. Being a non-narcotic and with a duration of
pharmacologic approaches. action for 4-6 hours, it is routinely prescribed even for
children in empirical doses. Recently, IV route has also
A. General measures been declared safe in children. The IV or IM dose of
Child should be made comfortable and less distressed, ketorolac is 0.2-0.5 mgkg-1 every 6 hours for 48 hours.
before surgery as well as during hospital stay. These Maximum permitted total dose per day is 120 mg.
measures include presence of parent with the child,
The commonly seen side effects with NSAID’s are
nursing in a comfortable environment, allowing the increased chances of bleeding, thrombocytopenia,
child to adopt most comfortable position and feeding if precipitation of asthma attacks, increase in heart rate,
permissible.
GEHDOO : POST OPERATIVE PAIN MANAGEMENT 409

retension of sodium and water, GI ulcerations, bleeding, a) Morphine : Morphine still remains the standard
hepatotoxicity, nephrotoxicity, nausea, vomiting, and opioid for pain relief in infants and children of all age
dyspepsia etc. groups. It is considered safest in a dose of 0.1 mgkg-1
intramuscularly in a spontaneously breathing child.33,34
e) Ketamine : Ketamine is in use routinely for
However, intramuscular injections are discouraged because
almost 3 decades. The role of the N-methyl-D-aspartate
they result in fluctuating plasma levels and cycles of pain,
receptor (NMDA) in the processing of nociceptive input
comfort and sedation.
has led naturally to a renewed clinical interest in the
NMDA receptor antagonists such as ketamine. It can be b) Codeine : This drug is used mainly as a powerful
administered alone or in conjunction with other agents via antitussive, than analgesic. A single oral dose of 1 mgkg-1 is
the oral, rectal, intramuscular, subcutaneous, intravenous good enough as both antitussive and analgesic. Respiratory
and intraspinal routes. There are evidences about the efficacy depression is never seen after a single dose.
of low dose ketamine (of less than 2 mgkg-1 intramuscularly
c)Pethidine : Pethidine is not very popular for
or less than 1 mgkg-1 intravenously or epidurally) in the
post-operative pain management in children because
management of acute postoperative pain. It is been
practically it offers no advantages over morphine. Injection
commented that a low dose ketamine may play an important
pethidine in a dose of 1.5-2 mgkg-1 IM is a useful premedicant
role in postoperative pain management in the future but,
and in a dose of 1 mgkg-1 I.V. is used for intraoperative and
some more study may be needed as regards the associated
postoperative analgesia.
side effects.31
d) Fentanyl : Though fentanyl has been tried in
II. Narcotic analgesics doses of 1-2 mgkg-1, it is not a popular systemic analgesic
Opioids are the mainstay in the management of for conventional post-operative analgesia in children.
post-operative pain and they provide increased tolerance
e) Buprenorphine : In a dose of 3-5 mgkg-1 is a
to pain. In newborns, clearance is diminished and
useful analgesic for intra-operative and post-operative
elimination half lives are prolonged as compared to the
analgesia. A tablet form for sublingual administration is
older children. Maturation gets completed by 3-6 months
suitable for use in older children who do not like injections.
and infants become no more susceptible to respiratory
depression.32 But close observation of the infants is still f) Pentazocine : A partial agonist, can also be used
needed, as the titration to the clinical effects is hampered in a dose of 1 mgkg-1 IM or 0.5-0.75 mgkg-1 I.V. When it
due to difficulty in the pain assessment and also sometimes is given I.V. in very small infants, careful respiratory
the presence of high risk factors like cardio-respiratory and monitoring is essential.
neurological abnormalities. Common side effects encountered with opioids are
The use of opioids in infants less than two months nausea, vomiting, dyspepsia, constipation, urinary retension,
must be with proper monitoring in the intensive care setting. respiratory depression, drowsiness, euphoria etc.
The elimination half life and clearance of morphine in
infants older than two months of age is similar to adults. Intravenous analgesia using opioids
Intravenous analgesia provides immediate relief of
In infants from six months up to one year, injection
pain. After an intravenous bolus dose of 0.1 mgkg-1 injection
morphine 0.1 mgkg-1 in or 0.05 mgkg-1 I.V. may be used.
morphine, the child gets relief from pain for 1-3 hours.
Careful respiratory monitoring and facilities for resuscitation
Intravenous analgesia can be given by two different ways as
must be available because of the problem of respiratory
i) continuous iintravenous infusion or ii) patient controlled
depression.
analgesia (PCA).
In children 1-6 years, narcotics can be safely used.
The intravenous route is the best for the postoperative i. Continuous I. V. infusion
analgesia as it provides immediate pain relief. Injection This technique maintains the drug concentration
morphine 0.1 mgkg-1 or pethidine 1 mgkg-1 I.V. are the above the therapeutic level so that it avoids the painful
usual drugs. periods in between the empirical doses. It requires a careful
Children more than six years can usually monitoring of the patient for the therapeutic effects as well
communicate well about the pain perception and can as possible complications, so as to titrate the appropriate
cooperate with the staff in pain management. So, in them, dosage.
besides all the above techniques, a number of newer Usually, this can be achieved by an initial dose
techniques can be used. of 0.05 mgkg-1 IV morphine, followed by an infusion of
410 PG ISSUE : PAED ANAESTH INDIAN JOURNAL OF ANAESTHESIA, OCTOBER 2004

0.015-0.025 mgkg-1hr-1 in children < 6 months and Problems and contraindications to paediatric PCA
0.025-0.030 mgkg-1hr-1 in older children. This provides a Contraindications to children using PCA are specific
satisfactory analgesia without respiratory depression. If a physical or cognitive disabilities or conditions that may
child is already intubated and being ventilated, higher prevent safe and effective self administration. This may
doses like 0.025 mgkg-1hr-1 can be given even in include the inability to activate the device to deliver the
small babies. In the newborn the dose must not exceed 10 opioid dose or an inability to understand the process.42 The
mgkg-1hr-1 as the neonates have a reduced clearance of child must have the ability to comprehend PCA instructions
morphine and increased sensitivity to toxic effects. and understand the concepts of “greater than” and “less
‘Apnea monitors’ and pulse oximeters should be than” to report pain scores.
used specially, if opioids are being used in infants < 6 Allowing someone other than the patient to activate
months of age, or in children with acute or chronic respiratory the PCA button removes a PCA safety mechanism. If
dysfunction etc. patient is the only person pushing the PCA button, and
if he falls asleep the dosing will get interrupted. Even,
ii. Patient controlled analgesia (PCA) Family Controlled Analgesia (FCA) and Nurse Controlled
This is another method to ensure a continuous pain Analgesia (NCA) have caused oversedation and respiratory
relief. Patient-controlled analgesia (PCA) has been studied depression in some cases.43 FCA remains a controversial
in the adult clinical setting since 1971.35 However, it was pain management technique.44
not until the late1980s that PCA was investigated for use
A 1.7% incidence of respiratory depression was
in the paediatric population.36
reported in children receiving parent controlled analgesia
PCA has been documented as decreasing children’s in combination with nurse controlled analgesia (NCA).45
anxiety about painful intramuscular injections and improving
their sense of control postoperatively.37 This is important Adverse effects of PCA in the pediatric population
because children may tolerate pain rather than request It is difficult to estimate the number of adverse
another analgesic injection.38 events associated with PCA therapy in pediatrics. However,
An adequate preoperative preparation of the medication adverse events are grossly underreported,
patient is needed for the use of PCA. Though expensive, especially in pediatrics.40 Overall, pediatric patients are at
still, there is a high degree of patient satisfaction as the high risk for adverse drug events because of several
patient himself participates in pain management. factors.47 These include the need for calculation of
Following appropriate pre-operative teaching children > 6 individualized doses based on age, body weight, BSA,
years of age can learn to use a PCA pump. An anaesthesiologist and clinical condition, as well as the unique and rapidly
states, ‘If a child can play video games, he or she can changing pharmacokinetic parameters exhibited by infants
master the use of PCA’.39 To use PCA, the child must and children at various ages and stages of maturational
understand the relationships between a stimulus (pain), a development. Additionally, there is a deficit of published
response (pushing the button), and a delayed result (pain information of Food and Drug Administration (FDA) approved
relief). It is important that the child understand the labeling regarding the dosing, pharmacokinetics,
expectation of PCA is pain control, not elimination of pain.40 efficacy, safety, and clinical use of drugs in the pediatric
The children must be carefully screened for their cognitive population.
and physical ability to manage their pain using PCA. Respiratory depression in pediatric patients receiving
This can be used as either PCA infusion alone or PCA therapy alone has been reported by one reviewer to
PCA with basal infusion. PCA has been reported to result range from 0 to 1.1%.48
in lower pain scores, and better satisfaction than To decrease such complications due to an inadvertent
intramuscular morphine use, even though, the total overdose secondary to supplemental opioid doses, an assessment
morphine used, time to oral intake, incidence of nausea and of the patient’s use of the PCA before the additional dosing
vomiting or urinary retention is same.41 Total hourly dose or dosing adjustments is necessary.49 Addition of an adjuvant
of 0.05 - 0.1 mgkg-1hr-1 of morphine can be used. Giving a agent, such as intravenous ketorolac, may improve analgesia
basal infusion of 1/3-1/4 of total hourly dose and PCA bolus without contributing to opioid adverse effects.
as remaining hourly dose divided in equal doses at
6-15 minutes of lockout periods works well. A basal morphine C. Regional techniques
infusion of 12-15 mgkg-1hr-1 41 has been successfully used Regional blocks are becoming increasingly popular
without any side effects. in paediatric surgery. It is also known that supplementing
GEHDOO : POST OPERATIVE PAIN MANAGEMENT 411

general anaesthetic with regional or nerve blocks, allows hydrocoelectomy and orchidopexy can also be performed
a smooth intra-operative course, decreased requirements under sacral epidural analgesia.
for general anaesthesia drugs, decreased stress response,
For the details of the technique please refer
pain free awakening, and avoidance of potentially deleterious
article on “Regional Anaesthesia in Paediatric Patients”
side effects that may occur with parenteral administration
(page no. 394-399) of this issue.
of narcotics during surgery and above all, an excellent
post operative pain relief. If used for thoracic and Undesired effects like numbness and motor weakness
upper abdominal surgery, regional anaesthesia improves after an epidural injection can be often distressing for the
pulmonary function also. child in the post-operative period. Epidural narcotics in this
situation have a more promising role.
Sometimes, regional anaesthesia is given to a
child even without a general anesthesia eg. older and Epidural clonidine
co-operative child who requires emergency peripheral
Recently, c1onidine has been discovered to enhance
surgery after recent food ingestion, child with chronic
and prolong the analgesia produced by epidural blocks.50
airway disease like asthma, child with neuromuscular
A 3 mgkg-1 of clonidine by lumbar epidural route and
disease having compromised respiratory reserve and poor
5 mgkg-1 by caudal route does not have significant
pharyngeal and laryngeal reflexes, and a child with family
haemodynamic or sedative effect. However, 5 mgkg-1 by
history of malignant hyperpyrexia.
lumbar route have been found to cause significant
Local anaesthetic drugs are used for regional hypotension and bradycardia.51
blocks. One must be aware that in infants less than 2
months, less bupivacaine is bound to the plasma proteins Neuraxial opioids
because of low levels of albumin resulting in higher Morphine, fentanyl and sufentanyl have been used
concentration of the free drug. Elimination half life is in single bolus doses or by continuous infusions by the
also prolonged. The myelination of nerves is incomplete in epidural route. Pain relief is obtained without any motor or
infants. sensory blockade. Neuraxial opioids should be avoided
in all infants who are born premature. Moreover, the
Various regional techniques which have been used
child should be subjected for monitoring by an apnoea
in children are lumbar epidural, caudal epidural, intercostal,
monitor and oximetry under the supervision of a nurse or
ilio inguinal and ilio hypogastric, 3 in l block, sciatic nerve
a doctor.
block, fascia iliaca block, brachial plexus block, wrist block,
penile block, infiltration block and topical analgesia. Caudal epidural morphine can be given in a dose
of 0.03-0.05 mgkg-1. Higher dosages like 0.1 mgkg-1 has
Before a regional or nerve block is done, considerations
been reported to cause respiratory depression.52 Single
must be given regarding NPO status, emergency airway
dose lumbar epidural morphine has been used in doses of
accesses, intravenous access, standard monitoring of cardio-
0.05 mgkg-1 for abdominal and lower extremity surgeries
respiratory function and resuscitative measures like oxygen,
and in doses of 0.12-0.15 mgkg-1 for thoractomies in a
suction, equipment for ventilation and intubation, and
volume of 0.05-0.56 mlkg-1 segment.53 The analgesia
emergency drugs etc.
lasts for 8-12 hours. For epidural infusion, a bolus of
Epidural injection 0.03-0.05 mgkg-1 is injected followed by an infusion of
0.004-0.006 mgkg-1hr-1.
Epidural injection can be done at thoracic, lumbar
and caudal levels in children. Single shot caudal blocks are The dose of epidural fentanyl is 0.5-1 mgkg-1 single
quite popular in the routine clinical practice in the children. dose in a volume of 0.05 mlkg-1 but the analgesia lasts for
The child almost always requires another method of pain only 3-4 hours. Epidural sufentanil can be given in a single
relief after 3-4 hours in case of bupivacaine and 8-16 hours dose of 0.75 mgkg-1 in the same volume as fentanyl but the
in case of morphine injection given caudally. duration of analgesia is only 2 hours.54

Sacral epidural (caudal) analgesia The adverse effects due to epidural opioids are
almost same like an opioid given by any other route, though
This is the most popular and useful regional block in
they may not be that severe and commoner. Though
paediatrics. It is simple to perform and easily adaptable to
rare, but the respiratory depression, following epidural
day-care surgery. Common indications of caudal block are
opioids is the most serious complication. Nausea and pruritis
circumcision, hypospadias repair, cystoscopy, anal surgery
are also commonly seen and can be taken care as suggested
and club foot repair. Inguinal surgery like hernia,
in (table 1).
412 PG ISSUE : PAED ANAESTH INDIAN JOURNAL OF ANAESTHESIA, OCTOBER 2004

Urinary retention can occur with both epidural local surgery. Similar effect has been seen by simple instillation
anaesthetics as well as epidural opioids of the local anaesthetic in the open wound after inguinal
hernia repair.55 However, topical application of lignocaine
Table - 1 : Suggested therapies for adverse effects due to jelly applied on completion of surgery and EMLA cream56
opioids
have been found to be less effective than dorsal nerve block
Adverse effect Treatment options of penis for post circumcision analgesia.
Respiratory Depression - Stop opioid + Airway management Topical analgesia with lignocaine patch 5% or a
- Naloxone – 0.5-1 mgkg-1dose-1 – as I.V. bolus topical local anaesthetic mixture EMLA (Eutectic Mixture
- 0.5-1 mgkg-1hr-1 – as infusion
of Local Anaesthetics),57 can penetrate the skin for 5 mm
Sedation - Stop opioid
- Stimulant medication like Methyl phenidate
depth, when covered with an occlusive dressing and left
Dysphoria - Change opioid drug undisturbed for 60-90 minutes. A routine perioperative use
Constipation - Stool softner like Cremaffin / enema of topical, local or regional analgesia, alone or as a
Nausea and vomiting - Promethazine 0.25 mgkg-1 up to 25 mg I.V./I.M. component of a multimodal approach with NSAID’s or
- Droperidol 0.01 mgkg-1 up to 0.625 mg acetaminophen is particularly useful.58
- Ondensetron 0.1 mgkg-1 I.V. up to 4 mg
Pruritis / Itching - Diphenhydramine 0.05 mgkg-1dose-1 s.c.
Ilio-Inguinal and Ilio-hypogastric nerves block
- Local soothening agents like caladryl etc.
Urinary retension - Catheterisation, if needed
For the details of the technique please refer
- Bethanecol 0.05 mgkg-1dose-1 s.c. article on “Regional Anaesthesia in Paediatric Patients”
(page no. 394-399) of this issue.
Continuous intercostal block
Others
This technique provides analgesia in fractured ribs
Important nerve blocks that can be given are 3-in-l
and upper abdominal or thoracic surgery. This block has
block for fracture femur and femoral osteotomies, sciatic
been seen to accelerate extubation and to improve the vital
nerve block for lower limb analgesia, brachial plexus
capacity postoperatively, and thereby to decrease pulmonary
block and wrist block for upper limbs and para-umbilical or
complications following thoracotomies. rectus sheath block for umbilical hernia repair (also repair
The catheter is placed by the surgeon with the chest of hernia of the linea alba).59,60
open, medial and superior to the posterior edge of the D. Non-pharmacological approaches
incision and dorsal to parietal pleura. The tip should be
posterio-medial, a few centimeters lateral to spine. Various non-pharmacological approaches eg.,
Lignocaine dose should be limited to 4-6 mgkg-1, while, psychological interventions like hypnosis, behavioral
Bupivacaine should be limited to 0.3-0.4 mgkg-1hr-1. therapy, Acupuncture, Transcutaneous electrical nerve
stimulation (TENS) have been described for post-operative
Nerve block of the penis analgesia. As all these techniques need a co-operation from
i) The dorsal nerve of penis block : This is the child, it’s usefulness is limited only in a select group
performed by injections at 10.30 and 1.30 clock positions of children. TENS have been seen to reduce postoperative
deep to the Buck’s fascia. 1-3 ml of 0.25% bupivacaine or narcotic requirement after thoracotomies.
1% lignocaine is used on both sides of the midline for the
block. It must be ensured that there is no intravascular Conclusion
injection and that the local anaesthetics do not contain It is now widely accepted that infants and children
epinephrine. require appropriate method of pain relief in the post-operative
period for a smoother and rapid outcome. But still there
ii) Subcutaneous ring block : This involves are lot of reservations and skepticism about the technique
subcutaneous infiltration of 0.25% bupivacaine outside to be employed, with the result being that child suffers further
Buck’s fascia pain because of inadequate or inappropriate therapeutic
iii) Topical lignocaine : Lignocaine jelly has been intervention. Relatively simpler nerve block techniques,
used to provide analgesia after circumcision and has been along with analgesic drugs can be employed safely so as to
used in the post discharge treatment of pain. relieve the post-operative pain. Newer modalities of pain
management should be also considered whenever possible.
Infiltration block and topical analgesia
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GEHDOO : POST OPERATIVE PAIN MANAGEMENT 413

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