Awareness and assessment of the pain in postoperative children is important Remember the different pharmacology in neonates, infants and children Multi-modal approach to preventing and treating pain to minimize adverse effects Regional analgesia must be considered unless contraindicated

1. CURRICULUM VITAE
Name : Dr. Arie Utariani, dr. SpAn. KAP
Dosen/Staff Pengajar Anestesiologi Fakultas Kedokteran
Universitas Airlangga
Posisi / Jabatan :
•Ketua Program Studi Anestesiologi & Terapi Intensif
Fakultas Kedokteran Universitas Airlangga
•Ketua Program Studi Anestesi Pediatrik Fakultas
Kedokteran Universitas Airlangga

2. ArieUtariani
Dept. of Anaesthesiology & Reanimation
Dr. Soetomo Hospital – University of Airlangga
Surabaya

3. The aim of effective post-operative pain
management is to:
• Improve the comfort and satisfaction of the patient
• Facilitate recovery and functional ability
• Reduce morbidity
• Promote rapid discharge from hospital
Recommendation
Post-operative pain should be treated adequately, to avoid post-
operative complications and the development of chronic pain
(Grade of Recommendation: B)

4. Clinical definition of pain
“An unpleasant sensory and emotional experience
associated with actual or potential tissue damage,
or described in terms of such damage...
1. IASP Pain Terminology. In Merskey H & Bogduk N eds. Classification of Chronic Pain,
Second Edition, IASP Task Force on Taxonomy. IASP Press, Seattle 1994:209-14.

5. Pain Pathway

6. Pain: Clinical Types
 Nociceptive pain
Transient pain in response to noxious stimuli
 Inflammatory pain
Spontaneous pain and hypersensitivity to pain in response to tissue
damage and inflammation
 Neuropathic pain
Spontaneous pain and hypersensitivity to pain in association with
damage to or a lesion of the nervous system
 Functional pain
spontaneous pain results from a dysfunction in central processing of
pain in dorsal horn or other regions of the spinal cord.
Woolf. Ann Intern Med. 2004;140:441-451.

7. Postoperative pain is nociceptive
Transmission
Transduction
Reuben et al. J Bone Joint Surg. 2000;82:1754-1766.

8. Key sites of developmental transition in infant pain pathway
Nature Clinical Practice Neurology (2009) 5, 35-50doi:10.1038/ncpneuro0984
(1) Peripheral innervation is vulnerable and sensitive to tissue injury.
(2) Dorsal horn sensory pathways undergo considerable postnatal reorganization.
(3) Nociceptive reflex pathways are diffuse and poorly tuned.
(4) Primary hyperalgesia develops before secondary hyperalgesia.
(5) Endogenous descending controls via the brainstem are unbalanced.
(6) Extensive cortical development begins postnatally, but little is known of the development of
intracortical network connections in infancy.
(7)The somatosensory cortex is activated by noxious stimulation from an early age, but little is
known of activation in other cortical regions.

9. Fitzgerald M. The birth of pain. MRC News (London) 1998; Summer: 20-23.

10. Fitzgerald M. The birth of pain. MRC News (London) 1998; Summer: 20-23.

11. Fitzgerald M. The birth of pain. MRC News (London) 1998; Summer: 20-23.

12. Lingering pain: For weeks after injury at birth damaged
skin can stay more touch sensitive than uninjured skin.
Fitzgerald M. The birth of pain. MRC News (London) 1998; Summer: 20-23.
0 1 2 3
normal
neonatally injured
area
Postnatal age in
weeks
Touchthreshold

13. Fitzgerald M andWalker SM (2008) Infant pain management: a developmental neurobiological approach
Nat Clin Pract Neurol doi:10.1038/ncpneuro0984
Methods of assessing infant pain
• The neurophysiological techniques EMG, EEG and NIRS are not used for routine
pain assessment but are increasingly being used in research studies of infant pain.
• Abbreviations: EMG, electromyogram; NIRS, near-infrared spectroscopy; pO2,
partial pressure of oxygen.

14. Pain Mechanisms in Newborns
 Complete myelination of nerve pathways 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 but offset by shorter distances

15.  Complete myelination of pain pathways to brainstem
and thalamus by 30 weeks gestation; thalamus to
cortex by 37 weeks
 Nociceptive nerve endings in cutaneous and mucous
surfaces by 20 weeks of gestation
 Inhibitory pathways do not develop until after birth
 Threshold for responding to cutaneous stimulation is
lowest in youngest neonates
Pain Mechanisms in Newborns,
cont.

16. What does it mean ?
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

17. Physiologic Response to pain

18. Stress Responses to Postoperative Pain in Neonate
Biochemical Changes:
 stress hormones
 corticosterone
 adrenaline, noradrenaline
 glucagon
 aldosterone
 metabolites
 glucose
 lactate
 pyruvate
Pain Responses
•Tachycardia
•Tchypnea
•Increase blood pressure
•Tissue trauma results in release of mediators of inflammation and stress hormons
•Activation of this stress response leads to:
- Retention of water and sodium
- Increase in metabolic rate
Complications
•Respiretory
•Cardiovascular
•Thromboembolic
•Gastrointestinal
•Musculoskeletal
•Psychological
Post-operative pain management. In: Guidelines on pain management. Arnhem, The Netherlands:
European Association of Urology (EAU); 2009 Mar. p. 62-82. [79 references]

19. Facts about Pain in Infants and Children
 Infants, regardless of age, feel pain.
 The youngest premature infant has the anatomic and
physiologic components to perceive pain or
“nociception” and demonstrates a severe stress
response to painful stimuli.
 Unrelieved pain in infants can permanently change
their nervous system and may “prime” them for having
chronic pain.

20. Postoperative pain can be divided into acute
pain and chronic pain:
 Acute pain is experienced immediately after
surgery (up to 7 days)
 Pain which lasts more than 3 months after the
injury is considered tobe chronic pain

21. Pain evaluation & assessment

22. Pain Assessment
• Careful pain assessment by the anesthetist, surgeon or the acute pain
team can lead to more efficient pain control, adequate doses of the
correct drugs, and diminished morbidity and mortality (Level of
evidence: 2a).
• Pain should be assessed before and after treatment.
• In the post-anaesthesia care unit (PACU), pain should be evaluated,
treated and re-evaluated initially every 15 minutes and then every 1-2
hours.
• After discharge from the PACU to the surgical ward, pain should be
assessed every 4-8 hours before and after treatment.
Recommendation
Adequate post-operative pain assessment can lead to more effective pain control
and fewer post-operative complications (Grade of recommendation: B).
Guidelines on pain management. Arnhem,The Netherlands: European Association of Urology (EAU);
2009 Mar. p. 62-82. [79 references]

23. Q – Question the child
U – Use pain rating scales
E – Evaluate child’s behavior
S – Secure parent’s involvement
T –Take cause of pain into account
T –Take earliest action
QUESTT
(One such standard approach of assessment of pain)
QUEST principles of pain assessment
Baker,Wong. Orthop Nurs 6,1987;11-21

24. PHYSIOLOGIC
Vital sign
O2 Changes
Hormonal changes
Sweating Palmar
VOCAL
Specific : Self report
Non specifik : Cry, Scream, groan
BEHAVIOR
Facial Expression
Postur
Activity
Behavior state
Response to intervention
PAIN
ASSESSMENT
QU
E E
ST
CONTEXTUAL
Pain Stimulus / History
Temperament
Age, Sex
Cultur
Significant Other input
Multidimensional Model of Pain Assessment
PAIN ASSESSMENT

25. PAIN SCALES
INFANTS TODDLERS AND
PRESCHOOLERS
SCHOOL AGE AND
ADOLESCENTS
CRIES CHEOPS
FLACC FLACC FACES
NIPS OUCHER SCALE NUMERIC
SUN
CRIES : Crying, Require s 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 : Combaines pictures with aVisual Analog Scale (VAS)

26. CRIES scales
(Crying, Require s O2 for saturation > 95%, IncreasedVS, Expression, Sleeplessness.)
ITEM Score 0 Score 1 Score 2
Crying No Higgh Pitched Inconsolable
Requires O2
For saturation > 95%
No < 30% O2 > 30% O2
Increased
Vital signs
HR and BP
= or < preop
Increase in
HR or BP
< 20% preop
Increase in
HR or BP
> 20% preop
Expression None Grimace Grimace / Grunt
Sleepless No Wakes at
frequent
Constantly
awake
Preop= Preoperative

27. PARAMETER FINDING :
characteristic
POINTS
Cry 4 8
Facial 3 3
Child verbal 3 6
Torse 6 11
Touch 5 9
Legs 5 9
Children's Hospital of Eastern Ontario Pain Scale (CHEOPS)
inYoung Children
The initial study was done on children 1 to 5 years of age.
According to Mitchell (1999) it is intended for ages 0-4.
Interpretation: minimum score: 4
maximum score: 13

28. FLACC Behavior Pain Assessment

29. Children and Infants Postoperative Pain Scale
(ChIPPS)
Item Score 0 Score 1 Score 2
Crying None Moaning Screaming
Facial expression Relaxed smiling Wry mouth Grimacing
Posture of the trunk Neutral Variable Rear up
Posture of the legs Neutral Kicking Tightened
Motor restlessness None Moderate Restless
Total score indicates how the baby should be managed according to the scale
• 0 - 3 No requirement for treating pain,
• 4 – 10 Progressively greater need for analgesia.
Behavior scale and /or Physiological stress parameter
ButtnerW, FinkeW: Paediatr Anaesth 2000;10(3):303-18.

30. Faces pain
assessment
scale
VRS pain
assessment
scale
NRS
assessment
scale
VAS
assessment
scale
Patient
Able to
Communicate
well ?
No
Yes
Choice of assessment tool

31. Wong-Baker Faces Scale (0-10)
For children over the age of three, for adults who are cognitively or
developmentally delayed, and for the use with geriatric patients who are
unable to use the numeric scale The care provider is to explain to
the patient that the "0" represents "NO PAIN" and "10" represents the
"WORST" pain.
How is Your Pain Today?

32. No
Pain
Worst
Pain
Numeric Scale = NRS
0 21 43 875 6 109
Moderate pain
No pain Little
pain
Medium
pain
Large
pain
Worst
pain
Verbal Ranting Scale =VRS

33. No Pain Worst Pain
Pain Intensity Ranting Scales
Visual-Analogue Scale = VAS
Usually 0-10 cm long line.
Placed either vertical or horizontal.
VAS or Face scale can be used from 5-6 year of age

34. INFANTS
(gold Standard – FACIAL expression)
• Eyes Forcibly closed
• Brows lowered and furrowed
• Nasal roots broadened and bulged
• Deepened nasolabial furrow
• Square mouth
• Cupped tongue

35. CHILDREN WITH COGNITIVE
IMPAIRMENT

36. Concept of “Total Pain Management”
Four aspects must be addressed:
1. Physical
2. Psychological
3. Social
4. Spiritual
Last 3 can be met only after pain and related
symptoms (e.g., N/V, anxiety) are controlled.

37. Pain management & monitoring

38. Is responsive to NSAID’s, coxibs, paracetamol and
opiates
Postoperative pain is nociceptive
Transmission
Transduction
Reuben et al. J Bone Joint Surg. 2000;82:1754-1766.

39. Procedure-related pain management
Intervention:
 The first & most essential intervention:
 prepare the child & family for painful procedure
 parents may benefit from written information
 Pharmacologic management:
 Analgesia
 Sedation
 Nonpharmacologic management:
 Effective for children
 Distraction, guided imagery, muscle relaxation
Texas CancerCouncil Booklet, 1999

40. Non-pharmacologic Interventions
Neonate/
infant
Toddler Preschooler School Age Adolescent
Sensory Sensory Sensory/
Behavior
Sensory/
Behavior/
Cognitive
Sensory/
Behavior/
Cognitive
• Positioning
• Swaddling
• Rocking/
Cuddling
• Touch/
massage
• Dim Lighting
• Visual
Distraction
• Sucking
• Sucrose/Water
solution on
pacifier
•Positioning
•Play therapy
•Hugging/
Holding
•Touch/ massage
•Security object
(blanket, toy,
stuffed animal)
•Distraction devices
(toys/music/videos)
•Heat/cold
application
•Imagery
•Pacifier
•Positioning
•Play therapy
•Hugging/
Holding
•Touch/ massage
•Distraction devices
(toys/music/videos/
games, books)
•Heat/cold
application
•Imagery
•Positioning
•Play therapy
•Hugging/
Holding
•Touch/ massage
•Distraction devices
(toys/music/videos/
breathing techniques)
•Heat/cold
application
•Imagery
•Humor
•Exercise
•Positioning
•Heat/cold
application
•Imagery
•Humor
•Prayers
• breathing
techniques
•Relaxation
techniques
•Distraction
devices
(especially
music/videos)

41. Pharmacologic Interventions
Mild Pain :
• Acetaminophen
• NSAIDs
Moderate to Severe Pain
• Opioid
• Non-Opioid
• Local/Topical anaesthetics

42. Analgesic drugs
 Nonsteroidal Anti-inflammatory Drugs
(acetaminophen, aspirin, ibuprofen, diclofenac sodium,
naproxen, cox-2 inhibitor)
 Opioids
(codein, oxycodone, pethidine, morphine, fentanyl)
 Adjuvants (co-analgesic drugs)
(amitriptyline, gabapentin, carbamazepine, lorazepam,
diazepam, corticosteroid)
The doses and routes of administration of drugs described above are general
examples and each patient should be assessed individually before prescribing.
Texas Cancer Council Booklet, 1999

43. Drug Dose
Diclofenac Oral, Rectal 1 mg/kg/8h
Ibuprofen Oral 10 mg/kg/8h
Ketorolac IV, IM, PO
Do not use with other NSAIDs
0,5 mg/kg/8h or
Continuous infustion
Paracetamol Rectal 40 mg /kg; followed by
30 mg/kg/8h
Oral 20 mg/kg and
30 mg/kg/12h
Newborn, rectal 20 mg/kg and
30 mg/kg/12 jam
Newborn , oral 30 mg/kg and
20 mg/kg/8h
NSAIDs and Paracetamol

44. Drug Dose
Morphin Newborn 0,02 mg/kg/8h
Newborn (for continuous infustion) 5-15 μg/kg/h
Children 0,05-0,1 mg/kg/h
Children (for continuous infustion) 0-30 μg/kg/h
Fentanyl According to surgery 2-10 μg/kg
In ICU 2-5 μg/kg/h
Oral transmucosal Fentanyl
Citrate lollipop
15-20 μg/kg
Remifentanil Surgery 0,5-1 μg/kg/min
In ICU 0,1-0,05 μg/kg/min
Codein Mainly used in combination with
Paracetamol (suppositories or syrup)
(not recommended for children under < 2 year)
0,5-1 mg /kg/4h
OPIOID

46. Local
Anaesthetic
Caudal
block
Lumbar
block
Thoracic
block
Bupivacaine 0,25% 2,5 mg/kg 2 mg/kg 1-1,2 mg/kg
Levobupivacaine 0,2-
0,25%
2-2,5 mg/kg 1,4-2 mg/kg 0,8-1 mg/kg
Ropivacaine 0,2% 2 mg/kg 1,4 mg/kg 0,8-1 mg/kg
Examples of local anaesthetics and mean
doses for single shot epidural

47. Local
Anaesthetic
Newborn and
Infants (up to 1
year)
Older Children
(>1 year)
Bupivacaine 0,125%
Levobupivacaine 0,1%
Ropivacain 0,1%
0,2 mg/kg/h 0,3-0,4 mg/kg/h
Ropivacaine is not licenced for use in infants under the age of 1 year
Examples of local anaesthetics and mean
doses for continuous infusion via catheter

48. Drug Dose
Morphine 0,02-0,05 mg/kg
Fentanyl 1,2 μg/kg or 0,5–1 μg/kg/h
Sufentanyl 0,2-0,3 μg/kg
Clonidine 1-2 μg/kg single shot or
3 μg/kg/24h in epidural infusion
Ketamine 0,5 mg/kg
Adjuvant drugs for epidural use

49. Local
anaesthetic/adjuvant
Newborns and infants
(up to 1 year)
Older Children
(>1 year)
Ropivacaine 0,2% or
Levobupivacaine 0,25%
0,2 mg/kg/h 0,4 mg/kg/h
Clonidine can be added
as adjuvant
3 μg/kg/h
Examples of local anaesthetics and mean
doses for continuouse peripheral nerve block
in children
Ropivacaine is not licenced for use in infants under the age of 1 year

50. Multimodal Analgesia Attacks Different Points
Along the Pain Pathway

51. Analgesic ladder:
The plan of anaesthesia should always include postoperative analgesia and
should be safe, effective and convenient.
This will have been discussed as part of the pre-operative visit.
Each child will return from theatre with an appropriate regime of post-operative analgesia
prescribed.
Those children who are receiving intravenous opioids will reviewed by the Pain Control Service.
They are also available for advice on all apsects of pain management.
Slight
Paracetamol
Mild
Paracetamol
+
NSID
Moderate
Paracetamol
NSID +
Weak opioid
Eq: codeine,
tramadol
Severe
Paracetamol
NSID +
Poten opioid
Eq: morphine,
pehtidine
Increasing pain

52. Observe for Improvement in Behavior
Following an Analgesic

53. Complication

54. Positive role of pain
Acute pain plays a useful "positive" physiological role by:
 Providing a warning of tissue damage
 Inducing immobilisation to allow appropriate healing
Negative effects of pain
Short term negative effects of acute pain include:
1. Emotional and physical suffering for the patient
2. Sleep disturbance
3. Cardiovascular side effects
4. Increased oxygen consumption
5. Impaired bowel
6. respiratory function
7. Delays mobilisation and promotes thromboembolism

55. Long term negative effects of acute pain:
 Severe acute pain is a risk factor for the
development of chronic pain
 There is a risk of behavioural changes in children for
a prolonged period (up to 1 year) after surgical pain

56. Conclution

57.  Awareness and assessment of the pain in
postoperative children is important
 Remember the different pharmacology in
neonates, infants and children
 Multi-modal approach to preventing and treating
pain to minimize adverse effects
 Regional analgesia must be considered unless
contraindicated

58. The Golden Rule
What is painful to an adult is
painful to an infant and child
unless proven otherwise.