Post operative pain relief for Infant - Analgesic after surgery

028. A two month old infant has undergone a major surgical procedure. Regarding post operative pain relief which one of the following is recommended:

1. No medication is needed as infant does not feel pain after surgery due to immaturity of nervous system

2. Only paracetamol suppository is adequate

3. Spinal narcotics via intrathecal route

4. Intravenous narcotic infusion in lower dosage

Answer

4. Intravenous narcotic infusion in lower dosage

Reference

http://www.nda.ox.ac.uk/wfsa/html/u07/u07_008.htm

Updates in Anaesthesia : Practical Procedures : Issue 7 (1997) Article 2: Page 6 of 7

The Management of Postoperative Pain (Continued)

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Discussion

Management of pain in children is often inadequate and there is no evidence to support the idea that pain is less intense in neonates and young children due to their developing nervous system. Children tend to receive less analgesia than adults and the drugs are often discontinued sooner. Furthermore, it is simply not true that potent analgesics are dangerous when used in children because of the risks of side effects and addiction. As with all pain, successful management depends upon the identification and treatment of all the factors which contribute, in particular fear and anxiety. In this context, careful explanations to child and parents can be helpful. A major problem in treating pain in children is associated with the difficulty in assessment

Explanation

1. Though the neonates have an immature brain, they nevertheless feel pain and anesthesia is needed.
2. Paracetamol is effective for mild to moderate pain. It can be given as an oral suspension in a dose of 15mg/kg to a maximum of 60mg/kg in 24 hours. Slightly higher doses (20mg/kg) are needed if this drug is used rectally as absorption is less reliable. Obviously this is not suited for our child as the infant has undergone a major surgical procedure
3. Intrathecal route is not the first choice
4. Morphine is the drug of choice for children who are inpatients. The preferred route of injection is intravenous but other routes can be used. Intramuscular injection is painful and unpopular with patients and nurses, however, this route may be used during the operation to provide analgesia at the time the child awakens from anaesthesia. The subcutaneous route can be useful when venous access is difficult. Intravenous morphine is painless once access has been established and if an infusion is to be used the same precautions must be taken to prevent accumulation as were outlined earlier. Normally a loading dose is infused over 30 minutes followed by a background infusion, titrated against the child's pain and the presence of side effects. If staff are experienced in looking after children postoperatively, there is no need for high dependency or intensive care facilities whilst these techniques are employed.

Comments

Doses of morphine orally are 200-400mcg/kg 4 hourly.

Subcutaneous or intramuscular routes 100-150mcg/kg 4 hourly. Intravenous doses 50-100mcg/kg over 30 minutes as a loading dose and then 5-40mcg/kg hourly.

Tips

Many procedures associated with the relief of pain can themselves be painful. The performance of regional blockade, wound infiltration and the placement of intravenous or subcutaneous lines and catheters may be carried out without discomfort or resistance whilst the patient is anaesthetized.