Postoperative analgesia: opioid infusions in infants and children
0
From the Department of Anaesthesia, British Columbia's Children's Hospital
,
Vancouver
,
British Columbia. of Anaesthesia, Lethbridge Regional Hospital
, 960 - 19th Street S, Lethbridge, Alberta,
T1J 1W5. Accepted f o r publication 1st July
, 1992
David R. Pounder Mo FRCPC,David J. Steward MBF~CPC The purpose of this review is to emphasise the ineffectiveness o f traditional analgesic therapy inpaediatric patients after surgery, to examine the sensation of pain in infants and children, and to describe the use o f intravenous opioids for postoperative analgesia. The management o f acute postoperative pain in the paediatric surgical population has been poor. This is despite the knowledge that infants and children have sufficient neurological development at birth to sense pain, and that the same hormonal and metabolic responses to nociceptive stimuli that occur in adult also occur in the neonate. Physicians frequently order analgesics in inappropriate doses, nurses are reluctant to administer opioids, and children themselves frequently compound the problem by refusing injections. The sophisticated techniques f o r providing postoperative analgesia which have been used so successfully in adults can also be used in paediatric patients. Two of these, continuous intravenous opioid infusion and patient-controlled analgesia, have proved to be very successful. Children older than six months can receive either modality safely with regular monitoring by qualified nursing staff. Infants younger than six months receiving continuous opioid infusions should be monitored in high-dependency units. La qualitd du traitement de la douleur aigu~ postopdratoire dans la population chirurgicale pddiatrique est douteuse. On sait pourtant que les b~bds et les enfants possddent un ddveloppement neurologique suffisant d~s la naissance pour ressentir la douleur et que les m~mes rdponses hormonales et
Postoperative analgesia: opioid infusions in infants and children
mdtaboliques aux stimulation, s nociceptives comme chez les
adultes se manifestent chez le nouveau-hr. Souvent, les
mddecins prescrivent des analgdsiques fi des doses inapproprides,
les infirmi~res sont rdticentes ~ administrer des opiacds, et
frdquemment, les enfants eux-mdmes compliquent le probl~me
en refusant les injections. Les techniques sophistiqudes
d'administration d'analgdsie postopdratoire utilisdes avec tant de
succks chez l'adulte peuvent aussi ~tre utilisdes chez l'enfant.
Deux de celles-cL la perfusion intraveineuse d'opiacds et
l'analgdsie contrrlde par le patient ont prouvd leur pleine
efficacitL Les enfants au-dessus de six mois peuvent bdndficier
de l'une ou l'autre mdthode en sdcuritd avec un monitorage
rdgulier et une dquipe soignante qualifide. Les enfants
endessous de six mois qui refoivent des perfusions continues
d'opiacds doivent ~tre suivis dans les unitds de haute
surveillance. L'objectif de cet article est de souligner l'inefficacitd de
l'analgdsie traditionnelle chez les patients pddiatriques apr~s
la chirurgie, d'examiner la perception de la douleur chez les
bdbds et les enfants, et de ddcrire l'utilisation intraveineuse des
opiacds pour l'analgdsie post-opdratoire.
At least fifteen surveys published between 1952 and
19901-5 attest to the failure o f intermittent intramuscular
injection o f narcotics to provide adequate postoperative
analgesia for adult surgical patients. The traditional
techniques o f postoperative pain control have been even
less successful in paediatric patients. Mather and Mackie 6
found that o f 170 paediatric surgical patients 16% did not
have a postoperative analgesic ordered, 39% did not
receive a postoperative narcotic analgesic, 40% were in
moderate to severe pain during the day of surgery, and
27% were similarly uncomfortable on the first
postoperative day. Doses o f analgesics which were ordered
were often inappropriate in amount and/or frequency, and
were ordered p r o re nata, which was interpreted by the
nursing staff to mean, "Give as few doses over the longest
period o f time as possible." Eland and Anderson 7 matched
25 children with 18 adults who were undergoing the same
operations. The 25 children received 24 doses o f
analgesics, o f which 11 were narcotics. The 18 adults received
671 doses of analgesics of which 372 were narcotics.
Thirteen of the 25 children received no analgesics,
including a four-year-old with an amputated foot, a six-year-old
who underwent heminephrectomy, and a seven-year-old
who had a repair of an ASD. One child received two
aspirin tablets following spinal fusion, and two with
65-70% second and third degree burns received one
aspirin and one acetaminophen tablet each. Beyer et al, 8
comparing 50 children with 50 adults undergoing open
heart surgery, showed that the adults received more than
twice as many doses of analgesics as the children.
Similarly, Schecter et al. 9 matched children and adults undergoing
inguinal herniorrhaphy or appendectomy or sustaining
fractured femurs o (...truncated)