Postoperative analgesia: opioid infusions in infants and children

Canadian Journal of Anesthesia/Journal canadien d'anesthésie, Nov 1992

The purpose of this review is to emphasise the ineffectiveness of traditional analgesic therapy in paediatric patients after surgery, to examine the sensation of pain in infants and children, and to describe the use of intravenous opioids for postoperative analgesia. The management of 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 for 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.

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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)


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David R. Pounder, David J. Steward. Postoperative analgesia: opioid infusions in infants and children, Canadian Journal of Anesthesia/Journal canadien d'anesthésie, 1992, pp. 969, Volume 39, Issue 9, DOI: 10.1007/BF03008348