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A multimodal approach to pain control allows the clinicians to treat the pain at multiple points in the process of pain generation.
Postoperative nausea and vomiting (PONV) may be due to multiple factors that are similar for adult and pediatric patients.
A clinician’s initial assessment of hydration status should focus on estimating capillary refill time, skin turgor, and respiratory patterns.
Pediatric patients in the Post-Anesthesia Care Unit (PACU) require vigilant attention after they receive anesthesia. One-to-one nursing, special vital sign monitoring, and the ability to evaluate patients quickly and accurately are some of the requirements of a pediatric PACU. The evaluation and treatment of a pediatric patient may require the clinician to utilize alternative methods than those used for an adult patient. For example, a child undergoing bilateral myringotomy tube placement may not have an intravenous (IV) catheter present to administer anti-emetic and pain medications.
The goal of managing a pediatric patient is to transition patients safely from anesthesia to discharge from the PACU. In addition to stable vital signs and adequate oxygenation and ventilation, three important patient factors to assess are adequate pain control, hydration status, and the degree of nausea and vomiting.
Assessments
Assessments of pediatric patients in the PACU should always begin with ensuring a patent airway, as well as assessing breathing and circulation (ABCs). Table 44.1 lists the normal, age-specific values for respiratory rate, heart rate, and blood pressure in awake pediatric patients.
| Age | Respiratory rate (breaths/min) | Heart rate (beats/min) | Systolic blood pressure (mmHg) | Diastolic blood pressure (mmHg) |
|---|---|---|---|---|
| 0–3 months | 35–55 | 100–150 | 65–85 | 45–55 |
| 3–6 months | 30–45 | 90–120 | 70–90 | 50–65 |
| 6–12 months | 25–40 | 80–120 | 80–100 | 55–65 |
| 1–3 years | 24–30 | 70–110 | 90–105 | 55–70 |
| 3–6 years | 20–25 | 65–110 | 95–110 | 60–75 |
| 6–12 years | 14–22 | 60–95 | 100–120 | 60–75 |
| 12+ years | 12–18 | 55–85 | 110–135 | 65–85 |
Pain in pediatric patients
All patients, from neonates to adults, can perceive pain. Therefore, it is imperative to accurately assess and treat pain with standardized methods in a patient of any age. Adequate pain control in children is complicated by their inability to communicate the type, intensity, and location of their pain. Many patients are pre-verbal or possess mental challenges that make communication difficult. However, many tools are available to evaluate a child at any age or development stage. They are categorized as being either observational or self-reported. Self-reported pain levels become relevant by the age of 5 to 6 years.[1]
Neonate pain assessment involves monitoring vital signs and observing the child. The CRIES (Crying, Requires O2 for SpO2 >95%, Increased vital signs, Expression, Sleepless) neonatal post operative pain measurement score shown in Table 44.2 was developed at the University of Missouri, Columbia.[2] Assessment should be carried out after every pain intervention. A CRIES score of zero represents no pain, while a score of 10 signifies maximal pain.
| 0 | 1 | 2 | |
|---|---|---|---|
| Crying | No | High pitched | Inconsolable |
| O2 required to maintain SpO2 >95% | No | FiO2 21–30% | FiO2 greater than 30% |
| Vital signs | HR and BP less than or equal to preoperative values | HR and BP up to 20% greater than preoperative | HR and BP over 20% greater than preoperative |
| Expressions | None | Grimace | Grimace/grunt |
| Sleeplessness | No | Wakes at frequent intervals | Constantly awake |
HR, heart rate; BP, blood pressure.
Several tools can be used to evaluate pain in patients aged 1 year old to pre-verbal. Commonly used scales include The Children’s Hospital of Eastern Ontario Pain Scale (CHEOPS), Toddler–Preschooler Postoperative Pain Scale (TPPPS), and the Fingers, Legs, Arms, Cry and Consolability (FLACC) scale,[3] which rely on vocal, facial, and bodily pain assessments. The FLACC scale (Table 44.3) is a measurement tool that assesses pain in children between the ages of 2 months and 7 years. The scale is scored from zero (no pain) to 10 (severe pain). It does not rely on a child’s ability to verbalize his or her degree of pain.
| Criteria | 0 | 1 | 2 |
|---|---|---|---|
| Fingers | No particular expression, or smile | Occasional grimace or frown, withdrawn or uninterested | Frequent to constant quivering chin, clenched jaw |
| Legs | Normal position or relaxed | Uneasy, restless, tense | Kicking or legs drawn up |
| Arms | Lying quietly, normal position, moves easily | Squirming, shifting back and forth, tense | Arched, rigid, or jerking |
| Cry | No cry (awake or asleep) | Moans or whimpers, occasional complaints | Crying steadily, screams or sobs |
| Consolability | Content, relaxed | Reassured by occasional touching, hugging, or being talked to | Difficult to console or comfort |
Assessing pain in the verbal child can be facilitated by tools that help the child convey their level of pain to the practitioner. Some tools available are the Oucher,[4] Faces pain scale, Numeric pain scale, and Visual Analog scale. These tools can help a clinician accurately evaluate pain in a pediatric patient.
Treatment of pain
The pain response is generated and transmitted via multiple mechanisms and pathways. A multimodal approach to pain control allows the clinicians to treat the pain at multiple points in the process of pain generation. Acetaminophen, non-steroidal anti-inflammatory drugs (NSAIDs), and opioids have all been shown to provide safe and effective analgesia in children.[5] Aspirin is not regularly used in the pediatric population because of its association with Reye syndrome.[6]
Medication administration may be complicated by the lack of IV access in some pediatric postoperative patients (e.g. myringotomy tubes). Oral, intramuscular, intraosseous, and rectal administration routes are options in patients without IV access. Dosing of medication is usually determined by weight in the pediatric population. In many instances, the dose of medication may differ from the adult dose. When using weight-based dosing, the dose should not exceed the recommended dose for adults.
Acetaminophen provides analgesia and antipyretic activity and is available in oral, IV, and rectal forms. The oral and IV dose is 15 mg/kg every 6 hours. The dose for rectal acetaminophen is 35 mg/kg every 6 hours. The maximum dose of the drug is the same for all routes of administration. The dose in neonates should not exceed 60 mg/kg/day. The dose in infants/children should not exceed 4 g/day.[7]
NSAIDs have been found to be effective in the treatment of pain in children after ambulatory surgery. They have a synergistic analgesic effect with opioids, while reducing the occurrence of opioid-related side effects.[8] Ibuprofen, naproxen, and ketorolac have all been studied in the pediatric population (Table 44.4).
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