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  • Severity of pain:
    • Minor or outpatient procedures require oral opioids or NSAIDs to complement any regional anesthesia block
    • Major surgery requires regional anesthesia, if applicable, and scheduled or continuous opiate administration with NSAIDs, benzodiazepines, or other pain medications as indicated
  • Type of surgery:
    • Abdominal: regional, opioids, NSAIDs, multimodal
    • Thoracic: regional strongly recommended, opioids, NSAIDs, multimodal
    • Laparoscopic: opioids, NSAIDs, local infiltration
    • Neurosurgical: opioids, infiltration regional (less loss of motor function in neurologic exam), avoid sedation, generally avoid NSAIDs
    • ENT: opioids, avoid sedation in airway compromise, avoid NSAIDs in T&A
    • Orthopedic: regional anesthesia, benzodiazepines and antispasmodics, opioids, NSAIDs
    • Plastic: opioids, NSAIDS for minor surgery—avoid in reconstructive surgery, local infiltration
    • Ophthalmologic: opioids, topical local anesthetics, NSAIDs
    • Urologic: regional anesthesia—caudals, opioids, NSAIDs, antispasmodics (bladder)
    • Cardiac: opioids, NSAIDs, regional anesthesia (neuraxial based on postoperative coagulation plan)
  • Age and size of child:
    • Weight-based dosing regimens to account for various sizes of children, ideal weight-based dosing for obese adolescents
    • Neonates:
      • Require higher monitoring due to generally narrower therapeutic range
      • Require continuous or scheduled delivery of pain medications due to inability to communicate
    • Infants have similar needs based on decreased communication. Frequent pain evaluation with developmentally appropriate rating scales prevents inadequate treatment of pain
    • By age 4, can communicate differing intensities of pain
    • Age 6 or 7: can self-administer medications through patient-controlled analgesia (PCA) and patient-controlled epidural analgesia (PCEA) systems; if they can play a video game, they should cognitively be able to press a button for pain
  • Use of regional anesthesia/analgesia:
    • Parents agree to regional anesthesia by experienced provider
    • Contraindications: local infection, sepsis, preexisting neurologic condition, allergy or hypersensitivity, coagulation issues per ASRA guidelines for neuraxial anesthesia
  • Comorbidities:
    • Spina bifida and previous spine surgery (myelomeningocele, hardware) and coagulopathy are relative contraindications to neuraxial regional anesthesia
    • Liver dysfunction requires dosing adjustments for opioids, benzodiazepines
    • Renal dysfunction requires dosing adjustments for opioids, NSAIDs
    • Respiratory dysfunction including OSA requires dosing adjustment for opioids, benzodiazepines; special consideration with NSAIDs and asthmatic patients
    • Neurologic dysfunction, central or peripheral deficits are relative contraindications to regional anesthesia


  • Multimodal pain treatment is guided by using different medications at moderate doses to decrease the risk of side effects or toxicity from any one therapy
  • Be flexible and adaptive in treating children’s (and parents’) pain, as all pain is perceived differently—some have more emotional pain; others have more sensory pain


  • Opioids can be delivered through many routes: PO, nasal, IV through PCA, continuous infusion and intermittently, epidural and intrathecal
  • IM and SQ injections should be avoided as young patients have more fear of the delivery method than of the pain itself
  • Local anesthetics can be delivered through peripheral injections, peripherally placed catheters, epidural catheters and caudal injections, as well as intrathecal placement. Topical gels and patches are contraindicated on incisions
  • Additional treatment medications: NSAIDs, benzodiazepines, NMDA antagonists, alpha-2 antagonists

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Typical Settings for IV Patient-Controlled Analgesia...
DrugDemand dose (μg/kg)

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