Skip to Main Content

++

  • 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

++
Table Graphic Jump Location
Favorite Table | Download (.pdf) | Print
Typical Settings for IV Patient-Controlled Analgesia...
DrugDemand dose (μg/kg)

Want remote access to your institution's subscription?

Sign in to your MyAccess profile while you are actively authenticated on this site via your institution (you will be able to verify this by looking at the top right corner of the screen - if you see your institution's name, you are authenticated). Once logged in to your MyAccess profile, you will be able to access your institution's subscription for 90 days from any location. You must be logged in while authenticated at least once every 90 days to maintain this remote access.

Ok

About MyAccess

If your institution subscribes to this resource, and you don't have a MyAccess profile, please contact your library's reference desk for information on how to gain access to this resource from off-campus.

Subscription Options

AccessAnesthesiology Full Site: One-Year Subscription

Connect to the full suite of AccessAnesthesiology content and resources including procedural videos, interactive self-assessment, real-life cases, 20+ textbooks, and more

$995 USD
Buy Now

Pay Per View: Timed Access to all of AccessAnesthesiology

24 Hour Subscription $34.95

Buy Now

48 Hour Subscription $54.95

Buy Now

Pop-up div Successfully Displayed

This div only appears when the trigger link is hovered over. Otherwise it is hidden from view.