Perioperative care and

Pain Management in
Pediatrics Surgical
Patients

Moderator: Dr Mengistu (Assistant professor of

Pediatric Surgery)
Presenter: Dr Bogale(GSR3)

ACSHMC, October 30,2024 GC

 Out Line
 Introduction
 Preoperative Care
 Perioperative care of some common Conditions
 Intraoperative Care
 Post operative Care
 Perioperative Pain management in pediatrics surgery
 Introduction

 The surgical management of infants and children requires

delicate, careful, and professional interactions with patient
 The physiology of the neonate, infant, child, and adolescent
differ significantly from each other and from the adult.
 The most distinctive and rapidly changing physiologic
characteristics occur during the neonatal period.
• The physiologic and anatomic immaturity sets up for
several specific and clinically significant problems
– CNS immaturity
– Pulmonary immaturity
– Cerebrovascular immaturity
– Skin immaturity
– GI underdevelopment
– Impaired bilirubin metabolism
– CVS immaturity
– Immature immune system
 Perioperative Care

– Preoperative care
– intraoperative care
– post operative care
 Pre operative evaluation

 is the process of evaluating the patient’s clinical

condition, aimed to define the risks and eligibility for
anesthesia and surgery through
 Proper history
 Adequate physical examination
 Complete investigations
 Pre operative care

 Aim of preoperative care

– Identifying and optimizing potential coexisting diseases

– Preparing the patient and the family for the specific

operation

– Adequate patient identification.

 History

 Age
 birth history vs full-term or premature or perinatal
complications
 A review of all organ systems
 Concurrent medical illnesses & nutritional status
 history of all past medical illnesses
 childhood syndromes with associated anomalies
 medications & any allergies
 Family history with increased anesthetic risks
Past medical illnesses in the mother and family

– Diabetes
– Thyroid disorders
– Hypertension
– Cardiac Ds
– maternal seizure disorders & AEDs
– Smoking, Alcohol, Cocaine
– Maternal nutritional status
– Previous maternal reproductive problems
 Obstetric history

 Events in present pregnancy

 Description of the labor
 Delivery
 Physical Examination

 General Condition:
 the color, activity
 Inspect for gross anomalie
 HEENT:
o HC (caput,Molding,suture,Fontanelles)
o Dysmorphic features of trisomy 21
o Choanal atresia, Cleft, Protruding tongue
o webbing,goiter
 CHEST:- signs of RD,deformity,air entry,added sound
 CVS:- rate, cyanosis,heart sounds,murmur
 Abdomen:
– Distended vs. scaphoid abdomen
– Abdominal wall defect (gastroschisis)
– organomegally
– Abdominal mass
– Hernias sites; umbilical and inguinal
– anus: Patency,location
 Genitalia :
 penis(Hypospadias, epispadias,)
 Testes(location),Hydrocele
 Premature(Prominent clitoris and minora,Labial fusion)
 Extremities :Digital abnormality,fractures, hip dislocation
 CNS:Awakenes and alertnes,moving extremities, body posture,reflex
 Investigation
 Full blood count, BG and RH
 U/A
 Serum electrolyte
 Coagulation status
 Blood cultures
 Imaging
 Preoperative preparation

 Informed consent
 NPO time
 Pre op fluid management
 blood request
 NG tube,urinary catheter if indicated
 bowel preparations
 premedication's
 Informed Consent

 Informed consent should disclose, at the minimum:

– the surgeon’s understanding of the problem;

– further measures to be taken to clarify the diagnosis, if
indicated;
– the indication for emergency operation;
– a brief description of the procedure;
– alternatives to treatment, including the option to
do nothing;
– the surgeon’s recommendation as to the best alternative;
– the benefits and risks of the proposed operation,
– compared with alternatives;
– the anticipated outcome
 Preoperative NPO guidelines

 The preoperative fast is an attempt to avoid regurgitation and

possibly aspiration of particulate matter and liquid from the
child’s stomach during induction of anesthesia.
 Each institution has its own NPO guidelines, however most
will agree to
 Fluid Replacement
 The goal of perioperative fluid management is to
maintain fluid homeostasis with normal organ
perfusion and normal glucose and electrolyte balance
 Perioperative fluid therapy has following
purposes:
 To supply water and thereby to create enough urine volume to excrete
solutes.
 To replace insensible fluid losses.
 To replace electrolytes lost from the urine, skin and gut.
 To supply calories to reduce tissue catabolism
 Preoperative deficits, maintenance fluids, and ongoing
intraoperative third space loss and blood losses must be
replaced
 Preoperative fluid deficits result from fasting and can be
calculated
– by multiplying the patient's normal fluid maintenance rate
by the number of hours fasted.
 This calculated fluid deficit is usually replaced over the first 3
hours of surgery,with half given in the first hour.
 The estimated fluid deficit (EFD)= Hours fasting ×
Maintenance fluid requirement (MFR) (ml/kg/hr)
– First hour fluid = MFR + ½ EFD
– Second hour fluid = MFR + ¼ EFD
– Third hour fluid = MFR + ¼ EFD
 MFR calculated
– 0 to 1 0 kg = 4 mL/kg/h,
– 1 1 to 20 kg = 4 mL/h + 2 mL/kg!h,
– >20 kg = 4mL/h +2ml+ 1 mL/kg/h.
 intraoperative fluid replacement amount of fluid lost depends
on the amount of tissue exposed and the degree of surgical
manipulation
 For superficial surgery 1-2 ml/kg/hr
 For abdominal procedure 6-10 ml/kg/hr
 For thoracic surgery 4-5 ml/kg/hr
 Glucose-containing solutions are not routinely used(RL
preferred
 Preoperative anxiety

 40%-60% of children develop significant fear and anxiety

 ages of 1 -5 years are at greatest risk
 separation from parents and induction of anesthesia is the
most stressful times
 associated behavioral manifestations with neuroendocrine
changes
 adversely affect the postoperative period, with higher
incidence of pain as well as short- and long-term behavioral
changes
 Pre op anxiety management

 behavioral interventions
 tours of the places they will see during the day of surgery
 films about surgery or anesthesia
 puppet shows, medical play, and photographs of previous
children’s experience
 avoid separation distress
 possibly decrease long-term behavior problems
 minimizing the need for preop premedication
 significant increase in parental satisfaction with the
perioperative experience.
 pharmacologic interventions (premedications)

– The anesthesia and preoperative team can also assist by the

administration of anxiolytic medications
– midazolame, ketamine, transmucosal fentanyl, and
meperidine
Prophylactic antibiotics
 Preoperative Consideration in some Common Conditions

 Prematurity
 Upper Respiratory tract infections:
 Asthma and Bronchial Hyperresponsiveness
 Cardiac problems
 DM
 Cerebral Palsy
 Trisomy 21
 Vaccinations
 Prematurity

 Bronchopulmonary dysplasia
 GERD
 intraventricular hemorrhage
 hypoxic encephalopathy
 laryngomalacia, or tracheal stenosis
 Postoperative apnea
 Bronchopulmonary dysplasia

 most common form of chronic lung disease in infants

 The triad airway obstruction, bronchial hyperreactivity, and
lung hyperinflation
 c/m: tachypnea,bradycardia,wheezing, coughing, febrile,
desaturation
 Effects of anesthesia:
 Increased airway reactivity & oral and bronchial secretions
 Pulmonary vasoconstriction, effects on myocardial
contractility
 preop pulmonary & cardia status must be evaluated &
optimized
 Bronchodilators, antibiotics, diuretics, corticosterod &
nutritional therapy
 require continuous postop monitoring and intensive pulmonary
therapy
 post op apnea

 immaturity of central and peripheral chemoreceptors

 drug-induced depression.
 at risk : < 56–60 weeks post conceptual age & hgb <10 g/dL
 should be admitted for cardiorespiratory monitoring 24 hrs
prior & post surgery
 Upper Respiratory tract infections

 airway laryngospasm, bronchospasm, hypoxia,

atelectasis, and post-extubation airway obstruction
 uncomplicated URI who are afebrile with clear
secretions and who are otherwise healthy: proceed
 more sever smx (mucopurulent secretions, productive
cough,pyrexia greater than 38º C or pulmonary
involvement) :
 postpone management is aimed at minimizing secretions
and avoiding stimulation
 Asthma and Bronchial Hyperresponsiveness

 Both the severity and the control of asthma must be

established preoperatively.
 a recent exacerbation of asthma that has required
hospitalization or emergency therapy within 4-6 weeks of
surgery precludes elective surgery
 should continue their regular medications before anesthesia.
 minimize/avoid airway manipulation
 Cardiac Problems

 Murmurs :
 a thorough history and physical examination
 pathological murmur ,signs and symptoms of CHD or ECG
findings
 delay surgery until an echocardiogram with a cardiology
consultation identifies or excludes a pathological condition
 CHD:
 Assessment of the child’s current health status
 optimize the pulmonary & cardia status
 medications Hx & search for other anomalies
 Endocarditis prophylaxis for dental procedures
 avoid anxiety and control pain
 Diabetic Miletus

 Target blood glucose levels

 Toddler& preschool 100-180mg/dl(HgA1C 7-9)
 School age 90-180mg/dl(6-8.5)
 Adolescents(13-19)90-130mg/dl(6-8
 Type I DM on insulin :
 on SPLIT MIX :
– rapid- or short-acting AND intermediate- or long-acting insulin
– took usual dose the night before morning : hold rapid/short acting & give 50% of
intermediate/long acting
 on insulin infusion:
– Administer insulin infusion on the morning of the procedure:
– Solution of 10% dextrose and 1/2 NS(maintenance rate)
– regular insulin (50 units/50 mL saline) via syringe pump
 Type II DM on oral agents:
– stop metformin 24 hours before procedure
– On day of procedure: Hold sulfonylureas and glyburide
 Cerebral Palsy

 is a polymorphic set of motor d/ors with a wide spectrum of

severity.
 increased oral secretions ,dysfunctional swallowing, reflex
disease
 ineffective gag and inadequate cough, resulting in the
development of reactive airway disease and recurrent
pneumonitis
 scoliosis may restrict ventilation
 Hypothermia is the most common perioperative complication
 Contractures and deformities limit positioning
 Trisomy 21

 Perioperative complications occur in 10 % of patients

 severe bradycardia, airway obstruction, difficult intubation,
post-intubation croup, and bronchospasm,OSA ,a smaller
caliber trachea
 atlanto-axial instability occurs in about 15%
 CHD (50%): (AVSD,ASD, VSD, PDA )
 GI abnormalities (5%):DA/S,TEF,IA,HSD,Omphlocele
 GU:Renal malformations,Hpospadias,Cryptorchidism
 Vaccinations

 Postpone an elective procedure that requires anesthesia rather

than vaccination, especially in neonates and infants.
 Postpone vaccinations, one week after general anesthesia.
 Postpone anesthesia to a week after vaccination with
inactivated vaccine
 Postpone anesthesia to three weeks after vaccination with live
attenuated vaccine
 Intraoperative care

 Preparation of the necessary anesthesia and surgical equipment

 Asepsis : skin preparations
 prevention of hypothermia
 difficult airway management
 safe induction, maintenance & extubation
 monitoring ( oxygenation, ventilation, circulation,& T0). This
can be accomplished by the use of oximetry, capnography,
electrocardiography, and blood pressure measurement
 continue fluid therapy
 blood transfusion
 Blood replacement

 preoperative hematocrit value of approximately 30% would

be considered a safe and adequate level for major
procedures
 An estimation of blood volume should be made before
induction
 EBV :
– premature(90-100 cc/kg),
– term(80-90 cc/kg),
– infant(70-80 cc/kg),
– older child(70 mL/kg),
– obese child( 60 to 65 mL/kg )
 ABL= Weight (kg) x EBV x (Ho-Hl) / H
 The minimum acceptable hematocrit varies according to
an individual child’s need
 20% to 25% range for an infant up to 3mn of age
 20% for an older child if there is little potential for
postoperative bleeding
 Estimated Blood Loss
 Soaked 4 x 4cm gauze :5-10 cc
 Soaked pack :80-100cc
 Hand full clotted blood :450-500 cc
 Objective measurement in the suction bottle
 Each ml of blood lost replaced by 3 mL of isotonic
crystalloid,
 If blood loss exceeds the MABL or if the hct drops to 20% to
25% transfusion with PRBCs or whole blood should be
started.
 Volume of PRBCs to be transfused:
 (Desired HCT - present HCT) X EBV/HCT of
PRBC( 60%) ml
 Post operative care

 Promote healing

 Prevent complications

 Intervene early if complications arise

 Wound and Dressing Care
 Extubation and Transfer
 Postoperative Orders
 Admission Order
 monitor V/S & fluid balance
 fluid (MF + preop or intraop FD + OL)
 post op pain mgt
 postop pulmonary care
 postop GIT care: early enteral feeding as per GI function
 drain output : NG,drains ,Catheter ..early removal unless
indicated
 postop wound assessment & care
 medications :ABX, Antiacids ,antipyretics
 lab request & imaging : as needed for control & complications
 Nutrition

 Specifically, neonates require a large energy intake because of

their high basal metabolic rate, requirements for growth and
development, energy needs to maintain body heat, and their
limited energy reserves.
 Energy requirements are increased 10–25 percent by surgery,
greater than 50 percent by infections, and potentially more in
children with burns
 The average neonate should gain between 20 and 30 g/day, ( 1–
2 percent of the total body wt)
 Protein =>of 2–3 g/kg per 24 hours
 30–40 percent of the total non-protein calories should be
provided as fat
 Pediatric pain management

 is defined by the international association for study of pain as

an
– “unpleasant sensory and emotional experience associated
with actual or potential tissue damage or described in terms
of such damage
 Children have been under treated for pain due to
– wrong notion that they neither, suffer or feel pain, nor
responded to or remembered the painful experiences to the
same degree that adult did.
– An unproved safety and efficacy of the analgesics.
 Children of all ages feel pain, but the type and intensity may
vary dramatically
 The response of infants and young children to pain is therefore
unpredictable, particularly in premature neonates, which often
leads to inadequate pain management.
 PERIOPERATIVE PLANNING AND
GENERAL APPROACH
 The goal of perioperative pain management is to maximize
patient comfort while minimizing side effects such as
excessive sedation or respiratory depression.
 Preoperative, intraoperative, and postoperative strategies for
minimizing pain should be based on the planned surgical
procedure, anticipated severity of postoperative pain,
anesthesia technique, and expected course of recovery.
 Children must be reassessed at frequent intervals, with
analgesic regimens modified accordingly
 Responses to pain
Physiologic
behavioral
 Physiologic
– Increase in HR, BP, RR, ICP
– Decreased SaO2
– Change in color (pale, poor perfusion or red,
increased perfusion)
 Behavioral
 Crying
 Facial expressions ( grimacing, quivering of chin,
squeezing eyes, furrowed brow)
 Body movements (limb withdrawal, fist clenching, hyper
tonicity or hypo tonicity
 State changes ( changes in sleep-wake cycles, & changes in
activity levels
 PAIN ASSESSMENT

 Pain assessment in pediatric patients can be challenging.

 Nonetheless, pain in children should be recognized, assessed,
and treated promptly
 Approach to a child in pain

 QUESTT
 Question the child
 Use a pain rating scale
 Evaluate the behavior and physiological changes
 Secure parents involvement
 Take cause of pain into account
 Take action and evaluate results
 Pain assessment tools
 For neonates
PIPP
Neonatal facial coding system
N-PASS=> 0 to 100 days
NIPS
 CRIES up to 6months
 FLACC – 2month to 7yrs
 CHEOPS– 1-7yrs
 3 to 8 yrs– Oucher scale, face rating scale
 >8yr– visual analogue scale
Neonatal infant pain scale
 ABCs of Pain Management

Recommended by the Agency for Health Care

Policy and Research (AHCPR), USA
A - Ask about pain regularly. Assess pain systematically.
B - Believe the patient and family in their reports of pain and
what relieves it.
C - Choose pain control options appropriate for the patient,
family, and setting.
D - Deliver interventions in a timely, logical, coordinated fashion.
E - Empower patients and their families. Enable patients to
control their course to the greatest extent possible
 Management

Can be pharmacological or non-pharmacological

 Non pharmacological
– Distraction
– Imagery
– Comfort measures
 Pharmacological
– Non opiods
– Opioids
– Local anesthetics
 Non pharmacological measures

 The first step in managing all levels of pain

 Alone do not relieve pain; however, their use reduces
agitation, which indirectly reduces pain
 Prevent the intensification of pain
 Parents should be encouraged and facilitated to engage
 Nonnutritive sucking, kangaroo care, facilitated tucking,
rocking, and holding, opportunities for grasping, hand
swaddling, decreasing light and noise, and body support and
containment
 When available breast feeding should be the first
choice to alleviate procedural pain in neonates”
 Sucrose administration– release of endorphins
– Preterm infants: 0.1 to 0.4 ml; dipping a pacifier into
sucrose results in 0.1-ml intake
– Term infants: 2 ml
 Administer 2 minutes before a painful procedure
 Analgesic effect lasts about 5 minutes
 Glucose solution (e.g., 33%–50%) can also be used
 Auditory intervention- music therapy
Pharmacologic measures
The World Health Organization designed a
three-step analgesic ladder
 Nonopoids
– Often overlooked
– Adequate for mild to moderate pain
– Reduce opioid requirement in cases of moderate to severe pain
– Have a ceiling effect
 Acetaminophen
o Most common antipyretic and nonopioid analgesic used in
children
o potent inhibitor of cyclooxygenase

o The primary toxicity of acetaminophen is hepatic injury,

 NSAIDs
 Ibuprofen one of the oldest orally administered NSAIDs
– Superior analgesia when compared with acetaminophen or
codeine in children with acute pain after musculoskeletal
trauma
 Diclofenac (1 mg/kg 8 hrs) PO, PR or IV
– PR –the relative bioavailability was greater and the peak
concentration was reached earlier than after PO
– Provide comparable analgesia to those who received caudal
bupivacaine or IV ketorolac for inguinal hernia repair
 Opioids

 The mainstay of pharmacologic therapy for moderate to severe

pain and have established roles in procedural and perioperative
pain management
 Have dose-dependent pain relief and respiratory depression;
 Side effects –decreased GI motility, nausea, and urinary
retention, histamine release (urticaria, pruritus, nausea,
bronchospasm)
 Naloxone(1-10mcg/kg) is the reversal agent used for adverse
effects (hypotension, respiratory depression)
 Therapy >7 -10 days may result in physical dependence,
requiring weaning before discontinuation to avoid withdrawal
 Avoid PRN rather Continuous IV opioid infusions are
excellent means of providing analgesia to children who are
unable to use PCA
 Preterm and term neonates have narrow therapeutic window
 Tramadol (1-2 mg/kg orally)
 Synthetic analogue of codeine
 Used for postop pain treatment and when transitioning
from IV opioids to oral analgesics
 Reduced respiratory depression, sedation, nausea, and
vomiting
 Used alone for mild to moderate pain and for its opioid-
sparing effect in children with severe pain
 Morphine
 most commonly used opioid and 1st line opioid
 Fentanyl
 has good CVS stability and decrease pulmonary vascular
resistance.
 chest wall rigidity and decreased lung compliance if
administered too quickly
 Local anesthesia

 Bupivacaine, ropivacaine, and lidocaine are the most

commonly used local anesthetics
 Provide adequate analgesia, thus reducing the need for higher
doses of opioids
 Regional anesthesia with a LA can be provided by topical
application or direct infiltration at desired sites
 Particularly advantageous in patients with potentially
increased sensitivity to opioids, including neonates and
children with chronic respiratory disease.
 Topical anesthesia—applied without sedation or anesthesia.
 Infiltration anesthesia– in cooperative or older children, or it
can be performed during surgical procedures
 Regional Anesthesia

 In children entails a lower risk of adverse effects, including nausea,

sedation, and respiratory depression, than does systemic opioid
therapy.
 Particularly advantageous in patients with potentially increased
sensitivity to opioids, including neonates and children with chronic
respiratory disease
 Regional Block
 RECTUS SHEATH BLOCK
 ILIOINGUINAL-ILIOHYPOGASTRIC BLOCK
 FASCIA ILIACA BLOCK.
 PENILE BLOCK
 NEURAXIAL BLOCK
 CAUDAL BLOCK
 Patient controlled analgesia(PCA)
 With PCA,
 opioid delivery is controlled by a device that allows
administration of small doses of drug in response to patient
request, usually by pressing a button; an appropriate lockout
interval is programmed to prevent excessive administration
 References

 Fundamental of Pediatrics Surgery, Second Edition

 Operative Pediatrics surgery, Second Edition
 Aschrafts Pediatrics Surgery, Sixth Edition
 Corans Pediatrics Surgery, Seventh Edition, Volume 1
 Perioperative Medicine in Pediatrics Anesthesia
 Uptodate
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