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Post-operative Patient-controlled Analgesia in Pediatric Patients

Despite advances in pain management over the past decade, post-operative pain in children continues to be under-treated. When an intravenous line is in place, the delivery of analgesia through patient-controlled anesthesia (PCA) can provide safe, effective, and convenient pain control in this special population.
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Throughout the past decade, the field of pediatric pain management has seen numerous advances. Despite these advances, multiple studies have suggested that pain in children continues to be under-treated post-operatively. It is essential to provide pain management to pediatric patients in a manner that will be accepted by children. Ideally, oral analgesic medication should have a flavor that is pleasant to them, and intra-muscular or subcutaneous injections should be avoided if possible. If the child has an intravenous line in place, it is preferable to administer analgesia via that route. The delivery of analgesia through intravenous patient-controlled anesthesia (PCA) provides pain control safely and efficiently, while maintaining patient satisfaction.1 This article provides a summary of current PCA information in pediatric patients.

Pediatric Pain Management Lacking

As noted, clinicians have made numerous advances in the diagnosis and treatment of children with post-operative pain. One advance has been the improvement in the diagnosis of pain through various age-related scales. Quantifying and standardizing pain intensity in children is a difficult task. Although these scales are ubiquitous in modern healthcare, there is continuous scrutiny in regard to their reliability. There has also been significant progress in understanding the physiology of specific pain pathways.2

Although clinicians have gotten better at understanding and diagnosing the cause of pediatric pain, studies have shown that pain management among children falls short of their adult counterparts. Indeed, researchers have found that after children and adults have undergone equivalent surgical procedures, pediatric patients have received a significantly lower relative dosage of opioid analgesia than adults. Pediatric patients were more likely to receive oral, non-opioid analgesia following major surgery, while adult patients were more likely to receive intravenous morphine.2,3

Many theories have attempted to explain the deficiency in pediatric post-operative pain control. One prevailing conjecture is that healthcare professionals are uncertain about age-specific and weight-specific dosing. Drug companies have been reluctant to conduct drug studies in pediatric patients.4 There is an underlying fear that analgesic drugs will produce severe adverse effects in children because of their age and small size.1 These fears can be alleviated by adhering to strict dosing protocols as well as diligent assessment and documentation of side effects.

Previous misconceptions have led to insufficiency in pain management in children. One of the main fallacies is the belief that children suffer less pain than adults.5 However, it has been documented that humans begin to feel pain early in intrauterine life.6 Unfortunately, if the child is not evaluated appropriately and frequently, healthcare workers may overlook the child’s pain. To adequately manage pain in children, it is imperative to assess pain with age-appropriate scales.

The Joint Commission has recently mandated that hospitals perform a systematic pain assessment on all patients and that they require a protocol for pain management.4,7

Special consideration must be given to pediatric patients regarding post-operative pain management. Often, the intense, acute pain of surgery goes unrecognized and undiagnosed in children, which leads to significant suffering.8 Therefore, it is important to identify post-operative pain in children and to provide appropriate analgesic treatment.

In the majority of cases, post-operative pain is most severe the first few daysafter a procedure but graduallyimproves over time. Thus, it is essential to manage pain carefully during this period.

In the majority of cases, post-operative pain is most severe the first few days after a procedure but gradually improves over time. Thus, it is essential to manage pain carefully during this period.

Pain treated insufficiently will cause the child significant stress, which will stimulate a hormonal response. It may also alter nociception by magnifying the pain pathway and may produce a chronic effect.1 Both of these factors can delay the child’s recovery.

Uncontrolled post-operative pain can produce long-term psychological effects on a child. It can elicit fear and suffering and substantially hinder the quality of life for both patients and their families. It is, therefore, the responsibility of healthcare workers to recognize pain and to provide sufficient analgesia to expedite recovery and allow the child to resume their daily activities.

Properties of Patient-Controlled Analgesia

Patient-controlled analgesia has significantly improved post-operative pain management.9 It is a method of pain control in which the patient self-administers medication by pressing a demand button connected to a pump. The medication is administered immediately, usually through an intravenous line, with the expectation that the patient will feel instantaneous relief. In children, PCA can initially be used at approximately 6 years old.2 The device requires that the child understands the relationship between pressing a button and receiving analgesia. It is also necessary for the patient to be awake and physically able to press the button attached to the pump.

Patient-controlled analgesia allows for a pre-determined dose of a specific analgesic medication to be dispensed through a sophisticated machine that the healthcare provider has previously programmed. Pre-determined variables are set through the PCA pump to establish the essential safety limits for the analgesia medication. The variables include an initial loading dose, a demand bolus dose, a lockout interval, background infusion rate, and 1-hour or 4-hour limits.9 (See Table.)

In addition to PCA pumps, many pain practitioners have advocated the use of a background infusion. A background infusion is a continuous rate of analgesia given regardless of the patient pressing the demand button. Continuous background infusion is generally reserved for patients with opioid tolerance due to a chronic pre-existing painful condition, such as malignancy. This subset of patients usually requires a higher baseline of opioid to reach their analgesic threshold.

Table. Variables of Patient-Controlled Analgesia

Initial loading dose

Provides preliminary pain relief in the post-operative setting; it is optimal that this dose is administered early.9 The initial loading dose titrates the medication to an analgesic level with the intention of preventing pain before it becomes severe.

Demand bolus dose

Last updated on: November 26, 2012
First published on: March 1, 2011