Acute pain management in children undergoing surgery and invasive procedures offers several specific and unique challenges for anesthesiologists (Table 56-16: Challenges for Acute Pain Management in Children).
- Nonparenteral Analgesics
- Nonopioid analgesics (oral or suppository acetaminophen, ibuprofen, ketorolac) are important adjuvant analgesic therapies, often with oral midazolam.
- Opioid Analgesics.Codeine in combination with acetaminophen is commonly used with good effect for the management of moderate postoperative pain in ambulatory patients. Intranasal sufentanil can also be used to manage preoperative anxiety and postoperative analgesia in children.
- Patient-controlled Analgesia. There are safety concerns with use of PCA in children that mandate a high level of surveillance with respect to the functioning of the equipment and careful patient monitoring that may be a limitation to its use in infants. PCA by proxy is a safety risk because there is no complete assurance that parents will be competent in assessing the intensity of their child's pain or be able to regulate bolus doses to avoid opioid overdosage.
- Epidural neuraxial analgesia (single-shot technique or continuous catheter technique) has become a key component of the perioperative pain management plan for infants and young children undergoing abdominal, urologic, and orthopedic procedures.
- Nerve Blocks in Children. The introduction of small stimulating needles and ultrasound imaging along with long-acting local anesthetics and continuous catheter techniques in selected patients has resulted in an increase in the use of peripheral nerve blocks in children undergoing orthopedic extremity procedures. Combined ilioinguinal and iliohypogastric nerve blocks performed under ultrasound guidance to reduce the volume of the injection have gained increasing interest for effective pain management in children undergoing inguinal herniorrhaphy.