Case Scenario

Dr. Suniel Ramessur, MBBS, BSc (Hons), FRCA, DipHEP

Justin is a 7-year-old boy who presents with severe abdominal pain and is now being assessed by the surgical team. You have been asked to see him in the emergency department to assist with his pain management.

What options can you consider to manage Justin's pain?

You will need to first assess Justin, which includes a medical history review and a physical examination. It is important to note the nature of his disease process and the pain pattern

- colicky pain may respond better to anti-spasmodics than to conventional analgesics. Note what, if any, analgesia he has already received. You will also need to assess the severity of his pain. While it is always prudent to begin at the bottom of the analgesic ladder, it is sometimes obvious that more than simple analgesics will be required.

Examine the child for signs of cardio-respiratory compromise as it may impact your analgesic regimen.

Acetaminophen would be a good background analgesic to use:

• Oral dose is 20 mg/kg (but be weary of using oral analgesics in this child as with an abdominal complaint, absorption may be variable and he may be vomiting).

A nonsteroidal can be considered but again remember the limitations of oral administration; rectal administration is likely to be distressing to a young child in pain and the IV route in a child may be controversial. It is also worth bearing in mind that the child may be dehydrated at this point and some argue that NSAIDs can predispose to intra-operative bleeding. For all these reasons it may be best to avoid a NSAID in the acute setting. You may decide he requires IV morphine:

• IV dose is 50-100 mcg/kg in titrated doses while monitoring the SpO2% and respiratory rate.

If giving opiates, then remember to prescribe an anti-emetic such as ondansetron 0.15 mg/kg.

Justin weighs 22 kg, and in addition to resuscitation fluids, you titrate 1.5 mg of morphine IV to settle his pain. He is more comfortable now and is having his SpO2% monitored. The surgeons diagnose him with bowel intussusception and make arrangements for him to go to operating room.

What intra-operative analgesia strategies will you use?

In small children a caudal dose of local anesthetic can be very effective. It may be relatively contraindicated if he is septic or you suspect that he is still significantly hypovolemic. Many will use a rapid-onset and short-acting opiate such as fentanyl (1-3 mcg/kg) or alfentanil (10-20 mcg/kg). Depending on the situation, one could consider giving acetaminophen rectally before the end of the anesthetic. You can also ask the surgeon to place local anesthetics into the wound at the end of the case. Remember the following maximum doses:

You decide to use fentanyl during the case and give a rectal dose of acetaminophen at the end of the case. The surgeons performed a laparotomy and resected some necrotic bowel. The plan is to extubate the child at the end of the case.

What postoperative analgesics do you think Justin will require?

In addition to background analgesia such as acetaminophen and the caudal, and in the absence of an epidural catheter, one will need to consider a long-acting opioid regimen. Depending on the age of the patient, patient- (or nurse) controlled analgesia should be considered (PCA/NCA). Each center will have its own protocol for setting up such an infusion. In case of significant respiratory depression, the dose of naloxone (0.01 mg/kg IV) should be administered.

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