1. Paediatric Postoperative Pain Management Rebecca Finnegan Clinical Nurse Consultant

2. Outline Postoperative pain management in children - why is it so important? - what are we aiming for? Consequences of poorly treated pain in children Postoperative pain prevention - preoperative anxiety management - preventing post operative pain through preoperative preparation of child and family Postoperative pain management - pharmacological - non-pharmacological What’s new and how can we do better?

3. Why is postoperative pain management so important? Why? It is the right of every child to have the best level of pain relief possible Poor postoperative pain management can cause stress and result in changes in behavioural and physiological well being These changes can be short term or can persist for months afterwards acute to chronic pain transition - Pain that persists >3 months after a surgical procedure - 30% children undergoing orthopaedic surgery reported interference in daily function and sleep due to pain 4 months after surgery (Fortier et al, 2011) Aims of postoperative pain management: Promote patient comfort and satisfaction Provide safe, effective pain relief with few side effects Allow for early mobilisation and physiotherapy Quicker recovery period Decrease the risk of unwanted effects of pain Staff and families work together to assess pain promptly and treat it effectively

4. Consequences of poorly treated postoperative pain Children and families Suffering – physical, psychological Poorly controlled pain - longer recovery - ↑risk of complications e.g infection - longer hospitalisation - unplanned re-admissions - chronic post surgical pain Clinicians Fail in ethical responsibility to “do no harm” Violation of hospital policy, failure to meet accreditation standards Society Expensive

5. Pre-operative Anxiety Distressing for child, parents and operating room staff Link between preoperative anxiety and adverse postoperative outcomes Emergence delirium Increased analgesic requirements Negative behavioural changes These adverse outcomes may persist for months after surgery 67% of children had new negative behaviors on the first day after surgery 45% on day two 23% at two weeks after surgery 20% up to 6 months post surgery 7.3% up to 1 year post surgery (Kain et al, )

6. Preoperative Anxiety Management Anxiety Screening : Various behavioural instruments to assess anxiety and behaviours State-Trait Anxiety Inventory for Children (STAIC) *Gold Standard* The Modified Yale Preoperative Anxiety Scale (mYPAS) The Perioperative Adult Children Behavioural Interaction Scale (PACBIS) Sedative pre-medication Midazolam Clonidine Parental presence at induction of anaesthesia (PPIA) Behavioural interventions

7. Pharmacological Postoperative Pain Management Multimodal Analgesia The combination of drugs from different classes to achieve more effective analgesia with less side effects Advantages: May be opioid sparing Mat result in decreased side effects More effective analgesia World Health Organisation (WHO) analgesic step ladder approach to pain relief Accurate pain assessment is key to providing adequate pain relief

8. WHO Step ladder approach World Health Organisation

9. Pharmacological Postoperative Pain Management Paracetamol NSAIDs Tramadol Opioids - PCA (children 8 years upwards, guided by ability for child to understand/use) - Infusions (infusion only, +/- PCA, +/- nurse initiated bolus) Ketamine Regional - epidural, caudal, spinal LA infiltration

10. Non-pharmacological Postoperative Pain Management Psychological strategies Distraction ( toys, books, iPad ) parental presence in recovery room Education Physical Strategies TENS Ice/heat Elevation/positioning Simple distraction techniques that divert attention away from the painful stimulus Positive incentive techniques which provide a small reward (e.g stickers, prizes) These strategies aim to decrease anxiety but are not adequate as a sole means of post operative pain management

11. What’s new and how can we do better? Online preoperative preparation workshops for parents Positive Outcome and Experience Management strategies (POEMS) in UK - Resources to teach parents how to reduce their child’s anxiety Reading material Photographic and video demonstrations British Psychological Society evidence based guidelines Cognitive based approach Distraction techniques Child-friendly environment Developmentally appropriate play materials PPIA is recommended Preoperative Gabapentin (continued postoperative vs single pre-op dose) Evidence to suggest overall improved analgesia and reduced morphine use in paediatric patients undergoing spinal fusion No difference in outcome measures for single preoperative dose TAP blocks TAP blocks have been around for a while but new studies demonstrate it to reduce postoperative pain in children post open appendicectomy

12. Summary Postoperative pain in children can have negative physical, behavioural and psychological effects which in some cases can persist for months after surgery Good postoperative pain management starts before the operation Link between preoperative anxiety and adverse postoperative outcomes Preoperative anxiety must be assessed and managed appropriately Postoperative pain management should include both pharmacological and non-pharmacological measures

13. References Hilly J, Horlin AL, Kinderf J, Ghez C, Menrath S, Delivet H, Brasher C, Nivoche Y, Dahmani S. Preoperative preparation worshop reduces postoperative maladaptive behaviour in children. Paediatric Anaesthesia. 2015; June 12 (Epub ahead of print) Kain ZN, Mayes LC, Caldwell-Andrews AA, Karas DE, McClain BC. Preoperative anxiety, postoperative pain, and behavioural recovery in young children undergoing surgery. Paediatrics. 2006; 118:651-658. O’Sullivan M. Preinduction techniques to relieve anxiety in children undergoing general anaesthesia. Oxford Online Journal. 2013 4. Schug S, Dodd P. Perioperative Anlagesia. Australian Prescriber - An Independent Review. 2004;27:152-4 Blount, R. L., McCormick, M. L., MacLaren, J. E., & Kain, Z. Preparing children for invasive procedures and surgery. Pain in children: A practical guide for primary care. Totowa, NJ: Humana Press. 2008.; p93-98 World Health Organisation Analgesic Ladder Fortier MA, Chou J, Maurer EL, Kain ZN. Acute to chronic postoperative pain in children: preliminary findings. Journal of Paediatric Surgery 2011;46:170-175. Yuki K, Daboul D.G. Postoperative Maladaptive Behavioural Changes in Children. M.E.J. Anaesthesia 2011; 21:183-192