Page 276 Guide to Pain Management in Low-Resource Settings

264 Dilip Pawar and Lars Garten

to adults, but in neonates it is almost twice as long as No evidence for the eff ectiveness and safety of these
in adults. An infusion rate of 1–4 μg/kg/hr usually pro- drugs in neonates and infants has been published.
vides adequate analgesia in children.
Is it possible to use patient-controlled
For remifentanil, which may only be used intraop-
analgesia (PCA)?
eratively, adequate analgesia is achieved with a loading
dose of 1 μg/kg/hr followed by maintenance infusion of A PCA device is an infusion pump with the facility to
0.25 μg/kg/min. Alfentanil is eff ective at a dose of 50 μg/ deliver a top-up dose whenever the patient feels the
kg followed by an infusion of 1 μg/kg/min. While pethi- need of it. In the pediatric patient, PCA use is pos-
dine (meperidine) has been used clinically for many sible at beginning school age (over 5 years). In children
years, it should not be used in continuous infusions any less than 5 years old, a “parent-controlled” or “nurse-
longer, as it can produce seizures in children. controlled” analgesia could be an alternative to PCA.
Th e pump can be programmed to prevent delivery of
What are some ways to reduce opioid toxic doses by using a lockout interval and a maximum
side eff ects?
hourly dose. Morphine is the usual drug of choice. Th e
Th e following methods can be tried by “trial and er- patient bolus delivers 10–25 μg/kg. A basal rate of con-
ror” to reduce opioid side eff ects: (1) dose reduction, (2) tinuous infusion of 10–20 μg/kg maximum might be ad-
change of opioid (e.g., from codeine to morphine), (3) ministered with a lockout interval of 6–12 minutes. In
change of route of administration (e.g., from oral to i.v.), children, a background infusion might be helpful dur-
and (4) symptomatic therapy (e.g., preventive remedies ing sleep and it does not seem to increase the total dose.
or a laxative for constipation). Patient-controlled regional analgesia is also possible. It
has been found to be eff ective in popliteal and fascia ili-
What is the maximum dose of morphine
per day? aca blocks as well as in epidural blocks. One should re-
member, though, that the lockout interval in these cas-
Th ere is no maximum dose of morphine. If an addition-
es should be longer than 30 minutes because the time
al reduction in pain without dangerous medication side
needed for the bolus dose to be eff ective is longer.
eff ects is possible with an increased dose, it is indicated.
Titration of the medication is recommended to identify
Regional and local anesthesia
the patient’s individual opioid dose for proper pain re-
lief. If tolerance develops after some time, the dose will
What is the therapeutic value of regional blocks
need to be increased to maintain the same degree of
in children?
pain relief.
In recent years, there has been a resurgence in the pop-
What are parenteral nonopioid analgesics ularity of regional blocks in children because of their
to consider? effi cacy in providing good pain relief. Regional blocks
Th ere has been a resurgence of interest in ketamine, an hold the key to provision of good pain relief in diffi cult
NMDA-receptor antagonist, for its analgesic properties. situations as they are simple to use, easy to learn, and
A dose of 0.1–0.5 mg kg i.v. has been found to provide cost-eff ective. Th ey provide profound analgesia, and lo-
eff ective intraoperative pain relief. Ketorolac has suf- cal anesthetics, such as lidocaine (lignocaine) and bupi-
fi cient analgesic potency for most day care cases and vacaine, are available even in the least affl uent countries.
maybe supplemented initially by parenteral tramadol. Commonly used blocks in children are given in Table 3.

Table 3
Common regional blocks practiced in children
Caudal epidural Hernia repair, orchidopexy, urethro plasty, circumcision
Lumbar epidural All upper and lower abdominal surgery, thoracotomy
Ilioinguinal/iliohypogastric Hernia repair
Dorsal nerve of penis Circumcision, advancement of prepuce
Axillary Surgery of hand and forearm
Femoral/iliac Th igh and femur surgery