Page 278 Guide to Pain Management in Low-Resource Settings

266 Dilip Pawar and Lars Garten

Availability of resources induction of anesthesia a caudal or ilioinguinal and ilio-
Limited resources can be defi ned as non-availability of a hypogastric block, followed by wound infi ltration at the
end of surgery. Two hours after surgery, oral paracetamol
potent analgesic such as morphine or fentanyl, or equip-
ment for drug delivery such as an infusion pump or a 300 mg or a combination of paracetamol and ibuprofen
(300 mg) is given 8-hourly until the pain score allows re-
PCA pump or skilled personnel to perform the proce-
dure and monitor the patient postoperatively. In such duction or stopping of the medication.
situations, the strategy should be to devise simple tech-
Plan 2
niques, which do not require precision equipment and
A newborn baby with an anorectal anomaly is scheduled
intensive monitoring in the postoperative period. Th ese
for an emergency colostomy. No oral medication is pos-
could be as follows:
sible. Th e baby can be managed with a spinal subarach-
• Eff ective use of commonly available oral medi-
noidal block with bupivacaine alone. In that case no
cations such as paracetamol, NSAIDs, and ket-
other intraoperative analgesic is needed. In case the baby
amine. Paracetamol and ketamine have been ex-
is administered general anesthesia, ketamine (0.5 mg/
tensively used in developing countries.
kg) and morphine (50 μg/kg) may be administered. For
• Optimum utilization of local anesthetics. Local
premature babies, opioids should be avoided due to im-
anesthetics can be applied by wound infi ltration,
mature respiratory function. Although ketamine is used
prior to incision, before closure, or continuously
in many places, there is no good evidence for the eff ec-
in the postoperative period.
tiveness and safety of this drug in neonates. At the end of
• Th e extremely low incidence of complications
surgery, wound infi ltration is also used. In the postopera-
after peripheral nerve blocks should encour-
tive period, the baby can be given oral paracetamol.
age using them more often when appropriate. In
single-injection regional nerve blocks, postopera- Plan 3
tive analgesia is limited to 12 hours or less. Con-
A 5-year-old boy is admitted to the emergency ward
tinuous peripheral nerve blocks provide an eff ec-
with acute burns and severe pain. A child with acute
tive, safe, and prolonged postoperative pain relief.
pain should be managed with available i.v. medication
Th ey have been used even in day-care cases up
such as morphine, ketamine, or tramadol or a combi-
to the age of 8 years. If all patients received a re-
nation of these drugs, along with low-dose midazolam
gional block intraoperatively, that would obviate
to avoid post-traumatic stress, but not for analgesia.
the need for potent parenteral opioids. Th e dura-
Once acute pain subsides, oral medication may be initi-
tion of analgesia provided by a caudal block can
ated with paracetamol 20 mg/kg. Th is child will require
be prolonged by addition of other adjuvants.
pain medication for physiotherapy, change of dressings,
• Alternative therapies such as acupuncture analge-
or even simple bedsheet changes subsequently. Th e child
sia might prove to be simple, safe, and economi-
and his parents should be prepared with an explanation
cal.
of what is being done. Th e pain can be managed with
• If infusion pumps are not available, a simple pe-
oral paracetamol and ketamine (8–10 mg/kg) and i.v.
diatric burette can be used for infusion. Th e au-
ketamine (1 mg/kg). If it comes to surgery, local infi ltra-
thor’s many years of experience have seen it to be
tion with local anesthetics of the donor area or a regional
safe, if only 2 hours’ worth of the dose is fi lled up
block would be benefi cial.
at any time (even with potent opioids like mor-
phine and fentanyl).
What monitoring would be
necessary for analgesia in the
Practical treatment plans
for a district hospital postoperative period?
Resuscitation measures should be available at the bed-
Plan 1
side for all patients who are receiving opioid infusions.
A 2 year old child weighing 15 kg is scheduled for her- Routine monitoring and recording of pain score, se-
nia repair as a day care procedure. Premedication with dation score, and respiratory rate is important in all
paracetamol 300 mg orally or 600 mg rectally, and after moderately to severely painful conditions, and for all