Pharmacology of pain management

Pediatric Anesthesia Historical Perspective

This article examines how anesthesia evolved to serve the needs of children. Discussion includes milestones in technologic advancement related to pediatric anesthetic care and how collaboration among pediatric surgeons, neonatologists, and pediatric anesthesiologists has helped our specialty to progress. Conversely, the significant contributions of pediatric anesthesiology to pediatric critical care medicine, pain management, and pediatric public health care are also presented.

Sedation/Analgesia for diagnostic and therapeutic procedures in children

Sedation/analgesia for diagnostic and therapeutic procedures in children has been associated with life-threatening adverse events. Reports of adverse events and recognition of wide variability in sedation practices has led to the development of guidelines and standards of care to ensure the safety of sedated children. The safety of sedated children can be enhanced by detailed presedation evaluation, careful patient selection, and the use of drugs with a wide margin of safety that are carefully titrated to desired depth of sedation by trained personnel. Once sedative drugs are administered, stringent monitoring, including continuous pulse oximetry and frequent assessment of vital signs and sedation depth, will permit early recognition of untoward drug effects and permit early intervention. Children with underlying medical conditions, such as airway abnormalities, may not be suitable subjects for sedation and may require consideration for general anesthesia to aid their procedure. Although significant strides have been made in recognition of the risks of sedation and in development of guidelinesfor safe sedation practices, further work must focus on development of newer sedation regimens with shorter-acting drugs and wider margins of safety.

Pain management in the pediatric intensive care unit

Control of pain in the pediatric intensive care unit has become increasingly important to intensivists. Improved understanding of the pharmacology of analgesics and the development of new techniques for analgesic administration have greatly enhanced the ability of intensivists to successfully manage patients in pain. The appropriate selection, use, and techniques for administration of analgesics in the treatment of pain in pediatric patients are discussed.

Opioid tolerance in neonates: mechanisms, diagnosis, assessment, and management

Opioid tolerance and withdrawal have been challenges for decades. The neurochemical mechanisms of tolerance and dependence are clinically important only because they can affect weaning schedules and the adjustment of doses for neonates. Analgesic effects are characterized by an increased depolarization threshold for the neuron, shorter duration of the action potential generated, and reduced release of neurotransmitters. Tolerance and withdrawal are associated with the reversal of these cellular effects. Adverse clinical effects associated with the use of opioids in neonates include respiratory depression, chest wall rigidity, urinary retention, and decreased gastrointestinal motility. The physiological systems most prominently affected by opioid withdrawal include the central nervous system, gastrointestinal system, and the autonomic nervous system. Opioid withdrawal symptoms in neonates can be assessed by using easily available scoring systems, although these need to be validated for different populations. Management of opioid withdrawal includes the use of other opioids, benzodiazepines and alpha-2 adrenergic receptor antagonist, clonidine. Careful titration of opioids with attention given to appropriate weaning schedules can reduce the incidence of withdrawal in neonates.