Table 46-2 Agents that Produce Analgesia ANALGESIC EFFECT COMPLICATIONS Acetaminophen and NSAIDs Moderate analgesia, antipyresis Ceiling effect, requires PO administration NSAIDs—gastrointestinal bleed, ulceration
Opioids No ceiling effect; respiratory depression, sedation, pruritus, nausea/vomiting, decreased gastric motility, urinary retention, tolerance with abuse potential
Fentanyl, alfentanil, Analgesia, sedation No adverse effects on cardiovascular system; stiff chest syndrome sufentanil
NSAIDs, Nonsteroidal anti-inflammatory drugs; PO, oral.
The subjective aspect of pain requires that self-reporting be used for assessment. Visual analog scales, developed for adult patients (allowing patients to rate pain on a scale of 1 to 10), have been used for older children. Pain scales for younger children often incorporate behavioral and physiologic parameters, despite the imprecision of physiologic responses.
Local anesthetics, such as lidocaine, can be used for minor procedures. However, lidocaine requires subcutaneous or intradermal injection. The use of EMLA, a cream containing lidocaine and prilocaine, is less effective than intradermal lidocaine but is preferred by many patients.
Patient-controlled analgesia is an effective method for providing balanced analgesia care in older children andadolescents. Children using patient-controlled analgesiahave better pain relief and experience less sedation thanpatients receiving intermittent, nurse-controlled, bolusanalgesics. Analgesics can be administered through thepatient-controlled analgesia pump with continuous basal infusions, bolus administration, or both. Morphine is the most frequent opioid used for patient-controlled analgesia.
Monitoring of oxygen saturations and respiratory rate arecrucial with continuous opioid infusions because of the shiftin CO2 response curve and potential to decrease ventilatoryresponse to hypoxia.
Epidural analgesia decreases the need for inhalation anesthetics during surgery and can provide significant analgesia without sedation in the postoperative period. Decreased costs and length of stay also may be benefits of epidural analgesic approaches. Medications used in epidurals include bupivacaine and morphine. Adverse effects include nausea and vomiting, motor blockade, and technical problems requiring catheter removal. Infection and permanent neurologic deficits are rare.
Kleinman ME, Chameides L, Schexnayder SM, et al: Part 14: pediatric advanced life support: 2010 American Heart Association guidelines for car diopulmonary resuscitation and emergency cardiovascular care, Circulation 122(Suppl 3):S876–S908, 2010
Kliegman RM, Stanton BF, St. Geme JW, et al, editors: Nelson Textbook of
Pediatrics, ed 19, Philadelphia, 2011, Elsevier
Paul A. Levy and Robert W. Marion
Among infants born in the United States, 2% to 4% have congenital malformations, abnormalities of form or function identifiable at birth. At 1 year of age, the number approaches 7%, because some anomalies may not be identifiable until after the neonatal period. The prevalence of congenital malformations is much greater in inpatient pediatric populations; 30% to 50% of hospitalized children have congenital anomalies or genetic disorders.
The clinical geneticist attempts to identify the etiology, mode of inheritance, and risk that a disorder might occur in the affected child’s siblings. In evaluating children with congenital malformations, the patient’s condition may be classified into one of five different categories: 1.
Single-gene mutations, accounting for 6% of children with congenital anomalies 2.
Chromosomal disorders, accounting for approximately 7.5% 3.