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A 10-Year-Old Boy With Acute Postoperative Pain

Case Scenario

A 40-kg, 10-year-old boy is admitted to the hospital with acute appendicitis and undergoes a laparoscopic appendectomy. During the procedure, the appendix is noted to be perforated with abscess formation. The laparoscopy is abandoned and converted to an open procedure with a large incision to the right lower quadrant. A balanced multimodal analgesic approach, including opioids, acetaminophen, and nonsteroidal anti-inflammatory drugs, is used by the anesthesiologist, and the surgical team subcutaneously infiltrates the incision with local anesthetic. In the postanesthesia care unit, the child complains of significant pain and asks for pain medicine. What are the options for pain management in this patient?
Background

Numerous standards, policies, and clinical practice guidelines exist for the management of acute pain in children and adults.[1,2] The Joint Commission on Accreditation of Healthcare Organizations in the United States introduced standards in 2001, in which pain is described as the "fifth vital sign."[3] Despite the existence of these standards, pain continues to be undertreated in hospitalized children.[4]

Numerous "barriers" to adequate pain management in children have been described.These include the following:

The myth that children, especially infants, do not feel pain the way adults do;
The lack of assessment for the presence of pain;
The notion that assessing pain in children takes too much time and effort; and
Fears of adverse effects of analgesic medications, including respiratory depression and addiction.

The purpose of this article is to provide guidance on the assessment and management of postoperative pain in children with a focus on rational opioid prescribing.


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