Postoperative pain management in children: Guidance from the pain committee of the European Society for Paediatric Anaesthesiology (ESPA Pain Management Ladder Initiative)

The main remit of the European Society for Paediatric Anaesthesiology (ESPA) Pain Committee is to improve the quality of pain management in children. The ESPA Pain Management Ladder is a clinical practice advisory based upon expert consensus to help to ensure a basic standard of perioperative pain management for all children. Further steps are suggested to improve pain management once a basic standard has been achieved. The guidance is grouped by the type of surgical procedure and layered to suggest basic, intermediate, and advanced pain management methods. The committee members are aware that there are marked differences in financial and personal resources in different institutions and countries and also considerable variations in the availability of analgesic drugs across Europe. We recommend that the guidance should be used as a framework to guide best practice.


| INTRODUCTION
Adequate pain therapy cannot be taken for granted. Although the Declaration of Montreal (September 2010) states that "Access to Pain Management is a Fundamental Right", it is estimated that 80% of the global population is affected by insufficient pain management, and this is a serious problem in over 150 countries. 1,2 The greatest burden of inadequate pain management is carried by the elderly, pregnant, and breastfeeding women, children, drug addicted persons, and the mentally ill. 3 For many years there have been increasing efforts to improve the perioperative pain management of children but there are still a substantial number of children suffering perioperative pain. [4][5][6][7][8][9][10] The practice of pediatric anesthesia varies considerably across Europe, including the provision of postoperative analgesia, as evidenced by the results of the recent Anaesthesia PRactice In Children Observational Trial (APRICOT). 11 The reasons are multifactorial but may reflect differences in knowledge, infrastructure, organization, and health care economics among EU countries. However, even in more affluent settings, pediatric postoperative pain management is highly variable and is still suboptimal in many centers. 12 Against this background, it is important to define the minimum standards of pediatric postoperative pain relief that children can expect after surgical procedures even in settings with limited resources. It is also important to outline how pediatric postoperative pain relief may evolve and improve. This ESPA supported document may enable clinicians and departments to influence decision-making to improve and advance pediatric postoperative pain relief regardless of the local context since adherence to suggested guidelines has been shown to be helpful in improving pain management, eg, for pediatric tonsillectomy. 13 Thus, the aim of the current ESPA initiative is to provide a consensus practice advisory document analogous to the WHO Pain Relief Ladder, 14 based pragmatically upon existing evidence and already published guidelines, to improve pediatric postoperative pain relief in Europe. Although primarily aimed at the European continent, we hope that it may also be applied in other countries around the world.

| MATERIALS AND METHODS
The ESPA Pain Committee selected 6 common pediatric surgical procedures and invited pediatric anesthetists experienced in treating postoperative pain from different countries to participate in working groups to develop 1 pain management ladder each aiming for a multimodal analgesic treatment approach 15,16 based upon the WHO Pain Relief Ladder including local and regional anesthetic techniques.
In the first step, each member of a particular pain ladder group was invited to provide the individual pain management of his/her institution to collate the most common pain management concepts and drugs used for each type of operation. Following this, the concepts were discussed by the working group and the literature was reviewed, including existing evidence-based guidelines. The ESPA Pain Management Ladder is a clinical practice advisory based upon the consensus opinions of these working groups. As a result, a basic acceptable level of pain management was suggested which should be achievable by all, even in institutions with limited resources. Oral and rectal administration of nonopioid drugs and regional anesthesia play a crucial role since they are available in most places. [17][18][19][20][21] Good use of these modalities has an important opioid-sparing effect. 7,8,15,22 Intravenous opioids are reserved for intraoperative use and the early postoperative period in settings with adequate monitoring. Furthermore, in all procedures where endotracheal intubation is essential, the administration of a small dose of a short-acting opioid may be considered in order to attenuate the hemodynamic response to laryngoscopy and tracheal intubation, 23,24 albeit at the expense of the possibility of increased postoperative nausea and vomiting.
Subanesthetic doses of ketamine/S-ketamine may be used to reduce intra-and early postoperative opioid requirements. 25,26

MANAGE MENT LADDE R
Before an institution considers changes in pain management, it has to be decided if there is a need for change. 27 Therefore, the first step would be to evaluate the current pain management for a certain type of operation. The drugs used and whether doses prescribed are actually administered are useful baseline assessments. It is strongly suggested that standardized pain assessment for the duration of hospital stay should be used, preferably with validated age-appropriate pain assessment tools. [28][29][30][31][32][33][34] Useful audit markers are the proportion of each patient's time spent with pain scores below 4/10 and child and family experiences of pain. If a lack of adequate pain management is revealed, a plan to improve the pain management and evaluate this improvement will be needed. 35,36 Considering pain as a vital sign is an excellent way to engender change, with incorporation of pain assessment into charts, nursing routines, and education programs. This must include an algorithm showing what actions to take when a pain score is high and how to evaluate the efficacy of any analgesic interventions. 34 The primary aim is to attain at least the basic level of the ESPA Pain Management Ladder. Since the basic level uses drugs and methods that are widely available, are proven to work, are safe, and do not require any complex monitoring, the major change initially required to achieve successful pain management is education, not new drugs or high-tech delivery systems. Basic techniques can do the job in a high proportion of cases if physicians and nurses are trained to take responsibility for providing pain control 37 and all staff dealing with children give pain assessment and pain management a high priority.
The secondary goal is to climb up the pain ladder as far as possible using all available resources. The intermediate and advanced levels should be considered as suggestions. These steps represent a gradual increase in complexity and require specific equipment and infrastructure. Analgesia may be improved: for example, a substantial improvement of success rate when using ultrasound-guided ilioinguinal/iliohypogastric nerve block instead of a landmark-based technique; using intravenous paracetamol greatly increases the likelihood of having adequate plasma levels of paracetamol in the recovery room. [38][39][40] The ESPA Pain Management Ladder may help to provide practitioners with a document to present to their local officials with the aim of promoting and improving postoperative analgesia for the pediatric population (Table 1). Surgical colleagues and hospital administrators should be aware that acceptable standards of pain management have to be provided and resourced before surgery in infants and children is undertaken. 41 The ability of structured initiatives to substantially improve postoperative analgesia in resource limited settings has recently been presented by Dr Burke (Tygerberg Children's Hospital, South Africa) 42 as well after day surgery in more affluent circumstances. 43 The aim is to develop a pediatric pain management portfolio that can be adapted for local use based upon availability of drugs, national recommendations, and drug registration rules in different countries. The target should be to achieve and maintain pain scores below the intervention threshold of 4 (on a 10-point scale). Pain T A B L E 1 Quality improvement steps using the ESPA Pain Ladder

Procedure Goal
Step 1 Written individualized standard prescription for current pain management for the procedure Exact prescription and administration of analgesics prescribed for each patient to improve pain management Step 2 Pain assessment: at least 3 times per day until discharge to check pain experience and efficacy of analgesia. Consider pain as a vital sign.
Makes pain visible by use of appropriate assessments. If inadequate pain management is revealed, improve the pain management regimen and culture Step 3 Improve pain management education and delivery of at least basic level of ESPA Pain Ladder.
Ensure analgesics are given as prescribed.
Ensure pain is assessed regularly Ensure pain score is <4/10 for as much time as possible Step 4 Re-evaluate to check for improvements Further adaptation of management if necessary Step 5 Introduce intermediate and advanced levels as appropriate to local needs and circumstances Ensure efficacy and safety by comprehensive education, staffing, and monitoring Example of improvement of pain management for Inguinal Hernia Repair Problem Improvement step Step 1 The lack of institutional agreement about how pain management should be performed has led to individual interpretation and management with variable efficacy.
No prescription for breakthrough pain in PACU (nurse has to call physician) Multidisciplinary agreement with written institutional instruction using techniques in basic level of ESPA Pain Ladder Intraoperative pain management: rectal NSAID or if not available rectal paracetamol (loading dose). Local anesthetic infiltration by the surgeon, Postoperative management: Oral NSAIDs and/or paracetamol in adequate dosing on demand or preferably timed by the clock Step 2 Missing or irregular pain assessment Regular pain assessment demonstrates inadequate pain management (prolonged breakthrough pain in PACU and frequent high pain scores in the ward) and proves the need for improvement of the pain management regimen Step 3 Inadequate pain management Adaptation of pain management-new standard prescription order: Intraoperative pain management: Rectal NSAID or if not available rectal paracetamol (loading dose) Local wound infiltration by the surgeon of a long-acting local anesthetic. Postoperative management: Intravenous fentanyl or morphine to treat breakthrough pain in the PACU. Oral NSAIDs and/or paracetamol in adequate dosing during the entire perioperative period.
Step 4 Persistent breakthrough pain in the ward in a number of patients Reassessment: leads to the use of intravenous nalbuphine or oral tramadol for serious breakthrough pain in the ward. Step

| RECOMME NDATIONS
The following Tables 2-7 provide the Pain Management Ladders for   6 frequently performed procedures in children.

| Drug and dosage suggestions
Below are some suggestions regarding dosing of some of the drugs that may be applicable to the different pain management ladder levels based on the available literature. 2,26, Table 8 shows dosage suggestions for systemic analgesia, special care must be taken when prescribing opiods in patients with obstructive sleep apnea. In Table 9, the reader can find dosage suggestions for regional anesthesia and Table 10 lists suggestions for the treatment of PONV.
These are only suggestions and ESPA does not accept any legal responsibility for these suggestions. Please confer with the pharmacopeia of your country before using these dosage suggestions. This

T A B L E 2 Inguinal hernia repair
Inguinal hernia repair (>1 mo of age) 138

145-147
• Intravenous fentanyl or morphine or other suitable agent (if available) to treat breakthrough pain in the PACU.
• Intravenous loading dose of paracetamol. 58 • Oral NSAIDs and/or paracetamol in adequate dosage during the entire postoperative period from the moment when the oral intake will be possible. 173,174 • Intravenous or oral tramadol or other suitable agent if available as rescue in the ward. [175][176][177][178] Intermediate level • Intravenous fentanyl or opioid of choice in divided doses • Loading dose of paracetamol/NSAID intravenously, after induction of anesthesia. In small children, rectal approach could be considered as well as oral paracetamol as a part of premedication (preemptive analgesia). [179][180][181][182] •  22,191,192 • Intravenous NSAID or loading dose of metamizole • Intravenous fentanyl or other suitable agent (if available) to treat breakthrough pain in the PACU • Intravenous NSAID, or paracetamol or metamizole in adequate dosing during the entire postoperative period • iv or oral tramadol or other suitable agent if available as rescue in the ward or • Consider iv-PCA (patient controlled analgesia) including adequate monitoring. 65,66,193 T A B L E 7 Limb fractures

Intraoperative Postoperative
Basic level • Fentanyl or opioid of choice in divided doses 49 • Rectal NSAID or rectal paracetamol 44,45 • If possible fracture infiltration by the surgeon with long-acting local anesthetic • Intravenous morphine or fentanyl or morphine or other suitable agent (if available) to treat breakthrough pain in the PACU 50,51,55,67 • Oral NSAIDs and/or paracetamol in adequate dosing during the entire postoperative period. • iv or oral tramadol or other suitable agent (if available) as rescue in the ward 56 Intermediate level • Intravenous NSAID or intravenous paracetamol • Landmark-guided peripheral nerve block (eg, interscalene, supraclavicular, axillar block for the upper limb; femoral, adductor canal, sciatic block, eventually in association, for the lower limb) with a long-acting local anesthetic combined with appropriate adjunct (clonidine) if available. If using a double block consider the total amount of local anesthetic. 54,139,[194][195][196][197] • If PNB is contraindicated fentanyl or opioid if choice in divided doses • Intravenous morphine or fentanyl or other suitable agent (if available) to treat breakthrough pain in the PACU • Oral NSAIDs and/or paracetamol in adequate dosing during the entire postoperative period. • iv or oral tramadol or other suitable agent (if available) as rescue in the ward Advanced level • Intravenous ketorolac.
• Intravenous loading dose of intravenous NSAID or paracetamol.
• Ultrasound-guided peripheral nerve block single, shot or continuous infusion, (eg, interscalene, supraclavicular, axillar block for the upper limb; femoral, adductor canal, sciatic block, eventually in association, for the lower limb) with a long-acting local anesthetic combined with appropriate adjunct (clonidine) if available. If using a double block consider the total amount of local anesthetic. [198][199][200][201][202] • If PNB is contraindicated: fentanyl or opioid of choice in divided doses.
• Intravenous fentanyl or other suitable agent (if available) to treat serious breakthrough pain in the PACU. • iv/oral paracetamol or iv/oral NSAID in adequate dosing during the entire postoperative period. 203 • iv or oral tramadol or other suitable agent (if available) as rescue in the ward • Consider patient-controlled regional anesthesia or iv-PCA if needed  8,133,134 Concerning the safe use of regional anesthesia in children, the joint practice advisory from the European Society of Regional Anaesthesia and Pain Therapy (ESRA) and the American Society of Regional Anesthesia and Pain Medicine (ASRA) is recommended. 135

| Use of corticosteroids
Corticosteroids may enhance postoperative pain relief and prolong the duration of regional anesthesia and help to prevent postoperative nausea and vomiting. 136,137

| CONCLUSIONS
The ESPA Pain Ladder is a synthesis of existing guidelines, availability of medications and other resources, economic costs, and patient safety.
We hope that the suggestions in this article will help improve pediatric postoperative analgesia in Europe and other parts of the world.

ETHICAL APPROVAL
No ethics approval provided.

CONFLI CT OF INTEREST
All authors declare no conflict of interest.