MULTIMODAL ANALGESIA OF PAIN MANAGEMENT IN PEDIATRIC APPENDECTOMY

Background: Acute appendicitis is one of the most common surgical emergencies in children, and appendectomy is still the definitive therapy. Effective pain management during the perioperative and postoperative periods is an essential component of pediatric surgical management, since uncontrolled pain can result in serious physiological, psychological, and clinical consequences. Objectives: Is to evaluate the efficacy of multimodal analgesia in the perioperative and postoperative management of pain in children undergoing appendectomy at Mosul city, Ibn Al-Atheer Teaching Hospital, Republic of Iraq, with a focus on pain scores, opioid requirements and adverse effect. Methods: This is a hospital-based prospective observational study. It was conducted between the 1st of July of year 2025 to the 10th of November of year 2025 at Mosul city, Ibn Al-Atheer Teaching Hospital, Republic of Iraq. Regarding the analgesic protocol, all of the patients received Fentanyl in a dose of 1 mcg/kg but can be increased into 2-3 mcg/kg during operation according to relief of pain that’s measured by heart rate like pulse oximetry and clinical observations. In addition to paracetamol 15 mg/kg during operation then after that every 6 hours at everyday of postoperative period according to pain sensation, diclofenac whenever needed at recovery in a dose of 1 mg/kg. As well as lignocaine 2% plain kind as a skin infiltration technique, before skin incision (for example grid iron incision) and after wound suturing at the end of operation. Ketamine 0.25-0.5 mg/kg was given during immediate postoperative recovery stage in the presence of mild-severe pain respectively. Postoperative pain assessment was done by anaesthetist in the surgical ward depending on visual analogue scale as well as patient general condition such as sleeping, moving in the ward, sitting in the bed and started eating or not yet. The primary outcomes were to evaluate postoperative pain score at time of immediate recovery and at 2, 4, and 8 hours after operation, whereas the secondary outcomes were to assess the patients’ side effect of drugs, such as hallucination and secondary outcome. Results: The study includes 63 pediatric age patients; of them 27 patients were male and 36 patients were females. Male: Female ratio was 1:1.33. The mean age ± standard deviation of the study patients was 11.02 ± 1.83 years. The mean time ± standard deviation of general anesthesia was 46.03 ± 11.46 minutes. At all of the time interval, the medium of VAS was less than 3. Anyhow, statistically significant difference between them (P value = 0.029) with higher pain occurred 4 hours after operation. No statistically significant difference between different time interval regarding vital signs and oxygen saturation. 6 (9.52%) patients developed nausea and vomiting, 14 (22.22%) developed moderate-severe pain necessitating additional opioid or other drugs like nefopam and 12 (19.04%) patients needed additional drugs other than opioid for example corticosteroids (dexamethasone and hydrocortisone), a benzodiazepine drugs for instance (midazolam) or even an antiemetic drug which is the ondansetron (it is also call devomit or zofran) and the last one used is sugammedex. Conclusion: Multimodal analgesia is an effective and safe strategy for managing postoperative pain in children after appendectomy. The use of paracetamol and NSAIDs as first-line drugs, along with local anesthetic drug and a small dose of ketamine that’s the analgesic dose at immediate phase of recovery period leads in lowering pain scores, less opioid intake and fewer opioid side effects.