Summary : This figure presents a proposed analgesic ladder for the treatment of pain in children with chronic pancreatitis, illustrating a stepwise approach to pain management based on severity, from non-opioid to stronger opioid interventions. flowchart: # Levels of Pain and Analgesic Intervention : ## Level I – Acute Intermittent Abdominal Pain (Non-Opioids) : • As needed NSAIDs and/or acetaminophen. • For continued uncontrolled pain: Schedule NSAIDs & acetaminophen every 6 hours, alternating every 3 hours. ## Level II – Moderate Persistent Abdominal Pain (Weaker Opioids) : • Continue scheduled Level I medications. • If >12 years old: Start Tramadol as needed for breakthrough pain. • If <12 years old: Stop acetaminophen and start hydrocodone/acetaminophen as needed for breakthrough pain. ## Level III – Severe Persistent Abdominal Pain (Stronger Opioids) : • Continue scheduled Level I medications. • Stop weaker opioids. • Restart scheduled acetaminophen if stopped. • Start oxycodone, oral immediate release morphine, or oral hydromorphone. ## Uncontrolled Severe Persistent Abdominal Pain : • Continued uncontrolled pain or unable to tolerate oral: recommend inpatient admission for pain control. # Layout : • The diagram is structured as a vertical ascending ladder with four steps, each representing increasing pain severity and corresponding escalation in analgesic potency. • Each step is color-coded: blue-green for non-opioids, green for weaker opioids, teal for stronger opioids, and dark green for uncontrolled pain requiring inpatient care. • The steps are labeled as Level I, Level II, and Level III, with the final step above Level III. # Analysis : • The figure visually emphasizes a stepwise, escalating approach to pain management in pediatric chronic pancreatitis, starting with non-opioid medications and progressing to stronger opioids and inpatient care as pain severity increases. • Nonpharmacologic pain care is assumed to be provided at all points in the ladder. • The structure supports careful titration and escalation of analgesic potency, with clear age-based recommendations for opioid use.

Table 38 | Management strategies for common symptoms in CKD <table><thead><tr><th>Symptom</th><th>Comment</th><th colspan="3">Management strategies</th></tr><tr><th></th><th></th><th>Lifestyle</th><th>Pharmacological</th><th>Other</th></tr></thead><tbody><tr><td>Pain</td><td>Management should be determined by etiology and severity</td><td>Physiotherapy, exercise and massage therapy, and heat for musculoskeletal pain.<br><br>Consider complementary therapies such as acupuncture.^838,840,849</td><td>Use of an adapted World Health Organization (WHO) Analgesic Ladder that takes into account pharmacokinetic data of analgesics in CKD.⁸⁵⁰<br><br>Before starting opioids, healthcare providers should assess risk of</td><td>Referral to a specialist pain clinic or palliative/ supportive care clinic may be beneficial for those at risk of aberrant behaviors, adverse outcomes, or in special circumstances such as end of life.⁸⁴⁹</td></tr></tbody></table>

A series of three clinical photographs (A-C) demonstrating the intraoperative steps of peri-articular multimodal drug injection (PMDI) during hip arthroplasty. All images show a lateral approach to the hip with the skin prepped in a sterile yellow antiseptic solution and marked with surgical ink. Figure A illustrates the deep injection into the hip capsule; a metallic retractor reflects the gluteus muscles to expose the joint space while a syringe delivers the analgesic cocktail. Figure B shows the second stage of injection into the gluteus medius muscle and tensor fascia lata after prosthesis insertion and muscle repair, with a retractor maintaining surgical access to the red, fleshy muscle tissue. Figure C depicts the final stage where the solution is injected into the subcutaneous tissue layer before skin closure, with the incision site partially apposed. This sequence serves as an educational guide for orthopedic surgeons on the standardized anatomical layers for local infiltration analgesia to optimize postoperative pain management.

Educational medical graphic combining a pain assessment tool and surgical material. The top section displays a Visual Analog Scale (VAS) used for clinical pain measurement. The scale features a numeric rating from 0 to 10 correlated with descriptive labels and a Wong-Baker style faces scale: 0 (No Pain, dark green smiling face), 1-3 (Mild, light green smiling face), 4-6 (Moderate to Severe, yellow neutral to orange frowning faces), 7-9 (Very Severe, dark orange distressed face), and 10 (Worst Pain Possible, red crying face). Below the scale is a high-resolution photograph of a self-gripping prosthetic mesh used in surgical procedures like inguinal hernia repair. The mesh is composed of a translucent, white synthetic monofilament knit into a diamond-shaped grid. Characteristic micro-grips or bulbous nodes are visible at the strand intersections, designed for sutureless fixation to anatomical tissues. This comparison illustrates tools used for evaluating patient outcomes, specifically postoperative pain levels relative to surgical techniques and materials.

This visual aid is an adaptation of a Faces Pain Rating Scale used for clinical assessment of patient-reported discomfort, often categorized under the Visual Analogue Scale (VAS) methodology. The infographic consists of four progressive facial icons and a corresponding intensity gradient bar below. 1) The first icon features a smiling mouth and 'crossed' eyes, representing no pain or 'very bearable' sensation. 2) The second icon shows a frowning mouth and cloud symbols, indicating mild discomfort or emerging distress. 3) The third icon displays a wavy, distressed mouth and motion lines around the head, signifying moderate to high pain levels. 4) The final icon depicts a wide-open mouth, closed eyes, and star symbols, representing severe or maximum pain. This tool is utilized in clinical settings, such as post-procedural hysteroscopy evaluations, to help patients quantify subjective pain levels when verbal communication may be limited or to supplement numerical ratings.

Recommendations	Strength of Recommendation	Quality of Evidence
Analgesia
1) We suggest that, in critically ill pediatric patients 6 yr old and older who are capable of communicating, pain assessment via self-report be routinely performed using the Visual Analog Scale, Numeric Rating Scale, Oucher Scale, or Wong-Baker Faces pain scale.	Conditional	Low
2) We recommend the use of either the Faces, Legs, Activity, Cry, and Consolability or COMFORT-B scales for assessing pain in non-communicative critically ill pediatric patients.	Strong	Moderate
3) We recommend the use of observational pain assessment tools rather than vital signs alone for assessment of postoperative pain in critically ill pediatric patients.	Strong	Moderate
4) We suggest the use of observational pain assessment tools rather than vital signs alone for assessment of procedure-related pain in critically ill pediatric patients.	Conditional	Low
5) We recommend that IV opioids be used as the primary analgesic for treating moderate to severe pain in critically ill pediatric patients.	Strong	Moderate
6) We recommend the addition of an adjunct NSAID (IV or oral) to improve early postoperative analgesia in critically ill pediatric patients.	Strong	Moderate
7) We suggest the addition of an adjunct NSAID agent (IV or oral) to decrease opioid requirements in the immediate postoperative period in critically ill pediatric patients.	Conditional	Low
8) We suggest the addition of adjunct acetaminophen (IV or oral) to improve early postoperative analgesia in critically ill pediatric patients.	Conditional	Low
9) We suggest the addition of adjunct acetaminophen (IV or oral) to decrease opioid requirements in the immediate postoperative period in critically ill pediatric patients.	Conditional	Low
10) We recommend that music therapy be offered to augment analgesia in critically ill postoperative pediatric patients.	Strong	Moderate
11) We recommend that nonnutritive sucking with oral sucrose be offered to neonates and young infants prior to performing invasive procedures.	Strong	High
Sedation
1) We recommend the use of the COMFORT-B Scale or the State Behavioral Scale, to assess level of sedation in mechanically ventilated pediatric patients.	Strong	Moderate
2) We suggest the use of the Richmond Agitation-Sedation Scale to assess level of sedation in mechanically ventilated pediatric patients.	Conditional	Low
3) We suggest that all pediatric patients requiring MV are assigned a target depth of sedation using a validated sedation assessment tool at least once daily.	Conditional	Low
4) We suggest the use of protocolized sedation in all critically ill pediatric patients requiring sedation and/or analgesia during MV.	Conditional	Low
5) The addition of daily sedation interruption to sedation protocolization is not suggested due to lack of improvement in outcomes.	Conditional	Low
6) During the periextubation period when sedation is typically lightened, we suggest the following bundle strategies to decrease risk of inadvertent device removal: a) Assign a target depth of sedation at increasing frequency to adapt to changes inpatient clinical status and communicate strategies to reach titration goal. b) Consider a sedation weaning protocol. c) Consider unit standards for securement of endotracheal tubes and safety plan. d) Restrict nursing workload to facilitate frequent patient monitoring, decrease sedation requirements, and risk of self-harm.	Conditional	Low
7) We suggest the use of alpha2-agonists as the primary sedative class in critically ill pediatric patients requiring MV.	Conditional	Low

Summary : This figure presents a side-by-side comparison of pain, sedation, and delirium assessment and management in pediatric intensive care, organized into four main categories: Assessment, Risk Factors, Complications, and Management. Each category is subdivided for pain, sedation, and delirium, with specific tools, risk factors, complications, and management strategies listed for each. flowchart/table hybrid: # Overall Structure : • The figure is divided into three vertical columns: Pain, Sedation, and Delirium. • Four horizontal sections: Assessment, Risk Factors, Complications, and Management. • Each cell contains bulleted lists of tools, factors, or strategies. # Pain : ## Assessment : • Self-report scales for communicative children: Visual Analog Scale, Numeric Rating Scale, Oucher Scale, Wong-Baker FACES pain scale. • Behavioral/observational scales for non-communicative children: FLACC, COMFORT-B. • Acute vital sign changes with NMBA use; consider NMBA holiday. ## Risk Factors : • Barriers to pain assessment: Developmental delay, altered mental status, mechanical ventilation (MV). ## Complications : • Iatrogenic Withdrawal Syndrome (IWS). ## Management : • Mild/Moderate: Acetaminophen, NSAIDs. • Moderate/Severe: First-line IV opioids, consider fentanyl for renal dysfunction. • Second-line: Improved pain control and opioid sparing (acetaminophen, NSAIDs, alpha-2 agonist). • Non-pharmacologic: Non-nutritive sucking, music therapy, parental presence. # Sedation : ## Assessment : • Arousal/Level of Consciousness: Monitor every 2 hours when on MV. • Comfort-B scale, State Behavioral Scale (SBS), Richmond Agitation-Sedation Scale (RASS). • Targeted sedation: Set goal, titrate sedation. • EEG-based monitoring and vital sign changes with NMBA use. ## Risk Factors : • Complications with over-sedation: Prolonged MV, prolonged PICU stay, delirium, IWS. ## Complications : • Over-sedation: Prolonged MV, delirium, prolonged PICU stay, IWS. ## Management : • Protocolized analgo-sedation may offer benefit. • First-line: Alpha-2 agonist (post-op, non-cardiac). • Second-line: Ketamine, minimize dose (4 mg/kg/h), minimize duration (<48h), benzodiazepines for delirium. • Peri-extubation strategies: Assign wean target, use extubation protocol, create standard for ETT securement, protect bedside nurse availability. # Delirium : ## Assessment : • Acute brain dysfunction: Inattention, fluctuating mental status. • Acute daily screening: Preschool (psCAM-ICU-5), school-age (pCAM-ICU-5), Cornell Assessment of Pediatric Delirium (CAPD). ## Risk Factors : • Predisposing/precipitating: Young age, developmental delay, congenital heart disease, MV, sedative/analgesic use. ## Complications : • Worse outcomes: Longer ICU/hospital stay, greater cost. ## Management : • First-line: Treat medical disease (labs, brain MAPS). • Hypoactive: Over-sedation, lack of sleep. • Hyperactive: Infections. • Second-line: Non-pharmacologic (sleep hygiene, early mobilization, family presence). • Third-line: Minimize sedation exposure, avoid benzodiazepines, consider alpha-2 agonist, may need dexmedetomidine for withdrawal/mood (hypoactive). # Design Encodings : • Blue, purple, and pink colour coding for Pain, Sedation, and Delirium columns. • Section headers highlighted with background shading. • Bulleted lists for clarity. • Icons for assessment, risk factors, complications, and management. # Analysis : • The figure provides a comprehensive, parallel overview of pain, sedation, and delirium management in pediatric critical care. • Each domain is addressed with specific assessment tools, risk factors, complications, and management strategies. • There is emphasis on protocolized approaches, minimizing complications, and integrating non-pharmacologic interventions. • The structure facilitates rapid comparison and highlights the interconnectedness of pain, sedation, and delirium in clinical practice.

Summary : This figure presents a side-by-side comparison of pain, sedation, and delirium assessment and management in pediatric intensive care, organized into four main categories: Assessment, Risk Factors, Complications, and Management. Each category is subdivided for pain, sedation, and delirium, with specific tools, risk factors, complications, and management strategies listed for each. flowchart/table hybrid: # Overall Structure : • The figure is divided into three vertical columns: Pain, Sedation, and Delirium. • Four horizontal sections: Assessment, Risk Factors, Complications, and Management. • Each cell contains bulleted lists of tools, factors, or strategies. # Pain : ## Assessment : • Self-report scales for communicative children: Visual Analog Scale, Numeric Rating Scale, Oucher Scale, Wong-Baker FACES pain scale. • Behavioral/observational scales for non-communicative children: FLACC, COMFORT-B. • Acute vital sign changes with NMBA use; consider NMBA holiday. ## Risk Factors : • Barriers to pain assessment: Developmental delay, altered mental status, mechanical ventilation (MV). ## Complications : • Iatrogenic Withdrawal Syndrome (IWS). ## Management : • Mild/Moderate: Acetaminophen, NSAIDs. • Moderate/Severe: First-line IV opioids, consider fentanyl for renal dysfunction. • Second-line: Improved pain control and opioid sparing (acetaminophen, NSAIDs, alpha-2 agonist). • Non-pharmacologic: Non-nutritive sucking, music therapy, parental presence. # Sedation : ## Assessment : • Arousal/Level of Consciousness: Monitor every 2 hours when on MV. • Comfort-B scale, State Behavioral Scale (SBS), Richmond Agitation-Sedation Scale (RASS). • Targeted sedation: Set goal, titrate sedation. • EEG-based monitoring and vital sign changes with NMBA use. ## Risk Factors : • Complications with over-sedation: Prolonged MV, prolonged PICU stay, delirium, IWS. ## Complications : • Over-sedation: Prolonged MV, delirium, prolonged PICU stay, IWS. ## Management : • Protocolized analgo-sedation may offer benefit. • First-line: Alpha-2 agonist (post-op, non-cardiac). • Second-line: Ketamine, minimize dose (4 mg/kg/h), minimize duration (<48h), benzodiazepines for delirium. • Peri-extubation strategies: Assign wean target, use extubation protocol, create standard for ETT securement, protect bedside nurse availability. # Delirium : ## Assessment : • Acute brain dysfunction: Inattention, fluctuating mental status. • Acute daily screening: Preschool (psCAM-ICU-5), school-age (pCAM-ICU-5), Cornell Assessment of Pediatric Delirium (CAPD). ## Risk Factors : • Predisposing/precipitating: Young age, developmental delay, congenital heart disease, MV, sedative/analgesic use. ## Complications : • Worse outcomes: Longer ICU/hospital stay, greater cost. ## Management : • First-line: Treat medical disease (labs, brain MAPS). • Hypoactive: Over-sedation, lack of sleep. • Hyperactive: Infections. • Second-line: Non-pharmacologic (sleep hygiene, early mobilization, family presence). • Third-line: Minimize sedation exposure, avoid benzodiazepines, consider alpha-2 agonist, may need dexmedetomidine for withdrawal/mood (hypoactive). # Design Encodings : • Blue, purple, and pink colour coding for Pain, Sedation, and Delirium columns. • Section headers highlighted with background shading. • Bulleted lists for clarity. • Icons for assessment, risk factors, complications, and management. # Analysis : • The figure provides a comprehensive, parallel overview of pain, sedation, and delirium management in pediatric critical care. • Each domain is addressed with specific assessment tools, risk factors, complications, and management strategies. • There is emphasis on protocolized approaches, minimizing complications, and integrating non-pharmacologic interventions. • The structure facilitates rapid comparison and highlights the interconnectedness of pain, sedation, and delirium in clinical practice.

This infographic illustrates the methodology for orthodontic pain assessment using the NRS-11 scale following mini-implant placement. The top section defines the Numeric Rating Scale (NRS-11) categories: 0 (No Pain), 1–3 (Mild Pain), 4–6 (Moderate Pain), and 7–10 (Severe Pain). Central to the figure is an anatomical diagram of the maxillary dental arch. Black arrows indicate the bilateral 'Mini-implant position' in the posterior region, specifically between the second premolars and first molars. Flanking the anatomical diagram are two data entry tables labeled 'Pain score' for the 'Right side' and 'Left side.' Each table contains columns for 'Time' (specified as 1 day post-treatment) and 'NRS-11' score. This layout is designed for a clinical study comparing postoperative pain levels between a treatment group and a control group in orthodontic procedures involving bone-anchored devices.

A series of eight clinical photographs (labeled 0-7) documenting various blood sampling procedures performed on neonates in a hospital setting, used to study neonatal pain responses. The images illustrate four distinct sampling modalities: fingertip (0), heel (1, 2), venous (4, 6), and arterial (3, 5, 7) blood collection. The infants are depicted in neonatal intensive care or nursery environments, showing varying degrees of medical support including nasogastric tubes, oxygen cannulae, chest leads for cardiac monitoring, and pulse oximetry sensors. The newborns exhibit a range of behavioral and physiological pain indicators, most notably facial grimacing and crying, particularly evident during arterial sampling in images 5 and 7. Healthcare personnel are shown performing the procedures at different anatomical sites such as the hands, heels, and antecubital fossa. This visual data supports the assessment of the Neonatal Infant Pain Scale (NIPS) and the development of automated pain recognition systems.

Educational medical graphic combining a pain assessment tool and surgical material. The top section displays a Visual Analog Scale (VAS) used for clinical pain measurement. The scale features a numeric rating from 0 to 10 correlated with descriptive labels and a Wong-Baker style faces scale: 0 (No Pain, dark green smiling face), 1-3 (Mild, light green smiling face), 4-6 (Moderate to Severe, yellow neutral to orange frowning faces), 7-9 (Very Severe, dark orange distressed face), and 10 (Worst Pain Possible, red crying face). Below the scale is a high-resolution photograph of a self-gripping prosthetic mesh used in surgical procedures like inguinal hernia repair. The mesh is composed of a translucent, white synthetic monofilament knit into a diamond-shaped grid. Characteristic micro-grips or bulbous nodes are visible at the strand intersections, designed for sutureless fixation to anatomical tissues. This comparison illustrates tools used for evaluating patient outcomes, specifically postoperative pain levels relative to surgical techniques and materials.

This infographic illustrates the methodology for orthodontic pain assessment using the NRS-11 scale following mini-implant placement. The top section defines the Numeric Rating Scale (NRS-11) categories: 0 (No Pain), 1–3 (Mild Pain), 4–6 (Moderate Pain), and 7–10 (Severe Pain). Central to the figure is an anatomical diagram of the maxillary dental arch. Black arrows indicate the bilateral 'Mini-implant position' in the posterior region, specifically between the second premolars and first molars. Flanking the anatomical diagram are two data entry tables labeled 'Pain score' for the 'Right side' and 'Left side.' Each table contains columns for 'Time' (specified as 1 day post-treatment) and 'NRS-11' score. This layout is designed for a clinical study comparing postoperative pain levels between a treatment group and a control group in orthodontic procedures involving bone-anchored devices.

Summary : This figure presents a numerical rating scale for pain intensity, used to assess a patient's worst or average pain over the past 24 hours, with both verbal and written instructions. scale: Title & Axes : • Title: "Numerical rating scale for pain intensity" (implied by heading). • X-axis: Numeric scale from 0 to 10, labeled at each integer. • No Y-axis present. Scale Points & Labels : • 0: None • 1–3: Mild • 4–6: Moderate • 7–10: Severe Instructions : • Verbal: "What number describes your worst/average pain, where zero is no pain and ten is the worst pain you can imagine." • Written: "Please circle the number that best describes your worst/average pain over the past 24 hours." Design Encodings : • Horizontal blue line connecting vertical tick marks at each integer from 0 to 10. • Brackets below the scale group numbers into pain categories (None, Mild, Moderate, Severe). Analysis : • The scale provides a simple, standardized method for patients to quantify pain intensity, facilitating communication and documentation. • Pain is categorized into four levels (None, Mild, Moderate, Severe) based on numeric ranges, allowing for both qualitative and quantitative assessment. • The scale is linear and evenly spaced, supporting consistent interpretation across users.

This pathophysiology diagram illustrates the biological mechanisms underlying radiotherapy-induced acute pain in Head and Neck Cancer (HNC). The flowchart categorizes pain into three primary types: Inflammatory, Nociceptive, and Neuropathic. The process begins with Radiation Therapy in HNC, branching into three initial pathways: 1) DNA damage and ROS production, which leads to failed DNA repair, apoptosis, cell death, and clinical manifestations like mucositis and dermatitis, resulting in inflammatory pain. 2) Activation of immune cells, leading to the release of inflammatory cytokines (e.g., IL1, IL-6, TNF-α, NF-κB, IFN, TGFβ, EGF, PG), which serve as nerve sensitizers triggering nociceptive pain. 3) Direct mechanical, thermal, and microenvironmental changes, including the release of protons (acid), ATP, bradykinin, and Substance-P, or direct nerve injury and fibrosis. These mechanical and chemical stimuli converge on nerve sensitizers to induce nociceptive pain, while direct nerve injury and chronic fibrosis specifically facilitate neuropathic pain. The diagram serves as an educational tool for oncology and pain management specialists to understand the multi-modal nature of radiation-induced toxicity.

This pathophysiology diagram illustrates the ascending nociceptive pathway and the associated microRNAs (miRNAs) involved in neuropathic pain. The schematic traces the signal flow from the periphery to the central nervous system. It begins with an immune cell and nociceptor/dorsal root ganglion (DRG) at the peripheral level, connecting to the spinal dorsal horn, depicted as a characteristic butterfly-shaped cross-section. The pathway continues cephalad to the anterior cingulate cortex and into various brain regions, including the prefrontal cortex, insular cortex, hippocampus, and amygdala. Each anatomical station is annotated with specific miRNAs (such as miR-124, miR-132, miR-143, and miR-21) that are causally associated with the maintenance of neuropathic pain within those specific tissues. The diagram effectively highlights the complex molecular and cellular landscape of pain chronification across the peripheral and central nervous systems, serving as an educational resource for understanding the epigenetic regulation of chronic pain states.

This pathophysiology diagram illustrates the neural pathways and neuroinflammatory mechanisms involved in neuropathic pain (NPP). The schematic follows a feedback loop starting from peripheral receptors, including skin receptors and muscle spindles, which transmit nociceptive signals. These signals undergo 'sensory information integration' within cross-sections of the spinal cord and 'upward transmission' to the brain. The brain subsequently processes this data and sends instructions via 'downward transmission' back through the spinal cord, culminating in the perception of pain. A significant portion of the diagram focuses on the cellular level, depicting an 'Activated microglia' with a star-shaped morphology near 'cell debris.' This microglial cell is shown releasing pro-inflammatory cytokines and factors, specifically IL-1β, IL-6, and iNOS. These substances act upon an adjacent neuron, leading to 'demyelination' and 'cytotoxicity,' which enhances sensory transmission and contributes to the persistence of chronic pain states. This educational visual integrates neuroanatomy, sensory physiology, and neuroimmunology to explain the development of pain following nerve injury.