A woman in her 80s was diagnosed with colon cancer, and she underwent chemotherapy after surgery. Oxycodone extended-release tablets were initiated for abdominal pain, but oral administration was difficult, leading to a change to fentanyl patches. Owing to severe numbness from the buttocks to the toes, tramadol/acetaminophen (T/A) tablets were initiated at a dose of 2 tablets per day. The fentanyl patch dose was increased to 2 mg/d, and pain was relieved on combination with 2 T/A tablets. The patient subsequently reported behavioral disturbances, including agitation, anxiety, and sudden diarrhea. She had been taking 1 T/A tablet 2 to 3 times per day at her discretion when the pain worsened. Suspecting an additive effect from the combination of the fentanyl patch and T/A tablets, the T/A tablets were immediately discontinued, and the symptoms resolved. Loxoprofen tablets were initiated at 180 mg/d, and the fentanyl patch dose was increased to 4 mg/d, without side effects such as agitation, anxiety, or behavioral disorders. The combined use of tramadol and fentanyl likely induced excessive serotonergic activity; careful observation is required in adult patients and those receiving multiple medications.

Transitional pain describes the clinically important phase in which acute pain resolves or progresses to chronic pain. This phase is particularly relevant after surgery and trauma, where the onset of tissue injury can be identified. Evidence suggests that chronic postsurgical or post-traumatic pain may arise through the interaction of biological, psychological, and social mechanisms, including peripheral and central sensitization, neuroimmune activation, psychological distress, pain catastrophizing, functional avoidance, and prolonged opioid exposure. Transitional Pain Services address this risk period through early identification, multidisciplinary intervention, opioid stewardship, rehabilitation, and psychological support. Current evidence suggests benefits for opioid tapering, pain interference, mood, and function, although stronger trials are needed to confirm whether such services reduce the incidence of chronic pain. Therefore, transitional pain should be understood as a modifiable risk state and a promising target for preventive perioperative pain care.

As mortality from pediatric critical illness has declined, post intensive care syndrome in pediatrics (PICS-p) has emerged as a framework to describe the broad and often long-lasting morbidities experienced by survivors of pediatric critical illness. PICS-p encompasses new or worsening impairment in physical, cognitive, emotional, and social health that affect both the child and their family. The term PICS-p also acknowledges and reinforces the traumatic impact of the critical care on the child and family dyad. Given the growing population of pediatric survivors of critical illness and the limited availability of newly emerging, specialized post-critical care clinics, it is imperative that general pediatricians, providing the child's medical home, are equipped to diagnose and manage PICS-p in the outpatient setting. In this review, we summarize the prevalence, pathophysiology, clinical course, and impact of PICS-p on children and families. We also review preventive strategies that can be implemented in the PICU and conclude with practical guidance for general pediatricians caring for children after critical illness.