Notat om omskæring af drenge - Sundhedsstyrelsen

FROM THE AMERICAN ACADEMY OF PEDIATRICSinfrequent and include only eitherminor skin reactions (ie, erythema,swelling) or, more rarely, blistering(especially in low birth weight infants).154 For this reason, penilenerve block techniques should bechosen for low birth weight infants.There is good and fair evidence thatboth reactions are less commonwith 4% lidocaine than with lidocaineprilocainecream. 142,150,153–155There is a theoretical risk of methemoglobinemiawith lidocaine-prilocaine. 152However, when methemoglobin has beenmeasured after lidocaine-prilocaineapplication, the level, although elevated,was not clinically significant. 150Nevertheless, there have been isolatedcase reports of clinically significantmethemoglobinemia involving prolongedapplication time or use in prematureinfants. 156,157,158DPNBMost commonly, DPNB consists ofinjections of 0.4 mL of 1% lidocainewithout epinephrine on both sides ofthe base of the penis. Systemic lidocainelevels obtained with use of thistechnique reached peak concentrationsat 60 minutes after injectionand were well below toxic ranges. 159There is good evidence that DPNB iseffective in reducing the behavioraland physiologic indicators of paincaused by circumcision, regardless ofthe device used. 144 There is good evidencethat DPNB is superior tolidocaine-prilocaine in relieving painduring and after circumcision innewborns. 142,160–162 One good-qualityprospective cohort study of 491 newborncircumcisions measured complicationsof DPNB analgesia; itreported an 11% incidence of bruisingand a 0.2% incidence of hematoma,none of which required any change inmanagement. 163 Another good-quality,blinded, randomized controlled trialfound a 43% incidence of smallhematomas in preterm and term newbornscircumcised by using DPNB. 142Subcutaneous Ring BlockTwo studies with fair evidence foundthat the subcutaneous circumferentialring block (0.8 mL of 1% lidocainewithout epinephrine injected at thebase or midshaft of the penis) is effectivein mitigating pain and its consequencesduring circumcision ofnewborns. 164One study presented fair evidence thatthe ring block was superior to usingno anesthesia but found a 5% failurerate with the technique (1 in 20 ringblock infants had heart rate and behavioralpain scores that were abovethe control mean during at least 50%of the measured intervals, while 19 of20 had heart rate and pain scoresless than the control mean). Therewere no hematomas in the infantsreceiving ring blocks. A second ringblock study had fair evidence that themethod was superior to either DPNBor lidocaine-prilocaine cream for painrelief in newborn circumcision, as thering block seemed to prevent cryingand increases in heart rate during allphases of the circumcision, with lesscrying and lower heart rates duringforeskin separation and incision thanseen with DPNB or lidocaine-prilocaine.152 No complications have beenreported in the use of this simple andhighly effective technique.Analgesia and Anesthesia fora Circumcision After the NewbornPeriodIn the United States, after the newbornperiod, general anesthesia is usedduring male circumcision because thesurgical procedure takes longer andinvolves hemostasis and the suturingof skin edges. Use of adjuvant localanesthetic techniques in addition togeneral anesthesia provides longerlastingpostoperative analgesia, minimizesthe need for intraoperative orpostoperative opioid administration,reduces adverse postoperative eventssuch as nausea and vomiting, anddecreases recovery time. Long-lastinganalgesia is achieved with either penilenerve block, by using any of themethods mentioned earlier, or caudalepidural analgesia in infants andchildren up to 3 years of age.General anesthesia carries a low riskof mortality (1 death per 400 000instances of general anesthesia). Therisk of adverse events (especially respiratoryevents) during general anesthesiaremains higher in infantsunder 1 year of age. 165 These risks areminimized when the procedure isperformed in infants in their optimalstate of health (no active reactiveairway disease or upper respiratoryinfection) and in a facility familiarwith the anesthesia care of infants. 166Additional concerns associated withsurgical circumcision in older infantsinclude time lost by parents andpatients from work and/or school.Caudal BlockCaudal block (CB) with bupivacaine isan anesthetic technique used forpostoperative analgesia for circumcisionin infants and older children up to3 years of age, as an alternative to ringblock and DPNB techniques. There isgood and fair evidence that there isa longer time to first postoperativeurination after CB without adverseclinical consequences. 167,168 There isgood evidence for a high incidence ofmild postoperative motor block anddelay in walking after the CB procedure(21% to 44%) in older children.167,169,170 Caudal analgesia maybe less available in facilities that donot treat many pediatric patients.DPNBThe reported failure rate of DPNB is1% to 10%. 171–175 When DPNB is usedPEDIATRICS Volume 130, Number 3, September 2012Downloaded from pediatrics.aappublications.org by guest on June 19, 2013e771