Good Practice in Postoperative and Procedural Pain Management ...

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2.7.2 OpthalmologyStrabismus surgeryIntraoperative LA blocks (subtenon’s or peribulbar)reduce PONV and may improve perioperative analgesiain comparison with IV opioid but provide no benefit overtopical LA: Grade BTopical NSAIDS do not improve pain scores or postoperativeanalgesic requirements when compared with topicalLA or placebo: Grade BIntraoperative opioid and NSAID provide similar postoperativeanalgesia but opioid use is associated withincreased PONV: Grade BVitreoretinal surgeryIn vitreoretinal surgery NSAID can provide similar analgesiabut lower rates of PONV compared with opioid:Grade CPeribulbar block improves early analgesia and mayreduce PONV compared with opioid: Grade C2.7.3 Dental proceduresNSAIDS with or without paracetamol reduce pain followingdental extractions: Grade BSwabs soaked with bupivacaine on exposed tooth socketsfollowing extraction produce no or minor improvementsin pain in the immediate postoperative period: Grade BIntraoperative LA infiltration reduces postoperative painfollowing dental extractions, but provides little additionalbenefit over NSAIDS and paracetamol alone:Grade B2.7.4 General surgery and urology (minor andintermediate)Sub-umbilical surgeryLA should be used when feasible: wound infiltration,transversus abdominis plane (TAP) block, ilio-inguinalnerve block and caudal analgesia are effective in theearly postoperative period following sub-umbilical surgery:Grade ACircumcisionCaudal epidural and dorsal nerve block are effective inthe early postoperative period, with low rates of complicationsand side effects: Grade ANeonatal circumcisionLA should be used as it is superior to other techniquesfor circumcision pain: Grade ADorsal nerve block is more effective than subcutaneousring block or topical LA: Grade AWhen using topical local anesthetic it must be appliedcorrectly and sufficient time allowed for it to becomeeffective: Grade AHypospadias repairLA central neuraxial or dorsal nerve block is effectivereducing the need for postoperative supplementary opioidadministration following hypospadias surgery: Grade AOrchidopexyCaudal block is effective in the early postoperative periodfor orchidopexy with low rates of complications andside effects: Grade AOpen inguinal hernia repairLA wound infiltration, ilio-inguinal nerve block, paravertebralblock or caudal analgesia are effective in the earlypostoperative period: Grade A2.7.5 General surgery and urology (Major)Major intra-abdominal surgeryIntravenous opioids either as continuous infusion, NCA,or PCA are effective following major abdominal surgery:Grade AEpidural analgesia with LA should be considered formajor abdominal surgery. The addition of neuraxialclonidine or opioid may further improve analgesia butside effects may also be increased: Grade BAppendicectomy (open)PCA combined with NSAID is effective for postappendicectomypain: Grade BFundoplication (open)Epidural LA + opioid is effective and may be associatedwith improved clinical outcome in selected patientsfollowing fundoplication: grade D8 ª 2012 Blackwell Publishing Ltd, Pediatric Anesthesia, 22 (Suppl. 1), 1–79
2.7.6 Laparoscopic surgeryGood practice pointsInfiltration of port sites with LA as part of a multimodalanalgesic strategy may reduce postoperative pain followinglaparoscopy.Although overall postoperative analgesic requirementsappear to be reduced following laparoscopy, pain maybe equivalent to the equivalent open procedure in somecircumstances, particularly during the first 24 h.2.7.7 Orthopaedics, spinal and plastic surgeryGood practice pointThere is no evidence from studies in children thatNSAIDs have a deleterious effect on bone fusion. Theanalgesic benefit of short-term NSAID use has beendemonstrated and may frequently outweigh any hypotheticalrisk.Lower limb surgeryPeripheral nerve blocks provide superior analgesia andare associated with fewer adverse effects compared withintravenous opioids: Grade BContinuous peripheral nerve blocks are feasible, effectiveand safe, and are associated with lower pain scores:Grade BEpidural opioids are effective, reduce the dose requirementsof local anesthetic, and rescue IV opioids butincrease the incidence of side effects: Grade BEpidural techniques are associated with lower painscores than intravenous opioid analgesia: Grade CSystemic paracetamol and NSAID reduce intravenousopioid requirements: Grade CUpper Limb SurgeryBrachial plexus blocks provide satisfactory analgesia forhand and forearm surgery extending into the postoperativeperiod: Grade BThe axillary, infraclavicular, supraclavicular, and interscaleneapproach are feasible and effective: Grade BSpinal surgeryEpidural techniques produce a modest improvement inpain control, compared with intravenous opioids inpatients undergoing corrective surgery for adolescent idiopathicscoliosis: Grade BIntrathecal opioids decrease intra-operative blood lossand IV opioid consumption postoperatively. The durationof action is 18–24 h: Grade CDual catheter epidural techniques should be considered, asthis permits coverage of multiple spinal levels: Grade CThe use of LA + lipophilic opioid in the epidural spacewith a single epidural catheter does not show an analgesicbenefit over intravenous opioid techniques: Grade CThe use of LA + hydrophilic opioids in the epiduralspace has a favorable analgesic profile compared withIV opioid, but at the expense of increased adverseeffects: Grade DCleft lip and palate and related procedures of headand neckInfraorbital nerve block provides effective analgesia forcleft lip repair in the early postoperative period: GradeA2.7.8 Cardiothoracic surgeryCardiac surgery (sternotomy)Epidural and intrathecal techniques with opioid and/orLA are effective for sternotomy pain but only marginalbenefits have been demonstrated, and there is insufficientdata concerning the incidence of serious complications:Grade BThoracotomyEpidural analgesia is effective for post-thoracotomypain: Grade D2.7.9 NeurosurgeryCraniotomy and major neurosurgeryGood practice pointAnalgesia following neurosurgery requires good communicationand close cooperation between members of theperioperative team. Frequent pain assessments should bea routine part of postoperative care. A multimodal analgesicapproach is suitable, which may include the use ofLA infiltration, paracetamol, NSAID (when not contraindicated),and parenteral or oral opioid as determinedby assessed analgesic requirements.ª 2012 Blackwell Publishing Ltd, Pediatric Anesthesia, 22 (Suppl. 1), 1–79 9
Page 1 and 2: PediatricAnesthesiaVolume 22 Supple
Page 3 and 4: doi: 10.1111/j.1460-9592.2012.3838.
Page 5 and 6: 1.6 Contact informationCorresponden
Page 7 and 8: RecommendationsChildren’s self-re
Page 9: Topical anesthetic preparations, fo
Page 13 and 14: In order to assess pain, effective
Page 16 and 17: Postoperative painl NCCPC-PV (Non-C
Page 18 and 19: 68 Broome ME, Richtsmeier A, Maikle
Page 20 and 21: however, reductions in the response
Page 22 and 23: increased success rate (i.e., less
Page 24 and 25: Newer preparations such as liposoma
Page 26 and 27: Good practice pointLubricant contai
Page 28 and 29: most effective. There are a number
Page 30 and 31: 12 Bellieni C, Bagnoli F, Perrone S
Page 32 and 33: venipuncture pain in a pediatric em
Page 34 and 35: 172 van Twillert B, Bremer M, Faber
Page 36 and 37: necessary to ensure that the patien
Page 38 and 39: when compared with LA alone and sal
Page 40 and 41: Peribulbar block improves early ana
Page 42 and 43: Analgesia Table 5.5.1 Sub-umbilical
Page 44 and 45: was more effective with less motor
Page 46 and 47: with using landmark techniques (205
Page 48 and 49: Good practice pointWound infiltrati
Page 50 and 51: Analgesia Table 5.6.4 Urological Su
Page 52 and 53: (298). Ketorolac did not influence
Page 54 and 55: well as the epidural technique for
Page 56 and 57: Good practice pointA multi-modal an
Page 58 and 59: 14 Grainger J, Saravanappa N. Local
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day-stay unit. Int J Paediatr Dent
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tinuous epidural infusion in childr
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245 Morton NS, O’Brien K. Analges
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321 Taenzer AH, Clark C, Taenzer AH
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Section 6.0AnalgesiaContents6.1 Ana
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enhance systemic absorption. Lidoca
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undergoes hepatic biotransformation
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tein binding are reduced and the ha
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a low-dose infusion but the child m
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Table 6.6.1 Paracetamol dosing guid
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steps that health care professional
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