Good Practice in Postoperative and Procedural Pain Management ...

Newer preparations such as liposomal encapsulatedLA or newer LA delivery systems may offeradvantages in some situations. Buffered injected LA,for example, lidocaine + bicarbonate 10:1, administeredwith a fine 30-g needle subcutaneously prior tocannulation is faster in onset and may be as acceptableand effective as topical preparations (81,82,88).Nitrous oxide (50–70%) inhalation has been used inchildren older than 6 years who can self-administerduring venepuncture in some circumstances. 70%nitrous oxide is not routinely available for selfadministrationin the UK. 50% nitrous oxide andEMLA have been shown to be equally effective forvenepuncture with further improvements in pain reductionusing a combination of the two (79,89).The efficacy of vapocoolant topical spray has notbeen clearly established. Vapocoolant spray was noteffective in reducing pain in one study of intravenouscannulation but did show a modest reduction in pain ina later study (90,91). In a study of children’s preferences,children who had experienced both methodsselected both ethyl chloride and Ametop Ò equally (92).A combination of cooling and vibration (Buzzy Ò ) withor without LA reduced pain and distress of venepuncturein one study (93).Psychological approaches such as distraction shouldbe offered to all children as it is easy to administer.Hypnosis can also be very effective for children requiringrepeated interventions (83,86).Analgesia Table 4.3.1Blood sampling and IV cannulation in childrenDirectevidenceLocal anesthesia Topical 1++Infiltration 1++50% nitrous oxide/oxygen 1+Psychological preparation 1)Psychological intervention 1++4.3.2 Lumbar puncture in childrenLumbar puncture (LP) is necessary in acutely ill childrenin whom meningitis is suspected. These childrenare likely to be unwell and anxious, and they may alsoundergo other painful procedures such as venepunctureas part of diagnosis and treatment.Other children require ‘elective’ or ‘planned’ LP:This may be for diagnostic reasons, such as evaluationof possible raised intracranial pressure, or for intrathecaltreatments such as chemotherapy.Positioning of the child is very important for success,and it is helpful to have assistance from trainedstaff with experience of correct positioning. Childrenwho require multiple LPs may cope better with theaddition of sedation (see NICE Guideline CG112‘Sedation in Children and Young People’ available at:http://www.nice.org.uk/CG112) or general anesthesia.See also section 4.0 and 4.2 on the general managementof painful procedures.RecommendationsBehavioral techniques of pain management should beused to reduce LP pain: Grade A (85,94).Topical LA and LA infiltration are effective for LP painand do not decrease success rates: Grade B (82,95,96).50% nitrous oxide/oxygen should be offered to childrenwilling and able to cooperate: Grade C (97).EvidenceFew studies have directly examined the efficacy of analgesicsin awake children undergoing lumbar puncture.Most commonly, local anesthesia is combined with sedativeagents, such as midazolam, or biobehavioral techniques,such as distraction or other cognitive–behavioralinterventions (85,94,95,98), is effective for LP pain, andmay also be used in combination with LA (either topicalor infiltration) and other strategies (97). Ketamine analgesia/sedationor general anesthesia is sometimes used inemergency departments and oncology units with appropriatefacilities (99–101). However, recent studies indicatethat analgesia practice for LP in emergencydepartments could be improved (102,103). It seemslikely that older children, especially those who may onlyneed to undergo this procedure once, may tolerate LPwith appropriate behavioral techniques and local anesthesia,whereas children requiring multiple LPs shouldbe offered sedation or GA (98).There is some evidence that technique modificationusing pencil point needles instead of standard needlesmay reduce the incidence of post-LP headaches(104).Analgesia Table 4.3.2 Lumbar puncture in childrenDirectevidenceLocal anesthesia Topical 1+Infiltration 1)50% nitrous oxide/oxygen 2+Psychological interventions 1++Indirectevidence22 ª 2012 Blackwell Publishing Ltd, Pediatric Anesthesia, 22 (Suppl. 1), 1–79