Good Practice in Postoperative and Procedural Pain Management ...

Good practice pointLubricant containing local anesthesia should beapplied to the urethral mucosa prior to bladdercatheterization.RecommendationsPsychological preparation and psychological and behavioralinterventions should be used during bladder catheterizationand invasive investigations of the renal tract:Grade B (111,112).Infants: Consider procedure modification as urethralcatheterization is less painful than SPA for urine sampling:Grade B (72,73).EvidenceBladder catheterization has been shown to cause significantpain and distress, but analgesia is not part of routinecare in many institutions (113). More complexinterventions, which include bladder catheterizationssuch as MCUG or VCUG, have also been shown tocause significant distress, which can be reduced by psychologicalpreparation and behavioral pain managementtechniques such as distraction or hypnosis(111,112,114). Local anesthetics incorporated into lubricantgels are frequently used in adults to reduce the painand discomfort of catheterization, but this has not beenwell studied in children. Pretreatment of the urethrawith lidocaine 10 min before catheterization reducedpain in a group of children (16 girls, four boys) with amean age of 7.7 years (115). However, in younger children(mean age 2 years), application of lidocaine gel tothe ‘genital mucosa’ for only 2–3 min before the procedureand its subsequent use as a lubricant did notdecrease pain (113). Techniques combining adequatepreparation, local anesthesia, and behavioral interventionsare likely to be more effective (116).Analgesia Table 4.3.4Bladder catheterization and urine sampling in childrenDirectevidenceLocal anesthesia Topical gel a 1+50% nitrous oxide 1+Psychological preparation 1+Psychological intervention 1+Procedure modification b 1+a Applied 10 min before catheterization.b Urethral catheterization instead of SPA.Indirectevidence4.3.5 Nasogastric tube insertionSee also sections 4.1, 4.2 and 4.3 for advice on the generalmanagement of painful procedures in neonates,infants, and children and 4.2.7 for NGT insertion inneonates. NGT insertion is a painful and distressingprocedure frequently performed with little attention topain-relieving strategies (75). Infants who are unwelland unable to feed, particularly those with respiratoryproblems such as bronchiolitis, may need to be ‘tubefed’ for a short period. NGT is often maintained in thepostoperative period and may need to be re-inserted ifthey become displaced. Older children may also be fedvia NGT, for example, in patients with cystic fibrosiswho sometimes require supplementary feeding on multipleoccasions. Clearly, it is particularly important tooptimize pain management in those patients who arelikely to need repeated NGT placement.Passing a NGT is a skilled procedure, and in theUK, the Department of Health has published guidelines(CMO Update no.39, publ DoH, UK; NPSA/2007/19), which should be followed.Good practice pointTopical local anesthetics such as lubricant gel containinglidocaine, applied prior to placement, are likely toreduce the pain and discomfort of NGT insertion.EvidenceNGT insertion has been little studied in children. In theadult, topical local anesthesia and lubricants have beenshown to reduce pain and facilitate placement (117–119). 10% nebulized lidocaine is also effective in adultsbut may also slightly increase the incidence of epistaxis(120). A recent RCT did not find any benefit from nebulizedlidocaine in children between 1 and 5 years (121).The additional use of vasoconstrictors such as topicalphenylephrine or cocaine may reduce this risk, findingsthat have not been confirmed in children. Indirect evidencealso suggests that the use of psychological/behavioraltechniques may be of benefit in older children.Analgesia Table 4.3.5 Nasogastric tube insertionDirectevidenceTopical LA 1++Non-nutritive sucking a 1+Tactile stimulation a 1+Psychological preparation 1+Psychological intervention 1+a Infants.Indirectevidence24 ª 2012 Blackwell Publishing Ltd, Pediatric Anesthesia, 22 (Suppl. 1), 1–79