Good Practice in Postoperative and Procedural Pain Management ...

most effective. There are a number of less painfulalternatives to simple wound suture in the awakepatient: Tissue adhesives in simple low-tension woundsand the hair apposition technique (HAT) in scalp lacerationsare examples.Also see section 4.0 and 4.2 for general considerationsin procedural pain management.Good practice pointFor extensive wounds or children who are very anxiousconsider sedation or general anesthesia.RecommendationsFor repair of simple low-tension lacerations, tissue adhesivesshould be considered as they are less painful, quickto use, and have a similar cosmetic outcome to sutures oradhesive skin closures (steri-strips): Grade A (146–148).Topical anesthetic preparations, for example, LAT (lidocaine–adrenaline–tetracaine)if available, can be used inpreference to injected LA, as they are less painful toapply; it is not necessary to use a preparation containingcocaine: Grade A (149–153).Buffering injected lidocaine with sodium bicarbonateshould be considered: Grade A (88).‘HAT’ should be considered for scalp lacerations. It isless painful than suturing, does not require shaving, andproduces a similar outcome: Grade B (154).If injected lidocaine is used, pretreatment of the woundwith a topical anesthetic preparation, for example, lidocaine–adrenaline–tetracaine(LAT) gel, reduces the painof subsequent injection: Grade B (155,156).50% nitrous oxide reduces pain and anxiety during lacerationrepair: Grade B (157–159).EvidenceLaceration repair has been relatively well studied inchildren. There are a number of alternatives to simplewound suture in the awake patient. Tissue adhesives insimple low-tension wounds and the hair appositiontechnique (HAT) in scalp lacerations are less painfulalternatives (147,154). A number of topical local anestheticmixtures are available; they can give equivalentanalgesia to infiltrated local anesthetic and are lesspainful to apply although a recent systematic review inadults and children concluded that there was insufficientevidence to unreservedly recommend topical LAin preference to injected LA (82,153). A systematicreview including trials in adults and children found that‘buffering’ local anesthetics with sodium bicarbonatesignificantly reduces the pain of injection (88). Nitrousoxide has been shown to be effective in reducing pain,anxiety, and distress in cooperative children (157,158).See section 6.7 for information on the use of nitrousoxide. Psychological techniques such as distraction andrelaxation are also likely to be useful (85).Analgesia Table 4.3.7 Repair of lacerations in childrenDirectevidenceIndirectevidenceLocal anesthesia Topical 1++Infiltration 1++Buffered 1++infiltration50% nitrous oxide 1+Procedure modification 1++Psychological intervention 1++4.3.8 Dressing changes in the burned childChildren with burns often require repeated, oftenextremely painful, dressing changes. Children withsevere burns are normally cared for in a specialist unit,but some children will be seen in Emergency Departments.Initial dressing changes are likely to be performedunder general anesthesia, and if childrenremain very distressed, this option may be favored forsubsequent procedures. Sedation is sometimes used tosupplement analgesia for burns dressings, see NICEGuideline CG112 ‘Sedation in Children and YoungPeople’ available at: http://www.nice.org.uk/CG112. Inthe early stages of burn pain management, childrenmay require continuous infusion of potent opioidssuch as morphine, and additional analgesia will berequired prior to dressing changes (160).Both pharmacological and nonpharmacological techniquesshould be used in the management of painfuldressing changes, see section 4.0, 4.1, and 4.2 for adviceon the general management of painful procedures.RecommendationsPotent opioid analgesia given by oral, transmucosal, ornasal routes according to patient preference and availabilityof suitable preparations should be considered fordressing changes in burned children: Grade A (161–164).Nonpharmacological therapies such as distraction andrelaxation should be considered as part of pain managementfor dressing changes in burned children: Grade B(165–170).26 ª 2012 Blackwell Publishing Ltd, Pediatric Anesthesia, 22 (Suppl. 1), 1–79