Good Practice in Postoperative and Procedural Pain Management ...

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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
EvidenceThe evidence base for managing burn pain in childrenis small and incomplete. Opioids are used extensivelyand should be given as necessary by intravenous orother routes (160). There are a number of small studiescomparing different opioid formulations and routes ofadministration, such as transmucosal or intranasal fentanyl,hydromorphone, oxycodone and morphine bythe oral route (161–164).There is evidence for distraction with children usinga variety of devices – such as helmet Visual Realitydevices or hand-held multimodal devices where thechild is an active participant in the game they are playingbeing more effective than standard distractionwhen burns dressings are being changed (168–173).Small studies have investigated different creams ordressings with some being less painful – more researchis needed in this area (174–176). Nitrous oxide is usedextensively for single painful procedure in childrenwho are able to cooperate; multiple or frequent administrationmay lead to bone marrow toxicity. Nitrousoxide has not been directly studied in this patientgroup, although there is one small cohort study assessingparent and patient satisfaction (177). See section6.7 for more information on the use of nitrous oxide.4.3.9 Botulinum injections for children withmuscle spasmBotulinum toxin is used to relieve muscle spasm; inpediatric practice, this is most often the spasticity associatedwith cerebral palsy. These injections can take along time – usually, multiple sites are chosen, andthere are three phases to the procedure: initial puncture,localization of correct muscle point, and theninjection. There is very little evidence for pain managementstrategies: In practice, many children are likely tobe offered general anesthesia or sedation.One observational study was identified, which investigatedthe level of pain felt by children undergoingthis procedure with local anesthetic cream and 50%nitrous oxide. In this study, half the children experiencedsevere pain, but the rest of the children managedwell with this combination (178). Further research isneeded.Good practice point50% nitrous oxide/oxygen should be considered in childrenwho are able to cooperate with self-administration.Analgesia Table 4.3.9 Botulinum toxin injectionsAnalgesia Table 4.3.8 Dressing changes in burned childDirectevidenceIndirectevidenceDirectevidenceIndirectevidenceOpioids 1++Nitrous oxide a 1++Psychological preparation 1+Psychological intervention 1+50% nitrous oxide 1+Topical LA 1+Psychological preparation 1+Psychological intervention 1+a No data for multiple administrations.References1 Anand KJ, Aranda JV, Berde CB et al.Summary proceedings from the neonatalpain-control group. Pediatrics 2006; 117:S9–S22.2 Mackenzie A, Acworth J, Norden M et al.Guideline Statement: Management of Procedure-RelatedPain in Neonates. Sydney,NSW, Australia: Paediatrics and ChildHealth Division RACP, 2005: 24.3 Batton DG, Barrington KJ, Wallman C.Prevention and management of pain in theneonate: an update. Pediatrics 2006; 118:2231–2241.4 Lago P, Garetti E, Merazzi D et al. Guidelinesfor procedural pain in the newborn.Acta Paediatr 2009; 98: 932–939.5 Carbajal R, Veerapen S, Couderc S et al.Analgesic effect of breast feeding in termneonates: randomised controlled trial. BMJ2003; 326: 13.6 Shah P, Aliwalas L, Shah V. Breastfeedingor breast milk for procedural pain in neonates.Cochrane Database Syst Rev 2006; 3:CD004950.7 Shah V, Taddio A, Rieder MJ. Effectivenessand tolerability of pharmacologic and combinedinterventions for reducing injectionpain during routine childhood immunizations:systematic review and meta-analyses.Clin Ther 2009; 31(Suppl. 2): S104–S151.8 Agarwal R. Breastfeeding or Breast Milkfor Procedural Pain in Neonates : RHLCommentary (last revised: 1 June 2011).The WHO Reproductive Health Library.Geneva: World Health Organization(WHO): 2011.9 Holsti L, Oberlander TF, Brant R. Doesbreastfeeding reduce acute procedural painin preterm infants in the neonatal intensivecare unit? A randomized clinical trial. Pain2011; 152: 2575–2581.10 Skogsdal Y, Eriksson M, Schollin J. Analgesiain newborns given oral glucose. ActaPaediatr 1997; 86: 217–220.11 Carbajal R, Chauvet X, Couderc S et al.Randomised trial of analgesic effects ofsucrose, glucose, and pacifiers in term neonates.BMJ 1999; 319: 1393–1397.ª 2012 Blackwell Publishing Ltd, Pediatric Anesthesia, 22 (Suppl. 1), 1–79 27
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Page 3 and 4: doi: 10.1111/j.1460-9592.2012.3838.
Page 5 and 6: 1.6 Contact informationCorresponden
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Page 11 and 12: 2.7.6 Laparoscopic surgeryGood prac
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
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Page 24 and 25: Newer preparations such as liposoma
Page 26 and 27: Good practice pointLubricant contai
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
Page 60 and 61: day-stay unit. Int J Paediatr Dent
Page 62 and 63: tinuous epidural infusion in childr
Page 64 and 65: 245 Morton NS, O’Brien K. Analges
Page 66 and 67: 321 Taenzer AH, Clark C, Taenzer AH
Page 68 and 69: Section 6.0AnalgesiaContents6.1 Ana
Page 70 and 71: enhance systemic absorption. Lidoca
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Page 77 and 78: 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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