Good Practice in Postoperative and Procedural Pain Management ...

necessary to ensure that the patient will have access tosuitable analgesia.Pain after surgery is usually most severe in the first24–72 h but may persist for several days or weeks.Analgesia can be given regularly (by the clock) in theearly postoperative period and then ‘as required’according to assessed pain. Drugs to counteractunwanted effects of analgesia or other side effects ofsurgery such as PONV should also be available andadministered when necessary.Postoperative pain should be assessed frequently: seesection 3.0 for further information. Analgesic regimensshould be sufficiently flexible to allow for inter-individualdifferences in the response to analgesics and thevariation in the requirement for pain relief that occursduring the postoperative period.5.2 ENT surgery5.2.1 MyringotomyDrainage of the middle ear, usually with insertion of atube, is a treatment for otitis media. Myringotomy isusually considered to be a minor procedure, undertakenon a day-case basis. See also section 5.1 for thegeneral principles of postoperative pain management.Good practice pointAs myringotomy is a brief procedure, oral paracetamolor NSAID should be administered preoperativelyto ensure adequate analgesia at the end of surgery.RecommendationsOral paracetamol or NSAIDS (ibuprofen, diclofenac, orketorolac) in suitable doses can achieve adequate earlypostoperative analgesia: Grade B (1–4).Opioids are effective but not recommended for routineuse because of side effects: Grade B (1,5–8).EvidenceParacetamol (oral) produces dose-related analgesia;10 mgÆkg )1 is no better than placebo (3) or is associatedwith higher supplemental requirements (8), whereas painscores are lower with 15–20 mgÆkg )1 (1,2,4,5,9).Ibuprofen and diclofenac appear to provide similaranalgesia to paracetamol (2,10), but the combinationhas not been tested.Ketorolac 1 mgÆkg )1 (intravenous) provides minorimprovements in analgesia when compared with lowdoses of paracetamol, 10 mgÆkg )1 (3,8); paracetamol10 mgÆkg )1 + codeine 1 mgÆkg )1 (8); paracetamol15 mgÆkg )1 (but only first 10 min there was no differenceat 20 min) (4). See section 6.5 for recommendeddoses of ketorolac and other NSAIDS.Opioids, for example codeine, butorphanol, orfentanyl, have been associated with increased sideeffects when compared with NSAIDs or paracetamol,without clinically significant improvements in analgesia;therefore, their use is not warranted for routinemyringotomy:i. increased sedation and time to discharge for oralcodeine: (1), nasal fentanyl (7) and nasal butorphanol (6)ii. increased vomiting with oral codeine or nasal butorphanol(8).LA block of the auricular branch of the vagus providedequivalent analgesia to intranasal fentanyl (11).Analgesia Table 5.2.1Opioid a 1)NSAID 1)Paracetamol 1)Directevidencea Not routinely recommended because of side effects: see text.5.2.2 TonsillectomyTonsillectomy (±adenoidectomy) is one of the mostfrequently performed procedures in children. Chronicor recurrent tonsillitis with tonsillar hyperplasia leadingto upper airway obstruction, for example in sleepapnea syndromes, is the most frequent indication fortonsillectomy. The choice of analgesia, postoperativemonitoring, and duration of hospital admission isinfluenced by the potential for serious complicationssuch as apnea, perioperative bleeding, and postoperativenausea and vomiting (PONV). Pain after tonsillectomycan persist for many days. See also section 5.1for the general management of postoperative pain.Good practice pointAs significant levels of pain, behavioral disturbance, sleepdisruption, and altered activity can persist for 5–8 daysfollowing tonsillectomy, regular administration of analgesiamay be necessary during this period. Information forfamilies about pain assessment and medication use followingdischarge is particularly important.34 ª 2012 Blackwell Publishing Ltd, Pediatric Anesthesia, 22 (Suppl. 1), 1–79