Good Practice in Postoperative and Procedural Pain Management ...

when compared with LA alone and saline controlgroups (41).Dexmedetomidine (IV) may reduce opioid requirementsand respiratory side effects in children after tonsillectomy,this may particularly benefit those withobstructive sleep apnea (OSA) or respiratory compromise.One microgram per kilogram produced less respiratorydepression than 100 lgÆkg )1 morphine but lesseffective analgesia (50). Higher doses, 2 and 4 lgÆkg )1 ,lengthened time to rescue opioid analgesia butincreased sedation in the early postoperative periodwhen compared to fentanyl 1 or 2 lgÆkg )1 IV (51).Dexmedetomidine 2 lgÆkg )1 + 0.7 lgÆkg )1 Æh )1 intraoperativereduced early postoperative opioid requirementsand agitation in children with OSA comparedwith fentanyl 1 lgÆkg )1 (52).Dexamethasone reduces PONV and postoperativepain scores following tonsillectomy (13,53).Most meta-analyses of posttonsillectomy analgesiahave focused on PONV and bleeding rather than analgesicefficacy. PONV following tonsillectomy is reducedby NSAID presumably because of a reduction inopioid requirement (33,54), and by intraoperative dexamethasone(see above). As posttonsillectomy bleedingis relatively rare, meta-analyses have included differenttrials and reached different conclusions:l Bleeding is increased by aspirin but not ibuprofen ordiclofenac (seven trials) (55).l Risk of bleeding and reoperation increased (NNH29), and NSAIDS should not be used (seven trials)(56).l Risk of reoperation (NNH 60) but not bleedingincreased, and NSAIDS should be used cautiously (25trials) (33)l NSAIDS do not increase risk of bleeding or reoperationbut further studies required (13 pediatric trials)(54).Although meta-analyses are currently inconclusive,perioperative diclofenac and ibuprofen appear to beassociated with minimal risk of posttonsillectomybleeding. Early studies using high doses of ketorolachave been included in the meta-analyses, but there areinsufficient data to assess the risks associated with differentNSAIDS.Analgesia Table 5.2.2AgentTechniqueDirectevidenceLA a Tonsillar fossa injection 1+*Topical 1+*Opioid 1+Tramadol 1+Dexamethasone 1+Ketamine 1+NSAIDS 1+Paracetamol 1+a No differences have been demonstrated based on route (topicalvs infiltration), type of LA, or time of injection (pre- vs postremoval).5.2.3 Mastoid and middle ear surgeryMastoidectomy may be performed to remove infectedtissue or cholesteatoma. As the incidence of chronicsuppurative otitis media is declining in many populations,this surgery is now less frequently required inthe UK. Middle ear surgery, such as reconstruction ofa damaged tympanic membrane by placement of surgicalgrafts, may be associated with significant PONV.See also section 5.1 for the general management ofpostoperative pain.RecommendationsGreat auricular nerve block can provide similar analgesiaand reduced PONV compared with morphine. Preincisiontiming of the block confers no additional benefit:Grade B (57,58).EvidenceThere are relatively few controlled trials specificallyinvestigating pain during and after mastoidectomy andinvasive middle ear surgery, and no further studiessince the last edition of this guideline. As NSAIDSand paracetamol improve analgesia for middle ear procedures,there is indirect evidence that they providebeneficial supplemental analgesia for mastoid surgery.However, compared with middle ear surgery, mastoidsurgery is associated with increased pain: patients aretherefore more likely to require opioids, treatment forPONV and hospital admission (59). In procedures thatrequire a postauricular incision, LA block of the greatauricular nerve can provide similar analgesia andreduced PONV compared with morphine (57). No differencewas found between performing the block preincisionvs prior to the end of surgery (58).36 ª 2012 Blackwell Publishing Ltd, Pediatric Anesthesia, 22 (Suppl. 1), 1–79