Good Practice in Postoperative and Procedural Pain Management ...

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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
Analgesia Table 5.2.3AgentTechniqueDirectevidenceLAGreater auricular 1)nerve blockOpioid 1)NSAID 1)Paracetamol 1)5.3 Opthalmology5.3.1 Strabismus surgeryIndirectevidenceStrabismus surgery (correction of squint) is associatedwith a high incidence of PONV, and intraoperativetension on ocular muscles may provoke a vagalresponse (oculocardiac reflex). See also section 5.1 forthe general management of postoperative pain.RecommendationsIntraoperative LA blocks (subtenon’s or peribulbar)reduce PONV and may improve perioperative analgesiain comparison with IV opioid but provide no benefit overtopical LA: Grade B (60–64).Topical NSAIDS do not improve pain scores or postoperativeanalgesic requirements when compared with topicalLA or placebo: Grade B (65–67).Intraoperative opioid and NSAID provide similar postoperativeanalgesia, but opioid use is associated withincreased PONV: Grade B (68–71).EvidenceIn many trials, reduction of PONV rather thanimprovement in analgesia has been the primary outcome.The duration of surgery varies from 25 to80 min in the reported studies, and many do not discriminatebetween unilateral or bilateral surgery orprocedures involving single or multiple muscles. Thismay contribute to the variability across studies in theincidence of side effects and analgesic requirements.Peribulbar or subtenon’s LA blocks reduce intraoperativeoculocardiac reflex responses (60,62,63) and PONV(60,62,63) when compared with intraoperative opioid.Peribulbar or subtenon blocks reduce perioperative analgesicrequirements when compared with opioid in some(60,63) but not all (61,62) trials. No complications of LAinjections were reported in these studies, but patientnumbers are small. Sub-tenon’s block provided no benefitcompared with less invasive topical tetracaine application(64). Topical LA applied prior to and at thecompletion of surgery reduced early distress (first30 min) but did not influence pain at later time points orreduce supplemental analgesic requirements (72).No difference in postoperative pain scores or analgesicrequirement has been detected between topical LAdrops and topical NSAIDS (65,67). Pain scores (CHE-OPS) were not reduced by topical NSAIDS when comparedwith placebo (66,67), but the authors questionedthe sensitivity of this measure for ocular pain.Direct comparisons of intraoperative NSAID andopioid (PR diclofenac vs IV morphine) (71) (IV ketorolacvs IV pethidine) (70) (IV ketorolac vs IV fentanyl)(68) have reported no difference in postoperative painscores or supplemental analgesic requirements butincreases in PONV in patients given opioids. Comparisonof intraoperative remifentanil and fentanyl reportedhigher early pain scores but less PONV with remifentanil(73). Comparisons of NSAID and placebo haveshown minor improvements in pain score and reductionsin supplemental analgesic requirements (69,74).Analgesia Table 5.3.1AgentTechniqueDirectevidenceLA Subtenon block a 1)LA Peribulbar a 1)LA Topical a 1+Opioid Parenteral b 1)NSAID Topical 1)Systemic b 1)Paracetamol 1)Indirectevidencea Few comparisons, but no advantage of subtenon over topicalin one trial.b Similar analgesia with systemic NSAID and opioid butincreased PONV with opioid; oral or rectal paracetamol givenas part of multimodal analgesia to all patients in several trialsbut efficacy not directly compared with other agents.5.3.2 Vitreoretinal surgeryVitreoretinal and retinal detachment surgery are associatedwith significant postoperative pain and PONV.Supplemental local anesthetic techniques may have arole, but the relative benefit vs risk has not been fullyevaluated. See also section 5.1 for the general managementof postoperative pain.RecommendationsIn vitreoretinal surgery, NSAID can provide similaranalgesia but lower rates of PONV compared with opioid:Grade C (75).ª 2012 Blackwell Publishing Ltd, Pediatric Anesthesia, 22 (Suppl. 1), 1–79 37
Page 1 and 2: PediatricAnesthesiaVolume 22 Supple
Page 3 and 4: doi: 10.1111/j.1460-9592.2012.3838.
Page 5 and 6: 1.6 Contact informationCorresponden
Page 7 and 8: RecommendationsChildren’s self-re
Page 9 and 10: Topical anesthetic preparations, fo
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
Page 22 and 23: increased success rate (i.e., less
Page 24 and 25: Newer preparations such as liposoma
Page 26 and 27: Good practice pointLubricant contai
Page 28 and 29: most effective. There are a number
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 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
Page 73 and 74: undergoes hepatic biotransformation
Page 75 and 76: tein binding are reduced and the ha
Page 77 and 78: a low-dose infusion but the child m
Page 79 and 80: Table 6.6.1 Paracetamol dosing guid
Page 81: steps that health care professional

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