Good Practice in Postoperative and Procedural Pain Management ...

Peribulbar block improves early analgesia andmay reduce PONV compared with opioid: Grade C(60,76–78).EvidenceKetoprofen and pethidine provided similar levels ofanalgesia, but PONV was less with ketoprofen (75).Peribulbar LA block appears to be effective (60,76).Concerns have been expressed that peribulbar blockmay present a higher risk in children than subtenon’sblock as the eye occupies a relatively greater volume ofthe bony orbit in a child, and large volumes of LA havebeen used in trials of peribulbar block (79). Comparedwith fentanyl, subtenon’s LA block reduces the incidenceof intra-operative oculo-cardiac reflexes andimproves early analgesia (77,80), but only one trialshowed a reduction in analgesic requirements andPONV (77). There has been no evaluation of the risk vsbenefit of these procedures in children.Topical LA gel at the beginning of surgery reducedintra-operative, but not postoperative, analgesicrequirements (81).Analgesia Table 5.3.2AgentTechniqueDirectevidenceLA Peribulbar block a 2+Subtenon block 1)Opioid 1)NSAID 1)Paracetamol 1)a No analysis of risk–benefit for peribulbar block.5.4 Dental proceduresIndirectevidenceDental procedures in children may range from minorrestoration and conservation requiring little or nopostoperative analgesia, to variable numbers of extractions,and sometimes more extensive surgery leading tosignificant postoperative pain. See also section 5.1 forthe general management of postoperative pain.RecommendationsNSAIDS with or without paracetamol reduce pain followingdental extractions: Grade B (82–84).Swabs soaked with bupivacaine on exposed tooth socketsfollowing extraction produce no or minor improvementsin pain in the immediate postoperative period: Grade B(85,86).Intraoperative LA infiltration reduces postoperative painfollowing dental extractions, but provides little additionalbenefit over NSAIDS and paracetamol alone:Grade B (83,84,87,88).EvidenceThe degree of postoperative pain following dentalextractions increases with the number of teeth removed(89,90).NSAIDS (82,91,92) and combinations of NSAIDand paracetamol (83,84,88) reduce pain following dentalextractions. However, adding paracetamol to ibuprofendid not improve early analgesia (15 minpostoperatively) compared with ibuprofen alone in onestudy (82).Opioids: no differences in analgesia were shown incomparisons with NSAIDS for extractions (93,94), butopioids may produce increased PONV (94). Similarly,for dental restorations without extractions, paracetamolprovided adequate analgesia, pain scores wereslightly lower with pethidine, but sedation wasincreased (95).LA infiltration (2% lignocaine with adrenaline)added to NSAID ± paracetamol (83,84,88,92) provideslittle additional benefit following dental extractions,but less postoperative bleeding in the recoveryroom (reduced need for suctioning rather than quantifiedlosses) was noted in one trial (88). Addition ofmorphine (25 lgÆkg )1 ) to the local anesthetic injectiondid not improve analgesia (96). The soft tissue numbnessassociated with LA infiltration may produce distressand increase biting of lips and cheeks in youngchildren (92). Distressing numbness was avoided by intraligamentalinjection of LA, but adding this toNSAID and paracetamol provided no additional benefit(83) or minor improvements in early analgesia(5 min) only (84). No improvements in analgesia ordistress were found when bupivacaine-soaked swabs inthe dental socket were added to paracetamol15 mgÆkg )1 (86) or diclofenac (85).Analgesia Table 5.4AgentTechniqueLA Local infiltration a 1+Soaked swabs a 1)Opioid 1)NSAID 1+Paracetamol 1)DirectEvidencea Improvements in early analgesia and no additional benefit overNSAID ± paracetamol.38 ª 2012 Blackwell Publishing Ltd, Pediatric Anesthesia, 22 (Suppl. 1), 1–79