Good Practice in Postoperative and Procedural Pain Management ...

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Analgesia Table 5.5.1 Sub-umbilical SurgeryAgentTechniqueDirectevidenceLA Wound infiltration a 1+LA Ilio-inguinal nerve block a 1+LA TAP Block 1)LA Caudal epidural 1+LA + Ketamine b Caudal epidural 1+LA + Clonidine b Caudal epidural 1+Opioid c 1+NSAID c 1+Paracetamol c 1+Indirectevidencea Possibly lower efficacy than caudal block: more studies arerequired.b Note on caudal additives: not all additives have undergone rigoroussafety testing, and concerns regarding potential toxiceffects have been expressed. See Section 6.c As part of a multi-modal technique5.5.2 CircumcisionCircumcision is regarded as a relatively minor surgicalprocedure, but it may be associated with significantpostoperative pain and distress. It is usually undertakenon an out-patient or day-case basis. Circumcisionin the neonate is considered separately in section5.5.3. See sections 5.1 for the general management ofpostoperative pain and 5.5.1 for a discussion of subumbilicalsurgery.Good practice pointAnalgesia with opioid alone should be avoided if possiblebecause of lower efficacy and higher incidence ofside effects in comparison with LA techniques.RecommendationCaudal epidural and dorsal nerve block are effective inthe early postoperative period, with low rates of complicationsand side effects: Grade A (133).EvidenceLocal anesthetic techniques involving a regional blockor topical application can provide good analgesic efficacyin the early postoperative period (133–135).Analgesia following caudal or dorsal nerve block wasequivalent and was superior to subcutaneous ‘ring’block (133,136–139). Caudal and dorsal nerve blockdemonstrated a low failure and serious complicationrate in all studies. This is in agreement with largercase series of both techniques (104,140). In somestudies, a caudal block reportedly increased the timeto micturition and incidence of motor blockcompared with dorsal nerve block and subcutaneousring block, but this finding was not seen in otherinvestigations (133,136–139). The ideal agent, dose, orconcentration for a caudal block has not been elucidated.The use of ultrasound for dorsal nerve block hasbeen shown to improve the efficacy and decrease theincidence of failed blocks (141) The use of subcutaneousring block was associated with a higher failure and complicationrate than caudal or dorsal nerve block(136,137). Pundendal nerve block has also been shownto provide effective perioperative analgesia for circumcision(142,143). One study compared topical local anesthesiawith dorsal nerve block for 6 h postoperativelyand showed no difference in analgesia (144).Caudal neuraxial analgesic additives 1 : Ketamine+ LA showed increased analgesic efficacy butalso increased motor block when compared with a LAdorsal nerve block (145). The addition of ketamine orclondine conferred no additional benefit comparedwith LA alone in other studies (146,147).Parenteral opioids are associated with lower analgesicefficacy and increased postoperative nausea andvomiting compared with LA techniques (135).NSAID (Diclofenac) as a sole agent was inferior todorsal nerve block, but the combination may decreasesupplementary analgesic use compared with eithertechnique in isolation (134).Analgesia Table 5.5.2 CircumcisionAgentTechniqueLA Topical a 1+LA Subcutaneous ‘ring’ block a 1)LA Pudendal nerve block 1)LA Dorsal n. block 1+LA Caudal epidural 1+Opioid b 1+NSAIDS b 1+Paracetamol b 1+a lower efficacy than caudal epidural or dorsal nerve block.b As part of a multi-modal technique.5.5.3 Neonatal CircumcisionDirectevidenceNeonatal circumcision is considered separately fromcircumcision in older children because of differences inclinical practice and evidence base. Premature neonatescan experience pain and therefore require good1 Note on caudal additives: not all additives have undergone rigoroussafety testing, and concerns regarding potential toxic effects have beenexpressed. See Section 6.3.40 ª 2012 Blackwell Publishing Ltd, Pediatric Anesthesia, 22 (Suppl. 1), 1–79
perioperative analgesia for surgical interventions.Many circumcisions are done in the awake neonate inthe first few hours or days of life; this is reflected inthe literature as studies have generally evaluated painduring the procedure. However, for neonatal circumcision,no single technique has been shown to reliablyalleviate pain in the awake patient, which thereforepresents a clinical challenge. Circumcision in infantsand older children is invariably performed under generalanesthesia (see section 5.5.1), the debate regardingthe necessity for general anesthesia in the neonateremains unresolved. See sections 5.1 for the generalmanagement of postoperative pain and 5.5.1 for afurther discussion of sub-umbilical surgery.Good practice pointGeneral anesthesia should be considered for neonatalcircumcision. A multi-modal analgesic approachshould include a local anesthetic technique at the timeof the procedure in combination with sucrose and paracetamol.RecommendationsLA should be used as it is superior to other techniquesfor circumcision pain: Grade A (148).Dorsal nerve block is more effective than subcutaneousring block or topical LA: Grade A (148).When using topical local anesthetic, it must be appliedcorrectly and sufficient time allowed for it to becomeeffective: Grade A (148).EvidencePostoperative pain after circumcision in the neonatehas not been well investigated, and available studieshave all examined pain during the procedure in awakeneonates. It has been suggested that the procedure beperformed in awake infants only during the first weekof life as pain scores during the procedure have beenshown to increase to unacceptable levels with increasingneonatal age (149). For all techniques studied,there was a significant failure rate (148,150). The useof LA was superior to either placebo or simple analgesicsand sucrose (148). Dorsal nerve block appears tobe superior to subcutaneous ring block or topical localanesthesia (caudal epidural analgesia has not beenstudied, see (107)) and was associated with lower cortisollevels in one study, but was operator dependentand not totally reliable (148,150). Efficacy of topicallocal anesthetic agents was very dependent on the techniqueof application and time allowed (148,151,152).No increased incidence of complications was seen inone technique compared with another (148). The durationof surgery (and therefore duration of intra-operativepain) was dependent on the surgical techniquewith the ‘Mogen Clamp’ associated with faster procedures(148,150).Analgesia Table 5.5.3 Neonatal CircumcisionAgentTechniqueDirectevidenceLA Topical 1++LA Subcutaneous ‘ring’ block 1++LA Dorsal nerve block 1++LA Caudal epidural 1+Paracetamol a 1+Sucrose b 1+a For postprocedure pain.b As part of multimodal technique.5.5.4 Hypospadias repairIndirectevidenceHypospadias surgery may be either relatively superficialand minor, or more major reconstructive surgeryinvolving the entire penile urethra may be undertaken,which will influence postoperative analgesia requirements.Some procedures are suitable for day-case surgerywhilst others require hospital admission overnightor longer, with the possibility of prolonged urethralcatheterisation and painful postoperative dressingchanges. See sections 5.1 and 5.5.1 for the generalmanagement of postoperative pain and for a furtherdiscussion of sub-umbilical surgery.RecommendationLA central neuraxial or dorsal nerve block is effectivereducing the need for postoperative supplementary opioidadministration following hypospadias surgery: Grade A(153–158).EvidenceCaudal LA was most commonly investigated for hypospadiasrepair. Good efficacy for the technique wasdemonstrated with a low failure and serious complicationrate; this is in agreement with large case series ofthis technique (104–106). Bupivacaine 0.25%,0.5 mlÆkg )1 was most frequently studied, but therewere few comparisons with other local anesthetics orbetween different concentrations or volumes. Onestudy found that caudal ropivacaine 0.1%, 1.8 mlÆkg )1 ,ª 2012 Blackwell Publishing Ltd, Pediatric Anesthesia, 22 (Suppl. 1), 1–79 41
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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 38 and 39: when compared with LA alone and sal
Page 40 and 41: Peribulbar block improves early ana
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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