Good Practice in Postoperative and Procedural Pain Management ...

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