Good Practice in Postoperative and Procedural Pain Management ...

to cord traction, but not with improved postoperativeanalgesia (174).Neuraxial analgesic additives: the addition of ketamine0.25–1 mgÆkg )1 as an adjunct to bupivacaineincreased analgesic efficacy but was associated with‘short-lived psychomotor effects’ at higher doses (176).The addition of IV dexamethasone with ropivavcainecaudal block was associated with increased analgesicefficacy (177).Transverse abdominal plane (TAP) block using plainLA, as part of a multi-modal analgesic technique, hasdemonstrated perioperative analgesic efficacy with nocomplications in a small case series (178).Analgesia Table 5.5.5 OrchidopexyAgentTechniqueDirectevidenceLA Wound infiltration a 1+LA Ilioinguinal block a 1+LA Caudal epidural 1+LA TAP block 3Opioid b 1+NSAID b 1+Paracetamol b 1+a Less effective than caudal block.b As part of a multi-modal technique.5.5.6 Inguinal hernia repair (open)IndirectevidenceSurgical repair of inguinal hernia is generally performedon a day-case basis. The following refers to theconventional ‘open’ technique, rather than laparoscopicrepair that is becoming more popular. See sections5.1 and 5.5.1 for the general management ofpostoperative pain and for a further discussion of subumbilicalsurgery.Good practice pointThe use of an ultrasound-guided technique for theplacement of an ilio-inguinal nerve block may decreasethe failure rate and improve analgesic efficacy.RecommendationsLA wound infiltration, ilio-inguinal nerve block, paravertebralblock, or caudal analgesia are effective in theearly postoperative period: Grade A (179–184).EvidenceCaudal block was the most commonly studied techniquewith good efficacy and a low failure complication rate inall studies. This is in agreement with large case series ofthis technique (104–106). Bupivacaine 0.25% was themost studied and compared LA, ropivacaine 0.25% wasfound to be equivalent in one study (185). Anotherstudy comparing different concentrations of bupivacainewith and without adjunctive opioid showed lowerefficacy for 0.125% bupivacaine (186). In a study ofbupivacaine 0.175% (+adrenaline 1 : 10 000), therewas no difference in efficacy or side effects at volumes ofbetween 0.7 and 1.3 mlÆkg )1 (187).Neuraxial analgesic additives: With LA; midazolam,ketamine, clonidine, fentanyl, neostigmine, adrenaline,morphine and tramadol have all been studied asadjuncts to local anesthesia for caudal block. They allshow good efficacy, but evidence of overall benefit isequivocal as in most studies few patients required furtheranalgesia following caudal block with plain LA(166,175,181,188–195). In studies where no comparisonwas made with plain LA: increasing the dose of ketaminealso increased efficacy, but neuro-behavioral sideeffects were seen at higher doses (196). Increasing clonidinedose from 1 to 2 lgÆkg )1 had limited or noeffects on efficacy, time to 1st analgesia was prolongedin one study, but not in another (188,197).Without LA: S (+) ketamine without local anestheticwas equivalent to bupivacaine + adrenalinemixture, and S (+) ketamine + clonidine mixtureshowed increased efficacy over ketamine alone(198,199). Another study comparing caudal withintramuscular S-ketamine showed increased efficacy inthe caudal group (200). Tramadol without local anestheticshowed reduced efficacy compared with plainbupivacaine or a bupivacaine + tramadol mixture(191).Placement of caudal block prior to surgery was alsoshown to have better efficacy in the postoperative periodthan placement at the end of surgery in one study(201).Comparison of paravertebral block with caudal LAor intraoperative opioid (fentanyl) showed increasedpostoperative analgesic efficacy, patient satisfaction,and earlier hospital discharge with the paravertebralblock (184,202).Ilioinguinal nerve block shows good efficacy andsafety, although a preferred agent, dose, or volume hasnot been demonstrated, although Levobupivacaineconcentrations below 0.25% show decreased efficacy(182,203–205). High failure rates have been associatedª 2012 Blackwell Publishing Ltd, Pediatric Anesthesia, 22 (Suppl. 1), 1–79 43