Good Practice in Postoperative and Procedural Pain Management ...

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with using landmark techniques (205,206). Ultrasoundguidedtechniques may increase the success rate andallow placement of the LA closer to the nerves withlower volumes being required for efficacy therebydecreasing the potential for systemic toxicity (206–208). No advantage was seen postoperatively with theaddition of genitofemoral nerve block or by using a‘double shot technique’ (182,203). In one study, thesuccess rate of the block using surface landmarks wasquoted as only 72% (203).Wound infiltration is effective when compared tocaudal block with plain LA or placebo, although inone study postoperative opioid use was comparativelyhigh (179,180,209). The timing of wound infiltration,either pre or postsurgery, did not influence efficacy(180,209,210). The use of Tramadol without LA forinfiltration was effective in one study (211).When using a perioperative opioid-based regimen(without LA block), multi-modal analgesia addingboth paracetamol and a NSAID is more effective thaneither opioid alone or opioid plus either paracetamolor NSAID (212,213).Analgesia Table 5.5.6 Inguinal Hernia Repair (Open)AgentTechniqueDirectevidenceLA Wound infiltration 1+LA Ilioinguinal Block 1+LA Paravertebral Block 1)LA Caudal Epidural 1+Opioid Wound infiltration 1)Opioid a 1) 1+NSAID a 1) 1+Paracetamol a 1) 1+a As part of a multi-modal technique.5.5.7 Umbilical hernia repairIndirectevidenceUmbilical hernia repair is usually regarded as a relativelyminor surgical procedure, but it may be associatedwith significant postoperative pain. It is oftenundertaken on an out-patient or day-case basis. Seesections 5.1 for the general management of postoperativepain.Good practice pointA multi-modal analgesic regimen combining localanesthesia and simple analgesics perioperatively isrecommended, opioid supplementation may berequired. Paracetamol and/or NSAID should be continuedpostoperatively for at least 48 h.EvidenceLocal anesthesia techniques including wound infiltration,rectus sheath block, and paraumbilical block areeffective with few complications. Ultrasound-guidedrectus sheath block showed increased intraoperativeanalgesic efficacy when compared with wound infiltration(214). Either bupivacaine or levobupivacaine0.25% were used in the studies, but there has been nocomparison between these agents or concentrations orvolumes (215–218). Ultrasound demonstrates the interindividualvariability in umbilical anatomy, its use mayincrease the rate of correct needle placement, improvedefficacy and reduce the volume of LA required(216,218).Analgesia Table 5.5.7 Umbilical Hernia RepairAgentTechniqueDirectevidenceLA Wound infiltration 2)LA Paraumbilical block 3LA Rectus sheath block 2)Opioid a 1+NSAID a 1+Paracetamol a 1+a As part of a multi-modal technique.Indirectevidence5.6 General surgery and urology (major)5.6.1 Intra-abdominal surgeryThis group includes a heterogeneous mixture ofabdominal procedures on the gastro-intestinal (GI)and genitourinary (GU) tracts including nephrectomy,pyeloplasty, ureteric reimplantation, and cystoplastyfor all of which a significant level of postoperative painis expected. Intravenous opioid techniques or epiduralanalgesia are acceptable for postoperative pain management;in clinical practice, supplementary analgesiawith NSAID and paracetamol is usually also administered.Appendicectomy and fundoplication are consideredseparately in sections 5.6.2, 5.6.3 and laparoscopictechniques in section 5.7. See also section 5.1 for generalmanagement of postoperative pain.Good practice pointMultimodal analgesia using parenteral opioids, centralneuraxial analgesia together with systemic NSAIDs44 ª 2012 Blackwell Publishing Ltd, Pediatric Anesthesia, 22 (Suppl. 1), 1–79
and paracetamol should be used unless specificallycontraindicated.RecommendationsIntravenous opioids either as continuous infusion, NCAor PCA are effective following major abdominal surgery:Grade A (219–223).Epidural analgesia with LA should be considered formajor abdominal surgery. The addition of neuraxial clonidineor opioid may further improve analgesia, but sideeffects may also be increased: Grade B (168,224–229).EvidenceThere is a considerable descriptive literature (predatingthe time limits of this guideline 1996–2011) describingthe use of opioid infusions, PCA, NCA, and LA epiduralinfusion with or without opioid for major surgerysuch that these techniques have become part of everydaypractice. For suitable regimens, see section 6. ParavertebralLA block has also been described and is a feasiblealternative. There are very few well-designed clinical trialscomparing these analgesic techniques. A variety ofsurgical procedures are included in most studies, theexact surgical incision employed is frequently not stated.Intravenous opioids as a continuous infusion, PCAor NCA are effective following abdominal surgery: theanalgesic response is a function of dose and developmentalage (219–223). See Section 6.1 for informationon doses and regimens.Continuous epidural analgesia with LA is acceptable.Bupivacaine, ropivacaine, and levobupivacainehave been shown to be effective in a variety of infusionconcentrations and dose rates (168,224,226,230,231).Epidural LA + opioid also provides good analgesia.Morphine, fentanyl, hydromorphone, and diamorphinehave been the most frequently described; the side effectprofile depends on the dose and particular opioid thatis used (168,226,228,232).Single-shot caudal epidural LA + clonidine has beencompared to LA alone, LA + opioid, LA + dexmedetomidineand clonidine alone. Clonidine causes dosedependantsedation and hypotension. Clonidine or clonidine+ LA were equally effective as part of a multimodalstrategy in combination with ketoprofen (233).Clonidine (1)2 lgÆkg )1 ) + LA has fewer side effectscompared to opioid + LA, efficacy may also be lower(228,234). Caudal epidural clonidine 2 lgÆkg )1 or dexmedetomidine2 lgÆkg )1 with LA prolonged the durationof LA without increasing side effects (235).Epidural opioid (without LA):Single doses of epidural opioid can improve postoperativeanalgesia and reduce requirements for ongoinganalgesia (236,237). Intermittent epidural morphinewas superior to intramuscular morphine in one study(238), but is less effective than LA containing (bupivacaine+ fentanyl) infusion (224).Peripheral nerve blocks (PNB): There is anincreasing interest in the use of single-shot and continuousperipheral nerve blocks. Paravertebral blockis feasible for abdominal surgery and has beenshown to decrease opioid requirements followingappendicectomy, see Section 5.6.2 (239,240). Transversusabdominis plane (TAP) block is feasible forabdominal surgery in neonates and children andappears to provide satisfactory analgesia in some circumstances(241–243). A systematic review in adultsand children that included TAP and rectus sheathblock did not draw conclusions regarding the efficacyof these techniques because of the small number ofstudies available (244). See also Sections 5.5.1, 5.6.2and 5.7.Analgesia Table 5.6.1 Abdominal surgeryAgentTechniqueDirectevidenceLA Epidural 1+LA Paravertebral block 1+TAP block 2)LA + opioid Epidural 1+LA + clonidine Epidural 1+Opioid Epidural 1+Clonidine Epidural 1)Opioid Intravenous 1+NSAID a 1)Paracetamol a 1+a As part of a multimodal technique.5.6.2 Appendicectomy (open)IndirectevidenceAppendicectomy is the most common indication forlaparotomy in children. Under normal circumstances,this procedure is performed through an incision in theright lower quadrant. In the majority of cases, appendicectomywill be performed as an emergency orunplanned procedure. See also sections 5.6 and 5.6.1for information on the general management of postoperativepain, and a further discussion of analgesia followingabdominal surgery.ª 2012 Blackwell Publishing Ltd, Pediatric Anesthesia, 22 (Suppl. 1), 1–79 45
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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 42 and 43: Analgesia Table 5.5.1 Sub-umbilical
Page 44 and 45: was more effective with less motor
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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