Good Practice in Postoperative and Procedural Pain Management ...

Good practice pointWound infiltration with LA following appendicectomyis a simple procedure that may be of benefit in theearly postoperative period as part of a multimodalanalgesic technique.RecommendationPCA combined with NSAID is effective for postappendicectomypain: grade B (245).Analgesia Table 5.6.2 AppendicectomyAgentTechniqueDirectevidenceLA* Wound infiltration 1)Paravertebral 1+TAP Block 1+Opioid Intravenous 1+NSAID a 1+Paracetamol a 1+a As part of a multimodal technique.IndirectevidenceEvidenceIntravenous opioids as a continuous infusion, PCA orNCA, together with a multimodal analgesic strategyincluding LA wound infiltration, NSAID and paracetamolis currently suggested practice following appendicectomy(245–250).Morphine PCA has been previously shown to beeffective, supplementation with NSAID improvesanalgesia, particularly for pain on movement (245).The addition of ketamine to morphine did notimprove analgesia in one study and neurobehavioralside effects were increased (248). Antiemetic additivesto the opioid such as droperidol or ondansetronoffered no advantage but may increase side effects(247,251).Wound infiltration with LA has previously beenfound to be of benefit (252), but results from morerecent studies are inconclusive. Neither pre nor postincisionbupivacaine 0.25–0.5% reduced postoperative morphinerequirement in the first 24 h when compared withplacebo or no infiltration (250,253). Bupivacaine 0.25%0.5 mlÆkg )1 may not confer additional benefit in childrenreceiving effective multi-modal analgesia with opioid,NSAID, and paracetamol (254). However,preincision bupivacaine followed by infiltration of themuscle layer on closure reduced pain scores for up to48 h in another study that included children and adults(255).Paravertebral block reduced time to first dose andtotal postoperative opioid requirements compared toplacebo (240).TAP block reduced pain scores and morphinerequirements in first 24 h compared to placebo (243).5.6.3 Fundoplication (open)This procedure usually involves an incision of the upperabdomen utilising either a midline, transverse supraumbilical,or left sub-costal approach. Increasingly laparoscopictechniques have been used for fundoplication,see section 5.7. The patient population is diverse, includingsignificant numbers of children with neurodevelopmentaldelay and communication difficulties, whichmay influence the choice of analgesic regime. See alsosections 5.1 and 5.6.1 for information on the generalmanagement of postoperative pain, and a further discussionof analgesia following abdominal surgery.Good practice pointMultimodal analgesia using parenteral opioids or epiduralanalgesia together with systemic NSAIDs andparacetamol should be used unless specifically contraindicated.RecommendationEpidural LA + opioid is effective and may be associatedwith improved clinical outcome in selected patientsfollowing fundoplication: grade D (256–258).EvidenceSome of the studies quoted have included other majorprocedures as well as fundoplication. There are noprospective studies comparing analgesic techniques followingopen fundoplication.Epidural analgesia has been favored followingfundoplication as this group of patients is at high riskof respiratory complications and includes significantnumbers with neurodevelopmental delay (258–260).Epidural LA: Ropivacaine without opioid providedsatisfactory analgesia for neonates and infants aftermajor thoracic and abdominal surgery including fourpatients following fundoplication (231).46 ª 2012 Blackwell Publishing Ltd, Pediatric Anesthesia, 22 (Suppl. 1), 1–79