Good Practice in Postoperative and Procedural Pain Management ...

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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
Epidural LA + opioid: buivacaine + fentanylappears to be effective; higher pain scores were notedin patients who had had fundoplication in one of thestudies but overall the regimen was considered to be‘satisfactory’ (257,260).Epidural clonidine or LA + clonidine: both werefound to be effective for a mixed surgical group aspart of a multimodal strategy including ketoprofen,although after fundoplication (n = 9) there was anincreased need for supplementary opioid on the firstpostoperative night (233).Intravenous opioid by continuous infusion PCA orNCA appears to be effective, but may be inferior fornonpain outcomes: see ‘epidural analgesia vs parenteralopioid’ below (256,261,262).Epidural analgesia vs parenteral opioid.Two retrospective observational studies have foundthat duration of hospital stay is prolonged in patientsselected for opioid analgesia even when spinal deformitypatients (scoliosis) were excluded in one study(256,258).Analgesia Table 5.6.3 Fundoplication (open)AgentTechniqueLA Epidural 3LA + opioid Epidural 3LA + clonidine a Epidural 3Clonidine a Epidural 3Opioid a Intravenous 1+NSAID a 1+Paracetamol a 1+a As part of a multimodal technique.5.6.4 Major urologyDirectevidenceIndirectevidenceThis category has been included because studies haveused a combination of different urological proceduresas the operative model, for example pyeloplasty,nephrectomy, heminephrectomy, hypospadias, bladderaugmentation/reconstruction, ureteric reimplantation.Postoperative pain is unlikely to be equivalent followingeach of these different procedures, but they are notuniformly distributed between studies, and the numbersof individual procedures in each study are oftenlow, thereby making it impractical to look at each procedurein isolation. See section 5.1 for the generalmanagement of postoperative pain.Good practice pointMultimodal analgesia using parenteral opioids orregional analgesia together with systemic NSAIDsand paracetamol should be used unless specificallycontraindicated.EvidenceLA techniques are commonly used perioperatively formajor urological surgery. Comparison with parenteralopioid techniques is limited, and little good evidenceexists with regard to the optimum analgesic regimen.Epidural LA± opioid: For a variety of urologicalprocedures, perioperative ropivacaine infusions, withor without opioid, have shown good analgesic efficacywith low pain scores and complication rates (263,264).Comparisons of fentanyl or sufentanil added to ropivacaine,and fentanyl or butorphanol added to bupivacaineshowed no difference in efficacy or pain scoresbetween these regimens (229,263).Epidural LA vs Parenteral Opioid: Comparison ofpostoperative epidural ropivacaine infusions with regularbolus tramadol or oxycodone plus paracetamol andNSAID showed no difference in pain scores up to 48 hbut increased rescue analgesia between 48 and 72 h(264).Caudal neuraxial analgesic additives: In childrenundergoing ureteric reimplantation, caudal analgesiawith LA + clonidine or opioid was effective. Therewas no difference in efficacy or pain scores from addingclonidine, morphine, or hydromorphone to caudalropivacaine 0.2% + epinephrine, patients receivingclonidine experienced fewer side effects (234).Paravertebral Block: Use of a ‘single-shot’ intraoperativeparavertebral block with levobupivacaine andregular paracetamol postoperatively was associatedwith low pain scores and low opioid use in the earlypostoperative period in patients undergoing majorrenal surgery (239).Wound Infiltration: A multimodal analgesic techniqueusing LA infiltration alongside opioids, NSAID,and paracetamol was associated with low pain scoresin children undergoing pyeloplasty and ureteric reimplantation(265,266).ª 2012 Blackwell Publishing Ltd, Pediatric Anesthesia, 22 (Suppl. 1), 1–79 47
Page 1 and 2: PediatricAnesthesiaVolume 22 Supple
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 46 and 47: with using landmark techniques (205
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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