Good Practice in Postoperative and Procedural Pain Management ...

Analgesia Table 5.6.4 Urological SurgeryAgentTechniqueDirectevidenceLA Epidural 1)LA + opioid Epidural 1)LA Caudal epidural 1)LA Paravertebral block 2)LA a Wound infiltration 3Opioid a Intravenous 3 1+NSAID a 3 1+Paracetamol a 3 1+a As part of a multimodal technique.5.7 Laparoscopic surgeryIndirectevidenceThere has been a dramatic increase in the amount ofpediatric laparoscopic surgery in the last decade. Thisis performed mainly through the body cavities (chestand abdomen) or potential spaces. Inguinal herniarepair, appendicectomy, fundoplication, urological andadrenal surgery are examples. For general managementof postoperative pain, see section 5.1.Good practice pointsInfiltration of port sites with LA as part of a multimodalanalgesic strategy may reduce postoperativepain following laparoscopy.Although overall postoperative analgesic requirementsappear to be reduced following laparoscopy, pain maybe equivalent to the equivalent open procedure insome circumstances, particularly during the first 24 h.EvidenceAdvantages of laparoscopic surgery may include fasterrecovery and overall reduction in pain and use of opioidanalgesia in comparison with the open surgicalcounterpart (246,267–272). Although the overall durationof postoperative pain appears to be reduced, analgesicrequirements may be at least as great on the firstpostoperative day as the equivalent open procedure(261,267,273–275). The use of robotic laparoscopictechniques may also decrease postoperative opioidrequirements after ureteric reimplantation surgery(276). The anatomical approach to laparoscopic surgeryhas not been shown to effect analgesic requirements(277,278).Multimodal analgesia including LA infiltration, opioid,NSAID, and paracetamol is suitable, and the useof carefully designed protocols may improve efficacy(279). Demand-led opioid regimens such as PCA orNCA are feasible and effective for some proceduresand require further evaluation (246,262).LA infiltration of port sites when combined withNSAID provided equivalent analgesia to caudal blockfor minor diagnostic and therapeutic laparoscopic proceduresand to TAP block following appendicectomy(280,281). Use of aerosolised bupivacaine after portinsertion, as part of a multimodal analgesic regimen,demonstrated some opioid sparing effect (282).Perioperative regional LA techniques have also beenshown to be effective and again require further evaluation(271,279). Little good evidence exists with regardto the optimum analgesic regimen.Analgesia Table 5.7 Laparoscopic surgeryAgentTechniqueLA* Infiltration 1)LA* Aerosolised 3LA Caudal 1)Opioid Parenteral/oral 3NSAID a 1)Paracetamol a 3a As part of a multimodal technique.DirectevidenceIndirectevidence5.8 Orthopedics, spinal and plastic surgery5.8.1 Lower limb surgeryThe surgery covered in this section ranges from relativelyminor single site orthopedic surgery to moremajor procedures such as multiple level osteotomies.The population of patients requiring femoral andpelvic osteotomies includes those suffering from cerebralpalsy; pain in this population can also precipitatepainful muscle spasm requiring specific managementwith benzodiazepines.Multimodal analgesia is suitable: there is particularlyextensive experience of the use of local anesthetic techniquesfor this type of surgery. Concerns have beenexpressed that NSAIDs may inhibit new bone growthfollowing orthopedic surgery; this is addressed below.Good practice pointThere is no evidence from studies in children thatNSAIDs have a deleterious effect on bone fusion. Theanalgesic benefit of short-term NSAID use has beendemonstrated and may frequently outweigh any hypotheticalrisk.48 ª 2012 Blackwell Publishing Ltd, Pediatric Anesthesia, 22 (Suppl. 1), 1–79