Good Practice in Postoperative and Procedural Pain Management ...

RecommendationsPeripheral nerve blocks provide superior analgesia andare associated with fewer adverse effects compared withintravenous opioids: Grade B (283,284).Epidural opioids are effective, reduce the dose requirementsof local anesthetic, and rescue IV opioids butincrease the incidence of side effects: Grade B(259,285,286).Continuous peripheral nerve blocks are feasible, effective,and safe and are associated with lower pain scores:Grade B (287–295).Epidural techniques are associated with lower painscores than intravenous opioid analgesia: Grade C(237,257,296,297).Systemic paracetamol and NSAID reduce intravenousopioid requirements: Grade C (298,299).EvidenceStudies have shown epidural analgesia using opioids,local anesthesia or a mixture of the two are effectivebut differences in efficacy and side effects between regimensare observed. Epidural opioids improve analgesiabut side effects are more frequent. The side effectprofile may be related to the individual properties ofspecific opioids: morphine, fentanyl, and hydromorphonewere of comparable analgesic efficacy in onestudy; respiratory depression, somnolence, and retentionof urine were higher in the morphine group;PONV and urinary retention had the lowest incidencewith hydromorphone (285). Single-dose epidural morphinewas equianalgesic with increasing dose (11.2, 15,and 20 lgÆkg )1 ), but the incidence of PONV increasedwith dose (300). In a study comparing bupivacaine+ fentanyl with bupivacaine (both with adrenaline),the fentanyl group had superior analgesia anddid not require rescue opioid but had a higher incidenceof PONV, whereas the bupivacaine grouprequired more bupivacaine and 10/26 (38%) requiredrescue opiates and antiemetic therapy, itching onlyoccurred in the fentanyl group (286).Epidural vs peripheral nerve blockA comparison of continuous epidural block with continuouspopliteal nerve block for major foot surgery showedno difference in pain or rescue analgesia, but adverseeffects and patient satisfaction were improved withperipheral nerve block (290). In congenital club foot surgery,a comparison of single-shot caudal anesthesia withsingle-shot peripheral nerve blocks (combined sciatic femoral,combined sciatic saphenous, and saphenous combinedwith local infiltration) showed no difference in theduration of analgesia and no difference in morphine consumptionwithin the first 24 h, there was no difference inthe incidence of nausea and vomiting between any of thegroups (301). Single-shot Psoas Compartment Blockshowed moderate reduction in postoperative opioidrequirements compared to caudal epidural followingopen hip reduction or osteotomy (302).Epidural compared with Intravenous techniquesIn a comparison between patient-controlled epiduralanalgesia (PCEA) with lidocaine, and nurse-controlledIV fentanyl, pain scores (unvalidated method), andPONV were lower in the epidural group (297). A singledose of epidural morphine 30 lgÆkg )1 reduced postoperativePCA morphine use, and VAS scores were also lowerin the epidural morphine group, and there was no differencein the incidence of severe pruritus or PONV (237).Peripheral nerve block vs intravenous techniquesComparisons between peripheral nerve blocks andintravenous morphine in pelvic osteotomy (283) andpatella realignment surgery (284) demonstrate reducedpain scores, reduced morphine consumption and areduction in the incidence of sedation with the use ofperipheral nerve blocks.A number of successful series of peripheral nerveblocks have been described, including popliteal nerveblock (288,290,292–294,303), fascia iliaca compartmentblock (288,303,304), sciatic nerve block(289,291,295,305),psoas compartment block (287,293), and femoral nerveblock (284,304).Continuous LA infusion vs PCRA/PCEAPCRA (Ropivacaine 0.2%) showed similar efficacy toa continuous regional technique, with a lower totaldose of LA for popliteal and fascia iliaca blocks (303).In a comparison of PCEA vs CEA, again efficacy wassimilar and a lower dose of LA used (306).Systemic analgesia with NSAID and paracetamolcan be combined with intravenous opioid or regionalanalgesia. In one study, a combination of paracetamoland ketoprofen significantly decreased pain scores andIV morphine requirements compared to either drugalone (299). In a case series of patients undergoingclub foot surgery and long bone osteotomy, ketorolacreduced IV morphine usage and associated GI effectsª 2012 Blackwell Publishing Ltd, Pediatric Anesthesia, 22 (Suppl. 1), 1–79 49