Good Practice in Postoperative and Procedural Pain Management ...

(298). Ketorolac did not influence bony union in a caseseries of lower limb osteotomies (307).Adjuvant analgesicsThe use of intravenous magnesium (50 mgÆkg )1 bolusfollowed by an infusion of 15 mgÆkg )1 Æh )1 ) reducedpostoperative pain scores and analgesic consumptionin children with cerebral palsy undergoing femoral osteotomy.Analgesia Table 5.8.1 Lower Limb surgeryAgentTechniqueDirectevidenceLA Peripheral nerve block 1+Caudal Epidural 1) 1)Lumbar Epidural 1+Opioid IV infusion 1+NSAID a 1+Paracetamol a 1+Clonidine Peripheral nerve block 3a As part of a multi-modal technique.IndirectevidenceAxillary brachial plexus block was the most studiedapproach; postoperatively patients were generally managedwith oral analgesia. There was no difference inpostoperative efficacy (time to 1st analgesia, analgesicconsumption, pain score) between 0.2% ropivacaineand 0.25% bupivacaine when used for axillary brachialplexus block (312). There was no benefit to using afractionated dose of LA compared to a single injectionfor axillary brachial plexus block, nor in placing theblock prior to or after surgery (309,316).Other studies have examined the feasibility of thedifferent approaches to brachial plexus block. The infraclavicular(311,313,315), the supraclavicularapproach (310), and the interscalene approach (291)are effective, and there were no incidences of pneumothoraxin these studies (412 patients).A comparison between peripheral nerve block at thewrist and intravenous alfentanil demonstrated superioranalgesia and a reduction in adverse events in theblock group (317).Analgesia Table 5.8.2 Upper Limb surgery5.8.2 Upper limb surgeryAgentTechniqueDirectevidenceIndirectevidenceSurgery on the upper limb is most commonly performedfor plastic and orthopedic procedures of hand and forearm,often following trauma. Local anesthesia of thebrachial plexus prior to surgery is frequently used.There is some controversy regarding the most safe andreliable approach to the brachial plexus. See section 5.1for the general management of postoperative pain.RecommendationsBrachial plexus blocks provide satisfactory analgesia forhand and forearm surgery extending into the postoperativeperiod: Grade B (308–313).The axillary, infraclavicular, supraclavicular, and interscaleneapproach are feasible and effective: Grade B(291,294,308,310–315).EvidenceAnalgesia following upper limb surgery has not beenwell studied, and few investigations of postoperativepain management have been undertaken. Brachialplexus block appears to be effective, but differencesbetween techniques have not been investigated. Theaxillary approach to the brachial plexus is theoreticallyless likely to lead to accidental pneumothorax. Thereare no comparisons between brachial plexus block andother alternatives such as intravenous opioid.LA Brachial plexus block 1+Opioid Intravenous 1+Oral 1+NSAID a 1+Paracetamol a 1+Clonidine Brachial plexus block 3a As part of a multi-modal technique.5.8.3 Spinal surgerySurgery to correct spinal deformity requires extensiveexposure of the spine which may be achieved posteriorly,anteriorly via thoracotomy or thoraco-abdominalapproach, or by a combined anterior–posteriorapproach. Postoperative pain can be severe and prolonged,necessitating the use of potent intravenous orneuraxial analgesic techniques for 3–5 days postoperatively.The use of intravenous opioid analgesia hasnot been well studied; however, the success of neuraxialtechniques in controlling postoperative pain inchildren has led to an interest in their use for spinalsurgery.The patient population requiring spinal surgeryincludes healthy adolescents and patients with severeunderlying medical conditions such as Duchenne’smuscular dystrophy and cerebral palsy. The choice ofanalgesic technique will be influenced by both patient50 ª 2012 Blackwell Publishing Ltd, Pediatric Anesthesia, 22 (Suppl. 1), 1–79