well as the epidural technique for the first 24 h, but epiduralwas superior at 36 <strong>and</strong> 48 h (138 patients) (318).Case series have demonstrated effective analgesia withthe follow<strong>in</strong>g regimes: bupivaca<strong>in</strong>e 0.0625–0.1% withfentanyl, hydromorphone or morph<strong>in</strong>e, 0.1% ropivaca<strong>in</strong>ewith hydromorphone, bupivaca<strong>in</strong>e 0.0625–0.125%with morph<strong>in</strong>e, bupivaca<strong>in</strong>e 0.0625% with fentanyl <strong>and</strong>clonid<strong>in</strong>e (332,336–339). Several authors commentedthat placement of the epidural catheter by direct visualisationdur<strong>in</strong>g surgery was important.Both 0.0625% bupivaca<strong>in</strong>e with fentanyl <strong>and</strong> withclonid<strong>in</strong>e <strong>and</strong> ropivaca<strong>in</strong>e with hydromorphone havealso been reported as successful us<strong>in</strong>g a dual cathetertechnique (327,328). Epidural analgesia may be associatedwith a more rapid return <strong>in</strong> GI function(318,330). The use of an epidural technique did notcompromise neurological assessment (336). There wasone report of a wound <strong>in</strong>fection occurr<strong>in</strong>g <strong>in</strong> a patientreceiv<strong>in</strong>g epidural analgesia (330) but no reports ofepidural hematoma or abscess.NSAIDS: There have been two retrospective reviewslook<strong>in</strong>g at the use of NSAIDS follow<strong>in</strong>g sp<strong>in</strong>al surgery.There was no difference <strong>in</strong> the <strong>in</strong>cidence of nonunion <strong>in</strong>patients who had received ketorolac (221 patients) comparedto controls (306 patients) (333,340).Adjuvant analgesics: The use of gabapent<strong>in</strong>(15 mgÆkg )1 preoperatively followed by 5 mgÆkg )1 tdsfor 5 days) reduced opioid consumption on postoperativedays 1 <strong>and</strong> 2 <strong>and</strong> reduced pa<strong>in</strong> scores on day 1compared with placebo, no difference was seen beyondday 2 <strong>and</strong> no difference was seen <strong>in</strong> side effects (341).No difference was seen <strong>in</strong> pa<strong>in</strong> scores or morph<strong>in</strong>econsumption when low-dose ketam<strong>in</strong>e was adm<strong>in</strong>istered<strong>in</strong>tra-operatively (0.5 mgÆkg )1 load<strong>in</strong>g dose followedby an <strong>in</strong>fusion of 4 lgÆkg )1 Æm<strong>in</strong> )1 ) comparedwith placebo (342). A retrospective review of the additionof dexmedetomid<strong>in</strong>e (0.4 lgÆkg )1 Æh )1 ) to PCAmorph<strong>in</strong>e was unable to demonstrate a significantdifference <strong>in</strong> pa<strong>in</strong> scores or morph<strong>in</strong>e consumptioncompared with PCA morph<strong>in</strong>e alone (343).Analgesia Table 5.8.3 Sp<strong>in</strong>al surgeryAgentTechniqueDirectevidenceLA Thoracic Epidural 1+LA Lumbo-thoracic 2 Catheter 1+Opioid Intrathecal 1+Opioid IV <strong>in</strong>fusion 1+Clonid<strong>in</strong>e Epidural 3NSAID a 1+Paracetamol a 1+Gabapent<strong>in</strong> 1+Indirectevidence5.8.4 Cleft lip <strong>and</strong> palate <strong>and</strong> related proceduresThis section <strong>in</strong>cludes a range of procedures such asrepair of Cleft Lip <strong>and</strong> Palate, Otoplasty, <strong>and</strong> Alveolarbone graft<strong>in</strong>g. See section 5.1 for the general managementof postoperative pa<strong>in</strong>.RecommendationInfraorbital nerve block provides effective analgesiafor cleft lip repair <strong>in</strong> the early postoperative period:Grade A (344–348).EvidenceThe evidence base support<strong>in</strong>g the efficacy of analgesicstrategies is weak for this group of procedures <strong>and</strong>postoperative analgesic requirements are not clear.Many patients appear to be successfully managed with<strong>in</strong>traoperative local anesthesia followed by NSAIDs,paracetamol, <strong>and</strong> low doses of opioid postoperatively.Cleft Lip Repair: <strong>in</strong>fra-orbital nerve block for cleft lipsurgery is feasible, <strong>and</strong> studies have demonstrated lowerpa<strong>in</strong> scores <strong>in</strong> patients who received <strong>in</strong>fra-orbital nerveblock compared with IV fentanyl (347,348) peri-<strong>in</strong>cisional<strong>in</strong>filtration of local anesthetic (344,345) <strong>and</strong> rectalParacetamol (346). Blocks were performed with 0.25%bupivaca<strong>in</strong>e <strong>in</strong> all these studies. The addition of opioidspethid<strong>in</strong>e or fentanyl significantly prolonged the durationof the block <strong>in</strong> two studies (349,350). Clonid<strong>in</strong>eadded to bupivaca<strong>in</strong>e resulted <strong>in</strong> a moderate improvement<strong>in</strong> postoperative analgesia <strong>in</strong> another (351).Cleft Palate Surgery: Local <strong>in</strong>filtration (352), palat<strong>in</strong>enerve block (353), <strong>and</strong> bilateral suprazygomaticmaxillary nerve block (354) have been associated withlow pa<strong>in</strong> scores follow<strong>in</strong>g cleft palate repair. The effectof NSAIDs on peri-operative bleed<strong>in</strong>g was reviewed <strong>in</strong>one small case series (20 patients), <strong>and</strong> there was noeffect associated with diclofenac 1 mgÆkg )1 b.d. (355).Alveolar Bone Graft: Morph<strong>in</strong>e PCA requirementsare low (
Analgesia Table 5.8.4 Plastic surgery procedures of head <strong>and</strong> neckAgentTechniqueDirectevidenceLA Local <strong>in</strong>filtration 1+LA Infraorbital nerve block a 1+Opioid b 1+NSAID b 1+Paracetamol b 1+a Repair of cleft lip alone.b As part of a multi-modal technique.5.9 Cardiothoracic surgery5.9.1 Cardiac surgery (sternotomy)IndirectevidenceClassically, cardiac surgery with cardiopulmonary bypass(CPB) will <strong>in</strong>volve division of the bony sternumto obta<strong>in</strong> access to the heart <strong>and</strong> great vessels. Anticoagulationwith hepar<strong>in</strong> is ma<strong>in</strong>ta<strong>in</strong>ed throughout CPB,which has implications for the use of regional techniques.<strong>Postoperative</strong> patients are nursed <strong>in</strong> ICU areas,often with a short period of mechanical ventilationprior to extubation of the trachea. <strong>Postoperative</strong> analgesiawith <strong>in</strong>travenous opioids, most frequently morph<strong>in</strong>eor fentanyl, has been st<strong>and</strong>ard practice for morethan 20 years <strong>in</strong> many <strong>in</strong>stitutions. See section 5.1 forthe general management of postoperative pa<strong>in</strong>.RecommendationEpidural <strong>and</strong> <strong>in</strong>trathecal techniques with opioid <strong>and</strong>/orLA are effective for sternotomy pa<strong>in</strong>, but only marg<strong>in</strong>albenefits have been demonstrated, <strong>and</strong> there are <strong>in</strong>sufficientdata concern<strong>in</strong>g the <strong>in</strong>cidence of serious complications:Grade B (360–368).EvidenceIntravenous opioids are the st<strong>and</strong>ard to which otheranalgesic techniques are to be compared. A comparisonof morph<strong>in</strong>e <strong>and</strong> tramadol NCA found no difference <strong>in</strong>efficacy between the two, although tramadol caused lesssedation <strong>in</strong> the early postoperative period (369).There has been an <strong>in</strong>creas<strong>in</strong>g <strong>in</strong>terest <strong>in</strong> regionalanalgesic techniques because of their potential toreduce stress responses <strong>and</strong> facilitate earlier trachealextubation with possible improvements <strong>in</strong> cl<strong>in</strong>ical outcome<strong>and</strong> economic cost reduction. The relativelysmall size of studies precludes accurate prediction ofvery rare but serious side effects such as epiduralhematoma <strong>and</strong> consequent neurological damage.Intrathecal opioid: morph<strong>in</strong>e or fentanyl produceequivalent analgesia (<strong>and</strong> side effects) to <strong>in</strong>travenousmorph<strong>in</strong>e with lower overall analgesic consumption(364,365).Intrathecal opioid + LA: improved pa<strong>in</strong> scorescompared with bolus IV fentanyl alone with loweroverall fentanyl consumption but no difference <strong>in</strong> opioidrelated side effects (366).Epidural: case series have demonstrated the feasibility<strong>and</strong> efficacy of epidural catheter techniques fromcaudal, lumbar or thoracic approaches with few <strong>and</strong>modest improvements <strong>in</strong> outcomes (360–362,368).There is a s<strong>in</strong>gle case report of epidural hematomarequir<strong>in</strong>g surgical decompression <strong>in</strong> an 18-year-oldwith TEB who rema<strong>in</strong>ed anticoagulated follow<strong>in</strong>g aorticvalve surgery (370).NSAIDS: ketorolac commenced 6 h postoperativelydid not <strong>in</strong>crease postoperative bleed<strong>in</strong>g, nor affect IVmorph<strong>in</strong>e requirements or reduce time to extubation <strong>in</strong>one study (371).Analgesia Table 5.9.1 Cardiac Surgery (sternotomy)AgentTechniqueDirectevidenceLA Caudal epidural catheter 3LA Thoracic epidural (TEB) 1)LA Intrathecal (SAB) 1)Opioid IV <strong>in</strong>fusion 1+Opioid Caudal 2)Opioid Thoracic epidural (TEB) 2)Opioid Intrathecal 1+NSAID a 1+Paracetamol a 1+a As part of a multi-modal technique.5.9.2 ThoracotomyIndirectevidenceAccess to the lungs, pleura, <strong>and</strong> <strong>in</strong>trathoracic structuresis obta<strong>in</strong>ed by an <strong>in</strong>tercostal <strong>in</strong>cision <strong>and</strong> separation <strong>and</strong>retraction of the ribs. Typical procedures <strong>in</strong>clude ligationof patent ductus arteriosus (PDA) resection of aorticcoarctation, lung biopsy, or partial resection, pneumonectomy,repair of tracheoesphageal fistula. Considerablepa<strong>in</strong> can be expected follow<strong>in</strong>g classical thoracotomy<strong>in</strong>cision. Recently, VATS (video assisted thoracoscopicsurgery), a m<strong>in</strong>imally <strong>in</strong>vasive technique, has been usedfor some relatively m<strong>in</strong>or thoracic procedures, for examplelung biopsy or smaller lung resections.ª 2012 Blackwell Publish<strong>in</strong>g Ltd, Pediatric Anesthesia, 22 (Suppl. 1), 1–79 53
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PediatricAnesthesiaVolume 22 Supple
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- Page 26 and 27: Good practice pointLubricant contai
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