Good Practice in Postoperative and Procedural Pain Management ...

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well as the epidural technique for the first 24 h, but epiduralwas superior at 36 and 48 h (138 patients) (318).Case series have demonstrated effective analgesia withthe following regimes: bupivacaine 0.0625–0.1% withfentanyl, hydromorphone or morphine, 0.1% ropivacainewith hydromorphone, bupivacaine 0.0625–0.125%with morphine, bupivacaine 0.0625% with fentanyl andclonidine (332,336–339). Several authors commentedthat placement of the epidural catheter by direct visualisationduring surgery was important.Both 0.0625% bupivacaine with fentanyl and withclonidine and ropivacaine with hydromorphone havealso been reported as successful using a dual cathetertechnique (327,328). Epidural analgesia may be associatedwith a more rapid return in GI function(318,330). The use of an epidural technique did notcompromise neurological assessment (336). There wasone report of a wound infection occurring in a patientreceiving epidural analgesia (330) but no reports ofepidural hematoma or abscess.NSAIDS: There have been two retrospective reviewslooking at the use of NSAIDS following spinal surgery.There was no difference in the incidence of nonunion inpatients who had received ketorolac (221 patients) comparedto controls (306 patients) (333,340).Adjuvant analgesics: The use of gabapentin(15 mgÆkg )1 preoperatively followed by 5 mgÆkg )1 tdsfor 5 days) reduced opioid consumption on postoperativedays 1 and 2 and reduced pain scores on day 1compared with placebo, no difference was seen beyondday 2 and no difference was seen in side effects (341).No difference was seen in pain scores or morphineconsumption when low-dose ketamine was administeredintra-operatively (0.5 mgÆkg )1 loading dose followedby an infusion of 4 lgÆkg )1 Æmin )1 ) comparedwith placebo (342). A retrospective review of the additionof dexmedetomidine (0.4 lgÆkg )1 Æh )1 ) to PCAmorphine was unable to demonstrate a significantdifference in pain scores or morphine consumptioncompared with PCA morphine alone (343).Analgesia Table 5.8.3 Spinal surgeryAgentTechniqueDirectevidenceLA Thoracic Epidural 1+LA Lumbo-thoracic 2 Catheter 1+Opioid Intrathecal 1+Opioid IV infusion 1+Clonidine Epidural 3NSAID a 1+Paracetamol a 1+Gabapentin 1+Indirectevidence5.8.4 Cleft lip and palate and related proceduresThis section includes a range of procedures such asrepair of Cleft Lip and Palate, Otoplasty, and Alveolarbone grafting. See section 5.1 for the general managementof postoperative pain.RecommendationInfraorbital nerve block provides effective analgesiafor cleft lip repair in the early postoperative period:Grade A (344–348).EvidenceThe evidence base supporting the efficacy of analgesicstrategies is weak for this group of procedures andpostoperative analgesic requirements are not clear.Many patients appear to be successfully managed withintraoperative local anesthesia followed by NSAIDs,paracetamol, and low doses of opioid postoperatively.Cleft Lip Repair: infra-orbital nerve block for cleft lipsurgery is feasible, and studies have demonstrated lowerpain scores in patients who received infra-orbital nerveblock compared with IV fentanyl (347,348) peri-incisionalinfiltration of local anesthetic (344,345) and rectalParacetamol (346). Blocks were performed with 0.25%bupivacaine in all these studies. The addition of opioidspethidine or fentanyl significantly prolonged the durationof the block in two studies (349,350). Clonidineadded to bupivacaine resulted in a moderate improvementin postoperative analgesia in another (351).Cleft Palate Surgery: Local infiltration (352), palatinenerve block (353), and bilateral suprazygomaticmaxillary nerve block (354) have been associated withlow pain scores following cleft palate repair. The effectof NSAIDs on peri-operative bleeding was reviewed inone small case series (20 patients), and there was noeffect associated with diclofenac 1 mgÆkg )1 b.d. (355).Alveolar Bone Graft: Morphine PCA requirementsare low (
Analgesia Table 5.8.4 Plastic surgery procedures of head and neckAgentTechniqueDirectevidenceLA Local infiltration 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 involve division of the bony sternumto obtain access to the heart and great vessels. Anticoagulationwith heparin is maintained throughout CPB,which has implications for the use of regional techniques.Postoperative patients are nursed in ICU areas,often with a short period of mechanical ventilationprior to extubation of the trachea. Postoperative analgesiawith intravenous opioids, most frequently morphineor fentanyl, has been standard practice for morethan 20 years in many institutions. See section 5.1 forthe general management of postoperative pain.RecommendationEpidural and intrathecal techniques with opioid and/orLA are effective for sternotomy pain, but only marginalbenefits have been demonstrated, and there are insufficientdata concerning the incidence of serious complications:Grade B (360–368).EvidenceIntravenous opioids are the standard to which otheranalgesic techniques are to be compared. A comparisonof morphine and tramadol NCA found no difference inefficacy between the two, although tramadol caused lesssedation in the early postoperative period (369).There has been an increasing interest in regionalanalgesic techniques because of their potential toreduce stress responses and facilitate earlier trachealextubation with possible improvements in clinical outcomeand economic cost reduction. The relativelysmall size of studies precludes accurate prediction ofvery rare but serious side effects such as epiduralhematoma and consequent neurological damage.Intrathecal opioid: morphine or fentanyl produceequivalent analgesia (and side effects) to intravenousmorphine with lower overall analgesic consumption(364,365).Intrathecal opioid + LA: improved pain scorescompared with bolus IV fentanyl alone with loweroverall fentanyl consumption but no difference in opioidrelated side effects (366).Epidural: case series have demonstrated the feasibilityand efficacy of epidural catheter techniques fromcaudal, lumbar or thoracic approaches with few andmodest improvements in outcomes (360–362,368).There is a single case report of epidural hematomarequiring surgical decompression in an 18-year-oldwith TEB who remained anticoagulated following aorticvalve surgery (370).NSAIDS: ketorolac commenced 6 h postoperativelydid not increase postoperative bleeding, nor affect IVmorphine requirements or reduce time to extubation inone 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 infusion 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, and intrathoracic structuresis obtained by an intercostal incision and separation andretraction of the ribs. Typical procedures include ligationof patent ductus arteriosus (PDA) resection of aorticcoarctation, lung biopsy, or partial resection, pneumonectomy,repair of tracheoesphageal fistula. Considerablepain can be expected following classical thoracotomyincision. Recently, VATS (video assisted thoracoscopicsurgery), a minimally invasive technique, has been usedfor some relatively minor thoracic procedures, for examplelung biopsy or smaller lung resections.ª 2012 Blackwell Publishing Ltd, Pediatric Anesthesia, 22 (Suppl. 1), 1–79 53
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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 48 and 49: Good practice pointWound infiltrati
Page 50 and 51: Analgesia Table 5.6.4 Urological Su
Page 52 and 53: (298). Ketorolac did not influence
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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