Good Practice in Postoperative and Procedural Pain Management ...

Good practice pointA multi-modal analgesic approach, including a localanesthetic technique and/or opioid with NSAID andparacetamol, is suitable for postthoracotomy pain.RecommendationEpidural analgesia is effective for postthoracotomy pain:Grade D (225,226,231,257,372).EvidenceThoracotomy is frequently included in studies ofanalgesia for major surgery in combination withother procedures such as abdominal and spinal surgery,making interpretation of findings difficult.Either epidural analgesia or intravenous opioids aspart of a multimodal strategy including NSAID andparacetamol have been used extensively for postthoracotomypain. Paravertebral block has also beendescribed.There are few studies comparing regional and systemictechniques directly, or with other more novelregimens. Although it might be anticipated that painfollowing VATS would differ from classical thoracotomy,there are no studies exploring this issue.Epidural analgesia is frequently recommended forpostthoracotomy pain; however, there is no conclusiveevidence that any particular regimen is more effective.Epidural LA: plain bupivacaine and ropivacainesolutions have been found to be effective for majorabdominal and thoracic surgery in neonates andinfants (225,231). Analgesia was reported as equivalentin a case series (272 patients, 29 thoracic) comparingchildren who received either plain ropivacaine or bupivacaine+ diamorphine as part of a multimodal analgesicstrategy (226).LA + opioid: bupivacaine with fentanyl, morphine,diamorphine, or other opioids is effective for postthoracotomypain, by continuous infusion or PCEA(226,257,372,373).Epidural opioid without LA: single-dose thoracicepidural morphine was equivalent to intravenous morphineinfusion in the first 24 h after thoracotomy(374). Single-dose caudal morphine with or withoutLA was less effective than thoracic epidural Morphine+ LA infusion; infusion patients also had betternonpain outcomes, for example earlier oral intake, lessPONV, and shorter ICU stay (373).Intrathecal opioid as part of a multimodal techniquehas been described in a small case series (375).Paravertebral block has been described as effectivein a number of small case series of neonates, infants,and children (376–382). There have been no comparisonswith other techniques.Intercostal nerve block: increased the time to furtheranalgesia when compared with a single dose of pethidineat skin closure (383).Opioids: intravenous infusion of opioid is frequentlyused for severe postoperative pain including postthoracotomy(384,385). PCA/NCA has been described instudies that have included a small number of postthoracotomypatients (220,221,223). Data on the efficacyof opioids for thoracotomy are inadequate to allowconclusive evaluation, and the role of multimodal analgesiahas also not been sufficiently evaluated. In acomparison of PCA and continuous infusion of morphinewithout supplementary NSAID and paracetamol,there was no difference between the groups, but20–40% of patients in each group had pain scores inthe ‘severe’ range on the first postoperative day (220).Analgesia Table 5.9.2 ThoracotomyAgentTechniqueDirectevidenceLA Thoracic epidural a 3LA Paravertebral block 3LA Intercostal block b 3LA + opioid Thoracic epidural a 3Opioid Thoracic epidural c 1)Opioid Intrathecal b 3Opioid Intravenous 2)NSAID b 1+Paracetamol b 1+a Caudal, lumbar and thoracic catheter insertion sites.b As part of a multi-modal technique.c 1st 24 h.5.10 NeurosurgeryIndirectevidenceNeurosurgical procedures in children include drainageof hydrocephalus and insertion or replacement of anextra cranial shunt, craniotomy, craniofacial surgery,and surgery for intracranial aneurism or other vascularmalformation. There has been little investigation ofanalgesic requirements or analgesia for this group ofpatients, but it is frequently asserted that severe postoperativepain is not a prominent feature, even followingmajor neurosurgical interventions, this has beendisputed (386). Postoperatively, many neurosurgicalpatients are admitted to ICU or high dependency areasfor monitoring; opioid analgesia must be used judiciouslyas excessive sedation may mask signs of acutechanges in intracranial pressure or interfere with thepatient’s ability to co-operate with neurological assessments.As the risk of postoperative bleeding is rela-54 ª 2012 Blackwell Publishing Ltd, Pediatric Anesthesia, 22 (Suppl. 1), 1–79