Good Practice in Postoperative and Procedural Pain Management ...

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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
tively high and potentially disastrous following someprocedures, NSAIDs are sometimes withheld duringthe first 24 h. See also section 5.1 on the general managementof postoperative pain, and section 5.10.1 forthe management of craniotomy and major neurosurgery.Good practice pointAnalgesia following neurosurgery requires goodcommunication and close co-operation betweenmembers of the peri-operative team. Frequent painassessments should be a routine part of postoperativecare. A multi-modal analgesic approach is suitable,which may include the use of LA infiltration,paracetamol, NSAID (when not contraindicated),and parenteral or oral opioid as determined byassessed analgesic requirements.EvidenceThe literature informing the management of postoperativepain after neurosurgery is limited. There have beenfew studies comparing standard analgesic regimens.Opioids: the use of parenteral opioids following craniotomyand major neurosurgery has been described(387–390). PCA with fentanyl plus a continuousinfusion of midazolam has been described (391). NCAwas reportedly used successfully in a small numberof patients
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PediatricAnesthesiaVolume 22 Supple
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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 54 and 55: well as the epidural technique for
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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