Good Practice in Postoperative and Procedural Pain Management ...

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Section 2.0Executive Summary and Quick Reference GuideContents2.1 Introduction2.2 Pain assessment2.3 Medical procedures2.4 Procedural pain in the neonate: general recommendations2.5 Procedural pain in the neonate: specific recommendations2.6 Procedural pain in older children2.7 Postoperative pain2.1 IntroductionThis evidence-based guideline for the management ofpostoperative and procedural pain in children was developedby a multidisciplinary guideline development groupof the Association of Paediatric Anaesthetists of GreatBritain and Ireland with representation from consumers,the Royal College of Paediatrics and Child Health(RCPCH), the British Pain Society (BPS), the RoyalCollege of Nursing (RCN) and the Faculty of Pain Medicineof the Royal College of Anaesthetists (FPMRCA).The guideline was complied using methodology developedby the Scottish Intercollegiate Guideline Network(SIGN). Descriptions of levels of evidence, grading ofrecommendations and their associated symbols can befound in Section 1.0 and in the technical report, Appendix1, of the supplementary materials. The guideline wasdeveloped for the use of health professionals. It isintended to inform decision making in the managementof acute postoperative and procedural pain. This is thesecond edition of the guideline, it supersedes previousversions. The guideline will be updated every 5 years.The guideline comprises evidence-based ‘Recommendations’and ‘Good practice points’. Recommendations aregraded A–D according to the strength of evidence underpinningthem, the grading does not reflect the importanceof the recommendation. Good practice pointsindicate best practice according to the clinical experienceand opinion of the guideline development committee.Not all recommendations are included in this quickreference guide, common abbreviations and completedetails are available in the relevant sections of theguideline.2.2 Pain assessmentPain assessment and measurement of pain intensity arevital components of good pain management practice.Self-report of pain by children who are able to do so,observation of behaviors or physiological parameters thatare known to reflect pain intensity using a standardizedpain ‘measure’, ‘instrument’, or ‘tool’ are options. Toselect an appropriate method, the principles and limitationsof standardized pain measures must be understood.A simple guide to valid measures for postoperativeand procedural pain is given in Table 1. But pleasenote that reliance on chronological age as the soleindicator of a child’s capacity to self-report will inevitablygenerate both false positives (invalid scores fromTable 1 Recommended measures for procedural and postoperativepain assessment as a function of the child’s chronological ageChild’s age*MeasureNewborn–3 years oldCOMFORT or FLACC4 years old FPS-R + COMFORT or FLACC5–7 years old FPS-R7 years old + VAS or NRS or FPS-R*With normal or assumed normal cognitive developmentchildren who do not understand the scale) and falsenegatives (not obtaining valid scores from childrenwho do understand the scale but were not asked).Good practice pointsTo assess pain, effective communication should occurbetween the child whenever feasible, their family or carers,and the professionals in the multi-disciplinary team.Standardized instruments should be used in their finalvalidated form. Even minor modifications that alterthe psychometric properties of the tool may bias clinicalassessments and render comparison between studiesinvalid.4 ª 2012 Blackwell Publishing Ltd, Pediatric Anesthesia, 22 (Suppl. 1), 1–79
RecommendationsChildren’s self-report of their pain is the preferredapproach: Grade BNo individual measure can be broadly recommended forpain assessment across all children or all contexts:Grade BAn observational measure should be used in conjunctionwith self-report with 3–5-year-olds as there is limited evidencefor the reliability and validity of self-report measuresof pain intensity in this age group: Grade B2.3 Medical proceduresRoutine medical care involving blood sampling andother painful diagnostic and therapeutic procedurescan cause great distress for children and their families.When such procedures are essential, it is importantthat they should be achieved with as little pain as possible.There are 10 general considerations to rememberprior to planning the management of a painful procedure:see Box 1.Box 1: Planning a painful procedure1. Infants and children of all ages, including prematureneonates, are capable of feeling pain andrequire analgesia for painful procedures.2. Developmental differences in the response topain and analgesic efficacy should be consideredwhen planning analgesia.3. Consider whether the planned procedure is necessary,and how the information it will providemight influence care? Avoid multiple procedures ifpossible.4. Plan the timing of procedures to minimize thefrequency of a painful procedure.5. Is sedation or even general anesthesia likely tobe required for a safe and satisfactory outcome?6. Would modification of the procedure reducepain? For example, venepuncture is less painful thanheel lance for blood sampling in infants.7. Is the planned environment suitable? Ideally,this should be a quiet, calm place with suitable toysand distractions.8. Ensure that appropriate personnel who possessthe necessary skills are available, enlist experiencedhelp when necessary.9. Allow sufficient time for analgesic drugs andother analgesic measures to be effective.10. Formulate a clear plan of action should theprocedure fail or pain become unmanageable usingthe techniques selected.Good practice pointsPain management for procedures should include bothpharmacological and nonpharmacological strategieswhenever possible.Children and their parents/carers benefit from psychologicalpreparation prior to painful procedures.2.4 Procedural pain in the neonate:general recommendationsBreast-feeding should be encouraged during the procedure,if feasible: Grade ANonpharmacological measures including nonnutritivesucking, ‘kangaroo care’, swaddling/facilitated tucking,tactile stimulation, and heel massage can be used forbrief procedures: Grade A2.5 Procedural pain in the neonate:specific recommendations2.5.1 Blood Sampling including percutaneous centralvenous catheter insertionSucrose or other sweet solutions can be used: Grade AVenepuncture (by a trained practitioner) is preferred to heellance for larger samples as it is less painful: Grade ATopical local anesthetics can be used for venepuncturepain: Grade BNonpharmacological measures including tactile stimulation,breast-feeding, nonnutritive sucking, ‘kangaroocare’, and massage of the heel can be used for heelprickblood sampling: Grade ATopical local anesthetics alone are insufficient for heellance pain: Grade AUsing the whole plantar surface of the heel reduces thepain of heelprick blood sampling: Grade BTopical tetracaine plus morphine is superior to topicalanalgesia alone for CVC insertion pain in ventilatedinfants: Grade B2.5.2 Ocular examination for retinopathy ofprematurity (ROP)Sucrose may contribute to pain response reduction inexamination for retinopathy: Grade AInfants undergoing examination for retinopathy shouldreceive local anesthetic drops in combination with othermeasures if an eyelid speculum is used: Grade BSwaddling, developmental care, nonnutritive sucking,pacifier should be considered for neonates undergoingexamination for retinopathy: Grade Bª 2012 Blackwell Publishing Ltd, Pediatric Anesthesia, 22 (Suppl. 1), 1–79 5
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Page 5: 1.6 Contact informationCorresponden
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Page 11 and 12: 2.7.6 Laparoscopic surgeryGood prac
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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
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Page 30 and 31: 12 Bellieni C, Bagnoli F, Perrone S
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Page 38 and 39: when compared with LA alone and sal
Page 40 and 41: Peribulbar block improves early ana
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Good practice pointA multi-modal an
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14 Grainger J, Saravanappa N. Local
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day-stay unit. Int J Paediatr Dent
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tinuous epidural infusion in childr
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245 Morton NS, O’Brien K. Analges
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321 Taenzer AH, Clark C, Taenzer AH
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Section 6.0AnalgesiaContents6.1 Ana
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enhance systemic absorption. Lidoca
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undergoes hepatic biotransformation
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tein binding are reduced and the ha
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a low-dose infusion but the child m
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Table 6.6.1 Paracetamol dosing guid
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steps that health care professional
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