Good Practice in Postoperative and Procedural Pain Management ...

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2.5.3 Lumbar punctureTopical local anesthesia is effective in reducing LP pain:Grade A2.5.4 Urine samplingTransurethral catheterization with local anesthetic gel ispreferred as it is less painful than suprapubic catheterizationwith topical local anesthesia: Grade BSucrose reduces the pain response to urethral catheterization:Grade C2.5.5 Chest drain (tube) insertion and removalSee older children below2.5.6 Nasogastric tube placement (See also; olderchildren, below)Sucrose can reduce the pain response from NGT insertion:Grade B2.5.7 Immunization and intramuscular injectionSwaddling, breast-feeding or pacifier, and sucroseshould be considered in neonates undergoing vaccination:Grade A2.6 Procedural pain in older childrenThis section includes all infants and children outsidethe neonatal period. Painful procedures are often identifiedas the most feared and distressing component ofmedical care for children and their families. Whenmanaging procedural pain in infants, older childrenand adolescents special emphasis should given not onlyto proven analgesic strategies but also to reduction inanticipatory and procedural anxiety by suitable preparatorymeasures. Families, play therapists, nursing staffand other team members play key roles in reducinganxiety by suitable preparation.Specific Recommendations2.6.1 Blood sampling and intravenous cannulationTopical local anesthesia should be used for intravenouscannulation: Grade APsychological strategies, for example, distraction or hypnosis,to reduce pain and anxiety should be used: Grade A2.6.2 Lumbar punctureBehavioral techniques of pain management should beused to reduce LP pain: Grade ATopical LA and LA infiltration are effective for LP painand do not decrease success rates: Grade B50% nitrous oxide in oxygen should be offered to childrenwilling and able to cooperate: Grade C2.6.3 Chest drain (tube) insertion and removalThere is little published evidence looking at analgesicoptions for chest drain insertion or removal.Good practice pointsFor chest drain insertion, consider general anesthesia orsedation combined with subcutaneous infiltration of bufferedlidocaine. Selection of appropriate drain type mayreduce pain by facilitating easy insertion.For chest drain removal, consider a combination of twoor more strategies known to be effective for painful proceduressuch as psychological interventions, sucroseor pacifier (in neonates), opioids, nitrous oxide, andNSAIDs2.6.4 Bladder catheterization and related urine samplingproceduresPsychological preparation and psychological and behavioralinterventions should be used during bladder catheterizationand invasive investigations of the renal tract:Grade BInfants: consider procedure modification as urethralcatheterization is less painful than SPA for urinesampling: Grade B2.6.5 Insertion of nasogastric tubesGood practice pointTopical local anesthetics such as lidocaine containinglubricant gel applied prior to placement are likely toreduce the pain and discomfort of NGT insertion.2.6.6 Immunization and intramuscular injectionPsychological strategies such as distraction should beused for infants and children undergoing vaccination:Grade AConsider additional procedure modifications such as vaccineformulation, order of vaccines (least painful first)needle size, depth of injection (25–mm, 25-gauge needle)or the use of vapocoolant spay: Grade ASwaddling, breast-feeding or pacifier, and sucrose shouldbe considered in infants undergoing vaccination: Grade A2.6.7 Repair of lacerationsFor repair of simple low-tension lacerations, tissue adhesivesshould be considered as they are less painful, quickto use, and have a similar cosmetic outcome to suturesor adhesive skin closures (steri-strips): Grade A6 ª 2012 Blackwell Publishing Ltd, Pediatric Anesthesia, 22 (Suppl. 1), 1–79
Topical anesthetic preparations, for example, LAT (lidocaine–adrenaline–tetracaine)if available, can be used inpreference to injected LA, as they are less painful toapply; it is not necessary to use a preparation containingcocaine: Grade ABuffering injected lidocaine with sodium bicarbonateshould be considered: Grade A‘HAT’ should be considered for scalp lacerations. It isless painful than suturing, does not require shaving, andproduces a similar outcome: Grade BIf injected lidocaine is used, pretreatment of the woundwith a topical anesthetic preparation, for example, lidocaine–adrenaline–tetracaine(LAT) gel reduces the painof subsequent injection: Grade B50% nitrous oxide reduces pain and anxiety during lacerationrepair: Grade B2.6.8 Change of dressings in children with burnsPotent opioid analgesia given by oral, transmucosal,or nasal routes according to patient preference andavailability of suitable preparations should be consideredfor dressing changes in burned children: Grade ANonpharmacological therapies such as distraction andrelaxation should be considered as part of pain managementfor dressing changes in burned children:Grade B2.6.9 Botulinum injections for children with musclespasmGood practice point50% Nitrous oxide/oxygen should be considered in childrenwho are able to cooperate with self-administration.2.7 Postoperative painPostoperative care is frequently shared between heathprofessionals from different disciplines: they shouldunderstand the general principles of pain assessmentand pain management in children. Postoperative analgesiashould be planned and organized prior to surgeryin consultation with patients and their families orcarers, and other members of the perioperative team.Good practice pointsProviders of postoperative care should understand thegeneral principles of good pain management in children;this includes knowledge of assessment techniques and theuse of analgesics at different developmental ages.Pediatric anesthetists are responsible for initiating postoperativeanalgesia. They should liaise with patients andtheir families/carers, surgeons, and other members of theteam providing postoperative care to ensure that pain isassessed, and suitable ongoing analgesia is administered.Postoperative analgesia should be appropriate to developmentalage, surgical procedure, and clinical setting toprovide safe, sufficiently potent, and flexible pain reliefwith a low incidence of side effects.Combinations of analgesics should be used unless thereare specific contraindications, for example; local anesthetics,opioids, NSAIDs, and paracetamol can be givenin conjunction, not exceeding maximum recommendeddose.Recommendations2.7.1 ENT surgeryMyringotomyOral paracetamol or NSAIDS (ibuprofen, diclofenac, orketorolac) in suitable doses can achieve adequate earlypostoperative analgesia: Grade BOpioids are effective but not recommended for routineuse because of side effects: Grade BTonsillectomyA combination of individually titrated intraoperative opioids,dexamethasone, and regularly administered perioperativemild analgesics (NSAIDS and /or paracetamol)is recommended for management of tonsillectomy pain:Grade ATopical application or injection of local anesthetic in thetonsillar fossa improves early pain scores following tonsillectomy:Grade AImplementation of standardized protocols including intraoperativeopioid ± anti-emetic, perioperative NSAID(diclofenac or ibuprofen) and paracetamol are associatedwith acceptable pain relief and low rates of PONV:Grade CMastoid and middle ear surgeryGreat auricular nerve block can provide similar analgesiaand reduced PONV compared with morphine. Preincisiontiming of the block confers no additional benefit:Grade Bª 2012 Blackwell Publishing Ltd, Pediatric Anesthesia, 22 (Suppl. 1), 1–79 7
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Page 3 and 4: doi: 10.1111/j.1460-9592.2012.3838.
Page 5 and 6: 1.6 Contact informationCorresponden
Page 7: RecommendationsChildren’s self-re
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 56 and 57: 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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