Download Asthmatic child POP

What are the choices for postoperative analgesia for an asthmatic
child aged 3 years presenting for repair of an inguinal hernia as a day
case? State briefly the advantages and disadvantages of each
method.
The choices are as follows:
1. Non-local anesthetic techniques rectal route: paracetamol, NSAIDs & opiates.
2. Local anesthetic techniques
a. Caudal
b. nerve block
c. local infiltration.
Discussion
Analgesia for children should provide subjective comfort by inhibition of traumainduced nociception to allow early restoration of normal life particularly in the day-case
setting. A multi-model approach with simultaneous administration of analgesics which
work by different mechanisms has the advantage of alternating nociceptive impulses at
various sites, thereby allowing the use of smaller doses of each drug, minimizing sideeffects.
There can be very few operations in children where the quality of analgesia is not
enhanced by concomitant use of paracetamol with or without a nonsteroid antiinflammatory drug (NSAID). Paracetamol is presented in a wide range of formulations,
and suppositories are an increasingly popular route for minor analgesic medication in
children, especially whilst the patient is under general anesthesia. The use of
suppositories should be discussed beforehand with the parents.
The initial analgesic dose of paracetamol when given by the rectal route is 20–
30mg/kg, and 20mg/kg per 6 hours thereafter. Paracetamol’s antipyretic properties are
useful in controlling postoperative malaise due to temperature.
There are three NSAIDs that are useful in pediatric postoperative analgesia:
ibuprofen, diclofenac and ketorolac. Only ibuprofen suspension is licensed for pain relief
in children over the age of 1 year. All three are commonly used for postoperative
analgesia, however. NSAIDs may be used in children with asthma, but if there is any
deterioration in respiratory status they must be stopped immediately. NSAIDs should be
given in the minimum effective dose.
Single-shot caudal extradural analgesia has been widely used in pediatric
anesthesia for many years. Plain bupivacaine 0.25% at a dose of 0.5mL/kg is given for
low thoracic blocks. Local anesthetic toxicity is rare in single-shot caudals. Short,
bevelled needles should be used as these are less likely to puncture epidural veins.
Unlike in adults, test doses of local anesthetic with adrenaline (15mcg) do not produce
consistent rises in heart rate in anesthetized children. Thus the total dose of local
anesthetic should be administered slowly in small increments. Single-shot blocks are
short-lived, however, and other analgesia must be provided, particularly in the day-case
setting.
Caudal extradural opioid given as a single shot is not recommended in daycase
anesthesia because of the high incidence of side-effects, namely pruritus, urinary
retention, nausea and vomiting.
Ilioinguinal and iliohypogastric nerve blocks can be performed for unilateral
hernia repair. The advantage of this technique is that anatomical landmarks are often
clearer in children than in adults. In experienced hands this is a safe, reliable technique
with a low failure rate.
Local anesthetic infiltration around the incision by the surgeon can also provide
effective pain relief. Bupivacaine is the local anesthetic of choice owing to its longer
action.
If a local anesthetic block cannot be performed, or if it is unsuccessful, a
parenteral narcotic such as fentanyl 1–2ug/kg should be administered intraoperatively.
Nausea, vomiting, dysphoria, respiratory depression and prolonged sedation – all of
which will delay discharge – are potential side-effects.
Procedures requiring repeated administration of narcotic analgesics are
unsuitable for day-case surgery.