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outcome measure is relatively insensitive (eg supplemental analgesic requirements following
procedures with low ongoing pain).
The use of ultrasound guidance has been has been shown to improve the accuracy, success
rate and quality of blockade as well as reduce the volume of local anaesthetic required
(Willschke et al, 2005 Level IV; Weintraud et al, 2008 Level IV). The efficacy of different local
anaesthetic techniques has been compared for common paediatric surgical conditions.
Additional procedure‐specific data are available (Howard et al, 2008).
The use of peripheral nerve catheters and plexus techniques in children has increased (Ganesh
et al, 2007; Level IV Rochette et al, 2007 Level IV). Descriptive studies of the efficacy and safety of
continuous peripheral nerve block infusions in children are encouraging (Fisher et al, 2006
Level IV) but further controlled comparisons with other analgesic techniques are required.
Femoral nerve or fascia iliaca compartment blocks provided analgesia for surgery on the
anterior aspect of the thigh and reduced pain associated with femoral fractures (Paut et al, 2001
Level IV), and psoas compartment block may be a useful alternative to neuraxial techniques for
unilateral hip and lower limb surgery (Dadure et al, 2004 Level IV; Schuepfer & Johr, 2005 Level IV).
For children undergoing major foot and ankle surgery, continuous popliteal nerve block with
0.2% ropivacaine produced comparable analgesia but fewer adverse events (postoperative
nausea and vomiting [PONV], early discontinuation) than continuous epidural infusion (Dadure
et al, 2006 Level II).
Axillary brachial plexus blocks provided satisfactory analgesia for hand and forearm surgery in
75% to 94% of cases (Fisher et al, 1999 Level IV). The use of ultrasound guidance has led to new
approaches to plexus anaesthesia in children (Fleischmann et al, 2003 Level III‐1; Ponde, 2008
Level IV) with improved success rates (De Jose Maria et al, 2008 Level III‐1).
Continuous paravertebral extrapleural infusions provided effective analgesia in infants
following thoracotomy (Fisher et al, 1999 Level IV). Single‐shot paravertebral injection provided
effective analgesia after renal surgery (Berta et al, 2008 Level IV) and inguinal hernia repair (Naja
et al, 2005 Level IV).
Specific procedures
Circumcision
A dorsal penile nerve block provided similar analgesia to a caudal block (Cyna & Middleton, 2008
CHAPTER 10 EMLA® (Choi et al, 2003 Level II). Caudal analgesia reduced the need for early rescue analgesia
Level I) and a longer duration of effect than application of a topical local anaesthetic cream,
when compared with parenteral analgesia (Allan et al, 2003 Level I).
Policy statements from the Royal Australasian College of Physicians (Royal Australasian College of
Physicians, 2004) and British Association of Paediatric Urologists (BAPU, 2007) emphasise the
need for adequate analgesia for neonatal circumcision. There are insufficient controlled trials
to adequately rank the efficacy of all local anaesthetic techniques for circumcision in awake
neonates, but as topical local anaesthetic cream only partially attenuates the pain response to
circumcision, more effective analgesic techniques such as dorsal penile nerve block are
recommended (Brady‐Fryer et al, 2004 Level I).
Inguinal surgery
Similar analgesic efficacy following inguinal hernia repair has been found with wound
infiltration, ilioinguinal / iliohypogastric nerve block or caudal analgesia (Splinter et al, 1995
Level II; Machotta et al, 2003 Level II). Ilioinguinal block is inherently safe, but ultrasound
guidance may improve safety and efficacy (Willschke et al, 2005 Level II; Weintraud et al, 2008
Level IV). In a small study following umbilical surgery, rectus sheath block offered no benefits

356 Acute Pain Management: Scientific Evidence