Page 405 Acute Pain Management

compared with infiltration of local anaesthetic (Isaac et al, 2006 Level II). Addition of clonidine to
bupivacaine for ilioinguinal block did not improve duration or quality of analgesia (Kaabachi et
al, 2005 Level II).
Tonsillectomy
Local anaesthetic by topical application or infiltration produced moderate reductions in pain
(mean reduction 7 to 19 mm on 0 to 100 mm VAS) following tonsillectomy (Grainger &
Saravanappa, 2008 Level I). Peritonsillar infiltration of ketamine 0.5 mg/kg reduced pain
following tonsillectomy (Honarmand et al, 2008 Level II) but was no more effective than the
same dose given systemically (Dal et al, 2007 Level II).

Head and neck surgery
Blocks of scalp branches of the frontal (supraorbital, supratrochlear), maxillary
(zygomaticotemporal), and auriculotemporal nerves as well as branches of the superficial
cervical plexus (greater auricular and occipital nerves) reduced pain following neurosurgery
(Pardey et al, 2008 Level IV).
Greater auricular nerve block provided similar analgesia with reduced PONV compared with
morphine following mastoidectomy (Suresh et al, 2004 Level II). Combined with a lesser occipital
nerve block, it was also effective following otoplasty (Pardey et al, 2008 Level II). Infraorbital
nerve block was superior to IV fentanyl following cleft lip repair (Rajamani et al, 2007 Level II).
Compared with intraoperative opioids, peribulbar and subtenon blocks reduced intraoperative
oculocardiac reflexes and PONV following strabismus surgery, but effects on postoperative
analgesic requirements were variable (Chhabra et al, 2005 Level III‐1; Steib et al, 2005 Level II;
Gupta et al, 2007 Level II); and relative risks of the procedures have not been fully evaluated.
Following cataract surgery, fewer children required rescue analgesia when subtenon block
was compared with intravenous fentanyl (Ghai et al, 2009 Level II).
Local anaesthetic infiltration reduced pain following dental extractions (Anand et al, 2005
Level III‐2) but addition of a small dose of morphine (25 mcg/kg) to the local anaesthetic did
not improve the quality or duration of analgesia (Bhananker et al, 2008 Level II).
10.7.2 Central neural blockade

The use of regional analgesia in children is well established but patient selection, technique,
choice of drugs, availability of experienced staff for performing blocks, APS resources and
adequacy of follow‐up vary in different centres (Williams & Howard, 2003).
Caudal analgesia
Single‐shot caudal analgesia is one of the most widely used regional techniques in children, CHAPTER 10
and provides intra‐ and postoperative analgesia for surgery on the lower abdomen, perineum
and lower limbs (Howard et al, 2008). Large series have reported a high success rate (particularly
in children under 7 years of age), and a low incidence of serious complications (Giaufre et al,
1996 Level IV; Royal College of Anaesthetists, 2009 Level IV).
Caudal bupivacaine, levobupivacaine and ropivacaine, produced similar times to onset of block
and quality of postoperative analgesia (Breschan et al, 2005 Level II; Ivani et al, 2005 Level II;
Frawley et al, 2006 Level II; Ingelmo et al, 2006 Level II). Concentration‐dependent differences have
been noted; ropivacaine 0.175% was superior to lower concentrations, and was as effective as
a 0.2% solution but produced less motor block (Khalil et al, 2006 Level II). Addition of adrenaline
to bupivacaine has minimal effect on the duration of analgesia, particularly in older children
(Ansermino et al, 2003 Level I).

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