Early Postoperative Pain
However, early postoperative pain after laparoscopy can be significant. The main hypothesis evoked for about twenty years is the persistence of CO 2 in the peritoneal cavity after exsufflation, the reabsorption time of which can be 48 hours. CO 2 causes significant local acidosis and inflammation peritoneal can to explain the pains early.
Use of Laparoscopic Needle Driver is a prudent choice for Training.
The CO2 _ trap between the Right diaphragmatic dome and the hepatic dome is also the cause of right scapular pain by traction on the Phreno-Hepatic Ligaments. In addition, there is, as with laparotomies, visceral pain in the operating area.
Parietal Pain
The pain after laparoscopic surgery is different from that observed after laparotomy. Indeed, parietal pain related to the scar and its mobilization during respiratory movements non-existing (except when a small incision is necessary for the extraction of the operative part as during splenectomies or nephrectomies). Similarly, the spastic pain caused by the ileus is much less, because the resumption of transit is faster.
Advantages in Laparoscopic Surgery in Children
Thus, laparoscopic surgery in children is beginning to bases on numerous proofs concerning its effectiveness and its various advantages on early rehabilitation. However, optimal management, allowing effective management of perioperative pain while entering into this rehabilitation process, has not yet explores. This is what interested us to do this work. We are therefore going to review the general recommendations concerning the management of postoperative pain in children in order to adapt them to post-laparoscopy pain.
You should know that the expression of pain in children differs from that of adults. The acute pain will generate tears, cries, agitation but if this pain is prolonged the attitude of the child will change with analgesic postures, withdrawal then apathy. Hence, the importance of having means of self or hetero pain assessment that reliable and adapts to the child's age:
• Between 0 and 4 years : the choice of the behavioral observation scale such as CHEOPS (Children's Hospital Of Eastern Ontario Pain Scale) or EDIN (pain and discomfort scale of the newborn) is determined by slice of age.
• Between 4 and 6 years old: a self-assessment proposes, using a scale of faces or a verbal scale simple.
• From 6 years old: self-assessment can use a visual analogue scale (VAS), a simple verbal scale, a simple numerical scale or a scale of faces.
Any analgesic prescription must precedes and followed by a systematic assessment of the pain using one of these validated scales, adapts to the age of the child, at a rate depending on the severity of the pain, with a regular reassessment.
Recommendations Postoperative Pain in Children
Recommendations exist on the management of postoperative pain in children, the most recent being an RFE from the SFAR in 2008 and recommendations for good practice from the AFSSAPS in 2009. We will review the main points. The postoperative analgesia strategy must establishes from the pre-anaesthetic consultation, specifying the modalities (local regional anaesthesia, PCA morphine, etc.). Specify to the parents that the quality of the analgesia will be reassessed using scales adapted to the age of the child. Postoperative analgesia will preferably be multimodal, it will combine several analgesics in order to seek an additive effect making it possible to reinforce analgesia and possibly reduce the need for morphine. As part of a multimodal analgesia, we can associate in children:
Analgesics no morphine
• An NSAID prescribes apart from general contraindications and certain surgeries (neurosurgery, tonsillectomy). Any prescription of NSAIDs will precedes by the correction of states of dehydration and hypovolemia. Ketoprofen probably uses intravenously from the age of 1 year (off-label). By rectal route, diclofenac is preferred to niflumic acid, the bioavailability of which is very low. NSAIDs have a morphine-sparing effect demonstrated in several randomized studies. This effect is greater than that of paracetamol alone. However, the combination of the two allows greater morphine savings than each molecule alone.
• Paracetamol will administers systematically from the time of surgery then every 6 hours (15mg/kg for children over one year old, half dose in children under 1 year).
The oral route will be preferred as soon as possible. The rectal route should no longer uses given the low and unpredictable bioavailability of this molecule.
Opioids
• Codeine recommends in combination but has a large genetic polymorphism that can reduce its effectiveness or lead to overdoses in a large number of children.
• Nalbuphine, an agonist/antagonist, has Marketing Authorization from 18 months. Pediatric literature is not very important on this subject; it is however, a molecule widely used in pediatrics for surgeries with little or moderate pain. It uses as a bolus (0.2 mg/kg/4 hours) or by continuous intravenous route (1.2 mg/kg/day after an initial bolus). There is a ceiling effect around 2mg/Kg/d, limiting its use for very painful surgeries. There is no clinically visible lung depression due to this upper limit effect, so there is no specific respiratory monitoring detached.
• Morphine indicates for surgery with predictable moderate or severe pain. Intravenous administration always precedes by SSPI titration. As soon as the level of understanding allows it, self-controlled analgesia is the technique of choice. The administration and monitoring procedures are identical to those for adults. It is preferable that the monitoring of children under 6 months carries out in a continuous monitoring unit. Continuous intravenous administration uses in the hospital sector, provides that written procedures establish the methods of administration, monitoring and the action to takes in the event of suspected or proven overdose. Adverse effects treats with low doses of naloxone.
The Ketamine
• Ketamine has an inhibitory action on postsynaptic NMDA glutamate receptors, receptors involved in hyperalgesia. Several Meta-Analyses show a favorable effect of perioperative administration of low doses of ketamine to optimize postoperative analgesia in adults. According to the authors, this effect results in a reduction in the self-controlled consumption of morphine, a reduction in pain scores, in the incidence of adverse effects of morphine and in the zone of secondary hyperalgesia around scarring.
Loco-Regional Anesthesia
• We will try, as soon as possible, to combine other analgesics with Loco-Regional anesthesia. It recalls in the RFE of the SFAR of 2008 that infiltration of trocar orifices and intraperitoneal instillation recommends for analgesia after laparoscopy for cholecystectomy and gynecological surgery. A 2006 Meta-Analysis indeed finds a benefit of intraperitoneal instillation of local anesthetics on early postoperative pain after cholecystectomy in adults. A 2011 Meta-Analysis found a similar effect after laparoscopic gastric surgery. In addition, several studies in adults have shown a decrease in postoperative opioid consumption when a TAP block (Transverse Abdominal Plane block) performs for laparoscopic cholecystectomy. It recommends in the RFE of the SFAR on pediatric ALR to perform a TAP block after abdominal surgery to reduce parietal pain.
Conclusion
Laparoscopic surgery represents an important part of Robert Debré's activity. Every year about 300 laparoscopies performs. Even if the indications are very diverse as seen above, the duration of hospitalization is often very short.
For more information visit our website: www.gerati.com
Comments