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Year : 2011  |  Volume : 8  |  Issue : 3  |  Page : 267-268
Preemptive analgesia in paediatric surgery


Department of Paediatric Surgery, Park Medical Research and Welfare Society, Kolkata, India

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Date of Web Publication11-Jan-2012
 

How to cite this article:
Chatterjee US. Preemptive analgesia in paediatric surgery. Afr J Paediatr Surg 2011;8:267-8

How to cite this URL:
Chatterjee US. Preemptive analgesia in paediatric surgery. Afr J Paediatr Surg [serial online] 2011 [cited 2020 Apr 4];8:267-8. Available from: http://www.afrjpaedsurg.org/text.asp?2011/8/3/267/91653
Postoperative pain in paediatric patients' is the commonest complication and disturbing also. On the other hand, alleviating the same is interesting and a great consolation to the parents. Surgical stress alters the metabolic state and immune functions; control of pain diminishes or abolishes those stress responses. For this reason, management of postoperative pain through preemptive analgesia has received considerable attention for the last few decades.

In this article, both the penile block and the caudal block are done before the onset of the surgical infliction. That is indicated and necessary as the central nervous system (CNS) sensitisation may be adequately decreased by blocking the afferent pain pathways with local anaesthetics before the surgical injury. [1] This is efficacious in controlling the pain for about more than 24 hours in the postoperative period. Once the CNS sensitisation is activated by the surgical injury, pain control with intramuscular/intravenous medications or even by regional block may be difficult or not be adequate or the requisite amount of analgesics may be higher. [2],[3]

Authors have judiciously kept a space of 20 min to allow the bupivacaine to act.

As the time elapses, the neural blockade made just before surgery begins to decay and the noxious stimulators from the surgical site get another chance to 're-sensitise' the CNS. Some authors are apprehended of this 're-sensitisation' and advocate further nerve blockade. [4] In this respect, nerve blockade before and after the surgical injury may be more efficacious in general. [5]

In some situations, presumed-operative-time may extend and further aliquot of anaesthetic administration as nerve blockade may be necessary. This is possible only through the pre-inserted epidural catheter. But in penile blockade, re-administration of another aliquot is possible without any change in the position.

Authors have excluded those patients' who would have needed re-administration of anaesthetics for nerve blockade for an obvious reason.

Epidural nerve block is guided by the bony land marks and that is the reason why it is more successful. Anatomical landmarks, not the bony landmarks, are less reliable and are responsible for the failure of the penile blocks. Still, ergonomically, the penile block is simple, seems to be easy as the further aliquot if necessary, may be administered easily. Above all, choices depend on the experiences, expertise and to some extent bias of the anaesthetist concern.

Another procedure of preemptive analgesia, i.e. instillation of anaesthetics medication on the surgical site is effective and decades-old [6] still not well known amongst paediatric surgeons who are supposed to take over the role of anaesthesiologist in application of instillation of local anaesthetics in the wound for preemptive analgesia. Surface instillation is usually applied at the end of surgical infliction and surprisingly, the efficacy is satisfactory as mentioned in many literatures! [7],[8]

Personally, I prefer surface instillation of anaesthetics for preemptive analgesics, particularly in hypospadias surgery. I use to instill the anaesthetics as soon as the inflict starts, plausibly, the anaesthetic will reach the cut nerve endings earlier than the pain-evoking-cytokines, which is supposed to be circulated after the surgical trauma. Although, I have not done the control study about the surface instillation, outcome is satisfactory.

Preemptive analgesia, metaphorically, is as effective as prophylactic antibiotics and both have made a break through advancement.

 
   References Top

1.Woolf CJ. Evidence for central component of post-injury pain hypersensitivity. Nature 1983;306:686-8.  Back to cited text no. 1
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2.Ejlersen E, Andersen HB, Eliasen K, Mogensen T. A comparison between preincisional and postincisional lidocaine infiltration and postoperative pain. Anesth Analg 1992;74:495-8.  Back to cited text no. 2
[PUBMED]  [FULLTEXT]  
3.Dierking GW, Dahl JB, Kanstrup J, Dahl A, Kehlet H. Effect of pre- Vs postoperative inguinal field block on postoperative pain after herniorrhaphy. Br J Anaesth 1992;68:344-8.  Back to cited text no. 3
[PUBMED]  [FULLTEXT]  
4.Woolf CJ, Chong MS. Preemptive analgesia-treating postoperative pain by preventing the establishment of central sensitization. Anesth Analg 1993;77:362-79.  Back to cited text no. 4
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5.Chhibber AK, Perkins FM, Rabinowitz R, Vogt AW, Hulbert WC. Penile block timing for postoperative analgesia of hypospadias repair in children. J Urol 1997;158:1156-9.  Back to cited text no. 5
[PUBMED]  [FULLTEXT]  
6.Thomas DF, Lambert WG, Williams KL. The direct perfusion of surgical wounds with anaesthetic solution: An approach to postoperative pain. Ann R Coll Surg Engl 1983;65:226-9.  Back to cited text no. 6
[PUBMED]  [FULLTEXT]  
7.Casey WF, Rice LJ, Hannallah RS, Broadman L, Norden JM, Guzzetta P. A comparison between bupivacaine instillation versus ilioinguinal/iliohypogastric nerve block for postoperative analgesia following inguinal herniorrhaphy in children. Anesthesiology 1990;72:637-9.  Back to cited text no. 7
[PUBMED]    
8.Goldstein A, Grimault P, Henique A, Keller M, Fortin A, Emile DE. Preventing postoperative pain by local anesthetic instillation after laparoscopic gynecologic surgery: A placebo-controlled comparison of bupivacaine and ropivacaine. Anesth Analg 2000;91:403-7.  Back to cited text no. 8
    

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Correspondence Address:
Uday S Chatterjee
Department of Paediatric Surgery, Park Medical Research and Welfare Society, 4, Gorky Terrace, Kolkata - 700 030
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0189-6725.91653

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