Postoperative analgesia in infants and children: new developments

Nowadays, postoperative pain control in infants and children is a big challenge. The only effective solution is a multidisciplinary work with accurate guidelines, starting from the preoperative period throughout the surgery and arriving at the postoperative period. The approach must be scientific, based on the recent studies and research. In recent years, there has been a renaissance in regional anesthesia in children, in part because of a greater concern about postoperative pain management in young patients, and in part because of technical advances in equipment to perform the blocks. In fact several techniques and routes can be used for pain treatment but all have side effects. We await data from the use of COX2 inhibitors, surely the future of NSAIDs, with valid anti-inflammatory action and fewer side effects in children. When possible/not controindicated, regional analgesia is often the best choice. Recently continuous peripheral infusion is successfully applied in infants and children, due to its safety, efficacy and well limited localisation of analgesia. All the variety of peripheral nerve blocks used in adults can be used in pediatrics. The indications to place a catheter for a continouos peripheral nerve blocks are the followings: major orthopedic procedures; the procedure is scheduled to last more than two hours; congenital malformation of foot or hand; fracture reduction; traction of femur fracture; when postoperative pain therapy is necessary for several days; painful physical therapy. The commonly performed continuous peripheral blocks in children are the brachial plexus block (parascalene or axillary), the femoral nerve block, the fascia iliaca block, the sciatic nerve block with the lateral or with the popliteal approach. In these last two years also our group performed several continuous peripheral nerve blocks particularly axillary, femoral and sciatic for major orthopedic surgery and trauma. In our institution, we use a bolus dose of 0.5-1 ml/kg (depending on the nerve to be blocked) of ropivacaine 0.2% or levobupivacaine 0.25% with clonidine 2 microg/kg and then in infants older than 6 months and children we use a continuous infusion of 0.1-0.3 ml/kg/h of 0.2% ropivacaine or 0.25% levobupivacaine with clonidine 3 microg/kg/24h for 48-72 hours. For older children doses and concentrations are usually the same used in adults.