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Pain Management for
Appendicitis at BCH Dr Doug Johnson
Options at BCH
• Oral Morphine
• IV bolus Morphine
• NCA/ PCA Morphine or Fentanyl +/-
Ketamine (with background).
• Plus Paracetamol and NSAID
• (Codeine)
NCA/ PCA Options
NCA/ PCA options
Intra-operative
• Local anaesthetic infiltration/ TAP block
TAP block
Carney J1, Finnerty O, Rauf J, Curley G, McDonnell JG, Laffey JG. Ipsilateral transversus abdominis plane block provides effective analgesia after appendectomy in children: a randomized controlled trial. Anesth Analg. 2010 Oct;111(4):998-1003
40 children having open appendicectomy. TAP reduced mean morphine requirement in first 48 hours and VAS pain scores
Ahmad Ramzy Shaaban. Ultrasound guided transversus abdominis plane block versus local wound infiltration in children undergoing appendectomy: A randomized controlled trial. Egyptian Journal of Anaesthesia. 2014 Oct; 30(4): 377-382
44 children undergoing open appendicectomy. Increased time to first analgesia, lower cumulative analgesia and lower Pain Scale scores in TAP group.
Sandeman DJ1, Bennett M, Dilley AV, Perczuk A, Lim S, Kelly KJ. Ultrasound-guided transversus abdominis plane blocks for laparoscopic appendicectomy in children: a prospective randomized trial. Br J Anaesth. 2011 Jun;106(6):882-6
93 children. TAP blocks increased anaesthetic time by 14 minutes but offered no clinical benefit over port-site infiltration
Long JB1, Birmingham PK, De Oliveira GS Jr, Schaldenbrand KM, Suresh S. Transversus abdominis plane block in children: a multicenter safety analysis of 1994 cases from the PRAN (Pediatric Regional Anesthesia Network) database. Anesth Analg. 2014 Aug;119(2):395-9
Upper incidence of complication is 0.3%. (only 2 complications)
Complications were very minor and did not require intervention.
Pain Team involvement
• 201 patients on Pain team database
(2015-2016)
• 128 Laparoscopic appendicectomy
• 73 open appendicectomy
Lap Appendix
128 patients. 125 received NCA/PCA
• 3 patients started pre-operatively
• 6 needed Ketamine adding
• 5 rotated from Morphine to Fentanyl due to
itch or nausea - All 11-14 years old (4 female).
• 3 needed increase in PO dose only
Open appendix
73 patients
• 2 started pre-operatively
• 2 started day 1 post-op after failed PO meds
• 1started day 3 post-op (PICU patient)
• 9 needed Ketamine adding. 2 of these
required rotating M to F. 1 had clonidine
patch.
Trends at BCH
• NCA/ PCA in all but the most simple/
straightforward laparoscopic appendix that is
expected to tolerate oral medication straight
away.
• Consider Fentanyl rather than Morphine in
teenagers (particularly female).
• Consider adding ketamine
• TAP block for open procedure
Pain team
• 3 consultant sessions a week
• Ward round 7 days a week
• 3.74 WTE specialist pain nurses
• 1x Band 8, 1x Band 7 and 3x Band 6s
Thank you