The main remit of the European Society for Paediatric Anaesthesiology (ESPA) Pain Committee is to improve the quality of pain management in children. The ESPA Pain Management Ladder is a clinical practice advisory based upon expert consensus to help to ensure a basic standard of perioperative pain management for all children. Further steps are suggested to improve pain management once a basic standard has been achieved. The guidance is grouped by the type of surgical procedure and layered to suggest basic, intermediate, and advanced pain management methods. The committee members are aware that there are marked differences in financial and personal resources in different institutions and countries and also considerable variations in the availability of analgesic drugs across Europe. We recommend that the guidance should be used as a framework to guide best practice.

https://onlinelibrary.wiley.com/doi/pdf/10.1111/pan.13373

Postoperative pain management in children: Guidance from the pain committee of the European Society for Paediatric Anaesthesiology (ESPA Pain Management Ladder Initiative)

Background. The rationale for replacing racemic bupivacaine with the s-enantiomers levobupivacaine and ropivacaine is to provide a wider margin of safety with the same analgesic efficacy and less postoperative motor block. In a randomized, double-blind, phase III, controlled trial we compared the caudal administration of levobupivacaine 0.25% and ropivacaine 0.25% with bupivacaine 0.25% in children. Methods. Ninety-nine ASA I–II children less than 10 yr old scheduled for elective sub-umbilical surgery were randomized to receive caudal block with bupivacaine 0.25%, ropivacaine 0.25% or levobupivacaine 0.25%. The primary outcome of the study was the clinical efficacy of the caudal block during the operation. Secondary outcome measures were analgesic onset time, pain relief after the operation and residual motor blockade. Results. The proportion of children with effective analgesia during the operation was similar among groups. There were no significant differences in the analgesic onset time of the caudal block. Bupivacaine produced a significant incidence of residual motor block compared with levobupivacaine or ropivacaine at wake-up (P Conclusion. During sub-umbilical surgery, caudal levobupivacaine, ropivacaine and bupivacaine provided comparable analgesic efficacy. Bupivacaine produced a higher incidence of residual motor blockade and a longer analgesic block than ropivacaine and levobupivacaine.

Randomized, double-blind, phase III, controlled trial comparing levobupivacaine 0.25%, ropivacaine 0.25% and bupivacaine 0.25% by the caudal route in children.

Summary

Background: The aim of our study was to compare postoperative analgesic efficacy, analgesic duration and motor blockade of levobupivacaine, ropivacaine and bupivacaine administered caudally in equal concentrations to children undergoing elective minor surgery.



Methods:  In the study, 182 children, aged 1–7 years, undergoing either inguinal hernia repair or orchidopexy, were randomly allocated to one of the three groups. They received via a caudal extradural either 1 ml·kg−1 levobupivacaine 0.2% (Group L) or 1 ml·kg−1 ropivacaine 0.2% (Group R) or 1 ml·kg−1 bupivacaine 0.2% (Group B).



Results:  No statistically significant difference was noted in age, weight, duration of the operation or level of the caudal block between the groups. The onset of analgesia was significantly later after levobupivacaine. Postoperative pain scoring evaluated with Children's and Infant's Postoperative Pain Scale observational scale showed no statistical difference between groups. Median postoperative analgesia was 5.75 h (SEMed: ± 0.65) in Group L, 5.7 h (SEMed: ± 0.8) in Group R and 5.35 h (SEMed: ± 1.3) in Group B the difference being statistically nonsignificant.



Conclusions:  The degree of motor block was significantly less after ropivacaine and levobupivacaine during the first 2 h postoperatively.

A prospective study comparing the analgesic efficacy of levobupivacaine, ropivacaine and bupivacaine in pediatric patients undergoing caudal blockade

Introduction
Perioperative continuous peripheral nerve blocks (CPNB) are increasingly being used in children. Only one previous study has reported adverse events of CPNB in a high number of pediatric cases. We evaluated the indications, block efficacy, and adverse events related to CPNB in children.

/pdf/continuous-peripheral-nerve-blocks-for-postoperative-wcj5kngmoq.pdf

Continuous peripheral nerve blocks for postoperative analgesia in children: feasibility and side effects in a cohort study of 339 catheters

In this prospective, randomized, observer-blinded clinical trial, we compared the incidence of unwanted lower extremity motor blockade and the analgesic efficacy between small-dose (0.125%; 0.2 mg x kg(-1) x h(-1)) postoperative epidural infusions of bupivacaine (Group B; n = 28), levobupivacaine (Group L; n = 27), and ropivacaine (Group R; n = 26) in children after hypospadias repair. Motor blockade and pain were assessed at predetermined time points during 48 h by using a modified Bromage scale and the Children's and Infant's Postoperative Pain Scale (CHIPPS). Postoperative analgesia was almost identical in all three study groups (CHIPPS range, 0-3), with no need for the administration of supplemental analgesia in any patient. However, significantly more patients in Group B (n = 6; P = 0.03) displayed signs of unwanted motor blockade during the observation period compared with Group L (n = 0) and Group R (n = 0). In conclusion, significantly less unwanted motor blockade was associated with postoperative epidural infusions of 0.125% levobupivacaine or ropivacaine in children after hypospadias repair as compared with a similar infusion of bupivacaine. However, no difference with regard to postoperative analgesia could be detected among the three different local anesthetics studied.

A comparison of epidural bupivacaine, levobupivacaine, and ropivacaine on postoperative analgesia and motor blockade.

https://rapm.bmj.com/content/rapm/27/2/157.full.pdf

Comparison of Racemic Bupivacaine, Ropivacaine, and Levo-Bupivacaine for Pediatric Caudal Anesthesia: Effects on Postoperative Analgesia and Motor Block

Summary

We describe the case of a 3-year-old boy with a subtotal amputation of the right foot who received treatment for pain via a peripheral catheter positioned at the level of the sciatic nerve (lateral approach).We administered a continuous infusion of 0.2% ropivacaine, 0.4 mg·kg−1·h−1 plus clonidine 0.12 μg·kg−1·h−1 for 21 days.



Pain relief was complete and the patient did not require any further rescue analgesia throughout the period even during medications and surgical treatment in our intensive care unit.



We discuss the safety and efficacy of the use of a peripheral continuous infusion in children compared with other techniques of analgesia.

A long‐term continuous infusion via a sciatic catheter in a 3‐year‐old boy

1,000 consecutive blocks in a children's hospital: How to manage them safely.

Background: This prospective surveillance study was designed to estimate the incidence of healthcare-associated infections (HAIs) and to analyze the risk factors for their developme

Surveillance study of healthcare-associated infections in a pediatric neurosurgery unit in Italy.

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Papers

Comparison of Racemic Bupivacaine, Ropivacaine, and Levo-Bupivacaine for Pediatric Caudal Anesthesia: Effects on Postoperative Analgesia and Motor Block

A long‐term continuous infusion via a sciatic catheter in a 3‐year‐old boy

1,000 consecutive blocks in a children's hospital: How to manage them safely.

Surveillance study of healthcare-associated infections in a pediatric neurosurgery unit in Italy.