34th Annual Scientific Meeting of the Association of Paediatric Anaesthetists of Great Britain and Ireland, 8?10 March 2007, Manchester. Perioperative pain management following laparoscopic retroperitoneal nephrectomy

Abstract

Introduction: Retroperitoneal laparoscopic nephrectomy has been shown to be safe and effective in children, with minimal postoperative analgesic requirements and a shorter postoperative recovery time and hospital stay compared with the transperitoneal laparoscopic approach (1). Indeed, some centres carry this procedure out as a day case (2). The purpose of this audit was to collate information regarding perioperative pain management in patients undergoing this procedure in order to determine whether parenteral opioid analgesia is necessary postoperatively. Methods: We retrospectively reviewed the pain management records of all patients undergoing retroperitoneal laparoscopic nephrectomy, heminephrectomy and nephroureterectomy at our institution over a 3-year period from September 2002 to September 2005. The following data were collected: patient demographics, operative time, intraoperative analgesia administered, method of postoperative opioid administration, cumulative dose of opioid administered, postoperative fasting times, pain scores (FLACC) for 48 h, incidence of side effects and carer satisfaction. Results: Retroperitoneal laparoscopic nephrectomy, heminephrectomy or nephrouretectomy was performed in a total of 78 patients. Seventy-five patients had complete pain management records and were studied (50 of these patients underwent laparoscopic nephrectomy, 18 heminephrectomy and 7 nephroureterectomy). The median age at surgery was 5.3 years (range 3.5 months–17 years). The median operative time was 120 min (range 40–290 min). All patients received an intraoperative opioid. Fentanyl was given to 93% of patients (median dose 2.7 μg·kg−1) and morphine was given in addition to 53% of patients (median dose 0.07 μg·kg−1). The majority of patients received intraoperative paracetamol (88%) and local anaesthetic infiltration was administered to 83% of cases. Postoperatively, all patients received parenteral morphine, delivered by Nurse (NCA) or Patient (PCA) Controlled infusion (67% and 33% respectively). The median dose of morphine administered was 0.16 μg·kg-1 (range 0.02–1.24·μg·kg−1) and the median duration of infusion was 19 h (range 13–69 h). These relatively small doses of morphine were reflected in FLACC pain scores of <3 for 86% of patients in the first 24 h following surgery. Although most patients received paracetamol postoperatively, only 27% were given a NSAID. The median time taken before first oral intake was 4 h (range 1–24 h). Despite a 21% incidence of nausea and/or vomiting on day 0 (reducing to 12% on day 1), 98% of carers rated the perioperative management as good or very good. Conclusions: Retroperitoneal laparoscopic nephrectomy is associated with minimal postoperative opioid requirements. Morphine PCA/NCA analgesia is therefore unnecessary for the majority of children following this procedure. As most patients are able to take oral medications within 4 h of surgery, regular oral analgesics including oromorph should be adequate. References 1 Lam JP, MacKinlay GA, et al. Endoscopic nephrectomy in children: is retro the way forward? JLaparoendosc Adv Surg Tech A 2006; 16: 59–62. 2 Kobashi KC, Chamberlin DA, Rajpoot D, Shanberg AM. Retroperitoneal laparoscopic nephrectomy in children. J Urol 1998; 160: 1142–1144.