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