Encouraging Oral Analgesia in the Fasted Child Attending a Trauma Review Clinic

Sir

Analgesia administration in paediatric patients attending a plastic surgery trauma review clinic is important to minimise pain during assessment of wounds. The “fasting” status of a potentially pre-operative patient should not deter parents or referring clinicians from recommending and administrating oral analgesia before review. The primary presentation of various soft tissue injuries is often to units such as local emergency departments and general practitioners, immediately after the injury. Following administration of first aid and initial assessment, many require specialist management due to complexity of the injury or the need for paediatric anaesthesia. Following consultation with an on call plastic surgery team, a review appointment is commonly planned for the following morning. Soft tissue injuries that do not threaten a patient’s systemic health or compromise limb and/or digit perfusion should await surgery during daylight hours. This has been proven to result in a lower rate of post-operative complications.1 The Royal College of Surgeons emergency surgery guidelines for plastic surgery allows operating on non-life or limb threatening emergencies during twilight hours only if the patient is already in hospital awaiting surgery. Night time surgery is not recommended. As a result of these guidelines, most referrals are reviewed the following morning.2 Patients are often requested to arrive at the review clinic fasting, so as to allow general anaesthesia to be undertaken should the need arise. However, the fasting status should not prevent the administration of analgesia in advance of the wound review. Commonly parents are afraid to administer analgesia, wrongly presuming any pending surgical intervention would be postponed as a result. Without guidance from the referring team, parents cannot be expected to administer analgesia orally. Similarly, analgesia is often omitted due to the relative pain free status of patients with quiescent injuries with undisturbed dressings. Upon review however, a loading dose of simple, over the counter analgesia is advisable before presentation to the plastic surgery team. The Association of Anaesthetists of Great Britain and Ireland has clear guidelines on the fasting times for paediatric patients.3 Solids including cow’s milk and formula should be withheld for six hours, breast milk should be withheld for four hours and clear fluids is allowable up until two hours before anaesthesia.

The preoperative recommendations published by the Royal College of Nursing, London is based on a systematic review of the available literature. The two hour clear fluids rule is again recommended, and in addition, 30ml of clear fluids is allowable right up the time of anaesthesia to enable the administration of oral medication including regular medications, premedication’s and analgesia.4 Given the well established guidelines on medication in the fasting patient, we encourage all referring clinicians to advise parents on the importance of over the counter analgesia prior to trauma clinic consultations, allowing us to ensure the child’s hospital experience is as positive as possible.

L Fitzgerald, JD Martin-Smith, M Dempsey

Department of Plastic Surgery, Our Lady’s Children’s Hospital, Crumlin, Dublin 12

Email: fitzgelo@tcd.ie

References 

  1. Kelz, R; Freeman, K ; Hosokawa, P; Asch, D; Spitz, F; Moskowitz, M; Henderson, W; Mitchell, M; Itani, K. Time of day is associated with postoperative morbidity: an analysis of the national surgical quality improvement program data. Annals of surgery 2008;247:544-52.
  2. Emergency Surgery: Standards for unsheduled care. Secondary Emergency Surgery: Standards for unsheduled care 2011. https://www.rcseng.ac.uk/publications/docs/emergency-surgery-standards-for-unscheduled-care.
  3. AAGBI Safety Guideline: Pre-operative Assessment and Patient Preparation, The Role of the Anaesthetist Secondary AAGBI Safety Guideline: Pre-operative Assessment and Patient Preparation, The Role of the Anaesthetist 2010. https://www.aagbi.org/sites/default/files/preop2010.pdf.
  4. Perioperative fasting in adults and children: An RCN guideline for the multidisciplinary team. Secondary Perioperative fasting in adults and children: An RCN guideline for the multidisciplinary team 2005. https://www.rcn.org.uk/__data/assets/pdf_file/0009/78678/002800.pdf.

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