Updates in Pediatric Regional Anesthesia and Its Role in the Treatment of Acute Pain in the Ambulatory Setting

Airway management and quadratus lumborum block for inguinal hernia repair in context of chromosome 4q deletion: A case report

Key Clinical Message

Chromosome 4q Deletion Syndrome (4QDS) is a rare chromosomal deletion that presents with various congenital defects that could affect anesthetic management. We present a patient with known 4QDS who underwent successful general anesthetic induction, tracheal intubation, and subsequently, bilateral quadratus lumborum nerve blocks, during laparoscopic inguinal hernia repair surgery.

Abstract

Chromosome 4q deletion syndrome (4QDS) is a rare chromosomal deletion with the potential for congenital defects that could affect the anesthetic management of affected patients, specifically with inconsistent reports of possible laryngeal narrowing which could precipitate intubation difficulties. We present a report of a patient with known 4QDS who underwent successful general anesthetic induction and tracheal intubation, followed by subsequent bilateral quadratus lumborum nerve blocks, in the context of laparoscopic inguinal hernia repair surgery. Given the inconsistent presentation of patients with 4QDS reported in the literature, steps were taken to exercise sufficient caution concerning the overall management of this patient per the most recent guidelines for pediatric patients.

Evaluation and Treatment of Pain in Fetuses, Neonates and Children

The perception of pain is individual and differs between children and adults. The structures required to feel pain are developed at 24 weeks of gestation. However, pain assessment is complicated, especially in neonates, infants and preschool-age children. Clinical scales adapted to age are the most used methods for assessing and monitoring the degree of pain in children. They evaluate several behavioral and/or physiological parameters related to pain. Some monitors detect the physiological changes that occur in association with painful stimuli, but they do not yet have a clear clinical use. Multimodal analgesia is recommended for pain treatment with non-pharmacological and pharmacological interventions. It is necessary to establish pharmacotherapeutic protocols for analgesia adjusted to the acute or chronic, type and intensity of pain, as well as age. The most used analgesics in children are paracetamol, ibuprofen, dipyrone, opioids (morphine and fentanyl) and local anesthetics. Patient-controlled analgesia is an adequate alternative for adolescent and older children in specific situations, such as after surgery. In patients with severe or persistent pain, it is very important to consult with specific pain services.

The Opioid Wars-CON: The Risks of Opioids for Pain Management Outweigh the Benefits

The entire field of medicine, not just anesthesiology, has grown comfortable with the risks posed by opioids; but these risks are unacceptably high. It is time for a dramatic paradigm shift. If used at all for acute or chronic pain management, they should be used only after consideration and maximizing the use of nonopioid pharmacologic agents, regional analgesia techniques, and nonpharmacologic methods. Opioids poorly control pain, their intraoperative use may increase the risk of recurrence of some types of cancer, and they have a large number of both minor and serious side effects. Furthermore, there are a myriad of alternative analgesic strategies that provide superior analgesia, decrease recovery time, and have fewer side effects and risks associated with their use. In this article the negative consequences of opioid use for pain, appropriate alternatives to opioids for analgesia, and the available evidence in pediatric populations for both are described.

A randomized controlled trial evaluating the hemodynamic impact of ultrasound-guided great auricular nerve block in middle ear microsurgery

BACKGROUND

The peri-operative effectiveness of ultrasound-guided great auricular nerve block (GANB) in patients, especially in adult patients undergoing middle ear microsurgery remains unclear. We hypothesized that ultrasound-guided GANB would decrease the hemodynamic responsiveness to incision and opioid consumption in middle ear microsurgery as well as the post-operative analgesia requirement.

METHODS

Sixty patients undergoing middle ear microsurgery were randomized into two equal groups to receive either a GANB with 2 ml of 0.25% ropivacaine under ultrasound guidance (GANB group) or to receive a blank control intervention (without any performed injection) before general anesthesia inductions. The primary outcomes were hemodynamic changes of MAP (mean artery pressure) and HR (heart rate) to skin incision. The secondary endpoints were to determine the consumptions of propofol and remifentanil during the operation and the incidence of remedial analgesia 48 h post-operation to maintain VAS ≤ 3.

RESULTS

The MAP post incision in GANB group was significantly lower than that in control group (GANB group 93.83 ± 11.72 mmHg vs. control group 100.87 ± 12.65 mmHg, P = 0.029). The increases for MAP and HR post incision were also lower in GANB group (∆MAP GANB group 11.90 ± 8.32 mmHg vs. control group 19.83 ± 10.37 mmHg, P = 0.002; ∆HR GANB group 3.67 ± 5.30 beat min^- 1 vs. control group 8.23 ± 8.56 beat min^- 1, P = 0.016). Remifentanil consumption was significantly decreased in GANB group (GANB group 401.55 ± 100.51 μg h^- 1 vs. control group 697.34 ± 215.45 μg h^- 1, P = 0.000). The incidence of remedial analgesia post-operation in GANB group (5/30) was significantly lower than that in control group (20/30, P = 0.000).

CONCLUSION

Ultrasound-guided GANB decreases the hemodynamic responsiveness to incision and remifentanil consumption in middle ear microsurgery as well as the post-operative analgesia requirement.

TRIAL REGISTRATION

This trial was retrospectively registered at http://www.chictr.org.cn with the registration number of ChiCTR1800014333 on 6 January, 2018.

Perioperative management of circumcision in children: Is there a difference between African and European hospitals?

CONTEXT

The circumcision is the most frequent procedure in paediatric surgery worldwide, performed for medical and ritual purposes. In developing countries, because of the difficult accessibility to healthcare, even a common procedure could be unsafe.

AIMS

The aim of the article is to compare the perioperative and anaesthesiological management of circumcision in children between two Italian and two sub-Saharan African hospitals.

MATERIALS AND METHODS

Medical records of paediatric circumcision from January 2014 to December 2016 have been reviewed. The involved hospitals were: Padua (Italy), Ferrara (Italy), Sao José em Bor (Guinea Bissau) and Yaoundé (Cameroun).

RESULTS

In Padua, 77 circumcisions were performed, 19 of these (24.6%) were ritual. In 75 children (97.4%), locoregional anaesthesia (LRA) together with sedation was used; only one complication (1.3%) occurred. In Ferrara, 200 interventions were done, 140 (70%) ritual; general anaesthesia was administered to 183 (93.5%) patients. There were five complications (2.5%). In Bissau, 53 procedures were performed, 21 (39.6%) ritual; in 34 children (64.1%), LRA with sedation was preferred. Two complications (3.8%) were reported. In Yaoundé, 60 children were circumcised, 15 (25%) for ritual purposes; in 51 (85%), only LRA was performed; there was only one (1.7%) complication. In the African hospital, no post-operative analgesia was administered.

CONCLUSION

Despite the different anaesthesiological techniques, the study shows no difference in rate of complications for the in-hospital setting. Training of the local medical team in pain management and post-operative care should be emphasised.

Day surgery for anterior cruciate ligament reconstruction in children: a prospective study on feasibility and satisfaction

PURPOSE

To evaluate the feasibility of day surgery anterior cruciate ligament reconstruction (ACLR) in children. Our hypothesis was that proper patient selection, adequate information and a streamlined clinical pathway would allow for a safe and satisfactory procedure.

METHODS

A total of 20 patients, seven girls and 13 boys, who underwent outpatient ACLR at mean age of 14 years (8 to 16) were included in this single institution prospective case series. Surgery took place under simple general anesthesia while analgesia protocol combined local anesthesia, oral analgesics for the postoperative period and compressive cryotherapy. The main failure criterion was the inability to return home the day of surgery or the need for rehospitalization during the first week after discharge. Secondary evaluation parameters were the rate of postoperative complications, postoperative pain, quality of life (QOL) and patients' satisfaction outcome questionnaire (PSOQ) at postoperative day 1, 7 and 31.

RESULTS

Of the 20 patients included, only one failed the ambulatory mode. The mean PSOQ score was, respectively for children and parents, 91.4% and 90.7% at day 7 and 94.6% and 95.7% at one month. Postoperative QOL at day 7 was very satisfying for all patients. Two minor early complications were reported. Both of the late complications, which included one partial wound dehiscence and one persistent knee swelling, resolved spontaneously.

CONCLUSION

This study indicates that, in a targeted and well-informed population, day surgery for children ACLR yields high level of patient and family satisfaction in a safely manner.

LEVEL OF EVIDENCE

IV, prospective case series.

Postoperative Pain and Opioid Use in Children with Supracondylar Humeral Fractures: Balancing Analgesia and Opioid Stewardship

BACKGROUND

Effective postoperative analgesia remains a priority in orthopaedic surgery, but concerns with regard to opioid diversion and misuse have brought overdue attention to improving opioid stewardship. Normative data for postoperative pain and opioid use are needed to guide and balance these dual priorities. We aimed to characterize postoperative pain and opioid use for an archetypal pediatric orthopaedic procedure: closed reduction and percutaneous pinning of a supracondylar humeral fracture.

METHODS

Children at a single pediatric trauma center who underwent closed reduction and percutaneous pinning of a supracondylar humeral fracture were enrolled and were prospectively followed. Validated pain scores (Wong-Baker FACES Pain Rating Scale) and opioid utilization data were collected using an automated text message-based protocol on postoperative days 1 to 7, 10, 14, and 21. Data were analyzed with descriptive and univariate statistics.

RESULTS

Eighty-one patients with a mean age (and standard deviation) of 6.1 ± 2.1 years (62% of whom were male) were enrolled, including 53.1% who had Type-II fractures and 46.9% who had Type-III fractures. The mean pain ratings were highest on arrival to the emergency department (3.5 ± 3.5 points) and the morning of postoperative day 1 (3.5 ± 2.4 points). By postoperative day 3, the mean pain rating decreased to <2 (1.8 ± 1.8 points) and the mean opioid doses decreased to <1 dose (0.8 ± 1.2 doses). Postoperative opioid use decreased in parallel to reported pain (r = 0.972; p < 0.001). The interquartile range of opioid use was 1 to 7 doses, and patients used only 24.1% of the prescribed opioids (mean, 4.8 ± 5.6 doses used and 19.8 ± 7.1 doses prescribed). There was no significant difference (p > 0.05) in pain ratings or opioid use by fracture classification, age, or sex.

CONCLUSIONS

Following closed reduction and percutaneous pinning for supracondylar humeral fracture, pain levels and opioid usage decrease to a clinically unimportant level by postoperative day 3. Patients who report pain scores of ≥6 points following discharge are outliers and should be screened for compartment syndrome or ischemia. Patients used <25% of prescribed opioid medication, suggesting the potential for overprescription and opioid diversion. A prescription for 7 opioid doses after discharge should allow adequate postoperative analgesia in the majority of patients while improving narcotic stewardship.

LEVEL OF EVIDENCE

Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Regional anesthesia to ameliorate postoperative analgesia outcomes in pediatric surgical patients: an updated systematic review of randomized controlled trials

Regional anesthesia is becoming increasingly popular among anesthesiologists in the management of postoperative analgesia following pediatric surgery. The main objective of this review was to systematically evaluate the last 5 years of randomized controlled trials on the role of regional anesthesia techniques in alleviating postoperative pain associated with various pediatric surgical procedures. Forty studies on 2,408 pediatric patients were evaluated. The majority of the articles published from 2013 to 2017 reported that the use of regional anesthesia minimized postoperative pain and reduced opioid consumption. Only a few surgical procedures (cholecystectomy, inguinal hernia repair, and non-laparoscopic major abdominal surgery) reported no significant difference in the postoperative pain relief compared with the standard anesthetic management. The growing number of randomized controlled trials in the pediatric literature is very promising; however, additional confirmation is needed to reinforce the use of specific regional anesthesia techniques to provide optimal postoperative pain relief for a few surgical procedures (reconstructive ear surgery, chest wall deformity, hypospadias, umbilical hernia, cleft palate repair) in pediatric patients. More randomized controlled trials are needed to establish regional anesthesia as an essential component of postoperative analgesia management in children.

Peribulbar block combined with general anesthesia in babies undergoing laser treatment for retinopathy of prematurity: a retrospective analysis

Background and objectives

Currently there is no agreement regarding which one is the most adequate anesthetic technique for the treatment of retinopathy of prematurity. Peribulbar block may reduce the incidence of oculocardiac reflex and postoperative apnea. The goal of this study was to report the outcomes of peribulbar block, when combined with general anesthesia, for the laser treatment for retinopathy of prematurity, in premature babies.

Methods

A retrospective analysis of anesthetic records of all babies who underwent laser treatment for retinopathy of prematurity from January 2008 through December 2015 in a tertiary hospital was performed.

Results

During that period a total of six babies was submitted to laser treatment for retinopathy of prematurity, all under peribulbar block combined with general anesthesia. A single infratemporal injection of 0.15 mL.kg⁻¹ per eye ropivacaine 1% or 0.75% was performed. At the end of the procedure, all babies resumed spontaneous ventilation. No perioperative complications were reported.

Conclusions

Peribulbar block was a safe anesthetic technique in our sample considered.

Surgical Treatment of Supracondylar Humeral Fractures in a Freestanding Ambulatory Surgery Center is as Safe as and Faster and More Cost-Effective Than in a Children's Hospital

BACKGROUND

Despite an 88% increase in the number of pediatric fractures treated in ambulatory surgery centers (ASCs) over a 10-year period, few studies have compared outcomes of fracture treatment performed in a freestanding ASC compared with those performed in the hospital (HOSP) or hospital outpatient department (HOPD). The purpose of this study was to compare clinical and radiographic outcomes, treatment times, and costs for treatment of Gartland type II supracondylar humeral (SCH) fracture in the ASC, HOSP, and HOPD.

METHODS

Retrospective review identified pediatric patients with isolated Gartland type II SCH fractures who had closed reduction and percutaneous pinning (CRPP) by board-certified orthopaedic surgeons from January 2012 to September 2016. On the basis of the location of their treatment, patients were divided into 3 groups: HOSP, HOPD, and ASC. All fractures were treated with CRPP under fluoroscopic guidance using 2 parallel or divergent smooth Kirschner wires. Radiographs obtained before and after CRPP and at final follow-up noted the anterior humeral line index (HLI) and Baumann angle. Statistical analysis compared all 3 groups for outcomes, complications, treatment time/efficiency, and charges.

RESULTS

Record review identified 231 treated in HOSP, 35 in HOPD, and 50 in ASC. Radiographic outcomes in terms of Baumann angle and HLI did not differ significantly between the groups at any time point except preoperatively when the HLI for the HOSP patients was lower (P=0.02), indicating slightly greater displacement than the other groups. Overall complication rates were not significantly different among the groups, nor were occurrences of individual complications. The mean surgical time was significantly shorter (P<0.0001) in ASC patients than in HOPD and HOSP patients, and total charges were significantly lower (P<0.001).

CONCLUSIONS

Gartland type II SCH fractures can be safely treated in a freestanding ASC with excellent clinical and radiographic outcomes equal to those obtained in the HOSP and HOPD; treatment in the ASC also is more efficient and cost-effective.

LEVEL OF EVIDENCE

Level III-retrospective comparative study.

Short-term Outcomes in Pediatric Patients Managed with Peripheral Nerve Blockade for Arthroscopic Anterior Cruciate Ligament Reconstruction and/or Meniscus Surgeries

Introduction

Peripheral nerve blockade (PNB) can be a useful component of a multimodal analgesia approach in managing pain after knee arthroscopy. However, the impact of PNB and short-term recovery in pediatric patients, particularly adolescents, who underwent knee arthroscopy for anterior cruciate ligament (ACL) reconstruction and/or meniscus surgery (repair or resection) has not been well characterized. This prospective study presents observational data on short-term patient outcomes and side effects for 72 hours following discharging home of pediatric patients who underwent arthroscopic ACL and/or meniscus procedures with PNB.

Methods

This is a single-center, single-surgeon prospective observational study conducted over a three-year period. We characterized 72-hour postoperative outcomes including pain scores, return of sensation to the affected limb, analgesic use [nonsteroidal anti-inflammatory drugs (NSAIDs) and opioids], readmission rate, and activities of daily living (ADL) via telephone survey. In addition, retrospective chart review was conducted to obtain perioperative and anesthesia details. Results for surgery groups were analyzed using descriptive and Pearson correlations using the SPSS version 24 (IBM Corp. Released 2016. IBM SPSS Statistics for Mac, Version 24.0. Armonk, NY, USA).

Results

We collected data on 47 patients undergoing ACL reconstruction with or without meniscus surgery (18/47, 38.3%) or meniscus surgery only (29/47, 61.7%). At 72 hours postsurgery, there were no readmissions or complications related to pain. Median-reported pain scores were 2.5 and 5.0 for the ACL and meniscus groups, respectively. A majority of patients continued to require opioids (45/47, 95.7%) and NSAIDs (46/47, 97.9%) at 72 hours postsurgery, but the number of daily opioid doses taken decreased with each day postoperatively. Over 93% of the patients could ambulate and shower at 72 hours postsurgery.

Conclusions

Regional nerve block appears to be an effective and safe analgesic strategy for pediatric arthroscopic ACL and meniscus procedures, with no short-term complications or readmissions related to pain in our cohort. Future prospective investigation is needed to characterize long-term pain outcomes in this surgical population.

[Peribulbar block combined with general anesthesia in babies undergoing laser treatment for retinopathy of prematurity: a retrospective analysis]

BACKGROUND AND OBJECTIVES

Currently there is no agreement regarding which one is the most adequate anesthetic technique for the treatment of retinopathy of prematurity. Peribulbar block may reduce the incidence of oculocardiac reflex and postoperative apnea. The goal of this study was to report the outcomes of peribulbar block, when combined with general anesthesia, for the laser treatment for retinopathy of prematurity, in premature babies.

METHODS

A retrospective analysis of anesthetic records of all babies who underwent laser treatment for retinopathy of prematurity from January 2008 through December 2015 in a tertiary hospital was performed.

RESULTS

During that period a total of six babies was submitted to laser treatment for retinopathy of prematurity, all under peribulbar block combined with general anesthesia. A single infratemporal injection of 0.15mL.kg^-1 per eye ropivacaine 1% or 0.75% was performed. At the end of the procedure, all babies resumed spontaneous ventilation. No perioperative complications were reported.

CONCLUSIONS

Peribulbar block was a safe anesthetic technique in our sample considered.

Outpatient Pediatric Orthopedic Surgery

Outpatient surgery refers to a surgical procedure that is performed without an overnight stay in a hospital. Outpatient surgery is associated with decreased individual and societal costs while achieving equivalent health outcomes and excellent patient satisfaction. Successful outpatient pediatric surgery is predicated on appropriate patient selection, adequate pain control, thorough preoperative education, and close clinical follow-up. Continuous research in quality, value, and patient safety are needed to ensure that this practice continues in as safe and efficient a manner as possible.

Surgical considerations and challenges in the pediatric and adolescent gynecologic patient

It is important for practitioners to recognize that there are special considerations when performing gynecologic surgery in a pediatric or adolescent patient. A provider must be familiar with differences in anatomy, physiology, surgical technique, and psychosocial concerns. This can be challenging for a provider who does not routinely operate on patients in this population. A minimally invasive surgical approach is preferred in the pediatric and adolescent patient whenever possible. While a good command of laparoscopy in the adult patient is certainly a useful skill when operating on pediatric and adolescent patients, there are technical adaptations and challenges to consider. This chapter reviews the pre-operative preparation, operative technique and challenges, and post-operative care of the surgical pediatric and adolescent gynecologic patient.