Local anaesthetic dosage of peripheral nerve blocks in children: analysis of 40 121 blocks from the Pediatric Regional Anesthesia Network database

Anatomical Studies Evaluating Pediatric Regional Anesthesia: A Scoping Review

BACKGROUND

Pediatric regional anesthesia has been driven by the gradual rise in the adoption of opioid-sparing strategies and the growing concern over the possible adverse effects of general anesthetics on neurodevelopment. Nonetheless, performing regional anesthesia studies in a pediatric population is challenging and accounts for the scarce evidence. This study aimed to review the scientific foundation of studies in cadavers to assess regional anesthesia techniques in children.

METHODS

We searched the following databases MEDLINE, EMBASE, and Web of Science. We included anatomical cadaver studies assessing peripheral nerve blocks in children. The core data collected from studies were included in tables and comprised block type, block evaluation, results, and conclusion.

RESULTS

The search identified 2409 studies, of which, 16 were anatomical studies on the pediatric population. The techniques evaluated were the erector spinae plane block, ilioinguinal/iliohypogastric nerve block, sciatic nerve block, maxillary nerve block, paravertebral block, femoral nerve block, radial nerve block, greater occipital nerve block, infraclavicular brachial plexus block, and infraorbital nerve block.

CONCLUSION

Regional anesthesia techniques are commonly performed in children, but the lack of anatomical studies may result in reservations regarding the dispersion and absorption of local anesthetics. Further anatomical research on pediatric regional anesthesia may guide the practice.

Erector spinae plane blocks for opioid-sparing multimodal pain management after pediatric cardiac surgery

OBJECTIVE

Peripheral regional anesthesia is proposed to enhance recovery. We sought to evaluate the efficacy of bilateral continuous erector spinae plane blocks (B-ESpB) for postoperative analgesia and the impact on recovery in children undergoing cardiac surgery.

METHODS

Patients aged 2 through 17 years undergoing cardiac surgery in the enhanced recovery after cardiac surgery program were prospectively enrolled to receive B-ESpB at the end of the procedure, with continuous infusions via catheters postoperatively. Participants wore an activity monitor until discharge. B-ESpB patients were retrospectively matched with control patients in the enhanced recovery after cardiac surgery program. Outcomes of the matched clusters were compared using exact conditional logistic regression and generalized linear modeling.

RESULTS

Forty patients receiving B-ESpB were matched to 78 controls. There were no major complications from the B-ESpB or infusions, and operating room time was longer by a median of 31 minutes. While blocks were infusing, patients with B-ESpB received fewer opioids in oral morphine equivalents than controls at 24 hours (0.60 ± 0.06 vs 0.78 ± 0.04 mg/kg; P = .02) and 48 hours (1.13 ± 0.08 vs 1.35 ± 0.06 mg/kg; P = .04), respectively. Both groups had low median pain scores per 12-hour period. There was no difference in early mobilization, length of stay, or complications.

CONCLUSIONS

B-ESpBs are safe in children undergoing cardiac surgery. When performed as part of a multimodal pain strategy in an enhanced recovery after cardiac surgery program, pediatric patients with B-ESpB experience good pain control and require fewer opioids in the first 48 hours.

Intravenous dexamethasone does not prolong the duration of pudendal nerve block in infants and children undergoing hypospadias surgery: A randomized clinical trial

BACKGROUND

The administration of intravenous dexamethasone increases the duration of neuraxial block and improves the quality of analgesia. However, little is known about these effects of dexamethasone on peripheral nerve blocks in children.

AIMS

In this study, we aimed to investigate the benefit of intravenous dexamethasone for enhancing the effect of pudendal block on postoperative analgesia in children who underwent hypospadias surgery.

METHODS

In total, 46 children aged 6-36 months who underwent hypospadias surgery were randomly allocated to either a control group (normal saline, group C) or dexamethasone group (0.5 mg/kg, group D). Pudendal block was performed before the surgery using 0.3 mL/kg of 0.225% ropivacaine on both sides. Parents were instructed to press the patient-controlled analgesia bolus button when their children's pain score was >4 points. The primary outcome measure was the time at which the first patient-controlled analgesia by proxy bolus dose was administered. The secondary outcome measures were pain score, number of patient-controlled analgesia administration by proxy bolus attempts, number of rescue analgesics required, total amount of fentanyl administered, and overall parental satisfaction.

RESULTS

The time of first patient-controlled analgesia bolus administration by proxy was not different between the control and dexamethasone groups (5.6 [5.2, 8.8] h versus 6.5 [5.4, 8.1] h, hazard ratio 0.8, 95% confidence intervals 0.43 to 1.47, p = .46). There were no statistically significant differences among the secondary outcomes.

CONCLUSIONS

Administration of intravenous dexamethasone did not enhance the duration of pudendal nerve block in infants and children aged 6-36 months who underwent hypospadias surgery.

Perioperative Regional Anesthesia Pain Outcomes in Children: A Retrospective Study of 3160 Regional Anesthetics in Routine Practice

OBJECTIVE

Randomized controlled trials indicate regional anesthesia (RA) improves postoperative outcomes with reduced pain and opioid consumption. Therefore, we hypothesized children who received RA, regardless of technique, would have reduced pain/opioid use in routine practice.

METHODS

Using a retrospective cohort, we assessed the association of RA with perioperative outcomes in everyday practice at our academic pediatric hospital. Patients 18 years or below undergoing orthopedic, urologic, or general surgeries with and without RA from May 2014 to September 2021 were categorized as single shot, catheter based, or no block. Outcomes included intraoperative opioid exposure and dose, preincision anesthesia time, postanesthesia care unit (PACU) opioid exposure and dose, PACU antiemetic/antipruritic administration, PACU/inpatient pain scores, PACU/inpatient lengths of stay, and cumulative opioid exposure. Regression models estimated the adjusted association of RA with outcomes, controlling for multiple variables.

RESULTS

A total of 11,292 procedures with 3160 RAs were included. Compared with no-block group, single-shot and catheter-based blocks were associated with opioid-free intraoperative anesthesia and opioid-free PACU stays. Post-PACU (ie, while inpatient), single-shot blocks were not associated with improved pain scores or reduced opioid use. Catheter-based blocks were associated with reduced PACU and inpatient opioid use until 24 hours postop, no difference in opioid use from 24 to 36 hours, and a higher probability of use from 36 to 72 hours. RA was not associated with reduced cumulative opioid consumption.

DISCUSSION

Despite adjustment for confounders, the association of RA with pediatric pain/opioid use outcomes was mixed. Further investigation is necessary to maximize the benefits of RA.

Median effective dose of 0.2% ropivacaine for ultrasound-guided median nerve block in young children

OBJECTIVE

To determine the median effective dose (ED₅₀) and the 95% effective dose (ED₉₅) of 0.2% ropivacaine for ultrasound-guided lower forearm median nerve block in paediatric patients.

METHODS

Eligible children were American Society of Anesthesiologists (ASA) status I-II scheduled to have elective open surgery for trigger thumb repair. Patients were stratified into two age groups: 1- to 3-year-olds and 3- to 6-year-olds. The ED₅₀ was determined by Dixon's up-and-down method. The first patient received an ultrasound-guided median nerve block by injection of 2 mL of 0.2% ropivacaine. Each subsequent patient's dose was determined by the response of the previous patient, the doses being adjusted in intervals of 0.2 mL. In addition, the 95% effective dose (ED₉₅) was obtained using a probit regression approach. The patients' general condition, postoperative pain scores, and adverse events were recorded.

RESULTS

A total of 52 children who were scheduled to undergo open surgery for trigger thumb were included in this study: 28 in the 1- to 3-year-olds group and 24 in the 3- to 6-year-olds group. The ED₅₀ (95% confidence interval) values were 0.9 (0.44-1.36) mL in 1- to 3-year-olds and 1.4 (1.14-1.66) mL in 3- to 6-year-olds. The ED₉₅ (95% confidence interval) values were 1.5 (0.98-1.58) mL in 1- to 3-year-olds and 1.7 (1.54-1.78) mL in 3- to 6-year-olds. No adverse events occurred.

CONCLUSIONS

A single dose of ropivacaine was an effective agent for young children requiring ultrasound-guided lower forearm median nerve block in open surgery for trigger thumb. The ED₅₀ (95% confidence interval) values were 0.9 (0.44-1.36) mL in 1- to 3-year-olds and 1.4 (1.14-1.66) mL in 3- to 6-year-olds. The ED₉₅ (95% confidence interval) values were 1.5 (0.98-1.58) mL in 1- to 3-year-olds and 1.7 (1.54-1.78) mL in 3- to 6-year-olds.

Pediatric lower limb peripheral nerve blocks: Indications, effectiveness, and the incidence of adverse events

AIM

While the proportion of pediatric anesthetics with regional anesthesia in pediatric patients has steadily increased, there are only a few series that describe the use of lower limb peripheral nerve blocks in children. Our aim was to describe the indications, anesthetic approach, and complications associated with lower limb blocks in children undergoing orthopedic surgery in a center with a large caseload of complex patients.

METHODS

In a retrospective analysis of prospectively collected data, we reviewed children who had a peripheral nerve block for orthopedic surgery placed between January 2016 and January 2021 at the Royal Children's Hospital Melbourne. Block data were sourced from the electronic medical record and departmental regional anesthesia database. Data collected included demographics, the site of catheter placement and technique of nerve block, presence of sensory/motor blockade, the use of perioperative opioids, and any complications related to peripheral nerve block.

RESULTS

A total of 1438 blocks were performed in 1058 patients. Four patients had clinical features of perioperative neurological injury giving an incidence of 3 per 1000 blocks (95% CI 1.1-8:1000). Only one patient had a sensory deficit persisting longer than 6 months for an incidence of 0.8 per 1000 blocks (95% CI 0.1-5:1000). All four peripheral nerve injury followed tibial osteotomy for lengthening procedures or correction of tibial torsion. The etiology of the injury could not be determined despite imaging and surgical exploration and the contribution of popliteal sciatic nerve block to the subsequent PNI could not be confirmed. There were no cases of local anesthetic systemic toxicity.

CONCLUSION

An increased risk of perioperative peripheral nerve injury is associated with pediatric tibial osteotomy for congenital deformity. While popliteal sciatic nerve block was not directly implicated in the nerve injury the presence of a prolonged sensory block can delay early recognition and treatment of peripheral nerve injury.

The Effect of Sugammadex on Time of Sciatic Block by Perineural Bupivacaine in Rats

OBJECTIVES

We aimed to investigate the effect of sugammadex on the motor, sensory and deep sensory block in the sciatic nerve created by bupivacaine in rats.

MATERIALS AND METHODS

18 Sprague-Dawley adult male rats treated with unilateral sciatic nerve block by bupivacaine (0.2 ml) were randomly divided into three groups. Control group (Group C, n = 6, 1.5 mL saline) perineural sugammadex group (Group PNS, n = 6, 16 mg/kg) and intraperitoneal sugammadex group (Group IPS, n = 6, 16 mg/kg) Motor, sensory, and deep sensory functions were evaluated every 10 minutes by a blind researcher. 6 tissue samples each belonging to the sciatic nerve, 1.5 cm in length and 0.2 cm in diameter, were taken from paraffin blocks. Sections of 3-4 micrometers were stained with Hematoxylin + Eosin, Masson Trichrome dyes and examined under a light microscope.

RESULTS

There was no statistically significant difference between 3 groups in terms of the time to return to normal motor, sensory and deep sensory function. There was also no significant difference in edema, extracellular matrix, and myelin. Inflammatory cells were seen in all groups, mainly epineurium, epineurium, and perineurium.

CONCLUSION

There are findings of no histological effects or effects on local block of sugammadex in rats undergoing sciatic nerve block.

Peripheral Nerve Block Complications in Children

Regional anesthesia, and in particular peripheral nerve block (PNB) techniques, complement existing anesthetic and pain management strategies and facilitate a comprehensively safer experience for the pediatric patient. Ultimately, the use of regional anesthesia cultivates a more satisfactory experience for all involved. Complication rates are very low, making PNBs a very safe option as proliferative incorporation of ultrasound technology has led to further enhancement of regional anesthesia safety and efficacy in the pediatric population.

Ultrasound in paediatric anaesthesia - A comprehensive review

The use of ultrasound is becoming more widespread in anaesthesia. In this review, we discuss the use of ultrasound in various aspects of paediatric anaesthesia and how it can be used to assist diagnostic and therapeutic interventions and the evidence available. We explore the use of ultrasound as an adjunct for regional anaesthesia, vascular access, airway management, bedside cardiac, pulmonary and abdominal imaging and intracranial pressure monitoring.

Neurotoxic Effects of Local Anesthetics on Developing Motor Neurons in a Rat Model

Neurotoxic effects of local anesthetics (LAs) on developing motor neurons have not been documented. We investigated the neurotoxic effects of LAs on developing motor neurons in terms of cell viability, cytotoxicity, reactive oxygen species (ROS), and apoptosis. Embryonic spinal cord motor neurons were isolated from Sprague-Dawley rat fetuses and exposed to one of the three LAs-lidocaine, bupivacaine, or ropivacaine-at concentrations of 1, 10, 100, or 1000 µM. The exposure duration was set to 1 or 24 h. The neurotoxic effects of LAs were determined by evaluating the following: cell viability, cytotoxicity, ROS production, and apoptosis. In the 1-h exposure group, the motor neurons exposed to lidocaine and bupivacaine had reduced cell viability and increased cytotoxicity, ROS, and apoptosis in a concentration-dependent manner. Lidocaine showed the highest toxicity, followed by bupivacaine. In the 24-h exposure group, all three LAs showed significant effects (decreased cell viability and increased cytotoxicity, ROS, and apoptosis) on the motor neurons in a concentration-dependent manner. The neurotoxic effects of lidocaine were greater than those of bupivacaine and ropivacaine. Ropivacaine appeared to have the least effect on motor neurons. This study identified the neurotoxic effects of lidocaine and bupivacaine on developing spinal cord motor neurons.

Updates on neurologic complications in pediatric regional anesthesia

Regional anesthesia has grown in popularity as a multimodal approach to analgesia. However, some anesthesiologists are fearful of regional blocks in pediatric patients as most require general anesthesia. One of the most alarming complications is neurologic injury. While there are limited case reports regarding the devastating neurologic injuries in pediatric patients, review of large databases has shown a level of safety in pediatric regional anesthesia that is comparable to that in adult patients. This review aimed to provide an update on the relevant literature regarding neurologic complications and the safety of regional blocks in pediatric patients. These large data sets have confirmed that regional anesthesia is a useful and safe modality in pediatric patients.

A Prospective, randomized comparative study between ultrasound-guided posterior quadratus lumborum block and ultrasound-guided ilioinguinal/iliohypogastric nerve block for pediatric inguinal herniotomy

BACKGROUND

Ilioinguinal/iliohypogastric nerve block is commonly performed to control postherniotomy pain. The posterior quadratus lumborum block has been recently described as an effective analgesic technique for pediatric low abdominal surgery. No data were found regarding the use of posterior quadratus lumborum block in comparison with the traditional ilioinguinal/iliohypogastric nerve block in pediatric inguinal surgery.

AIM

This randomized assessor-blinded study compared postoperative analgesic effects between ultrasound-guided posterior quadratus lumborum block and ilioinguinal/iliohypogastric nerve block in pediatric inguinal herniotomy.

METHODS

One- to seven-year-old children scheduled for unilateral open herniotomy were randomly assigned to receive either ultrasound-guided posterior quadratus lumborum block with 0.25% bupivacaine 0.5 mL/kg or ultrasound-guided ilioinguinal/iliohypogastric nerve block with 0.25% bupivacaine 0.2 mL/kg after induction of general anesthesia. The primary outcome was the proportion of patients who received postoperative oral acetaminophen. The required fentanyl in the recovery room, 24-hour acetaminophen consumption, success rate of regional blocks, block performance data, block-related complications, postoperative pain intensity, and parental satisfaction were assessed.

RESULTS

This study included 40 patients after excluding four cases who were ineligible. The number of patients who required postoperative oral acetaminophen was significantly lower in the posterior quadratus lumborum block group (15.8% vs 52.6%; OR: 5.9; 95% CI: 1.3, 27.3; P = .022). The pain scores at 30 minutes, 1, 2, 6, 12, and 24 hours were similar between groups. There was no evidence of between-group differences in block performance time, the number of needle passes, block-related complications, and parental satisfaction.

CONCLUSION

The posterior quadratus lumborum block with 0.25% bupivacaine 0.5 mL/kg provided better pain control than the ilioinguinal/iliohypogastric nerve block with 0.25% bupivacaine 0.2 mL/kg after open herniotomy in children. The ultrasound guidance technique for the posterior quadratus lumborum block is safe and as simple as the ultrasound-guided ilioinguinal/iliohypogastric nerve block for pediatric patients.

Epidemiology of regional anesthesia in children: Lessons learned from the European Multi-Institutional Study APRICOT

BACKGROUND

Recently, the European prospective observational multicenter cohort study, APRICOT, reported anesthesia techniques and complications in more than 31 000 pediatric procedures. The main objective of this study was to analyze the current practice in regional anesthesia in the 33 countries that participated to APRICOT.

METHODS

Data on regional anesthesia techniques were extracted from the database of APRICOT (261 centers across 33 European countries). All children, aged from birth to 16 years old, were eligible for inclusion during a 2-week period. Type of regional anesthesia, whether used awake or with sedation or general anesthesia, techniques of guidance, and the drugs administered were analyzed.

RESULTS

Regional anesthesia was used in 4377 pediatric surgical procedures. The large majority was performed under general anesthesia with central blocks and truncal blocks, representing, respectively, 42.6% and 41.8% of performed techniques. Caudal blocks represented 76.9% of all central blocks. The penile and ilioinguinal/iliohypogastric blocks were the most commonly performed truncal blocks. Anesthetists used mainly anatomical landmarks; ultrasound guidance was applied in only 23.8% of cases. A wide variability of practices was observed in terms of regional anesthesia techniques and local anesthetics among the participating European countries. No serious complications were reported.

CONCLUSION

These data show a large predominance of central and truncal blocks in APRICOT study. Ultrasound guidance was mainly used for peripheral nerve blocks while central blocks were performed using landmark techniques.