Psoas compartment block for acute postoperative pain management after hip surgery in pediatrics: a comparative study with caudal analgesia

Postoperative analgesic effects of the quadratus lumborum block III and transversalis fascia plane block in paediatric patients with developmental dysplasia of the hip undergoing open reduction surgeries: a double-blinded randomised controlled trial

OBJECTIVE

To evaluate the analgesic effectiveness of two novel regional nerve blocks in paediatric patients with developmental dysplasia of the hip (DDH) after open reduction surgeries.

DESIGN

Prospective, double-blinded, randomised controlled trial.

SETTING

2 tertiary teaching hospitals in China between August 2017 and July 2018.

PARTICIPANTS

110 paediatric patients aged 2-10 years with DDH undergoing open reduction surgeries were recruited, 95 were randomised and 90 were included in the final analysis.

INTERVENTIONS

Random assignment to quadratus lumborum block III (QLB III) group, transversalis fascia plane block (TFPB) group and the control (no region nerve block) group.

PRIMARY AND SECONDARY OUTCOME MEASURES

The primary outcome was the Face, Legs, Activity, Cry and Consolability (FLACC) Scale Scores. Secondary outcomes included perioperative opioid consumption, the time until first press of nurse-controlled analgesia/patient-controlled analgesia (NCA/PCA) pump and the total counts number of pressing, length of postanaesthesia care unit (PACU) stay, length of hospital stay, parental satisfaction with pain management and adverse events.

RESULTS

Mean FLACC Scores were significantly lower in QLB III group and TFPB group while in the PACU and for 48 hours postoperatively, compared with control group (p<0.0001, p<0.0001, respectively). No differences were found for FLACC Scores between QLB III group and TFPB group, neither at rest (p=0.0402) nor while posture changing (p=0.0306). TFPB prolonged the first-time request for NCA/PCA analgesia, and decreased the total number of pressing counts, compared with QLB III (22.5 (16.2 to 28.7) vs 11.7 (6.6 to 16.8), p<0.0001; 2.4 (1.3 to 3.6) vs 3.8 (2.8 to 4.8), p=0.0111, respectively). No patient experienced any adverse events.

CONCLUSIONS

We suggested that both ultrasound-guided QLB III and TFPB should be considered as an option for perioperative analgesia in children with DDH undergoing open reduction surgeries. TFPB was superior to the QLB III because it prolonged the first-time request for NCA/PCA analgesia and decreased the total counts number of pressing.

TRIAL REGISTRATION NUMBER

NCT03189966/2017.

Utilization of a Continuous Pericapsular Nerve Group (PENG) Block with an Opioid-Sparing Repair of a Femoral Neck Fracture in a Pediatric Patient

In the pediatric population, femoral neck fractures are usually associated with high-impact trauma and often present with pain in the groin area. Regional anesthesia can offer adjunctive therapy for acute pain management. Various techniques have been employed to circumvent pain related to hip fractures and resultant hip surgery. Neuraxial, lumbar plexus, caudal, epidural, fascia iliaca, and femoral continuous nerve block techniques are advantageous in mitigating hip pain. However, these approaches require patient repositioning during placement and carry the potential for motor blockade with resultant weakness. A newly described method, the Pericapsular Nerve Group (PENG) block, allows for analgesia of the anterior hip capsule via the obturator, accessory obturator, and femoral nerves while sparing motor blockade. PENG blockade has demonstrated efficacy in both adult and pediatric patients. Herein, we describe the perioperative course of a 9-year-old girl with a transcervical femoral neck fracture who underwent an opioid-sparing open repair with the utilization of a continuous PENG block. PENG blockade via a continuous nerve block resulted in optimal analgesia and markedly reduced perioperative opioid consumption with preserved motor function. Our experience facilitated early discharge and rehabilitation mobility while reducing potential rebound hyperalgesia and enabling parental/patient satisfaction.

Evaluation of postoperative analgesia in pediatric patients after hip surgery: lumbar plexus versus caudal epidural analgesia

Background:There continues to be focus on the value of regional and neuraxial anesthetic techniques when combined with general anesthesia to improve postoperative analgesia. The reported advantages include decreased postoperative opioid requirements, decreased medication-related adverse effects, decreased hospital length of stay, and increased patient satisfaction. Orthopedic procedures of the hip may be amenable to such techniques as there is significant postoperative pain with the requirement for hospital admission and the administration of parenteral opioids. Given the surgical site, various regional anesthetic techniques may be used to provide analgesia including caudal epidural anesthesia (CEA) or lumbar plexus blockade (LPB).

Purpose: The objective of this study was to assess the effectiveness of LPB versus CEA as an analgesic thechnique for patients undergoing elective hip surgery from the opioid consumption and pain scores perspective.

Patients and methods: The current study retrospectively reviews our experience with CEA and LPB for postoperative analgesia after hip surgery in the pediatric population. Regional anesthesia technique was reviewed as well as opioid requirements and pain scores.

Results: The study cohort included 61 patients, 29 who received an LPB and 32 who received CEA. No difference was noted in the demographics between the two groups. Intraoperative opioid use was 0.7 (IQR: 0.5, 1.1) mg/kg of oral morphine equivalents (MEs) in the LPB group compared to 0.6 (IQR: 0.5, 0.9) in the CEA group (p=0.479). Postoperative opioid use over the first 48 hrs was 4 (IQR: 1, 6) mg/kg of oral ME in the LPB group, compared to 2 (interquartile range [IQR]: 1, 3) in the CEA group (p=0.103). Over the first 24 hrs after surgery, the median pain score in the LPB group was 5 (IQR: 1–6), compared to 3 (IQR: 0, 5) in the CEA group (p=0.014).Conclusion: These retrospective data suggest a modest postoperative benefit of CEA when compared to LPB following hip surgery in the pediatric population. Postoperative pain scores were lower in patients receiving CEA; however, no difference in the intraoperative or postoperative opioid requirements was noted between the two groups.

Effect of ultrasound-guided lumbar plexus block on emergence agitation in children undergoing hip surgery: study protocol for a randomized controlled trial

Background

Emergence agitation (EA) is a common postoperative issue in children that causes self-injury, increases stress on healthcare team members, and even leads to postoperative maladaptive behavioral changes in children. Clear answers regarding a ‘gold standard’ for prevention of EA are not available. Pain is regarded as an important causative factor of EA, and ultrasound-guided lumbar plexus block is a safe and efficient anesthetic method that can provide satisfactory pain relief in pediatric hip surgery. The purpose of our study is to determine whether ultrasound-guided lumbar plexus block can reduce the incidence of EA in children undergoing hip surgery.

Methods/design

We designed a prospective, randomized, controlled, blinded trial to determine the effect of ultrasound-guided lumbar plexus block on EA. A total of 100 American Society of Anesthesiologists class I–II children (1–6 years old) scheduled for elective hip surgery will be recruited for this study. Participants will be randomized at a 1:1 ratio to receive either ultrasound-guided lumbar plexus block or fentanyl after the induction of general anesthesia. The primary outcome is the incidence of EA 30 min after emergence from anesthesia using the Pediatric Anesthesia Emergence Delirium (PAED) score. The secondary outcomes are the severity and duration of EA 30 min after emergence from anesthesia using the PAED score, postoperative pain evaluated by the Children’s Hospital of Eastern Ontario Pain Scale, and the incidence of postoperative adverse events. Randomization will be conducted using a computer-generated randomization schedule. Outcome assessors and data collectors will be blinded to the group allocations. Assessments will be performed before surgery, intraoperatively, and postoperatively at every time point.

Discussion

Our hypothesis in this trial is that ultrasound-guided lumbar plexus block can decrease the incidence of EA in children undergoing elective hip surgery. This trial will provide clinical answers to verify our hypothesis. If our hypothesis is confirmed, the results could provide a safe method to prevent EA.

Trial registration

Chinese Clinical Trial Registry, ChiCTR-INR-17011525. Registered on 30 May 2017.

Electronic supplementary material

The online version of this article (10.1186/s13063-018-3140-3) contains supplementary material, which is available to authorized users.

Everyday regional anesthesia in children

Regional anesthesia in children is an evolving technique with many advantages in perioperative management. Although most regional anesthesia techniques are sufficiently described in the literature, the implementation of these techniques into daily clinical practice is still lacking. The main problems associated with pediatric regional anesthesia (PRA) include the appropriate selection of blockade, the management around the block, and how to teach these techniques in an optimal manner. This review article provides an overview of these 'hot' topics in PRA.