Regional anesthesia in pediatrics: marching forward

Is Ultrasound-Guided Single-Shot Quadratus Lumborum Block a Viable Alternative to a Caudal Block in Pediatric Urological Surgery?

OBJECTIVE

 To review our experience with quadratus lumborum block (QLB) in pediatric urology.

MATERIALS AND METHODS

 This mixed prospective-retrospective study included 41 patients who received QLB following induction of general anesthesia. Data collected included: the duration of block induction, surgery, hospitalization, postoperative pain score, and the use of rescue analgesia. The results were compared with a matched cohort of patients who received caudal block (CB) during similar surgeries from our retrospectively acquired data registry.

RESULTS

 There was no difference between the type and length of surgery, weight, sex, and age of the patients between the two groups. The duration of block induction was significantly shorter in the CB group compared with the QLB group (35.6 ± 14.6 vs. 239 ± 33.4 seconds [p < 0.0001]). There was no difference between the groups in pain scores at 1, 4, and 24 hours postoperatively, in the time to first rescue analgesia, or in the postoperative opioid requirements. However, the QLB group required more rescue analgesia compared with CB group (p = 0.016). Finally, no differences were found in the use of rescue analgesics at home, pain record behavior, and overall satisfaction.

CONCLUSION

 Our data show that QLB might serve as a viable alternative to CB in pediatric urological surgery.

Regional Anesthesia Use in Pediatric Burn Surgery: A Descriptive Retrospective Series

Pediatric burns are a common and often devastating injury. Treatment, reconstruction, and rehabilitation are painful experiences. For some, the experience triggers post-traumatic stress disorder and/or a chronic pain syndrome. Given the role pain plays as a major secondary disease, it must be addressed to achieve optimal healing. Regional anesthesia has been used extensively to manage postoperative pain and reduce the need for opioids following other surgical procedures in children. However, regional anesthesia is not widely used in pediatric burn care. We present a descriptive, retrospective case series of 15 pediatric burn patients who received regional anesthesia as part of their intra-operative pain management. In our patient population, we saw low levels of anesthetic as well as opioid usage with well-controlled pain. In this cohort, 93% of patients scored a 0/10 on the Face, Legs, Activity, Cry and Consolability (FLACC) scale for pain by post-anesthesia care unit (PACU) discharge, with an average PACU stay of 70 minutes. Thirty-three percent of patients received no opioids, with the average opioid dose being 0.06mg/kg morphine equivalents. This case series serves to make clinicians aware of the feasibility of use and benefits of regional anesthesia in pediatric burn patients requiring operative repair.

Quadratus Lumborum Block As A Single Anesthetic Method For Laparoscopic Totally Extraperitoneal (Tep) Inguinal Hernia Repair: A Randomized Clinical Trial

Minimally invasive surgery for inguinal hernia repair is advantageous in terms of return to usual activities and lower rates of chronic pain; however, it requires general anesthesia. This study sought to analyze the benefits of ultrasound guided locoregional anesthesia of the quadratus lumborum muscle (QL block) as a single anesthetic technique for endoscopic totally extraperitoneal (TEP) inguinal hernia repair with regard to postoperative pain, length of hospital stay, and hospital cost. A total of 46 patients, aged 18 to 80 years, with unilateral inguinal hernia, one group that received general anesthesia and one that received sedation and QL block for TEP inguinal hernia repair. In the 46 patients the median pain score 6 hours after surgery was significantly lower (2 versus 4) among the QL block group than among the group receiving general anesthesia. Consequently, the former group showed a briefer median hospital stay (6 versus 24 hours, respectively). The anesthesia and hospital costs were also lower for the QL block group, with median reductions of 64.15% and 25%, respectively. QL block is a safe and effective option for patients undergoing TEP inguinal hernia repair, given the observed reduction in early postoperative pain, briefer hospital stay, and decreased anesthesia and hospital costs.

Paediatric regional anaesthesia: a current perspective

PURPOSE OF REVIEW

Effective analgesia is necessary for optimal recovery after surgery, but children often do not attain adequate postoperative pain control. This review examines the current trends in paediatric regional anaesthesia.

RECENT FINDINGS

Better pain assessment and therapeutic regimens are needed for our patients. Trunk blocks such as paravertebral, transversus abdominis plane, rectus sheath and ilioinguinal/iliohypogastric are becoming a popular means of providing analgesia for thoracic and abdominal procedures. The introduction of ultrasound guidance improves accuracy, efficacy, and safety of regional anaesthesia, and also decreases the amount of local anaesthetic injected. Single injection nerve blocks have a limited duration and the patients can benefit from adding an adjunct to local anaesthetic or placing a catheter. The use of adjuncts is reasonable, but it is difficult to find a medication with both minimal side-effects and the ability to combat pain for extended periods of time. More peripheral nerve block catheters are used in the paediatric inpatient and outpatient settings and recent data support the feasibility and efficacy of ambulatory peripheral nerve catheters.

SUMMARY

By using a multimodal approach that includes regional anaesthesia, paediatric pain management should aim to reduce patients' pain to an acceptable level without compromising their degree of mobilization. Undoubtedly, peripheral nerve blocks improve analgesia, but future large prospective studies should be conducted to further delineate their effectiveness, duration and safety.