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Katzir Y, Ganor L, Berant R, Shahar-Nissan K. Building Blocks-A Block-by-Block Approach to Better Emergency Care in Children. Pediatr Emerg Care 2024; 40:463-468. [PMID: 38563828 DOI: 10.1097/pec.0000000000003201] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/04/2024]
Abstract
OBJECTIVE We describe a case series of regional nerve blocks, which comprise an adapted framework for the pediatric emergency setting and were performed by pediatric emergency medicine physicians. METHODS A case series of 8 different ultrasound-guided nerve blocks and 1 anatomical block, performed in 11 pediatric patients, aged 7 weeks to 17 years. RESULTS All blocks resulted in adequate analgesia. No procedural complications were observed. CONCLUSION We describe a set of nerve blocks performed by emergency medicine physicians in the pediatric population in an ED setting. In suitable settings, this is a safe and effective tool for procedural analgesia or for pain management. In such cases, performing an ultrasound-guided nerve block in the ED is a viable alternative for repeated doses of opiates, deep procedural sedation, or the operating theater. We propose this set of regional anesthesia procedures as a pediatric-adapted toolkit for the emergency physician to be performed in children in the ED setting. Adopting this set of procedures ensures better and safer care for children and provides a training framework for pediatric ED physicians.
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Affiliation(s)
| | - Lior Ganor
- Hillel Yaffe Medical Center, Hadera, Israel
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2
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Sauter AR, Steinfeldt T. Editorial: Safety monitoring for peripheral nerve blocks - Is there a state-of-the-art standard to avoid nerve injuries? J Clin Anesth 2024; 94:111400. [PMID: 38359687 DOI: 10.1016/j.jclinane.2024.111400] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2023] [Revised: 12/29/2023] [Accepted: 01/19/2024] [Indexed: 02/17/2024]
Affiliation(s)
- Axel R Sauter
- Department of Anesthesia and Intensive Care Medicine, Oslo University Hospital, Oslo, Norway; Department of Anesthesiology, Bern University Hospital Inselspital, University of Bern, Bern, Switzerland.
| | - Thorsten Steinfeldt
- Department for Anesthesia, Intensive Care Medicine and Pain Therapy, BG Unfallklinik Frankfurt am Main gGmbH, Frankfurt, Germany; Department of Anesthesiology and Intensive Care, Philipps University Hospital, Philipps University Marburg, Marburg, Germany
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3
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Sbaraglia F, Cuomo C, Della Sala F, Festa R, Garra R, Maiellare F, Micci DM, Posa D, Pizzo CM, Pusateri A, Spano MM, Lucente M, Rossi M. State of the Art in Pediatric Anesthesia: A Narrative Review about the Use of Preoperative Time. J Pers Med 2024; 14:182. [PMID: 38392615 PMCID: PMC10890671 DOI: 10.3390/jpm14020182] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2023] [Revised: 02/05/2024] [Accepted: 02/05/2024] [Indexed: 02/24/2024] Open
Abstract
This review delves into the challenge of pediatric anesthesia, underscoring the necessity for tailored perioperative approaches due to children's distinctive anatomical and physiological characteristics. Because of the vulnerability of pediatric patients to critical incidents during anesthesia, provider skills are of primary importance. Yet, almost equal importance must be granted to the adoption of a careful preanesthetic mindset toward patients and their families that recognizes the interwoven relationship between children and parents. In this paper, the preoperative evaluation process is thoroughly examined, from the first interaction with the child to the operating day. This evaluation process includes a detailed exploration of the medical history of the patient, physical examination, optimization of preoperative therapy, and adherence to updated fasting management guidelines. This process extends to considering pharmacological or drug-free premedication, focusing on the importance of preanesthesia re-evaluation. Structural resources play a critical role in pediatric anesthesia; components of this role include emphasizing the creation of child-friendly environments and ensuring appropriate support facilities. The results of this paper support the need for standardized protocols and guidelines and encourage the centralization of practices to enhance clinical efficacy.
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Affiliation(s)
- Fabio Sbaraglia
- Department of Anesthesia and Intensive Care, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
| | - Christian Cuomo
- Department of Anesthesia and Intensive Care, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
| | - Filomena Della Sala
- Department of Anesthesia and Intensive Care, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
| | - Rossano Festa
- Department of Anesthesia and Intensive Care, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
| | - Rossella Garra
- Department of Anesthesia and Intensive Care, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
| | - Federica Maiellare
- Department of Anesthesia and Intensive Care, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
| | - Daniela Maria Micci
- Department of Anesthesia and Intensive Care, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
| | - Domenico Posa
- Department of Anesthesia and Intensive Care, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
| | - Cecilia Maria Pizzo
- Department of Anesthesia and Intensive Care, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
| | - Angela Pusateri
- Department of Anesthesia and Intensive Care, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
| | - Michelangelo Mario Spano
- Department of Anesthesia and Intensive Care, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
| | - Monica Lucente
- Department of Anesthesia and Intensive Care, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
| | - Marco Rossi
- Department of Anesthesia and Intensive Care, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
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4
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Baizhanova A, Zhailauova A, Sazonov V. Regional anesthesia for pain control in children with solid tumors-a review of case reports. Front Pediatr 2024; 11:1275531. [PMID: 38274469 PMCID: PMC10808161 DOI: 10.3389/fped.2023.1275531] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2023] [Accepted: 12/26/2023] [Indexed: 01/27/2024] Open
Abstract
Introduction Around seventy percent of all childhood cancer patients suffer from severe pain. This pain can arise from various sources, including tumors themselves, pain caused by metastasizing tumor cells or as the outcome of therapy meant to deal with tumors. If managed inadequately, such pain can lead to many hazardous sequelae. However, there are extreme cases when pain does not respond to standard treatment. For such cases, regional anesthesia or nerve blocks are utilized as the utmost pain control measure. Blocks are used to treat pain in patients who no longer respond to conventional opioid-based treatment or whose worsened condition makes it impossible to receive any other therapy. The data regarding the use of regional anesthesia for such cases in the children population is limited. Methods For this review we searched for case reports in Scopus and PubMed from inception to 2023. The descriptive search items included terms related to childhood cancer and the description of each block. The inclusion criteria for review include children (0-18 years old) receiving oncology-related surgical procedures or palliative care. The data collection was limited to solid tumor-related cases only. We analyzed a total of 38 studies that included case reports and one retrospective study. Results and discussion It was concluded that nerve blocks, although rarely performed, are a safe and efficient way of pain control in children with solid tumors. The major settings for block performance are postoperative pain control and palliative care. We observed that block indication and its outcomes depend on unique health circumstances in which they should be performed. Patients with similar diagnoses had differing outcomes while receiving the same block treatment.
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Affiliation(s)
| | - Azhar Zhailauova
- Department of Surgery, School of Medicine, Nazarbayev University, Astana, Kazakhstan
| | - Vitaliy Sazonov
- Department of Surgery, School of Medicine, Nazarbayev University, Astana, Kazakhstan
- Pediatric Anesthesiology and Intensive Care Unit, National Research Center for Maternal and Child Health, University Medical Center, Astana, Kazakhstan
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5
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Xie L, Tao H, Bao F, Zhu Y, Fang F, Bao X, Zhu S, Kang X. Major complications of caudal block: A prospective survey of 973 cases in adult anorectal surgery. Heliyon 2023; 9:e20759. [PMID: 37860549 PMCID: PMC10582384 DOI: 10.1016/j.heliyon.2023.e20759] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2023] [Revised: 09/26/2023] [Accepted: 10/05/2023] [Indexed: 10/21/2023] Open
Abstract
Background We conducted a prospective study of surgical inpatients at a teaching hospital to assess the incidence and potential risk factors for major complications of caudal anesthesia in anorectal surgery. Methods A total of 973 patients undergoing anorectal surgery under caudal block were included in this prospective, observer-blinded trial after providing consent. Demographic information, detailed perioperative information, anesthesia-related complications and postoperative follow-up information were recorded. Meanwhile, the incidence and risk factors for major caudal anesthesia-related complications were analyzed. Results A total of 973 patients underwent caudal block. The effective rate was 95.38 % (928 cases). However, there were still 38 (3.91 %) cases with insufficient block and 7 (0.72 %) cases with no block. The major anesthesia-related complications were local anesthetic systemic toxicity (9, 0.92 %), cauda equine syndrome (1, 0.10 %), transient neurological symptoms (3, 0.31 %) and localized pain at the caudal insertion site (30, 3.08 %). The identified risk factor for local anesthetic systemic toxicity was multiple attempts locating the caudal space (OR = 5.30; 1.21-23.29). The identified risk factor for localized pain at the caudal insertion site was multiple attempts locating the caudal space (OR = 10.57; 4.89-22.86). Conclusion The main complications of caudal block in adult patients are transient neurological symptoms, cauda equine syndrome, serious local anesthetic systemic toxicity and localized pain at the caudal insertion site. Overall, the incidence of complications is low and symptoms are mild. Caudal block is still a safe and reliable method for anesthesia in adult anorectal surgery.
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Affiliation(s)
- Liwei Xie
- Department of Anesthesiology, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Honglei Tao
- Department of Anesthesiology, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
- Tongde hospital of Zhejiang Province, China
| | - Fangping Bao
- Department of Anesthesiology, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Yeke Zhu
- Department of Anesthesiology, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Fuquan Fang
- Department of Anesthesiology, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Xiuxia Bao
- Department of Anesthesiology, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Shengmei Zhu
- Department of Anesthesiology, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Xianhui Kang
- Department of Anesthesiology, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
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6
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Miguel Ruano G, Leal Quiñones F, Arribas Sánchez C, Álvarez Avello JM. Ultrasound-guided sciatic popliteal block performed at the Emergency Department in a patient with a scorpion bite and severe pain. REVISTA ESPANOLA DE ANESTESIOLOGIA Y REANIMACION 2023; 70:358-361. [PMID: 37276965 DOI: 10.1016/j.redare.2022.06.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/08/2021] [Accepted: 06/26/2022] [Indexed: 06/07/2023]
Abstract
We report the case of a paediatric patient who presented at the Emergency Department with severe pain in the right lower extremity caused by a scorpion sting. Analgesics were ineffective, so we decided to perform an ultrasound-guided popliteal block, which provided complete analgesia and allowed the patient to be followed up in the outpatient department, with no adverse effects. The sting of the species of scorpion found in Spain is not dangerous to human life; however, it causes self-limiting localised pain that lasts for 24-48h, and can be severe. The first-line treatment is effective analgesia. Regional anaesthesia techniques are useful in the control of acute pain, and are an example of effective collaboration between the Anaesthesiology and Emergency services.
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Affiliation(s)
- G Miguel Ruano
- Departamento de Anestesia-UCI, Clínica Universidad de Navarra, Madrid, Spain.
| | - F Leal Quiñones
- Departamento de Anestesia-UCI, Clínica Universidad de Navarra, Madrid, Spain
| | - C Arribas Sánchez
- Departamento de Pediatría, Clínica Universidad de Navarra, Madrid, Spain
| | - J M Álvarez Avello
- Departamento de Anestesia-UCI, Clínica Universidad de Navarra, Madrid, Spain
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Vila Moutinho Tavares S, Tavares JC, Borges Marques J, Teixeira de Figueiredo J, Passos de Souza RL. Ketamine-dexmedetomidine combination for sedation in pediatric major surgery in a low-income country. Paediatr Anaesth 2023; 33:278-281. [PMID: 35445494 DOI: 10.1111/pan.14465] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2022] [Revised: 04/11/2022] [Accepted: 04/12/2022] [Indexed: 11/25/2022]
Abstract
Anorectal malformations are one of the most frequent congenital malformations treated by pediatric surgeons. In low-income countries, the surgical and anesthetic management of children in need of these procedures can be challenging. Limited oxygen supply, lack of equipment, especially pediatric, and intensive care units make the use of regional anesthesia appealing. We present a series of four cases of anorectal malformations corrections in Guinea Bissau, in children up to 13 months of age, under regional anesthesia and sedation with ketodex, a mixture of ketamine and dexmedetomidine (in a proportion of 1 mg to 1 μg). No child developed respiratory depression requiring airway intervention or supplemental oxygen, or had hemodynamic instability.
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Affiliation(s)
| | - João C Tavares
- Department of Anesthesiology 1, Centro Hospitalar Universitário do Algarve, Faro, Portugal
| | | | | | - Renato Lucas Passos de Souza
- Department of Anesthesiology, Hospital das Clínicas da Faculdade de Medicina de Ribeirão Preto, HCFMRP-USP, Ribeirão Preto, Brazil
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8
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Lönnqvist PA. Spinal anesthesia in children: a narrative review. Best Pract Res Clin Anaesthesiol 2023. [DOI: 10.1016/j.bpa.2023.01.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/10/2023]
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9
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Pearson AME, Roberts S, Turbitt LR. New blocks on the kids: core basic nerve blocks in paediatric anaesthesia. Anaesthesia 2023; 78:3-8. [PMID: 36220155 DOI: 10.1111/anae.15876] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/13/2022] [Indexed: 12/13/2022]
Affiliation(s)
- A M E Pearson
- Department of Anaesthesia, Bristol Royal Hospital for Children, University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK
| | - S Roberts
- Department of Anaesthesia, Alder Hey Children's Hospital, Liverpool, UK
| | - L R Turbitt
- Department of Anaesthesia, Belfast Health and Social Care Trust, Belfast, UK
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10
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Wyatt KE, Liu CJJ, Moffett B, Vogel AM, Medellin E, Owens-Stuberfield M, Lee A, Baijal RG. Ropivacaine concentrations after single-shot erector spinae plane block in children: a pilot pharmacokinetic modelling study. Br J Anaesth 2022; 129:e156-e158. [DOI: 10.1016/j.bja.2022.08.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2022] [Accepted: 08/26/2022] [Indexed: 11/02/2022] Open
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11
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Alrayashi W, Cravero J, Brusseau R. Unique Issues Related to Regional Anesthesia in Pediatric Orthopedics. Anesthesiol Clin 2022; 40:481-489. [PMID: 36049876 DOI: 10.1016/j.anclin.2022.05.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
This article will narrow its focus largely to notable issues related to regional anesthesia in pediatrics. First, the controversy surrounding awake versus anesthetized block placement will be addressed. There will also be a discussion on the use of regional anesthetics in orthopedics cases and the risk of compartment syndrome. Subsequently, the concern for regional anesthetics in the setting of an instrumented spine (eg, following spine fusion, baclofen pump placement) will be reviewed as such can have significant ramifications for patients. Finally, this article will consider ambulatory regional catheters and their increasing use in pediatric orthopedic anesthesia. Their utilization during the COVD epidemic played a key role in facilitating procedures that would have been canceled due to the protracted hospital bed shortage.
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Affiliation(s)
- Walid Alrayashi
- Department of Anesthesiology, Harvard Medical School, Home Analgesia Program, Critical Care and Pain Medicine, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA 02115, USA.
| | - Joseph Cravero
- Department of Anesthesiology, Harvard Medical School, Critical Care and Pain Medicine, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA 02115, USA
| | - Roland Brusseau
- Department of Anesthesiology, Harvard Medical School, Pediatric Regional Anesthesia Program, Critical Care and Pain Medicine, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA 02115, USA
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12
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Oppitz F, Hindriks-Keegstra A, Kaufmann J. [Perioperative Pain Management in Children]. Anasthesiol Intensivmed Notfallmed Schmerzther 2022; 57:536-549. [PMID: 36049738 DOI: 10.1055/a-1690-5637] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
Abstract
Acute pain therapy in children is highly complex. Already preoperatively, the course for a successful therapy is set in the interaction with the child and parents. The goal of the treatment is a satisfied child. This means the use of empathy and therapy planning aimed at a balance between effect and side effect and functionality. Modern concepts are opioid-sparing and procedure-specific. Regional anaesthesia plays a major role, among other things due to excellent safety data. Knowledge of age- and block-specific local anaesthetic dosages is essential. Little is known about pharmacodynamic data of analgesics in children. Although knowledge about pharmacokinetic characteristics is increasing, off-label use of analgesics is inevitable. International databases such as the Kinderformularium provide up-to-date information. When using opioids, rules for safe handling must be followed both in terms of use and prescribing. Non-opioids and adjuvants - individually or in combination - have an established place in perioperative pain management. Non-pharmacological interventions can reduce anxiety and pain. Anxiety is one of the risk factors for chronic postsurgical pain.
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Tafoya SP, Tumber SS. The Use of Multimodal Perineural Adjuvants in Pediatric Peripheral Nerve Blocks: Technique and Experiences. Cureus 2022; 14:e23186. [PMID: 35444912 PMCID: PMC9010002 DOI: 10.7759/cureus.23186] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/15/2022] [Indexed: 11/05/2022] Open
Abstract
Background Postoperative pain management in pediatric population can be very challenging. How to prolong the duration of single-injection peripheral nerve blocks has been widely discussed. Multiple medications are under investigation to accomplish this, yet data specifically focused on their use in pediatric peripheral nerve blocks are limited. Methods Anesthetic electronic medical records were queried for any instances where adjuvant drug(s) were used in peripheral nerve blocks during a two-year period at a pediatric surgical specialty hospital. These included buprenorphine, clonidine, dexamethasone, and dexmedetomidine. Results Out of 1,845 blocks placed during the study period, 1,148 (62.2%) utilized perineural adjuvants. Buprenorphine as a sole agent was the most common choice (49.5%), followed by buprenorphine and dexmedetomidine combined (39.9%), dexmedetomidine alone (10.1%), and the rare combination of all three drugs, buprenorphine, dexmedetomidine, and dexamethasone (0.5%). The mean dose of buprenorphine given was 3.6 mcg/kg total, 2.8 mcg/kg/block. The mean dose of dexmedetomidine given was 0.9 mcg/kg total, 0.6 mcg/kg/block. The mean dose of dexamethasone utilized was 2 mg total, 1 mg/block. Conclusions This report examined one institution’s use of multimodal perineural adjuvants in over 1,000 pediatric peripheral nerve blocks. Buprenorphine was the agent most commonly used to prolong the single-injection peripheral nerve block. This highlights the need for future prospective trials evaluating efficacy and safety.
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Liu CJJ, Rosenfeld SB, Wyatt K. Lumbar plexus catheter or single shot blockade for pediatric periacetabular osteotomies: Is there a difference? J Clin Anesth 2021; 75:110455. [PMID: 34280687 DOI: 10.1016/j.jclinane.2021.110455] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2021] [Revised: 07/03/2021] [Accepted: 07/06/2021] [Indexed: 10/20/2022]
Affiliation(s)
- Chyong-Jy Joyce Liu
- Department of Anesthesiology, Perioperative and Pain Medicine, Texas Children's Hospital, 6621 Fannin St, Ste A3300, Houston, TX 77030, United States of America; Department of Anesthesiology, Baylor College of Medicine, One Baylor Plaza, Houston, TX 77030, United States of America
| | - Scott B Rosenfeld
- Department of Orthopedics, Baylor College of Medicine, One Baylor Plaza, Houston, TX 77030, United States of America
| | - Karla Wyatt
- Department of Anesthesiology, Perioperative and Pain Medicine, Texas Children's Hospital, 6621 Fannin St, Ste A3300, Houston, TX 77030, United States of America; Department of Anesthesiology, Baylor College of Medicine, One Baylor Plaza, Houston, TX 77030, United States of America.
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15
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Heydinger G, Tobias J, Veneziano G. Fundamentals and innovations in regional anaesthesia for infants and children. Anaesthesia 2021; 76 Suppl 1:74-88. [PMID: 33426659 DOI: 10.1111/anae.15283] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/07/2020] [Indexed: 12/18/2022]
Abstract
Regional anaesthesia in children has evolved rapidly in the last decade. Although it previously consisted of primarily neuraxial techniques, the practice now incorporates advanced peripheral nerve blocks, which were only recently described in adults. These novel blocks provide new avenues for providing opioid-sparing analgesia while minimising invasiveness, and perhaps risk, associated with older techniques. At the same time, established methods, such as infant spinal anaesthesia, under-utilised in the last 20 years, are experiencing a revival. The impetus has been the concern regarding the potential long-term neurocognitive effects of general anaesthesia in the young child. These techniques have expanded from single shot spinal anaesthesia to combined spinal/epidural techniques, which can now effectively provide surgical anaesthesia for procedures below the umbilicus for a prolonged period of time, thereby avoiding the need for general anaesthesia. Continuous 2-chloroprocaine infusions, previously only described for intra-operative regional anaesthesia, have gained popularity as a means of providing prolonged postoperative analgesia in epidural and continuous nerve block techniques. The rapid, liver-independent metabolism of 2-chloroprocaine makes it ideal for prolonged local anaesthetic infusions in neonates and small infants, obviating the increased risk of local anaesthetic systemic toxicity that occurs with amide local anaesthetics. Debate continues over certain practices in paediatric regional anaesthesia. While the rarity of complications makes comparative analyses difficult, data from large prospective registries indicate that providing regional anaesthesia to children while under general anaesthesia appears to be at least as safe as in the sedated or awake patient. In addition, the estimated frequency of serious adverse events demonstrates that regional blocks in children under general anaesthesia are no less safe than in awake adults. In infants, the techniques of direct thoracic epidural placement or caudal placement with cephalad threading each have distinct advantages and disadvantages. As the data cannot support the safety of one technique over the other, the site of epidural insertion remains largely a matter of anaesthetist discretion.
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Affiliation(s)
- G Heydinger
- Department of Anesthesiology and Pain Medicine, Nationwide Children's Hospital, Columbus, OH, USA
| | - J Tobias
- Department of Anesthesiology and Pain Medicine, Nationwide Children's Hospital, Columbus, OH, USA
| | - G Veneziano
- Department of Anesthesiology and Pain Medicine, Nationwide Children's Hospital, Columbus, OH, USA
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Lönnqvist PA. What has happened since the First World Congress on Pediatric Pain in 1988? The past, the present and the future. Minerva Anestesiol 2020; 86:1205-1213. [DOI: 10.23736/s0375-9393.20.14391-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
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17
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Lönnqvist PA. Asleep or awake: is paediatric regional anaesthesia without general anaesthesia possible? Br J Anaesth 2020; 125:115-117. [PMID: 32475687 DOI: 10.1016/j.bja.2020.04.071] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2020] [Revised: 04/15/2020] [Accepted: 04/17/2020] [Indexed: 12/25/2022] Open
Affiliation(s)
- Per-Arne Lönnqvist
- Department of Physiology & Pharmacology, Karolinska Instituet, Karolinska University Hospital, Stockholm, Sweden.
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Utilization of a Continuous Pericapsular Nerve Group (PENG) Block with an Opioid-Sparing Repair of a Femoral Neck Fracture in a Pediatric Patient. Case Rep Orthop 2020; 2020:2516578. [PMID: 32733726 PMCID: PMC7378598 DOI: 10.1155/2020/2516578] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2020] [Revised: 06/11/2020] [Accepted: 06/18/2020] [Indexed: 12/26/2022] Open
Abstract
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.
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Atasever AG, Ermiş O, Demir BŞ, Kaşali K, Karadeniz MS. Comparison of bupivacaine alone and in a combination with lidocaine for caudal block in patients undergoing circumcision: A historical cohort study. Turk J Urol 2020; 46:243-248. [PMID: 32401707 DOI: 10.5152/tud.2019.19191] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2019] [Accepted: 11/04/2019] [Indexed: 01/09/2023]
Abstract
OBJECTIVE Optimal analgesia following ambulatory surgery is an important matter in patient satisfaction, and it reduces unnecessary hospital admissions. This study investigated whether a caudal block with bupivacaine alone or in a combination with lidocaine can alter postoperative pain scores, complications, and peroperative and postoperative analgesic consumption. MATERIAL AND METHODS This is a retrospective study that included children who underwent elective circumcision surgery under general anesthesia and caudal analgesia between January and June 2018. Among the 103 children, 17 cases were not analyzed due to an unsuccessful caudal block and procedures simultaneously underwent another operation unrelated to circumcision. We divided the study participants into two groups according to the type of local anesthetic applied: 0.5 mL/kg 0.25% bupivacaine (Group B) and 0.5 mL/kg 0.25% bupivacaine + 3 mg/kg 1% lidocaine (Group BL) caudally. RESULTS Pain scores were similar between these groups and remained in the mild-to-moderate range throughout the hospitalization (p>0.05). There were significant differences regarding the rescue analgesic use, first micturition, and mobilization times (p<0.001). In addition, we applied the multivariable logistic regression for fentanyl consumption adjusted for first mobilization and micturition time, unlike mobilization, a significantly increased risk for postoperative delayed micturition (OR, 1.06; 95% CI, 1.0-1.12; p=0.038) was found with intra-operative intravenous fentanyl use. CONCLUSION Our results suggest that the caudal block with a lidocaine+bupivacaine combination decreases rescue analgesic consumption at day-case surgery. In circumcision procedures, the caudal block is an effective and safe analgesic method for intraoperative and postoperative pain control with no side effects. This trial was registered at Clinicaltrals.gov, NCT03911648.
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Affiliation(s)
| | - Okan Ermiş
- Department of Anesthesia, Gazi University School of Medicine, Ankara, Turkey
| | | | - Kamber Kaşali
- Department of Biostatistics, Atatürk University School of Medicine, Erzurum, Turkey
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Astacio E, Echegaray G, Rivera L, Otero-Delgado JM, Olivella G, Ramírez N, Ramos-Alconini N, Foy C. Local Hematoma Block as Postoperative Analgesia in Pediatric Supracondylar Humerus Fractures. JOURNAL OF HAND SURGERY GLOBAL ONLINE 2020; 2:155-158. [PMID: 35415488 PMCID: PMC8991413 DOI: 10.1016/j.jhsg.2020.02.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2019] [Accepted: 02/20/2020] [Indexed: 11/29/2022] Open
Abstract
Purpose Supracondylar humerus fracture (SHF) is the most common type of fracture in children. The aim of this study was to evaluate the efficacy of local hematoma block with 0.25% bupivacaine as postoperative pain control in patients with pediatric SHF who underwent closed reduction pin fixation. Methods We performed an institutional review board–approved, prospective cohort study of 65 patients with SHF treated with closed reduction percutaneous pin fixation. For 6 months, all patients were randomly divided into 2 groups. The treatment group (35 patients) received an intraoperative local hematoma block using 0.25% bupivacaine whereas the control group (30 patients) did not receive a local hematoma block as postoperative pain management adjuvant. After surgery, all patients were prescribed opioid pain medication. To evaluate the efficacy of the hematoma block, postoperative morphine equivalent consumption and the Faces Pain Scale–Revised (FPS-R) survey were blindly recorded during postoperative day 1. Demographic data, surgical details, clinical neurovascular examination during the hospital stay, and complications were also evaluated. Results Comparison of the control group with the treatment group showed similar morphine equivalent consumption and Face Pain Scale–Revised Survey results. No hematoma block-associated complications were reported. Conclusions The result of this study do not favor the use of local hematoma block to improve pain control and decrease the need for opioid use on postoperative day 1 in pediatric SHF after patients undergo closed reduction percutaneous pin fixation. These results can lay the foundation for future studies while suggesting new, novel opioid-free pain control strategies in patients with SHF. Type of study/level of evidence Therapeutic II.
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Affiliation(s)
- Eric Astacio
- Orthopedic Department, University of Puerto Rico Medical Sciences Campus, San Juan, PR
| | - Gabriel Echegaray
- Orthopedic Department, University of Puerto Rico Medical Sciences Campus, San Juan, PR
| | - Lenny Rivera
- Orthopedic Department, University of Puerto Rico Medical Sciences Campus, San Juan, PR
- Corresponding author: Lenny Rivera, MD, Orthopedic Department, University of Puerto Rico Medical Sciences Campus, PO Box 365067, San Juan, PR 00936-5067.
| | | | - Gerardo Olivella
- Transitional Year Residency Program, St. Lukes Episcopal Hospital, Ponce, PR
| | - Norman Ramírez
- Pediatric Orthopedic Department, Hospital de la Concepción, San German, PR
| | - Nestor Ramos-Alconini
- Orthopedic Department, University of Puerto Rico Medical Sciences Campus, San Juan, PR
| | - Christian Foy
- Orthopedic Department, University of Puerto Rico Medical Sciences Campus, San Juan, PR
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Abstract
Anesthetic management of pediatric orthopedic patients is uniquely challenging. Approach to the pediatric patient must consider heightened preoperative anxiety and its postoperative behavioral and pain effects. Frequent respiratory infections can complicate timing of surgery and anesthetic care. Perioperative pain management usually involves a multimodal pharmacologic approach with the goal of minimizing opioid requirements. Regional anesthesia is valuable for postoperative pain control. Safety of its use in the pediatric population has been confirmed in recent studies. Included for discussion are fractures, slipped capital femoral epiphysis, club foot, and scoliosis.
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Affiliation(s)
- Jeffrey P Wu
- Department of Anesthesiology, Jersey Shore University Medical Center, 1945 Route 33, Neptune, NJ 07753, USA.
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Merella F, Canchi-Murali N, Mossetti V. General principles of regional anaesthesia in children. BJA Educ 2019; 19:342-348. [DOI: 10.1016/j.bjae.2019.06.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/20/2019] [Indexed: 01/22/2023] Open
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Luedi MM, Upadek V, Vogt AP, Steinfeldt T, Eichenberger U, Sauter AR. A Swiss nationwide survey shows that dual guidance is the preferred approach for peripheral nerve blocks. Sci Rep 2019; 9:9178. [PMID: 31235760 PMCID: PMC6591381 DOI: 10.1038/s41598-019-45700-3] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2018] [Accepted: 06/12/2019] [Indexed: 11/09/2022] Open
Abstract
Ultrasound has significantly increased safety and effectiveness in regional anesthesia. However, little is known about its clinical use. We studied clinical approaches currently used by anesthesiologists, conducted a nationwide survey, and analyzed data collected in ordered logistic regression models. All active members of the Swiss Society for Anaesthesiology and Resuscitation (SSAR/SGAR) were asked to participate. Reported practice in nerve localization, safety, and techniques used for peripheral nerve blocks (PNB) were main outcome measures. Experience ranged from 3 to >30 years. The mean number of block techniques mastered was 11.5 ± 5.9. Standard monitoring was regularly used, whereas sterile coats were less frequently used by anesthesiologists who self-estimated a higher level of expertise in PNB (ordered logit coefficient −0.05, 95% CI −0.07 to −0.02, P < 0.001; pseudo r2 = 0.019; probability > Chi2 = 0.02). The more self-estimated expertise anesthesiologists had, the less likely they were to use nerve stimulation in combination with ultrasound (dual guidance) (ordered logit coefficient −0.31; 95% CI −0.85 to −0.03: P = 0.03; pseudo r2 = 0.007; probability > Chi2 = 0.05). The high share of reported standard monitoring meets the recommendations of the Helsinki Patient Safety Declaration. Dual guidance appears to be the preferred approach for safely localizing nerves for PNB in Switzerland.
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Affiliation(s)
- Markus M Luedi
- Department of Anaesthesiology and Pain Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Vanessa Upadek
- Department of Anaesthesiology and Pain Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Andreas P Vogt
- Department of Anaesthesiology and Pain Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Thorsten Steinfeldt
- Department of Anaesthesiology, Diakonie-Klinikum Schwäbisch Hall, Schwäbisch Hall, Germany
| | - Urs Eichenberger
- Department of Anaesthesiology, Intensive Care and Pain Therapy, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | - Axel R Sauter
- Department of Anaesthesiology and Pain Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland. .,Division of Emergencies and Critical Care, Department of Anaesthesiology and Department of Research and Development, Oslo University Hospital, Oslo, Norway.
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Vittinghoff M, Lönnqvist PA, Morton NS. Reply to Haydar, Bishr; Holman, Ashlee; Galante, Dario, regarding their comment "ESPA pain management ladder: Caudal clonidine and cost/benefit considerations". Paediatr Anaesth 2019; 29:391-392. [PMID: 30735279 DOI: 10.1111/pan.13602] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- Maria Vittinghoff
- Department of Anesthesiology and Intensive Care Medicine, Medical University of Graz, Graz, Austria
| | - Per Arne Lönnqvist
- Department of Physiology & Pharmacology, Paediatric Anaesthesia & Intensive Care, Section of Anaesthesiology & Intensive Care, Karolinska Institutet, Stockholm, Sweden
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Wiegele M, Marhofer P, Lönnqvist PA. Caudal epidural blocks in paediatric patients: a review and practical considerations. Br J Anaesth 2019; 122:509-517. [PMID: 30857607 DOI: 10.1016/j.bja.2018.11.030] [Citation(s) in RCA: 90] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2018] [Revised: 11/21/2018] [Accepted: 11/30/2018] [Indexed: 11/15/2022] Open
Abstract
Caudal epidural blockade in children is one of the most widely administered techniques of regional anaesthesia. Recent clinical studies have answered major pharmacodynamic and pharmacokinetic questions, thus providing the scientific background for safe and effective blocks in daily clinical practice and demonstrating that patient selection can be expanded to range from extreme preterm births up to 50 kg of body weight. This narrative review discusses the main findings in the current literature with regard to patient selection (sub-umbilical vs mid-abdominal indications, contraindications, low-risk patients with spinal anomalies); anatomical considerations (access problems, age and body positioning, palpation for needle insertion); technical considerations (verification of needle position by ultrasound vs landmarks vs 'whoosh' or 'swoosh' testing); training and equipment requirements (learning curve, needle types, risk of tissue spreading); complications and safety (paediatric regional anaesthesia, caudal blocks); local anaesthetics (bupivacaine vs ropivacaine, risk of toxicity in children, management of toxic events); adjuvant drugs (clonidine, dexmedetomidine, opioids, ketamine); volume dosing (dermatomal reach, cranial rebound); caudally accessed lumbar or thoracic anaesthesia (contamination risk, verifying catheter placement); and postoperative pain. Caudal blocks are an efficient way to offer perioperative analgesia for painful sub-umbilical interventions. Performed on sedated children, they enable not only early ambulation, but also periprocedural haemodynamic stability and spontaneous breathing in patient groups at maximum risk of a difficult airway. These are important advantages over general anaesthesia, notably in preterm babies and in children with cardiopulmonary co-morbidities. Compared with other techniques of regional anaesthesia, a case for caudal blocks can still be made.
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Affiliation(s)
- Marion Wiegele
- Department of Anaesthesia, Critical Care and Pain Medicine, Division of General Anaesthesia and Intensive Care Medicine, Medical University of Vienna, Vienna, Austria
| | - Peter Marhofer
- Department of Anaesthesia, Critical Care and Pain Medicine, Division of General Anaesthesia and Intensive Care Medicine, Medical University of Vienna, Vienna, Austria.
| | - Per-Arne Lönnqvist
- Department of Paediatric Anesthesia and Intensive Care, Section of Anaesthesiology and Intensive Care, Karolinska University Hospital, Stockholm, Sweden; Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden
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Abstract
Despite the widespread use of ambulatory continuous peripheral nerve blocks in adults, its use in children has been sporadic. Indications for the use of ambulatory continuous peripheral nerve block in children involve orthopedic procedure, where significant pain is anticipated beyond 24 hours. Techniques to place the perineural catheters in children are similar to that used in adults. The incidence of serious side effects in pediatric ambulatory continuous peripheral nerve block is extremely rare. When this is combined with the potential to increase patient and family satisfaction and decrease opioid-related side effects, ambulatory continuous peripheral nerve block become a compelling choice.
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Affiliation(s)
- Sible Antony
- Department of Anesthesiology and Critical Care, The Children's Hospital of Philadelphia, 34th and Civic Center Boulevard, Philadelphia, PA 19104, USA
| | - Harshad Gurnaney
- Department of Anesthesiology and Critical Care, The Children's Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, 34th and Civic Center Boulevard, Philadelphia, PA 19104, USA
| | - Arjunan Ganesh
- Department of Anesthesiology and Critical Care, The Children's Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, 34th and Civic Center Boulevard, Philadelphia, PA 19104, USA.
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Vittinghoff M, Lönnqvist PA, Mossetti V, Heschl S, Simic D, Colovic V, Dmytriiev D, Hölzle M, Zielinska M, Kubica-Cielinska A, Lorraine-Lichtenstein E, Budić I, Karisik M, Maria BDJ, Smedile F, Morton NS. Postoperative pain management in children: Guidance from the pain committee of the European Society for Paediatric Anaesthesiology (ESPA Pain Management Ladder Initiative). Paediatr Anaesth 2018; 28:493-506. [PMID: 29635764 DOI: 10.1111/pan.13373] [Citation(s) in RCA: 61] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/14/2018] [Indexed: 12/21/2022]
Abstract
The main remit of the European Society for Paediatric Anaesthesiology (ESPA) Pain Committee is to improve the quality of pain management in children. The ESPA Pain Management Ladder is a clinical practice advisory based upon expert consensus to help to ensure a basic standard of perioperative pain management for all children. Further steps are suggested to improve pain management once a basic standard has been achieved. The guidance is grouped by the type of surgical procedure and layered to suggest basic, intermediate, and advanced pain management methods. The committee members are aware that there are marked differences in financial and personal resources in different institutions and countries and also considerable variations in the availability of analgesic drugs across Europe. We recommend that the guidance should be used as a framework to guide best practice.
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Affiliation(s)
- Maria Vittinghoff
- Department of Anesthesiology and Intensive Care Medicine, Medical University of Graz, Graz, Austria
| | - Per-Arne Lönnqvist
- Paediatric Anaesthesia & Intensive Care, Section of Anaesthesiology & Intensive Care, Department of Physiology & Pharmacology, Karolinska Institutet, Stockholm, Sweden
| | - Valeria Mossetti
- Department of Anesthesia and Intensive Care, Regina Margherita Children's Hospital, Torino, Italy
| | - Stefan Heschl
- Department of Anesthesiology and Intensive Care Medicine, Medical University of Graz, Graz, Austria
| | - Dusica Simic
- University Children's Hospital, Medical Faculty University of Belgrade, Serbia
| | - Vesna Colovic
- Royal Manchester Children's Hospital, Central Manchester University Hospitals, Manchester, UK
| | - Dmytro Dmytriiev
- Department of Anesthesiology and Intensive Care, Vinnitsa National Medical University, Vinnitsa, Ukraine
| | - Martin Hölzle
- Section of Paediatric Anaesthesia, Department of Anaesthesia, Luzerner Kantonsspital, Luzern, Switzerland
| | - Marzena Zielinska
- Department of Paediatric Anaesthesiology and Intensive Care, Wroclaw Medical University, Wroclaw, Poland
| | - Anna Kubica-Cielinska
- Department of Paediatric Anaesthesiology and Intensive Care, Wroclaw Medical University, Wroclaw, Poland
| | | | - Ivana Budić
- Centre for Anesthesiology and Resuscitation, Clinical Centre Nis Department of Anesthesiology, Medical Faculty, University of Nis, Nis, Serbia
| | - Marijana Karisik
- Institute for Children Diseases, Department of Anaesthesiology, Clinical Centre of Montenegro, Podgorica, Montenegro
| | - Belen De Josè Maria
- Department of Pediatric Anesthesia, Hospital Sant Joan de Deu, University of Barcelona, Barcelona, Spain
| | - Francesco Smedile
- Department of Pediatric Anesthesiology, Bambino Gesù Children's Hospital, Rome, Italy
| | - Neil S Morton
- Paediatric Anaesthesia and Pain Management, University of Glasgow, Glasgow, UK
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