Clinical implications of the transversus abdominis plane block in pediatric anesthesia

Transversus Abdominis Plane Block VS. Local Wound Infiltration for Elective Minimally Invasive Cholecystectomy in Children: A Prospective Randomized Trial

BACKGROUND

The efficacy of transversus abdominis plane (TAP) block versus local anesthetic wound infiltration (LWI) in pediatric laparoscopic surgery is largely unknown. The objective of this study was to prospectively analyze this in minimally invasive cholecystectomy. We hypothesized that TAP block would be superior to LWI in terms of pain control and post-operative complications.

METHODS

We conducted a prospective, randomized, single-blinded, controlled trial between 2017 and 2022 after obtaining Institutional Review Board (IRB) approval. After randomization, patients received a standard amount of ropivacaine via either 1) ultrasound-guided TAP block after general anesthesia induction or 2) local injection at port insertion by the operating surgeon. We collected data including operative time, pain scores, and medication usage post-operatively. We used descriptive statistics to report all endpoints and compared data with t-tests and Fisher's exact tests. A p-value less than 0.05 was considered statistically significant.

RESULTS

We enrolled 85 patients (43 LWI, 42 TAP). Mean [standard deviation] age and body mass index (BMI) in the LWI and TAP groups were 14.8 [1.9] and 14.7 [2] years and 29.9 [7.2] and 27.4 [8.2] kilogram/meter2 (kg/m2) respectively. We did not find any significant differences in postoperative opioid use, pain scores, and gastrointestinal symptoms. TAP patients had significantly longer time between anesthesia-start and procedure-start (p < 0.001), although total time under anesthesia was not significantly different (p = 0.540).

CONCLUSION

There are no significant differences between equal administration of local anesthetic by TAP block and surgeon administered LWI during minimally invasive cholecystectomy.

TYPE OF STUDY

Randomized clinical trial.

LEVEL OF EVIDENCE

Level II.

Transversus abdominis plane block with different bupivacaine concentrations in children undergoing unilateral inguinal hernia repair: a single-blind randomized clinical trial

BACKGROUND

Current knowledge on the ideal local anesthetic concentration for the ultrasound-guided transversus abdominis plane block (TAPB) in pediatrics is scarce. The purpose of this study is to compare the efficacy of US-guided TAPB at two different concentrations of bupivacaine in pediatrics undergoing unilateral inguinal hernia repair.

METHODS

After random allocation, 74 children aged 1-8 were randomized to receive US-guided TAPB by using 1 mg.kg^- 1 bupivacaine as either 0,25% (0,4 ml.kg^- 1) (Group 1) or 0,125% (0,8 ml.kg^- 1) (Group 2) concentration. All blocks were performed under general anesthesia, immediately after the induction, unilaterally with a lateral approach. All subjects received intravenous 15 mg/kg paracetamol 0.15 mg/kg dexamethasone and 0.1 mg/kg ondansetron intraoperatively. The primary outcome was the efficacy which is assessed by postoperative FLACC behavioral pain assessment score at 15', 30', 45', 1 h, 2 h, 6 h, and 24 h. The secondary outcomes were to assess the total dose of rescue analgesic consumption, length of hospital stay, the incidence of side effects, complications and satisfaction levels of the patients' parents and the surgeons.

RESULTS

Sixty-four children were recruited for the study. Postoperative pain scores were equal between the two groups. There was no need for a rescue analgesic in any group after the postoperative 6^thhour. No local or systemic complication or side effect related to anesthesia or surgery was reported.

CONCLUSION

TAPB using 1 mg.kg^- 1 bupivacaine administered as either high volume/low concentration or low volume/high concentration was providing both adequate analgesia and no side effects.

TRIAL REGISTRATION

This trial was retrospectively registered at Clinicaltrals.gov , NCT04202367 .

Evolving approaches in neonatal postoperative pain management

Neonates experience significant moderate and severe postoperative pain. Effective postoperative pain management in neonates is required to minimize acute and long-term effects of neonatal pain. Protecting the developing nervous system from persistent sensitization of pain pathways and developing primary hyperalgesia is essential. Opioids and acetaminophen are commonly analgesics used for pain control. Regional anesthesia provides adequate intraoperative and postoperative analgesia in neonates. It decreases exposure to opioids, reduces adverse drug effects, and facilitates early extubation. It suppresses the stress response and can prevent long-term behavioral responses to pain. The most common blocks performed in neonates are neuraxial blocks. Using ultrasound increased the number of peripheral nerve blocks performed in neonates. Recently, various peripheral nerve blocks (paravertebral, transverse abdominis plane, rectus sheath, quadratus lumborum, erector spinae plane blocks) were safely used. Many studies support analgesic efficacy but highlight neonates' unpredictability and variability of fascial blocks.

Ultrasound Verification of Laparoscopic-Assisted Transversus Abdominis Plane Blocks in Children Undergoing Laparoscopic Procedures

Purpose: Ultrasound-guided transversus abdominis plane (TAP) blocks have been demonstrated to decrease postoperative pain; however, laparoscopic-assisted TAP (L-TAP) blocks have not been well studied in children. Our study utilized intraoperative ultrasound to verify whether surgeon-administered blocks using only laparoscopic visualization were reliably delivered into the correct plane. Materials and Methods: Patients undergoing laparoscopic procedures were enrolled to receive L-TAP blocks. Preblock and postblock ultrasounds were performed to document the plane of local anesthetic delivery. Ultrasound images were reviewed by two blinded anesthesiologists to determine whether the L-TAP block was administered into the desired plane. Results: Fifty-one patients were enrolled. The average age was 5.9 years (range: 2 days to 17 years) and the mean weight was 25.4 kg (range: 2.64-118.8 kg). The most common procedures were inguinal hernia repair (n = 19), appendectomy (n = 10), and gastrostomy-tube placements (n = 13). Nine surgeons performed 93 L-TAP blocks (average: 10.3 blocks/surgeon). Ultrasound confirmed distribution in the correct plane in 53.5/93 blocks (57.5%; 58.0% for attending surgeons), with 77.4% concurrence between the anesthesiologist reviewers. Conclusion: L-TAP achieves delivery of local anesthetic into the correct tissue plane in over half the cases with minimal training. Further studies are needed to examine the effect of L-TAP blocks on reducing postoperative pain in pediatric patients.

Evaluation of the Postoperative Analgesic Effect of 2 Different Blocks after Pediatric Circumcision Surgery

BACKGROUND

Circumcision is a painful day-case surgery. Regional anesthesia techniques are used effectively for anesthesia and postoperative analgesia after pediatric circumcision surgery.

OBJECTIVE

Our prospective observational study aimed to compare postoperative analgesic efficiency of a dorsal penile nerve (DPN) block with a transversus abdominis plane (TAP) block after male pediatric circumcision surgery and complications related to each block.

STUDY DESIGN

We enrolled 80 male children under the age of 10 years with American Society of Anesthesiologists I-II status scheduled for circumcision in this prospective observational study. A TAP or DPN block was performed after induction of general anesthesia before surgery with ultrasound (US) guidance. Postoperative pain was assessed with Faces Pain Scale-Revised and the Faces, Legs, Activity, Cry and Consolability scale.

RESULTS

There was no statistically significant difference between the groups regarding 30-min pain score levels (p > 0.05). But, the 1st hour, 2nd hour, 6th hour, 12th hour, and 24th-hour pain score levels in the TAP block group were statistically significantly higher than those of the DPN block group (p < 0.05). The 1st rescue analgesic requirement in the TAP block group was at the 6th hour postoperative. There was no need for rescue analgesia in the DPN block group during the postoperative 24-h follow-up.

DISCUSSION

A US-guided DPN block provided effective and long-lasting postoperative analgesia for circumcision surgery with statistically significantly lower pain score levels than a US-guided TAP block.

CONCLUSION

This study found that a TAP block alone was insufficient to provide adequate postoperative analgesia for circumcision surgery compared to DPN block.

Laparoscopic versus ultrasound-guided visualization of transversus abdominis plane blocks

BACKGROUND

Ultrasound-guided (US) transversus abdominis plane (TAP) block is commonly utilized as part of a multi-modal approach for postoperative pain management. This study seeks to determine whether laparoscopic-guided TAP blocks are as effective as US-guided TAP blocks among pediatric patients.

METHOD

In this prospective, randomized controlled trial, pediatric patients undergoing laparoscopic procedures were randomly assigned to one of two treatment arms: US-guided TAP block (US-arm) or laparoscopic-guided TAP block (LAP-arm). Primary outcome was PACU pain scores. Secondary outcomes included PACU opioid consumption, block completion time and block accuracy.

RESULTS

Twenty-five patients were enrolled in each arm. In the LAP-arm, 59% of blocks were in the transversus abdominis plane compared to 74% of TAP blocks in the US-arm (p = 0.18). Blocks were completed faster in the LAP-arm (2.1 ± 1.9 vs. 7.9 ± 3.4 min, p<0.001). The average highest PACU pain score was 3.4 ± 3.1 for the LAP-arm and 4.3 ± 3.8 for the US-arm (p = 0.37). Overall PACU pain scores and opioid consumption were similar between the groups (1.2 ± 1.3 vs. 1.6 ± 1.6, p = 0.24; 2.2 ± 5.8 vs. 0.9 ± 1.4MME, p = 0.26).

CONCLUSION

Laparoscopic TAP blocks have equivalent efficacy in post-operative pain scores, narcotic use, and tissue plane accuracy as compared to US-guided TAP blocks. They are also completed faster and may result in less operating room and general anesthetic time for the pediatric patient.

The coagulation profile as a marker for acute appendicitis in the paediatric population: Retrospective study

INTRODUCTION

Appendicitis is the commonest and most frequently misdiagnosed acute abdominal surgical illness in the paediatric population worldwide. The aim of this study is to evaluate the role of coagulation profile in acute appendicitis (AA) in children.

MATERIALS AND METHODS

we retrospectively collected data of patients submitted to appendectomy from 2011 to 2017. According to histopathology, patients were divided into three groups: not histologically confirmed AA (NAA), simple AA (SAA) and complicated AA (CAA). White blood cell (WBC) count, relative neutrophilia (Neutr%), C-reactive protein (CRP), prothrombin time ratio (PTratio), activated partial thromboplastin time ratio (APTTratio) and fibrinogen (Fib) were compared among groups.

RESULTS

Three hundred and seven patients were included: 57 NAA, 184 SAA and 66 CAA. WBC was significantly different among groups: CAA (mean 16.67 × 10³/ml), SAA (14.73 × 10³/ml, P= 0.01) and NAA (10.85 × 10³/ml, P< 0.0001). Significant differences were found for Neutr% (mean CAA 81.14 vs. SAA 77.03 P= 0.006, vs. NAA 63.86 P< 0.0001) and CRP (mean NAA 2.56, SAA 3.26, CAA 11.58, P< 0.0001). PTratio and Fib increased with the severity of AA receiver operator characteristic curves were similar for CRP (0.739), Fib (0.726), WBC (0.746) and Neutr% (0.754), while for PTratio and aPTTratio were 0.634 and 0.441, respectively.

CONCLUSIONS

extrinsic coagulation pathway is altered in AA, especially in CAA. Coagulation can be useful in the diagnostic and perioperative anaesthetic management of AA in children. Fib seems to have the highest accuracy.

Transversus Abdominal Plane Block in Children: Efficacy and Safety: A Randomized Clinical Study and Pharmacokinetic Profile

BACKGROUND

The transversus abdominis plane (TAP) block has become a common regional anesthesia technique for pain management in a wide variety of abdominal procedures. Evidence to support any particular local anesthetic regimen as well as pharmacokinetic and systemic toxicity risks of TAP block remain insufficiently studied in children. The aim of this study was to compare the analgesic effects and investigate pharmacokinetic profile of levobupivacaine after ultrasound-guided TAP block using a low volume/high concentration (LVHC) or a high volume/low concentration (HVLC) solution in children.

METHODS

This prospective randomized study included children scheduled for day-case inguinal surgery. Children were randomized to receive TAP block using 0.4 mg·kg levobupivacaine as either HVLC (0.2 mL·kg of 0.2% levobupivacaine) or LVHC (0.1 mL·kg of 0.4% levobupivacaine). The primary outcome was the number of children who required opioid rescue analgesia postoperatively. Pharmacokinetic profile study of levobupivacaine was also performed.

RESULTS

Seventy patients were equally randomized, and 65 were included in the final analysis. Seventy-one percent of patients did not require any postoperative opioid analgesia. The number of patients who received rescue analgesia was 12 (35%) in the LVHC group and 7 (23%) in the HVLC group (relative risk, 0.64; 95% confidence interval [CI], 0.29-1.42; P = .26). Mean pain scores (FLACC [faces, legs, activity, cry, and consolability]) at postanesthesia care unit discharge did not differ between LVHC and HVLC groups, respectively, 0.39 ± 0.86 and 1 ± 1.71 with mean group difference -0.60 (95% CI, -1.27 to 0.06; P = .08). The pharmacokinetic profile of levobupivacaine was comparable in the 2 groups: the mean total and free levobupivacaine peak concentrations were 379 ± 248 and 3.95 ± 3.16 ng·mL, respectively, occurring 22.5 ± 11 minutes after injection. The highest total and free levobupivacaine concentrations collected, respectively, 1360 and 15.1 ng·mL, remained far below theoretical toxic thresholds.

CONCLUSIONS

In children, quality of postoperative pain control provided by TAP block using levobupivacaine 0.4 mg·kg administered as either HVLC or LVHC did not differ and was associated with a very low risk of local anesthetic systemic toxicity.

Transversus abdominis plane catheters for postoperative pain relief in pediatric patients

Regional techniques provides excellent post operative pain relief in pediatric patients. Transversus abdominis plane (TAP) block is a newer regional technique available. Though there is emerging evidence proving the efficacy of TAP blocks, there is limited literature on use of TAP catheters in pediatric patients. TAP catheters were placed in two children following laparotomy with transverse incisions and in both epidural was avoided, with good post operative pain relief. Ultrasound guidance was used in one child, while in the other the catheter was placed under direct vision after dissection of the plane between transversus abdominis and internal oblique. Intermittent boluses of high volumes of local anesthetic (0.6-0.7 ml/kg) were used through the TAP catheter, ensuring that the maximum permissible level of bupivacaine was not exceeded. In adults, continuous abdominal catheters have found a place for post-operative pain management, when epidural analgesia is contraindicated. At present, the use of TAP catheters by pediatric anesthesiologists is limited, though there exists diverse clinical scenarios when these catheters may be of benefit. Contraindication of neuraxial blockade and septic patients are the two scenarios we have reported. In conclusion, TAP catheters are effective analgesia technique for laparotomies with transverse incision in pediatric patients.

Regional anaesthesia in neonates, infants and children: an educational review

Prophylactic analgesia with local anaesthesia is widely used in children and has a good safety record. Performing regional blocks in anaesthetised children is a safe and generally accepted practice. When compared with adults, lower concentrations of local anaesthetics are sufficient in children; the onset of a block occurs more rapidly but the duration is usually shorter. Local anaesthetics have a greater volume of distribution, a lower clearance and a higher free (non-protein-bound) fraction. The recommended maximum dose has to be calculated for every individual. Peripheral blocks provide analgesia restricted to the site of surgery, and some of them have a very long duration of action. Abdominal wall blocks, such as transverse abdominis plane or ilio-inguinal nerve block, should be performed with the aid of ultrasound. Caudal anaesthesia is the single most important technique. Ropivacaine 0.2% or levobupivacaine 0.125 to 0.175% at roughly 1 ml  kg⁻¹ is adequate for most indications. Clonidine and morphine can be used to prolong the duration of analgesia. Ultrasound is not essential for performing caudal blocks, but it may be helpful in case of anomalies suspected at palpation and for teaching purposes. The use of paediatric epidural catheters will probably decline in the future because of the potential complications.

Transversus abdominal plane (TAP) block for postoperative pain management: a review

Transversus abdominal plane (TAP) block has a long history and there is currently extensive clinical experience around TAP blocks. The aim of this review is to provide a summary of the present evidence on the effects of TAP block and to provide suggestions for further studies. There are several approaches to performing abdominal wall blocks, with the rapid implementation of ultrasound-guided technique facilitating a major difference in TAP block performance. During surgery, an abdominal wall block may also be applied by the surgeon from inside the abdominal cavity. Today, there are more than 11 meta-analyses providing a compiled evidence base around the effects of TAP block. These analyses include different procedures, different techniques of TAP block administration and, importantly, they compare the TAP block with a variety of alternative analgesic regimes. The effects of TAP block during laparoscopic cholecystectomy seem to be equivalent to local infiltration analgesia and also seem to be beneficial during laparoscopic colon resection. The effects of TAP are more pronounced when it is provided prior to surgery and these effects are local anaesthesia dose-dependent. TAP block seems an interesting alternative in patients with, for example, severe obesity where epidural or spinal anaesthesia/analgesia is technically difficult and/or poses a risk. There is an obvious need for further high-quality studies comparing TAP block prior to surgery with local infiltration analgesia, single-shot spinal analgesia, and epidural analgesia. These studies should be procedure-specific and the effects should be evaluated, both regarding short-term pain and analgesic requirement and also including the effects on postoperative nausea and vomiting, recovery of bowel function, ambulation, discharge, and protracted recovery outcomes (assessed by e.g., postoperative quality of recovery scale).

Perioperative effects of caudal and transversus abdominis plane (TAP) blocks for children undergoing urologic robot-assisted laparoscopic surgery

INTRODUCTION

Regional anesthesia is often used in combination with general anesthesia for pediatric surgery, however, it is unknown if adjunctive regional blocks are beneficial to children undergoing urologic laparoscopic or robot-assisted laparoscopic (RAL) procedures.

OBJECTIVE

To compare perioperative outcomes in children with adjunctive caudal blocks, transversus abdominis plane (TAP) blocks, or no regional anesthesia for common RAL surgical procedures in pediatric urology.

STUDY DESIGN

Inclusion in this retrospective study was limited to children who underwent RAL renal or ureteral/bladder procedures and received a standardized regimen of scheduled intravenous ketorolac and oral acetaminophen for acute postoperative pain control, with opioids as needed (PRN). Perioperative outcomes were compared between patients with an adjunctive caudal block (n = 25), bilateral TAP blocks (n = 44), or no regional anesthesia (n = 51).

RESULTS

Children with a preoperative caudal block received less intraoperative opioids than children with TAP blocks or no regional anesthesia (p < 0.001). This difference was observed both for renal procedures (p < 0.01) and ureteral/bladder procedures (p = 0.01). Patients with caudal blocks were also the least likely to require postoperative antiemetics (p = 0.03). There were no significant differences between groups in postoperative opioid use, maximum pain scores within 6 and 24 hours postoperatively, or length of hospital stay (LOS). No complications attributable to regional blocks were identified by chart review.

DISCUSSION

Use of adjunctive caudal blocks for pediatric RAL renal or ureteral/bladder surgical procedures may reduce need for alternate analgesic and/or anesthetic agents intraoperatively, as well as decrease postoperative nausea and vomiting. These findings may be related, since nausea and vomiting are common side effects of opioids and inhalational anesthetics. Consideration of the potential impact of caudal blocks on general anesthetic requirements is timely in light of concerns regarding the risk of anesthetic neurotoxicity in young patients. There was no evidence of improved postoperative pain control or shorter LOS for children who received regional anesthesia. It is unknown if regional blocks would have a greater impact in the absence of scheduled pain medications, which all patients in our study received. Limitations of this study include its retrospective nature and moderate sample size. Future randomized controlled trials are necessary to provide a more definitive understanding of regional anesthesia's role in minimizing pediatric surgical and anesthetic morbidity.

CONCLUSION

Administration of caudal blocks should be considered for children of suitable age undergoing RAL surgery involving either the upper or lower urinary tract.

Dose effect of local anesthetics on analgesic outcomes for the transversus abdominis plane (TAP) block in children: a randomized, double-blinded, clinical trial

BACKGROUND

Current knowledge on local anesthetic dosage for the TAP block in pediatric patients is very limited.

OBJECTIVE

To evaluate the effect of two escalating local anesthetic doses on postsurgical analgesic outcomes in children receiving a TAP block.

METHODS

The study was a prospective, randomized, double-blinded, clinical trial. Children (<8 years) were randomized to one of the two intervention groups: TAP block with bupivacaine at a dose of 2.5 mg · kg(-1) or 1.25 mg · kg(-1). Analgesic outcomes included pain scores in the postanesthesia care unit (PACU), time to analgesic requirement and total number of analgesic requirements.

RESULTS

Thirty-six patients were recruited in the study. Pain scores in PACU were not different between study groups. The total number of analgesic dosage required in 24 h after surgery was higher in the lower dose group, median (IQR) of 4 (3 to 5) compared to 2.5 (1.5 to 3) in the greater dose group, P = 0.03. There was a clinically but not statistically significant difference in the time to first analgesic requirement in the 2.5 mg · kg(-1) group, median (IQR) of 248 (130 to 367) minutes compared to 146 (95 to 261) minutes in the 1.25 mg · kg(-1) dose group, P = 0.15.

CONCLUSIONS

The use of higher local anesthetic doses for the TAP block in children does not provide benefits on early pain scores but seems to improve analgesic duration and decrease the need for additional analgesics over 24 h after surgery. The use of higher, but yet safe, local anesthetic dosages for TAP blocks is a viable strategy to improve analgesia in children.

Pain relief after transversus abdominis plane block for abdominal surgery in children: a service evaluation

We carried out a prospective service evaluation of the quality of pain control after preoperative transverse abdominis plane (TAP) block in 100 children undergoing abdominal surgery. Data were collected on type of procedure, age, weight, level of the block, local anesthetic used, additional analgesia, and hourly pain scores. Of the 100 patients, 87 were included in the evaluation, 77% of who were less than 1 year old. Adequate pain relief was achieved in 93% of all patients. Almost half (47%) of our patients did not require intravenous (IV) opioids in the postoperative period and 27% did not need any IV opioids at all. Our results confirm the good quality of perioperative analgesia achieved with a TAP block as part of a multimodal approach in children undergoing abdominal surgery. Depending on the patient’s age and the type of procedure, a TAP block may eliminate the need for IV opioids.

Ultrasound-guided tranversus abdominis plane block for herniorrhaphy in children: what is the optimal dose of levobupivacaine?

BACKGROUND

Regional anaesthesic techniques are commonly used for the management of pain following lower abdominal surgery in children. The transversus abdominis plane (TAP) block has shown promise for perioperative analgesia, but data on the optimal dose regimen are limited.

OBJECTIVE

To evaluate the optimal dose of levobupivacaine for successful ultrasound-guided TAP block in children.

DESIGN

A dose finding prospective study using Dixon's up-and-down sequential method.

SETTING

University Hospital Paediatric Anaesthesia Unit.

PATIENTS

Twenty-seven consecutive children aged 1 to 5 years scheduled for day-case elective herniorrhaphy.

INTERVENTION

After standardised induction of general anaesthesia, ultrasound-guided TAP block was performed with a fixed volume of 0.2  ml  kg(-1) of levobupivacaine solution. The dose of levobupivacaine was determined by Dixon's up-and-down method starting from 0.5  mg  kg(-1)with an interval of 0.1 mg   kg(-1). Block failure was defined as a 20% increase in heart rate or mean arterial pressure from baseline. Rescue analgesia consisted of intravenous remifentanil infusion during surgery and intravenous nalbuphine in the postanaesthetic care unit (PACU). Patients were assessed using the FLACC (face, legs, activity, cry and consolability) pain scale, the rescue analgesic consumption in the PACU and day-case unit and the postoperative pain measure for parents score at home.

MAIN OUTCOME MEASURES

The mean effective dose of levobupivacaine resulting in an effective TAP block in 50% of cases (ED50) obtained by using Dixon's up-and-down sequential method. The ED50 and ED95 were further estimated by bootstrapping.

RESULTS

The ED50 according to the up-and-down staircase method was 0.22  mg   kg(-1) [95% confidence interval (CI) 0.19 to 0.25]. Bootstrap replicates of the original dataset resulted in ED50 and ED95 estimates of 0.16  mg    kg(-1) (95% CI 0.11 to 0.24) and 0.43 mg  kg(-1)(95% CI 0.30 to 0.57), respectively.

CONCLUSION

As part of a multimodal analgesia strategy, ultrasound-guided TAP block with 0.2  ml  kg(-1)of 0.2% levobupivacaine provides successful peroperative analgesia in 95% of children who underwent herniorrhaphy.

Ultrasound-guided peripheral nerve blocks for ventricular shunt revision in children

We describe using ultrasound-guided peripheral nerve blocks for postoperative pain control in 2 children undergoing ventricular shunt surgery. In the first patient undergoing ventriculo-peritoneal shunt revision, a combination of ultrasound-guided greater occipital nerve, superficial cervical plexus, and transversus abdominis plane blocks was used. In the second patient undergoing ventriculo-pleural shunt revision, a combination of ultrasound-guided greater occipital nerve, superficial cervical plexus, and intercostal blocks was used. Both patients, who underwent multiple revisions during their hospitalizations, showed decreased analgesic requirements after regional anesthesia. Our experience suggests this combined block technique may provide beneficial postoperative analgesia for patients undergoing shunt revision.

Outpatient analgesia via paravertebral peripheral nerve block catheter and On-Q pump--a case series

Outpatient pain management after iliac crest bone harvesting can be challenging. We report the use of home L2 paravertebral nerve block catheter (L2PVBC) in a series of five children. The pain scores were low, and analgesic medication consumption was minimal. No complications were reported related with these catheters, and the patients reported very high pain control satisfaction scores. Outpatient L2PVBC can be beneficial as part of a multimodal analgesia strategy in selected pediatric patients.

Neonatal pain

Effective management of procedural and postoperative pain in neonates is required to minimize acute physiological and behavioral distress and may also improve acute and long-term outcomes. Painful stimuli activate nociceptive pathways, from the periphery to the cortex, in neonates and behavioral responses form the basis for validated pain assessment tools. However, there is an increasing awareness of the need to not only reduce acute behavioral responses to pain in neonates, but also to protect the developing nervous system from persistent sensitization of pain pathways and potential damaging effects of altered neural activity on central nervous system development. Analgesic requirements are influenced by age-related changes in both pharmacokinetic and pharmacodynamic response, and increasing data are available to guide safe and effective dosing with opioids and paracetamol. Regional analgesic techniques provide effective perioperative analgesia, but higher complication rates in neonates emphasize the importance of monitoring and choice of the most appropriate drug and dose. There have been significant improvements in the understanding and management of neonatal pain, but additional research evidence will further reduce the need to extrapolate data from older age groups. Translation into improved clinical care will continue to depend on an integrated approach to implementation that encompasses assessment and titration against individual response, education and training, and audit and feedback.

Anesthetic management of common pediatric emergencies

PURPOSE OF REVIEW

To keep pediatric anesthesiologists up-to-date in their management of pediatric emergencies by identifying the key publications from 2012 that are relevant to the anesthetic management of common pediatric emergencies.

RECENT FINDINGS

Little has been published about specific pediatric emergencies. A large multi-institutional audit of tracheo-esophageal fistula demonstrated a wide range of anesthesia practice and a difficulty with ventilation on induction in 7% of cases. Large audits of bronchoscopy for foreign body have also demonstrated a variety of effective practices with a low complication rate. More generally, studies have increasingly demonstrated that postoperative pain may be substantial after many common procedures including some emergency surgery. The management of the full stomach remains controversial and the use of ultrasound to assess gastric volume is promising but unproven. Recent guidelines for resuscitation have been published. It is increasingly recognized that meticulous management of pediatric brain injury is vital, and although the evidence base is very weak, a more coherent anesthetic approach is emerging.

SUMMARY

Many areas of the management of pediatric emergencies remain controversial and based on little good evidence. In spite of this, the complication rate is low. Postoperative pain is an emerging problem while the optimal management of the full stomach is still unresolved.