The effectiveness of ambulatory continuous peripheral nerve blocks for postoperative pain management in children and adolescents

Safety Assessment of Prolonged Nerve Catheters in Pediatric Trauma Patients: A Case Series Study

INTRODUCTION

Nerve block catheters (NBCs) are increasingly used for pain management in pediatric trauma patients. While short-term efficacy has been well established, the long-term safety of NBCs is unknown. Methods/Cases: The retrospective chart review includes a cohort of nine pediatric trauma patients aged 3-15 years who received 52 peripheral nerve block catheters and epidurals for pain management. This study aimed to investigate the potential risks associated with the prolonged use of NBCs in pediatric trauma cases.

RESULTS

The NBCs (48 peripheral catheters and 4 epidural catheters) were maintained for about 2 weeks. The number of catheters per patient varied from 1 to 11. The study noted a low frequency of catheter-related complications. No catheter-site infection or local anesthetic toxicity symptoms were reported.

DISCUSSION

These findings suggest that NBCs can be safely maintained for extended periods in pediatric trauma patients without significantly increasing complications. Careful monitoring and adherence to infection control practices remain paramount when implementing extended catheter use.

Local anesthetic dosing and toxicity of pediatric truncal catheters: a narrative review of published practice

BACKGROUND/IMPORTANCE

Despite over 30 years of use by pediatric anesthesiologists, standardized dosing rates, dosing characteristics, and cases of toxicity of truncal nerve catheters are poorly described.

OBJECTIVE

We reviewed the literature to characterize dosing and toxicity of paravertebral and transversus abdominis plane catheters in children (less than 18 years).

EVIDENCE REVIEW

We searched for reports of ropivacaine or bupivacaine infusions in the paravertebral and transversus abdominis space intended for 24 hours or more of use in pediatric patients. We evaluated bolus dosing, infusion dosing, and cumulative 24-hour dosing in patients over and under 6 months. We also identified cases of local anesthetic systemic toxicity and toxic blood levels.

FINDINGS

Following screening, we extracted data from 46 papers with 945 patients.Bolus dosing was 2.5 mg/kg (median, range 0.6-5.0; n=466) and 1.25 mg/kg (median, range 0.5-2.5; n=294) for ropivacaine and bupivacaine, respectively. Infusion dosing was 0.5 mg/kg/hour (median, range 0.2-0.68; n=521) and 0.33 mg/kg/hour (median, range 0.1-1.0; n=423) for ropivacaine and bupivacaine, respectively, consistent with a dose equivalence of 1.5:1.0. A single case of toxicity was reported, and pharmacokinetic studies reported at least five cases with serum levels above the toxic threshold.

CONCLUSIONS

Bolus doses of bupivacaine and ropivacaine frequently comport with expert recommendations. Infusions in patients under 6 months used doses associated with toxicity and toxicity occurred at a rate consistent with single-shot blocks. Pediatric patients would benefit from specific recommendations about ropivacaine and bupivacaine dosing, including age-based dosing, breakthrough dosing, and intermittent bolus dosing.

Enhancing Postoperative Pain Management and Decreasing Hospital Length of Stay on a Pediatric Orthopedic Unit: Implementation of an Ambulatory Continuous Peripheral Nerve Block Program

PURPOSE

Pediatric Ambulatory Continuous Peripheral Nerve Block (ACPNB) programs are a safe and effective pain management modality that can reduce patient length of stay (LOS) while ensuring optimal, multimodal pain management at home after surgery. Our institution previously solely used electronic infusion pumps to deliver local anesthetic via peripheral nerve catheters, requiring postoperative inpatient admissions for pain management. We aimed to enhance postoperative pain management and decrease hospital LOS after orthopedic foot and ankle surgery through implementation of an ACPNB program.

DESIGN

An ACPNB program was developed and implemented for pediatric patients undergoing foot and ankle reconstruction surgery.

METHODS

We provide a detailed description of the multidepartment collaboration led by the acute pain service (APS) and orthopedics that resulted in the development and implementation of a pediatric ACPNB program using portable, elastomeric devices for patients undergoing reconstructive foot and ankle surgery. Implementation tools, including caregiver and nursing education resources, a data collection log, a process map, and staff surveys are shared.

FINDINGS

Twenty-eight patients received elastomeric devices during the 12 months of data collection. All 28 patients who required a continuous peripheral nerve block (CPNB) for pain management following foot and ankle reconstruction surgery received their block via an elastomeric device rather than an electronic hospital infusion pump. All patients and caregivers expressed positive satisfaction with pain management after hospital discharge. No patient with an elastomeric device required scheduled opioids for pain management by the end of their hospital admission. LOS on the orthopedic inpatient unit for foot and ankle surgery decreased by 58%, representing an estimated 29 days and $27,557.88 saved. A majority (96.4%) of staff survey respondents reported feeling satisfied with their overall experience working with an elastomeric device.

CONCLUSIONS

The successful implementation of a pediatric ACPNB program has led to positive patient outcomes, including a significant decrease in hospital LOS and health system cost savings for this patient population.

Continuous Epidural Analgesia Versus Continuous Peripheral Nerve Block in Unilateral Lower Extremity Pediatric Orthopedic Surgery: A Matched Case Comparison Study

Introduction Continuous epidural analgesia (CEA) provides effective postoperative pain relief but includes a substantial side effect profile. Continuous peripheral nerve blocks (CPNBs) have fewer side effects and may quicken ambulation. The purpose of this study was to compare the morphine milligram equivalents (MMEs), need for analgesic rescue, visual analog scale (VAS) pain scores, time to ambulation, postoperative blood pressures, length of stay (LOS), and adverse event rates. Methods This was a matched case comparison study of pediatric patients (ages 8-17) undergoing unilateral lower limb surgery (41 CEA and 36 CPNB). Patients with a history of chronic pain, previous lower extremity surgery, and developmental delay were excluded. The Chi-square test and Student's t-test were used, and p-values < 0.05 were considered significant. Results There were no statistically significant differences in demographics or the American Society of Anesthesiologists (ASA) grade. There were no significant differences in postoperative MMEs, the need for analgesic rescue, or VAS scores on any postoperative day. The CEA group had a longer time to ambulation (2.56 ± 0.93 days versus 1.89 ± 0.69 days, p = 0.004). The CEA group demonstrated a higher number of days of systolic hypotension (0.61 ± 0.97 mmHg versus 0.06 ± 0.23 mmHg, p = 0.0009) and diastolic hypotension (1.90 ± 1.24 mmHg versus 1.00 ± 0.93 mmHg, p = 0.0006). There were no significant differences in the length of stay between the CEA and CPNB groups (5.08 versus 4.24, p = 0.28). There was no statistically significant difference between the rates of pruritus, light-headedness, and altered mental status. The CEA group demonstrated higher rates of nausea (51.2% versus 13.9%, p = 0.001), constipation (36.6% versus 8.3%, p = 0.004), urinary retention (9.8% versus 0%, p = 0.006), and average number of minor adverse events per patient (1.02 versus 0.25, p = 0.002). Conclusions CPNBs and CEAs demonstrate equivalent postoperative opioid use after unilateral lower extremity surgery in the pediatric population. In our population, a low complication rate and a decreased time to ambulation were seen in the CPNB group. There may be certain select scenarios priorly managed with a CEA that can be appropriately managed with a CPNB. A prospective multicenter study incorporating patient satisfaction data could further facilitate the incorporation of CPNB in pediatric pain management protocols after orthopedic surgery.

Application of Continuous Sacral Block Guided by Ultrasound After Comprehensive Sacral Canal Scanning in Children Undergoing Laparoscopic Surgery: A Prospective, Randomized, Double-Blind Study

Purpose

The present study aimed to explore the effects of continuous sacral block on the postoperative pain of children and the satisfaction of the nurses in post-anesthesia care unit (PACU). Also, the influence of the modified protocol of continuous sacral block was investigated.

Patients and Methods

A total of 60 children undergoing laparoscopic surgery were randomly divided into two groups: GI and GC groups. The general anesthesia was induced with midazolam, propofol, sufentanil and succinylcholine in both groups. In addition, the patients were subjected to continuous sacral block with levobupivacaine in group GC. The modified protocol of continuous sacral block was divided into three steps: comprehensive lumbar and sacral vertebral canal scanning by ultrasound, catheterization and administration. The EVENDOL pain scales and pediatric anesthesia emergence delirium scales of the children were evaluated at 5 min after extubation (T₃), 90 min (T₄), and 4 h (T₅) after the operation. The nurses' satisfaction scores at T₃ -T₄ and adverse events, such as nausea and vomiting, were also recorded, after the operation.

Results

After ultrasonic scanning, one patient in group GC was excluded due to the sacral hiatus atresia, which might lead to failure of catheterization. Data of 59 patients were collected for statistical analysis. Compared to the GI group, the EVENDOL scores and the pediatric anesthesia emergence delirium scales were reduced at T₃, T₄, and T₅ (P < 0.05) in group GC. Furthermore, there was a higher rank of PACU nurses' satisfaction in the GC group compared to the GI group (P < 0.05).

Conclusion

Based on the modified protocol, continuous sacral block provides reliable and safety analgesia for children undergoing laparoscopic surgery, thereby improving the satisfaction of PACU nurses.

Effectiveness of a PENG catheter and the implications and a complication of tunnelling

Pericapsular nerve group (PENG) block is a recently developed technique for analgesia for hip surgeries. We chose to use a PENG catheter for effective analgesia perioperatively. In this case report, we performed PENG catheter for a patient posted for hip hemiarthroplasty. During the process of tunnelling after securing the catheter, we accidentally sheared the catheter and had to redo the procedure. The patient was comfortable during their stay with minimal pain. This case report emphasises the importance of securing a catheter in providing prolonged analgesia and also the importance of dealing with complications due to the procedure itself.

Unique Issues Related to Regional Anesthesia in Pediatric Orthopedics

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.

Continuous Peripheral Block as a Pain Treatment for Redressment and Physical Therapy in a 7-Year-Old Child - A Case Report

Continuous peripheral nerve block, also known as "local anesthetic perineural infusion," refers to percutaneous placement of a catheter near a peripheral nerve or plexus followed by administration of a local anesthetic through a catheter to provide anesthesia, or analgesia for several days, in some cases even for a month. This report describes the case of a 7 year old boy with left elbow contracture with limited flexion and extension who was admitted to the Clinic of Pediatric Surgery for redressment of the elbow and physical therapy. An ultrasound-guided axillary brachial plexus block was performed, with placement of a non-tunneled perineural catheter. Redressment of the left elbow was performed twice and before each redressment boluses of local anesthetic were applied through the perineural catheter. Physical therapy was performed painlessly with continuous perineural infusion. On the 5th day of catheter placement, the perineural catheter was removed without any prior complications such as hematoma, infection, catheter dislocation or leakage of local anesthetic. Our goal is to minimize the psychological and physical trauma to the patient, no matter how immature the patient is. Continuous regional anesthesia in children is a safe technique in postoperative pain management that facilitates early mobilization due to its sufficient analgesia and better comfort. It can provide in-home treatment, with adequate education for patients and parents, and improve rehabilitation in children.

Analgesia, sedation, and delirium in pediatric surgical critical care

The alleviation of discomfort and distress is an essential component of the management of critically ill surgical patients. Pain and anxiety have multifocal etiologies that may be related to an underlying disease or surgical procedure, ongoing medical therapy, invasive monitors, an unfamiliar, complex and chaotic environment, as well as fear. Pharmacologic and non-pharmacologic therapies have complex risk benefit profiles. A fundamental understanding of analgesia, sedation, and delirium is essential for optimizing important outcomes in critically ill pediatric surgical patients. There has been a recent emphasis on goal directed, evidence based, and patient-centered management of the physical and psychological needs of these children. The purpose of this article is to review and summarize recent advances and describe current practice of these important subjects in the pediatric surgical intensive care environment.

Pediatric Ambulatory Continuous Peripheral Nerve Blocks

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.

The Safety and Efficacy of the Continuous Peripheral Nerve Block in Postoperative Analgesia of Pediatric Patients

Postoperative analgesia is imperative in the youngest patients. Pain, especially if experienced during childhood, has numerous adverse effects—from psychological, through complications of the underlying disease (prolonged treatment, hospital stay, and increased costs of the treatment) to an increase in the incidence of death due to the onset of the systemic inflammatory response. Peripheral blocks provide analgesia for 12–16 h, and are safer due to rare side effects that are easier to treat. The continuous peripheral block (CPNB) has been increasingly used in recent years for complete and prolonged analgesia of pediatric patients, as well as a part of multidisciplinary treatment of complex regional pain syndrome. It has been shown that outpatient CPNB reduces the need for parenteral administration of opioid analgetics. It has also been proved that this technique can be used in pediatric patients in home conditions. Safety of CPNB is based on the increasing use of ultrasound as well as on the introduction of single enantiomers local anesthetics (ropivacaine and levobupivacaine) in lower concentrations. It is possible to discharge patient home with catheter, but it is necessary to provide adequate education for staff, patients, and parents, as well as to have dedicated anesthesiology team. Postoperative period without major pain raises the morale of the child, parents. and medical staff.

Periarticular Liposomal Bupivacaine Injection Versus Intra-Articular Bupivacaine Infusion Catheter for Analgesia After Total Knee Arthroplasty: A Double-Blinded, Randomized Controlled Trial

BACKGROUND

Intra-articular bupivacaine hydrochloride (HCl) infusion catheters and periarticular injections of liposomal bupivacaine are often used as postoperative local anesthetics. The purpose of this study was to compare the efficacies of these local anesthetics following total knee arthroplasty.

METHODS

This study was a superiority trial with a randomized, controlled, double-blinded design. Patients were randomly assigned to either delivery of bupivacaine HCl by the ON-Q* Pain Relief System pump (n = 96) or by an injection of Exparel (liposomal bupivacaine) (n = 104). The primary outcome of this study was cumulative narcotic consumption on postoperative days 0 through 3. Narcotic consumption data were collected retrospectively from in-hospital records while patients were in the hospital. Following discharge, narcotic consumption data were gathered from patient surveys, as were secondary outcomes measures.

RESULTS

We did not identify greater narcotic use in the ON-Q* group compared with the Exparel group (p = 0.641). The mean difference between the groups was 0.5 morphine equivalent (95% confidence interval [CI] = -1.7 to +2.8), with the ON-Q* group consuming an average 10.4 morphine equivalents (95% CI = 8.7 to 12.0) compared with 10.9 (95% CI = 9.3 to 12.5) in the Exparel group. There were no significant differences between groups with regard to any of the secondary measures of pain with the exception of pain while walking and pain with physical therapy (p = 0.019 and p = 0.010, respectively), both of which showed an approximately 1-point difference in favor of the ON-Q* group on a visual analog scale (VAS). There were also no differences in the postoperative side effects, including nausea, constipation, or vomiting, or in the rates of study-related complications, patient satisfaction, or length of hospital stay.

CONCLUSIONS

Exparel did not have superior efficacy compared with the ON-Q* Pain Relief System as reflected by narcotic consumption, our primary outcome. There were small significant differences, in favor of the ON-Q* group, in 2 secondary measures of pain during activity, but these approximately 1-point VAS differences are unlikely to be clinically relevant. The choice of a local anesthetic modality should be based on a combination of safety, convenience, and cost considerations.

LEVEL OF EVIDENCE

Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Regional Anesthesia Is Cost-Effective in Preventing Unanticipated Hospital Admission in Pediatric Patients Having Anterior Cruciate Ligament Reconstruction

BACKGROUND AND OBJECTIVES

Published studies have shown a benefit of regional anesthesia (RA) in preventing unplanned hospital admissions (UHAs) and decreasing hospital costs after orthopedic surgeries in adults but not pediatric patients. We performed a retrospective analysis to assess the effect of converting from an opioid to RA-based approach to pain management after pediatric anterior cruciate ligament (ACL) reconstruction.

METHODS

The records of patients having ACL reconstruction were reviewed. Two groups, those with (n = 115) and without (n = 39) nerve blocks, were identified. Single-shot blocks or indwelling catheters were performed in the operating room (OR) or a block room. Time to discharge readiness, postoperative opiate and antiemetic consumption, hospital admission or discharge, and complications were recorded. The cost of providing RA, the change in UHA and postanesthesia care unit utilization, and subsequent financial impact were calculated.

RESULTS

Regional anesthesia-based pain management was associated with a lower rate of UHA (P = 0.045), less time in postanesthesia care unit phase II (P = 0.013), and a reduction in opioid consumption (P < 0.001). Use of a dedicated RA team with a dedicated block room resulted in cost savings or neutrality, whereas RA catheters placed in the OR were associated with increased direct hospital costs.

CONCLUSIONS

Regional anesthesia for pain after ACL repair in pediatric patients facilitated reliable same-day surgery discharge and significantly reduced UHAs. Single-shot blocks and blocks performed outside the OR were the most cost-effective. In addition, nerve block patients required less opioids and were ready for discharge sooner.

Home peripheral nerve catheters: the first 24 months of experience at a children's hospital

CONTEXT

Home peripheral nerve catheters (PNCs) have become common practice for adult patients after major orthopedic surgery. However, use in pediatric patients is a recent application.

OBJECTIVES

The purpose of this study was to review the demographics and outcomes of pediatric patients receiving a PNC at our institution.

METHODS

This retrospective study included patients from October 2012 through October 2014 undergoing orthopedic procedures with a PNC placed for postoperative pain management.

RESULTS

A total of 118 patients aged 3.2-25.3 years were identified. The types of catheters included femoral (80.5%), interscalene (11.9%), sciatic (5.9%), and supraclavicular (1.7%). The majority of patients were discharged to home on the day of surgery (77.1%). In the postanesthetic care unit, the average pain score was 2.5, the incidence of nausea/emesis was 5.9%, and the need for opioid administration was 50.8%. There were no major complications. Minor complications included a 7.6% rate of early catheter removal with 5.9% of those due to catheter leakage and an unsecure dressing. There was one case of metallic taste in the mouth without other symptoms of local anesthetic toxicity that resolved without further complication.

CONCLUSION

The implementation of a home PNC program in pediatric patients at our institution has been highly successful with a high rate of ambulatory catheters, low pain scores, low rates of nausea and vomiting, and no serious complications. Minor complications included leaking of the catheter and early discontinuation of the catheter.

Postoperative pain control after arthroscopic rotator cuff repair

Arthroscopic rotator cuff repair (ARCR) can provide excellent clinical results for patients who fail to respond to conservative management of symptomatic rotator cuff tears. ARCR, however, can be associated with severe postoperative pain and discomfort that requires adequate analgesia. As ARCR continues to shift toward being performed as an outpatient procedure, it is incumbent on physicians and ambulatory surgical centers to provide appropriate pain relief with minimal side effects to ensure rapid recovery and safe discharge. Although intravenous and oral opioids are the cornerstone of pain management after orthopedic procedures, they are associated with drowsiness, nausea, vomiting, and increased length of hospital stay. As health care reimbursements continue to become more intimately focused on quality, patient satisfaction, and minimizing of complications, the need for adequate pain control with minimal complications will continue to be a principal focus for providers and institutions alike. We present a review of alternative modalities for pain relief after ARCR, including cryotherapy, intralesional anesthesia, nerve blockade, indwelling continuous nerve block catheters, and multimodal anesthesia. In choosing among these modalities, physicians should consider patient- and system-based factors to allow the efficient delivery of analgesia that optimizes recovery and improves patient satisfaction.

Pain after surgery in children: clinical recommendations

PURPOSE OF REVIEW

This article summarizes recent data related to the safety and efficacy of postoperative analgesia in children that influence clinical practice recommendations.

RECENT FINDINGS

Postoperative pain continues to be experienced by hospitalized children and following discharge after short stay or ambulatory surgery. Updated recommendations for post-tonsillectomy analgesia exclude codeine and suggest regular administration of paracetamol and NSAID, but evidence for the most appropriate dose and type of opioid for rescue analgesia is limited. The incidence of opioid-related respiratory depression/oversedation in hospitalized children ranges from 0.11 to 0.41%, with recent large series identifying high-risk groups and contributory factors that can be targeted to minimize the risk of serious or permanent harm. Data demonstrating feasibility and safety of regional analgesic techniques is increasing, but additional and procedure-specific evidence would improve technique selection and inform discussions of efficacy and safety with patients and families/carers. Persistent postsurgical pain is increasingly recognized following major surgery in adolescents. Evaluation of potential predictive factors in clinical studies and investigation of underlying mechanisms in laboratory studies can identify targets for both pharmacological and nonpharmacological interventions.

SUMMARY

Recommendations for postoperative pain in children continue to evolve, with data incorporated from randomized controlled trials, case series and large audits. Management of pain following surgery in children needs to not only encompass efficacy and safety in the immediate perioperative period, but also consider pain following discharge after ambulatory surgery and the potential risk of persistent postsurgical pain following major surgery.

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.