Long-term use of nerve block catheters in paediatric patients with cancer related pathologic fractures

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.

Ultrasound-Guided Peripheral Nerve Blocks: A Practical Review for Acute Cancer-Related Pain

PURPOSE OF REVIEW

Ultrasound-guided regional techniques, including catheter-based approaches, are a subset of interventional therapies that have gained interest as an option for managing acute cancer-related pain. The authors sought to review the available published evidence and to discuss practical recommendations for expanding access to such therapies.

RECENT FINDINGS

In a MEDLINE/Pubmed search of ultrasound-guided peripheral nerve blocks and peripheral nerve catheters for specific anatomic targets, a total of 28 case reports and case series were identified. Included studies described improved analgesia and reduced opioid requirements with highly variable duration of effect. Current level of evidence remains limited. Pain is a symptom that markedly impacts the quality of life of cancer patients and ultrasound-guided regional techniques are a promising therapeutic option albeit with a limited evidence base. Practical recommendations offered for coordinating access to such therapies in the inpatient, emergency department, and outpatient settings may expand interest and facilitate higher quality research.

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.

Managing Pain and Discomfort in Children with Cancer

PURPOSE OF REVIEW

Approximately 15,600 children are diagnosed with cancer annually. Many of these children have cancer-related pain that improves with cancer treatment, but some develop intractable pain from cancer progression or sequelae from treatment modalities. The purpose of this paper is to provide a critical evaluation of the literature relevant to pain management in children with cancer. We intend to emphasize important and up-to-date findings in pharmacology, interventional pain management, and complementary and alternative medicine.

RECENT FINDINGS

Alternative medications and routes of administration, complementary and alternative medicine techniques, and interventional pain procedures offer possible routes for a multi-pronged pediatric cancer pain management plan, although high-level data is often lacking. To improve pediatric cancer pain management, a multifaceted approach embracing the biopsychosocial model of pain is recommended, incorporating evidence-based pharmacology, complementary and alternative medicine techniques, and if needed, interventional pain procedures.

Prolonged continuous infraclavicular brachial plexus perineural infusion following replantation of a mid-humeral amputation

Replantation of a traumatic upper extremity amputation is a complex process accompanied by prolonged hospitalization, extended rehabilitation, and potential for graft failure secondary to poor perfusion to the distal extremity. The patient is faced with repeat visits to the operating room in addition to severe acute and chronic pain issues. We present the case of an 18-year-old male treated with prolonged continuous peripheral nerve blockade following traumatic left mid-humeral amputation and subsequent replantation. The patient maintained infraclavicular brachial plexus catheterization until hospital discharge, a course spanning 33 days and six follow-up surgical procedures. The patient was pain free and had been weaned off all opioids at a 4-week outpatient surgical debridement. Prolonged continuous infraclavicular brachial plexus blockade following replantation surgery has numerous potential benefits including augmentation of perfusion to the injured extremity, management of severe acute post-traumatic pain, and prevention of the chronic pain associated with transected nerves.

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.

[Chronic pain and regional anesthesia in children]

Chronic pain is usually underestimated in children, due to lack of knowledge and its specific signs. In addition to suffering, chronic pain causes a physical, psychological, emotional, social, and financial burden for the child and his family. Practitioners may find themselves in a situation of failure with depletion of medical resources. Some types of chronic pain are refractory to conventional systemic treatment and may require the use of regional anesthesia. Cancer pain is common in children and its medical management is sometimes insufficient. It is accessible to neuroaxial or peripheral techniques of regional anesthesia if it is limited to an area accessible to one of these techniques and no contraindications (e.g., thrombopenia) are present. Complex regional pain syndrome 1 is not rare in children and adolescents, but it often goes undiagnosed. Regional anesthesia may contribute to the treatment of complex regional pain syndrome 1, mainly in case of recurrence, because it provides rapid effective analgesia and allows rapid implementation of intensive physiotherapy. These techniques have also shown interest in phantom limb pain after limb amputation, but they remain controversial for erythromelalgia pain or chronic abdominopelvic pain. Finally, the treatment of postdural puncture headache due to cerebrospinal fluid leak can be treated by performing an epidural injection of the patient's blood, called a blood-patch. Finally, the management of children with chronic pain should be multidisciplinary (pediatrician, physiotherapist, psychologist, surgeon, anesthesiologist) to support the child and her problem in its entirety.