Multisite prospective study of perioperative pain management practices for anterior cruciate ligament reconstruction in adolescents: Society for Pediatric Anesthesia Improvement Network (SPAIN) Project Report

INTRODUCTION

Although 200 000 adolescents undergo anterior cruciate ligament reconstruction (ACLR) surgery annually, no benchmarks for pediatric post-ACLR pain management exist. We created a multicenter, prospective, observational registry to describe pain practices, pain, and functional recovery after pediatric ACLR.

METHODS

Participants (n=519; 12-17.5 years) were enrolled from 15 sites over 2 years. Data on perioperative management and surgical factors were collected. Pain/opioid use and Lysholm scores were assessed preoperatively, on postoperative day 1 (POD1), POD3, week 6, and month 6. Descriptive statistics and trends for opioid use, pain, and function are presented.

RESULTS

Regional analgesia was performed in 447/519 (86%) subjects; of these, adductor canal single shot was most frequent (54%), nerve catheters placed in 24%, and perineural adjuvants used in 43%. On POD1, POD3, week 6, and month 6, survey response rates were 73%, 71%, 61%, and 45%, respectively. Over these respective time points, pain score >3/10 was reported by 64% (95% CI: 59% to 69%), 46% (95% CI: 41% to 52%), 5% (95% CI: 3% to 8%), and 3% (95% CI: 1% to 6%); the number of daily oxycodone doses used was 2.8 (SD 0.19), 1.8 (SD 0.13), 0, and 0. There was considerable variability in timing and tests for postdischarge functional assessments. Numbness and weakness were reported by 11% and 4% at week 6 (n=315) and 16% and 2% at month 6 (n=233), respectively.

CONCLUSION

We found substantial variability in the use of blocks to manage post-ACLR pain in children, with a small percentage experiencing long-term pain and neurological symptoms. Studies are needed to determine best practices for regional anesthesia and functional assessments in this patient population.

Management challenges in the passing-through technique using a fogarty catheter to remove an endobronchial foreign body from an infant

BACKGROUND

Foreign body aspiration (FBA) is a potentially life-threatening condition in children, and removal of an aspirated bead can be difficult.

CASE REPORT

An 11-month-old male infant presented with a history of choking 6 days prior to admission. FBA was suspected, and initial examination revealed a bead occluding the left main bronchus. The surgeon tried to retrieve the foreign body, but the patient developed coughing episodes with desaturation. The patient was intubated and a bronchoscopy was performed with a flexible bronchoscope. A Fogarty catheter was passed through the bronchoscope and then advanced through the bead opening. The distal balloon was inflated, and the bead was removed as the Fogarty catheter was withdrawn.

CONCLUSION

We successfully removed an aspirated bead from an infant using the passing-through technique with a Fogarty catheter. Maintaining spontaneous ventilation for as long as possible and good coordination between the anesthesiologist and surgeon are crucial in such cases.

Acute respiratory distress following ultrasound-guided supraclavicular block

BACKGROUND

Brachial plexus blocks have become very common for patients undergoing upper extremity surgery. We report a case in which the patient developed ipsilateral phrenic nerve paralysis and acute respiratory failure following supraclavicular nerve block.

CASE REPORT

A 61-year-old female diabetic, morbidly obese patient presented for a repeat debridement of necrotizing fasciitis on her left arm. She received a left-sided supraclavicular brachial plexus block. Within a few minutes, the patient began to experience acute dyspnea, anxiety, and oxygen saturation of 90%. Breath sounds were diminished in the left hemithorax. Arterial blood gases revealed evidence of acute respiratory acidosis. The chest x-ray was normal. After induction, we intubated the patient. Subsequent arterial blood gases showed marked improvement in respiratory acidosis. We believed left phrenic nerve paralysis to be the cause of the distress. The patient was extubated in the surgical intensive care unit the following day, and infusion of ropivacaine 0.2% was started. The catheter was removed afterward secondary to its occlusion.

CONCLUSION

Phrenic nerve injury leading to respiratory distress is a rare complication of supraclavicular brachial plexus block. Anesthesiologists should be ready for emergency intubation when performing this kind of block.