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.

Standardizing nomenclature in regional anesthesia: an ASRA-ESRA Delphi consensus study of upper and lower limb nerve blocks

BACKGROUND

Inconsistent nomenclature and anatomical descriptions of regional anesthetic techniques hinder scientific communication and engender confusion; this in turn has implications for research, education and clinical implementation of regional anesthesia. Having produced standardized nomenclature for abdominal wall, paraspinal and chest wall regional anesthetic techniques, we aimed to similarly do so for upper and lower limb peripheral nerve blocks.

METHODS

We performed a three-round Delphi international consensus study to generate standardized names and anatomical descriptions of upper and lower limb regional anesthetic techniques. A long list of names and anatomical description of blocks of upper and lower extremities was produced by the members of the steering committee. Subsequently, two rounds of anonymized voting and commenting were followed by a third virtual round table to secure consensus for items that remained outstanding after the first and second rounds. As with previous methodology, strong consensus was defined as ≥75% agreement and weak consensus as 50%-74% agreement.

RESULTS

A total of 94, 91 and 65 collaborators participated in the first, second and third rounds, respectively. We achieved strong consensus for 38 names and 33 anatomical descriptions, and weak consensus for five anatomical descriptions. We agreed on a template for naming peripheral nerve blocks based on the name of the nerve and the anatomical location of the blockade and identified several areas for future research.

CONCLUSIONS

We achieved consensus on nomenclature and anatomical descriptions of regional anesthetic techniques for upper and lower limb nerve blocks, and recommend using this framework in clinical and academic practice. This should improve research, teaching and learning of regional anesthesia to eventually improve patient care.

Recommendations for effective documentation in regional anesthesia: an expert panel Delphi consensus project

Background and objectives

Documentation is important for quality improvement, education, and research. There is currently a lack of recommendations regarding key aspects of documentation in regional anesthesia. The aim of this study was to establish recommendations for documentation in regional anesthesia.

Methods

Following the formation of the executive committee and a directed literature review, a long list of potential documentation components was created. A modified Delphi process was then employed to achieve consensus amongst a group of international experts in regional anesthesia. This consisted of 2 rounds of anonymous electronic voting and a final virtual round table discussion with live polling on items not yet excluded or accepted from previous rounds. Progression or exclusion of potential components through the rounds was based on the achievement of strong consensus. Strong consensus was defined as ≥75% agreement and weak consensus as 50%–74% agreement.

Results

Seventy-seven collaborators participated in both rounds 1 and 2, while 50 collaborators took part in round 3. In total, experts voted on 83 items and achieved a strong consensus on 51 items, weak consensus on 3 and rejected 29.

Conclusion

By means of a modified Delphi process, we have established expert consensus on documentation in regional anesthesia.

Ultrasound determination of the dural sac to sacrococcygeal membrane distance in premature neonates

Background

Caudal epidural analgesia is the most common regional anesthetic performed in infants. Dural puncture, the most common serious complication, is inversely proportional to age. Measuring the distance from the sacrococcygeal membrane to the dural sac may prevent dural puncture. This study measures the sacrococcygeal membrane to dural sac distance using ultrasound imaging to determine feasibility of imaging and obtaining measurements.

Methods

Sacral ultrasound imaging of 40 preterm neonates was obtained in left lateral decubitus, a typical position for caudal blockade. No punctures were made. The sacrococcygeal membrane and termination of the dural sac were visualized, and the distance measured. The spinal levels of the conus medullaris and dural sac termination were recorded.

Results

20 males and 20 females former preterm neonates with an average weight (SD; range) of 1740 (290; 860–2350) g and average age (SD; range) of 35.0 (1.35; 32.2–39) weeks gestational age at the time of imaging. The average sacrococcygeal membrane to distal dural sac distance (SD; range) was 17.4 (3.1; 10.6–26.3) mm. Overall, the weights correlated positively with the distance but the coefficient of variation was large at 23%. The conus medularis terminated below the L3 level and dural sac below the S3 level in 20% and 10% of subjects respectively with hip flexion.

Conclusion

Ultrasound can be used to measure the sacrococcygeal membrane to dura distance in preterm neonates prior to needle insertion when performing caudal block and demonstrates large variability. Ultrasound imaging may identify patients at risk for dural puncture. When ultrasound is not available, needle insertion less than 3 mm/kg beyond the puncture of the sacrococcygeal membrane should prevent dural contact in 99.9% of neonates.

Standardizing nomenclature in regional anesthesia: an ASRA-ESRA Delphi consensus study of abdominal wall, paraspinal, and chest wall blocks

BACKGROUND

There is heterogeneity in the names and anatomical descriptions of regional anesthetic techniques. This may have adverse consequences on education, research, and implementation into clinical practice. We aimed to produce standardized nomenclature for abdominal wall, paraspinal, and chest wall regional anesthetic techniques.

METHODS

We conducted an international consensus study involving experts using a three-round Delphi method to produce a list of names and corresponding descriptions of anatomical targets. After long-list formulation by a Steering Committee, the first and second rounds involved anonymous electronic voting and commenting, with the third round involving a virtual round table discussion aiming to achieve consensus on items that had yet to achieve it. Novel names were presented where required for anatomical clarity and harmonization. Strong consensus was defined as ≥75% agreement and weak consensus as 50% to 74% agreement.

RESULTS

Sixty expert Collaborators participated in this study. After three rounds and clarification, harmonization, and introduction of novel nomenclature, strong consensus was achieved for the names of 16 block names and weak consensus for four names. For anatomical descriptions, strong consensus was achieved for 19 blocks and weak consensus was achieved for one approach. Several areas requiring further research were identified.

CONCLUSIONS

Harmonization and standardization of nomenclature may improve education, research, and ultimately patient care. We present the first international consensus on nomenclature and anatomical descriptions of blocks of the abdominal wall, chest wall, and paraspinal blocks. We recommend using the consensus results in academic and clinical practice.

Local anesthetic systemic toxicity in children: a review of recent case reports and current literature

BACKGROUND

Local anesthetic systemic toxicity (LAST) in children occurs at an estimated rate of 8 per 100 000 blocks (95% CI 0.3 to 1.6). Due to the potential lethality of this iatrogenic complication, a better clarity of risk factors, clinical presentation, and prognosis may be clinically useful for contemporary treatment and prevention.

METHODS

An extensive literature search and detailed analysis of reported cases of LAST in patients less than 18 years of age published between April 2014 and August 2019 was performed. Clinical patterns were summarized.

RESULTS

Thirty-two cases of LAST were described in 17 published articles and 2 additional cases reported to lipidrescue.org, for a total of 34 cases. Three patients did not meet the inclusion criteria. Thirty-one cases were included in the analysis.

DISCUSSION

Infants represented a disproportionately large number of reports of LAST. The majority of local anesthetic doses were within currently published guidelines. Among the reported cases, penile and caudal blocks were the most commonly associated with LAST. Needle aspiration and test dosing with epinephrine failed to predict LAST with certainty. When LAST presented with severe cardiac compromise, intravenous lipid emulsion was given within 10 min in 43% of cases (13 of 30 reported cases). The vast majority of children were under general anesthesia when local anesthetic medications were administered. In children under general anesthesia, LAST presented with cardiac manifestations in 90% of cases (19 of 21 cases). There were no deaths or long-term morbidity reported.

In the Arms of Morpheus without Morphia; Mitigating the United States Opioid Epidemic by Decreasing the Surgical Use of Opioids

The opioid epidemic is a major public health issue in the United States. Exposure of opioid naïve-patients to opioids in the perioperative period is a well-documented source of continued use with one in 20 opioid-naïve surgical patients continuing to use opioids beyond 90 days. There is no association with magnitude of surgery, major versus minor, and the strongest predictor of continued use is surgical exposure. Causal factors include over reliance on opioids for intraoperative and postoperative analgesia and excessive ambulatory opioid prescribing. Opioid-induced hyperalgesia can paradoxically result from intraoperative (anesthesia controlled) opioid administration. Increasing size of initial prescription is a strong predictor of continued use necessitating procedure specific supplies limited to under 3-days. Alternative multimodal pain management (non-opioid medications and regional anesthesia) that limit opioid use must be a high priority with opioids reserved for severe breakthrough pain. Barriers to implementation of opioid-sparing pathways include reluctance to adopt protocols and apprehension about opioid elimination. Considering the number of surgeries performed annually in the United States, perioperative physicians must aggressively address modifiable factors in surgical patients. Patient care pathways need to be constructed collaboratively by surgeons and anesthesiologists with continuing feedback to optimize patient outcomes including iatrogenic opioid dependence.

Distal Peripheral Nerve Stimulation Successfully Assesses Sciatic Nerve Integrity Following Parasacral Sciatic Motor Block: A Case Report

Following the placement of lumbar plexus and parasacral sciatic catheters for complex lower extremity surgery, a 19-kg child had dense sensory and motor blockades in the postanesthesia care unit. The surgical team felt obligated to exclude anatomically modifiable compression of the sciatic nerve and planned for surgical reexploration. Using an insulated short, beveled needle, direct electrical nerve stimulation distal to the parasacral sciatic block and proximal to the surgical site elicited tibial nerve motor function and confirmed nerve integrity. Peripheral nerve stimulation can be used to differentiate between the etiologies of motor blockade in time-critical situations.

American Society of Regional Anesthesia and Pain Medicine expert panel recommendations on point-of-care ultrasound education and training for regional anesthesiologists and pain physicians-part II: recommendations

Point-of-care ultrasound (POCUS) is a critical skill for all regional anesthesiologists and pain physicians to help diagnose relevant complications related to routine practice and guide perioperative management. In an effort to inform the regional anesthesia and pain community as well as address a need for structured education and training, the American Society of Regional Anesthesia and Pain Medicine Society (ASRA) commissioned this narrative review to provide recommendations for POCUS. The recommendations were written by content and educational experts and were approved by the guidelines committee and the Board of Directors of the ASRA. In part II of this two-part series, learning goals and objectives were identified and outlined for achieving competency in the use of POCUS, specifically, airway ultrasound, lung ultrasound, gastric ultrasound, the focus assessment with sonography for trauma exam, and focused cardiac ultrasound, in the perioperative and chronic pain setting. It also discusses barriers to POCUS education and training and proposes a list of educational resources. For each POCUS section, learning goals and specific skills were presented in the Indication, Acquisition, Interpretation, and Medical decision-making framework.

American Society of Regional Anesthesia and Pain Medicine expert panel recommendations on point-of-care ultrasound education and training for regional anesthesiologists and pain physicians-part I: clinical indications

Point-of-care ultrasound (POCUS) is a critical skill for all regional anesthesiologists and pain physicians to help diagnose relevant complications related to routine practice and guide perioperative management. In an effort to inform the regional anesthesia and pain community as well as address a need for structured education and training, the American Society of Regional Anesthesia and Pain Medicine (ASRA) commissioned this narrative review to provide recommendations for POCUS. The guidelines were written by content and educational experts and approved by the Guidelines Committee and the Board of Directors of the ASRA. In part I of this two-part series, clinical indications for POCUS in the perioperative and chronic pain setting are described. The clinical review addresses airway ultrasound, lung ultrasound, gastric ultrasound, the focus assessment with sonography for trauma examination and focused cardiac ultrasound for the regional anesthesiologist and pain physician. It also provides foundational knowledge regarding ultrasound physics, discusses the impact of handheld devices and finally, offers insight into the role of POCUS in the pediatric population.

Perioperative Point-of-Care Ultrasound in Children

Anesthesiologists and other acute care physicians perform and interpret portable ultrasonography—point-of-care ultrasound (POCUS)—at a child’s bedside, in the perioperative period. In addition to the established procedural use for central line and nerve block placement, POCUS is being used to guide critical clinical decisions in real-time. Diagnostic point-of-care applications most relevant to the pediatric anesthesiologist include lung ultrasound for assessment of endotracheal tube size and position, pneumothorax, pleural effusion, pneumonia, and atelectasis; cardiac ultrasound for global cardiac function and hydration status, and gastric ultrasound for aspiration risk stratification. This article reviews and discusses select literature regarding the use of various applications of point-of-care ultrasonography in the perioperative period.

Point-of-care ultrasound for the pediatric regional anesthesiologist and pain specialist: a technique review

Point-of-care ultrasound (PoCUS) has been well described for adult perioperative patients; however, the literature on children remains limited. Regional anesthesiologists have gained interest in expanding their clinical repertoire of PoCUS from regional anesthesia to increasing numbers of applications. This manuscript reviews and highlights emerging PoCUS applications that may improve the quality and safety of pediatric care.

In infants and children, lung and airway PoCUS can be used to identify esophageal intubation, size airway devices such as endotracheal tubes, and rule in or out a pulmonary etiology for clinical decompensation. Gastric ultrasound can be used to stratify aspiration risk when nil-per-os compliance and gastric emptying are uncertain. Cardiac PoCUS imaging is useful to triage causes of undifferentiated hypotension or tachycardia and to determine reversible causes of cardiac arrest. Cardiac PoCUS can assess for pericardial effusion, gross ventricular systolic function, cardiac volume and filling, and gross valvular pathology. When PoCUS is used, a more rapid institution of problem-specific therapy with improved patient outcomes is demonstrated in the pediatric emergency medicine and critical care literature.

Overall, PoCUS saves time, expedites the differential diagnosis, and helps direct therapy when used in infants and children. PoCUS is low risk and should be readily accessible to pediatric anesthesiologists in the operating room.

Seeing Is Believing: Ultrasound in Pediatric Procedural Performance

Point-of-care ultrasound is currently widely used across the landscape of pediatric care. Ultrasound machines are now smaller, are easier to use, and have much improved image quality. They have become common in emergency departments, ICUs, inpatient wards, and outpatient clinics. Recent growth of supportive evidence makes a strong case for using point-of-care ultrasound for pediatric interventions such as vascular access (in particular, central-line placement), lumbar puncture, fluid drainage (paracentesis, thoracentesis, pericardiocentesis), suprapubic aspiration, and soft tissue incision and drainage. Our review of this evidence reveals that point-of-care ultrasound has become a powerful tool for improving procedural success and patient safety. Pediatric patients and clinicians performing procedures stand to benefit greatly from point-of-care ultrasound, because seeing is believing.

Success of bedside ultrasound to identify puncture site for spinal anesthesia in neonates and infants

Spinal anesthesia (SA) may be difficult in small infants. Conceptual advantages of ultrasound imaging to view critical neuraxial structures and exploiting the acoustic window unique to infants have been described but not clinically verified. We present 14 preterm-infants aged 35-48 weeks, weighing 1575-5800 g, and describe ultrasound imaging to locate an appropriate puncture site for SA. The success rate for first puncture was 64%, and the overall success on three attempts was 86%. The mean dural depth was 8 mm (1.6). The inferior medullary cone location was just above L3-L4 in 85.7% of patients. Ultrasound imaging for SA in infants may offer advantages.

Persistent pain following common outpatient surgeries in children: A multicenter study in Italy

INTRODUCTION

The prevalence of persistent postsurgical pain in children is over 20% after major surgeries; however, data are scarce on the prevalence, character, and risk factors among children undergoing common ambulatory surgeries. The primary aim of this study was to evaluate the prevalence of persistent pain following pediatric ambulatory surgery at 1, 3, and 6 months. Secondary aims were to identify risk factors and characterize the pain and consequences of persistent postsurgical pain.

METHODS

ASA I-II, ages 1 month to 16 years old, undergoing elective hypospadias repair, herniorraphy, orchiopexy, and orthopedic surgery were enrolled in a prospective, longitudinal, observational study at 3 pediatric centers in Italy. All patients received general plus regional anesthesia. Postoperative pain was evaluated using age appropriate pain scales at 1 and 3 hours. At 1, 3, and 6 months, pain scores were obtained and Parent's Postoperative Pain Measures (<8 yo) and Child Activity Limitations Interview (>8 yo) surveys were administered.

RESULTS

About 350 patients completed the study. The prevalence of pain at 1, 3, and 6 months was 24% (84/350), 6.0% (21/350), and 4.0% (14/350), respectively. Inguinal herniorraphy patients experienced significantly higher pain at all 3-time points; 35.6%, 14.9%, and 9.2%. There was no significant association between mean pain scores >4 in PACU and persistent pain. Pain persisting at 6 months had neuropathic characteristics and frequently interfered with daily activities and sleep.

CONCLUSION

Our data support the presence of persistent pain in pediatric patients after common surgeries. Most patients who developed persistent pain at 6 months had pain at 1 month. We recommend questioning at follow-up visit about persistent pain and functional impairment with follow-up until resolution.

Ultrasound-guided lumbar plexus block in children and adolescents using a transverse lumbar paravertebral sonogram: Initial experience

BACKGROUND

The clinical reliability and reproducibility of ultrasound-guided lumbar plexus blocks is not established in pediatric populations. We present the results of a combined nerve stimulation ultrasound-guided lumbar plexus block using the vertebral body, transverse process, and psoas muscle as landmarks on a transverse lumbar paravertebral sonogram with mid-axillary transducer placement, "shamrock method," in children and adolescents.

AIMS

Our primary objective was to determine the rate of achieving sensory changes in the lumbar plexus distribution. Secondary outcomes were performance time, reliability of echo-landmarks, measures of patient comfort, and complications.

METHODS

We reviewed prospectively collected quality assurance data and electronic medical records of 21 patients having major orthopedic surgery with lumbar plexus block catheter for postoperative analgesia.

RESULTS

Twenty-one patients were studied with mean age and weight (SD, range) of 13.6 years (3.8, 6-18) and 49.3 kg (18.6, 19.2-87.6). Surgical procedures included periacetabular osteotomy, pelvic osteotomy, and proximal femoral osteotomy. Mean volume of 0.5 mL/kg (0.05) 0.2% ropivacaine produced thermal sensory changes to femoral and lateral femoral cutaneous nerves in 20/21 (95% CI 0.76 to >0.99) and 19/21 (95% CI 0.70-0.99) patients. Identification of transverse process (TP), vertebral body (VB), and psoas muscle (PM): 21/21 (95% CI 0.86-1.0). Average block performance time was 9:08 minutes (2:09, 2-13). Average opioid consumption (SD) in operating room, postanesthesia care unit, 0-12 and 12-24-hour periods were 0.17 mg/kg (0.08), 0.08 mg/kg (0.06), 0.06 mg/kg (0.06), and 0.06 mg/kg (0.05). Median pain score by severity category in postanesthesia care unit: (0-3) 66.7%, (4-6) 28.5%, (>7) 4.8%; 0-12 hours: (0-3) 76.2%, (4-6) 19.0%, (>7) 4.8%; 12-24 hours: (0-3) 57.2%, (4-6) 42.8%, (>7) 0%. No complications were recorded.

CONCLUSION

Ultrasound guidance using lateral imaging of transverse process, vertebral body, and psoas muscle allows practitioners to reach the nerves of the lumbar plexus and achieve sensory block in pediatric patients with a high success rate.

Technical success of the ultrasound-guided supra-inguinal fascia iliaca compartment block in older children and adolescents for hip arthroscopy

BACKGROUND

Hip arthroscopic surgery is performed on older pediatric patients. Fascia iliaca compartment block has proven efficacy in providing analgesia following hip surgery and can be performed with target location of local anesthetic below or above the inguinal ligament. The reported success of ultrasound-guided infra-inguinal fascia iliaca compartment block is lower when compared to traditional landmark technique, while the reliability of supra-inguinal fascia iliaca compartment block is unreported.

AIM

The primary aim was to report the results in obtaining sensory changes in the distribution of the femoral and lateral femoral cutaneous nerves following supra-inguinal fascia iliaca compartment block in patients undergoing arthroscopic hip surgery. Secondary outcomes are the ability to find echogenic landmarks and to report pain scores and opioid consumption.

METHODS

We reviewed the electronic medical record and regional anesthesia database of patients receiving ultrasound-guided fascia iliaca compartment block for arthroscopic hip surgery. Sensory changes to the femoral and lateral femoral cutaneous nerves were determined. Identification of echogenic landmarks was quantified. Pain scores and opioid consumption were determined.

RESULTS

Seventeen patients of mean age 15.4 years old (SD 1.3; range 13-17 years) were included. Sensory changes to both the femoral and lateral femoral cutaneous nerves occurred in 94% of patients (95% CI: 82%-100%). The average volume of ropivacaine 0.2% was 0.53 mL/Kg (SD 0.11 mL/Kg). Echogenic landmarks were identified in all patients. Pain scores and opioid consumption were generally low.

CONCLUSION

A supra-inguinal location for the deposition of local anesthetic when performing fascia iliaca nerve block for hip surgery is reliable in anesthetizing the femoral and lateral femoral cutaneous nerves and should encourage investigation into the clinical efficacy.

Dexmedetomidine as a Supplement to Spinal Anesthesia Block: A Case Report of Three Infants

We report a novel use for dexmedetomidine as a supplemental intravenous or intranasal sedative for spinal anesthesia in infants. The children were 1, 2, and 9 months old having either inguinal hernia repair or circumcision. None of them experienced clinically relevant hemodynamic changes or apnea. Pain scores were zero throughout the postoperative period.

Dermatomal spread following posterior transversus abdominis plane block in pediatric patients: our initial experience

INTRODUCTION

Several techniques for the transversus abdominis plane (TAP) block have been described. The extent of sensory changes using an ultrasound-guided posterior TAP block (pTAP) remains unclear in pediatric patients. The primary aim of this study was to report the extent of sensory changes achieved with pTAP; specifically the highest thoracic dermatome anesthetized. Secondary outcomes were pain scores (PS), opioid consumption, and complications.

METHODS

We retrospectively reviewed the medical records of patients less than 21 years of age undergoing abdominal surgery with a unilateral or bilateral pTAP(s) for postoperative analgesia. The local anesthetic was placed posterior to the termination of the transversus abdominis muscle where the thoracolumbar fascia overrides the quadratus lumborum muscle. The extent of sensory changes, pain scores, and opioid consumption were analyzed.

RESULTS

A total of 10 patients (15 pTAP blocks) met the inclusion criteria. The mean (sd; range) age and weight were 15 years (5 years; range 7-20 years) and 57 kg (21 kg; 27-97 kg), respectively. The cephalad dermatome levels achieved were: T7 in 6/15 (40%); T8 in 10/15 (67%); and T9 in 14/15 (93%). An inferior dermatome level of T12/L1 and sensory extension from midaxillary line to the midline was documented in 15/15 blocks. The mean intraoperative and postanesthesia care unit (PACU) opioid consumption in morphine equivalents were 0.34 mg·kg^-1 (sd = 0.12 mg·kg^-1 ) and 0.04 mg·kg^-1 (sd = 0.05 mg·kg^-1 ), respectively. PACU pain scores were mild (<4) in 60%, moderate (4-7) in 30%, and severe (>7) in 10% of patients. No complications were reported.

DISCUSSION

The current uncertainty regarding sensory blockade limits the clinical application of TAP blocks. While the midaxillary approach results in unpredictable sensory changes of the abdomen, we reliably achieved sensory changes up to a T9 level in 93% of the blocks.

CONCLUSION

In this small series of patients, we demonstrate a high technical success rate of achieving cutaneous analgesia to the abdominal wall. These results should encourage clinical studies of the efficacy of this block for abdominal surgery in pediatric patients.

Chloroprocaine: local anesthetic systemic toxicity in a 9-month infant with paravertebral catheter

Regional anesthesia use in pediatric patients has a good safety profile. 2-Chloroprocaine is used frequently in infants due to rapid onset, lack of accumulation, and rapid plasma degradation. We present a case of local anesthetic systemic toxicity following the administration of 3% 2-chloroprocaine through a paravertebral catheter in an infant. The episode lasted 40 s followed by complete recovery. The infrequent reporting of local anesthetic systemic toxicity and limited duration of symptoms supports the continued use of 2-chloroprocaine in infants. Volume should be restricted to the smallest amount providing analgesia.

Ultrasound-guided approach to the paravertebral space for catheter insertion in infants and children

BACKGROUND

Paravertebral perineural blocks are used to prevent pain in the thoracoabdominal dermatomes. Traditionally, a landmark-based technique is used in children, while ultrasound-guided (UG) techniques are being employed in adult patients.

OBJECTIVE

To describe an UG technique for placement of thoracic paravertebral nerve block (TPVNB) catheters in pediatric patients.

METHODS

Retrospective chart review of a series of 22 pediatric patients' ages 6 months to 17 years with weights from 6.25 kg to 135 kg using a transverse in-plane technique. Catheters were placed both bilateral and unilateral for a variety of thoracic and abdominal procedures. A linear ultrasound transducer was used in all cases with frequency of oscillation and transducer length chosen based on individual patient characteristics of age, weight, and BMI.

RESULTS

The median pain scores at 12, 24, 36, and 48 h were 1.2 (interquartile range, 4.5), 0.84 (interquartile range 3.0), 1.6 (interquartile range 2.9), and 0.83 (interquartile range 1.74), respectively. The median dose of opioid expressed as morphine equivalents consumed during the first 24 h after surgery was 0.14 mg·kg(-1) (interquartile range, 0.78 mg·kg(-1) ) and from 24 to 48 h the median dose was 0.11 mg·kg(-1) (interquartile range 0.44 mg·kg(-1) ). No complications were noted, and catheters were left an average of 3 days with a range of 1-5 days with good pain relief.

CONCLUSION

This technical description demonstrates the feasibility of placing PVNB catheters using a transverse in-line ultrasound-guided technique in a wide range of pediatric patients.