Benefit of epidural analgesia for postoperative pain control after a Kasai Portoenterostomy: A ten-year retrospective cohort study.

INTRODUCTION: Biliary atresia is a rare obstructive cholangiopathy that presents in infants. The Kasai portoenterostomy procedure, which reestablishes biliary drainage into the intestine, is a surgical procedure that has been found to improve survival with the native liver. The options for postoperative analgesia include systemic opioids and epidural analgesia. The primary objective of this study was to compare the postoperative systemic opioids used in morphine equivalents (mg/kg) on postoperative days 0 through 3 between patients who underwent a Kasai portoenterostomy and received a thoracic epidural infusion to those without thoracic epidural analgesia. METHODS: We conducted a retrospective cohort study of 91 infants with biliary atresia undergoing a Kasai portoenterostomy between January 1, 2009, and September 1, 2019, at the Children's Hospital of Philadelphia. RESULTS: Sixty-three of the 91 patients (69%) had a continuous epidural catheter placed intraoperatively for postoperative analgesia. The total opioid requirement (morphine equivalents) for the first 72 h in the epidural group of (Mean (95% confidence interval): 0.52 mg/kg (0.38, 0.67 mg/kg) was lower than the non-epidural group (Mean (95% confidence interval): 1.15 mg/kg (0.8, 1.48 mg//kg) for a difference in mean opioid requirement (95% confidence interval) of 0.63 mg/kg (0.32, 0.94 mg/kg). Patients in the non-epidural group had higher rates of unplanned ICU admissions (36% non-epidural group vs. 3.3% epidural group, difference in proportion (95% confidence interval) 32.7% (13, 52%), p < .01). A higher percentage of patients in the non-epidural group had a postoperative oxygen requirement (32.1% vs. 11.3%, difference in proportion (95% confidence interval) 21% (2, 40%), p = .02). CONCLUSION: In our cohort study, continuous thoracic epidural analgesia in patients undergoing a Kasai portoenterostomy was associated with lower postoperative opioid use. We also observed that the epidural group had a lower ICU admission rate and a lower rate of postoperative supplemental oxygen requirement over the first three postoperative days.

Functional near-infrared spectroscopy to assess pain in neonatal circumcisions.

INTRODUCTION: Pain assessment is challenging in neonates. Behavioral and physiological pain scales do not assess neocortical nociception, essential to pain encoding and central pain pathway development. Functional near-infrared spectroscopy (fNIRS) can assess neocortical activation to noxious stimuli from changes in oxy-(HbO) and total-hemoglobin concentrations (HbT). This study aims to assess fNIRS nociceptive functional activation in the prefrontal cortex of neonates undergoing circumcision through changes in HbO and HbT, and the correlation between changes in fNIRS and Neonatal Infant Pain Scale (NIPS), a behavioral pain assessment scale. METHODS: In healthy term neonates, HbO, HbT, and NIPS were recorded during sequential circumcision events 1-Prep before local anesthetic injection; 2-Local anesthetic injection; 3-Prep before incision; 4-Oral sucrose; 5-Incision; 6-Gomco (hemostatic device) attached; 7-Gomco twisted on; and 8-Gomco removed. fNIRS and NIPS changes after each event were assessed with Wilcoxon signed-rank test and summarized as median and interquartile range (IQR). Changes in fNIRS vs. NIPS were correlated with Spearman coefficient. RESULTS: In 31 neonates fNIRS increased (median [IQR] µmol/L) with noxious events: Local injection (HbO: 1.1 [0.5, 3.1], p < .001; HbT: 2.3 [0.2, 7.6], p < .001), Gomco attached (HbO: 0.7 [0.1, 1.7], p = .002; HbT: 0.7 [-0.2, 2.9], p = .02), and Gomco twisted on (HbO: 0.5 [-0.2, 1.7], p = .03; HbT: 0.8 [-0.1, 3.3], p = .02). fNIRS decreased with non-noxious event: Prep before incision (HbO: -0.6 [-1.2, -0.2] p < .001; HbT: -1 [-1.8, -0.4], p < .001). Local anesthetic attenuated fNIRS increases to subsequent sharp stimuli. NIPS increased with subsequent sharp stimuli despite local anesthetic. Although fNIRS and NIPS changed in the same direction, there was not a strong correlation between them. CONCLUSIONS: During neonatal circumcision, changes in fNIRS differed between different types of painful stimuli, which was not the case for NIPS, suggesting that fNIRS may complement NIPS to assess the quality of pain.

A retrospective comparison of ropivacaine and 2-chloroprocaine continuous thoracic epidural analgesia for management of postthoracotomy pain in infants.

INTRODUCTION: Continuous thoracic epidural analgesia is useful in the management of infants following thoracotomy. Concerns about drug accumulation and toxicity limit the amount of amide local anesthetics that can be delivered. Continuous epidural infusions of the ester local anesthetic chloroprocaine result in little drug accumulation allowing for higher infusion rates. We retrospectively compared patients managed with 1.5% 2- chloroprocaine or 0.1% ropivacaine epidural infusions to determine if the increased infusion rate resulted in similar or improved analgesia. METHODS: This retrospective cohort comparison consisted of full term infants 6 months or younger who underwent thoracotomy for congenital lung lesion resection. Patients were included if they were managed with either a 1.5% 2-chloroprocaine (Group C) (n = 26) or 0.1% ropivacaine (Group R) (n = 28) infusion administered through a caudally placed thoracic epidural catheter. The primary outcome was morphine administration at 0-24 h. RESULTS: Patients were similar in age, weight, length of stay, epidural location and duration. There was weak evidence for a difference in morphine use in the first 24 h in Group C compared to Group R (P = 0.08) but no difference 24-48 h. Group C was more commonly managed with ketorolac at 0-24 h (P = 0.03) and 24-48 h (P =< 0.01). DISCUSSION: The use of 2-chloroprocaine for continuous epidural infusion in infants following thoracotomy was not inferior to ropivacaine and there was weak evidence for a reduction in opioid consumption in the first 24 h postoperatively. However, the 2-chloroprocaine group was more likely to receive ketorolac.

Ambulatory continuous peripheral nerve blocks in children and adolescents: a longitudinal 8-year single center study.

BACKGROUND: Although the role of regional anesthesia in pediatric patients has been increasing over the last few years, there are only a few small case series that describe the use of ambulatory continuous peripheral nerve blocks (CPNBs) in this patient population. In this report, we describe our experience with the use of ambulatory CPNBs in 1285 children. METHODS: Data were collected for consecutive children who had a CPNB placed between January 2005 and December 2011 at The Children's Hospital of Philadelphia from the departmental regional anesthesia database. Data collected included demographics, the site of catheter placement and technique of nerve block, presence of sensory/motor blockade, use of perioperative opioids, and any complications related to CPNBs. RESULTS: Continuous infusions of local anesthetics were administered via the catheters in 1285 outpatients. The mean duration of the CPNB was 50.7 ± 14.4 hours (mean ± SD). Among patients discharged home with the CPNBs, 969 (75.4%) of the patients required either no supplemental opioids or oral opioids only on an "as needed" basis in the postoperative period (confidence interval, 73.0%-77.8%). Two patients were readmitted for IV pain management after they were discharged home with the CPNB catheters. No neurological deficit related to the CPNBs was identified in any of the patients at their 6-month follow-up with the orthopedic surgeon (confidence interval, 0%-0.29%). CONCLUSION: This audit of 1285 children shows ambulatory CPNBs can provide postoperative analgesia and may reduce the need for inpatient parenteral opioid therapy.

Effects of intrathecal morphine on transcranial electric motor-evoked potentials in adolescents undergoing posterior spinal fusion.

BACKGROUND: Intrathecal morphine (ITM) provides effective analgesia after posterior spinal fusion (PSF). Although most anesthetic drugs have well-characterized effects on evoked potentials, there is little data on the effects of ITM on transcranial electric motor-evoked potentials (tceMEPs). We performed this study to assess the effects of ITM on tceMEPs in the first 30 minutes after administration. We hypothesized that administration of ITM in doses currently used at our institution would not significantly affect mean tceMEP amplitudes and latencies of an ITM study group relative to control patients who did not receive the drug. METHODS: tceMEPs were recorded before ITM injection and 5, 10, 20, and 30 minutes after injection in 14 subjects ages 11 through 18 years undergoing PSF. These recordings were compared to an age-matched control group undergoing PSF in which ITM was not injected. The effects of ITM on tceMEP amplitude and latency were compared between the 2 groups. RESULTS: Fourteen subjects were enrolled in the ITM group and 16 served as controls. There were no significant differences in the baseline mean response amplitudes of the 2 groups for any of the 8 muscles studied. Mean response amplitudes over the 30-minute posttreatment period in the ITM group did not differ significantly from those of the control subjects. Average response amplitudes collapsed across all muscles for each subject were not significantly different during the baseline period (95% CI = -38% to 45%; P = 0.783), nor were they significantly different between the 2 groups during the posttreatment period (95% CI = -30% to 78%; P = 0.640). There also were no significant differences in the mean response latencies of the 2 groups in either the baseline or posttreatment periods. Average response latencies collapsed across all muscles for each subject were 4% larger for the ITM group than for controls during the baseline period (95% CI = -5% to 13%; P = 0.377), and 3% larger for the ITM group than for controls during the posttreatment period (95% CI = -4% to 12%; P = 0.359). CONCLUSIONS: Administration of ITM in doses currently used at our institution did not cause more than a 70% attenuation of mean tceMEP amplitudes or latency changes of an ITM study group relative to control subjects during the 30-minute period after injection. Further studies are required to determine if there are delayed effects after this initial time period.

Pediatric Pain Screening Tool: A Simple 9-Item Questionnaire Predicts Functional and Chronic Postsurgical Pain Outcomes After Major Musculoskeletal Surgeries.

Reliable, clinic-friendly screening for Chronic postsurgical pain (CPSP) risk is unavailable. Within a prospective, observational study, we evaluated Pediatric Pain Screening Tool (PPST), a concise 9-item questionnaire, as a preoperative screening tool to identify those at higher risk for CPSP (Numerical Rating Scale > 3/10 beyond 3 months post-surgery) and poor function (disability/Functional Disability Inventory [FDI]/quality of life/ Pediatric Quality of Life) after spine fusion and Nuss procedures. Incidence of CPSP was 34.86% (38/109). We confirmed PPST scale stability, test re-test reliability (ICC = 0.68; P< .001); PPST measures were positively correlated with known CPSP risk factors (P< .001) preoperative pain (Pearson or Spearman Correlation Coefficient [SCC]:0.672), Child anxiety sensitivity index (SCC:0.357), Patient Related Outcome Measures Information System pain interference (SCC:0.569), Patient Related Outcome Measures Information System depression (SCC:0.501), Pediatric Quality of Life (SCC:-0.460) and insomnia severity index (SCC0.567). Preoperative PPST and PPST physical sub-scores (median(IQR) were higher in CPSP (2[0.5,4], 1[0,2]) compared to non-CPSP (1[0,3], 0[0,1.5]) groups (P= .026, P= .029) respectively. PPST scores/sub-scores positively correlated with higher FDI at 6 months but only PPST total and PPST psychosocial subscore correlated with higher FDI at 12 months. Based on ROC, optimal PPST cutoff for CPSP was 2 (63.9% sensitivity, 64.7% specificity). CPSP risk was high (48.94% risk) if PPST ≥ 2 (n = 47) and medium (22.81%) if PPST < 2 (n = 57) after spine/pectus surgery. General and risk-strata specific, targeted psychosocial non-pharmacological interventions, need to be studied. Findings need validation in diverse, larger cohorts. CLINICALTRIALS.GOV IDENTIFIER: NCT02998138. PERSPECTIVE: The article supports Pediatric Pain Screening Tool, a simple 9-item questionnaire, as a preoperative screening tool for CPSP and function 6-12 months after spine/pectus surgeries. PPST measures correlate with known risk factors for CPSP. Risk stratification and targeted preventive interventions in high-risk subjects are proposed.

Evaluation of ultrasound-guided radial artery cannulation in children.

OBJECTIVE: To compare ultrasound (US)-guided radial artery cannulation with the traditional palpation technique. DESIGN: : Prospective randomized study. SETTING: Operating room in a tertiary care pediatric center. PATIENTS: One hundred fifty-two children under 18 yrs of age requiring radial artery cannulation. INTERVENTIONS: Patients were randomized to either 1) palpation or 2) US guidance technique for radial artery cannulation. MEASUREMENTS AND MAIN RESULTS: The primary end point of the study was the time taken for attempted cannulation by the first operator at the first site. Secondary end points included the number of attempts at arterial cannulation, the number of cannulae used, and the need for additional assistance from another anesthesiologist. Eighty and 72 children were randomized to the palpation and the US-guided groups, respectively. There were no statistically significant differences in age, gender, weight, and systolic blood pressure between the two study groups. The designated first operator (20 pediatric subspecialty trainees and eight consultant anesthesiologists) had previous experience in US-guided arterial cannulation in <10 cases, with 94% having experience in <5 cases. Although the radial artery was eventually cannulated in all patients, the designated operator was successful at the first site of cannulation in only 66% and 69% in the palpation and US groups, respectively. There were no statistically significant differences between the groups in time to successful cannulation, total number of attempts, number of successful cannulations during the first attempt, or in the number of cannulae used for catheterization. CONCLUSIONS: US guidance did not facilitate faster cannulation of the radial artery in children in our study.

Continuous Transversalis Fascia Plane Catheter Infusion in a Pediatric Patient Undergoing Alveolar Cleft Repair With Iliac Crest Bone Graft: A Case Report.

Harvesting of iliac crest bone graft for alveolar cleft repair in children is associated with significant postoperative pain. Transversalis fascia plane block has emerged as an alternative to local wound infiltration for iliac crest bone graft harvesting and has been used with good effect in adult patients requiring bone graft for orthopedic surgery. Little is known about the use of the transversalis fascia plane block in children or the feasibility of placing a continuous infusion catheter. In this report, we describe our experience using a continuous transversalis fascia plane infusion catheter in the management of a 6-year-old girl undergoing alveolar cleft repair with iliac crest bone graft.

Efficacy of addition of fentanyl to epidural bupivacaine on postoperative analgesia after thoracotomy for lung resection in infants.

BACKGROUND: The authors evaluated the efficacy of adding fentanyl to epidural bupivacaine in infants up to 6 months of age after a thoracotomy in a prospective, randomized, double-blind study. The primary outcome was the total amount of rescue doses of intravenous nalbuphine in the first 24 h after surgery. Secondary outcomes included (1) time to first rescue dose of nalbuphine, (2) pain scores, and (3) behavior scores. METHODS: Thirty-two infants were randomly assigned to receive an epidural infusion containing 0.1% bupivacaine (group B; n = 16) or 0.1% bupivacaine and 2 microg/ml fentanyl (group BF; n = 16). Patients were evaluated up to 24 h after surgery for pain; amount of analgesic rescues and time to first rescue; pain scores; behavior scores (five-item behavior score); and complications, including respiratory depression, oxygen requirement, vomiting, and urinary retention. RESULTS: The two groups had similar demographics. Nalbuphine consumption (P = 0.001) and pain scores (P < 0.001) in the first 24 h were significantly decreased in group BF compared with group B. The time to first analgesic rescue was significantly longer in group BF (P = 0.005). The five-item behavior score was significantly better in group BF than in group B (P = 0.01). The incidence of side effects, the time to first successful feeding, and the time to discharge were similar in both groups. CONCLUSIONS: Addition of 2 microg/ml epidural fentanyl to 0.1% bupivacaine results in improved postthoracotomy analgesia without any increase in side effects, compared with 0.1% bupivacaine, in infants up to 6 months of age.

Electrophysiologic effects of systemic and locally infused epibatidine on locus coeruleus neurons.

We evaluated the electrophysiologic response of locus coeruleus neurons to the systemic and local infusion of epibatidine. Rats were anesthetized with 2% halothane and single-unit locus coeruleus discharge was recorded after administration of systemic (2.5, 5 and 10 microg/kg subcutaneously) and intracoerulear (0.03-0.01-0.001 microg) epibatidine. The subcutaneous epibatidine activated locus coeruleus neurons only at the highest dose (10 microg/kg). The 2.5-5 microg/kg doses, previously shown to induce analgesia, did not activate locus coeruleus neurons. The intracoerulear infusion of epibatidine induced excitement of locus coeruleus neurons at every tested dose. Higher doses (0.03 and 0.01 microg) excited 100% of the recorded neurons. A significantly lower number of neurons (50% and 43% respectively) were excited when lower doses (0.005-0.001 microg) were used (P=0.035). The intracoerulear infusion of mecamylamine (1 microg) significantly reduced neuronal discharge rate (45%) and blocked the effects of epibatidine. The intra-dorsal raphe infusion of 0.03 microg epibatidine induced significant excitation of locus coeruleus neurons. These data show that the administration of epibatidine induces excitation of locus coeruleus neurons, which is mediated by nicotinic receptors. This activation occurs after systemic and selective local administration of epibatidine. The response of locus coeruleus neurons to systemic and locally administered epibatidine is dose-related.

Hyperosmolar, increased-anion-gap metabolic acidosis and hyperglycemia after etomidate infusion.

Hyperosmolar increased-anion-gap metabolic acidosis without hyperglycemia has been reported after infusions of etomidate and other medications containing propylene glycol. We report a case of this biochemical abnormality with severe hyperglycemia. Cessation of the etomidate infusion along with other supportive measures resulted in prompt resolution of the metabolic acidosis and hyperglycemia.

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.

Pathophysiology and management of opioid-induced pruritus.

Pruritus occurs frequently following opioid use, particularly after neuraxial administration. Although not life threatening, pruritus is discomforting and may decrease patient satisfaction. Even though the mechanism of opioid-induced pruritus is not yet fully understood, there is increasing evidence of the important role played by micro opioid receptors. Animal experiments pointing to the role of the micro opioid receptor and the efficacy of micro opioid receptor antagonists for opioid adverse effect prophylaxis and treatment have been replicated in several studies. Serotonin and dopamine D(2) receptors, prostaglandins and spinal inhibitory pathways may also be involved in the genesis of pruritus. Several pharmacological agents have been used both for the treatment of established pruritus and in its prevention. Of these, micro opioid receptor antagonists have been most consistent in terms of attenuating opioid-induced pruritus but present problems in dose and administration. Other drugs, including mixed opioid receptor agonist-antagonists, serotonin 5-HT(3) receptor antagonists, propofol, NSAIDs and D(2) receptor antagonists, have also been demonstrated to be useful. This review summarises the current understanding of the mechanisms causing opioid-induced pruritus and the pharmacological therapies available to prevent and/or manage this disorder.

The effects of clonidine on postoperative analgesia after peripheral nerve blockade in children.

BACKGROUND: The effect of clonidine on the duration of sensory blockade after peripheral nerve blockade is controversial. We evaluated the effects of clonidine on the duration of sensory and motor block and analgesia time in children who underwent a variety of peripheral nerve blocks. METHODS: We reviewed the regional anesthesia database that contains data on children who underwent an infraclavicular, lumbar plexus, femoral, fascia iliaca or sciatic nerve block for postoperative analgesia at The Children's Hospital of Philadelphia between October 2002 and December 2005. Patients were prospectively followed after the nerve block. RESULTS: Two hundred fifteen patients (47%) received either bupivacaine or ropivacaine local anesthetic (LA) and 220 (53%) a combination of local anesthetic and clonidine (LAC). The duration of sensory block was significantly longer in the LAC (17.2 +/- 5 h) compared with that in the LA group (13.2 +/- 5 h) (P = 0.0001). The increase in duration was independent from the type of peripheral nerve block, local anesthetic used and operation performed. The motor block duration was significantly longer in the LAC group (9.6 +/- 5 vs 4.3 +/- 4 h, P = 0.014). Two patients in the LAC and one in the LA group experience prolonged numbness (max 72 h). No paresthesia or dysesthesia was observed. CONCLUSION: The addition of clonidine to bupivacaine and ropivacaine can extend sensory block by a few hours, and increase the incidence of motor blocks.

The relationship between current intensity for nerve stimulation and success of peripheral nerve blocks performed in pediatric patients under general anesthesia.

BACKGROUND: We evaluated the relationship between the lowest current amperage used to obtain a motor response, the success rate and the incidence of neurological complications with peripheral nerve blocks (PNB) in pediatric patients under general anesthesia. METHODS: We reviewed the regional anesthesia database at The Children's Hospital of Philadelphia and included all pediatric patients who received a single-injection PNB under general anesthesia with the aid of a peripheral nerve stimulator between October 2002 and July 2006. Data analyzed included age, sex, type of block, stimulation threshold, presence of sensory and motor blockade, and neurological complications. RESULTS: Six-hundred sixty patients received a PNB during the study period. The average age of the patients was 13.8 yr (range = 2-18 yr). All the blocks were performed using a current ranging between 0.2 and 1 (median = 0.5 mA, interquartile range: 0.45-0.55 mA). The overall success rate was 96%. There was no difference in success rate between blocks performed using a stimulation threshold of < or =0.5 or >0.5 mA (96.3% vs 95.9%; P = 0.793). There was no correlation between the success rate and sex, type of block performed or intensity of current used. Two patients reported prolonged nerve blockade of the great toe and dorsum of the foot after a sciatic nerve block, which lasted for 72 h. No long-term sequelae were noted in our patients. CONCLUSION: In this study, a similar PNB success rate was observed with both a low (*0.5 mA) and a high stimulation threshold (>0.5 mA). Therefore, it may not be necessary to perform needle manipulations to achieve a low stimulation threshold (< or =0.5 mA), as this may increase the risk of intraneural injection.

Low-dose intrathecal morphine for postoperative analgesia in children.

BACKGROUND: We evaluated the efficacy and safety profile of low-dose (4-5 mcg/kg) intrathecal morphine for postoperative pain management after various surgical procedures in children. METHODS: We reviewed the pain management service database and the medical records of patients who received low-dose intrathecal morphine for postoperative analgesia at The Children's Hospital of Philadelphia between October 2003 and March 2006. Patients had been prospectively followed for 24-48 h after the intrathecal morphine administration. RESULTS: The medical records of 187 patients were examined. The mean age was 5.6 +/- 5.1 yr (median 4.0, interquartile range [IQR] 1.0-10.0). The median maximum pain score during the first 24 h in patients evaluated by the FLACC score and in those evaluated by the numeric verbal rating scale, was 0 (IQR 0-3) and 0 (IQR 0-4), respectively. The mean time to first rescue opioid was 22.4 +/- 16.9 h (range: 0-48 h, 95% CI: 19.9-24.8 h). During the first 24 h after surgery, 70 patients (37%) did not receive any opioids (oral or IV). Of the 117 patients who received opioids, 59 (50%) were managed with oxycodone only. Pain was managed with ketorolac in 33% of patients, either alone (11%) or in combination with IV or oral opioids (22%). The incidence of nausea or vomiting, pruritus, and urinary retention was 32%, 37%, and 6% respectively. One patient had transient postdural puncture headache, while two patients received supplemental oxygen beyond the first 60 postoperative minutes to manage occasional episodes of hypoxemia. No severe respiratory depression requiring assisted ventilation or naloxone administration was observed. CONCLUSION: We conclude that low-dose intrathecal morphine in the pediatric population can be a useful and safe adjunct for postoperative analgesia.

Continuous peripheral nerve blockade for inpatient and outpatient postoperative analgesia in children.

BACKGROUND: This is an audit of the continuous peripheral nerve blockade (CPNB) program that was implemented at our institution to provide postoperative analgesia after orthopedic procedures in children. METHODS: We reviewed the departmental regional anesthesia registry and the medical records of consecutive children who received CPNB for postoperative analgesia at The Children's Hospital of Philadelphia between February 2003 and July 2006. Patients were prospectively followed until cessation of the effects of CPNB and/or resolution of any related complications. Data collected contemporaneously included presence of sensory and motor blockade, pain scores in inpatients, opioid administration, and complications related to CPNB. RESULTS: A total of 226 peripheral nerve catheters were placed in 217 patients. One hundred eight patients (112 catheters) were discharged home with CPNB. The ages ranged from 4 to 18 yr (13.7 +/- 3.4). Local anesthetic solution (0.125% bupivacaine [n = 164], 0.1% ropivacaine [n = 12], or 0.15% ropivacaine [n = 27]) was infused at an initial rate of 2-12 mL/h based on patients' weights and locations of catheters. The mean duration of local anesthetic infusion was 48.4 +/- 29.3 h (range 0-160 h). The percentage of patients who did not require any opioids in the first 8, 24, and 48 h after surgery was 56%, 26%, and 21%, respectively. The incidence of nausea and vomiting was 14% (13% in outpatients, 15% in inpatients). Complications were noted in 2.8% of patients. Three patients had prolonged numbness (>24 h) that resolved spontaneously; one developed superficial cellulitis that resolved with a course of antibiotics; one had difficulty removing the catheter at home and one developed tinnitus 24 h after starting CPNB that resolved quickly after clamping of the catheter followed by removal. CONCLUSION: It is feasible to implement a CPNB program to provide an alternative method of inpatient and outpatient postoperative analgesia after orthopedic surgery in children when appropriate expertise is available. Patient and family education along with frequent follow-up are crucial to detect and address adverse events promptly.