Quadratus lumborum blocks for abdominal transplant surgeries at UPMC Children's Hospital of Pittsburgh-A five year experience.

BACKGROUND: Adequate perioperative analgesia for pediatric abdominal transplant surgery is essential for patient recovery. However, the risks of commonly used medications such as hepatotoxicity, nephrotoxicity, bleeding concerns, and poor graft results with opioids limit pain management in this population. Thoracic epidural, continuous erector spinae plane, and type-1 quadratus lumborum blocks (QLBs) have been described and utilized in the adult population in this setting. The safety and benefits of regional anesthetic techniques in pediatrics have been widely documented for different types of procedures except pediatric abdominal transplantation, where data remains scarce. Our primary goal was to determine if QLBs provided adequate perioperative analgesia when part of a multimodal approach. Secondary objectives were to examine complications and effects on the intensive care unit (ICU) and hospital stay. METHODS: We performed a retrospective, observational study of pediatric patients who underwent abdominal transplant surgeries at the University of Pittsburgh Medical Center Children's Hospital of Pittsburgh from January 2015 to July 2021 and received a single injection QLB for pain control. Data collected included: demographics, nerve block characteristics, perioperative opioid consumption, use of non-opioid analgesia, daily pain scores, and hospital and ICU stay. RESULTS: Forty-two patients met the inclusion criteria for our study. Our results suggest that QLBs decrease opioid consumption, facilitate early extubation, prevent reintubation in the ICU, and reduce ICU and hospital stay. CONCLUSIONS: QLB is feasible and can be used as a multimodal approach for postoperative pain control in pediatric solid organ transplantation.

Continuous ultrasound-guided sacral intervertebral block for postoperative analgesia in neonates.

A sacrococcygeal teratoma and a sacral agenesis represent a contraindication to a caudal block. We report two cases where the optimal use of ultrasound helped place a sacral intervertebral catheter in two neonates. Radiological and ultrasound studies of the sacrum and spine should be available before performing the procedure.

Quadratus lumborum blocks: Two cases of associated hematoma.

A quadratus lumborum block associated complication is a rare event. We report two cases of hematoma following the performance of quadratus lumorum blocks in two patients. Performing this block requires additional consideration of abdominal wall anatomy and patient coagulation status.

Single injection ultrasound-guided rectus sheath blocks for children: Distribution of injected anesthetic.

BACKGROUND: Single injection ultrasound-guided rectus sheath blocks are used for postoperative analgesia after midline abdominal incisions, but the ultrasonographic spread of medication posterior to the rectus muscle has not been investigated. AIMS: The primary goal of this study was to determine the ultrasound-measured medication spread superiorly and inferiorly after single injection ultrasound-guided rectus sheath blocks and to calculate the incidence of cases with spread up to the subcostal margin and below of umbilicus. The secondary goals were to correlate the spread with the volume of medication administered and with the patient's age, weight, height, sex, and body mass index. METHODS: Pediatric patients who underwent single injection ultrasound-guided rectus sheath blocks and underwent data collection of ultrasonographic information on medication spread along the plane of the posterior rectus sheath were identified retrospectively from an acute pain service database at UPMC Children's Hospital of Pittsburgh. RESULTS: Sixty-eight children, 10.2 ± 4.2 (mean ± SD) years old, 41.7 ± 17.9 kg, 140 ± 24.6 cm, had complete data collection. Mean injected volume of ropivacaine was 8.3 ± 2.8 mL (right) and 8.2 ± 2.8 mL (left). The average spread was measured as 3.9 ± 1.4 cm (right) and 3.4 ± 1.3 cm (left) cranial to the umbilicus, and 1.5 ± 1.6 cm (right) and 1.6 ± 1.4 cm (left) caudal to the umbilicus. Complete spread up to the level of the subcostal margin was observed in 52.9% (n = 36; right) and 36.8% (n = 25; left) of cases. The spread correlated closely with the volume of injected ropivacaine (right: 0.556, P < 0.001; left: 0.541, P < 0.001). The spread below umbilicus was 70.6% (n = 48, right) and 80.9% (n = 55, left). There was a positive strong correlation (P < 0.001) between total medication spread and age (right: 0.608; left: 0.538), weight (right: 0.600; left: 0.540), and height (right: 0.593; left: 0.526). CONCLUSION: After single injection ultrasound-guided rectus sheath blocks, incomplete cephalocaudal medication spread can be expected within the posterior rectus sheath.

Bilateral Paravertebral Blockade (T7-10) Versus Incisional Local Anesthetic Administration for Pediatric Laparoscopic Cholecystectomy: A Prospective, Randomized Clinical Study.

BACKGROUND: Single-injection paravertebral nerve blocks (PVBs) provide effective postoperative analgesia after adult laparoscopic cholecystectomy (LC). We sought to compare PVBs with local anesthetic injections at laparoscopic port sites in a pediatric population. METHODS: Eighty-three patients (8-17 years old) scheduled for LC were randomized prospectively to 2 treatment groups: the PVB group received ropivacaine 0.5% injected in the paravertebral space and normal saline injections at laparoscopic instrument sites, and the port infiltration group received normal saline in the paravertebral space and ropivacaine 0.5% at instrument sites. Postoperative analgesia was provided with hydromorphone via patient-controlled analgesia for up to 12 hours, followed by oxycodone and hydromorphone. The total amount of analgesic, serial visual analog scale scores for pain and subject pain control satisfaction, type and characteristics of pain, and complications were recorded for 24 hours. RESULTS: The intraoperative fentanyl requirement (ng/kg/min) was lower in the PVB group than in the port infiltration group (12.81 vs 16.57, P = 0.007). Total postoperative analgesic consumption and mean visual analog scale scores were not different between the groups. Baseline pain recorded before surgery correlated with self-reported postoperative pain scores only in the port infiltration group. The rate of complications was low and similar between groups. There was no difference in incidence of patient-reported incisional, visceral, or gas pain. Shoulder pain, however, was 49% less (95% confidence interval, 0.269-0.893) in the port infiltration group. CONCLUSIONS: PVBs did not reduce postoperative pain associated with pediatric LC but decreased intraoperative fentanyl requirements.

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.

Anesthetic drugs and onset of malignant hyperthermia.

BACKGROUND: The time between the beginning of anesthetic administration and recognition of the first sign of malignant hyperthermia (MH) (MH onset time) could differ among anesthetic drugs. METHODS: We examined the time of the first signs of suspected MH, anesthetic drugs administered, subject age, and year of event in Adverse Metabolic/Musculoskeletal Reaction to Anesthesia reports in the North American Malignant Hyperthermia Registry. Inclusion criteria were judgment by the reporting clinician that the event was possible or fulminant MH, documentation of the time when anesthetic administration began, and the time when the first MH sign was noted. Descriptive statistics, Kruskal-Wallis analysis, and nonparametric correlation were used to assess the difference in MH onset times under different conditions. RESULTS: Four hundred seventy-seven cases met inclusion criteria; 58.5% were possible MH and 41.5% fulminant MH. Inhaled anesthetic and succinylcholine were given in 53.9% of cases, inhaled anesthetic only in 41.7%, and succinylcholine without inhaled anesthetics in 2.9%. No causative anesthetic drugs were reported in 7 MH cases. In 394 patients exposed to only 1 of the 4 inhaled anesthetics, without regard for subject age, MH onset time was shorter in the presence of halothane than any of the other anesthetics and shorter after succinylcholine in all anesthetics. If succinylcholine was not given, MH onset was shorter during sevoflurane anesthesia than during desflurane or isoflurane. In 322 cases, 1 rather than multiple first signs of MH were reported with masseter spasm as the earliest MH sign. In 339 cases in which masseter spasm was not reported, there was no difference in MH onset time with or without succinylcholine. In 146 cases in which masseter spasm was not reported and succinylcholine was not given, MH onset was shorter during halothane anesthesia, than during exposure to desflurane, or isoflurane. MH onset time during sevoflurane was shorter than during desflurane or isoflurane. MH was reported later in the course of anesthesia after 1998, when halothane and succinylcholine were less often reported. MH occurred after succinylcholine administration in the absence of inhaled anesthetics. We could not separate an effect of age from that of other variables. CONCLUSION: The onset of MH has been observed later during desflurane and isoflurane anesthesia than during exposure to sevoflurane. Since 1998, MH signs have more often appeared later, in the second or third hour of anesthesia, than they did before 1998.

Outpatient analgesia via paravertebral peripheral nerve block catheter and On-Q pump--a case series.

Outpatient pain management after iliac crest bone harvesting can be challenging. We report the use of home L2 paravertebral nerve block catheter (L2PVBC) in a series of five children. The pain scores were low, and analgesic medication consumption was minimal. No complications were reported related with these catheters, and the patients reported very high pain control satisfaction scores. Outpatient L2PVBC can be beneficial as part of a multimodal analgesia strategy in selected pediatric patients.

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

BACKGROUND: Ambulatory continuous peripheral nerve blocks (CPNBs) are feasible for pediatric patients. We sought to evaluate the efficacy of CPNBs in a pediatric population. METHODS: This retrospective report of 33-month prospectively collected data investigates patient, parent, and nurse pain control satisfaction score (PCSS), the incidence and severity of pain, daily analgesic consumption following discharge home with various CPNBs and On-Q pumps, and any complications and side effects related to CPNBs. RESULTS: Four hundred and three patients (403; aged 5-22) were discharged home with 410 CPNBs (brachial and lumbar plexus, femoral, sciatic, and paravertebral); 76.7% on the day of surgery. The median/interquartile range (IQR) ropivacaine continuous infusion via On-Q pump was 0.24 (0.20-0.30) mg·kg(-1)·hr(-1), and the median/IQR duration was 72 (48-72) h. The median/IQR home PCSS was 10 (9-10). Median Postoperative Ambulatory Care Unit (PACU)/IQR pain control satisfaction scores were 10 (8-10) for the patient, 10 (9-10) for the parent, and 10 (9-10) for the nurse. Thirty-three (10.0%) patients did not report any pain at home, and median maximum home/IQR pain score was 4 (2-6). In the PACU, 126 (31.3%) patients did not report any pain and median/IQR pain score was 1 (0-3). No opioids were administered at home for 12 (4.3%) patients and in the PACU for 150 (37.4%). Sixty-three (14.4%) complications and side effects for 58 patients were reported. We report 93.1% ambulatory efficacy of CPNBs. CONCLUSION: Our patients and their caregivers were very satisfied with ambulatory CPNBs. When combined with oral analgesics, CPNBs provided effective home postoperative analgesia.

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.

Gaining Insight into Teenagers' Experiences of Pain after Laparoscopic Surgeries: A Prospective Study.

There is an anecdotal impression that teenage patients report exaggerated postoperative pain scores that do not correlate with their actual level of pain. Nurse and parental perception of teenagers' pain can be complemented by knowledge of patient pain behavior, catastrophizing thoughts about pain, anxiety, and mood level. Two hundred and two patients completed the study-56.4% were female, 89.6% White, 5.4% Black, and 5% were of other races. Patient ages ranged from 11 to 17 years (mean = 13.8; SD = 1.9). The patient, the parent, and the nurse completed multiple questionnaires on day one after laparoscopic surgery to assess patient pain. Teenagers and parents (r = 0.56) have a high level of agreement, and teenagers and nurses (r = 0.47) have a moderate level of agreement on pain scores (p < 0.05). The correlation between patient APBQ (adolescent pain behavior questionnaire) and teenager VAS (visual analog scale) and between nurse APBQ and teenager VAS, while statistically significant (p < 0.05), is weaker (r range = 0.14-0.17). There is a moderate correlation between teenagers' pain scores and their psychological assessments of anxiety, catastrophic thoughts, and mood (r range = 0.26-0.39; p < 0.05). A multi-modal evaluation of postoperative pain can be more informative than only assessing self-reported pain scores.

Utilizing Peripheral Nerve Blocks for Pain Management in Pediatric Patients during Embolization and Sclerotherapy for Vascular Malformations.

Vascular anomalies are a diverse group of abnormal blood vessel developments that can occur at birth or shortly afterward. Embolization and sclerotherapy have been utilized as a treatment option for these malformations but may cause moderate-to-severe pain. This study aims to evaluate the utilization of peripheral nerve blocks in opioid consumption, pain scores, and length of stay. A retrospective chart review was conducted at the UPMC Children's Hospital of Pittsburgh for all patients who underwent embolization and sclerotherapy between 2011 and 2020. Patient data were collected to compare opioid consumption, pain scores, and length of stay. In total, 854 procedures were performed on 347 patients. The morphine milligram equivalent per kilogram mean difference between groups was 0.9 (0.86, 0.95) with a p-value of <0.001. The pain score mean ratio was -1.17 (-2.2, -0.1) with a p-value of 0.027. The length of stay had an incident rate ratio of 0.94 (0.4, 2) and a p-value of 0.875. By decreasing opioid consumption and postoperative pain scores, peripheral nerve blocks may have utility in patients undergoing embolization and sclerotherapy while not clinically increasing the length of stay for patients. Their use should be individualized and carefully discussed with the interventional radiologist.

Ryanodine receptor type 1 gene variants in the malignant hyperthermia-susceptible population of the United States.

BACKGROUND: Mutations in the ryanodine receptor type 1 gene (RYR1) that encodes the skeletal muscle-specific intracellular calcium (Ca(2+)) release channel are a cause of malignant hyperthermia (MH). In this study, we examined RYR1 mutations in a large number of North American MH-susceptible (MHS) subjects without prior genetic diagnosis. METHODS: RYR1 was examined in 120 unrelated MHS subjects from the United States in a tiered manner. The α-1 subunit of the dihydropyridine receptor gene (CACNA1S) was screened for 4 variants in subjects in whom no abnormality was found in ≥ 100 exons of RYR1. RESULTS: Ten known causative MH mutations were found in 26 subjects. Variants of uncertain significance in RYR1 were found in 36 subjects, 16 of which are novel. Novel variants in both RYR1 and CACNA1S were found in the 1 subject who died of MH. Two RYR1 variants were found in 4 subjects. Variants of uncertain significance were found outside and inside the hotspots of RYR1. Maximal contractures in the caffeine-halothane contracture test were greater in those who had a known MH mutation or variant of uncertain significance in RYR1 than in those who did not. CONCLUSIONS: The identification of novel RYR1 variants and previously observed RYR1 variants of uncertain significance in independent MHS families is necessary for demonstrating the significance of these variants for MH susceptibility and supports the need for functional studies of these variants. Continued reporting of the clinical phenotypes of MH is necessary for interpretation of genetic findings, especially because the pathogenicity of most of these genetic variants associated with MHS remains to be elucidated.

Continuous postoperative analgesia via quadratus lumborum block - an alternative to transversus abdominis plane block.

Different transversus abdominis plane blocks techniques cause variations in postoperative analgesia characteristics. We report the use of unilateral quadratus lumborum catheter for analgesia following colostomy closure. The catheter was placed under direct ultrasound visualization and had good outcomes: low pain scores and minimal use of rescue analgesic medication. No complications were reported in this pediatric patient. More studies are needed to evaluate the effectiveness and safety of this regional anesthesia technique.

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.