Complications in Pediatric Regional Anesthesia: An Analysis of More than 100,000 Blocks from the Pediatric Regional Anesthesia Network.

WHAT WE ALREADY KNOW ABOUT THIS TOPIC: WHAT THIS ARTICLE TELLS US THAT IS NEW: BACKGROUND:: Complications in pediatric regional anesthesia are rare, so a large sample size is necessary to quantify risk. The Pediatric Regional Anesthesia Network contains data on more than 100,000 blocks administered at more than 20 children's hospitals. This study analyzed the risk of major complications associated with regional anesthesia in children. METHODS: This is a prospective, observational study of routine clinical practice. Data were collected on every regional block placed by an anesthesiologist at participating institutions and were uploaded to a secure database. The data were audited at multiple points for accuracy. RESULTS: There were no permanent neurologic deficits reported (95% CI, 0 to 0.4:10,000). The risk of transient neurologic deficit was 2.4:10,000 (95% CI, 1.6 to 3.6:10,000) and was not different between peripheral and neuraxial blocks. The risk of severe local anesthetic systemic toxicity was 0.76:10,000 (95% CI, 0.3 to 1.6:10,000); the majority of cases occurred in infants. There was one epidural abscess reported (0.76:10,000, 95% CI, 0 to 4.8:10,000). The incidence of cutaneous infections was 0.5% (53:10,000, 95% CI, 43 to 64:10,000). There were no hematomas associated with neuraxial catheters (95% CI, 0 to 3.5:10,000), but one epidural hematoma occurred with a paravertebral catheter. No additional risk was observed with placing blocks under general anesthesia. The most common adverse events were benign catheter-related failures (4%). CONCLUSIONS: The data from this study demonstrate a level of safety in pediatric regional anesthesia that is comparable to adult practice and confirms the safety of placing blocks under general anesthesia in children.

Rules and values: a coordinated regulatory and educational approach to the public health crises of chronic pain and addiction.

Chronic pain and opioid addiction are 2 pressing public health problems, and prescribing clinicians often lack the skills necessary to manage these conditions. Our study sought to address the benefits of a coalition of an academic medical center pain faculty and government agencies in addressing the high unintentional overdose death rates in New Mexico. New Mexico's 2012-2013 mandated chronic pain and addiction education programs studied more than 1000 clinicians. Positive changes were noted in precourse and postcourse surveys of knowledge, self-efficacy, and attitudes. Controlled substance dispensing data from the New Mexico Board of Pharmacy also demonstrated safer prescribing. The total morphine and Valium milligram equivalents dispensed have decreased continually since 2011. There was also a concomitant decline in total drug overdose deaths.

Ultrasound-guided parasacral approach to the sciatic nerve block in children.

BACKGROUND: The parasacral (PS) approach to sciatic nerve blockade has the potential for safe and effective use in children, but has never been studied in this population. Its potential advantages include increased posterior cutaneous nerve block reliability, potential for hip joint analgesia, and decreased nerve depth, making ultrasound guidance easier. OBJECTIVE: To assess the efficacy of an ultrasound-guided PS sciatic nerve block in children. METHODS: Nineteen patients, 1-16 years old, scheduled for lower limb surgery with peripheral nerve blockade (PNB) were prospectively enrolled. A PS sciatic block was performed using both ultrasound guidance and nerve stimulation, and 0.5 ml·kg(-1) ropivacaine 0.2% (maximum 20 ml) was administered. Patient demographics, the time to perform the block, the lowest intensity of nerve stimulation, evoked response, identification of gluteal arteries, and amount of narcotic given were recorded. Postoperatively, pain scores, block success or failure, block duration, and complications were recorded. RESULTS: The block was performed using the PS approach in 95% of the cases. The success rate was 100% in the PS sciatic blocks performed. The pain scores for all patients in the first postsurgical hour were zero, except one patient that had a pain score of 3 of 10 at 30 min; his pain improved to 0 of 10 after administration of one dose of fentanyl and distraction techniques. The blocks lasted 17.3 ± 5.4 h. No complications were identified. CONCLUSION: The PS approach is an effective option for sciatic nerve blockade to provide postoperative pain relief in children having lower extremity surgery.

A triple-masked, randomized controlled trial comparing ultrasound-guided brachial plexus and distal peripheral nerve block anesthesia for outpatient hand surgery.

Background. For hand surgery, brachial plexus blocks provide effective anesthesia but produce undesirable numbness. We hypothesized that distal peripheral nerve blocks will better preserve motor function while providing effective anesthesia. Methods. Adult subjects who were scheduled for elective ambulatory hand surgery under regional anesthesia and sedation were recruited and randomly assigned to receive ultrasound-guided supraclavicular brachial plexus block or distal block of the ulnar and median nerves. Each subject received 15 mL of 1.5% mepivacaine at the assigned location with 15 mL of normal saline injected in the alternate block location. The primary outcome (change in baseline grip strength measured by a hydraulic dynamometer) was tested before the block and prior to discharge. Subject satisfaction data were collected the day after surgery. Results. Fourteen subjects were enrolled. Median (interquartile range [IQR]) strength loss in the distal group was 21.4% (14.3, 47.8%), while all subjects in the supraclavicular group lost 100% of their preoperative strength, P = 0.001. Subjects in the distal group reported greater satisfaction with their block procedures on the day after surgery, P = 0.012. Conclusion. Distal nerve blocks better preserve motor function without negatively affecting quality of anesthesia, leading to increased patient satisfaction, when compared to brachial plexus block.