Regional anesthesia and analgesia in patients with spastic cerebral palsy undergoing orthopedic surgery: a historical cohort study.

PURPOSE: We sought to examine the incidence of severe postoperative pain in patients with cerebral palsy (CP) in the first 48 hr after surgery performed under combined regional and general anesthesia and its association with patient and surgical factors. METHODS: In a historical cohort study, we reviewed the electronic records of 452 patients with spastic CP who underwent orthopedic surgeries of the upper and lower extremities from April 2016 to February 2020. Collected data included patient characteristics, American Society of Anesthesiologists Physical Status, details of anesthesia and surgery, types of regional anesthesia applied, success rate of anesthesia, incidence of severe pain, and adverse events. RESULTS: We analyzed data from 440 patients; 404 patients underwent lower extremity surgery, 20 upper extremity surgery, and 15 both, and one patient required stem cell injection. All patients received general anesthesia before block performance. Single-injection neuraxial anesthesia was performed in 241 (54.8%) patients, brachial plexus block in 27 (6.1%) patients, and femoral/sciatic nerve blocks in 17 (3.9%) patients. Continuous neuraxial, brachial plexus, and femoral/sciatic nerve blocks were performed in 149 (33.9%), four (0.9%), and seven (1.6%) of the patients, respectively. Major and complex major surgeries were performed in 161 (36.6%) and 72 (16.4%) patients, respectively and continuous catheters were inserted in 50.3% of patients undergoing major surgery and in 91.7% of patients undergoing complex major surgery. Severe pain was reported by the caregivers of 68 (15.5%) patients who received nonopioid analgesic interventions. CONCLUSION: Despite the use of regional anesthesia, approximately 15% of patients with spastic CP undergoing orthopedic surgery for spastic cerebral palsy experienced severe pain that responded to treatment adjustments. STUDY REGISTRATION: CTRI.nic.in (027002); registered 5 August 2020.

RéSUMé: OBJECTIF: Nous avons cherché à examiner l'incidence de la douleur postopératoire sévère chez les personnes atteintes de paralysie cérébrale (PC) au cours des 48 premières heures suivant une chirurgie réalisée sous anesthésie régionale et générale combinée et son association avec les facteurs liés aux patient·es et les facteurs chirurgicaux. MéTHODE: Dans une étude de cohorte historique, nous avons examiné les dossiers électroniques de 452 personnes atteintes de PC spastique ayant bénéficié de chirurgies orthopédiques des membres supérieurs et inférieurs d'avril 2016 à février 2020. Les données recueillies comprenaient les caractéristiques des patient·es, le statut physique selon l'American Society of Anesthesiologists, les détails de l'anesthésie et de la chirurgie, les types d'anesthésie régionale appliqués, le taux de réussite de l'anesthésie, l'incidence de la douleur intense et les événements indésirables. RéSULTATS: Nous avons analysé les données de 440 patient·es; 404 ont bénéficié d'une chirurgie des membres inférieurs, 20 d'une chirurgie des membres supérieurs et 15 des deux, et une personne a nécessité une injection de cellules souches. Tou·tes les patient·es ont reçu une anesthésie générale avant la réalisation du bloc. Une anesthésie neuraxiale à injection unique a été réalisée chez 241 patient·es (54,8 %), un bloc du plexus brachial chez 27 patient·es (6,1 %) et des blocs du nerf fémoral/sciatique chez 17 (3,9 %) patient·es. Des blocs nerveux neuraxiaux, du plexus brachial et fémoraux/sciatiques continus ont été réalisés chez 149 (33,9 %), quatre (0,9 %) et sept (1,6 %) personnes, respectivement. Des chirurgies majeures et complexes ont été réalisées chez 161 (36,6 %) et 72 (16,4 %) patient·es, respectivement, et des cathéters continus ont été insérés chez 50,3 % des personnes bénéficiant d'une intervention chirurgicale majeure et chez 91,7 % des personnes bénéficiant d'une chirurgie majeure complexe. Une douleur intense a été signalée par le personnel soignant chez 68 patient·es (15,5 %) ayant reçu des interventions analgésiques non opioïdes. CONCLUSION: Malgré l'utilisation de l'anesthésie régionale, environ 15 % des patient·es atteint·es de PC spastique bénéficiant d'une chirurgie orthopédique pour leur paralysie cérébrale spastique ont ressenti une douleur intense qui a répondu aux ajustements du traitement. ENREGISTREMENT DE L'éTUDE: CTRI.nic.in (027002); enregistrée le 5 août 2020.

The utility of ultrasonography in anesthesia management in 3 cases of caudal regression syndrome.

Caudal regression syndrome is an extremely rare clinical entity. It is a challenge to anesthesiologist due to its multisystem involvement. Regional anesthesia literature on caudal regression syndrome is scarce. We report three cases where optimal use of ultrasonography aided in providing satisfactory peri-operative pain relief. Furthermore, a cogent and a logical review of the decision-making processes for the regional blockade in children with caudal regression syndrome are presented.

Avoidance of deep anesthesia and artificial airways in 1000 neonates and infants using regional anesthesia: A retrospective observational analysis.

BACKGROUND AND AIMS: Current concerns related to the anesthetic neurotoxicity have brought a renewed interest in regional anesthesia. Regional anesthesia reduces the need for opioids and inhalational anesthetics. The immaturity of the neonatal and infant nervous system may render them more prone to neurotoxicity. We describe our technique of anesthesia, which minimizes the exposure to general anesthetics and reduces airway instrumentation because the operability is rendered by the regional block. MATERIAL AND METHODS: This was a retrospective case series of neonates and infants undergoing common surface surgeries. We describe our technique of anesthesia where regional blocks are the mainstay. We also put up the data pertaining to block effectiveness, technique, end-tidal sevoflurane concentration and complications. RESULTS: One thousand patients, including neonates and infants, received central and peripheral nerve blockade. The failure rate in upper extremity blocks 0% without complications. 86.12% were given under ultrasonography (USG) guidance and 13.89% were given with peripheral nerve stimulation. The failure rate of sciatic block single shot and continuous was 0%. 92.53% were given with USG guidance while 7.46% received sciatic with nerve stimulation technique. Failure rate of caudal epidural block was 0. 78% requiring a rescue analgesic, 1.4% had blood in the needle. Out of the caudals, 33.33% were done with USG guidance and 66.67% blocks were given with traditional techniques. Out of the 322 penile + ring blocks given by traditional method, 1 block failed requiring rescue analgesics. The mean sevoflurane concentration was 1.2 +/- 0.32. CONCLUSION: It is feasible to conduct surface surgeries in the most vulnerable population such as neonates and infants under regional anesthesia without intubation and airway instrumentation.

Fascia iliaca compartment block: How far does the local anaesthetic spread and is a real time continuous technique feasible in children?

BACKGROUND AND AIMS: The fascia iliaca compartment block (FICB) is commonly administered in children for anterolateral thigh surgery. The actual spread of the local anaesthetic (LA) beneath the fascial layers in children is not known. We hypothesised that in children there could be a possibility of the LA to reach lumbar plexus with the dose we used. METHODS: This study included 25 children, aged 1-15 years for lower limb surgeries after standardised general anesthesia, the FICB was done with ultrasonography. Radio-opaque dye was tagged to LA and the fluoroscopic study was performed. The catheter was placed under ultrasonography. The primary objective was to investigate the fluoroscopic demonstration of the extent of LA spread by our technique and drug volume which is not known in children. The secondary objectives were to evaluate the intraoperative and postoperative analgesic efficacy, complications if any, of the continuous FICB catheters placed by our method. RESULTS: In all patients, the visualisation of ilium and iliacus muscle, the fascia iliaca and needle tip was possible. The fluoroscopic imaging showed that the LA did not spread till the lumbar plexus in 20 patients. In 5 patients, delineated the psoas muscle and reached the L4 vertebral level. The analgesia was adequate. In the postoperative period, 92% had sufficient pain relief. Mild soakage was an issue with catheters. CONCLUSION: Although single shot fascia iliaca compartment block has limited spread of local anaesthetic in children, it is efficacious. Continuous fascia iliaca compartment block is feasible and effective in this age group.

Role of ultrasound guided epidural anesthesia for lower limb surgery in children with previously repaired meningomyelocele.

BACKGROUND: Children that have had a meningomyelocele repair often present for hip and bilateral lower limb surgeries. Due to vertebral, epidural, and nerve root abnormalities, placement of epidural catheter is difficult. AIMS: We aim to describe the potential role of ultrasound in delineating the most appropriate intervertebral space for central neuroaxial blocks in these patients. METHODS: Twelve children with previous meningomyelocele repair, in the age group of 6-12 years posted for hip or bilateral lower limb surgeries were included. After induction of anesthesia, an ultrasound scan was done with the patient in the left lateral position. The central neuroaxial block was performed in the most appropriate intervertebral space seen on transverse scan of spine. These patients were studied with regard to visibility of the osseous framework of the spine, the anterior and posterior dural complexes, ease of insertion of catheter, evidence of dural puncture, and possibility of identification of the extent of peri-incisional fibrosis. RESULTS: One case required 2 attempts. There was no evidence of dural puncture. We could confirm the soft tissue shadow, the osseous framework, and the anterior and posterior dural complexes in all 12 patients. Ultrasonography guided in selecting the most appropriate space for epidural catheter placement. CONCLUSION: Ultrasound guidance aids in identification of normal intervertebral space and explicitly shows the abnormal space. It can be used as an aid to differentiate between normal and abnormal space in post-meningomyelocele repair.

Anesthetists approach in a neonate with nesidioblastoma undergoing pancreatectomy.

Persistent hyperinsulinemic hypoglycemia of infancy (PHHI) is rare, but an important cause of hypoglycemia in infants, associated with a number of structural abnormalities of the endocrine pancreas is collectively termed as "Islet cell dysmaturation syndrome." We present the anesthetic management in a clinically diagnosed case of PHHI in a 22 days old full term child, undergoing Subtotal Pancreatectomy. We have discussed the challenges faced in the intra-operative period in managing this neonate for pancreatic resection surgery with focus on intra-operative management of blood glucose levels.

Anesthesia management in a patient of Apert syndrome.

Apert syndrome is autosomal dominant disease associated with multiple craniofacial and limb deformities. These children usually face many orthopedic, orthodental operative procedures. As anesthetist, we face difficulties in airway management due to mid-facial hypoplasia, craniosynostosis. We report a case of Apert syndrome which was referred to us for syndactyly release, focusing on the difficulties and complications related to it.