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.

Infraclavicular block in children: Is blocking lateral or posterior cord equally successful?

Background and Aims: The most effective approach for infraclavicular brachial plexus block in adults is to target the posterior cord, usually situated posterior to axillary artery. However, we do not know if this can be extrapolated in children. Our primary objective was to compare the clinical success rate of ultrasound guided infraclavicular brachial plexus block in children with local anesthetic injection aimed at two targets. These were posterior to axillary artery (posterior cord) and lateral to axillary artery (lateral cord). The secondary objectives involved need for intraoperative rescue analgesia, evaluation of duration of analgesia, incidence of complications such as pneumothorax and arterial puncture, comparison of postoperative pain scores and fluoroscopic dye spread pattern was also observed. Material and Methods: It was a randomized, prospective pilot study. Forty children undergoing forearm and hand surgeries were randomized to two groups, in accordance with the target site of the block. Target sites of Group P (20 patients) and Group L (20 patients) were posterior and lateral to the axillary artery, i.e., posterior and lateral cord respectively. Aforesaid objectives were assessed. SPSS (Version 15.0) statistical package was used. Comparison between Group L and P was by using student's unpaired t test for age and weight. Fisher's exact probability test was applied to compare percentages between groups. Results: Blocks of both groups were equally successful. No patient required intraoperative rescue analgesia. Duration of analgesia was comparable. Both groups had no major complications and similar postoperative pain scores. Conclusions: The success rate of infraclavicular brachial plexus block by aiming at the lateral and posterior cord was similar.

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.

Does ultrasound guidance add accuracy to continuous caudal-epidural catheter placements in neonates and infants?

BACKGROUND: Caudo-lumbar and caudo-thoracic epidural anesthesia is an established technique that carries a low risk of dural puncture or spinal cord trauma in infants. Traditionally catheter advancement is based on external measurements. However, malpositioning of catheters are known to occur. We hypothesized that caudal-epidural catheters inserted under real-time ultrasound guidance may be more accurate than the accuracy of the measurements traditionally used for their placement. METHODS: We studied 25 patients, aged 2 days to 5 months, posted for abdominal or thoracic surgery, receiving general anesthesia followed by caudo-epidural continuous block. External measurement defined as the distance from the caudal space and the surgically congruent vertebral level was measured in centimeters with the back gently flexed. Subsequently, a caudo-epidural block was performed in the same position. The epidural catheter insertion was followed under real-time ultrasound guidance till the predetermined vertebral level was reached. The actual length placed under real-time ultrasound scan was defined as the actual length. The high-frequency probe was placed longitudinal and paramedian to the spine. The vertebral level was determined by identifying the lumbosacral junction in longitudinal saggital view and counting the vertebrae up from L5. The catheter length at the skin was compared with the length recorded by external measurement. RESULTS: The actual length placed under real-time ultrasound scan were consistently longer than the external distance between the caudal space and selected vertebral level. The mean values of ultrasound were higher than the mean values of external measurement with a difference of 4.28 cm. Accuracy was not affected by age or affected by the selected vertebral level in the age group we studied. CONCLUSION: We conclude that catheters placed under ultrasound guidance are more accurate than the traditional method developed before the advent of ultrasound in young infants.

Echo-guided estimation of formula for paravertebral block in neonates, infants and children till 5 years.

AIMS: The aim of the study was to derive a clinically useful formula for paravertebral block for thoracic, lumbar (L1) and cervical level (C6) as per the ultrasound-guided measurements in neonates, infants and children up to 5 years of age. SETTINGS AND DESIGN: Observational study. METHODS: Seventy-five patients from 2 days to 60 months were included. Paravertebral transverse ultrasound scans at cervical (C6), thoracic (T1-12) and lumbar (L1) regions were viewed to determine the optimal insertion point and depth for performing paravertebral blocks. The lateral distance from the spinous process to the insertion point and the depth from the insertion point to the paravertebral space or reference point (point just anterior to the transverse process) were measured. STATISTICAL ANALYSIS: Data was analyzed using the SPSS (V 10.0) package. Preliminary data was collected with the actual values of paravertebral parameters and weight and age. Initially, Pearson Bivariate Correlation Coefficients were calculated between parameters and age and weight so as to predict paravertebral parameters with the help of weight and age. As there were statistically significant associations between parameters and age and weight, an attempt was made to predict parameters with the help of age and weight. Multiple regression method (forward) was applied by taking parameters as dependent variables and age and weight as independent variables. RESULTS: Age and weight correlated very well (statistically significant) with paravertebral parameters; hence, prediction (regression) equations were calculated as: Prediction (regression) equation: C6A=0.005 × wt + 0.005 × age + 1.31 C6B=0.009 × wt + 0.002 × age + 1.78 T1-12 A=0.02 × wt + 0.003 × age + 0.93 T1 to 12 B=0.03 × wt + 0.03 × age + 1.02 L1A=0.03 × wt + 0.02 × age + 0.91 L1B=0.05 × wt + 0.02 × age + 0.94 CONCLUSIONS: We could derive equations to predict the values for paravertebral blocks in centimetres at different levels in the study population.

Role of ultrasound-guided continuous brachial plexus block in the management of neonatal ischemia in upper limb.

Neonatal upper limb ischemia due to accidental arterial damage remains a major concern, which can lead to devastating complications if untreated. The primary objective of this case report is to emphasize the role of continuous infraclavicular brachial plexus block, the issues related with block performance in an ischemic hand, and the importance of ultrasound guidance in this particular case scenario. A 1.1 kg infant suffered from distal forearm ischemia due to accidental arterial damage, which was treated with brachial plexus block. An ultrasound-guided single shot block with 0.5 mL/kg of 0.25% bupivacaine was followed by ultrasound-guided catheter placement in the target area. A continuous infusion of 0.03% of bupivacaine at the rate of 0.5 mL/kg/hr (approx. 0.15 mg/kg/h of bupivacaine) was administered for 36 h. This treatment resulted in reversal of ischemia. Permanent ischemic damage was eventually confined to the tips of 4 fingers. We conclude that ultrasound-guided continuous infraclavicular block has a therapeutic role to play in the treatment of hand ischemia due to arterial damage and subsequent arterial spasm in neonates with added benefits.

Feasibility and efficacy of placement of continuous sciatic perineural catheters solely under ultrasound guidance in children: a descriptive study.

BACKGROUND: Placement of sciatic catheters with ultrasound and stimulating catheters is known. Literature regarding catheter placements with only ultrasound is limited. We aimed to investigate the feasibility of performing continuous sciatic nerve block exclusively with ultrasound guidance and minimal equipment. METHOD: Forty ASA 1 and 2 patients aged 8 months-10 years posted for congenital talipoequinovarus surgery were included in the study. Continuous sciatic catheters were placed under ultrasound guidance with 18- gauge Tuohy needle at the infragluteal fold. Then, 0.25% of bupivacaine 0.5 ml·kg(-1) bolus was injected followed by continuous infusion later. Half the volume of the drug was injected prior to catheter insertion to improve visibility. The sciatic nerve, needle tip and shaft, catheter tip and the drug spread were visualized. The efficacy of the block intraoperatively and postoperatively was evaluated. RESULTS: The sciatic nerve, needle shaft, and tip were well visualized in all 40 patients. The catheter tip was seen in 72.5% of patients. The effect of block was complete intraoperatively and postoperatively. Clinically significant complications were absent. CONCLUSION: We conclude that in children, continuous sciatic catheters can be accurately and efficaciously placed with minimal equipment with ultrasound alone.

Ultrasound-guided sciatic nerve block in infants and toddlers produces successful anesthesia regardless of the motor response.

BACKGROUND AND OBJECTIVES: The primary objective of this study was to assess the success rate of ultrasound-guided sciatic needle placement regardless of the motor stimulation in infants and toddlers. METHODS: Forty-five consecutive patients aged 7 months-2 years, scheduled for foot surgery, were included in this prospective, descriptive and blinded study. After induction of general anesthesia, sciatic nerve block was performed under ultrasound guidance in the subgluteal area using an insulated needle connected to a nerve stimulator, with the power off. At the precise point when it was presumed that the needle was touching the sciatic nerve, the peripheral nerve stimulator was turned on at 0.5 mA and the current was slowly decreased to 0.2 mA. Presence and location of any motor responses were observed and recorded. Statistical analysis was applied to compare the success rate in patients who did and did not exhibit a motor response to electrical stimulation. Postoperatively, block duration and analgesic consumption were recorded. RESULTS: The sciatic nerve could be distinctly visualized in 44 children, and all these blocks were successful. Only 22% patients showed any motor response to electrical stimulation. There was no significant difference in block characteristics between patients who exhibited a motor response with electrical stimulation and those who did not. CONCLUSION: Success rate of ultrasound-guided sciatic nerve block remains unaltered irrespective of motor response to neurostimulation.

Does ultrasound guidance improve the success rate of infraclavicular brachial plexus block when compared with nerve stimulation in children with radial club hands?

BACKGROUND: The classical response to nerve stimulation may be altered in cases of radial club hand. Ultrasound guidance may prove to be a useful tool in such situations. In this study, we compared the success rate of ultrasound-guided infraclavicular brachial plexus block with nerve stimulation for children undergoing radial club hand repair. METHODS: Fifty children, aged 1-2 yr, undergoing radial club hand repair were randomly assigned to receive infraclavicular brachial plexus block guided by nerve stimulator (Group NS) or ultrasound (Group U) in combination with light general anesthetic. Bupivacaine 0.5 mL/kg of 0.5% was injected in both groups. Pain response to surgical stimulus was considered as block failure. The Children's Hospital Eastern Ontario Pain Scale pain score was recorded at 1, 4, 6, 8, and 10 postoperative hours. RESULTS: In Group NS, the blocks were successful in 16 of 25 patients (64%), whereas in Group U, 24 of 25 patients had successful blocks (P = 0.0053). There was no difference in the time to first analgesia or analgesic consumption in the 10-h study period. CONCLUSION: Ultrasound-guided infraclavicular brachial plexus block improves the success rate in patients with radial club hands when compared with nerve stimulation in patients undergoing radial club hand correction.

Continuous infraclavicular brachial plexus block: a modified technique to better secure catheter position in infants and children.

INTRODUCTION: The infraclavicular approach to the brachial plexus provides suitable anesthesia and also lends itself well to stabilizing and securing a catheter for a continuous infusion. We describe an approach for continuous infusions using an infraclavicular approach in children. METHODS: Twenty-five patients aged 8 mo to 3 yr, weighing 7-14 kg, scheduled for forearm and hand surgeries were studied. The infraclavicular brachial plexus was located using a nerve stimulator attached to a sheathed 19-gauge Touhy needle. The needle was inserted through the skin at 1 cm below and 1 cm lateral to the midpoint of the clavicle. The needle was advanced and directed toward the coracoid process maintaining an angle of 30 degrees with the skin. A 20-gauge epidural catheter was passed to the 5-7 cm mark through the Touhy needle. The Touhy needle was removed and the catheter left in place. Bupivacaine (1 mL/kg; 0.25%) was administered through the catheter. A continuous infusion of 0.25 mg/kg/h of bupivacaine (0.125%) was commenced near the end of surgery and continued on the first postoperative day. The continuous infusion was discontinued on the second postoperative day and intermittent boluses were administered every 4 to 6 h. In all patients the catheter was removed after 48 h. RESULTS: Twenty-four patients (96%) had a successful block. On the first postoperative day all patients were pain free (Children's Hospital Eastern Ontario Pain Scale score 4-6). On the second day, two children (8%) needed ibuprofen syrup along with a supplemental dose of local anesthesia. The catheter was passed with ease in all but four children. However, in these four patients, slight needle angulation and a bolus of 1-2 mL local anesthetic solution was required to overcome the resistance. None of the patients had catheter dislodgements or accidental removal, hemorrhagic tap, or pneumothorax. CONCLUSIONS: A modified technique for continuous infraclavicular brachial plexus block helps secure the catheter and provides effective intra- and postoperative pain relief in pediatric patients.