Confirmation of success rate of landmark-based caudal blockade in children using ultrasound: A prospective analysis.

BACKGROUND: Caudal epidural anesthesia is a frequently performed regional anesthesia block in infants and young children. Traditional landmark-based blind needle insertion remains the norm with no immediate, objective method to determine the presence of local anesthetic in the epidural space. Increasingly, ultrasound-imaging is used in pediatric regional anesthesia with demonstrated improvements in block efficacy and efficiency. The value of ultrasound-imaging in confirming success rate of traditional caudal placement is not well defined. AIM: To assess the success rate of conventional landmark-based caudal technique using ultrasound-imaging. METHODS: Prospective observational study of 30 children ages 1 month to 7 years undergoing surgical procedures with consent for caudal blockade. Provider success rate of caudal blockade placed by landmark technique was measured using ultrasound-imaging of needle tip and local anesthetic flow in the epidural space. RESULTS: Ultrasound-imaging demonstrated 80% success to correct positioning of the needle tip and local anesthetic in the epidural space. Failure was associated with decreasing experience and presence of anatomic variances. All improperly positioned needles were subsequently successfully positioned using real-time ultrasound-imaging. Mean time for confirmatory ultrasound-imaging (SD; range) was 1 minute (0.3; 1-3). CONCLUSION: The use of ultrasound-imaging can be used to identify proper needle placement in the sacral epidural canal and facilitate subsequent corrected placement.

Focused Cardiac Ultrasound in the Pediatric Perioperative Setting.

Focused cardiac ultrasonography (FoCUS) has become an important diagnostic tool for acute care physicians. FoCUS allows real-time visualization of the heart and, in combination with the physical examination, acts as a hemodynamic monitor to manage patient care in acute situations. Most of the available perioperative literature has focused on adult patients. Little has been published on the perioperative application of FoCUS for pediatric patients. This article provides an overview of FoCUS used at the bedside by pediatric anesthesiologists. Variations in clinical applications, technical aspects, and interpretation of FoCUS findings in children are described. Discussion of training and competency is included. Barriers to implementation by pediatric intensivists and emergency medicine physicians include a lack of understanding of indications and training opportunities in pediatric FoCUS. It is likely that similar barriers exist in pediatric anesthesiology resulting in underutilization of FoCUS. The use of FoCUS in the pediatric operating room, however, may positively impact care of infants and children and should be encouraged.

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.

Ultrasound-guided lumbar plexus block in children and adolescents using a transverse lumbar paravertebral sonogram: Initial experience.

BACKGROUND: The clinical reliability and reproducibility of ultrasound-guided lumbar plexus blocks is not established in pediatric populations. We present the results of a combined nerve stimulation ultrasound-guided lumbar plexus block using the vertebral body, transverse process, and psoas muscle as landmarks on a transverse lumbar paravertebral sonogram with mid-axillary transducer placement, "shamrock method," in children and adolescents. AIMS: Our primary objective was to determine the rate of achieving sensory changes in the lumbar plexus distribution. Secondary outcomes were performance time, reliability of echo-landmarks, measures of patient comfort, and complications. METHODS: We reviewed prospectively collected quality assurance data and electronic medical records of 21 patients having major orthopedic surgery with lumbar plexus block catheter for postoperative analgesia. RESULTS: Twenty-one patients were studied with mean age and weight (SD, range) of 13.6 years (3.8, 6-18) and 49.3 kg (18.6, 19.2-87.6). Surgical procedures included periacetabular osteotomy, pelvic osteotomy, and proximal femoral osteotomy. Mean volume of 0.5 mL/kg (0.05) 0.2% ropivacaine produced thermal sensory changes to femoral and lateral femoral cutaneous nerves in 20/21 (95% CI 0.76 to >0.99) and 19/21 (95% CI 0.70-0.99) patients. Identification of transverse process (TP), vertebral body (VB), and psoas muscle (PM): 21/21 (95% CI 0.86-1.0). Average block performance time was 9:08 minutes (2:09, 2-13). Average opioid consumption (SD) in operating room, postanesthesia care unit, 0-12 and 12-24-hour periods were 0.17 mg/kg (0.08), 0.08 mg/kg (0.06), 0.06 mg/kg (0.06), and 0.06 mg/kg (0.05). Median pain score by severity category in postanesthesia care unit: (0-3) 66.7%, (4-6) 28.5%, (>7) 4.8%; 0-12 hours: (0-3) 76.2%, (4-6) 19.0%, (>7) 4.8%; 12-24 hours: (0-3) 57.2%, (4-6) 42.8%, (>7) 0%. No complications were recorded. CONCLUSION: Ultrasound guidance using lateral imaging of transverse process, vertebral body, and psoas muscle allows practitioners to reach the nerves of the lumbar plexus and achieve sensory block in pediatric patients with a high success rate.

Persistent pain following common outpatient surgeries in children: A multicenter study in Italy.

INTRODUCTION: The prevalence of persistent postsurgical pain in children is over 20% after major surgeries; however, data are scarce on the prevalence, character, and risk factors among children undergoing common ambulatory surgeries. The primary aim of this study was to evaluate the prevalence of persistent pain following pediatric ambulatory surgery at 1, 3, and 6 months. Secondary aims were to identify risk factors and characterize the pain and consequences of persistent postsurgical pain. METHODS: ASA I-II, ages 1 month to 16 years old, undergoing elective hypospadias repair, herniorraphy, orchiopexy, and orthopedic surgery were enrolled in a prospective, longitudinal, observational study at 3 pediatric centers in Italy. All patients received general plus regional anesthesia. Postoperative pain was evaluated using age appropriate pain scales at 1 and 3 hours. At 1, 3, and 6 months, pain scores were obtained and Parent's Postoperative Pain Measures (<8 yo) and Child Activity Limitations Interview (>8 yo) surveys were administered. RESULTS: About 350 patients completed the study. The prevalence of pain at 1, 3, and 6 months was 24% (84/350), 6.0% (21/350), and 4.0% (14/350), respectively. Inguinal herniorraphy patients experienced significantly higher pain at all 3-time points; 35.6%, 14.9%, and 9.2%. There was no significant association between mean pain scores >4 in PACU and persistent pain. Pain persisting at 6 months had neuropathic characteristics and frequently interfered with daily activities and sleep. CONCLUSION: Our data support the presence of persistent pain in pediatric patients after common surgeries. Most patients who developed persistent pain at 6 months had pain at 1 month. We recommend questioning at follow-up visit about persistent pain and functional impairment with follow-up until resolution.

Technical success of the ultrasound-guided supra-inguinal fascia iliaca compartment block in older children and adolescents for hip arthroscopy.

BACKGROUND: Hip arthroscopic surgery is performed on older pediatric patients. Fascia iliaca compartment block has proven efficacy in providing analgesia following hip surgery and can be performed with target location of local anesthetic below or above the inguinal ligament. The reported success of ultrasound-guided infra-inguinal fascia iliaca compartment block is lower when compared to traditional landmark technique, while the reliability of supra-inguinal fascia iliaca compartment block is unreported. AIM: The primary aim was to report the results in obtaining sensory changes in the distribution of the femoral and lateral femoral cutaneous nerves following supra-inguinal fascia iliaca compartment block in patients undergoing arthroscopic hip surgery. Secondary outcomes are the ability to find echogenic landmarks and to report pain scores and opioid consumption. METHODS: We reviewed the electronic medical record and regional anesthesia database of patients receiving ultrasound-guided fascia iliaca compartment block for arthroscopic hip surgery. Sensory changes to the femoral and lateral femoral cutaneous nerves were determined. Identification of echogenic landmarks was quantified. Pain scores and opioid consumption were determined. RESULTS: Seventeen patients of mean age 15.4 years old (SD 1.3; range 13-17 years) were included. Sensory changes to both the femoral and lateral femoral cutaneous nerves occurred in 94% of patients (95% CI: 82%-100%). The average volume of ropivacaine 0.2% was 0.53 mL/Kg (SD 0.11 mL/Kg). Echogenic landmarks were identified in all patients. Pain scores and opioid consumption were generally low. CONCLUSION: A supra-inguinal location for the deposition of local anesthetic when performing fascia iliaca nerve block for hip surgery is reliable in anesthetizing the femoral and lateral femoral cutaneous nerves and should encourage investigation into the clinical efficacy.

Dermatomal spread following posterior transversus abdominis plane block in pediatric patients: our initial experience.

INTRODUCTION: Several techniques for the transversus abdominis plane (TAP) block have been described. The extent of sensory changes using an ultrasound-guided posterior TAP block (pTAP) remains unclear in pediatric patients. The primary aim of this study was to report the extent of sensory changes achieved with pTAP; specifically the highest thoracic dermatome anesthetized. Secondary outcomes were pain scores (PS), opioid consumption, and complications. METHODS: We retrospectively reviewed the medical records of patients less than 21 years of age undergoing abdominal surgery with a unilateral or bilateral pTAP(s) for postoperative analgesia. The local anesthetic was placed posterior to the termination of the transversus abdominis muscle where the thoracolumbar fascia overrides the quadratus lumborum muscle. The extent of sensory changes, pain scores, and opioid consumption were analyzed. RESULTS: A total of 10 patients (15 pTAP blocks) met the inclusion criteria. The mean (sd; range) age and weight were 15 years (5 years; range 7-20 years) and 57 kg (21 kg; 27-97 kg), respectively. The cephalad dermatome levels achieved were: T7 in 6/15 (40%); T8 in 10/15 (67%); and T9 in 14/15 (93%). An inferior dermatome level of T12/L1 and sensory extension from midaxillary line to the midline was documented in 15/15 blocks. The mean intraoperative and postanesthesia care unit (PACU) opioid consumption in morphine equivalents were 0.34 mg·kg-1 (sd = 0.12 mg·kg-1 ) and 0.04 mg·kg-1 (sd = 0.05 mg·kg-1 ), respectively. PACU pain scores were mild (<4) in 60%, moderate (4-7) in 30%, and severe (>7) in 10% of patients. No complications were reported. DISCUSSION: The current uncertainty regarding sensory blockade limits the clinical application of TAP blocks. While the midaxillary approach results in unpredictable sensory changes of the abdomen, we reliably achieved sensory changes up to a T9 level in 93% of the blocks. CONCLUSION: In this small series of patients, we demonstrate a high technical success rate of achieving cutaneous analgesia to the abdominal wall. These results should encourage clinical studies of the efficacy of this block for abdominal surgery in pediatric patients.

Thoracic Paravertebral Nerve Blocks in Pediatric Patients: Safety and Clinical Experience.

Thoracic paravertebral nerve blocks (PVNBs) provide excellent analgesia for many surgeries. The primary aim was to estimate the complication rate, and secondary aims were to provide information on the potential clinical application of PVNBs. Data on 2390 PVNBs were collected. A total of 625 catheters were performed on 468 patients, and 1765 single-injection PVNBs were performed on 403 patients. There was 1 case of local anesthetic systemic toxicity for a major complication rate of 1 per 2390 PVNBs. The minor complication rate was 13.2%. We demonstrate a low risk of complications in pediatric patients receiving PVNBs for various surgeries.

Chloroprocaine: local anesthetic systemic toxicity in a 9-month infant with paravertebral catheter.

Regional anesthesia use in pediatric patients has a good safety profile. 2-Chloroprocaine is used frequently in infants due to rapid onset, lack of accumulation, and rapid plasma degradation. We present a case of local anesthetic systemic toxicity following the administration of 3% 2-chloroprocaine through a paravertebral catheter in an infant. The episode lasted 40 s followed by complete recovery. The infrequent reporting of local anesthetic systemic toxicity and limited duration of symptoms supports the continued use of 2-chloroprocaine in infants. Volume should be restricted to the smallest amount providing analgesia.

A Phase 1, Dose-escalation, Double-blind, Block-randomized, Controlled Trial of Safety and Efficacy of Neosaxitoxin Alone and in Combination with 0.2% Bupivacaine, with and without Epinephrine, for Cutaneous Anesthesia.

BACKGROUND: Neosaxitoxin (NeoSTX) is a site-1 sodium channel blocker that produces prolonged local anesthesia in animals and humans. Under a Food and Drug Administration-approved phase 1 Investigational New Drug trial, the authors evaluated safety and efficacy of NeoSTX alone and combined with 0.2% bupivacaine (Bup) with and without epinephrine. METHODS: The authors conducted a double-blind, randomized, controlled trial involving healthy male volunteers aged 18 to 35 yr receiving two 10-ml subcutaneous injections. Control sites received Bup. In part 1, active sites received (1) 5 to 40 µg NeoSTX+Saline (NeoSTX-Saline), (2) 5 to 40 µg NeoSTX+Bup (NeoSTX-Bup), or (3) placebo (Saline). In part 2, active sites received 10 or 30 µg NeoSTX+Bup+Epinephrine (NeoSTX-Bup-Epi) or placebo. Primary outcome measures were safety and adverse events associated with NeoSTX. Secondary outcomes included clinical biochemistry, NeoSTX pharmacokinetics, and cutaneous hypoesthesia. RESULTS: A total of 84 subjects were randomized and completed the two-part trial with no serious adverse events or clinically significant physiologic impairments. Perioral numbness and tingling increased with NeoSTX dose for NeoSTX-Saline and NeoSTX-Bup. All symptoms resolved without intervention. NeoSTX-Bup-Epi dramatically reduced symptoms compared with other NeoSTX combinations (tingling: 0 vs. 70%, P = 0.004; numbness: 0 vs. 60%, P = 0.013) at the same dose. Mean peak plasma NeoSTX concentration for NeoSTX-Bup-Epi was reduced at least two-fold compared with NeoSTX-Saline and NeoSTX-Bup (67 ± 14, 134 ± 63, and 164 ± 81 pg/ml, respectively; P = 0.016). NeoSTX-Bup showed prolonged cutaneous block duration compared with Bup, NeoSTX-Saline, or placebo, at all doses. Median time to near-complete recovery for 10 µg NeoSTX-Bup-Epi was almost five-fold longer compared with Bup (50 vs. 10 h, P = 0.007). CONCLUSION: NeoSTX combinations have a tolerable side effect profile and appear promising for prolonged local anesthesia.

Paravertebral nerve block catheters using chloroprocaine in infants with prolonged mechanical ventilation for treatment of long-gap esophageal atresia.

BACKGROUND: Infants with long-gap esophageal atresia (LGEA) undergo repeated thoracotomies for staged surgical repair known as the Foker process (FP). Associated prolonged mechanical ventilation results in exposure to high doses of opioids and benzodiazepines, and prolonged weaning times and ICU stays. AIM: The aim of this study was to determine the effectiveness of short-term paravertebral nerve block (PVNB) catheters in reducing opioid/benzodiazepine exposure and effects on clinical variables. METHODS: The medical records of seventeen infants were retrospectively reviewed; 11 with PVNB and six without (CG). PVNB were placed using ultrasound-guidance and chloroprocaine infusions implemented in the ICU. Opioids and benzodiazepines were administered via the protocol for 5 days following thoracotomies for Foker-I and Foker-II. RESULTS: Foker-I: Average reduction in morphine and midazolam consumption was 36% (2.18 vs 3.40 mg·kg(-1) ·day(-1) ; P < 0.001) and 31% (2.25 vs 3.25 mg·kg(-1) ·day(-1) ; P = 0.033), respectively, in the PVNB compared with CG. Foker-II: Average reduction in morphine and midazolam consumption was 39% (3.19 vs 5.27 mg·kg(-1) ·day(-1) ) and 38% (3.46 mg·kg(-1) ·day(-1) vs 5.62; P < 0.001), respectively in the PVNB compared with CG. 24-h prior to extubation: Average reduction in morphine and midazolam consumption was 50% (2.91 vs 5.85 mg·kg(-1) ·24 h(-1) ; p = 0.023) and 61% (2.27 vs 5.83 mg·kg(-1) ·24 h(-1) ; P = 0.004), respectively, in the PVNB compared with CG. Infusion wean time, (independence from opioid/midazolam infusions) following extubation was 5 days in the PVNB group and 15 days in CG (P = 0.005). Median ICU stay (IQR) was 40 days (34-45 days) in PVNB patients and 71 days (42-106 days) in controls (P = 0.02). PVNB catheters were left an average of 7 days and there were no complications associated with the nerve blocks. CONCLUSION: Short-term PVNB placement decreases opioid and benzodiazepine exposure, weaning days and ICU stay in infants undergoing prolonged mechanical ventilation for LGEA repair in this small pilot study. Larger studies are warranted to confirm results.

A comparison of paravertebral nerve block catheters and thoracic epidural catheters for postoperative analgesia following the Nuss procedure for pectus excavatum repair.

INTRODUCTION: Thoracic epidurals (TE) have been advocated as a superior method for controlling postoperative pain after repair of pectus excavatum with a Nuss procedure. However, three recent reports of permanent neurologic injury after the Nuss procedure with concurrent TE analgesia have raised concerns about the safety of this combination. Paravertebral nerve blocks (PVNB) are used successfully for analgesia of the chest, but no studies are available comparing TE and PVNB catheters for postoperative analgesia in this patient population. This study was conducted to compare the efficacy of PVNB catheters with TE catheters for postoperative analgesia in pediatric patients undergoing the Nuss procedure. METHODS: We retrospectively reviewed the medical records of 20 adolescent males undergoing a thoracoscopic Nuss procedure with either bilateral PVNB catheters (n = 10) or TE catheter (n = 10) and compared postoperative opiate consumption and pain scores. RESULTS: There were no statistically significant differences between the groups with respect to demographics, opiate consumption measured in morphine equivalents, and pain scores. DISCUSSION: In this small series, bilateral PVNB catheters resulted in equivalent opioid consumption and pain scores when compared to TE for postoperative pain management in pediatric patients undergoing the Nuss procedure. Large prospective studies are needed to further compare the efficacy, incidence of side effects, and complications of TE and PVNB catheters for postoperative analgesia in this pediatric population.

Regional anesthesia in pediatrics: marching forward.

PURPOSE OF REVIEW: This review highlights new data and current trends of well tolerated and effective paediatric regional anesthesia. Historically, the practice of paediatric regional anesthesia was based largely on information from adult studies, but recent literature contains information on paediatric specific risks and benefits of old and new techniques as well as the impact of new ideas and technologies. RECENT FINDINGS: Excellent pain relief with regional anesthesia is well demonstrated in children. Several databases of paediatric regional anesthesia (over 46,000 regional anesthetics) demonstrate overall safety and lack of major complications. Detailed analysis demonstrates additional safety and decreased failure rates of peripheral compared with neuraxial nerve blocks. Ultrasound technology confers additional safety and efficacy benefits.Increasingly, data support the safety and efficacy of novel peripheral nerve blocks, transversus abdominis plane and ultrasound-guided paravertebral, and the use of perineural catheters for both inpatients and outpatients. Regional anesthesia as a sole agent for surgical anesthesia and the use of regional anesthesia for pain in nonsurgical pain patients remains underutilized. SUMMARY: Paediatric specific data for regional anesthesia are available to help guide optimal pain management. The paediatric regional anesthesia literature lags behind literature available for adult populations and increased studies are needed for additional information for informed decision-making.

Local anesthetic dosing and toxicity of pediatric truncal catheters: a narrative review of published practice.

BACKGROUND/IMPORTANCE: Despite over 30 years of use by pediatric anesthesiologists, standardized dosing rates, dosing characteristics, and cases of toxicity of truncal nerve catheters are poorly described. OBJECTIVE: We reviewed the literature to characterize dosing and toxicity of paravertebral and transversus abdominis plane catheters in children (less than 18 years). EVIDENCE REVIEW: We searched for reports of ropivacaine or bupivacaine infusions in the paravertebral and transversus abdominis space intended for 24 hours or more of use in pediatric patients. We evaluated bolus dosing, infusion dosing, and cumulative 24-hour dosing in patients over and under 6 months. We also identified cases of local anesthetic systemic toxicity and toxic blood levels. FINDINGS: Following screening, we extracted data from 46 papers with 945 patients.Bolus dosing was 2.5 mg/kg (median, range 0.6-5.0; n=466) and 1.25 mg/kg (median, range 0.5-2.5; n=294) for ropivacaine and bupivacaine, respectively. Infusion dosing was 0.5 mg/kg/hour (median, range 0.2-0.68; n=521) and 0.33 mg/kg/hour (median, range 0.1-1.0; n=423) for ropivacaine and bupivacaine, respectively, consistent with a dose equivalence of 1.5:1.0. A single case of toxicity was reported, and pharmacokinetic studies reported at least five cases with serum levels above the toxic threshold. CONCLUSIONS: Bolus doses of bupivacaine and ropivacaine frequently comport with expert recommendations. Infusions in patients under 6 months used doses associated with toxicity and toxicity occurred at a rate consistent with single-shot blocks. Pediatric patients would benefit from specific recommendations about ropivacaine and bupivacaine dosing, including age-based dosing, breakthrough dosing, and intermittent bolus dosing.