Recently, regional anaesthesia in children has generated increasing interest. But single injection techniques have a limited duration of postoperative analgesia. Then, continuous peripheral nerve blocks have taken an important position in the anaesthetic arsenal, allowing an effective, safe and prolonged postoperative pain management. As adults, indications for continuous peripheral nerve blocks depend on the analysis of individual benefits/risks ratio. Main indications are intense postoperative pain surgical procedures, with or without postoperative rehabilitation, and complex regional pain syndrome. Contraindications to these procedures are rather similar to those in adults, plus parental and/or children refusal. Continuous peripheral nerve blocks are usually performed under general anaesthesia or sedation in children, and require appropriate equipment in order to decrease the risk of nerve injury. New techniques, such as transcutaneous nerve stimulation or ultrasound guidance, appeared to facilitate nerve and plexus approach identification in paediatric patients. Nevertheless, continuous peripheral nerve block may theoretically mask a compartment syndrome after trauma surgical procedures. Finally, ropivacaine appears to be the most appropriate drug for continuous peripheral nerve blocks in children, requiring low flow rates and concentrations of local anaesthetic. These techniques may facilitate early ambulation by an improved pain management or even postoperative analgesia at home with disposable pumps. One might infer from the current review that excellent pain relief coupled with a reduction of side effects would contribute to improve the quality of life and to decrease the frequency of disabling behavioural modifications in children, sometimes psychologically injured by hospital stay and postoperative pain.
[Show abstract][Hide abstract] ABSTRACT: This is an audit of the continuous peripheral nerve blockade (CPNB) program that was implemented at our institution to provide postoperative analgesia after orthopedic procedures in children.
We reviewed the departmental regional anesthesia registry and the medical records of consecutive children who received CPNB for postoperative analgesia at The Children's Hospital of Philadelphia between February 2003 and July 2006. Patients were prospectively followed until cessation of the effects of CPNB and/or resolution of any related complications. Data collected contemporaneously included presence of sensory and motor blockade, pain scores in inpatients, opioid administration, and complications related to CPNB.
A total of 226 peripheral nerve catheters were placed in 217 patients. One hundred eight patients (112 catheters) were discharged home with CPNB. The ages ranged from 4 to 18 yr (13.7 +/- 3.4). Local anesthetic solution (0.125% bupivacaine [n = 164], 0.1% ropivacaine [n = 12], or 0.15% ropivacaine [n = 27]) was infused at an initial rate of 2-12 mL/h based on patients' weights and locations of catheters. The mean duration of local anesthetic infusion was 48.4 +/- 29.3 h (range 0-160 h). The percentage of patients who did not require any opioids in the first 8, 24, and 48 h after surgery was 56%, 26%, and 21%, respectively. The incidence of nausea and vomiting was 14% (13% in outpatients, 15% in inpatients). Complications were noted in 2.8% of patients. Three patients had prolonged numbness (>24 h) that resolved spontaneously; one developed superficial cellulitis that resolved with a course of antibiotics; one had difficulty removing the catheter at home and one developed tinnitus 24 h after starting CPNB that resolved quickly after clamping of the catheter followed by removal.
It is feasible to implement a CPNB program to provide an alternative method of inpatient and outpatient postoperative analgesia after orthopedic surgery in children when appropriate expertise is available. Patient and family education along with frequent follow-up are crucial to detect and address adverse events promptly.
Anesthesia and analgesia 11/2007; 105(5):1234-42, table of contents. DOI:10.1213/01.ane.0000284670.17412.b6 · 3.47 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: To review the recently published peer-reviewed literature involving regional anesthesia and analgesia in patients at home.
The potential benefits and risks of regional anesthesia and analgesia at home are pertinent queries, and increased data regarding these topics are rapidly becoming available. Of particular interest is the use of continuous peripheral nerve blocks at home and their potential effect upon hospitalization duration and recovery profile.
Advantages of regional techniques include site-specific anesthesia and decreased postoperative opioid use. For shoulder surgeries, the interscalene block provides effective analgesia with minimal complications, whereas the impact and risks of intraarticular injections remain unclear. Perineural catheters are an analgesic option that offer improved pain relief among other benefits. They are now being used at home in both adult and pediatric populations.
Current opinion in anaesthesiology 08/2008; 21(4):488-93. DOI:10.1097/ACO.0b013e328303bfb5 · 1.98 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Regional anaesthesia is a cornerstone in paediatric anaesthesia today. Many paediatric anaesthetists include regional anaesthetic techniques in their daily clinical practice to provide superior and long-lasting analgesia without the risk of respiratory depression. The first part this article reviews new scientific findings in the field of paediatric regional anaesthesia. The second part focuses on safety aspects and on the impact of ultrasound on paediatric regional anaesthesia.
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