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Pain Control in a Pediatric Patient With Sickle Cell Disease Using Regional Nerve Blocks for Laparoscopic Cholecystectomy: A Case Report

Hasan, Aysha MD*; Nanassy, Autumn D. MA; Disilvio, Gregory DO*; Meckmongkol, Teerin MD; Arthur, L. Grier MD; Taneja, Pravin A. MD, MBA*

doi: 10.1213/XAA.0000000000000862
Case Reports

The sickle cell patient population continues to provide challenges in pain control. Current therapies include narcotic usage with adjuvant therapies such as anti-inflammatories and nonpharmacological interventions. Poor pain management in the sickle cell patient population, especially postoperatively, can lead to hypoventilation, escalating opioid requirements, poor recovery, and longer hospital stays. This case report addresses a novel addition of ultrasound-guided paravertebral and rectus sheath blocks postinduction of general anesthesia and before surgical incision to assist with the intravenous postoperative pain management regimen after laparoscopic cholecystectomy in a 10-year-old boy with sickle cell disease.

From the *Department of Anesthesiology

Trauma Services Department

Department of Anesthesiology, Division of Acute Pain and Regional Anesthesiology, St. Christopher’s Hospital for Children, Philadelphia, Pennsylvania.

Accepted for publication July 3, 2018.

Funding: None.

The authors declare no conflicts of interest.

Address correspondence to Aysha Hasan, MD, Department of Anesthesiology, St. Christopher’s Hospital for Children, 160 E Erie Ave, Philadelphia, PA 19134. Address e-mail to

Sickle cell disease (SCD) is one of the most common inherited diseases in the world.1–4 It is characterized by hemolytic anemia with acute and chronic complications. The most intractable problems in children with SCD are the painful crises that result from tissue ischemia secondary to vaso-occlusion. These pain crisis episodes are the most common cause of morbidity and admissions to emergency departments and the hospital.3 Pain management in pediatric SCD patients requires a multidisciplinary approach and remains a challenging ordeal, in part, because of differences between pediatric and adult patient populations.5 Postsurgical pain further complicates the management of SCD patients. Close perioperative monitoring and assessment of these patients are crucial in avoiding the potential pain crisis.

The following case examines a SCD patient with choledocholithiasis who was scheduled for a laparoscopic cholecystectomy. The objective of this case report is to provide a reasonable approach to managing pain in the immediate postoperative period using regional anesthesia in conjunction with general anesthesia. This would help facilitate in providing superior analgesia, better respiratory function, and an uncomplicated postoperative course in this subset of population.

The Institutional Review Board approved this case report, and written consent was obtained from the patient’s mother.

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A 10-year-old, 32-kg male patient with SCD and no known drug allergies presented to the emergency department with 4 days of right upper quadrant pain that was refractory to his usual morphine doses. The patient was diagnosed with choledocholithiasis and underwent an endoscopic retrograde cholangiopancreatography with sphincterotomy. After the procedure, he developed acute chest syndrome. After recovery from his vaso-occlusive crisis and before his scheduled laparoscopic cholecystectomy under general anesthesia, he developed acute cholecystitis with reported pain scores of 7–9/10 on the numerical rating scale (NRS) despite multiple doses of intravenous (IV) morphine given around the clock. Given his medical history of SCD and current uncontrolled pain, the decision to include peripheral nerve blocks as part of his multimodal analgesic plan was formulated. After discussion with the surgeons about their laparoscopic port placement, it was determined that dermatomal levels on the right T8–T11 and bilateral T10 would require analgesic coverage.

In the preoperative holding area, consent was obtained from the family for general and regional anesthesia. Additionally, the patient received midazolam 2 mg for anxiolysis. In the operating room, general anesthesia was induced with propofol 150 mg, fentanyl 75 μg, and rocuronium 25 mg. A size 6.0-mm oral endotracheal tube was placed and secured uneventfully.

The patient was turned left lateral decubitus for placement of a single-shot thoracic paravertebral nerve block (PVB) under ultrasound guidance using a 9-MHz linear ultrasound transducer (Fujifilm Sonosite, Inc, Bothell, WA; L25x/13–6 MHz). After the patient was prepared in a sterile manner using a 10.5-mL chlorhexidine gluconate applicator, sterile towels, sterile gloves, and a sterile probe cover, the transducer was placed in the transverse position at the eighth thoracic vertebra at the spinous process. The transducer was moved laterally until the paravertebral space was identified as encompassed anterolaterally by the parietal pleura and posteromedially by the transverse process and superior costotransverse ligament (Figure 1). A 21 gauge × 100-mm Pajunk echogenic needle (PAJUNK, Norcross, GA) was inserted parallel to the probe for an in-plane technique of depositing the local anesthetic. The needle was visualized the entire time as it crossed the costotransverse ligament. Aliquots of normal saline were injected before local anesthetic to confirm appropriate needle location by observing pleural depression. A total of 22 mL of ropivacaine 0.2% was injected at this location. Excellent spread cephalad and caudad were visualized on the ultrasound image with the transducer turned sagittally at T8 (Figure 2).

Figure 1.

Figure 1.

Figure 2.

Figure 2.

The patient was placed back in the supine position uneventfully. Using the same ultrasound transducer and placing the transducer transversely on the abdomen immediately lateral to the umbilicus, the rectus muscles and posterior rectus sheath were identified. Four milliliters of ropivacaine 0.2% was injected between the rectus muscle and the posterior rectus sheath on the left side (Figure 3) followed by an injection of 4 mL of ropivacaine 0.2% on the right side (Figure 4) sterilely. Total local anesthetic dose used between the 3 block sites was 30 mL of ropivacaine 0.2%, and the total time to position the patient and perform these blocks was 16 minutes.

Figure 3.

Figure 3.

Figure 4.

Figure 4.

The surgeon made 4 laparoscopic port incisions on the abdomen including one 10-mm port at the umbilicus and 5-mm ports at the epigastrium, right midclavicular abdomen, and right lateral abdomen. The surgical case proceeded for 85 minutes and was uneventful. The surgeon did not inject additional local anesthetic at the incision sites.

Intraoperatively, the patient received a total of 2 mg of morphine IV and a single dose of 10 mg/kg of acetaminophen IV. The patient was extubated without difficulty and taken to the postanesthesia care unit (PACU) where he comfortably maintained adequate minute ventilation.

In the PACU, the patient reported pain scores on the NRS of 0–1/10. The analgesic distribution from the peripheral nerve blocks included right-sided dermatomes T6–T11 and T10 bilaterally. The patient received 1 dose of ketorolac IV in the PACU and was transferred to the floor bed after 30 minutes in the PACU.

The patient remained pain free with documented pain scores of 0–2/10 on the NRS for approximately 9.5 hours postoperatively. His pain returned first in the T6 dermatomes followed by T7–T11 dermatomes 9.5 hours later. His pain score on the NRS at the time of the block subsiding was 9/10 but was controlled after his normal dose of morphine IV was administered. Subsequent pain scores ranged from NRS 0 to 7/10 until discharge. The patient was discharged to go home the following day without complications.

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Pain related to SCD is unique among all pain syndromes due to the unpredictable, recurrent, and often persistent nature of the disease. Approximately 100,000 individuals in the United States are diagnosed with SCD.1–3 Although not curable, pain related to SCD can be effectively managed in most patients, including children, by using existing comprehensive multimodal approaches that include various pharmacological, physiological, behavioral, physical pain management, and regional anesthesia strategies. Despite pain being a universal feature of SCD, children remain one of the most undertreated populations.3 The standard treatment protocol for pain episodes focuses on rest, rehydration, oxygenation, and analgesics involving acetaminophen, oral and parenteral non-steroidal anti-inflammatory drugs, and oral, parenteral, or continuous infusion of opioids.6 A discussion involving multimodal pain management is essential, especially among the perioperative team. Improved pain management would also support the current escalating ethical issues surrounding pediatric opioid prescriptions and abuse.7

Concerns in the perioperative period in patients with SCD include managing variables such as adequate nonsickled hemoglobin (<30% hemoglobin sickle cell disease), anxiety control, hydration, normothermia, acidosis (normal end-tidal carbon dioxide), and oxygenation and addressing pain control with the use of opioids, acetaminophen, and non-steroidal anti-inflammatory drugs.4,6 Seldom does the discussion of optimal management include the use of regional anesthesia. Literature related to the control of pain using regional anesthesia in SCD patients in the perioperative setting outside of neuraxial techniques (spinals and epidurals) is sparse.6,8,9 Furthermore, neuraxial instrumentation presents its own limitations and complications including meningitis, total spinal, abscess or hematoma formation centrally, hypotension, bradycardia, and possible postdural puncture headache.6,8,9 Although regional anesthesia remains a controversial topic and is underutilized in the pediatric population secondary to limited data, opportunities exist for its use in the SCD population.10 Notably, the surgical removal of the gallbladder has become a less-invasive procedure requiring fewer opioids and allowing for faster recovery and discharge times in the general population. The same rewards of this surgery do not hold true among chronic pain patients, prompting a discussion in regional anesthetic use.11

In our case report, the patient exhibited preoperative pain that required morphine IV around the clock, a clinical indicator of a high-risk situation for uncontrolled postoperative pain.12 The collaborative decision to implement a regional anesthetic procedure, namely the ultrasound-guided paravertebral and rectus sheath blocks, arose from a multidisciplinary discussion among the patient’s care providers (ie, primary, surgical, anesthesiology, and child life care teams). Major contributing factors in deciding to place the regional anesthetic in our patient were his medical history, the likelihood of inadequate pain control from pharmacological measures used, the acute phase of recovery postoperatively, and his body habitus. The single-sided, ultrasound-guided PVB was chosen because of its capability of providing analgesia comparably to an epidural without having to instrument the neuraxial space.13,14 Common limitations to the PVB are the need for a trained anesthesiologist, failed block, slight increased risk of a pneumothorax, and positioning times.15 The rectus sheath block was added to cover the umbilical incision during surgery, the only incision with bilateral dermatomal involvement.

The American and European Society of Regional Anesthesia have collaboratively issued recommendations on ultrasound-guided peripheral regional anesthetic dosing to fall within 0.5–1.5 mg/kg.16 The maximum described toxic dose of ropivacaine is 3.0 mg/kg.17 Higher levels of evidence of actual dosing and local anesthetic delivery is yet to be established in the pediatric population. The spread of volume in certain peripheral blocks is crucial in dermatomal coverage, such as the PVB. On the basis of this principle, we used ropivacaine 0.2% instead of 0.5% because the higher concentration of local anesthetic in the pediatric population can limit the amount of volume deposited. Furthermore, using lower concentrations with larger volumes can help ameliorate the dosing challenges faced in the pediatric population.18

In summary, instituting regional anesthesia modalities can be very useful in helping outline postoperative multimodal pain management plans to help patients recover without escalating their need for greater opioid doses. While a variety of other peripheral truncal blocks such as the erector spinae and the quadratus lumborum blocks can also be used, our experience with these blocks and many other studies have shown that the more posterior the local anesthetic is deposited without instrumenting the neuraxiom, the more reliably the dermatomes are covered.19,20 Although the PVB is a safe and an effective modality of pain control for patients with SCD undergoing upper abdominal procedures, further research comparing efficacy is warranted.10

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Name: Aysha Hasan, MD.

Contribution: This author helped conceive, draft, and revise the manuscript.

Name: Autumn D. Nanassy, MA.

Contribution: This author helped conceive, draft, and revise the manuscript.

Name: Gregory Disilvio, DO.

Contribution: This author helped conceive, draft, and revise the manuscript.

Name: Teerin Meckmongkol, MD.

Contribution: This author helped conceive, draft, and revise the manuscript.

Name: L. Grier Arthur, MD.

Contribution: This author helped acquire the data and revise the manuscript.

Name: Pravin A. Taneja, MD, MBA.

Contribution: This author helped conceive, draft, and revise the manuscript.

This manuscript was handled by: Raymond C. Roy, MD.

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