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Variation Between and Within Hospitals in Single Injection Caudal Local Anesthetic Dose

A Report From the Pediatric Regional Anesthesia Network

Taenzer, Andreas H. MD, MS*; Hoyt, Matthew MD*; Krane, Elliot J. MD, FAAP†,‡; Walker, Benjamin J. MD§; Flack, Sean MBChB, FCA(SA); Bosenberg, Adrian MBChB, FFA(SA); Sethna, Navil F. MD, MA (Hon.), FAAP; Franklin, Andrew D. MD, MBA, FASA#; Polaner, David M. MD, FAAP for the PRAN investigators

doi: 10.1213/ANE.0000000000004447
Pediatric Anesthesiology: PDF Only

BACKGROUND: Given that variation exists in health care utilization, expenditure, and medical practice, there is a paucity of data on variation within the practice of anesthesia. The Pediatric Regional Anesthesia Network (PRAN) data lend itself to explore whether different medical practice patterns exist and if there are nerve blocks with more local anesthetic dosing variation than others.

The primary aim of this study was to quantify variation in single injection caudal block dosing, and the secondary aim was to explore possible causes for variation (eg, number of blocks performed versus geographic location).

METHODS: We queried the PRAN database for single injection caudal blocks in children <1 year of age. Data were analyzed for local anesthetic dose, variation within and across institutions, and possible causes.

RESULTS: Mean dose of bupivacaine equivalents per kilogram (BE·kg−1) among sites ranged from 1.39 to 2.22 with an interdecile range (IDR) containing the mid 80% of all doses ranging from 0.21 to 1.48. Mean dose (BE·kg−1) was associated with site, age, weight, and local anesthetic used (all P < .0001). Cohen’s F effect size estimate was 10 times higher for site (0.65) than for age (0.05) or weight (0.02). Variation (IDR) was not related to number of blocks done at each site (P = .23). Mean volume per kilogram was 0.9± ± 0.2 (mean ± ±standard deviation) and was more strongly associated with site (Cohen’s F 0.3) than age (0.04) or weight (0.07).

CONCLUSIONS: Wide variation in caudal local anesthetic dosing and administered volume exists. This variation is independent of the number of cases performed at each center but rather is determined by study site (ie, variation between centers) with considerable additional variation within study centers, suggesting additional variability dependent on individual practitioners. While there are legitimate reasons to vary dosing, the current approach is inconsistent and not supported by strong evidence over giving a standardized dose.

From the *Department of Anesthesiology, The Geisel School of Medicine at Dartmouth, Children’s Hospital at Dartmouth, Lebanon, New Hampshire

Department of Anesthesiology, Stanford University School of Medicine, Stanford, California

Department of Anesthesiology, Stanford Children’s Hospital, Palo Alto, California

§Department of Anesthesiology, University of Wisconsin School of Medicine and Public Health, American Family Children’s Hospital, Madison, Wisconsin

Department of Anesthesiology, University of Washington School of Medicine, Seattle Children’s Hospital, Seattle, Washington

Department of Anesthesiology, Harvard Medical School, Boston Children’s Hospital, Boston, Massachusetts

#Department of Anesthesiology, Vanderbilt Medical School, Monroe Carell Jr Children’s Hospital at Vanderbilt, Nashville, Tennessee.

Accepted for publication August 15, 2019.

Funding: None.

The authors declare no conflicts of interest.

A full list of contributors can be found at the end of the article.

The study proposal was reviewed and accepted by Pediatric Regional Anesthesia Network's (PRAN's) steering committee, and the manuscript was approved by PRAN’s publication committee.

Reprints will not be available from the authors.

Address correspondence to Andreas H. Taenzer, MD, MS, Department of Anesthesiology, Dartmouth Hitchcock Medical Center, One Medical Center Dr, Lebanon, NH 03756. Address e-mail to

© 2019 International Anesthesia Research Society
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