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Ambulatory Continuous Peripheral Nerve Blocks in Children and Adolescents: A Longitudinal 8-Year Single Center Study

Gurnaney, Harshad MBBS, MPH; Kraemer, F. Wickham MD; Maxwell, Lynne MD; Muhly, Wallis T. MD; Schleelein, Laura MD; Ganesh, Arjunan MBBS

doi: 10.1213/ANE.0b013e3182a08fd4
Pediatric Anesthesiology: Research Report
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BACKGROUND: Although the role of regional anesthesia in pediatric patients has been increasing over the last few years, there are only a few small case series that describe the use of ambulatory continuous peripheral nerve blocks (CPNBs) in this patient population. In this report, we describe our experience with the use of ambulatory CPNBs in 1285 children.

METHODS: Data were collected for consecutive children who had a CPNB placed between January 2005 and December 2011 at The Children’s Hospital of Philadelphia from the departmental regional anesthesia database. Data collected included demographics, the site of catheter placement and technique of nerve block, presence of sensory/motor blockade, use of perioperative opioids, and any complications related to CPNBs.

RESULTS: Continuous infusions of local anesthetics were administered via the catheters in 1285 outpatients. The mean duration of the CPNB was 50.7 ± 14.4 hours (mean ± SD). Among patients discharged home with the CPNBs, 969 (75.4%) of the patients required either no supplemental opioids or oral opioids only on an “as needed” basis in the postoperative period (confidence interval, 73.0%–77.8%). Two patients were readmitted for IV pain management after they were discharged home with the CPNB catheters. No neurological deficit related to the CPNBs was identified in any of the patients at their 6-month follow-up with the orthopedic surgeon (confidence interval, 0%–0.29%).

CONCLUSION: This audit of 1285 children shows ambulatory CPNBs can provide postoperative analgesia and may reduce the need for inpatient parenteral opioid therapy.

Published ahead of print January 9, 2014

From the Department of Anesthesiology and Critical Care Medicine, The Children’s Hospital of Philadelphia and Perelman School of Medicine at University of Pennsylvania, Philadelphia, Pennsylvania.

Accepted for publication June 5, 2013.

Published ahead of print January 9, 2014

Funding: Departmental Funds.

The authors declare no conflicts of interest.

This report was previously presented, in part, at the Society of Paediatric Anaesthesia meeting 2011.

Reprints will not be available from the authors.

Address correspondence to Harshad Gurnaney, MBBS, MPH, Department of Anesthesiology and Critical Care Medicine, The Children’s Hospital of Philadelphia and Perelman School of Medicine at University of Pennsylvania, 34th St. and Civic Center Blvd., Philadelphia, PA 19104-4399. Address e-mail to gurnaney@email.chop.edu.

The role of regional anesthesia in the pediatric population has been expanding over the past few years.1,2 An increasing number of procedures, which traditionally required postoperative admission for pain control, are now being performed in an outpatient setting.3,4 Regional anesthesia, in particular peripheral nerve blockade, has played a major role in the postoperative pain management for ambulatory patients. A single injection of local anesthetic can provide a limited duration of analgesia (12–16 hours),5 while infusions via a peripheral nerve block catheter extend the duration of postoperative analgesia.5,6 In children, there are reports demonstrating the feasibility of using continuous peripheral nerve blocks (CPNBs) in the inpatient and outpatient setting.2,7–9 It is routine practice to discharge adults with CPNBs thus extending the benefits of regional anesthesia beyond the hospital setting.3,10 However, the sample sizes in these earlier reports are small. This study reports our experience using ambulatory CPNBs for postoperative analgesia in 1285 children and adolescents after orthopedic surgery.

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METHODS

After obtaining approval from our IRB, the departmental regional anesthesia database was queried and all children who received a CPNB between January 1, 2005 and December 31, 2011 at The Children’s Hospital of Philadelphia were identified. The IRB waived the requirement for written informed consent. The patients who were discharged home with a CPNB in place were identified. Patient and block information including patient demographics, the site of catheter placement, nerve block technique (stimulation, ultrasound), and condition in which the catheter was placed (sedated or general anesthesia) was recorded. Additionally, postoperative data were collected about the presence of sensory/motor blockade, use of perioperative opioids, oral analgesics along with the type and dose of rescue medications, and any complications related to CPNBs. Data regarding all patients with CPNBs were also maintained in a departmental pain database as the pain service ordered and managed the CPNB infusions. Data between the 2 databases were constantly tallied to ensure accuracy of the data collected in the regional database.

Catheters were placed after the induction of anesthesia in 98.9% of patients, with 254 patients having 2 catheters placed. In 16 subjects, the catheters were placed with the child sedated. After the patients were positioned for the CPNB, the appropriate site for the peripheral nerve block was cleaned with chlorhexidine or povidone–iodine and draped with sterile towels. Full barrier protection was used for all catheter placements. Catheters for CPNBs were inserted with the aid of nerve stimulation (NS) only, NS plus ultrasound, or ultrasound guidance (USG) only, using the technique previously reported from our institution8 (Table 1). A drop of methyl methacrylate was applied at the perineural catheter entry site to secure the CPNB and to decrease the risk of pericatheter leakage. If there were doubts about the position of the tip of the catheter, 2 to 3 mL of Omnipaque 180 (GE Healthcare, Cork, Ireland) was injected through the catheter and a radiograph was obtained to verify position of the catheter. After placement of CPNBs, a bolus of local anesthetic, either 0.2% ropivacaine (for femoral, interscalene, infraclavicular CPNBs) or 0.1% to 0.15% ropivacaine (for sciatic CPNB), was administered before the start of the surgical procedure. The bolus volume was up to 1 mL/kg for the femoral CPNB (maximum volume of 40 mL) and 0.5 mL/kg (with a maximum of 20 mL) for the sciatic, interscalene, and infraclavicular CPNBs. A lower concentration of local anesthetic was used for the sciatic CPNB to reduce the incidence of motor block.

Table 1

Table 1

After the patients arrived at the postanesthesia care unit (PACU), morphine (0.025–0.05 mg/kg) boluses were administered if the patient’s pain rating was >3 on the numeric pain scale of 0 to 10. A continuous infusion of either bupivacaine or ropivacaine was initiated through the catheter using the Elastomeric ON-Q® pump (I-Flow Corporation, VQ OrthoCare, Irvine, CA) in the PACU. Since August 2006, ropivacaine has been used as the local anesthetic of choice for CPNB infusions because of its lower incidence of causing a motor block and a better safety profile in case of inadvertent injection of a large dose of local anesthetic. The choice of local anesthetic and its concentration was based on the proximity of the catheter tip to the nerve as assessed by the stimulation threshold or the ultrasound appearance of local anesthetic spread with the bolus injection. The lower concentration local anesthetics (ropivacaine 0.1% and 0.13%) were used with sciatic CPNB whereas the higher concentration local anesthetics (ropivacaine 0.2% and bupivacaine 0.125%) were used for femoral, infraclavicular, and interscalene CPNBs. The infusion rate was based on the location of the catheter and the patient’s weight. The elastomeric On-Q pump has a rate selection of 2 to 14 mL/h, with a reservoir size of 400 mL. The pumps are single use and were filled by the hospital pharmacy.

All patients had an initial evaluation in the PACU by a physician or nurse practitioner from the pain service. All patients (and their family members) received verbal and written instructions about the continuous infusion device system, techniques to remove the catheter, and recognition of potential complications before being discharged home (Appendix). Patients and families were also cautioned to avoid weight bearing on the extremities that were weak and to protect insensate areas from injury (e.g., from heat, cold, pressure, and other trauma). Instructions included clamping the catheter if there were signs of local anesthetic toxicity or excessive leakage. The patient’s family member(s) removed the peripheral nerve catheters at home. Contact information to reach the pain service was provided, and the family member(s) were instructed and encouraged to call the service if any questions arose regarding the CPNBs or postoperative pain control.

Nurse practitioners or physicians on the pain management service followed all patients with daily or twice a day phone calls until resolution of the sensory block or possible side effects. Parents were asked to record the duration of the sensory block and intake of oral opioids during the follow-up period and report these data to the interviewer. Data collected included supplemental IV or oral analgesics use, presence of nausea/vomiting or complications related to the CPNBs that included leakage around the catheter, dislodgement of the catheter, infection, local anesthetic toxicity, persistent paresthesia, or other signs of peripheral nerve injury. The data were entered on a peripheral nerve block datasheet and then transferred to the secure departmental regional anesthesia database. A CPNB was considered to be a failure if there was no sensory loss in the distribution of the nerve or if the CPNB could not be maintained for 24 hours after placement.

Descriptive statistics were used to assess the distribution of demographic characteristics among the patients. Mean and standard deviation were used for continuous variables whereas median and quartiles were used for ordinal variables. Kaplan-Meier survival analysis was obtained using SPSS statistical software (Version 20, IBM corporation, Chicago, IL), to describe the time to opioid medication use. Confidence intervals (CIs) were calculated using Stata statistical software (Version 10, StataCorp LP, College Station, TX). The Clopper-Pearson method was used to calculate the CIs.

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RESULTS

A total of 1954 peripheral nerve catheters in 1700 subjects aged 14.2 ± 3.1 years were placed successfully (Fig. 1). The mean duration of the CPNB in all patients was 51.7 ± 12.3 (range: 0–168) hours. Catheters were placed with the child sedated in 16 (0.9%) subjects and after the induction of anesthesia in 1684 (98.9%) children including interscalene catheters in 171 subjects. Of all catheters that were placed, 1393 were placed with USG and NS guidance, 193 were placed with only USG, and 368 were placed with only NS guidance. In 202 patients, radiographs were used to confirm the location of the catheter tip. In 156 of the 171 interscalene catheters a contrast (Omnipaque 180) study was done to verify position of the catheter tip before local anesthetic injection.

Figure 1

Figure 1

Based on the type of surgical procedure, we assessed the number of patients in whom a CPNB catheter was placed compared with those receiving only a single-injection nerve block. For an arthroscopic anterior cruciate ligament (ACL) repair, a femoral CPNB was placed in 493 patients (77%) versus a femoral single-injection block placed in 147 patients; for shoulder arthroscopy with rotator cuff repair, an interscalene CPNB was placed in 150 patients (54%) versus a single-injection interscalene block placed in 130 patients; for a calcaneal osteotomy with tendon transfer, a sciatic CPNB was placed in 131 patients (85%) versus a single-injection sciatic block in 23 patients; for a knee arthroscopy with meniscal repair, a femoral CPNB was placed in 61 patients (28%) versus a single-injection block placed in 155 patients. In 556 patients, morphine or fentanyl was administered intraoperatively by the attending anesthesiologist to aid with tracheal intubation or after intraoperative analgesia was determined to be inadequate.

In the 1285 patients discharged home with a CPNB catheter, 1492 peripheral nerve catheters were placed. The mean age of the patients who were discharged with CPNBs was 14. 4 ± 2.8 (range: 3–20) years, and the mean duration of the ambulatory CPNB was 50.7 ± 14.4 (range: 0–168 hours) (Fig. 1). We used both stimulating catheters (n = 1276) and nonstimulating catheters (n = 216) catheters. The overall failure rate among these catheters was 1.9%. Table 1 shows the success rate by the type of block placed. Among the patients discharged home with a CPNB catheter, 207 patients had 2 CPNB catheters placed for postoperative pain control. Of these 207 patients, 184 were undergoing an arthroscopic knee ligament (ACL, medial cruciate ligament, or posterior cruciate ligament) reconstruction using the patient’s ipsilateral hamstring tendon as an autograft (Table 2).

Table 2

Table 2

During the last 5 years, the percentage of patients discharged home with a CPNB has increased to approximately 80% (Fig. 2). A majority of the patients (1360 of 1492 [91.2%]) were discharged home within 24 hours with 531 (35.6%) on the day of surgery (DOS) and 829 (55.6%) on the first postoperative day. Significantly more subjects with interscalene catheters were discharged home on DOS compared with those with femoral nerve catheters (94 of 147 [63.9%] vs 283 of 802 [35.3%], P < 0.001, for interscalene versus femoral catheters, respectively) (Table 1).

Figure 2

Figure 2

We used either ropivacaine or bupivacaine as our local anesthetic infusion in the CPNB: 0.1% bupivacaine (n = 15), 0.125% bupivacaine (n = 100), 0.1% ropivacaine (n = 278), 0.13% ropivacaine (n = 128), 0.15% ropivacaine (n = 509), and 0.2% ropivacaine (n = 462) solutions (Table 1).

We were unable to contact 15 patients with ambulatory CPNBs in the immediate postoperative period (first 3 days). All these patients were seen in the surgical office for postoperative assessment and did not report any CPNB-related problems. Data on oral opioid use among the patients with ambulatory CPNBs after discharge were available for 1266 of the 1285 patients. One hundred sixty patients (12.6%) did not use any opioids after surgery. Eight hundred nine patients (63.9%) used oral opioids as needed, 194 patients (15.3%) used oral opioids every 4 hours around the clock, and 103 patients (8.1%) used opioids initially as needed followed by around the clock opioids. Of the patients for whom we had data on time for starting opioid medications, 74.8%, 32.5%, and 25.9% did not use any opioid medications in the first 8, 24, and 48 hours, respectively, after surgery (Fig. 3). The median time to first opioid use was 16 hours (CI, 15–16.9 hours) (Fig. 3).

Figure 3

Figure 3

Sixty-four patients had complications related to the CPNB (Table 3). We had 1 complication related to CPNB placement (mean = 0.08%; CI, 0.02%–0.43%). This was a vascular injury to a small vein during placement of an infraclavicular CPNB. This injury was observed during needle placement under USG. The needle was withdrawn, and pressure was held at the site of injury. No hematoma was observed on follow-up ultrasound examination, and the practitioner was able to place an infraclavicular CPNB. No complications were noted in the follow-up period for this patient. Three patients had catheter site problems; 1 had pain at the site, 1 developed a rash under his dressing, and 1 developed a superficial infection, which was treated with oral antibiotics. Two patients with interscalene CPNBs developed Horner syndrome, which resolved with clamping the catheters and the catheters were removed. One patient developed numbness on the nonoperative shoulder after being discharged home with an interscalene CPNB infusing 0.2% ropivacaine at 8 mL/h which resolved with clamping the catheter, the catheters and the CPNB was removed. This patient had no complications with a 20-mL bolus of 0.2% ropivacaine after catheter placement with USG and NS guidance. Two patients had difficulty removing their CPNB catheters at home for which they had to return to the hospital, where a member of the pain management team was able to uneventfully remove the catheter with continuous traction. One of these catheters was a lumbar plexus CPNB catheter, and the other one was an infraclavicular CPNB catheter. Four CPNB catheters were ineffective in the postoperative period. Two of these CPNBs were found to be improperly positioned with fluoroscopy. One of these was replaced in the operating room. An additional 10 patients needed at least 1 bolus of local anesthetic via the catheter in the PACU or on the floor postoperatively due to an inadequate sensory block. Two patients returned to the hospital after being discharged home with their CPNBs secondary to worsening pain, which was not controlled with oral pain medications. In one patient, the CPNB was leaking heavily and had to be removed, and in the other patient, a bolus of ropivacaine 0.2% was unable to establish a sensory block and the catheter was removed.

Table 3

Table 3

Three patients reported early signs of local anesthetic toxicity such as ringing in the ears or metallic taste in the mouth. In all 3 of these patients, the CPNB catheter was clamped immediately and removed with resolution of the symptoms. One patient was a 17-year-old who weighed 51.8 kg and had an interscalene catheter which was bolused with 30 mL of 0.1% ropivacaine followed by an infusion 0.1% ropivacaine at 6 mL/h (0.12 mg/kg/h) for 12 hours at the time of the complaint of metallic taste in the mouth which resolved with clamping the catheter and so it was removed. The other 2 patients had 2 CPNB catheter infusions (a femoral and a sciatic CPNB). The first one was a 15-year-old who weighed 88.2 kg and had a sciatic catheter bolused with 20 mL of 0.1% ropivacaine and infusing 0.1% ropivacaine at 6 mL/h and the femoral catheter bloused with 20 mL of 0.2% ropivacaine and infusing 0.2% ropivacaine at 8 mL/h (total infusion dose = 0.25 mg/kg/h), and the second was in a 13-year-old who weighed 63.2 kg and had a sciatic catheter bolused with 0.15% ropivacaine and infusing 0.13% ropivacaine at 4 mL/h and a femoral catheter bloused with 20 mL of 0.2% ropivacaine and infusing 0.2% ropivacaine at 8 mL/h (total infusion dose = 0.35 mg/kg/h). They both reported a metallic taste in the mouth at 24 hours after the start of the infusion, which resolved with clamping of the catheter. Their CPNB catheters were removed.

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DISCUSSION

The above data suggest that it is feasible to implement an ambulatory CPNB program in a pediatric hospital with a dedicated team performing the CPNBs and follow-up of these patients. The failure rate of the CPNB in this population was 1.9%. There was no instance of a permanent neurological injury. Most of the complications reported were minor and did not require further intervention. Of the 1285 patients discharged home with a CPNB catheter, 1283 patients were able to stay comfortable at home with oral opioid medications after major orthopedic surgery.

In a previous report, we have described 108 patients who were discharged home with their CPNB catheters.2 This program has continued to evolve over the past 5 years with an increasing percentage of our patients going home with their CPNB catheters.8 All patients received detailed verbal and written instructions regarding management of their CPNB catheters. The practice has continued to evolve to improve postoperative analgesia, such as applying Dermabond to decrease the incidence of catheter leakage, changing from a popliteal sciatic block to a subgluteal sciatic block for better postoperative analgesia after an ACL repair with hamstring autograft, and modifying our techniques by adding USG for all of our CPNB placements.11 One patient developed a contralateral numbness after having an interscalene CPNB for 17 hours. The position of the interscalene CPNB had been confirmed after placement with USG and the bolus injection had been visualized in the ipsilateral interscalene groove. We do not have any radiographic confirmation of the interscalene CPNB at the time of the complaint, so we cannot comment on the possibility that the catheter migrated or the local anesthetic spread along a fascial defect to the opposite side.12

In a report from the Pediatric Regional Anesthesia Network (PRAN) registry, the authors described 560 CPNB catheters that were placed at 8 pediatric institutions.13 Because the primary purpose of the PRAN registry is to assess regional anesthesia practice, risks, and complications, the authors were not able to distinguish between inpatient and outpatient CPNB catheters. They did report that they had 10 vascular punctures and 7 patients with excessive unplanned motor block. We found 1 report of vascular puncture in our review. We did have a considerable number of patients who developed a motor block but this always resolved with clamping the catheter for a few hours. The PRAN group also reported superficial infections in 3 patients, which resolved with oral antibiotics. One of the patients who had a femoral CPNB on an outpatient basis reported a superficial infection. It resolved after a course of oral antibiotics. The failure rate for placement of a lower extremity CPNB in our report is similar to that seen in the PRAN report. The PRAN group noted a higher failure rate with the upper extremity catheters (2 of 26). We did not see a higher failure rate in the placement of our upper extremity CPNB. Also, the initial PRAN report does not have follow-up data on the use of opioids after discharge and duration of the CPNB infusion, because this was not the primary focus of the PRAN group.

Other reports have described single institution pediatric CPNB programs, their implementation and postoperative quality of analgesia, and CPNB-related complications.7,14,15 In one of the reports the authors reported that 60% of their patients needed an opioid within the first 8 hours, of which 40% were given in the recovery room.14 A similar incidence of patients needing opioid analgesia in the first 8 hours was noted in this audit, which increased to about 74% by 48 hours with about 26% of the patients not requiring any opioid analgesics. This frequent use of opioids could have been due to our preference for a lower concentration and infusion rate of local anesthetic to avoid motor block and to stay well within the recommended 0.4 mg/kg/h maximum infusion rate recommended for ropivacaine. Another reason could be that multiple nerves need to be anesthetized (e.g., saphenous nerve for below knee procedures in addition to sciatic nerve block) to provide complete sensory block after certain procedures. In such cases, we elected to place a catheter for the most involved nerve and a single injection for the secondary nerve supplying the region. This would lead to increasing pain when the single-injection nerve block wore off (in 10–16 hours) and an increased use of opioid analgesics after this time point.

One of the limitations of our study is that it is a retrospective report of prospectively collected data on patients with CPNBs. Thus the information provided was collected by a heterogeneous group of practitioners and the patient or family member report, which may have led to variability in reporting. Data were collected from the patient on presence of numbness and the frequency of pain medication use to assess the efficacy of the CPNBs. This may not have been as accurate as data collected using sensory and motor testing. All patients before being discharged home had their pain controlled with the CPNBs and supplemental oral medications when needed. Almost all of these patients were able to stay comfortable with supplemental oral medications at home for the entire postoperative period. Another limitation is that there is no comparison of the benefits of the CPNB to an opioid-only regimen at home. In our prior experience, patients undergoing these surgical procedures were unable to be discharged home on the DOS or postoperative day 1 secondary to a need for supplemental IV medications to control their pain. Fifteen patients could not be contacted in the immediate postoperative period. However, the surgical offices confirmed that the CPNB had been discontinued without any side effects. This highlights the difficulty of ensuring adequate follow-up in patients after they are discharged home.

In conclusion, this study demonstrates that an outpatient CPNB program for pediatric patients is feasible with a dedicated team of practitioners for placement and follow-up. Such a program would allow pediatric practitioners to extend the benefits of CPNBs to an at-home setting and allow patients to return home sooner after major orthopedic surgery.

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APPENDIX: INSTRUCTION SHEET FOR THE FAMILY FOR HOME MANAGEMENT OF PERIPHERAL NERVE CATHETERS

Figure

Figure

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DISCLOSURES

Name: Harshad Gurnaney, MBBS, MPH.

Contribution: This author helped design and conduct the study, analyze the data, and write the manuscript.

Attestation: Harshad Gurnaney has seen the original study data, reviewed the analysis of the data, approved the final manuscript, and is the author responsible for archiving the study files.

Name: F. Wickham Kraemer, MD.

Contribution: This author helped design and conduct the study.

Attestation: F. Wickham Kraemer has seen the original study data and approved the final manuscript.

Name: Lynne Maxwell, MD.

Contribution: This author helped design and conduct the study.

Attestation: Lynne Maxwell approved the final manuscript.

Name: Wallis T. Muhly, MD.

Contribution: This author helped design and conduct the study.

Attestation: Wallis T. Muhly has seen the original study data, reviewed the analysis of the data, and approved the final manuscript.

Name: Laura Schleelein, MD.

Contribution: This author helped design and conduct the study.

Attestation: Laura Schleelein approved the final manuscript.

Name: Arjunan Ganesh, MBBS.

Contribution: This author helped design and conduct the study, analyze the data, and write the manuscript.

Attestation: Arjunan Ganesh has seen the original study data, reviewed the analysis of the data, approved the final manuscript, and is the author responsible for archiving the study files.

This manuscript was handled by: Peter J. Davis, MD.

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ACKNOWLEDGMENTS

We would like to acknowledge Mehernoor Watcha, MD, at Texas Children’s Hospital for his help in the preparation of the manuscript; Ari Weintraub, MD, Devika Singh, MD, and Jeffrey Feldman, MD who are members of our regional anesthesia team; the Nurse Practitioners on the Pain Management team: Theresa J. Di Maggio, MSN, CRNP, Kim Garay, MSN, CRNP, Linda B. Hurd, MSN, CRNP, Carrie P. Malavolta, MSN, CRNP, and Maureen Scollon-McCarthy, CRNP; and our research assistants: Therese Idell and Esther Wang.

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REFERENCES

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