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REGIONAL ANESTHESIA: Edited by Jacques E. Chelly

Paediatric regional anaesthesia

a current perspective

Visoiu, Mihaela

Author Information
Current Opinion in Anaesthesiology: October 2015 - Volume 28 - Issue 5 - p 577-582
doi: 10.1097/ACO.0000000000000238
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Abstract

INTRODUCTION

Children often fail to attain adequate pain control following surgery. Among hospitalized paediatric patients, the prevalence of moderate to severe postoperative pain that extends well into the postoperative period remains high [1–3]. To provide paediatric patients with a level of analgesia that meets their needs, a multimodal therapy that includes regional anaesthesia should be administered, as it offers a superior therapeutic regimen than the standard of care [4–7].

Regional anaesthesia comprises both central and peripheral techniques. Caudal block single injections are very often performed. Suresh et al.[8▪▪] looked at the outcome of 18 650 paediatric single-injection caudal blocks and did not find any temporary or permanent sequelae. Although neuraxial blocks produce excellent pain control and are commonly used for paediatric pain relief after a variety of surgical procedures, they carry a risk of serious complications such as paraplegia that can be more prevalent than is often realized [9]. By contrast, peripheral nerve blocks (PNBs) – which have become more prevalent with the increasing popularity of ultrasound – produce effective pain relief and have a low risk of morbidity [10,11▪▪,12]. Trunk blocks such as paravertebral, transversus abdominis plane (TAP), rectus sheath and ilioinguinal/iliohypogastric are becoming a preferred method of analgesia for thoracic and abdominal procedures and should be used instead of central nerve blocks (CNBs) whenever possible [13–15]. In addition, there is some evidence suggesting that femoral single-injection PNBs, in acute trauma settings, provide longer lasting analgesia with fewer adverse events than intravenous opioids [16]. Hence, although certain types of PNBs have been shown to improve analgesia in paediatric populations, more studies are needed to determine the efficacy and safety of the various types of PNBs available so as to optimize pain control for children in the postoperative period.

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Box 1:
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SPECIAL CONSIDERATIONS

There are many factors that need to be accounted for when performing PNBs in the paediatric population. These considerations are as follows:

  1. The pain assessment in paediatric patients is difficult. Among the several types of paediatric pain measurements, self-reported scales are considered the gold standard of pain assessment in older children. The pain scores should be judged in conjunction with other factors such as vital signs, pain behaviour as reported by caregivers, anticipated severity of pain and analgesics consumption, as well as psychosocial factors such as anxiety, catastrophizing thoughts to pain and mood level.
  2. The placement of all types of regional anaesthetic techniques under deep sedation or general anaesthesia is considered the standard of care in the paediatric population [17▪]. It is difficult, however, to find clear evidence showing that paediatric interscalene nerve blocks can be done safely under general anaesthesia. Even though a review of 518 interscalene nerve blocks (390 of which were performed under general anaesthesia) showed no serious adverse events and concluded that the placement of interscalene blocks in anaesthetized children is no more dangerous than placing these blocks in awake adults [18▪], these data should be interpreted with caution, as the number of catheters were limited (46) and 88.4% of patients were 10 years of age or older.
  3. Given the diminutive structures of paediatric patients and the close proximity of many vital structures, the use of ultrasound is recommended. The ability to visualize pleura, bone structures, relevant musculature and fascial layers with ultrasound offers many advantages over the conventional landmark-based fascial ‘pops’ technique that is more subjective [13,14]. Ultrasound improves the accuracy, efficacy and safety of regional anaesthesia and also decreases the amount of local anaesthetic injected [19▪▪].
  4. The local anaesthetic dosage should be based on the patient's age, weight, surgical procedure and desired duration of analgesia. More research is needed to determine the upper dose limit of local anaesthetic for CNBs and PNBs [20–22].
  5. Laparoscopic surgical techniques are minimally invasive but can be associated with unexpectedly high levels of postoperative pain [2,23]. The visceral and gas pain can be as severe as the incisional pain, and the incidence of shoulder pain can be as high as 78% [24▪]. To counter the pain following laparoscopic surgeries, a multimodal approach that includes PNBs and/or incisional local administration at the surgical instrument site could form the crux of an effective analgesic regimen. For example, a PNB containing a combination of local anaesthetic and adjunct can supply patients experiencing pain extending well into the postoperative period with adequate and long-lasting analgesia. Under such circumstances, a PNB catheter may be used instead, but many surgical laparoscopic procedures discourage the use of catheters.

ADJUNCTS FOR PERIPHERAL NERVE BLOCKS

To overcome the challenge of developing a blocking agent that has both minimal side-effects and a duration long enough to outlast the pain, additional substances (e.g. epinephrine, clonidine, dexamethasone, tramadol, buprenorphine, midazolam, dexmedetomidine and ketamine) have been added to the local anaesthetics comprising the nerve blocks [25,26▪▪,27]. Among the adjuvants, clonidine – an alpha 2 adrenoreceptor agonist – has been shown to prolong the duration of analgesia when administered in the epidural space in children [28▪▪]. By contrast, the data regarding perineurally administered clonidine are conflicting. Few small and under-powered paediatric studies showed at best a weak trend in favour of clonidine [29,30]. Side-effects reported after neuraxially or peripherally administered clonidine in conjunction with local anaesthetic are hypotension, sedation, fainting and prolonged motor blockade [28▪▪]. Clonidine 1–2 μg/kg is suggested for use with local anaesthetic for single-injection PNBs [28▪▪].

INTRAVENOUS ADJUNCT

On the basis of their success in adults, additional adjuncts may hold promise for paediatric patients. In an adult prospective study, the effectiveness of intravenous dexamethasone (8 mg) in prolonging the duration of analgesia seems to be similar to perineural dexamethasone [26▪▪]. A meta-analysis performed by Le Bot et al.[31] showed that intraoperative dexmedetomidine in adult patients reduces intraoperative and postoperative opioids consumption and postoperative nausea and emesis.

SPECIFIC PERIPHERAL NERVE BLOCKS TECHNIQUES

Paravertebral nerve blocks

The paravertebral blocks (PVBs) are ideal for surgeries of the thorax and abdomen and offer an alternative to epidural blocks in paediatric patients [15]. There are many controversies about the number of injections and the volume of local anaesthetic that needs to be administered to achieve adequate analgesia with these types of blocks. Albokrinov and Fesenko [32] suggest that when the injections are performed in an infant cadaver at the T12-L1 paravertebral level, a single injection of 0.2–0.3 ml/kg can cover five to six dermatomes of the lower abdomen.

Boretsky et al.[14] found that a lateral in-plane technique is the most reliable technique for continuous needle visualization in a series of infants and children as young as 6 months and as small as 6 kg. The anterior displacement of the pleura was used as a surrogate for inserting the needle in the correct position, but the dermatomal assessment was not done [14].

In comparing bilateral PVB with the incisional administration of local anaesthetic at the surgical instrument sites in 83 paediatric patients undergoing laparoscopic cholecystectomy, Visoiu et al.[24▪] did not find that PVB provided patients with any postoperative analgesic benefits compared with port infiltration. In particular, total postoperative analgesic consumption and mean visual analogue scale scores were no different between the groups [24▪]. All blocks were placed using a loss-of-resistance technique in anaesthetized patients. Because the study was double-blinded, a dermatomal assessment was not performed, and one concern about this study was the absence of confirmation of a successful block. Although the lack of analgesic efficacy might be explained by a high failure rate of the PVBs [33,34], all blocks were performed by an experienced paediatric regional physician and other results from the study suggest that the PVBs were adequate. Indeed, the intraoperative fentanyl requirement (ng/kg/min) was lower in the PVB group than the port infiltration group (12.81 vs. 16.57, P = 0.007), and 19 patients in the PVB group did not receive additional fentanyl compared with only five in the incisional group (new published data). Furthermore, there is discrepancy between the radiologic PVB distribution of contrast and the dermatomal loss of sensation [35], and paresthesia correlates poorly with reported pain scores. In this study, shoulder pain was a confounding factor and the results should be carefully interpreted. Paediatric patients undergoing laparoscopic cholecystectomy may benefit from local anaesthetic port infiltration that is less invasive and easily administered. The pain medication consumption and postoperative pain scores should be complemented by knowledge of individuals’ catastrophizing thoughts about pain, anxiety, depression and mood level. We should also focus our research to compare the failure rate and safety of ultrasound-guided technique with landmarks techniques.

Pain after the Nuss procedure is particularly severe, and adequate pain control to prevent respiratory complications and favour early ambulation is essential for these patients. Thoracic epidural catheters are effective for pain control, but their safety has recently been called into question after three patients suffered neurologic deficits associated with these catheters [9,15]. Even though no mechanism was elucidated, and the children may have been more susceptible to surgical-induced changes, it remains essential to find a pain control method that optimizes analgesia without compromising patient safety. For the Nuss procedure, single-injection PVBs may achieve this critical goal. Indeed, in a trial by Qi et al.[36], children who received single injection PVBs for the Nuss procedure showed decreased pain scores and opioid consumption as well as fewer behavioural disturbances than patients who did not receive regional anaesthesia. Furthermore, in a small retrospective series (20 patients), Hall Burton and Boretsky [15] showed that PVB catheters provided equivalent analgesia to thoracic epidural catheters. In summary, these studies suggest that paravertebral analgesia may be an effective regional anaesthesia technique for patients scheduled for Nuss procedure [37], but more prospective studies are needed to elucidate their efficacy, effectiveness, failure rate, safety and side-effects.

Transversus abdominis plane blocks

TAP blocks are increasingly being used to provide analgesia after paediatric surgeries involving the abdominal wall. Compared with postoperative administration, preoperative TAP block administration for analgesia after laparoscopic surgeries resulted in greater effects on early pain and opioid consumption [38▪]. Meta-regression analysis revealed an association between local anaesthetic dose and the TAP block's effect on late pain at rest and postoperative opioid consumption [38▪]. In another study, despite not improving early pain scores, higher local anaesthetic doses (2.5 mg/kg) for the TAP block in 36 children seemed to prolong analgesic duration and decrease the need for additional analgesics over 24 h after surgery [21].

The extent of analgesia that the TAP procedure provides depends upon the site of injection and the pattern of spread of local anaesthetic. Currently, there are several TAP approaches in use, and the spread of local anaesthetic between muscular layers varies from one approach to another. Compared with other approaches, a posterior ultrasound TAP approach and injection under the anterior border of quadratus lumborum muscle results in a posterior spread of local anaesthetic with a longer duration of analgesia [39–41]. Therefore, TAP blocks should be performed as posterior as possible.

In 45 children (1–9 years old) who underwent bilateral ureteral reimplantation, TAP blocks provided superior analgesia compared with the caudal block at 6–24 h after block placement. However, the TAP blocks appeared to be less effective than the caudal block in preventing viscerally mediated bladder spasms [42▪▪].

Long et al.[11▪▪] showed that overall complications associated with TAP blocks performed in 1994 children are very low (0.3%) (one vascular aspiration of blood before local anaesthetic injection and one peritoneal puncture). However, it is still unclear which type of surgical patients will benefit from TAP blocks. To determine TAP blocks’ effectiveness, the dermatomal assessment should be correlated with analgesic consumption. Unfortunately, quantifying and assessing pain and paresthesia in children presents challenges of validity. In addition, because both local and systemic effects of local anaesthetics may contribute to the analgesic response, the role of local anaesthetic absorbed during TAP blocks should be determined.

Rectus sheath blocks

The rectus sheath blocks are effective for midline abdominal incisions. Ultrasound use improves successful placement of local anaesthesia. This block can be the regional anaesthesia technique of choice for procedures such us umbilical hernia, laparoscopic appendectomy [43], single port laparoscopic appendectomy and cholecystectomy.

Ilioinguinal/Iliohypogastric nerve blocks

Ilioinguinal/iliohypogastric nerve blocks provide ipsilateral analgesia in the inguinal area. A relatively high failure rate has been reported with a conventional ‘pop’ technique.Thus, these blocks should always be administered using ultrasound.

Lumbar plexus nerve blocks

Currently, there is no established real-time, ultrasound-guided lumbar plexus nerve block technique, and all blocks are performed using a neurostimulator technique. Prepuncture ultrasound can be used to estimate the depth of the transverse process and the needle insertion site. Given age-related differences in musculoskeletal structures in paediatric populations, future studies can be considered to determine the efficacy of ultrasound technique described by Karmakar et al. [44▪▪].

AMBULATORY CONTINUOUS PERIPHERAL NERVE BLOCKS

Many paediatric patients who undergo orthopaedic surgeries experience moderate to severe pain after discharge home. It is feasible to discharge paediatric patients home with continuous PNBs (CPNBs) (brachial plexus, axillary, femoral, sciatic, femoral, lumbar plexus, lumbar paravertebral) as long as a dedicated interventional pain programme providing adequate education and follow-up is available [45▪,46,47▪]. Supporting this notion, Visoiu et al.[47▪] reported that 76.7% of 403 children (aged 5–22 years) discharged home on the day of surgery with ambulatory CPNBs reported a median home overall pain satisfaction score of 10/10. Among the studies examining paediatric ambulatory CPNBs, the failure rate of the ambulatory CPNBs ranged from 6.9 to 15% [47▪], which is low on a percentage basis but still represents an unacceptable outcome for many patients and the surgical team. The methodology used to report paediatric CPNB related complications varied from study to study. Although catheter leakage occurred frequently in some of the studies, the catheters continued to provide adequate pain control under these circumstances.

Ambulatory CPNBs provide adequate analgesia, but compared with adult populations, there is an increased need for oral opioids in this paediatric population. The effectiveness and safety should be determined by multicentre, prospective, controlled, blinded studies.

CONCLUSION

Millions of paediatric patients suffer from significant postoperative pain. Every hour of effective analgesia counts, as it improves quality of care and reduces healthcare costs. By using a multimodal approach that includes regional anaesthesia, paediatric pain management should aim to reduce patients’ pain to an acceptable pain level without compromising their degree of mobilization. Undoubtedly, PNBs improve analgesia, but future large prospective studies should be conducted to further delineate their effectiveness, duration and safety. If a patient is not a candidate for regional anaesthesia, local infiltration analgesia should be considered to reduce side-effects from opioid use. Every effort should be made to develop a blocking agent that has minimal side-effects and a duration long enough to outlast postoperative pain. Future research should explore the efficacy and safety of intravenously administered dexamethasone and dexmedetomidine, as these have been successful in adult populations. Nonpharmacologic therapy such as comfort and distraction should be considered whenever possible. Finally, optimal therapeutic regimens for our patients should consider psychosocial factors such as catastrophizing attention to pain, anxiety, depression and mood level.

Acknowledgements

None.

Financial support and sponsorship

None.

Conflicts of interest

There are no conflicts of interest.

REFERENCES AND RECOMMENDED READING

Papers of particular interest, published within the annual period of review, have been highlighted as:

  • ▪ of special interest
  • ▪▪ of outstanding interest

REFERENCES

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This study provides the first evidence that it is well tolerated to perform regional anaesthesia under general anaesthesia in children.

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This study compared the placement of interscalene blocks in awake/sedated and anaesthetized children.

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This is the first study to describe the distinct colour flow Doppler pattern for paediatric epidural and intrathecal injection.

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This is the first paediatric, double-blinded, prospective study that compared paravertebral single injection blocks with incisional local anaesthetic administration.

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This study supports the use of intravenous dexamethasone over perineural dexamethasone.

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A thorough review of current adjuncts in paediatric regional anaesthesia.

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This study improves the current knowledge on local anaesthetic dosage for the TAP block in paediatric patients.

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The authors described a new ultrasound lumbar plexus technique.

45▪. Gurnaney H, Kraemer FW, Maxwell L, et al. Ambulatory continuous peripheral nerve blocks in children and adolescents: a longitudinal 8-year single center study. Anesth Analg 2014; 118:621–627.

The longest and largest collected data for ambulatory continuous nerve blocks.

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47▪. Visoiu M, Joy LN, Grudziak JS, Chelly JE. The effectiveness of ambulatory continuous peripheral nerve blocks for postoperative pain management in children and adolescents. Paediatr Anaesth 2014; 24:1141–1148.

The first study to assess the satisfaction with pain control for ambulatory continuous PNBs in children.

Keywords:

adjuncts; children; local anaesthetic; peripheral nerve blocks; regional anaesthesia; ultrasound

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