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© 2001 International Anesthesia Research Society
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Abstract |
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We sought to determine the plasma concentrations of bupivacaine and its main metabolite after continuous fascia iliaca compartment (FIC) block in children. Twenty children (9.9 ± 4 yr, 38 ± 19 kg) received a continuous FIC block for either postoperative analgesia (n = 16) or femoral shaft fracture (n = 4). A bolus dose of 0.25% bupivacaine (1.56 ± 0.3 mg/kg) with epinephrine was followed by a continuous administration of 0.1% bupivacaine (0.135 ± 0.03 mg · kg-1 · h-1) for 48 h. Plasma bupivacaine levels were determined at 24 h and 48 h by using gas liquid chromatography. Heart rate, arterial blood pressure, respiratory rate, side effects, and pain scores were recorded at 4-h intervals during 48 h. No significant differences were found between mean plasma bupivacaine levels at 24 h (0.71 ± 0.4 µg/mL) and at 48 h (0.84 ± 0.4 µg/mL) (P = 0.33). FIC block provided adequate analgesia in most cases. No severe adverse effects were noted. We conclude that the bupivacaine plasma concentrations during continuous FIC block in children are within the safety margins. FIC block is well tolerated, and provides satisfactory pain relief in most cases.
Implications: In this study, we have shown that, in children, continuous fascia iliaca compartment block, a technique providing neural blockade of the thigh and the anterior part of the knee, was associated with safe plasma bupivacaine concentrations, was well tolerated, and provided satisfactory pain scores in most cases.
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Introduction |
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Fascia iliaca compartment (FIC) block is a modification of the "3-in-1" femoral block described by Winnie et al. (1). By using a single bolus dose of a mixture of lidocaine and bupivacaine with epinephrine, FIC block provides effective analgesia for a mean of 5 h after surgery of the lower limb in children (2). This duration of analgesia is insufficient in most cases, leading to the need for other techniques that provide prolonged analgesia. Continuous peripheral block techniques can extend block duration and have been widely used in adults (3). Pediatric studies of continuous peripheral blockade are limited, but they show some promise (4–7).
Continuous FIC block represents an alternative to continuous femoral nerve block, and the addition of lateral cutaneous and obturator nerve blocks to the femoral nerve block (2) may be helpful for pain control in children sustaining pain in the thigh or the anterior and medial aspect of the knee. There is little safety data concerning the use of continuous FIC block in children. For a safe use of continuous regional technique, it is important to test whether the plasma bupivacaine levels are within the safety margins. We conducted the present study to determine the plasma concentrations of bupivacaine and its main metabolite after a 48-h continuous FIC block in children. We also evaluated pain scores, side effects, and physiologic variables to determine the effectiveness of this technique.
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Methods |
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The study was designed as an open-label study and was approved by the hospital ethical committee. After written informed consent had been obtained from their parents, children >1 yr and <16 yr of age were included. All patients were ASA grade I or II with pain in the thigh or knee (anterior or lateral aspect of the knee). Exclusion criteria included an infectious process at the site of puncture, a clinical and/or biological coagulopathy, allergy to bupivacaine, or a neurologic deficit of the limb.
For children undergoing a surgical procedure, the anesthesia technique was standardized: induction with propofol or sevoflurane, maintenance with sevoflurane or isoflurane in 50% N2O/O2, fentanyl, and atracurium for neuromuscular blockade. Continuous FIC block was performed at the end of the procedure. For the nonoperated trauma patients, FIC block was performed after local anesthesia of the skin while the child was breathing a mixture of nitrous oxide and oxygen (50%/50%). FIC block was performed by using the technique of Dalens et al. (2). An 18-gauge catheter, 55 mm in length was used for the puncture. The puncture point was 0.5–1 cm below the inguinal ligament, at the union of the lateral one-third and medial two-thirds of the line pubic tubercle-ASIS. The needle was introduced at a 45°–60° angle with the skin, until the perception of two losses of resistance corresponding to the crossing of the fascia lata and then the fascia iliaca. A bolus dose of 0.25% bupivacaine with epinephrine (1:200.000) was injected, using a protocol based on the children’s weight (8). Then, a 20-gauge catheter (Contiplex®, B. Braun, Melsungen, Germany) was introduced through the 55-mm cannula, and advanced in for 40 to 70 mm after the cannula extremity, depending on the child’s size. Plain 0.1% bupivacaine was then administered continuously at the rate of 0.5 mL/h per year of age.
Pain was assessed 60 min after FIC block, and then at 4-h intervals until the 48th hour. Pain was assessed at rest and during movement by using either the Children’s Hospital of Eastern Ontario pain scale (CHEOPS) for the children below 8 yr of age or a visual analog scale (VAS) (0–100 mm) for older children. The overall FIC block efficacy was evaluated by a nurse using a four-point scale (very good efficacy, good efficacy, moderate efficacy, or poor efficacy of the technique to provide pain relief). If analgesia was considered insufficient, defined as a VAS score >40 mm or CHEOPS score >7, supplemental analgesia was provided with the administration of a bolus dose of 0.1% bupivacaine (1/4 of volume of the initial bolus dose, maximum 2 boluses per day) and/or with IV propacetamol, the IV precursor of paracetamol, (30 mg/kg as a 20-min infusion) and/or nalbuphine (0.2 mg/kg). Side effects were noted in the protocol chart. Physiologic variables, heart rate, blood pressure, and respiratory rate, were monitored at 4-h intervals from the 4th h to the end of the study.
Plasma bupivacaine and 2,6-pipecolyxylidide (PPX) levels were measured at 24 h and 48 h by using a gas liquid chromatography method previously published (9). After one-step extraction, the extract was injected into a gas chromatograph fitted with a capillary column and nitrogen phosphorus detector under constant temperature. The detection limits were 15 ng/mL for the drug and its metabolite.
Analysis of variance for repeated measures was used to test whether there was any variation in physiologic variables with time, and a paired t-test was used to compare the bupivacaine plasma levels at the 24th and 48th h. P < 0.05 was considered significant.
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Results |
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Twenty children aged 9.9 ± 4.3 yr (2–15 yr) and weighing 38.1 ± 19 kg (13–75 kg) were studied. Sixteen continuous blocks were performed for postoperative analgesia after surgery of the thigh or knee. Four continuous blocks were performed for analgesia of nonoperated femoral shaft fractures ( Table 1). Sixteen children had the FIC block for the entire study period; in four children, FIC block was discontinued early. One patient had his catheter accidentally removed at the 12th h during a dressing change (Patient 1), one catheter was displaced at the 24th h (Patient 11), one patient was afraid of the catheter and asked for its removal at the 24th h (Patient 12), and one catheter was removed by the investigator because of failure to provide analgesia after the 4th h (Patient 13).
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The mean bupivacaine bolus dose was 1.56 mg/kg (1–2.3 mg/kg), corresponding to a volume of bupivacaine 0.25% with epinephrine at 0.62 mL/kg (0.41–0.91 mL/kg). The hourly bupivacaine dose administered by continuous infusion was 0.135 mg · kg-1 · h-1 (0.06–0.2 mg · kg-1 · h-1) corresponding to the hourly infusion rate of plain bupivacaine 0.1% at 0.135 mL · kg-1 · h-1 (0.06–0.2 mL · kg-1 · h-1). With this administration regimen, and including the bolus doses of bupivacaine for seven patients, the mean total dose of bupivacaine was 3.32 mg · kg-1 · d-1 (1.44–6.13 mg · kg-1 · d-1) for the first 24 h and 3.23 mg · kg-1 · d-1 (1.44–4 mg · kg-1 · d-1) for the second day of infusion. Bupivacaine and PPX plasma levels were determined twice for 16 patients. Two patients had no blood samplings (Patients 1 and 13), one patient had only one blood sampling at 24 h (Patient 12) because of the premature termination of the protocol, and in one patient who had blood samplings, the bupivacaine plasma levels could not be measured. Mean bupivacaine and PPX plasma levels were respectively 0.71 ± 0.4 and 0.16 ± 0.08 µg/mL at 24 h and 0.83 ± 0.4 and 0.21 ± 0.09 µg/mL at 48 h. No statistical significant difference was found between plasma concentrations at 24 h and 48 h (P = 0.33).
In 14 children (mean age 12.3 ± 2 yr), pain was assessed by using the VAS, whereas in six other children (mean age 4 ± 2 yr), pain was assessed by using CHEOPS. The time courses of mean VAS and CHEOPS scores at rest and during mobilization are represented in Table 2. By using the four-point scale, the nurse (unblinded observer) stated that effective analgesia (defined as very good or good efficacy of the technique to provide effective analgesia) was obtained for 70% to 90% of the patients from the first hour after FIC completion to the end of the study period. Details of additional doses of analgesics consumed by the patients during the study period are reported in Table 1. Among the 16 children who completed the entire 48-h study, 7 needed no further analgesic technique, and 9 needed a bupivacaine bolus dose or additional analgesics (1 dose for 2 children, 2 doses for 5 children, 3 doses for 1 child, and 4 doses for 1 child).
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No severe side effects were reported. Thirteen side effects were reported in 10 patients, not necessarily related to the FIC block. Three patients presented with nausea or vomiting, two had retention of urine requiring bladder catheterization (twice for one child), three patients presented with muscle weakness of the thigh, and two patients presented paresthesia of the thigh. These partial motor blockade and paresthesias were transient, well tolerated, and rapidly disappeared after discontinuation of the bupivacaine infusion.
Neither heart rate (P = 0.874), blood pressure (P = 0.358), nor respiratory rate (P = 0.147) were affected at any time from the 4th to the 48th h after FIC block was performed.
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Discussion |
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TopAbstractIntroductionMethodsResultsDiscussionReferences |
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In this study, we found that continuous FIC block is well tolerated in children. Bupivacaine plasma concentrations were determined twice at the 24th and the 48th hours to ensure that plasma bupivacaine levels had achieved a plateau (10). With the dose regimen used in our study, bupivacaine plasma levels were within the safety margin for this local anesthetic (10,11). Mean bupivacaine concentrations were between 0.71 and 0.84 µg/mL, whereas the group maximal concentration was 1.877 and 1.466 µg/mL at the 24th and 48th hours, respectively.
Experience with plasma bupivacaine level monitoring in pediatric patients during continuous femoral block is limited. Johnson (7) determined plasma bupivacaine concentrations in three children with femoral fracture receiving a continuous femoral nerve block via an infusion of 0.125% bupivacaine at the rate of 0.375 mg · kg-1 · h-1. Bupivacaine levels ranged between 0.67 and 0.93 µg/mL, approximating the levels we found in our study. However, direct comparison with our results is difficult because of the differences in infusion regimen and in the time of blood sampling for determining plasma bupivacaine levels (7). More data are available for bupivacaine concentrations during continuous epidural anesthesia. Desparmet et al. (10) showed that a continuous epidural infusion of 0.2 mg · kg-1 · h-1 bupivacaine in children provided plasma levels within a 0.2–1.2-µg/mL range. In another study (12), mean bupivacaine concentrations were 0.5 µg/mL (0.25–0.87 µg/mL) in children receiving a continuous epidural infusion of 0.31 mg · kg-1 · h-1 of bupivacaine.
Continuous FIC block was well tolerated in our study. The side effects we report are often encountered in the postoperative period. Surprisingly, two children had urinary retention, leading to bladder catheterization (twice for one child). The significance of this side effect is unknown and it had not been reported for a single shot FIC block (2). We have also shown that continuous FIC block was not associated with modification of physiologic variables and that pain scores were consistent with an adequate pain relief in most cases. This latter assumption needs to be validated in further studies with a control group of patients.
Femoral nerve blockade is effective in children with femoral shaft fracture (13). A single injection of 2 mg/kg of plain 0.5% bupivacaine provides prompt, effective analgesia allowing the children to be transported, and to have radiographic examination and traction under optimal conditions (13). As described by Winnie in 1973 (1), the "3-in-1" block is a modification of the femoral nerve block. With a single injection, it allows anesthesia of three nerves: the femoral, the lateral cutaneous, and the obturator nerves. In a prospective, randomized study comparing FIC block and 3-in-1 block in 120 children, FIC block provided adequate analgesia in 90% of cases, whereas 3-in-1 block provided adequate analgesia in 20% of patients (2). The small success rate of 3-in-1 block was attributed to inconstant sensory blockade of the lateral cutaneous, obturator, and femoral branch of the genitofemoral nerves after a 3-in-1 block (2,14).
Peripheral block duration can be extended by using continuous techniques, and thereby reduce the need to use continuous epidural anesthesia. Some theoretical advantages of peripheral nerve blockade are that it avoids bilateral motor block and other potential hazards of epidural blockade, such as dural puncture and subarachnoid injection (4,15). Furthermore, a large retrospective survey suggested that the incidence of complications was smaller after peripheral nerve blocks than after central blocks, leading the authors to encourage the use of peripheral nerve blocks in place of central blocks (16). Few studies have focused on continuous nerve block of the lower limb in children. Continuous femoral nerve blockade provides some degree of pain relief in children with a femur fracture (5–7). The use of a continuous FIC block extends the neural blockade to lateral cutaneous and obturator nerves in addition to femoral nerve blockade (2). This then allows for a good postoperative analgesia in the lateral aspect of the thigh and in the anterior and medial aspect of the knee, which is important after some surgical interventions.
We conclude that, in children sustaining a traumatic injury or surgery of the thigh or the knee, the plasma bupivacaine and metabolite concentrations associated with continuous FIC block are safe. Continuous FIC block was well tolerated and pain scores were compatible with an adequate pain relief in the majority of patients, suggesting that this is an effective analgesic technique. The efficacy of this analgesia technique needs to be confirmed by comparative studies with control groups.
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Acknowledgments |
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Supported, in part, by a grant from Assistance Publique, Hôpitaux de Marseille (AP-HM promoteur, 1997).
The authors thank Ms. Wanda Paredero, pain service nurse, and all the nurses and medical staff from the orthopedic ward (Pr G. Bollini) for their participation in the study. They also thank Bernard Dalens, MD, for expertise, and Marc Dubreuil, MD.
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References |
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TopAbstractIntroductionMethodsResultsDiscussionReferences |
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Winnie A, Ramamurthy S, Durrani Z. The inguinal paravascular technique for lumbar plexus anesthesia: the "3-in-1" block. Anesth Analg 1973; 52: 989–96.
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Dalens B, Vanneuville G, Tanguy A. Comparison of the fascia iliaca compartment block with 3-in-1 block in children. Anesth Analg 1989; 69: 705–13.
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Edwards N, Wright E. Continuous low-dose 3-in-1 nerve blockade for postoperative pain relief after total knee replacement. Anesth Analg 1992; 75: 265–7.
[Abstract/Free Full Text] - Berde C. Regional anesthesia in children: what have we learned? Anesth Analg 1996; 83: 897–900.[Web of Science][Medline]
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Rosenblatt R. Continuous femoral anesthesia for lower extremity surgery. Anesth Analg 1980; 59: 631–2.
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- Dalens B. Anesthésie locorégionale de la naissance à l’âge adulte. Paris: Editions Pradel, 1993: 535.
- Lorec A, Bruguerolle B, Attolini L, Roucoules X. Rapid simultaneous determination of lidocaine, bupivacaine, and their two main metabolites using capillary gas-liquid chromatography with nitrogen phosphorus detector. Ther Drug Monit 1994; 16: 592–5.[Web of Science][Medline]
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Berde C. Convulsions associated with pediatric regional anesthesia. Anesth Analg 1992; 75: 164–6.
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- Ronchi L, Rosenbaum D, Athouel A, et al. Femoral nerve blockade in children using bupivacaine. Anesthesiology 1989; 70: 622–4.[Web of Science][Medline]
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