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Anesth Analg 2003;97:687-690 © 2003 International Anesthesia Research Society
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Abstract |
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Continuous peripheral nerve blocks (CPNB) after pediatric major orthopedic surgery are not widely used. We conducted a prospective descriptive study to evaluate the effectiveness of disposable elastomeric pumps for CPNB in children. After inducing general anesthesia, 25 consecutive children scheduled for major orthopedic surgery received a 0.5-mL/kg bolus of a mixture of 1% lidocaine with epinephrine and 0.25% bupivacaine in axillary, femoral, or popliteal catheters. After surgery, disposable pumps with 0.2% ropivacaine were connected. Pump flows were adjusted to the patient’s weight. Postoperative pain was evaluated using a visual analog scale or Children and Infants Postoperative Pain Scale scores at H1, H6, H12, H24, and H48, as well as amounts of rescue analgesia, adverse events, and motor and sensory block. An ambulation score for the children was also evaluated. Eleven popliteal, nine femoral, and five axillary continuous blocks were performed. All the blocks were effective for surgery. The mean total dose consumption of 0.2% ropivacaine was 10.1 mg/kg. Disposable pump flow varied from -9.61% to +8.6% compared with the theoretical one. Postoperative analgesia was excellent. The median of pain score was zero at each period studied. Sensory and motor block were noted at H1 and decreased from the sixth hour. No adverse events were noted. We concluded that the use of elastomeric disposable pumps for CPNB in children was an effective technique.
IMPLICATIONS: In children, continuous nerve blocks with disposable pumps allow optimal analgesia and early ambulation after orthopedic surgeries.
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Introduction |
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Regional analgesia, in the perioperative period, is a safe and effective technique for children (1). Continuous peripheral nerve blocks (CPNB) may be used, but few studies have shown the effectiveness of such a technique for children (2,3). CPNB usually involve electronic devices for continuous infusion and therefore require immobilization of the patient in bed. The use of disposable pumps has already been evaluated in orthopedic surgery for adults and allows the ambulatory management of regional analgesia (4–6).
The aim of this prospective descriptive study was to evaluate the effectiveness of disposable elastomeric pumps for perioperative CPNB analgesia after major orthopedic surgery of the upper or lower limbs in children and to assess the benefits of restoring the young patient’s autonomy.
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Methods |
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TopAbstractIntroductionMethodsResultsDiscussionReferences |
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Twenty-five consecutive ASA physical status I or II children were enrolled in this study after institutional approval and parental written consent had been obtained. The patients were all scheduled to undergo major orthopedic surgery of the upper or lower limb. The patients were premedicated with 0.4 mg/kg of midazolam and 20 µg/kg of atropine. General anesthesia was induced using sevoflurane and 1 µg/kg of IV fentanyl, and the patients were intubated or a laryngeal mask airway inserted. Mechanical ventilation was controlled. Anesthesia was maintained with 50% nitrous oxide in oxygen and a 2.5% inspiratory fraction of sevoflurane. Peripheral nerve blocks were performed before the surgical procedure using a nerve stimulator for precise nerve location (Stimuplex®, Braun, Melsungen, Germany). The landmarks of Singelyn et al. (7) were used for popliteal blocks and of Dalens (8) for "3-in-1" and axillary blocks. With a starting output of 1.5 mA (frequency of 1 Hz and time of 50 ms), needles were advanced until they provoked the required nerve movement. The position was judged adequate when muscle contractions were still elicited at 0.5 mA. The 20-gauge multiperforated catheter (Plexolong®, Pajunk, Geisingen, Germany) was threaded from 3 cm (popliteal block) to 5 cm ("3-in-1" block). Contrast medium (0.1 mL/kg of Iopamidol 200, Shering pharmaceutical, Lys-Lez-Lannoy, France) was injected into the catheter, and an anteroposterior radiograph of the region was taken within 5 min. An equal-volume 0.5-mL/kg mixture of 0.25% bupivacaine and 1% lidocaine with 1:200000 epinephrine was injected via the catheter over a 2-min period. In the postoperative period, a continuous infusion of 0.2% ropivacaine was administered at 0.1 mL · kg-1 · h-1 using disposable elastomeric pumps (200-mL Infusor LV, Baxter, Paris, France) (Fig. 1). The disposable pumps used were multirate infusion pumps with a flow of 1, 2, or 3 mL/h for young children and a flow of 2, 3, 5, or 7 mL/h for teenagers. Propacetamol (30 mg/kg four times daily) and niflumic acid (40 mg/kg twice daily) were administered IV over a 15-min period to all children. If pain control was considered insufficient (visual analog scale [VAS] or Children and Infants Postoperative Pain Scale [CHIPPS] score >3) in the postoperative period, an IV injection of 0.2 mg/kg of nalbuphine was administered as rescue analgesia.
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In the postoperative period, sensory block was evaluated by using cold ether on a ball of cotton wool tested at H1, H6, H12, H24, and H48. At the same time, motor block was evaluated for the selected muscles of each nerve territory using a Bromage scale (9). Postoperative pain was evaluated at H1, H6, H12, H24, and H48 with a VAS ranging from 0 (no pain) to 10 cm (most imaginable pain) or the CHIPPS score for very young children (10), as well as amounts of rescue analgesia. Any adverse effects (pruritus, nausea, vomiting, dysesthesia, hematoma, urinary retention, local infection, or local anesthetic [LA]toxicity) were noted. Finally, the volumes of LA actually infused, measured by comparing the difference in infusor weight between the beginning of pump use and its withdrawal, were noted and compared with the theoretical volumes infused (calculated according to the flow as indicated by Baxter Laboratories and printed on each disposable pump).
Statistical analysis was performed using SAS software version 6.11 (SAS Institute, Cary, NC). The quantitative anthropometric scores were expressed as median (extremes), motor block as median (10th–90th percentiles), sensory block as percentages of patients with a sensory block, and pain score as median (25th–75th percentiles and extremes). Repeated-measure analysis of variance was used for continuous variables. Comparisons between values at the times studied were made using the Mann-Whitney U-test for nonparametric data, and the 
2 test was used for categorical data. A significance threshold of P < 0.05 was retained.
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Results |
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Twenty-five patients were included in this study. The median age was 10 yr (range, 1–15 yr), and the median weight was 34 kg (range, 15–75 kg). The median duration of surgical procedure was 90 min (range, 25–150 min). Eleven popliteal nerve blocks, 9 "3-in-1" blocks, and five axillary nerve blocks were performed. No block failures were noted. All the nerve blocks were effective during surgery. All the catheters were correctly located with a contrast medium.
Thirteen disposable pumps with a flow of 2 mL/h, 9 with 5 mL/h, and 3 with 7 mL/h were used over 45.5 h (range, 18–50 h). The median dose of ropivacaine administered was 10.1 mg/kg (range, 6.2–12.6 mg/kg). The flow of the disposable pumps varied from -9.61% to +8.6% compared with the theoretical flow. The VAS and CHIPPS values are reported in Figure 2. The median pain scores were zero for each period studied. The use of rescue analgesia was very small (nine children required a nalbuphine injection at H24 and three at H48).
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A sensory block was noted at H1 in 18 of 25 children (72%) and this decreased from H6 onwards (Fig. 3). Motor block was noted in the postoperative period (at H1) with a median of three and decreased totally from H6 onwards (the median for motor block was 0.5)(Fig. 3).
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Two children (8%) had nausea at H24 and 2 children had pruritus. None of the children had hematomas or any other associated catheter infection. No dysesthesia, urinary retention, or any sign of LA toxicity were noted. No neurological symptoms recurred after withdrawal of the disposable pumps. There was no accidental removal of the catheter during the period studied.
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Discussion |
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TopAbstractIntroductionMethodsResultsDiscussionReferences |
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The results of this study show that the use of disposable elastomeric pumps for CPNB LA infusion in children is an effective and reliable method of analgesia after major orthopedic surgery.
We demonstrated satisfactory pain scores in children with CPNB. The use of rescue analgesia (nalbuphine) was minimal.
Disposable elastomeric pumps present advantages for children in postoperative analgesia. Their simplicity of use enables young patients to use this method and experience the same analgesic effect as that experienced by adults (4,6).
Disposable elastomeric pumps provide freedom of movement for children with CPNB. Ninety-two percent of the children studied were able to ambulate in or outside their room. Kotiniemi et al. (11,12) emphasized the fact that inadequate pain relief in children was one of the predicting factors of problematic behavioral changes in the near postoperative period. These changes could persist for three to four weeks after surgery. Moreover, hospital-influenced play was a significant variable in the occurrence of behavioral problems (12). The authors recommended encouraging play to help children cope with the challenging experience of hospitalization, anesthesia, and surgery. The use of disposable elastomeric pumps makes it easier for children to play, as demonstrated by our study.
Continuous infusion of 0.2% ropivacaine at 0.1 mL · kg-1 · h-1 is sufficient for obtaining optimal pain relief with CPNB without motor block or adverse effects. Sciard et al. (3) used CPNB with 0.2% ropivacaine at 0.17 and 0.2 mL · kg-1 · h-1, respectively, on 2 children without any adverse effects or complications. In our study, we did not report a motor block after six hours of infusion despite the efficient analgesia. This differential block observed with a small dose and small concentration of ropivacaine has also been shown in different studies on epidural analgesia in adults (13,14). In children, some studies have shown a differential block with a small concentration of ropivacaine (15,16); however, another study did not find a differential block in this population (17). When used with disposable pumps, the differential block allowed easy mobilization of our young patients.
A CPNB with a disposable elastomeric pump is a safe technique for children. No major adverse events have been reported. Our results are consistent with those of other studies on adults (18,19). The incidence of vomiting and nausea in our study was less frequent (8%) compared with the results reported in the literature. Kotiniemi et al. (11) found 17% of nausea and vomiting after orthopedic surgery because of pain and the use of opioids in the postoperative period. They added that effective prevention of pain could be expected to reduce postoperative vomiting and nausea, as has also been suggested by Andersen and Krogh (20). In our study, effective pain management and the restricted use of opioids contributed to decreasing nausea and vomiting in children. We conclude that the continuous peripheral nerve infusion of 0.2% ropivacaine with disposable elastomeric pumps in children is effective.
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Acknowledgments |
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Supported, in part, by the Association pour le Développement et la Recherche en Anesthésie Réanimation, CHU Lapeyronie, Montpellier, France.
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Footnotes |
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Presented, in part, at the annual meeting of the American Society of Regional Anesthesia, Chicago, IL, May 2002.
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References |
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TopAbstractIntroductionMethodsResultsDiscussionReferences |
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- Giaufre E, Dalens B, Gombert A. Epidemiology and morbidity of regional anesthesia in children: a one-year prospective survey of the French-Language Society of Pediatric Anesthesiologists. Anesth Analg 1996; 83: 904–12.[Abstract]
- Paut O, Sallabery M, Shreiber-Deturmeny E, et al. Continuous fascia iliaca compartment block in children: a prospective evaluation of plasma bupivacaine, pain scores, and side effects. Anesth Analg 2001; 92: 1159–63.
[Abstract/Free Full Text] - Sciard D, Matuszczak M, Gebhard R. Continuous posterior lumbar plexus block for acute postoperative pain control in young children. Anesthesiology 2001; 56: 1129–30.
- Klein SM, Grant SA, Greengrass RA, et al. Interscalene brachial plexus block with a continuous catheter insertion system and a disposable infusion pump. Anesth Analg 2000; 91: 1473–8.
[Abstract/Free Full Text] - Ganapathy S, Amendola A, Lichfield R, et al. Elastomeric pumps for ambulatory patient controlled regional analgesia. Can J Anaesth 2000; 47: 897–902.[Web of Science][Medline]
- Capdevila X, Macaire P, Aknin P, et al. Patient-controlled perineural analgesia after ambulatory orthopedic surgery: elastomeric versus electronic pumps. Anesth Analg 2003; 96: 414–7.
[Abstract/Free Full Text] - Singelyn FJ, Gouverneur JM, Gribomont BF. Continuous popliteal sciatic nerve block: an original technique to provide postoperative analgesia after foot surgery. Anesth Analg 1997; 84: 383–6.[Abstract]
- Dalens B. Pediatric local and regional anesthesia: from birth to adulthood. Baltimore: Williams and Wilkins, 1996.
- Bromage PR. A comparison of the hydrochloride and carbon dioxide salts of lidocaine and prilocaine in epidural analgesia. Acta Anaesthesiol Scand Suppl 1965; 16: 55–69.[Medline]
- Büttner W, Finke W. Analysis of behavioural and physiological parameters for the assessment of postoperative analgesic demand in newborns, infants and young children: a comprehensive report on seven consecutive studies. Paediatr Anaesth 2000; 10: 303–18.[Web of Science][Medline]
- Kotiniemi LH, Ryhänen PT, Moilanen IK. Postoperative symptoms at home following day-case surgery in children: a multicentre survey of 551 children. Anaesthesia 1997; 52: 963–9.[Web of Science][Medline]
- Kotiniemi LH, Ryhänen PT, Moilanen IK. Behavioural changes in children following day-case surgery: a 4 week follow-up of 551 children. Anaesthesia 1997; 52: 970–6.[Web of Science][Medline]
- Greengrass RA, Klein SM, D’Ercole FJ, et al. Lumbar plexus and sciatic nerve block for knee arthroplasty: comparison of ropivacaine and bupivacaine. Can J Anaesth 1998; 45: 1094–6.[Web of Science][Medline]
- Zaric D, Nydahl P, Philipson L, et al. The effect of continuous lumbar epidural infusion of ropivacaine (0.1%, 0.2%, and 0.3%) and 0.25% bupivacaine on sensory and motor block in volunteers: a double-blind study. Reg Anesth 1996; 21: 14–25.[Web of Science][Medline]
- Ivani G, Lampugnani E, Torre M, et al. Ropivacaine in paediatric surgery: preliminary results. Paediatr Anaesth 1998; 8: 127–9.[Web of Science][Medline]
- Ivani G, Lampugnani E, Torre M, et al. Comparison of ropivacaine with bupivacaine for paediatric caudal block. Br J Anaesth 1998; 81: 247–8.
[Abstract/Free Full Text] - Khalil S, Campos C, Farag AM, et al. Caudal block in children: ropivacaine compared with bupivacaine. Anesthesiology 1999; 91: 1279–84.[Web of Science][Medline]
- Auroy Y, Narchi P, Messiah A, et al. Serious complications related to regional anesthesia. Anesthesiology 1997; 87: 479–86.[Web of Science][Medline]
- Cuvillon P, Ripart J, Lalourcey L, et al. The continuous femoral nerve block catheter for postoperative analgesia: bacterial colonization, infectious rate and adverse effects. Anesth Analg 2001; 93: 1045–9.
[Abstract/Free Full Text] - Andersen R, Krogh K. Pain as a major cause of postoperative nausea. Can Anaesth Soc J 1976; 23: 366–9.[Web of Science][Medline]
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