| JOURNAL HOME | CME HOME | THIS MONTH | PAST ISSUES | ETOC | COLLECTIONS |
| AUTHORS | REVIEWERS | EDITORIAL BOARD | FEEDBACK | RSS | HELP |
 
|
|
|
||
|
|
Anesth Analg 2004;98:1653-1655 © 2004 International Anesthesia Research Society doi: 10.1213/01.ANE.0000114084.01266.E5
|
||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
 |
Abstract |
|---|
 Top Abstract IntroductionCase ReportDiscussionReferences |
|---|
The use of catheters for continuous nerve blocks has been established in children, although in most series only one catheter was used. We report a case of a 3-yr-old child who underwent a toe-to-finger transfer managed with 2 regional catheters: axillary and sciatic. A pain score of 0 was noted during the entire study period. The total dose of bupivacaine was limited to an acceptable range, and the child recovered completely. This report adds to growing evidence in favor of the safety and efficacy of continuous peripheral nerve blocks in pediatric patients.
IMPLICATIONS: Double continuous nerve blocks allow optimal analgesia in burned children after complex orthopedic surgery without major adverse events. Plasma concentrations of bupivacaine remained small during the study period.
|
Introduction |
|---|
|
TopAbstractIntroductionCase ReportDiscussionReferences |
|---|
Continuous axillary and popliteal sciatic nerve blocks are established as effective analgesic methods for forearm and foot surgery, respectively, both during and after surgery in adults and children (1,2). Continuous peripheral block techniques can extend block duration and have been widely used in adults (3). Peripheral nerve blocks (PNBs) are safe and effective techniques in children (4). Although only a few pediatric studies of continuous PNBs have been reported, they have yielded promising results against postoperative pain (5–8). There is little information on complications, infusion rates, or plasma local anesthetic levels in children (5–7). For safe use of continuous regional techniques it is important to verify that the plasma concentrations of the local anesthetics remain within safe limits. We report a case of regional anesthetic management in a 3-yr-old burn patient who underwent a toe-to-hand transfer. The anesthesia and postoperative analgesia were achieved primarily with continuous infusions of bupivacaine in both axillary and popliteal sciatic nerve blocks. The rate of systemic absorption of local anesthetics in double continuous PNB in infants has not been established. We measured the plasma concentrations of bupivacaine for 48 h in this child.
|
Case Report |
|---|
|
TopAbstractIntroductionCase ReportDiscussionReferences |
|---|
A 3-yr-old boy weighing 13 kg was scheduled for a toe-to-hand transfer after severe burns of the trunk and forearm with total loss of the right fingers in a domestic accident. Before the surgical procedure, pain was managed with continuous IV infusion of a potent opioid. To control the pain, progressively increased rates of infusion were necessary. Optimal pain relief was difficult to achieve. After informed consent from the parents, the child was premedicated with midazolam 0.4 mg/kg and atropine 20 µg/kg. Anesthesia was induced with sevoflurane, and an IV catheter was inserted. After the induction of anesthesia, propofol 3 mg/kg and fentanyl 1.5 µg/kg were administered to facilitate tracheal intubation, and ventilation was controlled. Anesthesia was maintained with 60% nitrous oxide in oxygen and sevoflurane.
The two PNBs were performed before the surgical procedure by using a nerve stimulator for precise nerve location (Stimuplex®; Braun, Melsungen, Germany). The child was placed in a right lateral position, and a popliteal sciatic nerve block was performed by using the landmarks of Singelyn et al. (1). The required position of the needle was determined when an output <0.5 mA still produced a characteristic motor response. A 20-gauge multiperforated catheter (Plexolong®; Pajunk, Geisingen, Germany) was threaded a distance of 5 cm and secured with a transparent occlusive dressing. After the patient was turned to the dorsal position, an axillary brachial plexus block was performed by using the landmarks of Dalens (2). With a starting output of 1.5 mA (frequency, 1 Hz; time, 50 µs), the needle was advanced until it provoked the required muscle movement. The position was judged adequate when characteristic muscle contractions were still elicited at 0.5 mA. A 20-gauge multiperforated catheter (Plexolong®) was inserted through the introducer needle for 7 cm into the fascial sheath around the plexus and was secured with a transparent occlusive dressing. Both catheter locations were verified by injection of contrast medium (0.1 mL/kg of Iopamidol® 200; Shering Pharmaceutical, Lys-Lez-Lannoy, France) into the catheters, and anteroposterior radiographs of the region were made (Fig. 1). Six milliliters of 0.25% bupivacaine and 1% lidocaine with epinephrine 1:200,000 were injected into each catheter.
|
The duration of surgery was 265 min. After general anesthesia was discontinued and the child was tracheally extubated and transferred to the recovery room, a postoperative continuous infusion of 0.125% plain bupivacaine was administered by infusion pumps at 2 mL/h into each catheter for 48 h. In accordance with the multimodal analgesia concept, propacetamol 30 mg/kg IV (4 times a day) was administered systemically. Pain was assessed by using the Children and Infants Postoperative Pain Scale (9). If analgesia was considered insufficient (Children and Infants Postoperative Pain Scale score >3), supplemental analgesia was provided by administering nalbuphine 0.2 mg/kg. At every evaluation during the 48-h study period (1, 6, 12, 18, 24, 36, and 48 h), the same pain score of 0 was noted. In addition to the continuous PNBs, the child received only 1 dose of nalbuphine 2 h after tracheal extubation.
Total plasma bupivacaine concentrations were determined by gas chromatography at 1, 6, 24, and 48 h after the initial loading dose (Fig. 2). Plasma concentrations of bupivacaine remained less than the toxic levels found in other studies (5,7,10) (0.22 µg/mL at 1 h, 0.31 µg/mL at 6 h, 0.57 µg/mL at 24 h, and 0.83 µg/mL at 48 h). There was no adverse side effect or complication related either to catheter placement or drug infusion. The technique provided safe and effective pain relief. Both parents and nurses were satisfied by postoperative pain management. At 24 and 72 h, pain during wound dressing was effectively prevented by continuous infusion of bupivacaine into the catheters.
|
|
Discussion |
|---|
|
TopAbstractIntroductionCase ReportDiscussionReferences |
|---|
This is the first reported case of double continuous PNB for postoperative pain management in a child. The concomitant axillary and popliteal sciatic nerve blocks achieved by continuous infusion of bupivacaine provided safe and effective control of perioperative acute pain in this burn patient. The need for rescue analgesia (nalbuphine) was minimal.
Burns are considered to be among the most painful types of trauma. Treatment for pain in burned children is often unsatisfactory (11,12). The initial painful stimulation of nerve endings by the burn and persistent painful stimuli combine, leading to pain amplification mediated by peripheral and central mechanisms. This may result in the development of chronic pain syndromes that are complex to treat (13,14). Providing safe and effective pain management for burned children is difficult. Managing such pain with continuous PNB limits the use of opioids and their adverse effects and reduces the severity of subsequent painful stimuli. The observed minimal pain scores show that more than one continuous PNB can be used to effectively combat postoperative pain in children while avoiding side effects, including the sedation, nausea, and vomiting often observed with potent IV opioids.
Inberg et al. (15) reported that brachial plexus blockade increases blood flow to the extremity with a reimplanted digit by preventing neurally mediated vasospasm. Excellent peripheral circulation, as well as the prevention of vascular spasm and vascular thrombosis, is vitally important for primary graft survival.
However, there is little information on complications related to infusion rates or plasma local anesthetic levels in children (5,7). For safe use of this type of continuous regional technique, plasma total bupivacaine levels must remain within safe limits. In this case, we used 2 concomitant continuous PNBs and determined the plasma concentrations of bupivacaine at regular intervals during the first 48 hours. Plasma concentrations of bupivacaine remained small during the study period. For this child, we used bupivacaine 0.25 mg · kg–1 · h–1 in each PNB catheter.
Experience with plasma bupivacaine level monitoring during continuous PNBs in pediatric populations is limited. Paut et al. (5) determined plasma bupivacaine concentrations in 20 children with continuous fascia iliaca compartment block (infusion of 0.1% bupivacaine at 0.135 ± 0.03 mg · kg–1 · h–1) for 48 hours. Bupivacaine levels ranged from 0.71 ± 0.45 µg/mL at 24 hours to 0.84 ± 0.4 µg/mL at 48 hours. Johnson (7) also determined plasma bupivacaine concentrations in 3 children who had a continuous femoral nerve block for a femoral fracture. In that series, the femoral block consisted of infusion of 0.125% bupivacaine at 0.375 mg · kg–1 · h–1, and bupivacaine levels ranged from 0.67 to 0.93 µg/mL at 24 and 48 hours, respectively. More data are available for bupivacaine concentrations during continuous epidural anesthesia (10,16). Luz et al. (10) reported higher plasma levels (0.25–0.87 µg/mL) in a continuous epidural infusion of bupivacaine 0.31 mg · kg–1 · h–1 in children. In addition, a bupivacaine concentration less than 1.5 µg/mL was considered acceptable. Despite the use of the largest dose of bupivacaine, the concentrations observed in our study are consistent with those of other studies in which bupivacaine was used for epidural or peripheral nerve infusion. However, plasma protein levels may be considerably decreased in a child with extensive burns and in reaction to the increase of the free fraction of bupivacaine. The free fraction of bupivacaine may most likely produce toxic effects, and, in this case, it was useful to measure the free bupivacaine level.
This report adds to growing evidence in favor of the safety and efficacy of continuous PNBs in pediatric patients. PNBs constitute a good alternative for patients with severe burns, relieving chronic background pain and limiting the severity of acute painful stimuli.
|
References |
|---|
|
TopAbstractIntroductionCase ReportDiscussionReferences |
|---|
- 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 & Wilkins, 1996.
- Horlocker TT. Peripheral nerve blocks-regional anesthesia for the new millennium. Reg Anesth Pain Med 1998; 23: 237–40.[Web of Science][Medline]
- Giaufre F, 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, Schreiber-Deturmeny E, et al. Continuous fascia iliaca compartment block in children: a prospective evaluation of plasma bupivacaine concentrations, pain score, and side effects. Anesth Analg 2001; 92: 1159–63.
[Abstract/Free Full Text] - Tobias J. Continuous femoral nerve block to provide analgesia following femur fracture in a pediatric ICU population. Anaesth Intensive Care 1994; 22: 616–8.[Web of Science][Medline]
- Johnson C. Continuous femoral nerve blockade for analgesia in children with femoral fractures. Anesth Intensive Care 1992; 22: 281–3.
- Sciard D, Matuszczak M, Gebhard R, et al. Continuous posterior lumbar plexus block for acute postoperative pain control in young children. Anesthesiology 2001; 56: 1129–30.
- 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]
- Luz G, Wieser C, Innerhofer P, et al. Free and total bupivacaine plasma concentrations after continuous epidural anesthesia in infants and children. Paediatr Anaesth 1998; 8: 473–8.[Web of Science][Medline]
- Kohler H, Schulz S, Wieblock A. Pain management in children: assessment and documentation in burn units. Eur J Pediatr Surg 2001; 11: 40–3.[Web of Science][Medline]
- Beushausen T, Mucke K. Anesthesia and pain management in pediatric burn patients. Pediatr Surg Int 1997; 12: 327–33.[Medline]
- Gallagher G, Rae CP, Kinsella J. Treatment of pain in severe burns. Am J Clin Dermatol 2002; 1: 329–35.
- Latarjet J. The pain from burns. Pathol Biol (Paris) 2002; 50: 127–33.[Medline]
- Inberg P, Kassila M, Vilkki S, et al. Anaesthesia for microvascular surgery in children: a combination of general anaesthesia and axillary plexus block. Acta Anaesthesiol Scand 1995; 39: 518–22.[Medline]
- Desparmet J, Meistelman C, Barre J, Saint-Maurice C. Continuous epidural infusion of bupivacaine for postoperative pain relief in children. Anesthesiology 1987; 67: 108–10.[Web of Science][Medline]
This article has been cited by other articles:
|
|
 |
|
  A. Ganesh and G. Cucchiaro Multiple simultaneous perineural infusions for postoperative analgesia in adolescents in an outpatient setting Br. J. Anaesth., May 1, 2007; 98(5): 687 - 689. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
P.-A. Lonnqvist and N. S. Morton Postoperative analgesia in infants and children Br. J. Anaesth., July 1, 2005; 95(1): 59 - 68. [Full Text] [PDF]
|
|
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
