Continuous peripheral nerve block analgesia effective in pediatric orthopedic surgery patients

Appropriate patient and family education, frequent follow-up recommended to prevent or correct complications from the procedure.

Continuous peripheral nerve block can be used for postoperative analgesia in pediatric orthopedic surgery patients, and may allow for earlier discharge from the hospital, according to a study by physicians at The Children's Hospital of Philadelphia.

"The main advantage is that the patients can leave the hospital sooner," Arjunan Ganesh, MBBS, pediatric anesthesiologist and lead author of the study, noted in a press release. "And, you are able to ensure better pain control and to decrease use of opioids and their side effects, such as itching and nausea," he said.

Ganesh and colleagues studied outcomes for 217 children who received 226 catheters to deliver continuous peripheral nerve block (CPNB) for pain management after orthopedic surgery between 2003 and 2006. They published their results in Anesthesia & Analgesia.

Children averaged 13.7 years of age, ranging from 4 to 18 years. Of the 217 children, 108 (112 catheters) were discharged home with CPNB.

For analgesia, physicians used 0.125% bupivacaine in 164 children, 0.1% ropivacaine in 12 children and 0.15% ropivacaine in 27 children. Infusions were initially administered at a rate of 2 mL/hour to 12 mL/hour, based on patients' weights and catheter locations, and were applied for an average duration of 48.4 ? 29.3 hours, according to the study.

The researchers found that 56% of children did not require any opioids in the first 8 hours postop, 26% did not require opioids at 24 hours and 21% did not require opioids at 48 hours, according to the study.

Nausea and vomiting were experienced by 14% of children overall, including 13% of outpatients and 15% of inpatients. However, only 2.8% of children experienced complications, the investigators reported.

"Three patients had prolonged numbness (greater than 24 hours postop) that resolved spontaneously; one developed superficial cellulitis that resolved with a course of antibiotics; one had difficulty removing the catheter at home and one developed tinnitus 24 [hours] after starting CPNB that resolved quickly after clamping of the catheter followed by removal," the authors wrote.

Adults have benefited from CPNB for more than 7 years, but little research has been done regarding the feasibility, safety and effectiveness of the technique in children. The study looked at some of the main concerns, namely how patients fare with placement of catheters under general anesthesia, and how well patients' families follow at-home directions, according to the release. Physicians at Children's Hospital of Philadelphia have now used CPNB for pain management on almost 500 patients since January 2003.

"CPNB has never been done routinely in pediatrics," Ganesh noted. "I don't know of any other institution that regularly sends children home with catheters. They may be starting to do it now, after we have shown in studies that it works. One of the main reasons for the successful launch of this program was the acceptance and interest generated by our orthopedic surgeons and pain nurse practitioners who helped train the post-anesthesia care unit and educate parents, without whom this program would not have taken off," Ganesh said in the release.

The study authors caution that hospitals must provide appropriate patient and family education concerning in-home use, as well as frequent follow-up, to prevent and correct complications from the procedure. Complications may include infections, difficulty in removing the catheter, inadequate analgesia, leakage from the insertion and injury resulting from a fall or trauma to the extremity. In the study, the overall failure rate was 15%.

Also, because of the limited number of patients examined in this study, the incidence of rare serious adverse events could have been underestimated. Thus, additional studies are needed, the authors noted.

For more information:
Ganesh A, Rose JB, Wells L, et al. Continuous peripheral nerve blockade for inpatient and outpatient postoperative analgesia in children. Anesth Analg. 2007;105:1234-1242.