Transcript Central Blocks in Children

Continuous Peripheral Nerve
Blockade in Children
Giorgio Ivani
Regina Margherita Children’s Hospital
Turin Italy
Giorgio Ivani, Italy
[email protected]
Postoperative Pain Control and
RA
Single shot analgesia, even with the
addition of adjuvants is not enough
for:
- long-term surgery
- long-term pain
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Postoperative Pain Control and
RA: techniques
 Single
Shot : minor surgery
 Continuous
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Infusion: - long-term
surgery
- painful postop.
Postoperative Pain Control and
RA
When a long-term pain control is
required pain treatment becomes a
challenge:
- complete pain relief
- without interference with the daily life
- drugs with as few side effects as
possible
patient well-being
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Continuous Infusion and Outcome
Surgical Stress Control:oesophageal
atresia
 Optimal Pain Control
 Reduced Need of Opioids
 Reduced Need of Muscle Relaxants
 Ventilatory Support Reduction

Bosenberg A et al. Pediatr Surg Int 1992;7:289-91
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Is epidural analgesia associated with
an improved outcome following open Nissen
fundoplication?
retrospective study, 104 open Nissen
iv morphine infusion:10-40 mcg/kg/h vs
epi 0.125% bupivacaine/fentanyl
4 mcg/ml 0.4 ml/kg/h
Wilson et al. Paediatr Anaesth 2001;11:65-70
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Is epidural analgesia associated with
an improved outcome following open Nissen
fundoplication?
Hospital stay: GA 13 days vs RA 8 days
over 7 days discharge:
GA 44% vs RA 25%
ICU stay: GA 33% vs RA 17%
ICU ventilation: GA 21% vs RA 8%
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Peripheral Pain Control
several techniques/ routes can be used
- intramuscolar
pain, some drug absorption unpredictability
-iv opioids
nausea,vomiting,pruritus,urinary retention,
GI impairment,respiratory depression
-epidural infusion
anaesthesia/analgesia also in controlateral leg
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Postoperative Pain Control
and RA
As continuous epidural infusion is a
technique of choice when there is a
prolonged operation or an intense
postoperative pain,
why not a peripheral infusion for a
peripheral pain?
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Continuous Peripheral Blocks
In adults it is a well established
and commonly performed
technique
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Peripheral Catheter
Positioning
- as efficient as epidural continuous
infusion
- easy to perform
- long-term analgesia
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Pediatric Data
Very Few Papers
Mainly Case Reports
Usually short term infusion (48h)
A review of CPNB in Children
Syngelyn. TRAPM 2002,vol 6 n3;108-114
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Matuszczak et al.Anesthesiology
2001;95:A1236
brachial plexus block
36 patients; age 2-16 years
catheter lasting 2-13 days, mean 4 days
arm/and trauma, vascular/congenital
surgery,complicated fractures
optimal analgesia
no complications
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Pediatric Data
25 children, major orthopedic surgery
CPNB with elastomeric pumps
0.2% ropivacaine 0.1 ml/kg/h
mean age 10 yrs
mean duration 45 h
no complications,no accidental removal
Dadure et al. Anesth Analg 2003;97:687-690
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Continuous infusions:
Safety/Efficacy
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Asepsis
Dedicated Pediatric Tools
Nerve Stimulator
Strictly observed Drugs Guide-Lines
Continuous monitoring : instrumental
nurses
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Material: needles and
catheteres
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radial artery catheterization set for
axillary block (Tan et al.Anesth
Analg1995;80:640-641)
epidural kit for femoral block
(Johnson.Anaesth Int Care 1994;22:281283)
central venous catheter set for femoral
block (Tobias. Anaesth Int Care
1994;22:616-618)
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Case Report 1
3 1/2 y,
left foot semiamputation
sciatic block
15 days of continuous infusion
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Case Report 2
3 y old boy
right foot semiamputation
sciatic block
21 days of continuous infusion
Ivani et al. Paediatr Anaesth 2003 ; in press
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Case Report 2
bolus dose:
0.2% ropivacaine 0.6 ml/kg +
clonidine 2 mcg/kg
continuous infusion:
0.2% ropivacaine 0.4 mg/kg/h +
clonidine 3 mcg/kg/24h
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Case Report 2
 better
blood flow
 daily wound treatments
( 2-3 times per day) and surgical
cleaning
without any additional pain killer
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Peripheral Catheter
Positioning
axillary sciatic femoral (fascia iliaca) bl.
starting dose
0.25% bupiv., 0.2% ropivacaine
0.4-0.6 ml/kg (Syngelin)
1.5% lidocaine+0.2% ropivacaine
(Matuszczack)
0.2% ropiv/levob. 0.3-0.6 ml/kg+ clonidine
2mcg/kg (Ivani)
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Peripheral Catheter
Positioning
continuous infusion
0.125%- 0.25% levobupivacaine,
0.1%-0.2% ropivacaine
0.1-0.3 ml/kg/h
0.2-0.4 mg/kg/h
+ clonidine 3 mcg/kg/24h
30%
reduction
for
infants
<
6
mo
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Pediatric Regional Anesthesia:
the Future
Continuous Infusion:
Technical difficulties have been overcome
Pediatric tools availability for peripheral
continuous infusion:
can provide effective analgesia optimizing
drugs administration and pain
management
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