Giorgio Ivani, Italy Continuous Peripheral Nerve Blockade in Children Giorgio Ivani Giorgio Ivani Regina Margherita Children’s Hospital Turin Italy [email protected]

Giorgio Ivani, ItalyGiorgio Ivani, Italy

Continuous Peripheral Nerve Blockade in Children

Continuous Peripheral Nerve Blockade in Children

Giorgio IvaniGiorgio Ivani

Regina Margherita Children’s HospitalRegina Margherita Children’s Hospital

Turin ItalyTurin [email protected]@libero.it


Postoperative Pain Control and RA


Single shot analgesia, even with the

addition of adjuvants is not enough for:

- long-term surgery

- long-term pain


Postoperative Pain Control and RA: techniques

Postoperative Pain Control and RA: techniques

Single ShotSingle Shot : : minor surgeryminor surgery

Continuous InfusionContinuous Infusion:: - long-term - long-term

surgerysurgery

- painful postop. - painful postop.




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


Continuous Infusion and OutcomeContinuous 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


Is epidural analgesia associated with an improved outcome following open Nissen

fundoplication?


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



fundoplication?


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%


Peripheral Pain Control Peripheral Pain Control

several techniques/ routes can be used - intramuscolar

pain, some drug absorption unpredictability

-iv opioidsnausea,vomiting,pruritus,urinary retention, GI

impairment,respiratory depression

-epidural infusionanaesthesia/analgesia also in controlateral leg


Postoperative Pain Control and RAPostoperative Pain Control and RA

As continuous epidural infusion is a As continuous epidural infusion is a technique of choice when there is a technique of choice when there is a prolonged operation or an intense prolonged operation or an intense

postoperative pain,postoperative pain,

why not a peripheral infusion for a why not a peripheral infusion for a peripheral pain?peripheral pain?


Continuous Peripheral BlocksContinuous Peripheral Blocks

In adults it is a well established and commonly performed

technique


Peripheral Catheter Positioning


- as efficient as epidural continuous infusion

- easy to perform

- long-term analgesia


Pediatric DataPediatric 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


Matuszczak et al.Anesthesiology 2001;95:A1236

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


Pediatric DataPediatric 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 removalDadure et al. Anesth Analg 2003;97:687-690


Continuous infusions:Safety/Efficacy

Continuous infusions:Safety/Efficacy

Asepsis Dedicated Pediatric Tools Nerve Stimulator Strictly observed Drugs Guide-Lines Continuous monitoring : instrumental nurses


Material: needles and catheteres

Material: needles and catheteres

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;22:281-283)

central venous catheter set for femoral block (Tobias. Anaesth Int Care 1994;22:616-618)


Case Report 1Case Report 1

3 1/2 y,

left foot semiamputation

sciatic block

15 days of continuous infusion



3 y old boy

right foot semiamputation

sciatic block

21 days of continuous infusion

Ivani et al. Paediatr Anaesth 2003 ; in press



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



better blood flowdaily wound treatments

( 2-3 times per day) and surgical cleaning

without any additional pain killer




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)




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


Pediatric Regional Anesthesia:the Future

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

Documents

Giorgio Ivani, Italy Continuous Peripheral Nerve Blockade in Children Giorgio Ivani Giorgio Ivani Regina Margherita Children’s Hospital Turin Italy [email protected]