Abstract
Regional anesthesia is widely employed for postoperative pain control in both adults and children. Central or perineural approaches can be performed as a bolus injection or as a continuous infusion of local anesthetics. However, bolus injections, even with the addition of adjuvants, are inadequate for prolonged surgery and long-term pain control. Continuous infusion remains the technique of choice when there is a prolonged operation or intense postoperative pain. This article reviews the safety and efficacy of central and perineural continuous infusions for postoperative pain control in children.
The literature confirms the very low rate of complications and adverse effects of regional anesthesia in children. However, clinicians need to be aware of the key points for performing a block and placing a catheter in children: good knowledge of anatomic and physiologic differences between adults and children is necessary; the use of newer local anesthetics, such as ropivacaine and levobupivacaine, increases the therapeutic window; and that it is mandatory to work with dedicated pediatric equipment. Through the use of new techniques such as nerve mapping and/or ultrasound the success of blocks can be improved and the risks reduced.
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References
Anand KJ, Sippell WG, Aynsley-Green A. Randomised trial of fentanyl anaesthesia in preterm babies undergoing surgery: effects on the stress response. Lancet 1987; 1: 62–6
Morton NS. Pain assessment in children. Paediatr Anaesth 1997; 7: 267–72
Kokki H. Current management of pediatric postoperative pain. Expert Rev Neurother 2004 Mar; 4: 295–306
Ivani G. Modification of the stress response by regional analgesia in children. In: Van Zundert A, editor. Highlights in pain therapy and regional anesthesia. VI. Barcelona: Permanyer Publications, 1997: 199–202
Taddio A, Katz J, Ilersich AL, et al. Effect of neonatal circumcision on pain response during subsequent routine vaccination [see comments]. Lancet 1997; 349: 599–603
Gunter JB. Benefit and risks of local anesthetics in infants and children. Pediatr Drugs 2002; 4: 649–72
Ivani G. Ropivacaine: is it time for children [editorial]. Paediatr Anaesth 2002; 12: 383–7
Bosenberg A, Thomas J, Lopez T, et al. The efficacy of caudal ropivacaine 1, 2 and 3mg x 1(-1) for postoperative analgesia in children. Paediatr Anaesth 2002 Jan; 12(1): 53–8
Ivani G, De Negri P, Lonnqvist PA, et al. Comparison of three different concentrations of levobupivacaine for caudal block in children. Anesth Analg 2003; 97: 368–71
Ivani G, DeNegri P, Conio A, et al. Comparison of racemic bupivacaine, ropivacaine, and levo-bupivacaine for pediatric caudal anesthesia: effects on postoperative analgesia and motor block. Reg Anesth Pain Med 2002; 27: 157–61
De Negri P, Ivani G, Tirri T, et al. Comparison of epidural bupivacaine, levobupivacaine and ropivacaine on postoperative analgesia and motor blockade. Anesth Analg 2004; 99: 45–8
Ivani G, De negri P, Lonnqvist PA, et al. Caudal anesthesia for minor pediatric surgery: a prospective randomized comparison of ropivacaine 0.2% vs levobupivacaine 0.2%. Pediatr Anesth 2005; 15: 491–4
McNeely JK, Farber NE, Rusy LM, et al. Epidural analgesia improves outcome following pediatric fundoplication. A retrospective analysis. Reg Anesth 1997; 22(1): 16–23
Giaufre E, Dalens B, Gombert A, et al. 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
Ivani G, Taglietto M, L’Erario M, et al. 7605 consecutive blocks in a children’s hospital. Regional anesthesia is safe and effective [abstract]. Anesthesiology 2006; 105: A1353
Llewellyn N, Moriarty A. The national pediatric epidural audit. Pediatr Anesth 2007; 17: 520–33
Faccenda KA, Finucane BT. Complications of regional anaesthesia: incidence and prevention. Drug Saf 2001; 24: 413–22
Rodgers A, Walker N, Shug S, et al. Reduction of postoperative mortality and morbidity with epidural or spinal anaesthesia: results from overview of randomised trials. BMJ 2000; 321: 1–12
Dahlgren N, Tornebrandt K. Neurological complications after anaesthesia: a follow-up of 18000 spinal and epidural anaesthetics performed over three years. Acta Anaesthesiol Scand 1995; 39: 872–80
Marhofer P, Sitzwohl C, Greher M, et al. Ultrasound guidance for infraclavicular brachial plexus anaesthesia in children. Anaesthesia 2004; 59: 642–6
Ivani G, editor. Paediatric regional anaesthesia: a practical approach. Florence: SEE Editrice, 2001
Dalens B. Anesthésie locorégionale de la naissance à l’age adulte. Paris: Edition Pradel, 1993
Bosenberg AT, Bland BAR, Schulte-Steimberg O, et al. Thoracic epidural anesthesia via caudal route in infants. Anesthesiology 1988; 69: 265–9
Krane E, Dalens B, Murat I, et al. The safety of epidurals placed during general anesthesia [editorial]. Reg Anesth Pain Med 1998; 23(5): 433–8
Bosenberg AT, Ivani G. Regional anaesthesia: children are different [editorial]. Paediatr Anaesth 1998; 8: 447–50
Agarwal R, Gutlove DP, Lockhart CH. Seizures occurring in paediatric patients receiving continuous infusion of bupivacaine. Anaesth Analg 1994; 75: 284–6
Berde CB. Toxicity of local anaesthetics in infants and children. J Pediatr 1993; 122: 14–20
Luz G, Wiesen CH, Innerhofer P, et al. Free and total plasma concentration after continuous epidural anaesthesia in infants and children. Paediatr Anaesth 1998; 8: 473–8
Lönnqvist PA, Westrin P, Larsson BA, et al. Ropivacaine pharmacokinetics after caudal block in 1–8 year old children. Br J Anaesth 2000; 85: 506–11
Hansen TG, Ilett KF, Reid C, et al. Caudal ropivacaine in infants: population pharmacokinetics and plasma concentrations. Anesthesiology 2001; 94: 579–84
Sang CN, Berde CB. A multicentric study of safety and risk factors in pediatric regional anaesthesia [abstract]. Anaesthesiology 1994; 81: A1386
Berde CB. Convulsions associated with paediatric regional anaesthesia. Anaesth Analg 1992; 75: 164–6
Hansen TG, Ilett KF, Lim SI, et al. Pharmacokinetics and clinical efficacy of longterm epidural ropivacaine infusion in children. Br J Anaesth 2000; 85: 347–53
Dalens B, Ecoffey C, Joly A, et al. Pharmacokinetics and analgesic effect of ropivacaine following ilioinguinal/iliohypogastric nerve block in children. Paediatr Anaesth 2001; 11: 415–20
Deng X-M, Xiao W-J, Tang G-Z, et al. The minimum local anesthetic concentration of ropivacaine for caudal analgesia in children. Anesth Analg 2002; 94: 1465
Gunter JB, Gregg T, Varughese AM, et al. Levobupivacaine for ilioinguinal/iliohypogastric nerve block in children. Anesth Analg 1999; 89: 647–9
Stoddart PA, Bolton C, Schily M, et al. Effectiveness of levobupivacaine with and without fentanyl for postoperative analgesia in infants and children [abstract]. Anesthesiology 2001; 95: A1242
Lerman J, Stoddart PA, Bolton C, et al. Efficacy and pharmacokinetics of levobupivacaine with and without fentanyl in a paediatric population. IMRAPT 2002; 14 Suppl.: 80
Taylor RH, Convery PN, Austin S. Pharmacokinetics of levobupivacaine and bupivacaine during caudal block in children. IMRAPT 2002; 14 Suppl.: 83
Ivani G, Codipietro L, Gagliardi F, et al. A long term infusion via a sciatic catheter in a 3-years-old-boy. Paediatr Anaesth 2003; 13: 718–21
Ivani G, Mossetti V. Continuous peripheral nerve block (CPNB). Pediatr Anesth 2005; 15: 87–90
Dadure C, Pirat P, Raux O, et al. Perioperative continuous peripheral nerve block with disposable infusion pumps in children: a prospective descriptive study. Anesth Analg 2003; 97(3): 687–90
Dadure C, Raux O, Troncin R, et al. Continuous infraclavicular brachial plexus block for acute pain management in children. Anesth Analg 2003; 97(3): 691–3
Dadure C, Raux O, Gaudard P, et al. Continuous psoas compartment blocks after major orthopedic surgery in children: a prospective computed tomographic scan and clinical studies. Anesth Analg 2004; 98(3): 623–8
Galante D. Preoperative apnea in a preterm infant after caudal block with ropivicaine and clonidine. Paediatr Anaesth 2005; 15(8): 708–9
Passariello M, Almenrader N, Canneti N, et al. Caudal analgesia in children: S(=)-ketamine vs S(+)-ketamine plus clonidine. Paediatr Anaesth 2004; 14(10): 851–5
Hager H, Marhofer P, Sitzwohl P, et al. Caudal clonidine prolongs analgesia from S(+)-ketamine in children. Anesth Analg 2002; 94(11): 1169–72
Dadure C, Motais F, Ricard C, et al. Continuous peripheral nerve blocks at home for treatment of recurrent complex regional pain syndrome I in children. Anesthesiology 2005; 102: 387–91
Steinbach TV, Nadvorna H, Arazi D. A five year follow-up study of phantom limb pain in post traumatic amputees. Scand J Rehabil Med 1982; 14: 203–7
Morey TE, Giannoni J, Duncan E, et al. Nerve sheath catheter analgesia after amputation. Clin Orthop Relat Res 2002; 397: 281–9
Enneking FK, Scarborough MT, Radson EA. Local anesthetic infusion through nerve sheath catheters for analgesia following upper extremity amputation. Clinical report. Reg Anesth 1997; 22: 351–6
Lierz P, Schroegendorfer K, Choi S, et al. Continuous blockade of both brachial plexus with ropivacaine in phantom pain a case report. Pain 1998; 78: 135–7
Halbert J, Crotty M, Cameron ID. Evidence for the optimal management of acute and chronic phantom pain: a systematic review. Clin J Pain 2002; 18: 84–92
Bosenberg AT, Raw R, Boezaart AP. Surface mapping of peripheral nerves in children with a nerve stimulator. Paediatr Anaesth 2002; 12: 398–403
Hadzic A, Dilberovic F, Shah S, et al. Combination of intraneural injection and high injection pressure leads to fascicular injury and neurologic deficits in dogs. Reg Anesth Pain Med 2004; 29: 417–23
Grau T. Ultrasonography in the current practice of regional anaesthesia. Best Pract Res Clin Anaesthesiol 2005 Jun; 19(2): 175–200
Rapp HJ, Folger A, Grau T. Ultrasound-guided epidural catheter insertion in children. Anesth Analg 2005 Aug; 101(2): 333–9
Marhofer P, Willschke H, Kettner S. Imaging techniques for regional nerve blockade and vascular cannulation in children. Curr Opin Anaesthesiol 2006 Jun; 19(3): 293–300
Marhofer P, Bosenberg A, Sitzwohl C, et al. Pilot study of neuraxial imaging by ultrasound in infants and children. Paediatr Anaesth 2005 Aug; 15(8): 671–6
Willschke H, Marhofer P, Bosenberg A, et al. Epidural catheter placement in children: comparing a novel approach using ultrasound guidance and a standard loss-of-resistance technique. Br J Anaesth 2006 Aug; 97(2): 200–7
Willschke H, Marhofer P, Bosenberg A, et al. Ultrasonography for ilioinguinal/iliohypogastric nerve blocks in children. Br J Anaesth 2005 Aug; 95(2): 226–30
Ivani G, Mossetti V, Andreacchio A. Ultrasound-guided peripheral catheter placement for upper limb amputation in a 12 years old boy: possible phantom limb pain prevention? Pediatr Anaesth. In press
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No sources of funding were used to assist in the preparation of this review. The authors have no conflicts of interest that are directly relevant to the content of this review.
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Ivani, G., Mossetti, V. Regional Anesthesia for Postoperative Pain Control in Children. Pediatr-Drugs 10, 107–114 (2008). https://doi.org/10.2165/00148581-200810020-00005
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DOI: https://doi.org/10.2165/00148581-200810020-00005