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Increasing the use of regional anaesthetic techniques in paediatric populations.

Last post 17 Oct 2018, 1:40 AM by Nicole Wylie. 0 replies.
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  •  17 Oct 2018, 1:40 AM 2672

    Increasing the use of regional anaesthetic techniques in paediatric populations.

    Strom et al. described the patient characteristics of infants and small children undergoing general anaesthesia in Denmark, and found that the majority of anaesthetics were administered for surgical procedures, many of which were likely to be painful [1].

    Inadequate pain relief after surgery is associated with significant morbidity and mortality in children, in part due to the post-operative onset of the associated inflammatory response [2]. This poses a challenge to the paediatric anaesthetist, especially in the face of recent FDA contraindications applied to tramadol [3], as well as warnings and concerns surrounding the use of opioids in children [4] in the context of a global opioid misuse epidemic.

    Particularly striking amongst Strom et al.’s findings was the observation of an increased use of regional analgesic and combined regional-general anaesthetic techniques during the 10-year study period. The increasing pervasiveness of, and clinician proficiency with, ultrasound has led to significant interest and capability in regional anaesthesia in paediatrics [5, 6], with demonstrable patient benefit [5, 7]. Despite this, when compared to the use of regional techniques in adult anaesthesia, overall rates remain low [7]. 

    Although the already-low complication rates remain superior in the regional than central neuro-axial modalities [6, 7], local anaesthetic agents are both typically well tolerated in children and have a favourable safety profile in this population [5-7].  Regional or central neuro-axial analgesic techniques seem, then, to be a logical next step in the analgesic armamentarium available to those who practice paediatric anaesthesia, but whether the systemic benefit is limited to specific site of deposition of local anaesthetic remains questionable.

    A recent audit of 24 cases of patients undergoing femoral osteotomy in my institution demonstrated shortened median length of stay (LOS) in the PACU as well as shortened overall hospital LOS in patients receiving local anaesthetic agents via either central neuro-axial routes (caudal) or simply local wound infiltration by surgeons.  Whilst numbers were small, the median hospital LOS was 47 hours (IQR 34) in those with local infiltration into the wound, 45 hours (IQR 31) with caudal block, and 68 hours (IQR 98 hours) in those patients in whom no local anaesthetic agent was used. Opioid use was similarly decreased in those given local anaesthetic, regardless of route of administration.

    This has changed our institutional practice. There is a stronger focus on ensuring local anaesthetic agents are used where possible, that equipment for regional techniques is readily available in theatre, and more recently that catheter infusion options are considered and utilised more frequently.

    Strom et al.’s findings of increasing use of regional techniques are a timely reminder of how far this area of anaesthetic practice has come, supported by significant innovations in technology and education. This, coupled with the encouraging safety profile of local anaesthetic agents, a global increase in paediatric obesity [8] and a concurrent opioid epidemic, suggest these techniques should be far more widely used. 

    It is time that we as anaesthetists include local anaesthetic agents in our paediatric cases where possible, especially via a regional route. This will aid in our efforts to encourage good multimodal analgesia and to minimize adverse effects from other agents in this vulnerable population. 

     

    N. Wylie

    Women’s and Children’s Hospital,

    Adelaide, Australia. 

    Email: nicole.wylie@sa.gov.au

     

    No external funding and no conflicts of interest declared.

     

    References

    1.      Strom C, Lundstrom LH, Afshari A, Lohse N. Characteristics of children less than 2 years of age undergoing anaesthesia in Denmark 2005-2015: a national observational study. Anaesthesia 2018; 73: 1195-206.

    2.      Simic D, Stevic M, Stankovic Z, Simic I, Ducic S, Petrov I, Milenovic M. The safety and efficacy of the continuous peripheral nerve block in post operative analgesia of pediatric patients. Frontiers in Medicine (Lausanne) 2018; 9: 57.

    3.      US Food and Drug Administration. Communication: FDA Drug Safety Communication: FDA restricts use of prescription codeine pain and cough medicines and tramadol pain medicines in children; recommends against use in breastfeeding women11th January, 2018. https://www.fda.gov/Drugs/DrugSafety/ucm549679.htm (accessed 21/10/2018).

    4.      Morton NS, Errera A. APA national audit of pediatric opioid infusions. Paediatric Anaesthesia 2010, 20: 119-25.

    5.      Hasani A. Regional anaesthesia in children: indications and limitations. Periodicum Biologorum 2015; 117: 215-8.

    6.      Polaner DM, Taenzer AH, Walker BJ et al. Pediatic Regional Anaesthesia Network (PRAN): a multi-institutional study of the use and incidecne of complications of pediatric regional anaesthesia. Anesthesia and Analgesia 2012; 115: 1353-64.

    7.      Ecoffey C, Lacroix F, Giaufré E, Orliaguet G, Courrèges P; Association des Anesthésistes Réanimateurs Pédiatriques d'Expression Française (ADARPEF). Epidemiology and morbidity of regional anaesthesia in children: a follow-up one-year prospective survey of the French-Language Society of Paediatric Anaesthesiologists (ADARPEF). Pediatric Anaesthesia 2010; 20: 1061-9.

    8.      Jackson-Leach R, Lobstein T. Estimated burden of paediatric obesity and co-morbidities in Europe. Part 1. The increase in the prevalence of childhood obesity in Europe is itself increasing.  International Journal of Pediatric Obesity 2009; 1: 26-32.

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