Maria Matuszczak MDProfessor of Anesthesiology

Division Chief Pediatric Anesthesia

Pediatric Regional

Anesthesia6th Anesthesia And Critical Care

ConferenceKuwait 20-22 Nov 2014

Nothing to disclose

Know the commonly use regional blocks in children

Know the treatment of local anesthetic toxicity

Know how to set up a pediatric regional service

Objectives

1.  Regional anesthesia for neonates/infants.

2.  Update on intralipid protocol for pediatrics

3.  System setup for regional anesthesia program

Regional anesthesia for

neonates/infants.

contrarily to adults,blocks should not be performed onawake children

Asleep vs. Awake - Does it matter?Pediatric regional block complications by patient state.

A report from the Pediatric Regional Anesthesia Network (PRAN).Andreas H. Taenzer, et al. Reg Anesth Pain Med 2014 39(4): 279-83

53,564 pediatric regional anesthesia blocks from an observational prospective database (PRAN) were analyzed in regard of the rate of adverse events in relation to the patient being awake or anesthetized at the time of block placement

Primary outcomes: 1. (PONS) postoperative neurologic symptoms 2. (LAST) local anesthetic systemic toxicity ( either in the form of cardiovascular symptoms or seizures )

Secondary outcome: 1. extended hospital stay due to a block complication.

Landmarks

little modifications

small children have less well defined landmarks

Distance skin-nerve

bony growth is not the same for long, short or flat bones

variations of body fluids have influence on skin thickness

Pharmacokinetic ofLocal Anesthetics

• little information concerning diffusion,protein binding and LA metabolism,

• lower level of alpha-1-glycoprotein means higher fraction of free local anesthetic, considerable individual variations• local spread is easier in children, fat is less dense,

Single Shot maximum dosage for

Local Anesthetics

• Bupivacaine 2.5mg/kg• Ropivacaine 2-3mg/kg• Lidocaine 7mg/kg• Prilocaine 7-10mg/kg

Maximum hourly doses

Bupivacaine/Ropivacaine

0.4-0.5 mg/kg/hr in children

0.20-0.25 mg/kg/hr in newborns

the continuous infusion rate should not exceed:

Use of Adjuvant

Clonidine can be used at 1-2 mcg/kg

to prolong a peripheral/central single shot nerve block or 1-2mcg/ml for continuous

infusion

But: hematoma, infection,transient arterial vasospasmAnd local anesthesia toxicity !!!

Complications ?

closed claim analysis: no data concerning nerve injury from peripheral nerve blocks in children

Epidemiology and morbidity of regional anesthesia in children: A one-year prospective survey of the French-language society of pediatric anesthesiologists. E. Giaufre et al. Anesthesia & Analgesia 1996; 83:904-912

• prospective 1-year survey of regional anesthesia in French-language Society of Pediatric Anesthesiologists,

• 24409 blocks, 60% central blocks ( mostly caudals)

• 4090 peripheral blocks, 997 upper extremity

• 103/997 in children younger than 3 years

• no complications related to peripheral nerve blocks

• 1.5% complications all related to caudal epidural blocks

Epidemiology and morbidity of regional anesthesia in children: a follow-up one-year prospective survey of the french-Language Society of Pediatric AnaesthesiologistsC Ecoffey et al, Pediatr Anesth 2010, 20:1061-1069

• Anonymous survey,

• 104,612 pure GA; 29,870 GA with blocks; 1,262 pure blocks

• 34% of all RA = central blocks

• 66% PNB, 29% extremities, 71% trunk blocks and face blocks

• < 3 years: central = PNB; > 3 years: 4x more PNB

• 41 complications in 40 patients, overall 0.12% complications

• complications 6 x higher for central than for PNB

Pediatric Regional Anesthesia Network (PRAN)A Multi-institutional Study of the Use nd Incidence of Complications of Pediatric Regional AnesthesiaD. Polaner, A Taenzer, B.Walker Anesth Analg 2012, 10:1-12

• Prospective data collection, April 2007 March 2010

• 14,917 rgional blocks on 13,725 children

• No deaths or complication > 3 months

• 95% blocks placed under GA

• 40 % caudals, 35% peripheral nerve blocks

• complications are higher for central than for PNB

• 33% of complications due to catheter dislocations

• Paravertebral /Intercostal Block

• Rectus Sheath Block

• Transabdominal Plan Block

• Ilioinguinal/Hypogastric Nerve Block

• Dorsal Penile Block

TRUNKAL

BLOCKS

TRUNKAL BLOCKS 3 Abdominal wall blocks: ilioinguinal/hypogastric block rectus sheath block TAP block

TRUNKAL BLOCKS Ilioinguinal/hypogastric block

TRUNKAL BLOCKSRectus sheath block

TRUNKAL BLOCKS TAP block

TRUNKAL BLOCKS Intercostal Block

Grau: Ultraschall in der Anaesthesie und Intensivmedizin

Central Block

Caudal Block

Update on intralipid

protocol for pediatrics

Successful Use of a 20% Lipid Emulsion to Resuscitate a Patient

after a Presumed Bupivacaine-related Cardiac ArrestMA. Rosenblatt, M Abel, GW Fischer, CJ Itzkovich, JB Eisenkraft

Anesthesiology 2006; 105:217–8

First published case 58Y, 82kg, intra-scalene block, 20ml Bupi 0.5% + 20ml Mepi 1.5%20 minutes CPR100ml of 20% intralipid, within seconds return to sinus rythm

Treatment of Local Anesthetic Systemic Toxicity (LAST)Guy L. Weinberg, MD

Reg Anesth Pain Med 2010;35: 188Y193

Review articleAirway managementSeizure suppression ( Benzo first choice, Propofol??)Circulatory support ( bypass , no permanent cardiac injury)Lipid infusion ( Cyclodextrins capture local anesthetics)Generalization of lipid infusion ( used for other medication overdosage)Vasopressor therapy ( vasopressin no advantage over epinephrine)

Timing and safety ?

Treatment regimen ?

Use in children ?

Alternative formulation ?

Treatment of CNS symptoms of toxicity ?

Dosing ?

Unanswered questions about:

Safety of High Volume Lipid Emulsion InfusionA First Approximation of LD50 in Rats

DB Hiller, G Di Gregorio, K Kelly, R Ripper, L Edelman, R Boumendjel, K Drasner, GL Weinberg

Reg Anesth Pain Med 2010;35: 140-144

Study safety and systemic adverse effects of high volume lipid emulsion administrationDixon‘s up-and-down Method of estimating LD50Rats weighting between 385 and 413 g anesthetised,

LD50 = 67.7ml +/-10.7 equivalent human LD50 dose 10.5-16.4ml

hemorrhagic pulmonary vascular congestion @ 80 ml

Safety of High Volume Lipid Emulsion Infusion

Infusing lipid emulsion is not without risk

Neonates: possible pulmonary embolus

“fat overloading syndrome” with pulmonary fat emboli causing death in 4 infants

large lipid globules can lodge in the lung, engorge pulmonary capillaries, and exacerbate ventilation-perfusion mismatches in the preterm lung.

Autopsy found evidence of pulmonary fat microemboli.

Successful resuscitation in infants/neonates

Successful resuscitation following ropivacaine-induced systemic toxicity in a neonate

M. Huebler, et al, Anaesthesia, 2010, 65, pages 1137–1140

Use of Intralipid in an infant with impending cardiovascular collapse

due to local anesthetic toxicityS Shah et al, J Anesth (2009) 23:439–441

Successful resuscitation of bupivacaine-imduced cardiotoxicity

in a neonateEP Lin et al, Pediatr Anesth 2010, 20:955-957

36 weeker, 41 week old 4 kg, recieves 10mg/kg of ropi unintentionally via caudal CPR with 30ml gelatine, normal SR before lipid infusion ready

1 month 4.9kg baby 4 ml bupi with epi via caudal CPR started lipid infusion 10ml stabilization over 2 minutes

2 day old 3.2 kg baby bupi 0.25 1ml /kg via caudal with US CPR started lipid 1 ml/kg Ecg normalized over 3 min

Recommendation for treatment of Local Anesthetic Systemic Toxicity (LAST)

www.lipidrescue.org

www.aagbi.org/publications/guidelines/docs/latoxicity07.pdf

System setup for regional anesthesia program

Dedicated block team?

MD, resident, nurse, CRNA, AA ?

Separate regional block room ?

Which block to perform in the OR?

Block performed pre-or postop ?

Blocks in PACU?

Blocks on the floor?

The Efficacy of Pre-versus Post Surgical Axillary Block on Postoperative Pain in Paediatric Patients

Fatis Altintas et al. PaediatrAnaesth 2000, 10:23-28

double blind randomized study,

55 children, 1-11 years, ASA I-II,

axillary block after induction, before surgery or after surgery,

use of nerve stimulation

no use of opioids, faces pain scales recorded for 24 hours,

no difference in cumulative pain scores, significant difference @ 10 hours after surgery,

additional analgesic consumption was similar in both groups,

lower isoflurane concentration in pre-surgical block group, faster emergence, faster recovery could not demonstrate preemptive analgesia

Regional anesthesia, block room and efficiency: putting things in perspective

P Drolet, M Girard Can J Anesth 2004, 51: 1 pp 1–5

Factors impacting on-time transfer to the operating room in patients undergoing peripheral nerve blocks in the

preoperative area JE Chelly, JL Horne, ME Hudson, JP Williams

J Clin Anesth 2010, 22: 115–121

maria.matuszczak@uth.tmc.edu

Questions ?