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Continuous Peripheral Nerve Blockade in Children

Continuous Peripheral Nerve Blockade in Children. Giorgio Ivani Regina Margherita Children’s Hospital Turin Italy gioivani@libero.it. Postoperative Pain Control and RA. Single shot analgesia, even with the addition of adjuvants is not enough for: - long-term surgery

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Continuous Peripheral Nerve Blockade in Children

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  1. Continuous Peripheral Nerve Blockade in Children Giorgio Ivani Regina Margherita Children’s Hospital Turin Italy gioivani@libero.it

  2. Postoperative Pain Control and RA Single shot analgesia, even with the addition of adjuvants is not enough for: - long-term surgery - long-term pain

  3. Postoperative Pain Control and RA: techniques • Single Shot : minor surgery • Continuous Infusion: - long-term surgery - painful postop.

  4. 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

  5. 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

  6. 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

  7. 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%

  8. 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

  9. 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?

  10. Continuous Peripheral Blocks In adults it is a well established and commonly performed technique

  11. Peripheral Catheter Positioning - as efficient as epidural continuous infusion - easy to perform - long-term analgesia

  12. 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

  13. 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

  14. 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

  15. Continuous infusions:Safety/Efficacy • Asepsis • Dedicated Pediatric Tools • Nerve Stimulator • Strictly observed Drugs Guide-Lines • Continuous monitoring : instrumental • nurses

  16. Material: needles and catheteres • radial artery catheterization setforaxillary 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)

  17. Case Report 1 3 1/2 y, left foot semiamputation sciatic block 15 days of continuous infusion

  18. 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

  19. 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

  20. Case Report 2 • better blood flow • daily wound treatments ( 2-3 times per day) and surgical cleaning without any additional pain killer

  21. 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)

  22. 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

  23. 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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