Page of

Pediatric Orthopedic Surgery 

Pediatric Orthopedic Surgery
Chapter:
Pediatric Orthopedic Surgery
Source:
Acute Pain Medicine
Author(s):

Karen Boretskty

DOI:
10.1093/med/9780190856649.003.0023

1. Preoperative Factors

1.1. What patient factors need to be taken into consideration when preparing a plan for the anesthesia and analgesia for this patient?

Forearm fractures are common injuries during childhood. When presenting for repair, both acute and chronic conditions need to be considered for purposes of perioperative planning. Elective surgery should be delayed for 2 hours following clear liquids and 6 hours following full liquids or a light meal. Heavy meals with a high fat content require 8 hours of digestion. The rate of gastric emptying, however, is slowed by both pain and opioid administration, and a conservative approach to induction and airway management, including a rapid-sequence induction with endotracheal intubation, may be prudent regardless of time from food intake to induction of anesthesia. Preinduction gastric imaging with ultrasound has recently been advocated as a more objective method of determining gastric volume and possible risk of aspiration.

Emergent surgery is indicated in the event of an open fracture, exposed bone, or neurovascular compromise (i.e., lack of perfusion and arterial pulses). Surgery should be planned as soon as feasible and gastric aspiration precautions observed. A mature and cooperative pediatric patient may have regional anesthesia (RA) in the form of a brachial plexus block with local anesthetic (LA) plus intravenous sedation. A rapid-sequence induction with endotracheal intubation is preferred if general anesthesia (GA) is indicated. Cuffed endotracheal tubes are recommended in children of this age. The use of succinylcholine in pediatric patients carries a black box warning from the Food and Drug Administration (FDA) due to potential hyperkalemic cardiac arrest in the presence of undiagnosed muscular dystrophy. Duchenne’s muscular dystrophy is the most common of the muscular dystrophies, occurring predominantly in males, and the diagnosis is usually made in the first 5 years of life. Because the incidence of aspiration of gastric contents is more common than muscular dystrophy, and given the low probability that this patient has an undiagnosed myopathy, the use of succinylcholine may be justified. A modified rapid sequence using a nondepolarizing muscle relaxant is also acceptable.

This patient’s medical history includes attention deficit hyperactivity disorder (ADHD) treated with extended-release methylphenidate, a form of amphetamine. ADHD occurs in 8% to 12% of pediatric patients and is an added risk factor for long bone fractures. Patients on chronic amphetamine treatment will have depleted endogenous catecholamine stores and may be more susceptible to intraoperative hypotension and bradycardia. These hemodynamic changes will not respond to indirect-acting catecholamine drugs like ephedrine, and patients will likely require direct-acting drugs such as epinephrine in the event of hypotension. The literature on patients having surgery without stopping chronic amphetamines is mixed; some patients have had dramatic episodes of refractory hypotension, and others have experienced no issues. For patients on these medications, the last dose administered should be confirmed and subsequent doses held pending surgery.

Further Reading

Cartabuke RS, Tobias JD, Rice J, Tumin D. Hemodynamic profile and behavioral characteristics during induction of anesthesia in pediatric patients with attention deficit hyperactivity disorder. Paediatr Anaesth. 2017;27:417–424.Find this resource:

Chou IC, Lin CC, Sung FC, Kao CH. Attention-deficit-hyperactivity disorder increases risk of bone fracture: a population-based cohort study. Dev Med Child Neurol. 2014;56:1111–1116.Find this resource:

Fischer SP, Healzer JM, Brook MW, Brock-Utne JG. General anesthesia in a patient on long-term amphetamine therapy: is there cause for concern? Anesth Analg. 2000;91:758–759.Find this resource:

Fischer SP, Schmiesing CA, Guta CG, Brock-Utne JG. General anesthesia and chronic amphetamine use. Anesth Analg. 2006;103:203–206.Find this resource:

Larach MG, Rosenberg H, Gronert GA, Allen GC. Hyperkalemic cardiac arrest during anesthesia in infants and children with occult myopathies. Clin Pediatr. 1997;36:916.Find this resource:

Mazurek AJ, Rae B, Hann S, Kim JI, Castro B, Coté CJ. Rocuronium versus succinylcholine: are they equally effective during rapid-sequence induction of anesthesia? Anesth Analg. 1998;87:1259–1262.Find this resource:

Schmitz A, Schmidt AR, Buehler PK, et al. Gastric ultrasound as a preoperative bedside test for residual gastric contents in children. Paediatr Anaesth. 2016;12:1157–1164.Find this resource:

Shi F, Xiao Y, Xiong W, Zhou Q, Huang X. Cuffed versus uncuffed endotracheal tubes in children: a meta-analysis. J Anesth. 2016;30:3–11.Find this resource:

1.2. What are the considerations for multimodal analgesia in the pediatric population?

Bone-related pain following open reduction internal fixation is often severe and difficult to treat. In children, acute pain is best managed by a multimodal approach in which nonpharmacologic methods, smaller doses of opioid and nonopioid analgesics, local anesthetic infiltration, and regional anesthetic techniques are combined to target multiple pain pathways. The result is better pain control with fewer drug-induced adverse effects. Such a multimodal technique advocates for opioids as a rescue therapy and no longer as first-line pain therapy.

The most commonly used nonopioid analgesic in pediatric practice is acetaminophen. While the exact mechanism of action is unclear, inhibition of prostaglandin synthesis in the central nervous system, activation of descending serotonergic pathways, cannabinoid agonism, and NMDA/Substance P antagonism are postulated pathways. Acetaminophen has minimal anti-inflammatory effect, lacks renal toxicity, and has not been implicated in antiplatelet activity or bone healing. Intravenous administration of acetaminophen avoids first-pass hepatic exposure, which may reduce the potential for hepatic injury, but acetaminophen should be used cautiously in patients with severe hepatic impairment or active liver disease. The recommended dose is 15 mg/kg PO or IV administered every 6 hours as needed. The daily maximum dose in children/adolescents is 75 mg/kg/d or 4 g, whichever is less. For preterm and term infants the daily maximum dose is 30 and 60 mg/kg/d, respectively.

Nonsteroidal anti-inflammatory drugs (NSAIDs) have established efficacy in children via anti-inflammatory and analgesic mechanisms through the blockade of prostaglandin and thromboxane synthesis by cyclooxygenase-1 (COX-1) and cyclooxygenase-2 (COX-2) enzymes. Nonselective NSAIDs such as ibuprofen, naproxen, and ketorolac, inhibit both COX-1 and COX-2. Of note, irritation of the gastric mucosa by COX nonselective NSAIDs is less common in children. The COX nonselective NSAIDs also reversibly inhibit platelet aggregation and cause small increases in bleeding time, rarely exceeding normal values. While there is no evidence that NSAIDs increase surgical bleeding complications, this may cause concern for some practitioners and should be individually considered. Selective COX-2 inhibitors such as celecoxib cause minimal gastric irritation or changes in platelet function. While NSAIDs have been linked to delayed bone healing in some animal models, they are widely considered appropriate in pediatrics, especially for short durations following surgery. Pediatric doses for the most common NSAIDs are shown in Table 23.1.

Table 23.1: Dosing recommendations for common NSAIDs

Drug

COX-2 Specific

Route

Dose

Interval

Maximum Dose (Single)

Maximum Dose (24-hour)

Ibuprofen

No

PO/IV

10 mg/kg

q6–8h

400 mg

2400 mg

Ketorolac

No

IV/IM

0.5 mg/kg

q6–8h

30 mg

120 mg

Celecoxib

Yes

PO

>10–25 kg

50 mg

q12h

50 mg

100 mg

>25 kg

100 mg

q12h

100 mg

200 mg

Nonopioid analgesics, when used alone, are best suited for mild to moderate pain. NSAIDs and acetaminophen are often combined for treating mild to moderate postoperative pain and result in superior analgesia to either drug alone. Nonopioid analgesics should be administered on a scheduled basis after an acute injury and not as needed in order to provide consistent basal analgesia and prevent analgesic gaps. Pediatric data on the perioperative value of ketamine and gabapentin are limited, but there are benefits in patients with chronic pain.

Further Reading

Anderson BJ. Paracetamol (acetaminophen): mechanisms of action. Paediatr Anaesth. 2008;18:915–921.Find this resource:

Bertolini A, Ferrari A, Ottani A, et al. Paracetamol: new vistas of an old drug. CNS Drug Rev. 2006;12:250–275.Find this resource:

Gazal G, Mackie IC. A comparison of paracetamol, ibuprofen or their combination for pain relief following extractions in children under general anaesthesia: a randomized controlled trial. Int J Paediatr Dent. 2007; 7:169–177.Find this resource:

Graham GG, Scott KF. Mechanism of action of paracetamol. Am J Ther. 2005;12:46–55.Find this resource:

Hartling L, Ali S, Dryden DM, et al. How safe are common analgesics for the treatment of acute pain for children? A systematic review. Pain Res Manag. 2016:5346819.Find this resource:

Jahr JS, Lee VK. Intravenous acetaminophen. Anesthesiol Clin. 2010;28:619–645.Find this resource:

Kokki H. Nonsteroidal anti-inflammatory drugs for postoperative pain: a focus on children. Paedr Drugs. 2003;5:103–123.Find this resource:

Munsterhjelm E, Niemi TT, Ylikorkala O, et al. Influence on platelet aggregation of i.v. parecoxib and acetaminophen in healthy volunteers. Br J Anaesth. 2006;97:226–231.Find this resource:

Niemi TT, Taxell C, Rosenberg PH. Comparison of the effect of intravenous ketoprofen, ketorolac and diclofenac on platelet function in volunteers. Acta Anaesthesiol Scand. 1997;41:1353–1358.Find this resource:

O’Connor JP, Lysz T. Celecoxib, NSAIDs and the skeleton. Drugs Today. 2008;44:693–709.Find this resource:

Wong I, St John-Green C, Walker SM. Opioid-sparing effects of perioperative paracetamol and nonsteroidal anti-inflammatory drugs (NSAIDs) in children. Paediatr Anaesth. 2013;23:475–495.Find this resource:

Yaster M. Multimodal analgesia in children. Eur J Anaesthesthiol. 2010;27:851–857.Find this resource:

1.3. What are considerations related to opioid administration in this patient?

In situations where opioid therapy is warranted, combination therapy with nonopioid and opioid medications (i.e., multimodal) results in a lower risk of serious and minor adverse events compared with opioid monotherapy. This reinforces the concept of adding opioid medications to, rather than replacing, nonopioid medication for moderate to severe pain. Opioid analgesics have the greatest risk of sedation, respiratory depression, nausea and vomiting, constipation, and pruritis. Similar to in adults, morphine, fentanyl, and hydromorphone are the most commonly administered IV opioid analgesics. Additionally, oxycodone, hydrocodone, and morphine are the most commonly administered oral opioids and can often be found in fixed combination with acetaminophen. In pediatric patients, it is recommended to administer the opioid and acetaminophen as separate medications and not as a combined formulation, to avoid potential acetaminophen over- and underdosing.

Codeine is no longer advocated for use in children. Codeine is a prodrug that has no intrinsic analgesic properties and must be metabolized into morphine. Large individual pharmacogenetic variation in the efficiency of conversion results in a subgroup of patients, hypermetabolizers, who produce excessive amounts of morphine when exposed to codeine. Hypermetabolism has been associated with inadvertent overdose, respiratory depression, and death. The FDA has issued a black box warning, and most pediatric hospitals in the United States have removed codeine from their formularies. Dosing for the most common opioids is shown in Table 23.2.

Table 23.2: Guidelines for opioid dosing

Drug

Route

Dose

Maximum single Dose (opioid naive)

Interval

Morphine

IV

0.05–0.1 mg/kg

PO

0.15–0.3 mg/kg

30

q4–6h

Hydromorphone

IV

0.01–0.02 mg/kg

PO

4

q4–6h

Fentanyl

IV

0.5–1 mcg/kg

Oxycodone

PO

0.05–0.1 mg/kg

10

q4–6h

Sample calculations for the given case: 36-kg patient with a forearm fracture:

  1. 1. Acetaminophen: 15 mg/kg × 36 kg = 540 mg q6h. Start oral dosing upon arrival at hospital and continue q6. Convert to IV administration if a dose is due while patient is in the operating room. Convert back to PO when oral intake resumes.

  2. 2. Ketorolac: 0.50 mg/kg × 36 kg = 18 mg q6h IV; round to 15 mg q dose to avoid dilution errors. Utilize 15 mg q6h when IV access is first established, either in the emergency department or in the operating room. Continue for 24 hours total.

  3. 3. Morphine sulphate (IV): 0.05 × 36 kg = 1.8 mg. Round to 1.5 mg q dose to avoid dilution errors. Titrate doses q 5 to 10 minutes to establish comfort in the emergency room, then order 1.8 mg IV q2–4h PRN breakthrough pain ≥4/10. Convert to oxycodone when oral intake resumes.

  4. 4. Oxycodone: 0.05 × 36 kg = 1.8 mg. Round to 1.5 mg q dose to avoid dilution errors. Order 1.5 mg PO q4–6h PRN breakthrough pain ≥4/10.

Further Reading

Hartling L, Ali S, Dryden DM, et al. How safe are common analgesics for the treatment of acute pain for children? A systematic review. Pain Res Manag. 2016:5346819.Find this resource:

Tobias JD, Green TP, Coté CJ. Codeine: time to say “no.” Pediatrics. 2016;138:e1–e7.Find this resource:

Tobias JD, Green TP, Coté CJ, Racoosin JA. Death and respiratory arrest related to ultra-rapid metabolism of codeine to morphine. www.fda.gov/downloads/AdvisoryCommittees/CommitteesMeetingMaterials/PediatricAdvisoryCommittee/UCM343601.pdf. Accessed January 6, 2017.

2. Regional Anesthesia Considerations

2.1. Discuss how regional anesthesia use and timing differ in pediatric populations compared with adult populations

Peripheral nerve blocks (PNBs) offer safe and effective alternatives to GA and neuraxial anesthesia. A PNB may be used as the sole anesthetic (with or without sedation), as a supplement to GA, and/or for postoperative analgesia. In pediatric patients the latter 2 are most common. A brachial plexus block to provide analgesia should be considered for this patient and placed while in the operating room. In pediatrics, RA is most often used in combination with GA. Nerve block placement commonly occurs after anesthetic induction due to the safety concerns of performing RA in an awake and uncooperative child. Although this necessitates 2 anesthetics, RA adds benefit by decreasing dose exposure to GA and providing excellent control of postsurgical pain. Placement of RA may occur before or after the surgery, depending on the type of procedure, location of the nerve block, and expected placement of a perineural catheter. In small children, catheter dressings may approach the surgical field; therefore, placement of the catheter at the end of the surgery may be preferred.

Most PNBs utilized in adults have been used in children of all ages. Primary differences include the size and location of the nerves, as well as the proximity to adjacent critical structures. An infraclavicular brachial plexus block with a catheter is a good choice for this patient due to anticipated inpatient stay, affected bone distal to the midhumeral shaft, and incisions over the forearm. Supraclavicular or axillary blocks may also be acceptable choices, but catheter fixation and retention may be challenging. In the infraclavicular location, the brachial plexus lies deep to both pectoralis muscles, which provide better tethering to secure a catheter. In the case of lower extremity fracture, PNB, plexus block, or epidural analgesia can be used. However, recent large studies demonstrate a lower failure rate and more favorable risk profile for PNBs when compared with neuraxial blocks.

Further Reading

Coté C, Lerman J, Anderson B. A Practice of Anesthesia for Infants and Children. 5th ed. Philadelpa, PA: Elsevier; 2013.Find this resource:

    Ecoffey C, Lacroix F, Giaufre E, et al. Association des Anesthesistes Reanimateurs Pediatriques d’Expression F. Epidemiology and morbidity of regional anesthesia in children: a follow-up one-year prospective survey of the French-Language Society of Paediatric Anaesthesiologists (ADARPEF). Pediatr Anesth. 2010;20:1061–1069.Find this resource:

    Krane EJ, Dalens BJ, Murat I, Murrell D. The safety of epidurals placed during general anesthesia. Reg Anesth Pain Med. 1998;23:433–438.Find this resource:

    Polaner D, Taenzer A, Walker B, et al. Pediatric Regional Anesthesia Network (PRAN): a multi-institutional study of the use and incidence of complications of pediatric regional anesthesia. Anesth Analg. 2012;115:1353–1364.Find this resource:

    2.2. Evaluate the safety data of performing regional anesthesia in the unconscious pediatric patient

    In adult populations, placement of RA under GA has been highly discouraged due to concerns of masking early warning signs of complications such as local anesthetic systemic toxicity (LAST) and nerve trauma. RA placement in awake children is often not feasible due to lack of cooperation; consequently, nerve block placement in children under GA has been accepted as the standard of care. In 2014, a multicenter analysis using the Pediatric Regional Anesthesia Network database demonstrated no difference in morbidity or mortality whether RA was administered in awake or anesthetized children. This is true for both neuraxial and PNBs. Similarly, the use of neuromuscular blocking drugs at the time of placement of regional anesthesia did not affect outcomes. LAST was more common in young children, and neurologic complications occurred most often in older children, yet both were rare events. When neurologic deficits did occur as the result of RA, they were most often transient and resolved within 6 months. Controversy still exists about the safety of performing interscalene blocks in children under GA or heavy sedation due to risk of catastrophic complications. American Society of Regional Anesthesia and Pain Medicine (ASRA) guidelines recommend placement of interscalene nerve blocks in awake or lightly sedated patients. However, a recent study of nearly 400 interscalene blocks placed under GA in pediatric patients reports no associated complications.

    In adult populations, the use of ultrasound guidance has decreased the incidence of LAST without an appreciable difference in postblock nerve injury. Pediatric-specific data addressing changes in the incidence of infrequent complications as a result of increased ultrasound use are still lacking. However, ultrasound guidance does improve block efficacy and decrease required local anesthetic dose for select blocks in children.

    Further Reading

    Bernards CM, Hadzic, A, Suresh S, Neal JM. Regional anesthesia in anesthetized or heavily sedated patients. Reg Anesth Pain Med. 2008;33:449–460.Find this resource:

    Ecoffey C, Oger E, Marchand-Maillet F, et al, SOS French Regional Anaesthesia Hotline. Eur J Anaesthesiol. 2014;31:606–610.Find this resource:

    Krane EJ, Dalens BJ, Murat I, Murrell D. The safety of epidurals placed during general anesthesia. Reg Anesth Pain Med. 1998;23:433–438.Find this resource:

    Neal JM, Bernards CM, et al. ASRA practice advisory on neurologic complications in regional anesthesia and pain medicine. Reg Anesth Pain Med. 2008;33:404–415.Find this resource:

    Oberndorfer U, Marhofer P, Bosenberg A, et al. Ultrasound guidance for sciatic and femoral nerve blocks in children. Br J Anaesth. 2007;98:797–801.Find this resource:

    Taenzer A, Walker BJ, et al. Asleep vs. awake: does it matter? Pediatric regional block complications by patient state: a report from the pediatric regional anesthesia network. Reg Anesth Pain Med. 2014;39:279–283.Find this resource:

    Taenzer A, et al. Interscalene brachial plexus blocks under general anesthesia in children: is this safe practice? Reg Anesth Pain Med. 2014;39:502–505.Find this resource:

    2.3. Discuss general indications and contraindications for regional anesthesia in pediatric patients

    General considerations for the performance of RA include suitability for the proposed surgery, experience in performing the block, and patient/caregiver cooperation. RA has the advantage of improved patient satisfaction, superior analgesia, decreased incidence of postoperative nausea and vomiting, decreased exposure to GA medications (which may be especially important in younger children), and fewer postoperative cognitive changes. Risks of RA include seizures, cardiac arrest, temporary or chronic nerve damage, localized infection, and block failure.

    Absolute contraindications to RA are the same in children as in adults and include patient refusal, infection at the needle insertion site, and true allergy to LA medication. True allergic reactions are rare and require further identification of the LA class as there is no cross-reactivity between amides and esters. Ester LA has a higher incidence of allergic reactions than amide LA.

    Relative contraindications are more controversial. Placement of RA in the presence of coagulopathies depends on the degree of anticoagulation and the location of the nerve relative to the neuraxis. For neuraxial blocks (epidurals and spinals), the ASRA has published extensive evidence-based guidelines applicable to all patients of all ages. The evidence to direct decisions on deep plexus (lumbar plexus) and paraneuraxial (paravertebral) blocks in the anticoagulated patient is less clear, but most practitioners adhere closely to the ASRA guidelines for these blocks. In the case of the more peripheral PNBs, where the consequences of bleeding are less problematic, there is little evidence to support the same strict adherence to these guidelines, which many experts consider overly restrictive when applied to PNBs in the absence of data.

    The placement of RA in patients with preexisting neuropathies also needs to be approached with caution. While PNB placement may hypothetically increase the risk of perineural injury in the setting of preexisting neuropathy, current data are unclear regarding the validity of such risk. Thus, an individualized risk-benefit analysis is suggested. When placing a PNB in a patient with a preexisting neuropathy, ultrasound for nerve localization will minimize the number of needle passes and help to accomplish a safe distance from the nerve. Additionally, using the lowest allowable dose of local anesthetic is advised.

    The use of RA in patients at risk for acute compartment syndrome (ACS) is debated, with most surgeons taking a very conservative approach of avoidance. ACS occurs when pressure is increased in a closed muscle compartment secondary to bleeding and edema; it occurs most often following long bone fractures in the lower leg and forearm. Prophylactic fasciotomies are sometimes recommended for open reduction internal fixation of high-impact ulnar, radial, and tibial fractures at the time of repair, making ACS much less likely. Pediatric case series demonstrate the safe use of RA in ACS with timely recognition of neurovascular compromise. While there is no evidence that RA, especially PNBs, will mask the ischemic pain of ACS, this is still a cause for concern for some practitioners, and potential risks must be considered. Pediatric patients with ACS present with the “3 As,” agitation, anxiety, and (increasing) analgesic requirement, in contrast to adults, who present with the “6 Ps,” pain, paresthesia, pallor, paralysis, pulselessness, and poikilothermia. When a perineural catheter is used in a patient at risk for ACS, the lowest doses and concentrations of LA that provide relief are recommended. One suggested protocol is shown in Box 23.1. While block failure is a consideration, continued increases in pain should alert providers to the development of compartment syndrome.

    Further Reading

    Bae DS, Kadiyala RK, Waters PM. Acute compartment syndrome in children: contemporary diagnosis, treatment, and outcome. J Pediatr Orthop. 2001;21:680–688.Find this resource:

    Benzon H. Regional anesthesia in the anticoagulated patient. www.nysora.com/mobile/regional-anesthesia/foundations-of-ra/3300-ra-in-anticoagulated-patient.html. Accessed January 17, 2017.

    Chelly JE, Clark LD, Gebhard RE, Raw RM, Atchabahian A. Consensus of the Orthopedic Anesthesia, Pain, and Rehabilitation Society on the use of peripheral nerve blocks in patients receiving thromboprophylaxis. J Clin Anesth. 2014;26:69–74.Find this resource:

    Horlocker TT, Vandermeuelen E, Kopp SL, Gogarten W, Leffert LR, Benzon HT. Regional anesthesia in the patient receiving antithrombotic or thrombolytic therapy: American Society of Regional Anesthesia and Pain Medicine Evidence-Based Guidelines (Fourth Edition). Reg Anesth Pain Med. 2018 Apr;43(3):263–309.Find this resource:

    Neal JM, Bernards CM, et al. ASRA practice advisory on neurologic complications in regional anesthesia and pain Medicine. Reg Anesth Pain Med. 2008;33:404–415.Find this resource:

    Noonan KJ, McCarthy JJ. Compartment syndromes in the pediatric patient. J Pediatr Orthop. 2010;30(2 suppl):S96–S101.Find this resource:

    Walker BJ, Noonan KJ, Bosenberg AT. Evolving compartment syndrome not masked by a continuous peripheral nerve block: evidence-based case management. Reg Anesth Pain Med. 2012;37:393–397.Find this resource:

    2.4. Review local anesthetic dosing guidelines for pediatric patients

    Both amide and ester local anesthetics can be utilized for PNBs. Amides are most commonly used for single bolus injections, and choice of drug depends on desired speed of onset, duration of action, drug safety profile, and type of block to be performed ). The LA dose for each block in children is calculated by weight, with dose being expressed as milliliters per kilogram (Table 23.3). Lean body mass is used for the weight when calculating the pediatric dose, and age-specific pharmacokinetics of local anesthetics must be considered when administering the drug. In general, children have a higher volume of distribution than adults, imparting some protection against LAST, although young infants and neonates have decreased plasma proteins, resulting in increased unbound plasma levels of LA. Additionally, adult hepatic function is not achieved until 3 to 6 months of age. Children with chronic disease and significant comorbidities may have hypoalbuminemia and resultant increases in the free fraction of LA. The maximum dose of local anesthetics should be calculated prior to placement of multiple nerve blocks in a single patient to avoid LAST.

    Table 23.3: Recommended single-injection/bolus local anesthetic doses for pediatric regional anesthetic technique

    Bupivacaine 0.25%, mL/kg

    Ropivacaine 0.2% mL/kg

    Femoral

    0.20–0.25

    0.20–0.25

    Lumbar plexus

    0.50

    0.50

    Fascia iliaca

    0.50

    0.50

    Sciatic (gluteal or anterior)

    0.20–0.25

    0.20–0.25

    Sciatic (popliteal)

    0.20–0.25

    0.20–0.25

    Interscalene

    0.15–0.20

    0.15–0.20

    Infraclavicular/

    supraclavicular

    0.20–0.25

    0.20–-0.25

    Paravertebral

    0.25–0.50

    0.25–0.50

    Quadratus lumborum

    0.40–0.50

    0.40–0.50

    Rectus sheath

    0.10–0.20

    0.10–0.20

    Meticulous attention to dosing of continuous infusions in children is essential due to concerns of drug accumulation. In particular, dosing by patient weight necessitates individual calculations and creates potential for mathematical errors. Ropivacaine, bupivacaine, chloroprocaine, and lidocaine have all been used for infusions in children. Lidocaine, however, has a theoretical risk of increased neurotoxicity in young children. Ropivacaine is often favored over bupivacaine due to decreased cardiotoxicity and increased motor-sparing properties. The maximum recommended infusion rate of ropivacaine for children is 0.4 to 0.5 mg/kg/h. Liver function and conjugation function of amide local anesthetics do not reach adult maturity until 4 to 6 months of age. Therefore, in children less than 4 to 6 months of age, infusions should not exceed 0.2 to 0.3 mg/kg/h. Some practitioners argue to use chloroprocaine infusions in infants less than 4 to 6 months of age, since chloroprocaine is metabolized by plasma esterases and theoretically is less likely to cause LAST in this group, but there currently are no studies to support this practice.

    Dosing of perineural infusions depends also on the nerve to be blocked. Regional techniques involving direct visualization of the nerve, such as brachial plexus blocks, under ultrasound, usually require less volume per hour. This is in contrast to larger volume nerve blocks, such as epidural, paravertebral, and abdominal wall blocks, in which success may be dependent on larger volume for more extensive spread of LA. Recommended ropivacaine infusion rates for specific peripheral nerve blocks are presented in Table 23.4.

    Table 23.4: Recommended continuous infusion starting rates for peripheral nerve catheters. Catheters may be titrated up to maximum dosage: 0.4–0.5 mg/kg/h. This may be achieved by increased rate (mL/h) or concentration of local anesthetic (i.e., 0.2% ropivacaine)

    Nerve Catheter

    Rate (mL/kg/h)

    Maximum Rate (mL/h)

    % Ropivacaine

    Femoral

    0.15

    8

    0.1

    Lumbar plexus

    0.25

    15

    0.1

    Fascia iliaca

    0.25

    15

    0.1

    Sciatic (gluteal)

    0.1

    5

    0.1

    Sciatic (popliteal)

    0.1

    8

    0.1

    Interscalene

    0.1

    7

    0.1

    Infraclavicular/

    supraclavicular

    0.15

    10

    0.1

    Paravertebral (unilateral)

    0.25

    15

    0.2

    Paravertebral (per side for bilateral)

    0.15

    10

    0.2

    Quadratus Lumborum

    (per side for bilateral)

    0.15

    10

    0.1 or 0.2

    Rectus Sheath

    (per side for bilateral)

    0.15

    10

    0.1 or 0.2

    Calculations for case: infraclavicular approach to the brachial plexus in a 36-kg patient:

    1. 1. Bolus/single injection: 0.1 to 0.2 mg/kg or 4 to 7 mL of 0.2% ropivacaine or 0.25% bupivacaine (minimum volume to accomplish perineural surround is advised).

    2. 2. Infusion: 0.1% ropivacaine or bupivacaine can be used at a rate of 0.1 ml/kg/h. In this patient, the calculated rate is 3 to 3.6 mL/h. If compartment syndrome is a risk, follow the recommended protocol and start infusion at 2.5 mL/h.

    Further Reading

    Berde C. Convulsions associated with pediatric regional anesthesia. Anesth Analg. 1992;75:164–166.Find this resource:

    Gunter JB. Benefit and risk of local anaesthetics in infants and children. Paediatr Drugs. 2002;4:649–672.Find this resource:

    Mossetti V, Vicchio N, Ivani G. Local anesthetics and adjuncts in pediatric regional anesthesia. Curr Drug Targets. 2012;13:952–960.Find this resource:

    Noonan KJ, McCarthy JJ. Compartment syndromes in the pediatric patient. J Pediatr Orthop. 2010;30(2 suppl):S96–S101.Find this resource:

    3. Postoperative Considerations

    3.1. Should an opioid prescription be written at discharge? If so, is persistent postsurgical opioid use in this population a concern?

    An adequate postoperative pain management plan is essential to facilitate a successful transition to the home environment. Inadequate pain relief and adverse drug effects are the 2 most common reasons for prolonged length of stay and hospital readmission. Due to the severity of pain following orthopedic procedures, a short course of opioid analgesics to supplement around-the-clock acetaminophen and NSAIDs is typically utilized.

    While there is increasing concern over exposing pediatric patients to opioids with the potential for addiction and abuse, acute pain must be addressed to prevent unnecessary suffering and the possible transition to chronic pain. Prescription opioid abuse is not common in patients less than 12 years of age, and any increased incidence of opioid overdose presentations to emergency departments is predominantly the result of accidental ingestion of medications prescribed to family members. Adolescents are, however, an at-risk group, with increasing potential for opioid abuse and addiction. Preoperative risk factors in adolescents such as substance use disorder, chronic pain, preoperative opioid prescription filling, and female gender have recently been described as being associated with prolonged opioid use following surgery. Physicians and ancillary healthcare professional should be aware of risk factors for opioid abuse, which include a family history of substance abuse, psychiatric diagnosis, childhood trauma, sexual abuse, loss of a parent, violence, or an environment where prescription drug abuse is common. Adolescents should be screened for risk factors and monitored accordingly. Most states have drug monitoring programs that allow for and often mandate that physicians register opioid prescriptions and check for evidence of duplicate prescriptions. Massachusetts law limits opioid prescriptions for acute pain to minors to a 7-day supply, and other states such as North Carolina have instituted opioid prescribing limits for acute postsurgical pain. Ambulatory RA catheter programs are increasingly available for pediatric patients and allow the continued benefit of the RA at home, including opioid minimization in the immediate postdischarge time frame. Several pediatric studies have demonstrated the feasibility and safety of ambulatory catheters.

    In summary, a multimodal approach to analgesia, including RA techniques, should be used to address pediatric pain for orthopedic surgery. Pain should be adequately addressed in both the hospital and home environments.

    Further Reading

    Bukstein O. Challenges and gaps in understanding substance use problems in transitional age youth. Child Adolesc Psychiatr Clin North Am. 2017;26:253–269.Find this resource:

    Centers for Disease Control and Prevention. Opioid painkiller prescribing: where you live makes a difference. Atlanta, GA. www.cdc.gov/vitalsigns/opioid-prescribing/. Accessed March 8, 2017.

    Dadure C, Pirat P, Raux O, Troncin R, Rochette A, Ricard C, Capdevila X. Perioperative continuous peripheral nerve blocks with disposable infusion pumps in children: a prospective descriptive study. Anesth Analg. 2003;97:687–690.Find this resource:

    Gurnaney H, Kraemer FW, Maxwell L, Muhly WT, Schleelein L, Ganesh A. Ambulatory continuous nerve blocks in children and adolescents: a longitudinal 8-year single center study. Anesth Analg. 2014;118:621–627.Find this resource:

    Harbaugh CM, Lee JS, Hu HM, McCabe SE, Voepel-Lewis T, Englesbe MJ, Brummett CM, Waljee JF. Persistent opioid use among pediatric patients after surgery. Pediatrics. 2018 Jan;141(1):e20172439.Find this resource:

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