Practice Advisory on Pediatric Regional Anesthesia:

Transcription

1 ESRA/ASRA Joint Committee: Practice Advisory on Pediatric Regional Anesthesia: Giorgio Ivani Regina Margherita Children s Hospital Turin Italy gioivani@libero.it

2

3 Why?

4 Obsolete?

5 Advances in Anesthesia

6

7 ADARPEF: Complications Complications (41 involving 40 patients) were rare and usually minor. They did not result in any sequelae. The study revealed an overall rate of complication of 0.12%; CI 95% [ ], significantly six times higher for central than for peripheral blocks. 96% were performed on GA or heavy sedation

8 Pediatric Regional Anesthesia Network (PRAN): a multi-institutional study of the use and incidence of complications of pediatric regional anesthesia. Polaner DM et al. Anesth Analg Dec;115(6): A total of 14,917 regional blocks, performed on 13,725 patients, were accrued from April 1, 2007 through March 31, There were no deaths or complications with sequelae lasting >3 months (95% CI 0-2:10,000). Single-injection blocks had fewer adverse events than continuous blocks, although the most frequent events (33% of all events) in the latter group were catheter-related problems. Ninety-five percent of blocks were placed while patients were under general anesthesia. Single-injection caudal blocks were the most frequently performed (40%), but peripheral nerve blocks were also frequently used (35%), possibly driven by the widespread use of ultrasound (83% of upper extremity and 69% of lower extremity blocks).

9 Age range:1 day to 18 years total blocks were performed: 53.4% central blocks and 46.6% peripheral blocks. Caudal blocks represented 82.1% of central blocks, We recorded 164 peripheral catheter placements (1.9% of all peripheral blocks): 1688 epidural catheter placements (17.3% of all central blocks): 259 thoracic and 1429 lumbar. Complications:12 dura punctures with 2 headache; 1 Horner s syndrome; 2 infected catheters.(0.12%) All blocks performed under sedation/general anesthesia All blocks performed in spontaneous ventilation

10 PRA Today It is an established technique, part of the clinical daily practice but... so far there are criticisms and controversies coming mainly from the world of adult anesthesia and even among the pediatric anesthesiologists there are discussions and different opinions and approaches

11 Paediatr Anaesth Oct;22(10): Anesth Analg 1975; 54: Guest discussion on regional anaesthesia in children. Anesth Analg 1975;54:

12 The dark age Paraplegia following intracord injection during attempted epidural anesthesia under general anesthesia Bromage FR,Benumof JL Reg Anesth Pain Med 1998;23:104-7 This case reinforces the admonition against attempting epidural puncture above the termination of the cord in unconscious, areflexic patients, and the opinion that risk of such gravity is only justified as a life-saving measure under exceptional circumstances

13 early 90ties submitted paper on epidural clonidine in children rejected because: - the Hannallah Broadman Pain Score not validated for italian children! - why clonidine (it is an antihypertensive drug!) - Your language is not english (checked by B Scott!) - Why general and regional anesthesia: double risks!

14 International Meeting, 2013 Do caudals Pay attention to peripheral blocks, they can be dangerous!

15 First steps Request to ESRA and ASRA presidents to start a new collaboration after the successful The American Society of Regional Anesthesia (ASRA) and the European Society of Regional Anesthesia (ESRA) Joint Committee Recommendations for Education and Training in Ultrasound Guided Regional Anesthesia B Sites,V Chan, J Neal, T Grau, Z Koscielnak-Nielsen, G Ivani RAPM.2009; 34(1):40-6. June-September 2013: ESRA ASRA agreement on Pediatric Committee

16 Practice Advisory on Pediatric Regional Anesthesia ASA San Francisco october 2013: first meeting : who are the experts? 4 pediatric anesthesiologists from ESRA PA Lonnqvist, C Ecoffey, F Veyckemans, G Ivani 4 pediatric anesthesiologists from ASRA S Suresh, D Polaner, E Krane, A Bosenberg ESRA and ASRA Presidents M Van de Velde, J Neal

17 Timetable June-October 2014: work at home Ivani Bosenberg : Compartment Syndrome Veyckemans Polaner : Test dose Lonnqvist Suresh : Awake vs Asleep Ecoffey- Krane : Air vs Saline Chicago april 2014: 2nd meeting Seville september 2014 : 3rd meeting New Orleans october 2014: final meeting Presentation at ESRA and ASRA annual meetings in 2015 submission to RAPM

18 our work 7 drafts december 17, 2014 final draft january 2015 final check and submission to RAPM

19 Pediatric Regional Anesthesia can be considered a safe procedure to be performed in the daily clinical practice but... in experienced hands

20 Reg Anesth Pain Med Sep-Oct;40(5):

21

22

23

24

25

26

27

28

29 anesthesiologist s weapons

30 orthopedic s weapons

31

32 Postsurgical compartment syndrome of the forearm diagnosed in a child receiving a continuous infra-clavicular peripheral nerve block. Sermeus L, Boeckx S, Camerlynck H, Somville J, Vercauteren M. Acta Anaesthesiol Belg. 2015;66(1): Opinions diverge as to whether or not regional anaesthesia delays the diagnosis of evolving acute compartment syndrome. Withholding regional anaesthesia from patients with painful orthopaedic injuries may be ethically unacceptable, however. In this report, we describe a case of acute compartment syndrome in a 4-year old child who underwent resection of a forearm osteochondroma. Analgesia was satisfactory during the first post-operative night, but the child later complained of pain despite an effective infra-clavicular block. Motor function and sensibility were disturbed and the fingers were swollen. The forearm cast was removed as it was suspected to be causing external compression. Pain disappeared while motor function and sensation recovered. The child was discharged without any complications. Despite an effective peripheral nerve block and the young age of the patient, the diagnosis of acute compartment syndrome could be made thanks to a well-defined postoperative analgesia protocol, a high level of suspicion and careful clinical assessment when break-through pain occurred.

33

34 1992 C Berde. Guidelines on Local anesthetics in pediatric regional anesthesia

35 The future is now!

36 Future ESRA/ASRA recommendations on local anesthetics and adjuvants in pediatric regional anesthesia