Canadian Journal of Anesthesia 51:928-930 (2004)
© Canadian Anesthesiologists' Society, 2004
Obstetrical and Pediatric Anesthesia
Patient-controlled regional analgesia is effective in children: a preliminary report
[L’analgésie régionale auto-contrôlée est efficace chez les enfants : une étude préliminaire]
Frédéric Duflo, MD*,
Youssef Qamouss, MD*,
Charlotte Rémond, MD*,
Agnès Pouyau, MD*,
Armand Heilporn, MD*,
Patricia Taylor, MD*,
Brigitte Paturel, MD*,
Sylvie Combet, MD*,
Emmanuel Boselli, MD*,
Franck Chotel, MD
,
Jérôme Bérard, MD PhD and
Dominique Chassard, MD PhD*
* From the Departments of Anesthésie-Réanimation, and
Chirurgie Infantile Orthopédique, Hôpital Debrousse, Lyon, France.
Address correspondence to: Dr. Frédéric Duflo, Département d’Anesthésie-Réanimation, Hôpital Debrousse, 29, rue S
ur Bouvier, 69322 Lyon Cedex 05, France. Phone: 33-4-72-41-31-72; Fax: 33-4-72-41-31-35; E-mail: frederic.duflo{at}chu-lyon.fr
 |
Abstract
|
|---|
Purpose: To report a preliminary analysis of prospectively recorded data in 27 children in whom patient-controlled regional analgesia (PCRA) was used for postoperative pain control following lower limb surgery.
Methods: Under general anesthesia, perineural catheters (popliteal and fascia iliaca compartment block) were inserted and infused with ropivacaine 0.2% (0.02 mL·kg–1·hr–1). Additional demand doses were left to the child’s discretion (0.1 mL·kg–1and a 30-min lockout interval).
Results: The average total dose of ropivacaine administered was 4.9 ± 2 mg·kg–1over 48 hr. Visual analogue scale and Children’s Hospital of Eastern Ontario Pain Scale scores were always inferior to 5/10 and 6/13, respectively. Motor block was observed in two children and two children needed rescue analgesia.
Conclusions: Our preliminary observations indicate that PCRA in children provides satisfactory postoperative pain relief following lower limb surgery.
|
Introduction
|
|---|
IT is customary to use regional analgesia for postoperative pain control in children after orthopedic procedures. The continuous epidural or peripheral infusion of a local anesthetic provides satisfactory pain relief, however, the goal of either analgesic technique is to achieve adequate analgesia with a minimal amount of drug to decrease any side effect associated with the local anesthetic. In adults, patient-controlled epidural analgesia (PCEA) offers the possibility for optimal analgesia with a smaller amount of local anesthetic than during continuous epidural analgesia (CEA).1 In addition, we and others have recently showed the benefits of PCEA over CEA in children after major orthopedic surgery.2,3 However, a recent prospective survey of regional anesthesia stressed the extremely low incidence of complications (zero in the study) after peripheral nerve blocks prompting pediatric anesthesiologists to use them in the place of a central block.4 In keeping with this recommendation, several studies have recently suggested the advantage of continuously administered local anesthetics through a peripheral nerve catheter for postoperative pain relief.5,6 While the concept of patient-controlled regional analgesia (PCRA) to reduce local anesthetic administration has been evaluated in adults,7 it has not been reported in children. Therefore, we prospectively evaluated PCRA with ropivacaine 0.2% after pediatric orthopedic procedures.
|
Methods
|
|---|
After Institutional approval and obtaining written informed consent from parents, we studied children aged four to 17 yr. Children were scheduled for lower limb orthopedic procedures that required major analgesia. Patients were visited before their operation and taught to use the trigger of the PCRA machine (Abbott Pain Manager; Abbott Laboratories, Chicago, IL, USA). Exclusion criteria followed regional anesthesia guidelines. After the surgical procedure, under general anesthesia, catheters were placed for fascia iliaca compartment block (Contiplex A®, Braun Medical, Boulogne, France) or sciatic nerve popliteal block (Contiplex Tuohy® with neurostimulator Stimuplex®, Braun Medical) as described previously.5,8 After placement of the catheter, 0.5 mL·kg–1of ropivacaine 0.2% were administered through the catheter. In the postanesthesia care unit, patients received a low dose infusion of 0.02 mL·kg–1·hr–1of ropivacaine 0.2% and self administered demands were set at 0.1 mL·kg–1with a 30-min lockout interval and a maximal dose of 1 mL·kg–1over a four-hour period. During the 48 hr study period, the quality of analgesia was assessed by using the visual analogue scale (VAS) or the Children’s Hospital of Eastern Ontario Pain Scale (Cheops) when applicable, and demand to delivery (D/D) ratios. Children were not awakened for assessment, and "asleep" was recorded on the chart at these times. The degree of motor block in the lower extremities was recorded with a modified Bromage scale (score: 0 = no movement; 1 = ankle only; 2 = ankle and knee; 3 = ankle, knee, and hip). Pain and motor block scores and volume of ropivacaine infused were recorded every four hours for 48 hr by an independent observer. All patients received paracetamol 15 mg·kg–1and ketoprofen 1 mg·kg–1intravenously every six hours. Supplemental analgesia (nalbuphine 0.2 mg·kg–1 iv) was given if patients complained of inadequate analgesia despite activating the demand button. At the end of the 48 hr postoperative period, the total consumption of ropivacaine was noted. Specific issues, such as regional catheter-related problems (disconnection, leakage, and local inflammation), were also recorded. Data are presented as mean and standard deviation.
|
Results
|
|---|
Twenty-seven children were studied. All patients underwent successful regional catheter placement. Demographic characteristics of the children are presented in the Table
. VAS, Cheops, the total number of boluses received and attempted and the D/D ratio averaged 1.09 ± 1.15, 4.75 ± 1.1, 10.6 ± 9.9, 26.1 ± 32.8 and 2.19 ± 1.5, respectively, during the 48 hr postoperative period. Patients received 4.9 ± 2 mg·kg–1of ropivacaine 0.2% over 48 hr and the total dose of ropivacaine was 190.7 ± 102.2 mg over 48 hr. Two patients received supplemental analgesia. Two patients presented a motor blockade. One catheter was removed by the investigator because of leakage around the insertion site (patient excluded). No complication such as skin infection, accidental removal, local hematoma or nerve injection was noted.
|
Discussion
|
|---|
Our preliminary study shows, for the first time, that PCRA of the lower extremity with plain ropivacaine 0.2% provides satisfactory analgesia in children during the first 48 hr after surgery, as evidenced by low pain scores or supplemental analgesic requirements. In addition, this self administered regional anesthetic technique enables low local anesthetic consumption leading to theoretically diminished cost and toxicity. Although we and others have reported the potential benefit of PCEA over CEA,2,3 there are no studies on the use of PCRA with ropivacaine 0.2% for postoperative analgesia in children. Ropivacaine 0.2% has been used in children and several studies have reported its clinical efficacy and safety when administered for epidural and peripheral anesthesia.2,9 Similarly, continuous peripheral infusion of ropivacaine 0.2% has been reported to provide satisfactory analgesia after orthopedic procedures.6 In an elderly population, PCRA showed subsequent advantages over continuous regional analgesia,7 i.e., a reduction of cost and toxicity of local anesthetic, and over morphine patient-controlled analgesia,10 i.e., a reduction of nausea and pruritus. Although we did not compare PCRA with continuous regional analgesia, we suspect that analgesia with PCRA is obtained at, approximately, half the dose of ropivacaine used by others for similar procedures.6 Thus, as in adults, PCRA may help to reduce local anesthetic doses by adjusting analgesia to demand. With regards to the continuous fixed-rate infusion used in our study, this method has shown to be associated with a better sleep pattern than without a background infusion when using iv opiates or PCEA.2,11 Whether a background infusion is required or not during PCRA in children for improving sleep pattern has never been questioned. The D/D ratio has been used as an indirect indicator of pain relief during PCA or PCEA. Adequate analgesia is usually provided with a D/D ratio less than 2.12 This study reported a mean D/D ratio of 2.19 very close to the satisfactory ratio of 2. Additionally, although eight out of the 27 children seemed to attempt to access drug beyond the limit sets (averaged D/D ratios > 2), only one required supplemental analgesia.
In summary, our preliminary results suggest that the use of PCRA of the lower extremity provides satisfactory pain relief after orthopedic surgery in children. This technique would, theoretically, offer advantages over continuously administered local anesthetics. However, further studies are required to confirm the safety of the technique.
|
Footnotes
|
|---|
Accepted for publication April 16, 2004. Revision accepted August 2, 2004.
|
References
|
|---|
1 Gambling DR, Yu P, Cole C, McMorland GH, Palmer L. A comparative study of patient controlled epidural analgesia (PCEA) and continuous infusion epidural analgesia (CIEA) during labour. Can J Anaesth 1988; 35: 249–54.[Abstract/Free Full Text]
2 Antok E, Bordet F, Duflo F, et al. Patient-controlled epidural analgesia versus continuous epidural infusion with ropivacaine for postoperative analgesia in children. Anesth Analg 2003; 97: 1608–11.[Abstract/Free Full Text]
3 Birmingham PK, Wheeler M, Suresh S, et al. Patient-controlled epidural analgesia in children: can they do it? Anesth Analg 2003; 96: 686–91.[Abstract/Free Full Text]
4 Giaufre E, Dalens B, Gombert A. Epidemiology and morbidity of regional anesthesia in children: a one-year prospective survey of the French-language society of pediatric anesthesiologists. Anesth Analg 1996; 83: 904–12.[Abstract]
5 Paut O, Sallabery M, Schreiber-Deturmeny E, Remond C, Bruguerolle B, Camboulives J. Continuous fascia iliaca compartment block in children: a prospective evaluation of plasma bupivacaine concentrations, pain scores, and side effects. Anesth Analg 2001; 92: 1159–63.[Abstract/Free Full Text]
6 Dadure C, Pirat P, Raux O, et al. Perioperative continuous peripheral nerve blocks with disposable infusion pumps in children: a prospective descriptive study. Anesth Analg 2003; 97: 687–90.[Abstract/Free Full Text]
7 di Benedetto P, Casati A, Bertini L. Continuous subgluteus sciatic nerve block after orthopedic foot and ankle surgery: comparison of two infusion techniques. Reg Anesth Pain Med 2002; 27: 168–72.[Medline]
8 Konrad C, Johr M. Blockade of the sciatic nerve in the popliteal fossa: a system for standardization in children. Anesth Analg 1998; 87: 1256–8.[Abstract/Free Full Text]
9 Dalens B, Ecoffey C, Joly A, et al. Pharmacokinetics and analgesic effect of ropivacaine following ilioinguinal/iliohypogastric nerve block in children. Paediatr Anaesth 2001; 11: 415–20.[Medline]
10 Borgeat A, Tewes E, Biasca N, Gerber C. Patient-controlled interscalene analgesia with ropivacaine after major shoulder surgery: PCIA vs PCA. Br J Anaesth 1998; 81: 603–5.[Abstract/Free Full Text]
11 Doyle E, Robinson D, Morton NS. Comparison of patient-controlled analgesia with and without a background infusion after lower abdominal surgery in children. Br J Anaesth 1993; 71: 670–3.[Abstract/Free Full Text]
12 Ginsberg B, Gil KM, Muir M, Sullivan F, Williams DA, Glass PS. The influence of lockout intervals and drug selection on patient-controlled analgesia following gynecological surgery. Pain 1995; 62: 95–100.[Medline]
This article has been cited by other articles:
|
|
|
|
 
F. Duflo, V. Sautou-Miranda, A. Pouyau, P. Taylor, S. Combet, F. Chotel, N. Bleyzac, and D. Chassard
Efficacy and plasma levels of ropivacaine for children: controlled regional analgesia following lower limb surgery
Br. J. Anaesth.,
August 1, 2006;
97(2):
250 - 254.
[Abstract]
[Full Text]
[PDF]
|
|
|
TOP
Abstract
Introduction
