How Has Ultrasound Changed the Practice of Pediatric Regional Anesthesia? Update on Pediatric Regional Anesthesia
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1 How Has Ultrasound Changed the Practice of Pediatric Regional Anesthesia? Edward R. Mariano, MD, MAS Associate Professor of Anesthesia Stanford University School of Medicine Chief, Anesthesiology and Perioperative Care Veterans Affairs Palo Alto Health Care System Financial Disclosures Teleflex Medical Research Support Miramar Labs Consulting SonoSite, I-Flow Educational Programs The contents of the following presentation were solely the responsibility of the speaker without input from any of the above companies. 1
2 Overview Challenges with regional anesthesia in children Practice patterns 1990s-2000s Applications of ultrasound in pediatric regional anesthesia Eid Evidence basis for ultrasound guidance in pediatric regional anesthesia Overview Challenges with regional anesthesia in children Practice patterns 1990s-2000s Applications of ultrasound in pediatric regional anesthesia Eid Evidence basis for ultrasound guidance in pediatric regional anesthesia 2
3 Traditional Nerve Localization Methods Anatomic landmarks Electrical nerve stimulation Sustained twitch at < 0.5 ma current suggests appropriate needle position Pops Regional Anesthesia for Kids vs. Adults Landmarks cm rules do not apply Performed under GA Test dose unreliable 1 Pharmacokinetics Dec plasma proteins 2 Pharmacodynamics Dec min anesthetic concentration 3 1. Desparmet J, et al. Anesthesiology 1990;72: Thomas J, et al. Clin Pharm Ther 1975;19: Benzon HT, et al. BJA 1988;61:754 3
4 Dangers in Pediatric Regional Anesthesia Nerve targets are close to critical structures (eg, pleura) Patients are often sedated or under general anesthesia Volume is limited due to local anesthetic toxicity concerns Difficult to Assess Benefits Cannot measure onset when under GA Can measure intraop anesthetic requirements Can measure recovery time from GA Can measure opioid requests Return of GI function (less opioids)? Stress response? Tsui BCH, et al. RAPM 2010;35:S47 Ross AK, et al. A&A 2000;91:16 Bosenberg A. Paed Anaes 2004;14:398 4
5 Not All Crying is Pain (Only Sometimes) FLACC scale: ages 0-3 yrs or non-verbal all ages Pain Scales for Older Kids Wong scale: ages 3-7 yrs Numeric rating scale: ages 7 yrs and up 5
6 Overview Challenges with regional anesthesia in children Practice patterns 1990s-2000s Applications of ultrasound in pediatric regional anesthesia Eid Evidence basis for ultrasound guidance in pediatric regional anesthesia Practice Patterns (1990s) French Language Society of Pediatric Anesthesiologists (ADARPEF) Prospective multi-center study (38 institutions in Europe) Voluntary reporting from May 1993 April 1994 Of 85,412 total pediatric anesthetics, 24,409 cases involved a regional or local anesthetic ± general anesthesia Giaufre E, et al. A&A 1996;83;904 6
7 Practice Patterns (1990s) PNB 16.8% Giaufre E, et al. A&A 1996;83;904 Practice Patterns (2000s) Follow-up study from ADARPEF Prospective multi-center study (47 institutions in Europe and Canada) Voluntary reporting from November 2005 October 2006 Of 135,744 total pediatric anesthetics, 31,132 cases involved a regional anesthetic ± general anesthesia Ecoffey C, et al. Ped Anes 2010;20;1061 7
8 Practice Patterns (2000s) PNB 66.0% Ecoffey C, et al. Ped Anes 2010;20;1061 Peripheral vs. Neuraxial Blocks Avoid urinary retention Less hypotension Sparing of nonoperative limb No risk of epidural hematoma or spinal cord injury Ross AK, et al. A&A 2000;91:16 8
9 Why Did Things Change? Emergence of truncal blocks since 1 st ADARPEF study (eg, ilioinguinal) Continuous peripheral nerve blocks possible decreased interest in neuraxial techniques Evolution of devices for perineural catheter insertion Ultrasound is not specifically mentioned Ecoffey C, et al. Ped Anes 2010;20;1061 What about the United States? Pediatric Regional Anesthesia Network (PRAN) began in 2006 with 6 pilot sites (13 sites as of 2012) De-identified data on every regional anesthesia procedure are prospectively gathered from each site and submitted to one central server Data are routinely audited to confirm accuracy and true number of procedures Polaner DM, et al. Ped Anes 2012;22:115 Polaner DM, et al. A&A, in press 9
10 Sneak Preview of PRAN Data Initial analysis of data gathered from April 2007 March ,917 regional anesthesia procedures performed on 13,725 patients Approximately one-third were peripheral nerve blocks Nerve localization technique was recorded Polaner DM, et al. Ped Anes 2012;22:115 Polaner DM, et al. A&A, in press Sneak Preview of PRAN Data Single injection blocks: Neuraxial (n=6210; 3% ultrasound) Upper extremity (n=455; 82% ultrasound) Supraclavicular most common technique Lower extremity (n=2307; 70% ultrasound) Truncal (n=1849; >50% ultrasound) Ultrasound-guided continuous nerve blocks: 92% of upper extremity catheters (n=26) 64% of lower extremity catheters (n=543) Polaner DM, et al. A&A, in press 10
11 Current PRAN Centers Seattle Children s Hospital Children s Hospital Colorado (Denver) Children s Hospital at Dartmouth Children s Memorial Hospital (Chicago) Lucile Packard Children s Hospital (Stanford) Children s Medical Center, Dallas Columbia University The Cleveland Clinic Children s Hospital, Boston Texas Children s Hospital University of Texas, Houston University of New Mexico Oregon Health Sciences University 11
12 Overview Challenges with regional anesthesia in children Practice patterns 1990s-2000s Applications of ultrasound in pediatric regional anesthesia Eid Evidence basis for ultrasound guidance in pediatric regional anesthesia Early Published Advantages of Ultrasound Direct visualization of relevant anatomy Real-time confirmation of local anesthetic spread Improved operator performance? and outcomes Improved quality? and patient safety?? Improved po doperator ao performance and doutcomes o Kapral S, et al. A&A 1994;78:507 Ootaki C, et al. RAPM 2000;25:600 Sandhu, NS, et al. BJA 2002;89:254 12
13 Safety of Regional Anesthesia in Kids Complication rates (1 yr) per 1000 neuraxial 0 per 1000 peripheral 5 yr study: no permanent adverse events 2 Case reports 34 3,4 Epidural abscess Spinal cord injury 1. Giaufre E, et al. A&A 1996;83; DeVera HV, et al. J Ped Ortho 2006;26: Larsson BA, et al. A&A 1997;84: Kasai T, et al. A&A 2003;96:65 First Report of UGRA in Pediatrics 13
14 Enthusiasm for UGRA in Pediatrics RCT of infraclavicular block with ultrasound vs. nerve stimulation 1 Less pain during block placement Faster onset and longer duration Also used to image interscalene brachial plexus, sciatic nerve, lumbar plexus, and ilioinguinal nerve 2-5 Safer under GA? 1. Marhofer P, et al. Anaes Anaes 2004;59: Marhofer P, et al. BJA 2005;94:7 3. Gray AT, et al. A&A 2003;97: Kirchmair L, et al. Anesth 2004;101: Mariano ER, et al. Ped Anes 2008;18:598 Ultrasound-Guided Extremity Blocks Fredrickson MJ. Brachial plexus 2. van Geffen GJ, Lumbar plexus 7 Femoral nerve 8 Sciatic nerve 3,8,9 1. Fredrickson MJ. Anaes Int C 2007;35:807 GJ, et al. Paed Anaes 2006;16: Mariano ER, et al. Ped Anes 2008;18: De Jose Maria B, et al. Paed Anaes 2008;18: Marhofer P, et al. Anaes 2004;59: Loland & Mariano. Ped Anes 2009:19: Kirchmair L, et al. Anes 2004;101: Oberndorfer U, et al. BJA 2007;98: Schwemmer, et al. Paed Anaes 2004;14:
15 Ultrasound-Guided Truncal Blocks Transversus abdominis plane 1,2 Ilioinguinal, iliohypogastric 3,4 Rectus sheath 5 EO IO 1. Lashgari & Harmon. JCA 2008;20: Suresh & Chan. Paed Anaes 2009;19: Willschke H, et al. BJA 2005;95: Weintraud M, et al. A&A 2009;108: Willschke H, et al. BJA 2006;97:244 TA Rectus Recent Reviews of UGRA in Pediatrics Anesthesiology 2010;112:473 Anesthesiology 2010;112:719 15
16 Interscalene Block with Ultrasound Position: supine with head turned away Anterior or posterior approach Performed with or without nerve stimulation 1,2 1. Jan van Geffen G, et al. Paed Anaes 2006;16: Mariano ER, et al. Ped Anes 2008;18:598 Supraclavicular Block with Ultrasound Patient in semi-recumbent position or supine High-frequency linear probe is placed medial to clavicle to visualize subclavian artery in cross section Insert needle posterior to probe in-plane Faster than infra: 9 min vs. 13 min De Jose Maria B, et al. Ped Anes 2008;18:838 16
17 Infraclavicular Block with Ultrasound Small curvilinear or linear probe placed infracoracoid for XS image of axillary artery Insert needle cephalad to probe and direct in-plane toward artery Deposit local anesthetic around each cord 1. De Jose Maria B, et al Ped Anes 2008;18: Marhofer P, et al. Anaes 2004;59: Loland VJ, et al. Ped Anes 2009:19:905 Femoral Nerve Block with Ultrasound Place high-frequency h linear probe at inguinal crease Identify femoral nerve lateral to artery below fascia iliaca Inject local anesthetic under fascia iliaca and surround nerve Oberndorfer U, et al. BJA 2007;98:797 17
18 Subgluteal Sciatic Block with Ultrasound Place large lowfrequency curvilinear or linear probe between femur and ischial tuberosity Insert needle lateral to probe and aim medially Deposit local anesthetic below gluteal fascia around nerve 1. Van Geffen GJ, et al. A&A 2006;103: Gray AT, et al. A&A 2003;97: Sukhani R, et al. A&A 2004;99:584 Popliteal Sciatic Block with Ultrasound Image sciatic nerve with high-frequency linear probe Insert needle laterally and advance in-plane through biceps femoris Inject local anesthetic around nerve 1. Schwemmer U, et al. Paed Anaes 2004;14: Mariano ER, et al. Ped Anes 2008;18:598 18
19 Ultrasound for Continuous Nerve Blocks Limited to case reports and series In children, primary indication is pain control with reduction in opioid consumption May be helpful for physical therapy and rehabilitation (increasing prevalence of sports injuries) May improve vascular supply for reconstructive surgeries van Geffen GJ, et al. A&A 2006;103:328 van Geffen GJ, et al. CJA 2007;54:952 Mariano ER, et al. Ped Anes 2008;18:598 Loland & Mariano. Ped Anes 2009;19:905 Overview Challenges with regional anesthesia in children Practice patterns 1990s-2000s Applications of ultrasound in pediatric regional anesthesia Eid Evidence basis for ultrasound guidance in pediatric regional anesthesia 19
20 Review of the Evidence RAPM 2010;35:S1-S9 RAPM 2010;35:S47-S54 Review of the Evidence Neal JM, et al. RAPM 2010;35:S1 20
21 Review of the Evidence Neal JM, et al. RAPM 2010;35:S1 Jadad AR, et al. Con Clin Trials 1996;17:1 Review of the Evidence? 12 publications met the criteria for inclusion Peripheral nerve blocks: 6 RCTs (only 2 with Jadad score of 5) 6 case series n>10 Neuraxial blocks: 1 RCT 1 other comparative study 10 case series n>10 Tsui BCH, et al. RAPM 2010;35:S47 21
22 Review of the Evidence Tsui BCH, et al. RAPM 2010;35:S47 Review of the Evidence Summary: Tsui BCH, et al. RAPM 2010;35:S47 No evidence that US reduces block performance time US hastens block onset 1 US does not improve block success for upper ext PNB 1 but does for trunk 2 US prolongs analgesia for upper/lower e ext PNB 13 1,3 US decreases LA volume required ( ml/kg) 3,4 US allows visibility of neuraxial structures 5 1. Marhofer P, et al. Anaes 2004;59: Weintraud M, et al. A&A 2009;108: Oberndorfer U, et al. BJA 2007;98: Willschke H, et al. A&A 2006;102: Marhofer P, et al. Ped Anes 2005;15:671 22
23 Summary Pediatric regional anesthesia practice continues to evolve Ultrasound guidance for regional anesthesia offers potential benefits to the pediatric patient Techniques in children differ slightly from adults More randomized clinical trials and large outcomes studies are still needed 23
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