How Has Ultrasound Changed the Practice of Pediatric Regional g Anesthesia? Edward R. Mariano, MD, MAS

Associate Professor of Anesthesia Stanford University School of Medicine Chi f Anesthesiology Chief, A th i l and d Perioperative P i ti Care C Veterans Affairs Palo Alto Health Care System

Update on Pediatric Regional Anesthesia

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

Update on Pediatric Regional Anesthesia

Overview 

 



Challenges with regional anesthesia in children Practice patterns 1990s-2000s Applications of ultrasound in pediatric regional anesthesia E id Evidence basis b i for f ultrasound lt d guidance id in i pediatric regional anesthesia

Update on Pediatric Regional Anesthesia

Overview 

 



Challenges with regional anesthesia in children Practice patterns 1990s-2000s Applications of ultrasound in pediatric regional anesthesia E id Evidence basis b i for f ultrasound lt d guidance id in i pediatric regional anesthesia

2

Update on Pediatric Regional Anesthesia

Traditional Nerve Localization Methods 



Anatomic landmarks Electrical nerve stimulation 



Sustained “twitch” at < 0.5 mA current suggests appropriate needle position

“Pops”

Update on Pediatric Regional Anesthesia

Regional Anesthesia for Kids vs. Adults 

 

Landmarks – cm rules do not apply Performed under GA Test dose unreliable1 

Pharmacokinetics 



Pharmacodynamics 

1. Desparmet J, et al. Anesthesiology 1990;72:249 2. Thomas J, et al. Clin Pharm Ther 1975;19:426

Dec plasma proteins2 Dec min anesthetic concentration3

3. Benzon HT, et al. BJA 1988;61:754

3

Update on Pediatric Regional Anesthesia

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

Update on Pediatric Regional Anesthesia

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

Update on Pediatric Regional Anesthesia

Not All Crying is Pain (Only Sometimes)

FLACC scale: ages 0-3 yrs or non-verbal all ages

Update on Pediatric Regional Anesthesia

Pain Scales for Older Kids

Wong scale: ages 3-7 yrs

Numeric rating scale: ages 7 yrs and up

5

Update on Pediatric Regional Anesthesia

Overview 

 



Challenges with regional anesthesia in children Practice patterns 1990s-2000s Applications of ultrasound in pediatric regional anesthesia E id Evidence basis b i for f ultrasound lt d guidance id in i pediatric regional anesthesia

Update on 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

Update on Pediatric Regional Anesthesia

Practice Patterns (1990s)

PNB 16.8%

Giaufre E, et al. A&A 1996;83;904

Update on Pediatric Regional Anesthesia

Practice Patterns (2000s)  





Follow up study from ADARPEF Follow-up 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

Update on Pediatric Regional Anesthesia

Practice Patterns (2000s)

PNB 66.0%

Ecoffey C, et al. Ped Anes 2010;20;1061

Update on Pediatric Regional Anesthesia

Peripheral vs. Neuraxial Blocks 

 



Avoid urinary retention Less hypotension Sparing of nonoperative limb N risk No i k off epidural id l hematoma or spinal cord injury Ross AK, et al. A&A 2000;91:16

8

Update on Pediatric Regional Anesthesia

Why Did Things Change? 







Emergence of truncal blocks since 1st 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

Update on Pediatric Regional Anesthesia

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

Update on Pediatric Regional Anesthesia

Sneak Preview of PRAN Data 







Initial analysis of data gathered from April 2007 – March 2010 14,917 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

Update on Pediatric Regional Anesthesia

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 (n=1849; 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

Update on Pediatric Regional Anesthesia

Current PRAN Centers  







Seattle Children’s Hospital Children’s Hospital Colorado (Denver) Children’s Hospital at Dartmouth Children’ss Memorial Hospital Children (Chicago) Lucile Packard Children’s Hospital (Stanford)



      

Children’s Medical Center, Dallas Columbia University The Cleveland Clinic Children’s Hospital, Boston T Texas Children’s Child ’ Hospital H it l University of Texas, Houston University of New Mexico Oregon Health Sciences University

Update on Pediatric Regional Anesthesia

11

Update on Pediatric Regional Anesthesia

Overview 

 



Challenges with regional anesthesia in children Practice patterns 1990s-2000s Applications of ultrasound in pediatric regional anesthesia E id Evidence basis b i for f ultrasound lt d guidance id in i pediatric regional anesthesia

Update on Pediatric Regional Anesthesia

Early Published Advantages of Ultrasound

Direct visualization of relevant anatomy Real--time confirmation of local anesthetic spread Real

?

? ?

Improved p o d operator op a o performance p o a and a d outcomes ou o s

?

Improved quality and patient safety

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

Update on Pediatric Regional Anesthesia

Safety of Regional Anesthesia in Kids 

Complication rates (1 yr)1  





1.5 per 1000 neuraxial 0 per 1000 peripheral

5 yr study: no permanent adverse events2 34 C Case reports t 3,4  

Epidural abscess Spinal cord injury

1. Giaufre E, et al. A&A 1996;83;904 2. DeVera HV, et al. J Ped Ortho 2006;26:801

3. Larsson BA, et al. A&A 1997;84:1245 4. Kasai T, et al. A&A 2003;96:65

Update on Pediatric Regional Anesthesia

First Report of UGRA in Pediatrics

13

Update on Pediatric Regional Anesthesia

Enthusiasm for UGRA in Pediatrics 





RCT of infraclavicular block with ultrasound vs. nerve stimulation1  Less pain during block placement  Faster onset and longer duration Also used to image interscalene brachial plexus, l sciatic i ti nerve, lumbar l b plexus, l and d 2-5 ilioinguinal nerve Safer under GA? 1. Marhofer P, et al. Anaes 2004;59:642

2. Marhofer P, et al. BJA 2005;94:7 3. Gray AT, et al. A&A 2003;97:1300 4. Kirchmair L, et al. Anesth 2004;101:445 5. Mariano ER, et al. Ped Anes 2008;18:598

Update on Pediatric Regional Anesthesia

Ultrasound-Guided Extremity Blocks    

Brachial plexus11-66 Lumbar plexus7 Femoral nerve8 Sciatic nerve3,8,9

1. Fredrickson MJ. Anaes Int C 2007;35:807 2 van 2. an Geffen GJ, GJ et al al. Paed Anaes 2006;16:330 2006 16 330 3. Mariano ER, et al. Ped Anes 2008;18:598 4. De Jose Maria B, et al. Paed Anaes 2008;18:838 5. Marhofer P, et al. Anaes 2004;59:642 6. Loland & Mariano. Ped Anes 2009:19:905

7. Kirchmair L, et al. Anes 2004;101:445 8. Oberndorfer U, et al. BJA 2007;98:797 9. Schwemmer, Schwemmer, et al. Paed Anaes 2004;14:1005

14

Update on Pediatric Regional Anesthesia

Ultrasound-Guided Truncal Blocks 

 

Transversus abdominis plane1,2 Ilioinguinal, iliohypogastric3,4 Rectus sheath5 EO IO

1. Lashgari & Harmon. JCA 2008;20:156 2. Suresh & Chan. Paed Anaes 2009;19:296 3. Willschke H, et al. BJA 2005;95:226 4. Weintraud M, et al. A&A 2009;108:1488 5. Willschke H, et al. BJA 2006;97:244

TA Rectus

Update on Pediatric Regional Anesthesia

Recent Reviews of UGRA in Pediatrics

Anesthesiology 2010;112:473

Anesthesiology 2010;112:719

15

Update on Pediatric Regional Anesthesia

Interscalene Block with Ultrasound 





Position: supine with head turned away Anterior or posterior approach Performed with or without nerve stimulation1,2

1. Jan van Geffen G, et al. Paed Anaes 2006;16:330 2. Mariano ER, et al. Ped Anes 2008;18:598

Update on Pediatric Regional Anesthesia

Supraclavicular Block with Ultrasound 







Patient in semi semi-recumbent 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

Update on Pediatric Regional Anesthesia

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 t toward d artery t Deposit local anesthetic around each cord

1. De Jose Maria B, et al Ped Anes 2008;18:838 2. Marhofer P, et al. Anaes 2004;59:642 3. Loland VJ, et al. Ped Anes 2009:19:905

Update on Pediatric Regional Anesthesia

Femoral Nerve Block with Ultrasound 





Pl Place high-frequency hi h f 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

Update on Pediatric Regional Anesthesia

Subgluteal Sciatic Block with Ultrasound 





Place large lowlow frequency curvilinear or linear probe between femur and ischial tuberosity Insert needle lateral to probe and aim medially Deposit local anesthetic below gluteal fascia 1. Van Geffen GJ, et al. A&A 2006;103:328 around nerve 2. Gray AT, et al. A&A 2003;97:1300 3. Sukhani R, et al. A&A 2004;99:584

Update on Pediatric Regional Anesthesia

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;14:1005 2. Mariano ER, et al. Ped Anes 2008;18:598

18

Update on Pediatric Regional Anesthesia

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

Update on Pediatric Regional Anesthesia

Overview 

 



Challenges with regional anesthesia in children Practice patterns 1990s-2000s Applications of ultrasound in pediatric regional anesthesia E id Evidence basis b i for f ultrasound lt d guidance id in i pediatric regional anesthesia

19

Update on Pediatric Regional Anesthesia

Review of the Evidence

RAPM 2010;35:S1-S9

RAPM 2010;35:S47-S54

Update on Pediatric Regional Anesthesia

Review of the Evidence

Neal JM, et al. RAPM 2010;35:S1

20

Update on Pediatric Regional Anesthesia

Review of the Evidence

Neal JM, et al. RAPM 2010;35:S1 Jadad AR, et al. Con Clin Trials 1996;17:1

Update on Pediatric Regional Anesthesia

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

Update on Pediatric Regional Anesthesia

Review of the Evidence

Tsui BCH, et al. RAPM 2010;35:S47

Update on Pediatric Regional Anesthesia

Review of the Evidence Tsui BCH, et al. RAPM 2010;35:S47 

Summary:   

  

No evidence that US reduces block performance time US hastens block onset1 US does not improve block success for upper ext PNB1 but does for trunk2 13 US prolongs p olongs analgesia fo for upper/lower ppe /lo e e extt PNB1,3 US decreases LA volume required (0.1-0.3 ml/kg)3,4 US allows visibility of neuraxial structures5

1. Marhofer P, et al. Anaes 2004;59:642 2. Weintraud M, et al. A&A 2009;108:1488 3. Oberndorfer U, et al. BJA 2007;98:797

4. Willschke H, et al. A&A 2006;102:1680 5. Marhofer P, et al. Ped Anes 2005;15:671

22

Update on Pediatric Regional Anesthesia

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