◊ BACKGROUND AND OBJECTIVES:
We assessed the feasibility and efficacy of postoperative pain control by continuous peripheral nerve blockade (CPNB) in children after early home discharge under parental surveillance.
◊ METHODS:
All children scheduled for primary elective ankle or foot surgery under sciatic popliteal CPNB and general anesthesia were evaluated. After obtaining the surgeon's consent, the children were discharged on either the day (D) of surgery (D0), or on postoperative D1 or D2 (depending on whether they needed a plaster cast or a suction drainage). The CPNB was continuously infused, using an elastomeric pump. Before the procedure, the parents were taught how to assess their children's pain, to use rescue analgesia, and to manage an infusion elastomeric pump device, and when to call the hospital in case of emergency. The children returned to the hospital for catheter removal and the recording of any postoperative event.
◊ RESULTS:
Forty-seven children were entered into this observational study. Two were discharged home on the same day, 30 were discharged home 1 day after surgery, and 15 were discharged home 2 days after surgery. The mean duration of infusion elastomeric pump at home was 3 days (range, 2 to 4 days). Analgesia was rated as excellent or good in 89% of the cases, and the quality of sleep was always good, except for three patients. Some minor untoward effects were recorded. Two children returned to the hospital because of accidental disconnection of the infusion elastomeric pump from the catheter. Four patients presented skin redness at the puncture site, but no infection was observed, and all catheters remained sterile. No parents called the hospital. The children's quality of life was rated as excellent or as satisfactory overall, by both the children and their parents.
◊ CONCLUSIONS:
Shortening hospital stays with the use of at-home CPNB under sole parental supervision is feasible, after selecting children with a suitable family environment.
◊ Reviewed by P. Narchi, MD
France
Many recent publications have focused on the feasibility of home analgesia using peripheral nerve catheters after moderate and even major orthopedic surgery in adults. Indeed, these catheters have been extensively evaluated in adults after moderate surgical procedures known to be postoperatively painful, such as shoulder cuff repair, anterior cruciate ligament repair and foot surgery. The feasibility of such nerve catheters to provide analgesia at home (after discharging the patients at Day 1) has been demonstrated even after major orthopedic surgeries such as total shoulder arthroplasty, total elbow arthroplasty, total hip arhroplasty, and total knee arthroplasty.
However, such an elegant and innovative mode of analgesia cannot be promoted without restrictions such as stable medical health status, optimal psychosocial conditions, and regular follow-up at home by experienced nurses.
Very few studies have so far investigated the advantages of using peripheral nerve catheters at home in children. The present study deals with the use of popliteal nerve catheters at home in pediatric patients after orthopedic surgery. Indeed, foot and ankle surgery are known to be postoperatively very painful and popliteal nerve catheter is considered the gold standard for analgesia in this setting. Before using ambulatory nerve catheter analgesia in children, a preoperative screening of parental environment is crucial. The parents should be able to understand and follow all instructions delivered by doctors otherwise the child should be managed as inpatient. Forty-seven children were included in this study and intraoperative analgesia (using this catheter) was effective in all patients. The hourly bolus injections of a mixture of 0.75% ropivacaine and 1% lidocaine with epinephrine during surgery seem generous especially with regard to the long-acting local anesthetic ropivacaine.
I appreciate the authors’ recommendation to wait in the recovery room for block regression before starting the infusion of local anesthetics in order to check the absence of nerve injury and to confirm the efficacy of infusion analgesia after disappearance of the surgical block. However, the addition of clonidine to 0.2% ropivacaine for postoperative infusion can be questioned because clonidine can
- postoperatively enhance motor blockade
and
- induce dizziness which at home can lead to falls.
The observed quality of postoperative analgesia at home was very promising with 42% of patients considered as “pain-free”, 47% using only acetaminophen and only 11% using acetaminophen and codeine. These results are comparable to previous studies using popliteal nerve catheters confirming the position of this catheter as the gold standard after foot and ankle surgery. Moreover, indicators of quality of life such as quality of sleep and behavioral status were excellent which represent a major advantage in pediatric patients.
Analysis of complications is encouraging since none was major (nerve injury, blood toxicity or infection). Two cases of catheter disconnection have been observed but no accidental catheter withdrawal was reported (knowing that the mean duration of home infusion was 3 days). Finally, it is noteworthy that despite the highly sensitive psychological environment, there was not even one phone call to the surgical center during the whole study period confirming the high quality of the whole process (screening, efficacy, monitoring, etc …).
The small sample size only allows for limited conclusions, however, this observational study is very encouraging. Larger studies in the future are needed to confirm the safety of these catheters at home. Besides the excellent analgesia provided by nerve catheters, this concept allows for an earlier discharge home and respects the quality of life and the environment of these children.
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