P90
BUILDING BLOCKS TO ENHANCED RECOVERY IN PAEDIATRIC PATIENTS UNDERGOING COMPLEX MAJOR SURGERY
E. R. Temple-Murray, D. P. D. Nielsen, A. J. Stilwell, C. Vega, C. Hill
King's College Hospital, London, UK
Introductions and Aims
Regional anaesthetic techniques reduce systemic opioid requirements and subsequently associated adverse effects. Our hospital regularly carries out complex major surgery for paediatric patients, including Kasai procedures for biliary atresia1 and congenital pulmonary airway malformation excisions. Traditionally these patients would receive opioid analgesia, including a nurse-controlled analgesic pump (NCA). Numerous adult studies, including a Cochrane review2, demonstrate paravertebral blocks to be equivalent or superior to intravenous opioids in managing post-operative pain3. We aimed to determine the effectiveness and side effect profile of regional anaesthetic blocks in paediatric patients undergoing major surgery.
Methods
This was a retrospective observational study reviewing the post-operative course of children undergoing major surgeries. Two cohorts were compared; standard analgesic methods of systemic opioids, caudal or epidural anaesthesia versus patients receiving regional techniques such as paravertebral block/catheter. The primary outcome was total opioid consumption. Secondary outcomes were length of stay and incidence of post-operative nausea and vomiting (PONV), pruritus, sedation, urinary retention and ileus.
Whether patients received a regional anaesthetic technique was dependent upon the responsible consultant anaesthetist. Data was retrospectively collected from electronic patient records. Data collected included post-operative pain assessments, daily peak pain score, NCA demands and rescue analgesia administered.
Results
An initial pilot study was conducted reviewing paediatric patients undergoing Kasai procedure for biliary atresia between October 2023 and February 2024. 7 patients were identified. 4(57%) patients received a paravertebral nerve block. 1(14%) patient received systemic opioids alone, 1(14%) was supplemented by spinal anaesthesia and 2(28%) patients had wound catheters, with all 3(43%) analysed in the standard care group. There were lower pain scores in the paravertebral group on days 1 and 2 post-operatively compared to the standard care group (median pain score of 0 vs 4 in the standard care group). NCA demands were similar. The pilot study numbers were small and not powered to be significant, but these results have driven the next phase of the study reviewing increased patient numbers and types of surgeries in each arm.
Discussion and conclusion
Peripheral nerve blocks as analgesic adjuncts and anaesthetic sparing techniques are underused in the paediatric population. This is despite demonstrable superiority to central neuraxial techniques and a reassuring safety profile3.
The results of our pilot study demonstrate positive benefits to performing peripheral nerve blocks for paediatric patients undergoing major surgery. These results enabled us to proceed with phase 2 of the study comparing 50 patients from cases over a four-month period. The greater number of patients in phase 2 will enhance reliability in comparison of the primary and secondary outcomes between the two groups. We hope that these results will promote the use of peripheral nerve Plan A and B blocks3 in paediatric patients through demonstrating improved analgesic provision.
References:
1 Matcovici M, Stoica I, Smith K, Davenport M. What Makes A “Successful” Kasai Portoenterostomy “Unsuccessful”? Journal of Pediatric Gastroenterology and Nutrition. 2023 Jan;76(1):66.
2 Yeung JH, Gates S, Naidu BV, Wilson MJ, Smith FG. Paravertebral block versus thoracic epidural for patients undergoing thoracotomy. Cochrane Database of Systematic Reviews [Internet]. John Wiley & Sons, Ltd; 2016 [cited 2024 Feb 7];(2). Available from: https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD009121.pub2/information
3 New blocks on the kids: core basic nerve blocks in paediatric anaesthesia - Pearson - 2023 - Anaesthesia - Wiley Online Library [Internet]. [cited 2024 Feb 7]. Available from: https://associationofanaesthetists-publications.onlinelibrary.wiley.com/doi/abs/10.1111/anae.15876
4 Arroyo AG del, Sanchez J, Patel S, Phillips S, Reyes A, Cubillos C, et al. Role of leucocyte caspase-1 activity in epidural-related maternal fever: a single-centre, observational, mechanistic cohort study. British Journal of Anaesthesia. Elsevier; 2019 Jan 1;122(1):92–102.