Giorgio Ivani, Italy Continuous Peripheral Nerve Blockade in Children Giorgio Ivani Giorgio Ivani Regina Margherita Children’s Hospital Turin Italy

Giorgio Ivani, Italy Postoperative Pain Control and RA Single shot analgesia, even with the addition of adjuvants is not enough for: - long-term surgery - long-term pain

Giorgio Ivani, Italy Postoperative Pain Control and RA: techniques ä Single Shot : minor surgery ä Continuous Infusion: - long-term surgery surgery - painful postop. - painful postop.

Giorgio Ivani, Italy Postoperative Pain Control and RA When a long-term pain control is required pain treatment becomes a challenge: - complete pain relief - without interference with the daily life - drugs with as few side effects as possible patient well-being

Giorgio Ivani, Italy Continuous Infusion and Outcome l Surgical Stress Control:oesophageal atresia l Optimal Pain Control l Reduced Need of Opioids l Reduced Need of Muscle Relaxants l Ventilatory Support Reduction Bosenberg A et al. Pediatr Surg Int 1992;7:289-91

Giorgio Ivani, Italy Is epidural analgesia associated with an improved outcome following open Nissen fundoplication? retrospective study, 104 open Nissen iv morphine infusion:10-40 mcg/kg/h vs epi 0.125% bupivacaine/fentanyl 4 mcg/ml 0.4 ml/kg/h Wilson et al. Paediatr Anaesth 2001;11:65-70

Giorgio Ivani, Italy Is epidural analgesia associated with an improved outcome following open Nissen fundoplication? Hospital stay: GA 13 days vs RA 8 days over 7 days discharge: GA 44% vs RA 25% ICU stay: GA 33% vs RA 17% ICU ventilation: GA 21% vs RA 8%

Giorgio Ivani, Italy Peripheral Pain Control several techniques/ routes can be used - intramuscolar pain, some drug absorption unpredictability -iv opioids nausea,vomiting,pruritus,urinary retention, GI impairment,respiratory depression -epidural infusion anaesthesia/analgesia also in controlateral leg

Giorgio Ivani, Italy Postoperative Pain Control and RA As continuous epidural infusion is a technique of choice when there is a prolonged operation or an intense postoperative pain, why not a peripheral infusion for a peripheral pain?

Giorgio Ivani, Italy Continuous Peripheral Blocks In adults it is a well established and commonly performed technique

Giorgio Ivani, Italy Peripheral Catheter Positioning - as efficient as epidural continuous infusion - easy to perform - long-term analgesia

Giorgio Ivani, Italy Pediatric Data Very Few Papers Mainly Case Reports Usually short term infusion (48h) A review of CPNB in Children Syngelyn. TRAPM 2002,vol 6 n3;

Giorgio Ivani, Italy Matuszczak et al.Anesthesiology 2001;95:A1236 brachial plexus block 36 patients; age 2-16 years catheter lasting 2-13 days, mean 4 days arm/and trauma, vascular/congenital surgery,complicated fractures optimal analgesia no complications

Giorgio Ivani, Italy Pediatric Data 25 children, major orthopedic surgery CPNB with elastomeric pumps 0.2% ropivacaine 0.1 ml/kg/h mean age 10 yrs mean duration 45 h no complications,no accidental removal Dadure et al. Anesth Analg 2003;97:

Giorgio Ivani, Italy Continuous infusions: Safety/Efficacy   Asepsis   Dedicated Pediatric Tools   Nerve Stimulator   Strictly observed Drugs Guide-Lines   Continuous monitoring : instrumental   nurses

Giorgio Ivani, Italy Material: needles and catheteres   radial artery catheterization set for axillary block (Tan et al.Anesth Analg1995;80: )   epidural kit for femoral block (Johnson.Anaesth Int Care 1994;22: )   central venous catheter set for femoral block (Tobias. Anaesth Int Care 1994;22: )

Giorgio Ivani, Italy Case Report 1 3 1/2 y, left foot semiamputation sciatic block 15 days of continuous infusion

Giorgio Ivani, Italy Case Report 2 3 y old boy right foot semiamputation sciatic block 21 days of continuous infusion Ivani et al. Paediatr Anaesth 2003 ; in press

Giorgio Ivani, Italy Case Report 2 bolus dose: 0.2% ropivacaine 0.6 ml/kg + clonidine 2 mcg/kg continuous infusion: 0.2% ropivacaine 0.4 mg/kg/h + clonidine 3 mcg/kg/24h

Giorgio Ivani, Italy Case Report 2 J J better blood flow J J daily wound treatments ( 2-3 times per day) and surgical cleaning without any additional pain killer

Giorgio Ivani, Italy Peripheral Catheter Positioning axillary sciatic femoral (fascia iliaca) bl. starting dose 0.25% bupiv., 0.2% ropivacaine ml/kg (Syngelin) 1.5% lidocaine+0.2% ropivacaine (Matuszczack) 0.2% ropiv/levob ml/kg+ clonidine 2mcg/kg (Ivani)

Giorgio Ivani, Italy Peripheral Catheter Positioning continuous infusion 0.125%- 0.25% levobupivacaine, 0.1%-0.2% ropivacaine ml/kg/h mg/kg/h + clonidine 3 mcg/kg/24h 30% reduction for infants < 6 mo

Giorgio Ivani, Italy Pediatric Regional Anesthesia: the Future Continuous Infusion: Technical difficulties have been overcome Pediatric tools availability for peripheral continuous infusion: can provide effective analgesia optimizing drugs administration and pain management