DGH Paediatric Analgesia 2 D O 5

Steve.Roberts@ Alderhey.nhs.uk

Pharmacological Methods Regional Techniques

• Elective Day Case• Why This Is Important• General Approach• Specific Examples

Why ? ……Patient

• Humane

• Improved Recovery

• ↑ Patient & Family Satisfaction

•

Why ?.......Patient30-40% Moderate-

Severe Pain in 1st 48 hrs

@ Problematic Behaviour

2/3 Seek Help e.g. GP

Time Off Work

Why ? ……..Trust

• Earlier 1st & 2nd Stage Discharge

• ↓ Nurse Workload

• ↑ Bed Utilisation

• ↓ Unplanned Admission 2⁰: Pain or Opiate SE

• ↑ DC Basket e.g. R/O Femoral Blade Plate

10,000 DC / Year

0

5

10

15

20

25

10/11 11/12 12/13 13/14 14/15 15/16 16/17 17/18 18/19

%

DSU % Kids Triggering Rescue Analgesia (Pain score > 3)

Continuous e-Audit

No e-Anaesthetic Record

Paper Audits

Regular Feedback

Multidisciplinary

Pharmacological Methods

✓ Paracetamol

✓ Ibuprofen NOT Diclofenac

Ø No Opiates

Pharmacological Methods

All Patients Preoperative

Except: Refusal (IV PR)ContraindicatedResp & Gastro

Gastroenterology Pain Score >3

0

2

4

6

8

11/12 12/13 13/14 14/15 15/16 16/17 17/18

% P

atie

nts

Caudal

Superficial Cervical Plexus

PECS 1PVB/ES

Rectus SheathTAP/QL1,2?

SupraclavicularForearm

Metacarpal, Ring

Femoral / SubsartorialPopliteal, Ankle

Metatarsal, Ring

Penile

Regional Techniques

LA = Superior Analgesia

Can Operate Under LA

Block Selection

1-7 YO

Unilateral Hernia or Orchidopexy

0.5ml/kg LA No Adjuncts

QL x 15Hrs 1st Analgesia

TAP x 10Hrs

? Greater Paravertebral Spread

• See Target Nerve or Fascial Plane

• Guide Needle Tip Real-Time

• Safer

• Greater Success

• LA Spread

Block Delivery – All With US

6-14 YO

Limited Spread 0.2ml/kg

Needle direction? Greater Vol.

Advantages in Children• Under GA

• Smaller Mass

• ↓ Vol. LA

• Vulnerable

Structures

Congenital Abnormalities

PNS 64% Successful36% Failed, No Twitch

US 100% Successful

Variable Landmarks

Poorly Described

Techniques

Lower Rate of Ossification

Advantages in Children

LALA: 2 IssuesDurationCatheter OTT

No Catheter Skill

No Postop Care

ToxicityCardiac

Local neuronal

CNS

Adjuvants Old LALA in New Formulations

New LALA

Adjuvants

• Prolong RA

• Partially Failed Block

• Visceral Pain

• Non-Surgical Pain

e.g. Headache

• May ↓ MAC

• May ↓ ED

Adjuvants

Every Block Use 1 or More

IV or Perineural ?

Clonidine & PF Morphine

Licensed CNS

Which ?

Clonidine

Dexmedetomidine

Dexamethasone

Morphine

Ketamine

α2 AgonistsCNS: α2 Receptor

PNS: LA Properties

Sensory > Motor C fibres

? Systemic Absorption ?

Dexmedetomidine: ↑ Duration ↑ Onset More SelectiveNo Neuroapoptosis Studies

No ADR

DexamethasonePNB No MOA

Adult Studies No Difference

Few Paediatric Study Showing Benefit PNB

No Paediatric Study Showing Safe in PNB

Give INTRAVENOUSLY

ENT✓ Paracetamol

✓ Ibuprofen

Ø No Opiates

The Nerve of Arnold

Lidocaine Placebo

Pain Score 2.8 4.8

% ReceivingParacetamol

13 45

TonsillectomyIbuprofen

Paracetamol

Dex & Ondansetron

Levobupivacaine

Plus:

Morphine 50mcg/kg

Or

Ketamine 0.3mg/kg

Clonidine 2mcg/kg

AH DC Tonsillectomy

Rescue Analgesia

Unplanned Admissions

Anaesthetic Changes95%< Dex, Paracetamol and Ibuprofen

Intra-op Morphine 50mcg/kg ↓ 85% to 65%

Intra-op Ketamine 0.3mg/kg → 50% to 50%

Intra-op Clonidine 2mcg/kg ↑ 15% to 45%

Surgical Changes

Dissection to Coblation

↑ LA from 35% to 90% (2015-2017)

Circumcision

e-Audit

Rescue Analgesia

Pain >3

Paper Audit

= Less Pain

= Less Pain

Cumulative % Patients Discharged

014

71

93

100

0

23

59

7277

81

95100

0

20

40

60

80

100

120

0-1 1-2 2-3 3-4 4-5 5-6 6-7 7-8

Perc

en

tag

e

Hours

No opiate Opiate

2 Admissions in

Opiate Group

• Pre-op Analgesics

• Anatomy & Block Performance

• Correct Needle – Neonatal LP

• 0.5% Levobupivacaine

• Dexamethasone 0.1mg/kg

• No Infiltration

Feedback

SummaryPreop Paracetamol & Ibuprofen

Regional Anaesthesia (US)

α2 Agonists (Clonidine 1mcg/kg)

IV Dexamethasone 150mcg/kg

Needle Location

Newbies & Experienced

Paediatric USRA Great But….

Complex - Sensory Overload

Sporadic Case Mix

↓ No. Cases / Year

Courses Adult Content

How to LearnBlocking Culture - AH Block for Everything !

Need to Build One

Mentor Availability:

Burckett-St Laurent DA, Cunningham MS, Abbas S, et al. Teaching USRA remotely: a feasibility study. Acta Anaesthesiol Scand 2016; 60:995–1002

• Delayed Ambulation

• Difficulty assessing Post op

e.g Compartment Syndrome

(ESRA-ASRA) 0.5%

• Bad Regional Anaesthetists

#1 Surgeons

#2 TrainingAge: Old

1 Step Forward

Age: Young

Rotation

Both:

Sporadic Case Mix

Overbooked Lists

#3 Fear of Failure (2-9% PRAN)

• Poor needling • Poor block selection• Forgotten Nerve • Stray Surgeon• Anatomical Variability (US)• Visceral Pain

• Training Issues

RING BLOCK

Transverse view of MY MIDDLE FINGER

PENILE BLOCK

TOP US TRAINING TIP – SCAN YOURSELF

Transverse view of MY……………..

#4 Concerns re - Safety

Polaner DM et al.. Anesth Analg 2012; 115:1353–1364.

• PNS vs CNS (US)

#4 Safety – US is the Solution?

• Nerve Damage ???• LAST• Pneumothorax ?• Phrenic nerve palsy

• Only One Aspect

#5 RA DURATION - In Patient

• Single Shot Block 6-12 hour duration

• Major surgery• Facilitate physiotherapy• Potentiate perfusion post reimplantation Sx• Manage CRPS 1 or Palliative care

• ‘Just in case’ PCA/NCA

#5 Duration - Solutions

•ULTRASOUND ?

•Simple stuff REG vs PRN

•Parental education

•Catheters ? home

•Liposomal bupivacaine

Why used Adjuvants (Rishi’s Sprinkles)

• Prolong RA

• Partially Failed Block

• Visceral Pain

• Non-surgical pain

e.g. headache

• ↓ LA SE e.g. Epidurals

Which ‘Sprinkles’ ?

• Clonidine: 1-2mcg/kg IV, CNS, PNB

• Dexamethasone 0.1mg/kg IV ONLY

Too many good effects e.g. anti-emetic

• Mg++ 100mg/kg IV Muscle spasms

• Ketamine 0.1-0.5mg/kg IV, CNS

(> 0.5mg/kg Hallucinate)

R I S H I D I W A N

Ketamine

• Nah• (0.5mg/kg) significantly prolongs the duration of blockade. However,

evidence of its neuroapoptotic effects have ↓ its use, especially in

DENTAL

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