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Pediatric Regional Anesthesia Network PRAN A.15
Pediatric Regional Anesthesia Network PRAN A.15
egional anesthesia is increasingly used in pediatric patients to provide postoperative analgesia and
intraoperative anesthesia. There is a large body of
literature describing the techniques of regional blockade
in children, the pharmacokinetics and pharmacodynamics
of local anesthetics, use of adjunctive drugs, and reports
Author affiliations are provided at the end of the article.
Accepted for publication April 10, 2012.
The authors declare no conflicts of interest.
This report was previously presented, in part, at the Annual Meetings of the
Society for Pediatric Anesthesia/American Academy of Pediatrics Section
on Anesthesiology and Pain Management and the American Society of
Anesthesiologists 2009 and 2010.
Benjamin J. Walker, MD, is currently affiliated with the Department of
Anesthesiology, University of Wisconsin School of Medicine and Public
Health, Madison, WI.
Reprints will not be available from the authors.
Address correspondence to David M. Polaner, MD, FAAP, Departments
of Anesthesiology and Pediatrics, Childrens Hospital Colorado, 13123
East 16th Ave., B090, Aurora, CO 80045. Address e-mail to david.polaner@
ucdenver.edu
Copyright 2012 International Anesthesia Research Society
DOI: 10.1213/ANE.0b013e31825d9f4b
METHODS
Data Collection
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Data Entry
Data Parameters
confirm catheter placement (none, nerve stimulator, fluoroscopy, ultrasound, or epidurogram), and whether a test
dose was administered.
The local anesthetic administered and its c oncentration,
volume, and epinephrine content were recorded, as were
the doses of any adjunctive drugs (opioids, clonidine).
Related variables, including the starting infusion rate, and
the date of catheter removal and reason for removal (no
longer needed, dislodgement, development of a complication) were collected for catheter blocks in the postoperative
period. Some of these data are not included in this initial
report, and will be analyzed and reported in subsequent
papers from PRAN.
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The presence or absence of adverse events and complications was recorded for every block, and categorized
as intraoperative or postoperative dependent on when
the complication occurred (Table 1, a and b). Definitions
were specified by the Steering Committee. A complication
describes a serious event (nerve injury, local anesthetic
toxicity, postdural puncture headache, serious cardiac or
respiratory events, deep infection). Adverse events describe
undesirable side effects (Horner syndrome, pruritus) and
events (unintended unilateral block, inability to place a
block, failed block, positive test dose, or aspiration of blood
from a needle or catheter) that did not result in patient harm
or sequelae. The nature of each complication or event and
whether an intervention was necessary and its outcome
were recorded. A failed block was defined as one that was
completed but resulted in no apparent analgesia or blockade. This includes epidural blocks in which epidurography
demonstrated the catheter outside the epidural space. An
abandoned block was one that could not be placed and the
operator aborted further attempts.
Data Analysis
All cases entered into the PRAN database from April 1, 2007,
when data collection commenced, through March 31, 2010,
are included in this report. The dataset was analyzed only
after audits described above were completed. The data in this
initial report are descriptive, and are presented in the aggregate. Individual data from each center were not analyzed
separately. The incidence of complications is reported in raw
numbers and then calculated as percentage rates or occurrences per 1000 or 10,000 where appropriate. When indicated,
the data are described with summary statistics including
mean SD for normally distributed data and median (interquartile range) for non-normally distributed data. Exact binomial 95% confidence intervals (CIs) were calculated for some
incidence rates, and are reported in parentheses. Statistical
analysis was performed using STATA software (version 11.1;
StataCorp LP, College Station, TX). In analyzing the use of
imaging and localizing techniques, blocks were divided
according to the following variables:
Regional anesthetic techniques were analyzed by location and by single-
injection or continuous catheter
techniques.
Nerve blocks performed >100 times were analyzed
individually.
Nerve blocks performed <100 times were grouped
with similar blocks (e.g., upper extremity catheters of
all types).
The most common localizing technique was listed
when it was used to perform >3% of the nerve blocks.
Those nerve blocks performed using >1 technique
(ultrasound, nerve stimulator) were also analyzed, and
thus those numbers may add up to >100%.
RESULTS
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4500
4000
3500
3000
2500
2000
Female
1500
Male
1000
500
0
<1 Month
in ASA physical status I, 30% in ASA II, 15% in ASA III, and
0.76% in ASA IV patients. Only 1 block was placed in an ASA
physical status V patient. Block type, numbers, and incidences of complications are detailed in Tables 2 and 3. There
were no deaths and no serious complications with sequelae
lasting >3 months (95% CI 02:10,000). The distribution of
block types among centers is shown in Figure 2.
Data Audits
Single-Injection Group
Neuraxial Blocks
There were 6210 blocks in this category, of which the majority
(6011, or 97%) were caudals and 83 were subarachnoid blocks
(Table 2). The vast majority of caudal blocks were performed
in young children, predominantly 3 years and younger (Fig.
3). No complications were reported in the caudal group
(95% CI 06:10,000) or in the other single-injection neuraxial
groups with the exception of a teenager who had hypotension from a subarachnoid block. There were 183 adverse
events, an incidence of 3% (95% CI 2635:1000) (Table 3).
The most common adverse event (104, or 2% of the total and
57% of all events) was the inability to place the block or block
failure. S
ingle-injection caudal blocks were predominantly
performed without any technical aids or imaging (93%);
ultrasound guidance was used in 3% of cases.
Upper Extremity Blocks
The greatest variation in practice among study centers
occurred with upper extremity blocks. Four hundred
fifty-five blocks were performed, but 3 sites accounted for
nearly all, and 1 site nearly half, of these blocks (Fig. 2).
Supraclavicular blocks were performed more often than
any other technique. Inability to place the block or a failed
block was the most common adverse event. Two (of 164)
supraclavicular blocks lasted >12 hours; these were considered prolonged beyond their expected duration. Most
upper extremity blocks were placed using ultrasound guidance (82%) (Table 4).
Table 2. Summary of S
ingle-Injection Blocks and
Adverse Event Rates for All Centers
No
Total
sequelae
Total
adverse
No
change in
procedures events (%) sequelae treatment
Neuraxial
Caudal
6011
172 (3)
60
112
Lumbar
103
5 (5)
1
4
Thoracic
13
2 (15)
0
2
Subarachnoid
83
5 (6)
4
1
Total neuraxial
6210
183 (3)
64
119
Upper extremity
Interscalene
80
0
0
0
Supraclavicular
164
6 (4)
2
4
Infraclavicular
40
0
0
0
Axillary
99
2 (2)
1
1
Musculocutaneous
5
0
0
0
Elbow
1
0
0
0
Wrist
7
0
0
0
Other
58
0
0
0
Total
455
8 (2)
3
5
Lower extremity
Lumbar plexus
78
6 (8)
4
2
Fascia iliaca
221
1 (0.5)
0
1
Femoral
872
6 (0.7)
3
3
Sciatic
413
14 (3)
3
11
Popliteal fossa
319
2 (0.6)
0
2
Saphenous
78
0
0
0
Other
325
5 (2)
2
3
Total
2307
33 (1)
11
22
Head and neck
Supraorbital/
58
0
0
0
supratrochlear
Infraorbital
139
0
0
0
Greater auricular/
157
0
0
0
superficial
cervical
Occipital
101
0
0
0
Greater palatine
11
0
0
0
Other
89
0
0
0
Total
556
0
0
0
Other block type
Intercostal
39
0
0
0
Ilioinguinal/
737
3 (0.4)
1
2
iliohypogastric
Rectus sheath
294
0
0
0
Paravertebral
14
1 (7)
0
1
Penile
230
0
0
0
TAP
140
1 (0.7)
0
1
Other
395
0
0
0
Total
1849
5 (0.3)
1
4
Total adverse event rates reported in parentheses. Rates <1% reported as
decimals and >1% rounded to nearest whole number.
Note that in the neuraxial category and the lower extremity category, the total
number of complications are fewer than the cumulative sums of the individual
types. This is because there were 3 cases in which 2 blocks were done in
a single patient, 1 successful block after a complication in the other, and
because of ambiguity in the data entry, it was impossible to determine which
block was placed first. To assign the most conservative complication rate to
the specific block category, the complication was counted against both blocks,
but the total number of complications in that general block type is accurate.
See text for more details.
There were no serious complications or sequelae reported in any s
ingle-
injection group.
TAP = transversus abdominis plane.
Catheter Group
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Caudal
Lumbar
Thoracic
Subarachnoid
Total
TD
DP
VP
AB
FB
Other
Total
events
Total
procedures
18
0
0
n/a
18
5
2
1
n/a
7
38
0
0
0
38
71
2
1
2
76
26
0
0
2
28
1
0
0
1
2
0
0
0
0
0
0
0
0
0
0
13
1
0
1
15
172
5
2
6
184
6011
103
13
83
6210
TD = positive test dose; DP = dural puncture; VP = vascular puncture; AB = abandoned block; FB = failed block; C = cardiovascular; R = respiratory; N =
neurological.
2500
2000
1500
1000
500
0
A
Number of caudals
2500
2169
2000
1494
1500
1260
918
1000
500
89
78
0
<1
month
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Interscalene/parascalene
Supraclavicular
Infraclavicular
Axillary
Musculocutaneous
Elbow
Wrist
Other
Totals
None
2
2
1
14
2
0
7
33
61
Nerve stimulator
16 (20%)
22 (13%)
11 (28%)
12 (12%)
0
0
0
2 (3%)
64 (14%)
Fluoroscopy
0
0
0
1
0
0
0
3
4
Ultrasound
78 (98%)
158 (96%)
38 (95%)
77 (78%)
3 (60%)
1 (100%)
0
19 (33%)
375 (82%)
More than 1 technology can be used for a block, thus totals may exceed 100%.
Total
78
None
8
Nerve stimulator
60 (77%)
221
872
413
319
78
325
2307
166
35
13
11
9
119
361
4 (2%)
313 (36%)
195 (47%)
151 (47%)
5 (6%)
36 (11%)
764 (33%)
Fluoroscopy
9 (12%)
Ultrasound
9 (12%)
0
1 (0.1%)
0
2 (0.6%)
0
20 (6%)
32 (1%)
48 (22%)
760 (87%)
303 (73%)
265 (83%)
65 (83%)
169 (52%)
1619 (70%)
Other
1 (1%)
0
0
0
0
0
0
1 (0.4%)
More than 1 technology can be used for a block, thus totals may exceed 100%.
Total blocks
39
737
294
14
230
140
395
1849
None
8
158
32
8
224
2
198
630
Nerve stimulator
0
2
2
0
0
0
3
7
Fluoroscopy
0
3
0
1
0
0
44
48
Ultrasound
30 (77%)
563 (76%)
256 (87%)
4 (29%)
2 (0.9%)
129 (92%)
147 (37%)
1131 (61%)
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274
261
195
1518
695
2946
36 (13)
38 (15)
26 (13)
243 (16)
177 (25)
520 (18)
12
10
12
57
23
114
24
28
14
186
154
406
DISCUSSION
9
7
8
0
1
26
4 (44)
1 (14)
0
0
1 (100)
6 (23)
181
0
169
150
33
8
544
36 (20)
0
29 (17)
29 (19)
3 (9)
0
97 (18)
1
1
0
0
3
19
24
0
0
0
0
0
1 (5)
1 (4)
0
0
0
1
1
1
Neonate
Infant
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thoracic
lumbar
caudal
9-12
years
>12
years
Table 8a. Continuous Neuraxial Blocks: Intraoperative Adverse Events and Complications
Caudal-sacral
Caudal-lumbar
Caudal-thoracic
Lumbar
Thoracic
Totals
TD
3
4
3
1
2
13
DP
2
2
0
14
8
26
VP
11
4
0
8
10
33
AB
2
1
4
12
5
24
FB
2
1
1
8
10
22
R
0
0
0
0
0
0
C
0
0
0
1
0
1
N
0
0
0
0
0
0
IO
5
2
2
7
3
19
TD = positive test dose; DP = dural puncture; VP = vascular puncture; AB = abandoned block; FB = failed block; R = respiratory; C = cardiovascular; N =
neurological; IO = infection other.
Level of insertion data missing for 3 patients (no complications).
Table 8b. Continuous Neuraxial Blocks: Postoperative Adverse Events and Complications
Caudal-sacral
Caudal-lumbar
Caudal-thoracic
Lumbar
Thoracic
Totals
UUB
PB
EMB
CP
ADR
RP
NP
PO
1
1
0
23
15
40
0
0
0
1
0
1
1
4
1
35
9
50
5
6
5
71
54
141
1
8
2
30
26
67
1
0
0
5
0
6
0
0
0
8
15
23
0
0
0
0
0
0
2
2
7
9
12
32
2
3
1
23
14
43
UUB = unintentional unilateral blockade; PB = prolonged blockade; EMB = excessive motor blockade; CP = catheter problem (dislodgment, occlusion); ADR =
adverse drug reaction; RP = respiratory problem; NP = neurological problem; H = hematoma; I = infection; PO = postoperative other.
None
274
261
195
1518
695
2946
241
200
107
1337
587
2475
Nerve stimulator
0
2
1
5
3
11
Fluoroscopy
Ultrasound
8 (3%)
10 (4%)
25 (13%)
30 (2%)
23 (3%)
96 (3%)
14 (5%)
20 (8%)
22 (11%)
24 (2%)
19 (3%)
99 (3%)
Epidurogram
15 (5%)
31 (12%)
48 (25%)
93 (6%)
58 (8)
245 (8%)
Other
0
0
1
0
0
1
Table 10. Use of Localizing Techniques for Continuous Lower Extremity Blocks
Lumbar plexus/psoas
compartment
Fascia iliaca
Femoral
Sciatic
Popliteal fossa
Other
Totals
Total blocks
None
181
22 (12)
153 (85)
9 (5)
23 (13)
0
169
150
33
8
544
0
5 (3)
5 (3)
0
0
33 (6)
0
102 (60)
72 (47)
13 (39)
1
342 (63)
0
1
1
0
0
11 (2)
0
156 (92)
131 (85)
31 (94)
7 (88)
349 (64)
Limitations
Nerve stimulator
Fluoroscopy
Ultrasound
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Practice Patterns
CONCLUSIONS
AUTHOR AFFILIATIONS
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The Society for Pediatric Anesthesia generously provides logistical and administrative support and financial assistance to the
PRAN. PRAN thanks Axio Research, LLC, for their generous
assistance to PRAN in startup development and ongoing data
management and website support. PRAN is endorsed by the
American Academy of Pediatrics Section on Anesthesiology
and Pain Management.
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