Continuous Peripheral Nerve Block for
Postoperative Pain Control at Home: A Prospective
Feasibility Study in Children
Hugues Ludot, M.D., Joëlle Berger, M.D., Vincent Pichenot, M.D.,
Mohamed Belouadah, M.D., Karim Madi, M.D., and
Jean-Marc Malinovsky, M.D., Ph.D.
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 disconnec-
tion 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. Reg Anesth Pain Med 2008;33:52-56.
Key Words: Postoperative analgesia, Ambulatory surgery, Peripheral nerve blockade, Local anesthetics,
Continuous analgesia.
A fter major orthopedic surgery, discharge from
the hospital is primarily delayed by pain man-
agement. Systemic analgesic therapy is often asso-
tions, especially in children.1 Moreover, it is typi-
cally a hospital-based technique, not available for
home use. In contrast, continuous peripheral nerve
ciated with side effects. Regional anesthesia is effec- blockade (CPNB) is a reliable alternative that pro-
tive in the postoperative period; nevertheless, vides good pain control with fewer side effects than
epidural analgesia has some well-known limita- epidural analgesia. Continuous peripheral nerve
blockade was first reported as a postoperative anal-
From the Department of Pediatric Surgery (M.B., K.M.), and
gesic 60 years ago,2 and was more recently used in
the Department of Anesthesia and Intensive Care, American adults at home.3
Memorial Hospital (H.L., J.B., V.P., J.-M.M.), and the Hôpital Continuous peripheral nerve blockade in an am-
Maison Blanche (J.-M.M.), Centre Hospitalier et Universitaire
(CHU) Reims, France.
bulatory setting has been well-documented for
Accepted for publication July 4, 2007. adult patients.4 In children, it is used in postopera-
Reprint requests: Jean-Marc Malinovsky, M.D., Ph.D., De- tive hospitalized patients,5-7 or at home in patients
partment of Anesthesia and Intensive Care, American Memo-
rial Hospital, Hôpital Maison Blanche, F-51092 Reims, France. with complex, regional pain syndromes.8 Cur-
E-mail: jmmalinovsky@chu-reims.fr rently, little is known about its pediatric postoper-
© 2008 by the American Society of Regional Anesthesia and ative use at home.9
Pain Medicine.
1098-7339/08/3301-0001$34.00/0 Because CPNB at home with a caretaker is effi-
doi:10.1016/j.rapm.2007.07.014 cient at treating postoperative pain in adults, we
52 Regional Anesthesia and Pain Medicine, Vol 33, No 1 (January–February), 2008: pp 52–56
CPNB for Postoperative Pain Control at Home • Ludot et al. 53
prospectively investigated the feasibility of this and of 1% lidocaine with 1/200,000 epinephrine
practice in children under parental surveillance, for was administered through the needle. Then a cath-
the sake of shortening hospital stays. eter was introduced 15 mm beyond the introducer
cannula, affixed securely to the skin by a “U” stitch,
Methods covered by transparent dressing, and taped onto the
thigh. After negative aspiration, 0.2 mL/kg of anes-
After institutional review board approval and the thetic mixture was injected in divided doses via the
written, informed consent of both parents and chil- catheter, with gentle aspiration every 2 mL.
dren, we prospectively enrolled American Society During the surgical procedure, if intravenous al-
of Anesthesiologists physical status 1 patients (aged fentanil rescue was required (because of tachycar-
3 to 15 years), scheduled for primary, elective, uni- dia, increase in blood pressure, hyperventilation,
lateral ankle or foot surgical procedures (eg, club- pupillary dilatation, or movement of the child), the
foot, metatarsal osteotomy, great-toe arthrodesis, blockade was considered ineffective, and the cath-
Grice procedure, or ankle arthrodesis). Usually, these eter was removed. In such cases, the patient was
major orthopedic procedures require the lengthy excluded from the study. When surgery lasted ⬎1
administration of potent analgesics, and the average hour, an additional injection of 0.1 mL/kg of the
duration of hospitalization is 4 to 5 days. Inclusion same local anesthetic solution was administered
in this study was decided after preoperative screen- hourly. For surgical procedures, a tourniquet was
ing. Parents were required to (1) live within a applied at the thigh, and inflated according to the
1-hour drive from the hospital, (2) be able to con- surgeon’s discretion.
tact medical staff or nurses 24 hours a day, (3) be In the post-anesthetic care unit, the sensory
able to return to the hospital quickly as required,
and motor blockade of the foot was evaluated. As
(4) understand a visual analog scale (VAS) or the
soon as the child’s toe motor function recovered,
Parent’s Postoperative Pain Measure Scale
the sciatic popliteal catheter was connected to a
(PPPM)10 for children ⬍6 years of age, (5) provide
multirate, disposable infusion elastomeric pump
rescue oral analgesics, (6) observe the analgesic de-
(Infusor LV, Baxter, Paris, France), containing
vice (catheter and elastomeric pump) and the skin
200 mL of 0.2% ropivacaine, with 1.5 g/mL
under the dressing, and (7) screen possible local
clonidine (mainly for its sedative effect in children),
anesthetic-related complications. Among the exclu-
giving a fixed infusion rate according to the child’s
sion criteria were (1) delayed psychological devel-
weight (0.1 to 0.15 mL/kg, up to 5 mL/h) and the
opment, (2) contraindications for sciatic popliteal
infusor-rate possibilities (0.5 to 5 mL/h).
nerve blockade, (3) current chronic analgesic ther-
apy, (4) epilepsy, (5) allergy to the study medica- In the hospital, if pain control was considered
tions, (6) known hepatic, renal, or heart disease, (7) insufficient, intravenous acetaminophen (10 mg/
the patient’s refusal, and (8) the presence of a do- kg, at a maximum of 6 times daily) was given, and
mestic animal at home. then nalbuphine (0.2 mg/kg, at a maximum of 6
Peripheral nerve catheters were all placed in the times daily) as rescue. The CPNB was considered
patients under general anesthesia just before sur- excellent if no added analgesic was given, good if
gery. After premedication with rectal midazolam in only acetaminophen was administered, and poor if
young children or oral hydroxyzine in older chil- nalbuphine was needed. Any adverse effect (eg,
dren, anesthesia was induced and maintained by pruritus or vomiting) was recorded.
using sevoflurane, oxygen, and nitrous oxygen via The criteria for discharge from the hospital de-
a face mask. pended on the presence of a plaster splint (obser-
Intravenous saline solution, at a rate of 5 to 10 vation day 1 in hospital) or suction drainage (re-
mL/kg/h, was infused throughout the procedure. moved 2 days later), and the absence of local
The children received antibiotic and antiemetic pro- postoperative complications. Totally efficient CPNB,
phylaxis (0.2 mg/kg dexamethasone). According to ie, the ability to ambulate with crutches for older
the landmarks described by Singelyn et al.,11 with patients without assistance or dizziness, or in
the child in lateral position, the sciatic nerve was stroller for younger patients, urinary voiding, and
identified in the popliteal fossa by nerve stimulation oral intake tolerance without vomiting, were also
(1 Hz, 1 ms, 0.5 mA; Stimuplex HNS 11, Braun, required before home discharge. Before home dis-
Melsungen, Germany) through a 55-mm insulated charge, nurses gave parents the following training:
stimulating needle (Contiplex D, Braun). When extensive explanation about PPPM behavioral items
evoked motor activity of the foot was still apparent or the use of VAS to diagnose pain, elastomeric
at ⬍0.5 mA, a test dose of 1 mL of a mixture device surveillance, and evaluation of sensory and
containing the same volumes of 0.75% ropivacaine motor blockade, spontaneous mobility, and short
54 Regional Anesthesia and Pain Medicine Vol. 33 No. 1 January–February 2008
delay in coloring after pressure on the child’s test median weight of 40 kg (range, 12 to 79 kg), and 25
toes. boys at a median age of 9.7 years (range, 4 to 15
When the children fulfilled the criteria for dis- years) and median weight of 40 kg (range, 15 to 90
charge, the medical staff checked both the child’s kg), were included in this study. All surgical proce-
and parents’ comprehension of the provided in- dures were performed under CPNB and sevoflu-
structions. The parents agreed never to leave their rane, and none required analgesic rescue. Within
children alone, and to record (4 times daily, at the first 6 postoperative hours, analgesia was excel-
breakfast, lunch, dinner, and bedtime) the follow- lent in 40 (85%) children, good in 3 others, and
ing items: changes in behavior, sleep disturbance, poor in 4 (3 had exhibited vomiting after nalbu-
quality of appetite, play activity, the occurrence of phine).
any adverse effects and technical problems possibly No dysesthesia, urinary retention, or any signs of
related to the analgesic technique, temperature, local anesthetic toxicity were noted. None of the
evaluation of the blockade and the integrity of the children had hematomas, pruritus, or any other
child’s dressing, episodes of pain, and the use of a associated catheter infection. All children were dis-
rescue analgesic. At home, the VAS or PPPM were charged with effective CPNB without motor block-
used only to detect, not to rate, a painful state. A ade to their homes after the surgeon’s consent. Two
prescription for oral analgesic rescue (acetamino- children were discharged on the evening of surgery,
phen twice a day, or a combination of acetamino- 30 with a plaster splint were discharged the next
phen and codeine at bedtime) was provided to all morning, and 15 remained in hospital 2 days after
children, and the use of oral analgesic rescue was surgery (for suction drainage removal).
left to the parents’ judgment. Instructions were pro- The median duration of whole CPNB was 4.0
vided regarding protection of the anesthetized limb, days (range, 3 to 5 days), and 2.8 days at home
signs of local anesthetic toxicity, a direct return to (range, 2 to 4 days) (Table 1). Only 5 children
the hospital if needed, and 24-hour contact infor- (10.6%) took acetaminophen and codeine, 22
mation. Telephone numbers of both the ward and (46.8%) took acetaminophen, and the remaining
the anesthesiologist on duty were given in case of 20 (42.5%) children needed no analgesic rescue
problems. The risk of toxicity as a result of noncom- after home discharge. The parents recorded no ob-
pliance with instructions was emphasized. vious motor effects or delayed toe discoloration.
The elastomeric pump was filled before dis- Sleep quality was described as deep and calm in 42
charge. If the volume required to maintain analge- (89%) patients, sleepless with nightmares in 3 oth-
sia over several days was too great, patients were ers, and not specified in 2 cases. Only 6 (12.7%)
requested to return in order to change the pump. At played less and acted more quietly than usual, de-
the end of the procedure, the children returned to spite analgesic rescue.
hospital and met with the medical staff. The parents There was no accidental dislodgement of the cath-
shared their feelings and observations about the eter during our study. However, in 2 cases, the elas-
postoperative period at home, and their overall sat- tomeric pump fell off while the child was walking,
isfaction. They reported information on pain, anal- and was disconnected from the infusion line between
gesic rescue, and any change in the behavior or the filter and catheter. In another case, the filter was
sleep of their child. The catheter was then removed,
broken by direct contact with the boy’s crutches.
and its distal portion was sent for bacteriologic anal-
These children returned to the hospital, and the cath-
ysis. One month later, all the children were seen at
eter was removed without further complication. In
the surgical office.
4 cases, skin redness was observed at the site of the
catheter entrance, but disappeared after removal of
Results
the device. The family had reported no other side
Forty-seven patients, including 22 girls at a me- effects, and had never called the ward. No neu-
dian age of 10.8 years (range, 3 to 15 years) and rologic symptoms recurred after withdrawal of
Table 1. Times of Discharge and of CPNB Withdrawal, and Duration of Infusion by Elastomeric Pump in the
Children of the Present Study
Time of discharge at home D0 D1 D2
Time of CPNB withdrawal (postoperative days) D2 D3 D3 D4 D5 D4 D5
Duration of infusion elastomeric pump at home (days) 2 3 2 3 4 2 3
Number of children (n ⫽ 47) 1 1 8 15 7 10 5
NOTE. D0 corresponds to day of surgery, D1 to postoperative day 1, and D2 to postoperative day 2.
Abbreviations: CPNB, continuous peripheral nerve blockade; D, day.
CPNB for Postoperative Pain Control at Home • Ludot et al. 55
the analgesic device. Each bacteriological culture Another concern about sending children home
of the distal catheter tip proved sterile. with an indwelling catheter is the occurrence of
Overall satisfaction with this practice was judged neurologic complications. The incidence of such
to be excellent in 44 children (93.6%) and good in complications was very low in a large survey of
3 other children. Analgesic-device management adults.14 As it would be difficult to screen in
was rated as very easy, and was well-tolerated by younger patients, those aged ⬍3 years were not
the children. All of the children and their parents included in this study. We believe that there is no
said that they would agree to renew this practice if absolute contraindication for CPNB with a plaster
surgery had to be planned again. cast, and parents received instructions to call the
ward if any change in sensory perception, delayed
toe coloration after pressure, or motor blockade
Discussion
occurred with 0.2% ropivacaine. No call was re-
The main finding of this observational study is corded, and neurologic examinations after catheter
that analgesia at home by CPNB with an infusion withdrawal and 1 month later remained normal.
elastomeric pump is effective and feasible, and en- In our pilot study,15 several children had pre-
ables children to experience ambulatory or short- sented leakages around the catheter insertion site,
ened hospital stays. Another interesting point is and in one case, the catheter was inadvertently
that parents trained by nurses readily understood removed, with the inherent risks. Thus, in the
the method of pain screening, and managed the present study, catheters were systematically affixed
analgesic device well. The use of rescue analgesia securely to the skin with a “U” stitch and a trans-
was minimal, and CPNB clearly offered improve- parent reinforcing dressing, and the site remained
ments in pain control, with a quick restoration of dry. We obtained a 100% catheter retention rate for
autonomy, which is known to help young patients ⬎72 hours, during which time all patients were free
cope with the challenging experience of surgery. A to play and ambulate at home. Moreover, we did
long CPNB (up to 5 days) was necessary to manage not observe kinking or accidental catheter displace-
pain in some patients without other major analge- ment despite increasing physical activity by the
sics. children, contrary to what was reported in other
This practice is quite new, and raises questions series with sciatic CPNB.5,6,11,16,17
about acceptance and safety on the part of children The most innovative feature of our study was the
and their parents. Several potential inherent risks role of parents as sole home-caretaker for their
are involved with the sciatic popliteal catheter and children, with the immediate availability of the
infusion of continuous local anesthetic.4,6 The liter- ward staff and anesthesiologist throughout the du-
ature emphasizes that complications that can be ration of infusion.
managed routinely within the hospital may take
longer to identify or be more difficult to manage in Acknowledgment
medically unsupervised home patients. An appro-
priate selection of both children and parents is cru- The authors are grateful to Marie-Laurence Poli-
cial. Not all patients can or want to cope with the Mérol, M.D., Ph.D., for her technical assistance and
analgesic device and its demands. critical review of the manuscript.
There were no emergency calls in this series, and
the parents reacted well by returning to the hospital References
when a technical problem occurred. In 4 cases, we 1. Kokki H, Hendolin H. Comparison of spinal anaes-
observed transient skin redness at the site of punc- thesia with epidural anaesthesia in paediatric sur-
ture, without other inflammatory signs. It was re- gery. Acta Anaesthesiol Scand 1995;39:896-900.
cently reported that perineural catheters in adults 2. Ansboro F. Method of continuous brachial plexus
were commonly colonized by microorganisms, but block. Am J Surg 1946;71:716-722.
only a low percentage of patients showed signs of 3. Rawal N, Axelsson K, Hylander J, Allvin R, Amilon
local inflammation.12-18 Nevertheless, all catheters A, Lidegran G, Hallen J. Postoperative patient-con-
remained sterile in our study, and several explana- trolled local anesthetic administration at home.
Anesth Analg 1998;86:86-89.
tions may be put forth: an absence of pilosity, and
4. Ilfeld BM, Enneking FK. Continuous peripheral
better compliance with hygiene instructions (even nerve blocks at home: a review. Anesth Analg 2005;
if children sit and play on the floor). For the same 100:1822-1833.
reason, any pets at home were an exclusion crite- 5. Dadure C, Acosta C, Capdevila X. Perioperative pain
rion. Absence of microbiological colonization of management of a complex orthopedic surgical pro-
catheters needs to be further investigated in a larger cedure with double continuous nerve blocks in a
sample of children. burned child. Anesth Analg 2004;98:1653-1655.
56 Regional Anesthesia and Pain Medicine Vol. 33 No. 1 January–February 2008
6. Dadure C, Pirat P, Raux O, Troncin R, Rochette A, 13. Sciard D, Matuszczak M, Gebhard R, Greger J,
Ricard C, Capdevila X. Perioperative continuous pe- Al-Samsam T, Chelly JE. Continuous posterior
ripheral nerve blocks with disposable infusion pumps lumbar plexus block for acute postoperative pain
in children: a prospective descriptive study. Anesth control in young children. Anesthesiology 2001;95:
Analg 2003;97:687-690. 1521-1523.
7. Ivani G, Codipietro L, Gagliardi F, Rosso F, Mossetti 14. Capdevila X, Pirat P, Bringuier S, Gaertner E, Singe-
V, Vitale P. A long-term continuous infusion via a lyn F, Bernard N, Choquet O, Bouaziz H, Bonnet F.
sciatic catheter in a 3-year-old boy. Paediatr Anaesth Continuous peripheral nerve blocks in hospital wards
2003;13:718-721. after orthopedic surgery: a multicenter prospective
8. Dadure C, Motais F, Ricard C, Raux O, Troncin R, analysis of the quality of postoperative analgesia and
Capdevila X. Continuous peripheral nerve blocks at complications in 1,416 patients. Anesthesiology 2005;
home for treatment of recurrent complex regional 103:1035-1045.
15. Ludot H, Pichenot V, Malinovsky JM, Leon A. Con-
pain syndrome I in children. Anesthesiology 2005;102:
tinuous peripheral nerve block at home for postop-
387-391.
erative pain control in children. Anesthesiology 2005;
9. Ilfeld BM, Smith DW, Enneking FK. Continuous re-
103:A970.
gional analgesia following ambulatory pediatric or-
16. White PF, Issioui T, Skrivanek GD, Early JS, Wake-
thopedic surgery. Am J Orthop 2004;33:405-408.
field C. The use of a continuous popliteal sciatic nerve
10. Chambers CT, Finley GA, McGrath PJ, Walsh TM. block after surgery involving the foot and ankle: does
The parents’ postoperative pain measure: replication it improve the quality of recovery? Anesth Analg
and extension to 2-6-year-old children. Pain 2003; 2003;97:1303-1309.
105:437-443. 17. Zaric D, Boysen K, Christiansen J, Haastrup U, Ko-
11. Singelyn FJ, Aye F, Gouverneur JM. Continuous foed H, Rawal N. Continuous popliteal sciatic nerve
popliteal sciatic nerve block: an original technique to block for outpatient foot surgery—a randomized,
provide postoperative analgesia after foot surgery. controlled trial. Acta Anaesthesiol Scand 2004;48:337-
Anesth Analg 1997;84:383-386. 341.
12. Capdevila X, Macaire P, Aknin P, Dadure C, Bernard 18. Cuvillon P, Ripart J, Lalourcey L, Veyrat E, L’Hermite
N, Lopez S. Patient-controlled perineural analgesia J, Boisson C, Thouabtia E, Eledjam JJ. The continu-
after ambulatory orthopedic surgery: a comparison of ous femoral nerve block catheter for postoperative
electronic versus elastomeric pumps. Anesth Analg analgesia: bacterial colonization, infectious rate and
2003;96:414-417. adverse effects. Anesth Analg 2001;93:1045-1049.
