Chapter 3: Pain Management and Procedural Sedation for the Injured Child

Lois K. Lee, Travis H. Matheney

Chapter Outline

Introduction

Pain management in the pediatric patient presenting with a musculoskeletal injury spans a continuum beginning with the initial presentation, continuing through the fracture treatment, and finally during the postmanagement phase of care. It includes a multimodal approach that can involve both pharmacologic and nonpharmacologic interventions. As the practice has evolved we have seen the inclusion of not just opioid analgesics, but also an increase in the appropriate use of nonsteroidal anti-inflammatories and local and regional anesthetics as well as other nonpharmacologic modalities, such as including the child life specialists as adjuncts to patient care.71,84,89,106 Working with the patient and family to improve their understanding of the process can improve their expectations and outcomes as well. The objectives of this chapter are to discuss the acute pain management, use of procedural sedation, types of local/regional anesthesia, and postoperative care for children and adolescents with fractures. We will discuss current strategies to assess and treat pain in the pediatric patient presenting to the emergency department (ED) with a fracture. In addition, we will elaborate on the “how to” portion of pain management techniques from initial presentation to the posttreatment period. As always, proper indications for the use of any of these modalities require a thorough understanding of the risks and benefits of each treatment by the orthopedist, emergency medicine specialist, anesthesiologist, and nurses caring for the patient. 

Emergency Department Management of Orthopedic Injuries

For children and adolescents, orthopedic fractures are among one of the most painful presenting conditions, and in the ED fracture reduction is one of the most painful procedures performed.5,63,85 Effective and safe analgesia and sedation are essential for the management of fractures in the ED, as it decreases the child's pain and anxiety and improves patient, parent, and provider satisfaction. Initial analgesia can be provided by oral, intranasal (IN), intramuscular (IM), or intravenous (IV) medications.5,104 Depending on the type of fracture reduction required, local or regional anesthesia can be applied or procedural sedation can be used.63,85 Procedural sedation provides anxiolysis, analgesia, and sedation along a continuum while the patient maintains cardiorespiratory function, which enables painful procedures such as fracture reduction to be performed safely and effectively in the ED. 

Emergency Department Management of Pain and Anxiety

The assessment and treatment of pain is a Joint Commission mandated priority for children presenting to the ED with potential fractures or other painful musculoskeletal injuries.110 Several validated pain measurement tools have been developed for children, and they should be used for the initial assessment as well as ongoing evaluation of pain before, during, and after treatment. Pediatric pain scales include the faces pain scales (e.g., Wong–Baker Faces Pain Rating Scales, Faces Pain Scale-Revised) for children 3 to 18 years old,45,57,112 the visual analog scale (VAS) for children greater than 5 years old,16,93,114 and the color analog scale for children 6 to 15 years old.81 
Awareness of the need for initial and ongoing pain assessment and management are important as children with fractures, including angulated fractures or children reporting severe pain, are not routinely treated with pain medications.19,26,36 Early immobilization, in triage or during the initial assessment, with a splint and/or sling as well as elevation and ice packs are important in the initial pain management.2 During the physical examination or during radiographic evaluation, manipulation of the injured area can result in movement of the fracture, causing increased pain; therefore, early administration of pain medications is essential for the ongoing management of fracture-related pain.48 For nondisplaced fractures, oral pain medications may be sufficient (Table 3-11).48 One strategy is to administer ibuprofen (10 mg/kg) and/or acetaminophen (15 mg/kg), as long as the child has no allergies to these medications, and has not received them in the past 4 to 6 hours.2,27 If the child continues to have complaints of pain or elevated pain scores after acetaminophen and ibuprofen, oral oxycodone may be administered.2,5,23 Codeine is a less optimal analgesic as pharmacogenomic data demonstrates up to 50% of individuals may be poor metabolizers who are not able to metabolize codeine to an active analgesic, resulting in suboptimal pain control for these children.5 Other children may be ultrarapid metabolizers of codeine and are at risk for the side effects of opioid intoxication, including death.78 Several studies have demonstrated ibuprofen is either equally effective as or more effective than codeine for analgesia, and with fewer side effects.5,27,37,44 
 
Table 3-1
ASA Physical Status Classification System
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Table 3-1
ASA Physical Status Classification System
ASA Physical Status 1—A normal healthy patient
ASA Physical Status 2—A patient with mild systemic disease
ASA Physical Status 3—A patient with severe systemic disease
ASA Physical Status 4—A patient with severe systemic disease that is a constant threat to life
ASA Physical Status 5—A moribund patient who is not expected to survive without the operation
ASA Physical Status 6—A declared brain-dead patient whose organs are being removed for donor purposes
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For displaced fractures or for children reporting higher pain scores, IV, IM, or IN pain medications may be necessary. Fentanyl may be preferable as the initial narcotic as it is a fast-acting drug with a shorter duration of action compared to morphine, which is slower in onset but has a longer duration.104 IN fentanyl provides safe and effective analgesia to children with pain when an IV is not available.105 In addition, subdissociative doses of ketamine at 0.25 to 0.5 mg/kg IV can be administered for analgesia.104 

Author's Preferred Method of Treatment

In our ED, pain management guidelines begin in triage with immobilization and application of ice packs to the injured extremity. The Wong–Baker Faces Pain Rating Scale is used for children 3 years and older. For a moderate pain score of 4 or higher, both ibuprofen (10 mg/kg) and acetaminophen (15 mg/kg) are given orally. For higher pain scores, IN fentanyl is offered for rapid pain relief and can be given prior to x-ray evaluation. Given the short duration of IN fentanyl, additional pain medications (e.g., ibuprofen, acetaminophen, oxycodone, or IV fentanyl) should be considered, depending on the child's pain level and type of fracture. 

Pain Management After Discharge

After ED discharge, children report the highest levels of pain in the first 48 hours after injury and use pain medications for analgesia for up to 3 days after injury.38 Children with both nondisplaced and displaced fractures requiring ED reduction report clinically meaningful pain after discharge.111 Caregiver's instructions for pain management after ED discharge should include the use of oral analgesics (e.g., ibuprofen for moderate pain and oxycodone for higher levels of pain) (Table 3-11).5,23,37,38 Given the risks associated with codeine,78 our institution has removed this medication from the formulary with a recommendation to use oxycodone instead. 

Procedural Sedation for Emergency Department Fracture Reduction

Procedural sedation is defined as the method of administering sedatives or dissociative medications, with or without analgesics, to induce an altered state of consciousness, which allows the patient to tolerate unpleasant procedures while maintaining cardiorespiratory function.8 Fracture reduction and casting for the majority of displaced and angulated fractures can be safely and successfully achieved in the ED with procedural sedation for analgesia, anxiolysis, amnesia, and sedation.87 Sedation occurs along a continuum as the drug dose increases and drug levels in the central nervous system (CNS) increase, consciousness decreases, and the risk of cardiorespiratory depression increases. Minimal sedation, or anxiolysis, is a drug-induced state where the patient can still respond normally to verbal commands, but may have cognitive or coordination impairment while maintaining normal cardiorespiratory function. With moderate sedation (previously conscious sedation) patients may respond purposefully to verbal commands, either alone or with tactile stimulation, while maintaining cardiorespiratory function. The next level of sedation is dissociative sedation, which results in profound analgesia and amnesia while the patient is able to retain protective airway reflexes and maintain cardiopulmonary function. With deep sedation patients are not easily aroused, but may respond purposefully with repeated or painful stimulation. This level of sedation may result in impairment of spontaneous ventilation while cardiovascular function is maintained. Finally, with general anesthesia the patient has loss of consciousness with impairment of ventilatory and sometimes cardiovascular function.69,87 

Personnel

Providers administering procedural sedation must be trained to rapidly identify and treat the most common cardiorespiratory complications of sedation agents (respiratory depression, central and obstructive apnea). They must also be able to perform maneuvers to maintain airway patency and provide assisted ventilation, if necessary. At least two providers are required: one to administer medications and provide airway support and another for monitoring and documentation.70,87 

Presedation Assessment

To evaluate children for the potential risks of sedation, a presedation assessment should be performed. This assessment should include a directed history (including allergies and history of any prior adverse reactions to sedatives or anesthetics) and a physical examination, with emphasis on the child's airway and cardiopulmonary status.87 The American Society of Anesthesiologists' (ASA) physical status classification for preoperative risk stratification can be used to stratify risk, with most children undergoing ED procedural sedation being ASA class 1 or 2 (Table 3-1).69 

Preprocedure Fasting

Concern for pulmonary aspiration of gastric contents is the primary reason for assessment of preprocedure fasting status. Overall, the relative risk of aspiration during ED procedural sedation is rare and is likely much lower than during general anesthesia.92 A prospective study of 905 children undergoing ED procedural sedation found that 56% were not fasted in accordance with established guidelines, and there was no association between preprocedural fasting and adverse events.3 For children in the ED, a prolonged fasting period would not allow for a timely fracture reduction to be performed. However, this must be balanced with consideration of a patient's individual risk of aspiration, including recent oral intake, for ensuring safe and effective, as well as timely, procedural sedation. 
A consensus-based clinical practice advisory for ED preprocedural fasting outlined the stratification of aspiration risk by assessment of: (1) Potential airway/respiratory complications and systemic disease; (2) timing and nature of recent oral intake; (3) urgency of the procedure; and (4) targeted depth and length of sedation.53 For a standard risk patient (normal airway, ASA < 3) with no oral intake or only clear liquids in the 3 hours prior to the procedure, all levels of sedation could be performed for fracture reduction. For a standard risk patient with a light snack 3 hours prior to the procedure, dissociative sedation with ketamine, >20 minutes of moderate sedation or <10 minutes deep sedation would be acceptable. If the standard risk patient had a heavier snack or meal in the 3 hours prior to sedation, dissociative sedation or >20-minute moderate sedation would be acceptable.53 

Monitoring

Continuous close observation and monitoring of the child is crucial throughout the sedation. The child's face, mouth, and chest wall must be observed for respiratory effort. Noninvasive monitoring with continuous pulse oximetry, capnography, and cardiorespiratory monitoring must be maintained during the procedure. Capnography noninvasively measures the concentration of carbon dioxide in exhaled breath, providing continuous monitoring of ventilatory status, including respiratory rate, and provides the earliest indication of respiratory compromise.52 In young children who can rapidly develop oxygen desaturation because of their smaller functional residual capacity and higher oxygen consumption,90 early detection of respiratory compromise is critical in preventing more serious complications related to prolonged hypoxia.69 Vital signs should be recorded before, during, and after the sedation at predetermined intervals, depending on the level of sedation. 
Supplemental oxygen (e.g., high-flow oxygen by mask) administered during procedural sedation is recommended to reduce the risk of sedation-associated hypoxia.7,9,33 Suction, reversal agents, and medications and equipment for advanced airway management must be readily available.87 The highest risk for complications occurs 5 to 10 minutes after IV drug administration and immediately following the completion of the procedure, when the painful stimuli have concluded.70 After the procedure is completed, the child should be monitored until he/she has returned to baseline with normal vital signs (Tables 3-2, 3-3, and 3-4) and age-appropriate level of consciousness, and can talk and sit as appropriate for their age (Table 3-5).69 
 
Table 3-2
Normal Values for Heart Rate by Age
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Table 3-2
Normal Values for Heart Rate by Age
Age Range (beats/min)
Newborn 110–150
1–11 mos 80–150
2 y 85–125
4 y 75–115
6 y 65–110
8 y 60–110
 

From: Rasch DK, Webster DE. Clinical Manual of Pediatric Anesthesia. New York, NY: McGraw-Hill; 1994:16, with permission.

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Table 3-3
Normal Values for Blood Pressure by Age
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Table 3-3
Normal Values for Blood Pressure by Age
Blood Pressure (mm Hg)
Age Systolic Diastolic
Full-term infant 60 (45) 35
3–10 days 70–75 (50) 40
6 mos 95 (55) 45
4 y 98 57
6 y 110 60
8 y 112 60
12 y 115 65
16 y 120 65
 

The numbers in parentheses refer to mean arterial blood pressure.

 

Data from: Steward DJ. Manual of Pediatric Anesthesia. New York, NY: Churchill-Livingstone; 1990:24; Rasch DK, Webster DE. Clinical Manual of Pediatric Anesthesia. New York, NY: McGraw-Hill; 1994:17, with permission.

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Table 3-4
Calculation of Normal Blood Pressure by Age
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Table 3-4
Calculation of Normal Blood Pressure by Age
80 + (2 × age in years) = normal systolic blood pressure for age
70 + (2 × age in years) = lower limit of normal systolic blood pressure for age
 

From: Rasch DK, Webster DE. Clinical Manual of Pediatric Anesthesia. New York, NY: McGraw-Hill; 1994:197, with permission.

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Table 3-5
Recommended Discharge Criteria After Sedation
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Table 3-5
Recommended Discharge Criteria After Sedation
  1.  
    Cardiovascular function and airway patency are satisfactory and within normal limits.
  2.  
    The patient is easily arousable, and protective reflexes are intact.
  3.  
    The patient can talk (if age-appropriate).
  4.  
    The patient can sit up unaided (if age-appropriate).
  5.  
    For a very young or disabled child incapable of the usually expected responses, the presedation level of responsiveness or a level as close as possible to the normal level for that child should be achieved.
  6.  
    The state of hydration is adequate.a
 

From: American Academy of Pediatrics Committee on Drugs. Guidelines for monitoring and management of pediatric patients during and after sedation for diagnostic and therapeutic procedures. Pediatrics. 1992; 89:110–115, with permission.

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Pharmacologic Agents Used in Pediatric Procedural Sedation and Analgesia

Nitrous oxide (N2O)

Nitrous oxide (N2O) is an odorless gas that provides anxiolysis and mild analgesia while the patient remains awake and is able to follow commands. It can be used for mild to moderately painful procedures as a sole agent or can be used for more painful procedures supplemented with local or regional anesthesia (e.g., hematoma or nerve blocks). Nitrous oxide is dispensed at concentrations between 30% and 70% in combination with oxygen.104 Because of its rapid diffusion into air-filled cavities, N2O is contraindicated in a patient with pneumothorax, bowel obstruction, head injury, or pregnancy. Other contraindications for the use of nitrous oxide include cardiac or pulmonary disease. Emesis is the most common adverse effect, reported in up to 10% of patients (Table 3-6).104 
 
Table 3-6
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Table 3-6
Medications for Analgesia and Procedural Sedationa
Medication Dose Contraindications Advantages Disadvantages
Nitrous Oxide (N2O) 30–50% N2O with oxygen by mask
  •  
    Pneumothorax
  •  
    Bowel obstruction
  •  
    Pregnancy
  •  
    Rapid onset
  •  
    Rapid offset
  •  
    Emesis
Midazolam PO: 0.25–0.5 mg/kg (max dose: 20 mg)
IN: 0.2–0.3 mg/kg (max dose: 0.5 mg/kg or 10 mg)
IM: 0.05–0.15 (max dose: 10 mg)
IV: 0.05–0.1 mg/kg (max dose: 10 mg)
  •  
    History of adverse reaction to benzodiazepines
  •  
    Reversible with flumazenil (10 μg/kg IV) if necessary
  •  
    Rapid onset
  •  
    No analgesia
  •  
    Respiratory depression, especially when combined with opioids
Fentanyl IV: 0.001 mg/kg, may give in increments to a maximum of 0.003 mg/kg
IN: 0.0015 mg/kg
  •  
    History of adverse reaction to opioids
  •  
    Rapid onset
  •  
    Reversible with nalbuphine (0.1 mg/kg IM or IV) if necessary
  •  
    No amnesia
  •  
    Risk of respiratory depression, especially when combined with benzodiazepines
Ketamine IM: 4 mg/kg
IV: 1–2 mg/kg
  •  
    <3 months old
  •  
    History of psychosis
  •  
    Provides sedation, amnesia, analgesia
  •  
    Rapid onset
  •  
    Laryngospasm
  •  
    Recovery agitation—may be managed with midazolam
  •  
    Emesis—may be managed with ondansetron
  •  
    May have prolonged recovery
Propofolb IV: 2 mg/kg (loading dose in infants/young children, followed by bolus of 1 mg/kg)
1 mg/kg (loading dose in older children/teenagers followed by bolus of 0.5 mg/kg)
  •  
    Allergies to soy or eggs
  •  
    Rapid onset
  •  
    Rapid offset
  •  
    Respiratory depression and apnea common
  •  
    Pain on injection—pretreat vein with l–2% lidocaine in IV with tourniquet in place
  •  
    Hypotension
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There is a rapid onset of action (5 minutes to peak effect) and offset (5 minutes) because of its low blood–gas solubility coefficient allowing it to rapidly reach equilibrium in the brain.104 As a result, fracture reduction can proceed after 5 minutes of N2O administration. Nitrous oxide and a hematoma block provide anxiolysis, amnesia, and analgesia for fracture reduction, while allowing the older child to be awake and responsive.56 After the fracture reduction, supplemental oxygen at 100% is administered by face mask for 5 minutes to wash out the nitrous oxide and palliate any diffusional hypoxia.56,104 A randomized ED comparison of N2O with a hematoma block to ketamine plus midazolam in 102 children with fracture reduction, after initial oxycodone administration, found similar increases in distress during the reduction in both groups. However, the N2O/hematoma block group had a significantly shorter recovery time and reported fewer adverse effects.76 Randomized controlled trials of N2O compared to other sedation regimens for ED fracture reduction are limited;85 therefore, the specific use of N2O, with or without a hematoma block, should be based on the skill and training of the treating providers as well as the individual patient and fracture type. 

Author's Preferred Method of Treatment

When nitrous oxide is used by the authors it is most commonly used with a hematoma block. The authors use this regimen in patients with mild to moderately displaced fractures requiring reduction provided the patient can cooperate with self-administration of N2O by face mask. 

Benzodiazepines and Opioids

When used in combination, benzodiazepines and opioids are another option for fracture reduction, with midazolam and fentanyl being used the most commonly for moderate and deep sedation. When used together these two drugs have a synergistic effect with a higher risk of hypoxia and apnea compared to they are when used alone. Therefore, careful IV titration with close monitoring for respiratory depression must be exercised when using these agents.69,77,104 

Midazolam

Midazolam is a short-acting benzodiazepine with anxiolytic, amnestic, sedative, hypnotic, muscle relaxant, and anticonvulsant properties; however, it does not provide analgesia.69,104 With IV administration, peak effect occurs within 2 to 3 minutes and lasts 45 to 60 minutes. In addition, midazolam can be administered intranasally or buccally in an aerosolized form, without need for IV access.67,104 Midazolam can also be administered orally, but may result in unreliable clinical effects due to first-pass hepatic metabolism.104 
Adverse effects of midazolam include mild cardiovascular depression, nausea, vomiting, and paradoxical reactions – which may be manifest by inconsolable crying, combativeness, disorientation, agitation, and restlessness.63,69 Flumazenil is the benzodiazepine antagonist used to reverse severe respiratory depression and oversedation.63 The duration of action of flumazenil is shorter (20 to 30 minutes) than that of midazolam, so multiple doses may be required to maintain reversal of benzodiazepine effects.104 

Fentanyl

IV fentanyl is a rapidly-acting, extremely potent opioid with peak effect at 2 to 3 minutes and a duration of 20 to 60 minutes. It is preferred to morphine for procedural sedation because of its faster onset, shorter recovery time, and lack of histamine release. In infants and young children, more frequent dosing may be required as they have a higher clearance of the drug.104 As it provides no sedation or anxiolysis at low doses (1 to 2 mcg/kg), fentanyl should be used in combination with a benzodiazepine (e.g., midazolam) for sedation of painful procedures.69 Adverse effects of fentanyl include nasal pruritus and respiratory depression. Naloxone is an opioid antagonist that reverses opioid effects within 1 to 2 minutes of administration and lasts 20 to 40 minutes.104 

Ketamine

Ketamine is a rapidly acting dissociative agent, which provides sedation, analgesia, and amnesia, while preserving cardiovascular stability and airway reflexes. This drug is classified as a dissociative as it chemically disconnects the thalamocortical and limbic systems resulting in a dissociation of the CNS to external stimuli, causing a trancelike cataleptic state.48,63 It has a rapid onset of action (IV: 30 to 60 seconds; intramuscular [IM]: 3 to 5 minutes), with sedative effects lasting 10 to 15 minutes with a single dose and 20 to 30 minutes with multiple doses. Given its rapid onset, ketamine should not be administered until the orthopedist is ready to begin the procedure. The initial dose of IV ketamine should be administered over 30 seconds, as rapid administration can result in transient central apnea.48 Recovery time is generally 50 to 110 minutes for IV administration and 60 to 140 minutes for IM.64,80,100,104 Although it may be given IM, the IV route is generally preferred, as recovery is faster and emesis less common. It is associated with nystagmus, diplopia, pupillary dilatation, increased muscle tone, and transient hypertension.104 Ketamine is contraindicated in children <3 months old because of the increased risk for airway adverse events, and in patients with a history of psychosis. Relative contraindications include: History of airway problems (e.g., tracheal surgery), active pulmonary infection or asthma, cardiovascular disease, any concern for increased intracranial pressure, or a thyroid disorder.48 
Ketamine does not exhibit a typical dose–response relationship like other sedative and analgesic agents. At lower doses (0.25 to 0.5 mg/kg IV) it causes analgesia and disorientation, but does not result in a dissociative effect. These subdissociative doses can be used for analgesia prior to a procedure or in combination with propofol for painful procedures.104 To reach a dissociative state, a dosing threshold for ketamine of approximately 1 to 2 mg/kg IV or 4 to 5 mg/kg IM needs to be administered. Additional or higher doses do not deepen the dissociative state and do not affect airway integrity; therefore, additional doses are only needed to maintain the dissociative state over time.48,69 
Adverse events associated with ketamine are primarily respiratory compromise, emesis, or recovery reactions. A meta-analysis of airway and respiratory events associated with ketamine analyzed 8,282 pediatric ketamine sedations and found that the overall prevalence of airway or respiratory adverse events was 3.9%, including 0.3% with laryngospasm and 0.8% with apnea.50 A secondary case-control analysis from this larger meta-analysis did not demonstrate any clinical, dosing, or age-related factors associated with an increased risk of laryngospasm.49 Although laryngospasm may be a rare event, the clinician administering ketamine must be prepared to rapidly identify and manage respiratory complications including performing bag-valve-mask ventilation or tracheal intubation.48 Another meta-analysis of the same cohort of 8,282 children found the overall prevalence of emesis was 8.4%, any recovery agitation (e.g., agitation, crying hallucinations, and nightmares) 7.6%, and recovery agitation described as severe and/or requiring treatment 1.4%. Early adolescence and IM administration was associated with more ketamine-associated emesis. There was no age relationship or change in risk with coadministered medications and recovery agitation.51 A clinical practice guideline for ED ketamine sedation supports its use in healthy adults without cardiac disease and recommends treatment of recovery reactions with benzodiazepines.48 In a study of post-ED discharge outcomes after procedural sedation, 18% of children had emesis, but there was a low prevalence of adverse behavioral events.82 
The coadministration of prophylactic anticholinergics to decrease hypersalivation and the risk of airway complications is no longer recommended. Similarly, the prophylactic use of benzodiazepines to prevent recovery reactions is also no longer recommended, although they should be available to treat any unpleasant recovery reactions that may occur. In contrast, ondansetron may either be given prophylactically for vomiting (number needed to treat 13),72 or may be given as needed after nausea/emesis has occurred.48,104 When considering narcotic pretreatment for pain, one retrospective study of 858 children given ketamine for procedural sedation examined the use of morphine pretreatment and found no increase in the number of adverse events compared to those children without morphine pretreatment.118 Pretreatment with morphine before ketamine sedation, however, is associated with a longer recovery time compared to having no narcotic pretreatment.75 
At dissociative doses ketamine is a very effective agent for ED fracture reduction because of its dissociative effects while preserving airway and cardiopulmonary status.77 One study of 260 children randomized them to either a combination of fentanyl and midazolam or ketamine and midazolam for ED fracture reduction. The children receiving ketamine and midazolam had lower distress scores and parental ratings of pain and anxiety than children in the fentanyl group, and had fewer respiratory complications. Vomiting was more frequent in those receiving ketamine, and they also had a longer recovery.64 Another study of 114 children given ketamine either IV or IM for fracture reduction reported that children had minimal or no pain during the reduction, as measured by the orthopedic surgeons using the Children's Hospital of Eastern Ontario Pain Scale (CHEOPS) with high parent satisfaction.80 When adverse effects between ketamine and fentanyl/midazolam are compared, ketamine is associated with fewer respiratory adverse events, but more vomiting.91,99 

Propofol/Ketofol

Propofol is an extremely rapidly acting (15 to 30 seconds) sedative with a narrow therapeutic range, and as a result has a higher risk of airway obstruction and central apnea.63,104 It also has a very short recovery time (5 to 15 minutes) and inherent antiemetic properties.69 With no analgesic properties, it must be combined with either ketamine (ketofol) or a narcotic for painful procedures. Several studies have reported the safety and efficacy of propofol for painful ED procedures including fracture reduction.12,47,107 More recently studies have examined the use of ketamine/propofol (ketofol) for fracture reduction and reported effective sedation and analgesia. The most commonly reported adverse effects were respiratory complications, inadequate sedation, or recovery agitation.10,121 Given the risks of apnea and respiratory depression associated with both of these drugs, providers must be skilled in the administration of the drugs and management of potential adverse reactions when ketamine and/or propofol are used for fracture reduction. 

Author's Preferred Method of Treatment

For angulated and displaced fractures requiring manipulation for reduction and casting, the authors prefer the use of IV ketamine, without premedication, as it provides the most effective sedation and analgesia with the least risk of respiratory adverse events.85 Ketamine sedation must be administered by a clinician who is knowledgeable about the effects and risk of this medication. The provider must also be skilled in the rapid recognition of respiratory complications as well as the capability of advanced airway management including bag-valve-mask ventilation and tracheal intubation, which may be indicated for laryngospasm. Although fentanyl and midazolam may be used for fracture reduction, when compared to the use of ketamine and midazolam for fracture reduction, fentanyl plus midazolam is more likely to be associated with respiratory complications and less effective sedation.64,85 The use of propofol for procedural sedation is expanding in our ED, but at this time is not routinely being used for fracture reduction. 

Perioperative Pain Management

Regional Anesthesia in Children for a Musculoskeletal Injury

The purpose of regional anesthesia is to provide site-specific analgesia, and it can be divided into three categories: Neuraxial, peripheral, and field blocks. Regional anesthetics are often preferred when possible over general anesthetics because of their decreased systemic side effects. Neuraxial blockade is injection of anesthetic agents into the epidural or intrathecal space. As this procedure is typically performed by an anesthesiologist, this chapter will focus on the latter two forms of blockade. As always, any of the described techniques should be performed within the strict comfort level of the treating physician and are not recommended for use without a clear understanding of the relevant anatomy. We will focus on specific techniques to perform procedural regional anesthesia with a “how to” organization. A basic review of local anesthetics will also be included. 

Regional and Local Anesthetic Agents

Several effective techniques for local and regional anesthesia have been described in the pediatric population including hematoma, IV regional, and regional nerve blocks. As always, use of these medications requires a thorough understanding of the pharmacokinetics and appropriate dosing of these drugs as well as proficiency in the techniques of administering them safely. Local and regional anesthetic drugs work by blocking the conduction of nerve impulses. At the cellular level they depress sodium ion flux across the nerve cell membrane. This results in the inhibition of the initiation and propagation of action potentials.108,122 After injection, local anesthetics diffuse toward their intended site of action and also toward nearby vasculature where uptake is determined by the number of capillaries, the local blood flow, and the affinity of the drug for the tissues. Vasoconstrictors such as epinephrine are mixed with local anesthetics to decrease the vascular uptake and prolong the anesthetic effect. 
Duration of action for the various local anesthetic medications is also determined in part by the type of regional block performed. For example, single-dose brachial plexus blocks tend to have a far longer duration than single-dose epidural or subarachnoid blocks.30 Adverse effects in the tissue surrounding injection sites have been described and include erythema, swelling, and rarely, ischemia when injected into tissues supplied by terminal arteries. Adverse systemic effects are caused by high blood levels of local anesthetics and include tinnitus, drowsiness, visual disturbances, muscle twitching, seizures, respiratory depression, and cardiac arrest. Bupivacaine can be particularly dangerous because it binds with high affinity to myocardial contractile proteins and can cause cardiac arrest. 

Equipment

Before placing any anesthetic block it is important to consider ahead of time the equipment and medication that will be required for the procedure. Simple blocks may only require a weight-based dose of the preferred anesthetic agent, needle(s), syringe(s), and a sterile cleaning solution. For blocks that are placed in deeper planes such as the axillary and femoral nerve blocks and IV (Bier) blocks, additional equipment considerations include appropriate electrocardiographic monitoring, airway management equipment, and a double-cuffed tourniquet (Bier block). In addition, medications that should be readily available include IV diazepam to manage seizures and IV lipid to prevent potential cardiovascular collapse induced by accidental intravascular injection of the anesthetic (especially with bupivacaine). Again, a thorough understanding of the appropriate dosing and resuscitation procedures in the event of local anesthetic toxicity is necessary before performing these procedures. The use of nerve stimulators with insulated needles has gained in popularity. Their use as well as the use of ultrasound have dramatically improved efficacy of many regional blocks. 

Local Anesthesia Toxicity

At least three types of adverse reactions can occur from local anesthetic agents. Clinically, the most important is systemic toxicity of the CNS and cardiovascular system from a relative overdose into the circulation (Table 3-7). This type of reaction is not a medication allergy, but is a function of having too much medication into the bloodstream. In the presence of a major artery, even a low dose of a local anesthetic can lead to seizure activity. In most cases, however, the severity of systemic toxicity is directly related to the concentration of local anesthetic in the bloodstream.30 Seizures and cardiac arrest may be the initial manifestations of systemic toxicity in patients who rapidly attain a high serum level of medication.39,86,94 Agents with greater intrinsic potency, such as bupivacaine and etidocaine, require lower levels for the production of symptoms.30 Dysrhythmias and cardiovascular toxicity may be especially severe with bupivacaine, and resuscitation of these patients may be prolonged and difficult.4,30 The prevention and treatment of acute local anesthetic systemic toxicity are outlined in Table 3-8. Although the potential for CNS toxicity may be diminished with barbiturates or benzodiazepines, given either as premedications or during the treatment of convulsions, these measures do not alter the cardiotoxic threshold of local anesthetic agents. With rapid and appropriate treatment, the fatality rate from local anesthetic-related seizures can be greatly decreased.30 It is essential to stay within accepted dose limits when using any local anesthetic (Table 3-9). To aid in dose calculations, a simple formula for converting percent concentration to milligrams per milliliter is provided in Table 3-10. Local nerve damage and reversible skeletal muscle changes have also been reported from the use of local anesthetics.30 
 
Table 3-7
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Table 3-7
Manifestations of Local Anesthetic Toxicitya
  1.  
    Numbness of the lips and tongue, metallic taste in the mouth
  2.  
    Light-headedness
  3.  
    Visual and auditory disturbances (double vision and tinnitus)
  4.  
    Shivering, muscle twitching, tremors (initial tremors may involve the muscles of the face and distal parts of the extremities)
  5.  
    Unconsciousness
  6.  
    Convulsions
  7.  
    Coma
  8.  
    Respiratory arrest
  9.  
    Cardiovascular depression and collapse
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Table 3-8
Prevention and Treatment of Acute Local Anesthetic Systemic Toxicity
Preventive Measures
  1.  
    Ensure availability of oxygen administration equipment, airway equipment, suction equipment, and medications for treatment of seizures (diazepam or midazolam, thiopental, succinylcholine).
  2.  
    Ensure constant verbal contact with patient (for symptoms of toxicity) and monitor cardiovascular signs and oxygen saturation.
  3.  
    Personally prepare the dose of local anesthetic and ensure it is within the accepted dosage range.
  4.  
    Give the anesthetic slowly, and fractionate the dose.
Treatment
  1.  
    Establish a clear airway; suction if required.
  2.  
    Give oxygen by face mask. Begin artificial ventilation if necessary.
  3.  
    Give diazepam 0.1–0.3 mg/kg IV in incremental doses until convulsions cease. Lorazepam (0.05–0.1 mg/kg) may be used instead, also in increments until convulsions cease.
  4.  
    Succinylcholine (1 mg/kg IV) may be used if there is inadequate control of ventilation with the other medications. Artificial ventilation and possibly endotracheal intubation are required after using succinylcholine.
  5.  
    Use advanced cardiac life-support measures as necessary to support the cardiovascular system (more likely with local anesthetics of increased potency, such as bupivacaine).
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Table 3-9
Maximal Recommended Doses of Commonly Used Local Anesthetics in Children
Injection Dose (mg/kg)
Agent Plain With Epinephrinea
Lidocaineb (Xylocaine) 5 7
Bupivacainec 2.5 3
(Marcaine, Sensorcaine)
Mepivacaine (Carbocaine) 4 7
Prilocained 5.5 8.5
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Table 3-10
Conversion Formula from Percent Concentration to Milligrams/Milliliter
Percentage concentration × 10 × Number of mg/mL
Examples: 0.25% bupivacaine has 2.5-mg bupivacaine/mL; 2% lidocaine has 20-mg lidocaine/mL
Decreasing the percent concentration of anesthetic (as is done in the mini-dose Bier block technique) permits the infusion of a larger volume (mL) of drug with lower risk of systemic toxicity because the total amount (mg) of lidocaine is lower.
X

Intravenous Regional Anesthesia

Bier Block

Bier block anesthesia was originally described in 1908 by August Bier who used IV cocaine to obtain analgesia.15,17,60 Although it declined in popularity as brachial plexus blocks were developed, it was revived in 1963, when its safe and successful use for the reduction of forearm fractures in adults was reported.58 Subsequently, a number of studies have described the effective use of this technique of anesthesia for the treatment of upper extremity fractures in children in an ambulatory setting.11,15,17,21,74 The block has also been described for use in lower extremity fractures, but is less commonly utilized for this indication.74 
The technique for administering the Bier block in the upper extremity involves placement of a deflated pneumatic cuff above the elbow of the injured extremity. Holmes58 introduced the concept of two cuffs in an effort to minimize tourniquet discomfort with prolonged inflation, but the practice has not proven to be necessary for the limited amount of time it takes for fracture reduction in a child.11,17,29 The tourniquet should be secured with tape to prevent Velcro failure.88 IV access is established in a vein on the dorsum of the hand of the injured extremity with a 22- or 23-gauge butterfly needle. The arm is exsanguinated by elevating it for 1 to 2 minutes (Fig. 3-1A). Although exsanguination with a circumferential elastic bandage is described classically, this method can be more painful and difficult to perform in an injured extremity and is no more efficacious than the gravity method.17,29,54,60 The blood pressure cuff is then rapidly inflated to either 100 mm Hg above systolic blood pressure or between 200 and 250 mm Hg (Fig. 3-1B).17,29,54,60 The arm is lowered after cuff inflation. Next, lidocaine is administered, the IV catheter removed, and reduction of the fracture performed (Fig. 3-1C). In the traditional technique, the lidocaine dose is 3 to 5 mg/kg11,29,88 and, in the “mini-dose” technique, 1 to 1.5 mg/kg.17,54,60 
Figure 3-1
 
A–C: Exsanguination with Esmarch bandage (A), application of the double-cuff tourniquet (B), and intravenous injection of local anesthetic into injured limb (C).
 
(From: Military Advanced Regional Anesthesia Handbook, with permission. www.arapmi.org/maraa-book-project.html)
A–C: Exsanguination with Esmarch bandage (A), application of the double-cuff tourniquet (B), and intravenous injection of local anesthetic into injured limb (C).
View Original | Slide (.ppt)
Figure 3-1
A–C: Exsanguination with Esmarch bandage (A), application of the double-cuff tourniquet (B), and intravenous injection of local anesthetic into injured limb (C).
(From: Military Advanced Regional Anesthesia Handbook, with permission. www.arapmi.org/maraa-book-project.html)
A–C: Exsanguination with Esmarch bandage (A), application of the double-cuff tourniquet (B), and intravenous injection of local anesthetic into injured limb (C).
View Original | Slide (.ppt)
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The tourniquet is kept inflated until the fracture is immobilized and radiographs are obtained, in case repeat manipulation is necessary. In any event, the tourniquet should remain inflated for at least 20 minutes to permit the lidocaine to diffuse and become adequately fixed to the tissues, thus minimizing the risk of systemic toxicity.88,115 The blood pressure cuff may be deflated in either a single stage or graduated fashion, although single stage release has proven to be clinically safe and technically easier.42,60,88 During the entire procedure, basic respiratory monitoring is required, and cardiac monitoring is also suggested because of the potential cardiac toxicity. Routine IV access in the uninjured extremity is highly recommended because of the potential for cardiac effects, but is not required.11,54 Patients should be observed for at least 30 minutes following cuff deflation for any adverse systemic reactions. Motor and sensory function typically returns during this period, allowing assessment of neurovascular status of the injured extremity prior to discharge.115 
The literature within the past decade certainly speaks to the effectiveness of the traditional Bier block, utilizing a lidocaine dose of 3 to 5 mg/kg, in managing forearm fractures in children. Four large series with a total of 895 patients undergoing this technique demonstrated satisfactory anesthesia and successful fracture reduction in over 90% of cases.11,29,88,113 The most common adverse effect of the procedure in these studies was tourniquet pain in about 6% of patients.29,113 One patient experienced transient dizziness and circumoral paresthesias.113 One patient developed persistent myoclonic twitching following tourniquet deflation and was hospitalized for observation.88 
Despite the efficacy and relatively low number of complications with the “traditional” Bier block (lidocaine, 3 to 5 mg/kg), concerns and anecdotal reports of systemic lidocaine toxicity (i.e., seizures, hypotension, tachycardia, arrhythmias) have prompted the development of a “mini-dose” (lidocaine, 1 to 1.5 mg/kg) technique of Bier block anesthesia.17,42,60 Reports by Farrell et al.42 and Bolte et al.17 utilizing a lidocaine dose of 1.5 mg/kg and by Juliano et al.60 using a dose of 1 mg/kg in a total of 218 patients have shown the mini-dose Bier block to be effective in achieving adequate anesthesia in 94% of children studied. Although the exact mechanism of action is uncertain, the primary site of action of the Bier block is thought to be the small peripheral nerve branches. At this anatomic level, blockade is better achieved with a larger volume of anesthetic that can be distributed more completely to the peripheral nerve receptors. It appears to be the quantity (i.e., volume) and not the dose of anesthetic that predicates success of the block. For any given dose of lidocaine, diluting the concentration permits the administration of a larger volume of fluid (Table 3-4). This mechanism explains the success of the mini-dose technique. In the series by Juliano et al.60 forearm fracture reduction was pain free in 43 of 44 patients (98%) following Bier block performed with a very dilute lidocaine solution (0.125%) and a relatively small total dose (1 mg/kg). 
Bier block anesthesia, using either the traditional or mini-dose technique has several advantages. First, the technique is fairly easy to administer. Also the onset of action of the block is relatively fast (<10 minutes), but also of relatively short duration, which allows for the assessment of neurovascular function in the extremity after fracture reduction and immobilization. However, rapid recovery may also be considered a disadvantage as the analgesic effect of the local anesthetic is lost once the tourniquet is deflated. A recent report in adults examined the addition of the nonsteroidal anti-inflammatory drug (NSAID) ketorolac to the local anesthetic solution and found that patients did obtain prolonged analgesia after the tourniquet was released.97 An empty stomach is not required. However, no pediatric studies have been performed on this technique. 
Tourniquet discomfort is the most common adverse side effect. Inadvertent cuff deflation with loss of analgesia or systemic toxicity is a potentially significant problem. Compartment syndrome has also been reported. Technically, placing the tourniquet and obtaining IV access in the injured extremity can be a challenge in the uncooperative child, and application of the splint or cast can be cumbersome with the tourniquet in place. IV regional anesthesia is unsuitable for lesions above the elbow.58 This technique is contraindicated in patients with underlying heart block, known hypersensitivity to local anesthetic agents, and seizure disorders. Although not completely contraindicated, caution is urged when using this technique in patients with underlying hemoglobinopathies such as sickle cell disease. 

Author's Preferred Treatment

The basic steps involved in performing an Bier block are as follows: 
  1.  
    Confirm the immediate availability of a functioning positive-pressure oxygen delivery system, as well as appropriate airway management equipment. Also, confirm the immediate availability of medications for the treatment of anesthetic-induced convulsions (Table 3-8). Personnel familiar with administration of rescue medications and emergency airway management should also be available.
  2.  
    Place an IV in the contralateral, uninjured, arm. A patent IV line is of paramount importance in treating the complications of this block. Obtain a baseline set of vital signs, including heart rate, respiratory rate, oxygen saturation, and blood pressure. Pulse oximetry as well as cardiorespiratory status should be monitored continuously.
  3.  
    Select an appropriate tourniquet. An orthopedic tourniquet that can be fastened securely should be used. Because Velcro may become less adhesive with time, check the tenacity of the tourniquet before use. As an added safety measure, the tourniquet may be covered with strong adhesive tape or an elastic bandage after application. The tourniquet should fully encircle the arm and overlap back on itself by at least 6 cm. The arm may be minimally padded with cast padding underneath the tourniquet.17 If a pneumatic tourniquet is used, the provider must be familiar with the location of the tourniquet pressure gauge and valves, because these features vary in location from model to model.29 Narrow-cuffed double tourniquets may not effectively occlude arterial flow, and their use has been discouraged.58 Tourniquet discomfort should not be a problem during short procedures, but if this develops, a second tourniquet can be applied distally over the anesthetized area of the arm.
  4.  
    Palpate the radial pulse of the injured limb.
  5.  
    Place and secure a short 22-gauge cannula or 23-gauge butterfly needle in a vein on the dorsum of the hand of the fractured limb. IV catheters can be secured more readily. If a distal vein is unavailable, a proximal vein or even an antecubital vein can be used, but may result in a less effective block.58
  6.  
    With the tourniquet deflated, exsanguinate the limb by vertically elevating it above the level of the heart for 60 seconds.
  7.  
    Rapidly inflate the tourniquet to a pressure of 225 to 250 mm Hg or 150 mm Hg above the patient's systolic blood pressure.43 Check for disappearance of the radial pulse. Cross-clamping the tubing of the cuff after inflation is discouraged because it might prevent detection of a small leak.58 Constant observation of the cuff pressure gauge is recommended.
  8.  
    Lower the extremity and slowly inject the local anesthetic. This injection should be done over a period of 60 seconds. A concentration of 0.125% to 0.5% plain lidocaine (1.25 to 5 mg/mL) is used. Bupivacaine is contraindicated for this block because of its cardiotoxicity. To prevent thrombophlebitis, the local anesthetic solution must be free of any additives or preservatives.31 In different studies, the recommended dose of lidocaine has varied from 1.5 to 3 mg/kg.11,17,29,42,88,113 A dose of 1.5 mg/kg appears to be safe and effective and may be associated with a decreased rate of complications.17 One study has recommended a maximal lidocaine dose of 100 mg for this block.42 The skin of the extremity becomes mottled as the drug is injected. The patient, unless he or she is very sedated, and the parents, if they are watching, should be warned that the extremity will look and feel strange. Analgesia and muscle relaxation develop within 5 minutes of injection.58 For fractures at the wrist, placement of a regular Penrose drain tourniquet around the distal forearm may improve distribution of the local anesthetic solution at the fracture site.
  9.  
    To improve analgesia for fracture reduction, the last 2 mL of local anesthetic solution may be injected directly into the fracture hematoma. The technique of local infiltration anesthesia, or hematoma block, is discussed later in this chapter.
  10.  
    Reduce the fracture and apply the cast or splint.
  11.  
    Leave the cuff inflated for at least 15 minutes, even if the surgical procedure takes less time to prevent significant entry of local anesthetic into the general circulation.58
  12.  
    Monitor the patient closely for at least 15 minutes for any complications related to the block. The treatment of local anesthetic-induced systemic toxicity has been discussed (Table 3-8).
  13.  
    Depending on whatever sedation has been administered, the patient should be monitored until discharge criteria are met (Table 3-5). An assistant must be present to watch the patient, the tourniquet, and the monitors at all times.

Regional Nerve Blockade of the Upper Extremity

Regional nerve blockade can be administered at several levels of the upper extremity from the axilla to individual digits. In the following section, various nerve blocks will be described based upon anatomic level. 

Axillary Block

The axillary block is the most common method to anesthetize the majority of the brachial plexus. This can be used for procedures at, or below the elbow. The only sensory nerve not reliably anesthetized with an axillary nerve block is the musculocutaneous nerve, from which the anterolateral cutaneous nerve of the forearm arises. Therefore, achieving a complete block of the forearm may require an additional, separate injection to anesthetize this nerve (see musculocutaneous nerve block below). A single infraclavicular injection could be utilized to obtain the same result, but usually requires ultrasound guidance. As there are easily palpable landmarks for an axillary block, this block can be performed without ultrasound. 
Potential complications of an axillary nerve block include systemic lidocaine toxicity, hematoma formation, and persistent neurologic symptoms. During injection for an axillary nerve block, the provider should not continue to inject if they feel any resistance, as this may be a sign that the needle is within the nerve substance. Horner syndrome has also been reported. In actuality, complications of axillary block anesthesia are rare.120 None were encountered in the series reported by Cramer et al.31 of 111 children with displaced forearm fractures treated in an ED setting. Contraindications to axillary block anesthesia are the presence of a coagulopathy of any type, a pre-existing neurologic or vascular abnormality of the extremity, axillary lymphadenitis, or an uncooperative or combative patient. 

Author's Preferred Treatment

The basic steps involved in performing an axillary block are as follows: 
  1.  
    The axillary artery is the primary landmark for this block. The child is positioned supine with the injured arm abducted and externally rotated 90 degrees. Procedural sedation may be required for block placement in children.
  2.  
    The axilla is prepped with a bactericidal solution and draped with sterile towels.
  3.  
    The axillary artery is palpated in the axillary fossa and trapped between the index and long fingers against the humerus. If difficult to find, asking the patient to gently adduct the arm against resistance highlights the groove between the coracobrachialis and the pectoralis muscle where the artery can be located (Fig. 3-2).
  4.  
    A 1% lidocaine solution at a dose of 3 to 5 mg/kg is used for injection. The target for delivery of the anesthetic agent is the axillary sheath, which contains the axillary artery and vein surrounded by the radial nerve (posterior), median nerve (anterolateral), and ulnar nerve (medial). The musculocutaneous nerve courses outside of this sheath through the coracobrachialis muscle on its way to run between the biceps and the brachialis, and therefore, may escape blockade. Proper placement of the needle can be confirmed by several methods. If available, ultrasound and/or nerve stimulator can be very helpful in placement. If a nerve stimulator is available, it is attached to a 22-to 25-gauge insulated needle, set to 1 mA current, and the needle is inserted in line with the artery at a 45-degree angle until one of the three things happen: Blood returns, paresthesias are noted by patient, or distal muscle twitches are elicited. If local muscles are stimulated you need to back out and redirect as you have penetrated nearby muscles and will miss the desired nerves. Following this, the stimulator is switched off, and a weight-based dose of anesthetic is injected, stopping every 5 mL to aspirate to check for intravascular needle migration.
  5.  
    Alternatively, the transarterial method of axillary block has also been shown to be efficacious in a pediatric population.31 It has the benefit of not requiring a nerve stimulator or ultrasound to localize the nerves.
  6.  
    Similar to the above description, the axillary artery is palpated in the axillary fossa between the index and long fingers in line with the upper arm.
  7.  
    A 25-gauge butterfly needle attached to tubing and a syringe with the desired amount of injectable anesthetic preloaded is inserted perpendicularly to the skin and artery.
  8.  
    The needle is advanced while being continuously aspirated until a flash of arterial blood is seen, and then it is advanced through the artery. In an effort to maximize the spread of anesthetic into all areas around the artery, approximately two-thirds of the lidocaine is injected into the sheath deep to the artery, checking by aspiration after every 5 cc to ensure extravascular positioning.
  9.  
    The needle is then withdrawn to the superficial side of the artery and the remaining lidocaine is injected.
  10.  
    Pressure is held over the puncture site for 5 minutes to reduce the chance of hematoma formation.
  11.  
    Onset time, duration, and completeness of anesthesia will depend on type of anesthetic and how close the injection was to the radial, median, ulnar, and musculocutaneous nerves.
  12.  
    If there is incomplete anesthesia of the volar lateral forearm a supplemental injection can be performed at the elbow as described below.
Figure 3-2
Technique of needle insertion for axillary block.
 
The axillary artery is palpated and the needle is inserted at the lateral edge of the pectoralis major and parallel to the coracobrachialis. This is illustrated here by the clinical photograph (A) and drawing (B) of the left axilla. The patient's arm is abducted and externally rotated. The needle is seen inserted just lateral to the index finger of the person performing the block.
 
(Adapted from: McCarty EC, Mencio GA. Anesthesia and analgesia for the ambulatory management of children's fractures. In: Green NE, Swiontkowski MF, eds. Skeletal Trauma in Children. 3rd ed. Philadelphia, PA: Saunders; 2003.)
The axillary artery is palpated and the needle is inserted at the lateral edge of the pectoralis major and parallel to the coracobrachialis. This is illustrated here by the clinical photograph (A) and drawing (B) of the left axilla. The patient's arm is abducted and externally rotated. The needle is seen inserted just lateral to the index finger of the person performing the block.
View Original | Slide (.ppt)
Figure 3-2
Technique of needle insertion for axillary block.
The axillary artery is palpated and the needle is inserted at the lateral edge of the pectoralis major and parallel to the coracobrachialis. This is illustrated here by the clinical photograph (A) and drawing (B) of the left axilla. The patient's arm is abducted and externally rotated. The needle is seen inserted just lateral to the index finger of the person performing the block.
(Adapted from: McCarty EC, Mencio GA. Anesthesia and analgesia for the ambulatory management of children's fractures. In: Green NE, Swiontkowski MF, eds. Skeletal Trauma in Children. 3rd ed. Philadelphia, PA: Saunders; 2003.)
The axillary artery is palpated and the needle is inserted at the lateral edge of the pectoralis major and parallel to the coracobrachialis. This is illustrated here by the clinical photograph (A) and drawing (B) of the left axilla. The patient's arm is abducted and externally rotated. The needle is seen inserted just lateral to the index finger of the person performing the block.
View Original | Slide (.ppt)
X
In most children, the axillary sheath is superficial because of the dearth of subcutaneous fat, which makes this a technically easier procedure in a child than in an adult. Of course, this advantage can be offset if the child is obese or uncooperative. For this reason IV midazolam may assist in administration of this block in a child by providing better tolerance of the procedure. 

Nerve Blocks About the Elbow

Blockade at either the elbow or wrist anesthetizes the peripheral branches of the brachial plexus supplying the hand. Although a more proximal blockade (e.g., the axillary block) can serve the same purpose, the more peripheral alternatives are available if infection impedes access to the brachial plexus, the patient suffers from coagulation abnormalities, bilateral surgery is indicated, the patient has a difficult anatomy, or if blockade of the brachial plexus requires further supplementation. 
Ultrasound imaging has diminished emphasis on other means of approximating the location of nerves (e.g., surface anatomy, nerve stimulation, and elicitation of paresthesias). The description to follow, however, is intended to guide the user in performing elbow and wrist blocks in the event that ultrasound imaging is unavailable. 

Author's Preferred Treatment

The basic steps involved in performing blockade of the median, radial, musculocutaneous, and ulnar nerves at the elbow are as follows and a drawing of the basic nerve location about the elbow are shown in Figure 3-3
Figure 3-3
Illustration of frontal view of right antecubital fossa and cross-sectional view showing the relative location of median, radial, and ulnar nerves.
(From: Military Advanced Regional Anesthesia Handbook, with permission. www.arapmi.org/maraa-book-project.html)
(From: Military Advanced Regional Anesthesia Handbook, with permission. www.arapmi.org/maraa-book-project.html)
View Original | Slide (.ppt)
X

Median Nerve

  1.  
    A line is drawn connecting the two humeral epicondyles. Medial to the point of intersection of this line and the biceps tendon is the brachial artery. Medial still is the median nerve (Fig. 3-4).
  2.  
    A 22- to 25-gauge needle and preloaded syringe with weight-based allowance of anesthetic are inserted in the region of the median nerve.
  3.  
    After eliciting nerve stimulation or paresthesias, aspirate first, flush any blood encountered back out, and redirect 2 to 3 mm more medially.
  4.  
    Injection of 3 to 5 mL of anesthetic is usually sufficient to obtain complete blockade.
Figure 3-4
Left antecubital fossa.
 
“X” marks signify injection sites for radial nerve (top of picture) and median (bottom of picture) nerve. The dotted lines signify the location of the biceps tendon. Solid line signifies brachial artery location.
 
(From: Military Advanced Regional Anesthesia Handbook, with permission. www.arapmi.org/maraa-book-project.html)
“X” marks signify injection sites for radial nerve (top of picture) and median (bottom of picture) nerve. The dotted lines signify the location of the biceps tendon. Solid line signifies brachial artery location.
View Original | Slide (.ppt)
Figure 3-4
Left antecubital fossa.
“X” marks signify injection sites for radial nerve (top of picture) and median (bottom of picture) nerve. The dotted lines signify the location of the biceps tendon. Solid line signifies brachial artery location.
(From: Military Advanced Regional Anesthesia Handbook, with permission. www.arapmi.org/maraa-book-project.html)
“X” marks signify injection sites for radial nerve (top of picture) and median (bottom of picture) nerve. The dotted lines signify the location of the biceps tendon. Solid line signifies brachial artery location.
View Original | Slide (.ppt)
X

Radial Nerve

  1.  
    A line is drawn connecting the two humeral epicondyles (Fig. 3-4).
  2.  
    The radial nerve courses over the lateral epicondyle and it can be anesthetized by inserting a needle approximately 2 cm lateral to the intersection between the intercondylar line and biceps tendon.
  3.  
    Advance a 22- to 25-gauge needle and preloaded syringe with a weight-based allowance of anesthetic until bone is encountered.
  4.  
    A fan-shaped injection of 3 to 5 mL of local anesthetic solution effectively blocks the radial nerve.

Musculocutaneous Nerve

  1.  
    A line is drawn connecting the two humeral epicondyles.
  2.  
    To anesthetize the musculocutaneous nerve (perhaps as a supplement to the axillary block), the needle should be positioned 1 cm lateral and 1 cm proximal to the intersection between the intercondylar line and biceps tendon.
  3.  
    Advance a 22- to 25-gauge needle and preloaded syringe with a weight-based allowance of anesthetic into the subcutaneous tissue.
  4.  
    A fan-shaped injection of 3 to 5 mL of local anesthetic solution effectively blocks the musculocutaneous nerve.

Ulnar Nerve

  1.  
    The ulnar nerve traverses the medial epicondyle on the posterior aspect of the elbow. Injection at this location, perhaps as a consequence of insulation by fibrous tissue, carries a higher risk of nerve injury (Fig. 3-5).
  2.  
    An alternative injection site is at a point 1 to 2 cm proximal to a line connecting the medial epicondyle and the olecranon.
  3.  
    Advance a 22- to 25-gauge needle and preloaded syringe with a weight-based allowance of anesthetic in the superficial subcutaneous tissue only. No paresthesia should be evoked using this approach.
  4.  
    A fan-shaped injection of 3 to 5 mL of lidocaine is employed in a fan-like manner.
Figure 3-5
Picture of flexed left elbow.
 
The dotted line signifies the location of the ulnar nerve and large blue dot the medial epicondyle. Note the needle is inserted 1 to 2 cm proximal to the epicondyle.
 
(From: Military Advanced Regional Anesthesia Handbook, with permission. www.arapmi.org/maraa-book-project.html)
The dotted line signifies the location of the ulnar nerve and large blue dot the medial epicondyle. Note the needle is inserted 1 to 2 cm proximal to the epicondyle.
View Original | Slide (.ppt)
Figure 3-5
Picture of flexed left elbow.
The dotted line signifies the location of the ulnar nerve and large blue dot the medial epicondyle. Note the needle is inserted 1 to 2 cm proximal to the epicondyle.
(From: Military Advanced Regional Anesthesia Handbook, with permission. www.arapmi.org/maraa-book-project.html)
The dotted line signifies the location of the ulnar nerve and large blue dot the medial epicondyle. Note the needle is inserted 1 to 2 cm proximal to the epicondyle.
View Original | Slide (.ppt)
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Nerve Blocks About the Wrist

Radial, median, and ulnar nerve blocks as well as hematoma blocks can also be achieved for hand- and wrist-based anesthetic needs. Based on the location of the planned procedure, the clinician may opt for a nerve block at the wrist. 

Author's Preferred Treatment

The basic steps involved in performing blockade of the median, radial, and ulnar nerves at the wrist are as follows: 

Median Nerve

  1.  
    The forearm is supinated and a 22- to 25-gauge needle is inserted roughly 2 cm proximal to the wrist crease, between the flexor carpi radialis and palmaris longus tendons. In patients lacking a palmaris longus tendon, the median nerve is approximately 1 cm ulnar to the flexor carpi radialis tendon (Fig. 3-6).
  2.  
    The needle should be inserted vertically and advanced to a depth of roughly 1 cm, until the flexor retinaculum is pierced (indicated by a slight “pop”).
  3.  
    At this point, 3 to 5 mL of anesthetic may be injected. Begin injecting while the needle is deeply inserted and continue while withdrawing the needle to the surface. Doing the opposite may result in deposition of solution above the retinaculum.
Figure 3-6
Picture of the volar aspect of the left wrist.
 
The hashed lines indicate the flexor palmaris longus (upper) and flexor carpi radialis (lower). The needle and “x” on the median nerve injection site.
 
(From: Military Advanced Regional Anesthesia Handbook, with permission. www.arapmi.org/maraa-book-project.html)
The hashed lines indicate the flexor palmaris longus (upper) and flexor carpi radialis (lower). The needle and “x” on the median nerve injection site.
View Original | Slide (.ppt)
Figure 3-6
Picture of the volar aspect of the left wrist.
The hashed lines indicate the flexor palmaris longus (upper) and flexor carpi radialis (lower). The needle and “x” on the median nerve injection site.
(From: Military Advanced Regional Anesthesia Handbook, with permission. www.arapmi.org/maraa-book-project.html)
The hashed lines indicate the flexor palmaris longus (upper) and flexor carpi radialis (lower). The needle and “x” on the median nerve injection site.
View Original | Slide (.ppt)
X

Radial Nerve

  1.  
    Because of the branching fibers of the radial nerve, blocking its various projections requires a field block (Fig. 3-7).
  2.  
    A 22- to 25-gauge needle is inserted at the base of the first metacarpal, superficial to the extensor pollicis longus tendon and 2 mL of local anesthetic is injected.
  3.  
    A similar amount is injected superficial to the extensor pollicis brevis tendon, on the opposite side of the anatomic snuffbox.
  4.  
    Smaller injections of 1 mL should be administered over the dorsum of the wrist until the dorsal midline of the wrist is reached.
Figure 3-7
Picture of the radial aspect of the left wrist.
 
Solid line indicates the location of the radial artery. The vertical dashed line indicates the area to inject for the field block that will block the sensory branches of the radial nerve.
 
(From: Military Advanced Regional Anesthesia Handbook, with permission. www.arapmi.org/maraa-book-project.html)
Solid line indicates the location of the radial artery. The vertical dashed line indicates the area to inject for the field block that will block the sensory branches of the radial nerve.
View Original | Slide (.ppt)
Figure 3-7
Picture of the radial aspect of the left wrist.
Solid line indicates the location of the radial artery. The vertical dashed line indicates the area to inject for the field block that will block the sensory branches of the radial nerve.
(From: Military Advanced Regional Anesthesia Handbook, with permission. www.arapmi.org/maraa-book-project.html)
Solid line indicates the location of the radial artery. The vertical dashed line indicates the area to inject for the field block that will block the sensory branches of the radial nerve.
View Original | Slide (.ppt)
X

Ulnar Nerve

  1.  
    At the level of the wrist, the ulnar nerve is medial to the ulnar artery and both are radial to the flexor carpi ulnaris (FCU) tendon (Fig. 3-8).
  2.  
    A 22- to 25-gauge needle is advanced perpendicular to the long axis of the forearm roughly 6 cm proximal to the wrist crease (this will ensure anesthetization of the nerve before the palmar cutaneous and dorsal radiations branch off) to a depth of approximately 1.5 cm, your goal is to insert the needle tip just deep to the FCU sheath.
  3.  
    This approach may elicit paresthesias or a motor/sensory response to nerve stimulation.
  4.  
    Aspirate to confirm extravascular placement.
  5.  
    When one of these end points is encountered, 4 to 8 mL of local anesthetic solution can be deposited.
Figure 3-8
Picture of the volar aspect of the left wrist.
 
Circle drawn on the skin signifies the ulnar styloid and nearby solid line the ulnar artery. The needle is over the injection site for an ulnar nerve block at the wrist.
 
(From: Military Advanced Regional Anesthesia Handbook, with permission. www.arapmi.org/maraa-book-project.html)
Circle drawn on the skin signifies the ulnar styloid and nearby solid line the ulnar artery. The needle is over the injection site for an ulnar nerve block at the wrist.
View Original | Slide (.ppt)
Figure 3-8
Picture of the volar aspect of the left wrist.
Circle drawn on the skin signifies the ulnar styloid and nearby solid line the ulnar artery. The needle is over the injection site for an ulnar nerve block at the wrist.
(From: Military Advanced Regional Anesthesia Handbook, with permission. www.arapmi.org/maraa-book-project.html)
Circle drawn on the skin signifies the ulnar styloid and nearby solid line the ulnar artery. The needle is over the injection site for an ulnar nerve block at the wrist.
View Original | Slide (.ppt)
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Local Infiltration Anesthesia: Hematoma Block

The hematoma block has been a popular method of anesthesia for the reduction of fractures, particularly in the distal radius, but also for the ankle.1,6,22,35,59 In this technique, a local anesthetic agent is injected directly into the hematoma surrounding the fracture, the location of which is confirmed by aspirating blood into the syringe. This block is quick and relatively simple to administer. The anesthetic inhibits the generation and conduction of painful impulses primarily in small nonmyelinated nerve fibers in the periosteum and local tissues.95 Although the medication is rapidly absorbed into the circulation, the resulting systemic blood levels of local anesthetic have been shown to be well below those required for CNS toxicity.83 Although direct injection of the hematoma theoretically converts a closed fracture into an open one, there have been no reports of infection with this technique.22 Reported complications with hematoma blocks in the upper extremity include compartment syndrome, temporary paralysis of the anterior interosseous nerve, and acute carpal tunnel syndrome.68,123 Because of its greater cardiovascular risk profile with intravascular injection, bupivacaine is not recommended for this type of block. 

Author's Preferred Treatment

The basic steps involved in performing a hematoma block are as follows: 
  1.  
    The skin overlying the fracture site is prepped in a sterile manner.
  2.  
    A more concentrated solution of plain lidocaine (1 to 3 mg/kg) is recommended to increase efficacy and prevent the need to inject more than 10 mL of solution. This avoids soft tissue and compartment pressures.
  3.  
    A 20- or 22-gauge needle with attached syringe preloaded with plain lidocaine is inserted aspirating as it is advanced until fracture hematoma is encountered.
  4.  
    Once identified, plain lidocaine is injected to a maximum volume of 10 mL as previously mentioned (Fig. 3-9).
Figure 3-9
Picture of a fractured wrist with dorsally displaced distal radius (hand at top of picture).
 
The needle is placed into the fracture site and aspiration performed to confirm injection into the fracture.
The needle is placed into the fracture site and aspiration performed to confirm injection into the fracture.
View Original | Slide (.ppt)
Figure 3-9
Picture of a fractured wrist with dorsally displaced distal radius (hand at top of picture).
The needle is placed into the fracture site and aspiration performed to confirm injection into the fracture.
The needle is placed into the fracture site and aspiration performed to confirm injection into the fracture.
View Original | Slide (.ppt)
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Digital Nerve Blocks

Although brachial plexus anesthesia may be efficacious for any fracture of the upper extremity below the elbow, more distal upper extremity blocks at the wrist or of the digital nerves in the hand may be useful for treatment of fractures or minor surgical procedures of the hand. Anesthesia to the digits can be achieved by block of the common digital nerves near the point of bifurcation at the level of the metacarpal heads or by block of the radial and ulnar digital nerves at the base of each finger. This technique is most useful for treatment of phalangeal fracture(s) of a single digit and soft tissue injuries to the fingertip and nail bed. 
The anatomy of the hand consists of four nerves supplying each finger. Two of these run on the volar aspect of each finger and supply the volar surface of that digit; and two are dorsal in location and sensory distribution. The notable exception to this generalization is that the two volar nerves of the middle three fingers also provide sensation to the nail beds of these fingers. Nail beds of the thumb and fifth digit, however, are supplied by the two nerves running on the dorsal surface. This difference in sensory distribution is important when procedures involve the fingertip. In case of the middle three fingers, medicating the two volar nerves will suffice; whereas, in case of the thumb and fifth digit, anesthetizing all four nerves is necessary. The two blocks discussed here are the ring block and the transthecal block. The ring block is performed from a dorsal approach through a single needle stick on both sides of the digit raising a wheal of subcutaneous anesthetic on radial and ulnar aspects of the base of the digit. The transthecal block is performed via single needle stick on the volar aspect of the hand at the level of the metacarpal head.24 The goal is to inject local anesthetic into the flexor tendon sheath to obtain anesthesia of the entire digit. Anesthetic solutions should not contain epinephrine to avoid causing digital ischemia. 

Author's Preferred Treatment

The basic steps involved in performing a digital block are as follows: 

Ring Block

  1.  
    The ring block begins with the hand in pronation and the skin is prepped in a sterile manner.
  2.  
    A 25-gauge needle is positioned from a dorsal approach into the proximal region of the web space, as close as possible to the phalanx in question.
  3.  
    Going off to one side of the finger, the nearby dorsal nerve can be anesthetized by raising a small skin wheal using 1 mL of local anesthetic.
  4.  
    The needle is then advanced toward the palm until the skin on the palmar surface begins to tent, then the needle is retracted slightly.
  5.  
    The palmar branch nearby can be blocked using 1 to 2 mL of solution.
  6.  
    The same protocol is repeated to block the corresponding two nerves on the opposite side of the finger.

Transthecal Block

  1.  
    The hand is placed in supination and the skin is prepped in a sterile manner.
  2.  
    A 25-gauge needle is inserted perpendicular to the skin, directly over the metacarpal head and advanced until bone is encountered.
  3.  
    After making contact with bone, the needle is withdrawn slightly, your nondominant index finger is used to apply pressure proximal to the area of injection (to prevent flow into the proximal tendon sheath) and injection begun until the anesthetic flows easily into the flexor tendon sheath.

Regional Nerve Blockade of the Lower Extremity

Regional nerve blockade can be administered at several levels of the lower extremity from the inguinal ligament to individual digits. In the following section, various nerve blocks will be described based upon anatomic level. 
Neural supply to the lower extremities is derived from the lumbar plexus, comprising the anterior rami of the L1–L4 spinal nerves, and the sacral plexus, comprising the anterior rami of the S1–S4 spinal nerves. The L2–L4 branches of the lumbar plexus supply the thigh and can be divided into the anterior and posterior branches. The anterior portions of L2–L4 include the obturator nerve, which innervates the medial aspects of the thigh. The posterior branches give rise to the femoral nerve (L2–L4) and the lateral femoral cutaneous nerves (L2–L3), which supply the anterior and lateral parts of the thigh, respectively. Once the femoral nerve passes under the inguinal ligament, it enters the thigh and immediately divides into several branches. Those descending anteriorly provide sensation to the anterior thigh from the inguinal ligament to the knee, whereas branches lying more posterior provide motor function to the extensors of the leg. The saphenous nerve descends into the leg along the medial aspect of the knee with the femoral artery and vein, branching off above the knee to run between the sartorius and gracilis muscles at the medial knee. At this point, the saphenous nerve becomes subcutaneous and forms branches that innervate the medial aspect of the leg and foot. 
Both the lumbar and the sacral plexuses contribute to the formation of the sciatic nerve (L4–S3). The ventral branches of L4–S3 comprise that aspect of the sciatic nerve that will become the tibial nerve and dorsal branches form that part that will become the common peroneal nerve. Immediately after originating from the rami mentioned above, the sciatic nerve traverses the greater sciatic foramen (along with the posterior cutaneous nerves, S1–S3), and continues under the piriformis muscle, between the greater trochanter and the ischial tuberosity. At the lower edge of the gluteus maximus muscle, the nerve is at its most superficial point before descending to the popliteal fossa, where it divides into the tibial and common peroneal nerves. The tibial nerve is medial and anterior, whereas the common peroneal lies more posterior and lateral. Along its course, the sciatic nerve innervates the posterior thigh, as well as all areas below the knee (with the exception of the medial aspect of the foot, which is the domain of the saphenous nerve). 

Femoral Nerve Block

Femoral nerve blockade can be used in the treatment of femoral fractures.14,25,34,98,119 Although the majority of children with femoral fractures are not managed on an outpatient basis, femoral nerve blockade can provide excellent anesthesia and analgesia for the initial management of this injury including manipulation of the fracture, application of an immediate spica cast, or placement of a traction pin. It is a good option for children unable to undergo general anesthesia or procedural sedation. This technique is most effective for fractures of the middle third of the femur. In one randomized control study, regional blockade of the femoral nerve was shown to provide clinically superior pain relief compared with IV morphine sulfate throughout the initial 6 hours of management in children aged 16 months to 15 years with isolated femoral shaft fractures.119 In the reports of this technique, there have been few inadvertent arterial punctures with no long-term sequelae and no neurologic complications.34,55,102 Other potential complications include systemic toxicity from intravascular injection, infection, and injury to the nerve. As with the axillary block, this method may be difficult in obese children as well as the young and/or uncooperative child. Contraindications include any pre-existing neurologic abnormality of the injured lower extremity and the inability to manage complications of systemic toxicity. 

Author's Preferred Treatment

The basic steps involved in performing a femoral nerve block are as follows: 
  1.  
    Prepare and drape the inguinal area and palpate the femoral artery.
  2.  
    A 22- or 23-gauge needle on a syringe containing an appropriately dosed local anesthetic agent (typically either 1% to 1.5% lidocaine with 1:200,000 epinephrine, dosed up to 7 mg/kg14 or 0.5% bupivacaine, dosed at 1 to 1.5 mg/kg102) is inserted one fingerbreadth lateral to the artery and 1 to 2 cm below the inguinal ligament (Fig. 3-10).
  3.  
    The needle is advanced at a 30- to 45-degree angle to the skin and the syringe aspirated as the needle passes through the deep fascia into the femoral triangle. There is occasionally a palpable “pop” when passing this fascial plane (Fig. 3-11).
  4.  
    If no blood is aspirated, the anesthetic agent is injected around the femoral nerve.
  5.  
    Alternatively, the nerve can be blocked more proximally within the fascia iliaca compartment by entering just above the inguinal ligament with the advantage of accessing all branches of the nerve before it starts to arborize. As with axillary block, the volume of the anesthetic is the key to achieving anesthesia with this technique. The onset of analgesia occurs within 10 minutes and, with the use of long-acting agents such as bupivacaine, may last up to 8 hours.34
Figure 3-10
Picture of the anterior right hip and groin.
 
The dotted line signifies the inguinal ligament, large blue dot the injection site for femoral nerve block, and adjacent lines the location of the femoral artery.
 
(From: Military Advanced Regional Anesthesia Handbook, with permission. www.arapmi.org/maraa-book-project.html)
The dotted line signifies the inguinal ligament, large blue dot the injection site for femoral nerve block, and adjacent lines the location of the femoral artery.
View Original | Slide (.ppt)
Figure 3-10
Picture of the anterior right hip and groin.
The dotted line signifies the inguinal ligament, large blue dot the injection site for femoral nerve block, and adjacent lines the location of the femoral artery.
(From: Military Advanced Regional Anesthesia Handbook, with permission. www.arapmi.org/maraa-book-project.html)
The dotted line signifies the inguinal ligament, large blue dot the injection site for femoral nerve block, and adjacent lines the location of the femoral artery.
View Original | Slide (.ppt)
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Figure 3-11
Picture of the lateral right hip illustrating the correct angle of needle placement for a femoral nerve block distal to the inguinal ligament.
(From: Military Advanced Regional Anesthesia Handbook, with permission. www.arapmi.org/maraa-book-project.html)
(From: Military Advanced Regional Anesthesia Handbook, with permission. www.arapmi.org/maraa-book-project.html)
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Saphenous Nerve

Blockade of this terminal branch of the femoral nerve is usually combined with a sciatic nerve block for procedures of the leg (distal to the knee) or a popliteal block for procedures involving the foot and ankle.18,116 It becomes superficial at the level of the knee, runs with the greater saphenous vein, and has many smaller branches as it descends the medial aspect of the lower leg as it heads toward the ankle and foot (Fig. 3-12). For this reason the block should be made as distal as possible while still remaining proximal to the region of interest to maximize block effect. 
Figure 3-12
Illustration of the medial aspect of the knee.
 
Highlighted is the course of the saphenous nerve about the knee.
 
(From: Military Advanced Regional Anesthesia Handbook, with permission. www.arapmi.org/maraa-book-project.html)
Highlighted is the course of the saphenous nerve about the knee.
View Original | Slide (.ppt)
Figure 3-12
Illustration of the medial aspect of the knee.
Highlighted is the course of the saphenous nerve about the knee.
(From: Military Advanced Regional Anesthesia Handbook, with permission. www.arapmi.org/maraa-book-project.html)
Highlighted is the course of the saphenous nerve about the knee.
View Original | Slide (.ppt)
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Author's Preferred Treatment

The basic steps involved in performing a saphenous nerve block are as follows18
  1.  
    The patient is placed supine and the knee may be flexed 45 degrees.
  2.  
    The primary landmark is the tibial tuberosity.
  3.  
    A 22- to 23-gauge, 1.5-in needle is inserted subcutaneously at 2 cm medial to the superior aspect of the tibial tuberosity in a line parallel to the tibial plateau.
  4.  
    Five to 10 mL of 1% lidocaine or 0.25% bupivacaine (for longer duration) with 1:200,000 epinephrine is used to raise a wheal from the starting point to the medial aspect of the knee.

Popliteal Block

The goal of the popliteal block is to localize the sciatic nerve prior to its division into the common peroneal and tibial nerves. This block is indicated in foot and ankle surgery, and is preferred over an ankle block in cases employing a calf tourniquet.18,74,116 If surgery involves the medial aspect of the foot or if a calf tourniquet is employed, blocking the saphenous nerve is also essential (see above). 
The muscular borders of the popliteal fossa are the medial and lateral heads of the gastrocnemius muscles (inferiorly) and the semimembranosus and semitendinosus muscles and biceps femoris muscles (superiorly). In the proximal portion of the fossa, the sciatic nerve is flanked on its medial aspect by the popliteal vein, and anteriorly by the popliteal artery (Fig. 3-13). Within the popliteal fossa the sciatic nerve branches into the common peroneal nerve (lateral) and the tibial nerve (which proceeds through the fossa). Utilization of a nerve stimulator with insulated needle and/or ultrasound can be helpful in locating the best placement of anesthetic. When not available, anatomic landmarks can be utilized. Potential complications include nerve injury from direct injection and intravascular injection. 
Figure 3-13
Cadaveric dissection of the popliteal fossa.
 
The pickups are underneath the tibial and peroneal branches of the sciatic nerve after they have separated.
 
(From: Military Advanced Regional Anesthesia Handbook, with permission. www.arapmi.org/maraa-book-project.html)
The pickups are underneath the tibial and peroneal branches of the sciatic nerve after they have separated.
View Original | Slide (.ppt)
Figure 3-13
Cadaveric dissection of the popliteal fossa.
The pickups are underneath the tibial and peroneal branches of the sciatic nerve after they have separated.
(From: Military Advanced Regional Anesthesia Handbook, with permission. www.arapmi.org/maraa-book-project.html)
The pickups are underneath the tibial and peroneal branches of the sciatic nerve after they have separated.
View Original | Slide (.ppt)
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Author's Preferred Treatment

The basic steps involved in performing a popliteal block are as follows116
  1.  
    The popliteal block is commonly performed using a posterior approach.
  2.  
    Flexing the knee slightly and placing a rolled towel bolster under the ankle makes the borders of the fossa more evident and frees the foot to allow visible response.
  3.  
    The borders of a triangle are drawn with the knee crease as the base, the tendons of the semitendinosus and gracilis as the medial border, and the biceps femoris as the lateral border (Fig. 3-14).
  4.  
    A line is drawn from the apex of the triangle and ending perpendicular to the base.
  5.  
    Needle placement is approximately 1 cm lateral to the midline, and 7 to 9 cm superior to the base.
  6.  
    The needle is inserted at a 45-degree angle and advanced anterosuperiorly until paresthesias or nerve stimulator response (foot inversion) is evoked using 0.5 mA.
  7.  
    The syringe is aspirated to confirm extravascular placement, and 30 mL of anesthetic is injected. As always, if significant resistance is encountered do not inject as this may be a sign the needle is within the nerve.
  8.  
    Ultrasound imaging provides direct visualization of the sciatic nerve bifurcation, eliminating the need for surface landmarks.
Figure 3-14
Photograph of the posterior aspect of the knee (patient's foot is to the left of the photo).
 
The popliteal triangle is illustrated with a dotted line. The medial and lateral hamstrings make up the medial and lateral borders.
 
(From: Military Advanced Regional Anesthesia Handbook, with permission. www.arapmi.org/maraa-book-project.html)
The popliteal triangle is illustrated with a dotted line. The medial and lateral hamstrings make up the medial and lateral borders.
View Original | Slide (.ppt)
Figure 3-14
Photograph of the posterior aspect of the knee (patient's foot is to the left of the photo).
The popliteal triangle is illustrated with a dotted line. The medial and lateral hamstrings make up the medial and lateral borders.
(From: Military Advanced Regional Anesthesia Handbook, with permission. www.arapmi.org/maraa-book-project.html)
The popliteal triangle is illustrated with a dotted line. The medial and lateral hamstrings make up the medial and lateral borders.
View Original | Slide (.ppt)
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Nerve Blocks About the Ankle

There are five peripheral nerves that innervate the foot. A drawing of the ankle in cross section is seen in Figure 3-15 illustrating their general relationships to adjacent structures. The saphenous nerve originates from the femoral nerve and the remainder originates from the sciatic. At or slightly below the head of the fibula, the common peroneal nerve gives rise to its superficial and deep branches that eventually descend to the foot. The tibial nerve produces two of its own branches, the posterior tibial and sural nerves, at or slightly below the tibial midshaft. The two branches traverse the ankle on either side of the Achilles tendon: The sural nerve lies laterally, whereas the posterior tibial is medial. The last of the five nerves, the saphenous nerve, is a terminal branch of the femoral nerve and it supplies the proximal, medial aspect of the foot.18,73 
(From: Military Advanced Regional Anesthesia Handbook, with permission. www.arapmi.org/maraa-book-project.html)
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Figure 3-15
Illustration depicting the cross-sectional anatomy of the lower leg at the level of the malleoli.
(From: Military Advanced Regional Anesthesia Handbook, with permission. www.arapmi.org/maraa-book-project.html)
(From: Military Advanced Regional Anesthesia Handbook, with permission. www.arapmi.org/maraa-book-project.html)
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The indications for an ankle block include any procedure involving the distal foot. A complete block typically requires at least three injections. It is contraindicated in the presence of infection. The regions of the foot by nerve are the following. 
  1.  
    Sural: Achilles and posterior heel, plantar heel to midfoot, and midportion of the lateral third of the foot between lateral malleolus and fifth metatarsal head
  2.  
    Posterior tibial (medial and lateral plantar branches): Medial and lateral plantar foot distal half of the sole and plantar aspects of toes
  3.  
    Saphenous: Medial malleolus and (mixed with superficial peroneal) medial foot and arch
  4.  
    Deep peroneal: Dorsal and plantar aspects of first web space and short toe extensors
  5.  
    Superficial peroneal: Medial malleolus, dorsum of foot and toes, and (mixed with saphenous) medial arch and foot

Author's Preferred Treatment

The basic steps involved in performing an ankle block are as follows: 

Posterior Tibial Nerve

  1.  
    With the patient prone, the posterior tibial artery can be palpated (immediately posterior to the medial malleolus) and used as a landmark (Fig. 3-16).
  2.  
    The skin is prepped with cleaning solution.
  3.  
    Slightly posterior to this artery, at the level of the medial malleolus, a 25-gauge needle may be inserted and advanced toward the medial malleolus.
  4.  
    At a depth of 0.5 to 1 cm, paresthesias should be sought by moving the needle from side to side.
  5.  
    If paresthesias are successfully evoked, aspiration should be performed to assess for intravascular placement, followed by injection of 3 to 5 mL of anesthetic. If resistance is met then withdraw 1 mm, aspirate, then try injecting once again as your needle tip may be lodged in nerve or tendon.
  6.  
    If no paresthesias are elicited, the needle is advanced until it encounters bone, and then withdrawn slightly before depositing 7 to 10 mL of solution.
Figure 3-16
Photograph of the medial aspect of the ankle.
 
The needle in the inferior portion of the picture depicts the insertion site for block of the posterior tibial nerve.
 
(From: Military Advanced Regional Anesthesia Handbook, with permission. www.arapmi.org/maraa-book-project.html)
The needle in the inferior portion of the picture depicts the insertion site for block of the posterior tibial nerve.
View Original | Slide (.ppt)
Figure 3-16
Photograph of the medial aspect of the ankle.
The needle in the inferior portion of the picture depicts the insertion site for block of the posterior tibial nerve.
(From: Military Advanced Regional Anesthesia Handbook, with permission. www.arapmi.org/maraa-book-project.html)
The needle in the inferior portion of the picture depicts the insertion site for block of the posterior tibial nerve.
View Original | Slide (.ppt)
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Sural Nerve

  1.  
    The nerve courses between the lateral malleolus and the Achilles tendon, a relative safe zone free from superficial vascular structures.
  2.  
    With the patient prone, the skin between the lateral malleolus and Achilles tendon from the level of the malleolus to 2 cm proximal is prepped with cleaning solution (Fig. 3-17).
  3.  
    A 25-gauge needle is inserted lateral to the tendon (approximately 1 cm above the lateral malleolus) and advanced toward the malleolus while injecting 5 to 7 mL of anesthetic subcutaneously.
Figure 3-17
Photograph of the lateral aspect of the ankle.
 
The needle in the inferior portion of the picture depicts the insertion site for block of the posterior sural nerve.
 
(From: Military Advanced Regional Anesthesia Handbook, with permission. www.arapmi.org/maraa-book-project.html)
The needle in the inferior portion of the picture depicts the insertion site for block of the posterior sural nerve.
View Original | Slide (.ppt)
Figure 3-17
Photograph of the lateral aspect of the ankle.
The needle in the inferior portion of the picture depicts the insertion site for block of the posterior sural nerve.
(From: Military Advanced Regional Anesthesia Handbook, with permission. www.arapmi.org/maraa-book-project.html)
The needle in the inferior portion of the picture depicts the insertion site for block of the posterior sural nerve.
View Original | Slide (.ppt)
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Peroneal and Saphenous Nerves

  1.  
    To block the two peroneal nerves, as well as the saphenous nerve through the same needle-entry point, a line should first be drawn connecting the two malleoli on the dorsal aspect of the foot.
  2.  
    The skin along this anterior ankle line is prepped with cleaning solution between malleoli.
  3.  
    Next, the anterior tibial artery is identified by palpating the area between the extensor hallucis longus tendon (which is evident on dorsiflexion of the first toe) and extensor digitorum longus muscle.
  4.  
    After prepping the skin with cleaning solution, raise a skin wheal immediately lateral to the artery.
  5.  
    A long (3.75 cm, or 1.5 in) 25-gauge needle can be inserted perpendicular to the skin.
  6.  
    To anesthetize the deep peroneal nerve, the needle is advanced under the extensor hallucis longus tendon until it encounters the tibia (usually at a depth of 1 cm, Fig. 3-18).
  7.  
    At this point, aspirate to confirm extravascular placement and inject 3 to 5 mL of anesthetic.
  8.  
    To anesthetize the saphenous nerve, the needle is withdrawn to a subcutaneous position without removing it completely.
  9.  
    The needle is then maneuvered medially, remaining subcutaneous until the midportion of the medial malleolus is reached, and another 3 to 5 mL of solution deposited (Fig. 3-19).
    1.  
      Alternatively, as the saphenous nerve may bifurcate as many as 3 cm proximal to the medial malleolus, a second subcutaneous injection may be more efficacious.
  10.  
    Having just anesthetized the deep peroneal and saphenous nerves, the needle is withdrawn from areas medial to the tibia, and maneuvered laterally (through the same skin insertion point) toward the superficial peroneal nerve (located midway between the extensor hallucis longus tendon and the lateral malleolus) (Fig 3-20).
  11.  
    After aspirating, 5 to 7 mL of anesthetic is injected subcutaneously.
Figure 3-18
Photograph of the anterior aspect of the ankle.
 
The needle in the central portion of the picture depicts the insertion site for block of the deep peroneal nerve.
 
(From: Military Advanced Regional Anesthesia Handbook, with permission. www.arapmi.org/maraa-book-project.html)
The needle in the central portion of the picture depicts the insertion site for block of the deep peroneal nerve.
View Original | Slide (.ppt)
Figure 3-18
Photograph of the anterior aspect of the ankle.
The needle in the central portion of the picture depicts the insertion site for block of the deep peroneal nerve.
(From: Military Advanced Regional Anesthesia Handbook, with permission. www.arapmi.org/maraa-book-project.html)
The needle in the central portion of the picture depicts the insertion site for block of the deep peroneal nerve.
View Original | Slide (.ppt)
X
Figure 3-19
Photograph of the anteromedial aspect of the ankle.
 
The needle in the superior portion of the picture depicts the insertion site for block of the saphenous nerve. The dotted line is the region where a wheel of anesthetic should be raised to hit all branches.
 
(From: Military Advanced Regional Anesthesia Handbook, with permission. www.arapmi.org/maraa-book-project.html)
The needle in the superior portion of the picture depicts the insertion site for block of the saphenous nerve. The dotted line is the region where a wheel of anesthetic should be raised to hit all branches.
View Original | Slide (.ppt)
Figure 3-19
Photograph of the anteromedial aspect of the ankle.
The needle in the superior portion of the picture depicts the insertion site for block of the saphenous nerve. The dotted line is the region where a wheel of anesthetic should be raised to hit all branches.
(From: Military Advanced Regional Anesthesia Handbook, with permission. www.arapmi.org/maraa-book-project.html)
The needle in the superior portion of the picture depicts the insertion site for block of the saphenous nerve. The dotted line is the region where a wheel of anesthetic should be raised to hit all branches.
View Original | Slide (.ppt)
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Figure 3-20
Photograph of the anterolateral aspect of the ankle.
 
The needle in the superior portion of the picture depicts the insertion site for block of the superficial peroneal nerve. The dotted line is the region where a wheel of anesthetic should be raised to maximize the chance to anesthetize it.
 
(From: Military Advanced Regional Anesthesia Handbook, with permission. www.arapmi.org/maraa-book-project.html)
The needle in the superior portion of the picture depicts the insertion site for block of the superficial peroneal nerve. The dotted line is the region where a wheel of anesthetic should be raised to maximize the chance to anesthetize it.
View Original | Slide (.ppt)
Figure 3-20
Photograph of the anterolateral aspect of the ankle.
The needle in the superior portion of the picture depicts the insertion site for block of the superficial peroneal nerve. The dotted line is the region where a wheel of anesthetic should be raised to maximize the chance to anesthetize it.
(From: Military Advanced Regional Anesthesia Handbook, with permission. www.arapmi.org/maraa-book-project.html)
The needle in the superior portion of the picture depicts the insertion site for block of the superficial peroneal nerve. The dotted line is the region where a wheel of anesthetic should be raised to maximize the chance to anesthetize it.
View Original | Slide (.ppt)
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Digital Nerve Blocks

The neural anatomy of the toes is similar to that of the fingers with four nerves supplying each digit. As with the thumb, the technique used to block the hallux varies slightly from that used for the lateral four toes. Because of its circumference, it is often necessary to utilize two injection sites. Like the hand, dorsal needle insertion sites are preferable, especially in the awake patient and epinephrine is strictly avoided in anesthetic solutions because of its vasoconstrictive effects. 

Author's Preferred Treatment

The basic steps involved in performing a digital block of the foot are as follows: 
  1.  
    For the great toe, the skin over the dorsal aspect of the first metatarsal–phalangeal joint is cleaned with alcohol or similar prep solution.
  2.  
    A 25-gauge (or smaller) needle is positioned perpendicularly to the skin, dorsolateral to the proximal phalanx and advanced in the subcutaneous tissue to the plantar surface of the toe until skin tenting is noted.
  3.  
    Inject 1% lidocaine (0.25% bupivacaine or 50:50 mix of bupivacaine: Lidocaine can also be utilized) as the needle is withdrawn, raising a wheal from the plantar to dorsal aspect of toe to ensure the two nerves on the lateral aspect of this toe are anesthetized.
  4.  
    The needle is then withdrawn completely and reinserted on the contralateral side of the great toe, with this protocol repeated.
  5.  
    For the lesser toes the same procedure may be followed. Alternatively, because of the relatively smaller circumference of the smaller toes it may be possible to administer anesthetic to both sides of the metatarsal–phalangeal joint through the same needle stick.

Postoperative Analgesia

Postprocedural analgesia can include both operative and nonoperative treatments. Pain management should begin before the procedural portion begins with a plan for preprocedure, procedural, and postprocedural pain control. Therefore, the treating team should briefly discuss a plan for proper management so that pain management is optimized. 

Nonpharmacologic Treatment

Introduction of nonpharmacologic interventions such as relaxation, distraction, and education may assist the patient and family by decreasing anxiety and perceived interpretation of pain.89,106 Child life specialists are frequently involved in pediatric as well as nonpediatric centers, and when available they can lend significant benefits as far as distracting the child and thereby reducing intensity and amount of perceived pain.89 Though common practice in many institutions, addition modalities that bear mentioning include the use of elevation and ice for injured extremities both before and after fracture treatment. Use of transcutaneous electrical stimulation (TENS) may also affect activation of inhibitory nerve fibers. Currently there is no definitive evidence on its efficacy in the pediatric population.71,89,106 

Nonsteroidal Anti-inflammatory Drugs

This class of medications includes analgesics, antipyretics, and anti-inflammatories that work by the inhibition of cyclooxygenase leading to a decreased production of prostaglandins.116 Although the potential side effects are many including sodium retention and edema, gastritis, and increased bleeding time, when combined with opioids postoperatively they can dramatically enhance pain relief while significantly decreasing opioid requirements.84,89,109 The use of NSAIDs has been controversial with concern raised over the potential effect on bone healing. However, increasing literature suggests these concerns may be exaggerated in the pediatric population and further support is building for their use in pain control following bony procedures. Several studies in both animals and humans point to the fact that attaining normal bone strength may be slightly delayed in the initial period; however, there does not appear to be a significant difference in overall healing while decreasing duration and amount of opioid use.20,46,61,62,66,103 In addition, a meta-analysis of studies assessing the efficacy of NSAIDs following surgery in pediatric populations showed that their use significantly decreased postoperative side effects of narcotic pain medication such as nausea and vomiting.84 A listing of common NSAIDs and their dosing is presented in Table 3-11
Table 3-11
Dosing Formulations and Schedules for oral Analgesic Medications for Children and Adolescentsa
Medication Formulationb Dose
Acetaminophenc Children's suspension: 160 mg/5 mL
Chewable tablet: 80 mg
Oral disintegrating tablet: 80 mg, 160 mg
Tablet: 325 mg, 500 mg
Rectal suppository: 80 mg, 120 mg
10–15 mg/kg/dose q4–6h, maximum dose 975 mg/dose
Hydrocodone with acetaminophen (Lortab, Anexsia, Co-Gesic, DuoCet, Hy-Phen, Vicodin) 2.5-mg hydrocodone/5-mL acetaminophen 120 mg/5 mL (Lortab Liquid) Adult dose: Hydrocodone 5–10 mg q4–6h
Children (only antitussive dose is published): 0.6 mg/kg/day divided in three to four doses/day.
<2 y: Do not exceed 1.25 mg/dose.
2–12 y: Do not exceed 5 mg/single dose.
>12 y: Do not exceed 10 mg/single dose.
Hydromorphone (Dilaudid, Hydromorphone HCl) 5-mg hydromorphone/5-mL solution Optimal pediatric dosage for analgesia not established.
Antitussive dose is:
6–12 y: 0.5 mg q3–4h
>12 y: 1 mg q3–4h
Ibuprofen Infant's suspension: 50 mg/1.25 mL
Children's suspension: 100 mg/5 mL
Chewable tablet: 100 mg
Tablet: 200 mg
10 mg/kg/dose q6–8h, maximum dose 800 mg/dose
Morphine (morphine sulfate, Roxanol) 10 mg/5 mL and 20 mg/5 mL solution 0.2–0.4 mg/kg q4h (adult dose is 10–30-mg solution q4h). Absorption from the gastrointestinal tract is variable.
Naproxen (oral) 125-mg/5-mL suspension
tablets: 250, 375, 500 mg
5–7.5 mg/kg q12h, maximum dose 600 mg/day
Oxycodone Oral solution: 5 mg/5 mL
Capsule: 5 mg
Tablet: 5 mg, 10 mg, 15 mg, 20 mg, 30 mg
0.1–0.2 mg/kg/dose q6–8h, maximum dose 10–20 mg/dose
Oxycodone + acetaminophen Oral solution: 5-mg oxycodone + 325-mg acetaminophen/5 mL
Capsule: 5-mg oxycodone + 500-mg acetaminophen
Tablet: 2.5-mg oxycodone + 325-mg acetaminophen
5-mg oxycodone + 325-mg acetaminophen
7.5-mg oxycodone + 325-mg acetaminophen
7.5-mg oxycodone + 500-mg acetaminophen
10-mg oxycodone + 325-mg acetaminophen
10-mg oxycodone + 650-mg acetaminophen
Based on oxycodone content: 0.1–0.2 mg/kg/dose q6–8h, maximum dose 5 mg/dose
 

Adapted from: Opiate Agonists. In McEvoy CK, Litvak K, Weish OH Jr, eds. AHFS Drug Information 1994. Bethesda, MD: American Society of Hospital Pharmacists; 1994; Taketomo CK, Hodding JHJ, Kraus DM. Pediatric Dosage Handbook. 2nd ed. Hudson, OH: Lexi-Comp; 1993; Ragers J, Moro M. Acute postoperative and chronic pain in children. In: Rasch DK, Webster DE, eds. Clinical Manual of Pediatric Anesthesia. New York, NY: McGraw-Hill; 1994, with permission.

 

Adapted from: Nonsteroidal Anti-inflammatory Agents. In: McEvoy GK, Litvak K, Welsh OH Jr, eds. AHFS Drug Information 1994. Bethesda, MD: American Society of Hospital Pharmacists; 1994; Walson PD, Mortensen ME. Pharmacokinetics of common analgesics, anti-inflammatories, and antipyretics in children. Clin Pharmacokinet. 1989; 17:116–137, with permission.

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Local and Regional Anesthetics

Utilization of both local and regional anesthetic can provide an excellent addition to intraoperative and postoperative pain relief.79 Local anesthetic nerve blockade and the methods used to perform these were previously covered. Central blocks for pediatric orthopedic patients include epidural catheters and peripheral nerve blocks, the latter can include a plexus or isolated peripheral nerve. Benefits include less intraoperative narcotic and anesthetic needs, so the patient is more alert and has fewer anesthetic side effects.32 Moreover, there is evidence in the pediatric surgical literature that preoperative infiltration of the intended surgical site is more effective at providing pain relief than postoperative injections for hernia repair.40 
Contraindications to regional blocks include systemic or local infection near the injection site, coagulopathies, and anatomic abnormalities that prevent adequate block placement. Lidocaine and bupivacaine are commonly used local anesthetics. Dosing limits for common local anesthetics are listed in Table 3-9. Risks of peripheral blocks include inability to recognize nerve damage and/or compartment syndrome masked by a dense sensory block.106 

Postoperative Analgesia with Opioids

Opioids act as analgesics by raising the pain threshold in the spinal cord and peripheral nerves and by altering the brain's perception of pain.116 There are three major groups of opioids. Natural derivatives of the opium poppy include codeine and morphine.101 Semisynthetic opioids are hydrocodone and oxycodone. Synthetic opioids are fentanyl, meperidine, and sufentanil.101 Morphine is more effective when given intravenously than orally because of the faster onset, better maintenance of blood concentration, and avoidance of significant first-pass metabolism in the liver.106 IM administration should be avoided secondary to unpredictable absorption, discomfort, and patient fear of injections.41,65,106,116 Using patient-controlled analgesia (PCA) pumps decreases fear of an injection. PCA is highly effective with fewer side effects of over- or underdosing for children of ages 6 years and older with normal cognitive function.41,65 Oral morphine dosing is 0.2 to 0.4 mg/kg every 3 to 4 hours. Duration of action is 4 to 6 hours, with peak effects occurring after 15 to 30 minutes.101 Parenteral morphine dosing is a 0.1-mg/kg bolus every 3 to 4 hours, 0.015 mg/kg every 8 minutes via PCA, or 0.02 to 0.04 mg/kg per hour for a continuous infusion.65 Sutters et al.109 studied pediatric orthopedic patients in a randomized prospective study comparing morphine via PCA with and without ketorolac. Patients in the two groups were comparable with respect to demographics and surgical procedures. Patients given ketorolac had better analgesia, reduced morphine use, and fewer opioid side effects. 
Meperidine (Demerol, Sanofi Synthelab Inc., New York, NY) is a synthetic opioid given intravenously at 1 to 1.5 mg/kg every 3 to 4 hours with a maximum of 7.5 mg/kg per day.101,116 Peak effects occur in 30 to 60 minutes.117 It may be used in a PCA, but has one-tenth the potency of morphine.101 Meperidine also has a greater euphoric side effect, giving it a higher risk of psychological dependence with prolonged repeated doses.101,116 Fentanyl is a short-acting synthetic opioid that lasts 20 to 60 minutes, with an onset of less than 30 seconds.101,116 Given intravenously, it has similar characteristics to natural opioids. Its fast onset and ease of titration make it an excellent choice for immediate postoperative pain management and for use during outpatient surgeries.96 However, Claxton et al.28 found pediatric patients given fentanyl in the recovery room after ambulatory surgery had higher pain levels compared with patients given morphine. This may be due to the need for frequent dosing to maintain adequate relief. Unique side effects of fentanyl include chest wall rigidity, laryngospasm, and nasal pruritus.116 Unlike other opioids, fentanyl does not cause histamine release.116 
Oral narcotics can be used when a patient tolerates oral intake. Codeine is no longer routinely recommended because of its inconsistent metabolism in children, which can result in either therapeutic failure with suboptimal pain control in poor metabolizers or severe opioid intoxication in the ultrarapid metabolizers.78 Oxycodone, which is slightly more potent than hydrocodone, is now recommended instead of codeine.106,116 It is commonly formulated with other pharmaceuticals, including acetaminophen. Hydrocodone is present in Lortab (UCB Pharma Inc, Atlanta, GA), Lorcet (Forest Pharmaceuticals, New York, NY), and Vicodin (Abbott Laboratories, Abbott Park, IL) and given at 0.2 mg/kg every 3 to 4 hours.106 Oxycodone is found in Roxicodone (Elan Pharmaceuticals Inc, San Diego, CA), OxyContin (Purdue Frederick Co., Norwalk, CT), Percocet (Endo Pharmaceuticals Inc, Chadds Ford, PA), and Tylox (Ortho McNeil Corp., Raritan, NJ). It is given at 0.2 mg/kg every 3 to 4 hours.106 A listing of common parenteral and oral opioid medications and their dosing schedules is presented in Tables 3-11, 3-12 and 3-13
 
Table 3-12
Patient-Controlled Analgesia in Children
View Large
Table 3-12
Patient-Controlled Analgesia in Children
Loading dose: Morphine, 0.025–0.05 mg/kg
Maintenance dose: Morphine, 0.01–0.02 mg/kg
Lockout interval: 6–10 min
4-hr maximum: Morphine, 0.4 mg/kg/4 hr
Treatment of Side Effects
Pruritus: Diphenhydramine (0.5 mg/kg IV) OR low-dose naloxone (0.5–1 μg/h)
Nausea/vomiting: Metoclopramide (0.1 mg/kg IV) OR droperidol (10–30 μg/kg IV or IM) OR ondansetron (0.15 mg/kg IV over 15 min) OR low-dose naloxone as for pruritus
Urinary retention (<1 mL/kg/h in the face of adequate fluid intake): Low-dose naloxone infusion as above
Respiratory depression: Specify vital sign parameters that require treatment and method for contracting responsible physician. Stop PCA pump. Give 100% oxygen and maintain the airway. Give naloxone (1–5 μg/kg IV bolus); repeat as needed. Consider naloxone infusion (3–5 μg/kg/h).
 

From: Rogers J, Moro M. Acute postoperative and chronic pain in children. In: Rasch DR, Webster DE, eds. Clinical Manual of Pediatric Anesthesia. New York, NY: McGraw-Hill; 1994:298, with permission.

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Table 3-13
Parenteral Opioid Dosing Schedule for Analgesia in Childrena
IMb: Morphine, 0.1–0.15 mg/kg q3–4h; Meperidine, 1–1.5 mg/kg q3–4h
IV: Morphine, 0.05–0.1 mg/kg q2h; Meperidine, 0.5–1 mg/kg q2h
 

Adapted from: Roger L, Moro M. Acute postoperative and chronic pain in children. In: Rasch DK, Webster DE, eds. Clinical Manual of Pediatric Anesthesia. New York, NY: McGraw-Hill; 1994: 297, with permission.

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Opioids have many potential adverse effects. Severe respiratory depression, depressed cough reflex, and triggering of nausea and emesis can all contribute to significant risk for the patient if improperly administered and/or monitored.106,116 Other side effects include urinary retention due to an increase in antidiuretic hormone, postoperative ileus, and constipation. In addition, histamine release from mast cells can result in urticaria, diaphoresis, vasodilatation, and bronchoconstriction.57,116 

Author's Preferred Method of Treatment

We prefer that postoperative analgesia incorporates a multimodal approach whenever possible. This should include at a minimum acetaminophen, nonsteroidal, and narcotic medication. In addition, we advocate the liberal use of regional blockade to not only improve pain management during procedures but also in the short- to midterm post injury and/or procedural period. The use of child life specialists are also frequently employed when available. 

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