Asleep or awake: is paediatric regional anaesthesia without general anaesthesia possible?
Editorial examining the original article: Zadrazil M, Opfermann P, Marhofer P, Westerlund AI, Haider T. Brachial plexus block with ultrasound guidance for upper-limb trauma surgery in children: a retrospective cohort study of 565 cases. Br J Anaesth. 2020;125(1):104-109.
Briefly discusses the background of paediatric regional anaesthesia being performed under general anaesthesia or deep sedation which is widely considered safe, and supported by 2 prospective large scale multicentre studies from the ADARPEF (French Language Society of Paediatric Anaesthesia) and a report from the Pediatric Regional Anesthesia Network (PRAN) based on the prospective collection of more than 100,000 paediatric nerve blocks, all showing that the rate of complications is reassuringly low. This is supported by a joint statement from ESRA and ASRA.
Proceeds to examine the article by Zadrazil et al. detailing a Viennese cohort study of 565 US guided brachial plexus blocks in paediatric trauma patients.
- Expressed concern about limited numbers in oldest and youngest age groups examined, when age was reported as an independent predictor of block failure.
- Surmised that perhaps the higher rate of failure in the older children stemmed from less experienced generalists or registrars performing the blocks in older children as opposed to more experienced and better trained paediatric anaesthetists in the younger age groups.
- Suggests the line between awake or light sedation vs. deep sedation or general anaesthesia (with or without an airway) should be more clearly defined.
- Considers the possibility of ‘awake’ regional anaesthesia potentially changing the way we view fasting guidelines in certain groups, thus perhaps resulting in a more effective use of limited hospital resources, but suggests further study needed.
- Lastly, the authors here felt that the Viennese group did not show sufficient data to either suggest or refute the potential for nerve injury in the more awake or lightly sedated paediatric patient, as had previously been suggested by the original PRAN study. Perhaps this was due to the limited sample size compared to the collection of 100,000 blocks in the PRAN study.
The Bottom Line:
A good review article critically looking at the cohort study by Zadrazil et al., examined in the context of some of the original evidence surrounding paediatric regional anaesthesia under general anaesthesia.
Reviewed by Dr Dana Perrignon Roth
