Brachial plexus block with ultrasound guidance for upper-limb trauma surgery in children: a retrospective cohort study of 565 cases.
Population:
This is a retrospective cohort study looking at children admitted with upper limb trauma to a major Austrian Trauma centre between March 2014 and October 2018.
This encompassed 781 unilateral upper limb injuries – 565 deemed suitable for regional block. 35 anaesthetists performing the blocks.
Primary Outcome:
Success rate of brachial plexus block as the primary anaesthetic method for the surgical management of paediatric upper limb trauma cases.
Block failure was defined as the child spontaneously moving or HR increasing >25% from baseline after skin incision, unless a single shot of fentanyl 1 mcg/ kg eliminated the need for subsequent GA and mechanical ventilation.
Result:
Overall success rate of brachial plexus block was 94.9%. A switch to GA due to block failure was documented for 5.1% of children. No block complications were observed.
Secondary Outcomes:
Independent predictors of block failure.
Result:
The only statistically significant independent predictor of block failure noted was age, with a higher rate (12.5%) seen in the 15-18yr age group. This was also the smallest group (n=48).
Interesting points:
‘Standard of care’ in this hospital was developed over 12 years prior to this study and includes: transfer to the preoperative ward, EMLA application, premedication (midazolam +/- S-ketamine), IV cannulation, +/- propofol sedation, minimum staffing requirement = assistant nurse & 2 anaesthesiologists.
Midazolam +/- S-ketamine premedication was used in 92% of cases and intraoperative propofol 0.1mg/kg/min (6mg/kg/hr) used in 78% of cases.
Brief mention of fasting and sedation – a grey area in the context of the paediatric trauma patient, but the authors assumed practitioners followed guidelines here. No cases of pulmonary aspiration noted.
THE BOTTOM LINE:
With the right systems in place, it is possible to effectively treat paediatric upper limb trauma with a regional-anaesthesia-based approach with a high likelihood of success, but to do so appears to require significant levels of ‘sedation’.
This is an interesting article worth a read, but it would be good to assess the external validity of this approach in a centre without such a streamlined well-staffed method of providing regional blocks to paediatric trauma patients.
Reviewed by Dr. Dana Perrignon Roth
