Continuous Epidural Block Versus Continuous Popliteal Nerve Block for Postoperative Pain Relief After Major Podiatric Surgery in Children: A Prospective, Comparative Randomized Study

Abstract

Foot and ankle surgery in children is very painful postoperatively. Adverse effects from opioids and continuous epidural block (CEB) limit their use in children. Continuous popliteal nerve blocks (CPNB) have not been studied for this indication in children. In this prospective, randomized study we evaluated the effectiveness and adverse events of CPNB or CEB in children after podiatric surgery. Fifty-two children scheduled for foot surgery were separated into four groups by age and analgesia technique. After general anesthesia, 0.5 to 1 mL/kg of an equal-volume mixture of 0.25% bupivacaine and 1% lidocaine with 1:200000 epinephrine was injected via epidural or popliteal catheters. In the postoperative period, 0.1 mL x kg(-1) x h(-1) (group CPNB) or 0.2 mL x kg(-1) x h(-1) (group CEB) of 0.2% ropivacaine was administered for 48 h. Niflumic acid was routinely used. Adverse events were noted in each treatment group. Postoperative pain during motion was evaluated at 1, 6, 12, 18, 24, 36, and 48 h. Requirement for rescue analgesia (first-line propacetamol 30 mg/kg 4 times daily or second-line 0.2 mg/kg IV nalbuphine), and motor blockade were recorded. Parental satisfaction was noted at 48 h. Twenty-seven patients were included in the CEB groups and 25 in CPNB groups. There were 32 children 1 to 6 yr of age (CPNB = 15; CEB = 17) and 20 children 7 to 12 yr of age (CPNB = 10; CEB = 10). The demographic data were comparable among groups. Postoperative analgesia was excellent for the two continuous block techniques and in the two age groups. Motor block intensity was equal between techniques. Adverse events (postoperative nausea or vomiting, urinary retention, and premature discontinuation of local anesthetic infusion in the 1- to 6-yr-old group) were significantly more frequent in the CEB group (P < 0.05). Eighty-six percent of the parents in the CEB groups and 100% in the CPNB groups were satisfied. We conclude that although both CEB and CPNB resulted in excellent postoperative analgesia in this study, CPNB was associated with less urinary retention and nausea and vomiting. Therefore, we recommend CPNB as the ideal form of postoperative analgesia after major podiatric surgery in 1- to 12-yr-old children.

Continuous peripheral nerve blocks for postoperative analgesia in children: feasibility and side effects in a cohort study of 339 catheters

“…Postoperative analgesia was excellent. As demonstrated in other studies, [4][5][6]11 CPNB provided a high level of satisfaction in postoperative pain management in our pediatric patients. Nevertheless, we did not compare CPNB with other methods of postoperative analgesia.…”

“…These results are similar to those reported in the literature. The suggested dose for continuous infusion via a perineural catheter ranged from 0.1 4,5,11 to 0.2 mL Á kg…”

“…In a limited number of patients, continuous peripheral nerve block (CPNB) has been reported to allow complete and prolonged postoperative pain relief in children. [4][5][6] CPNBs are associated with fewer side effects after lower limb surgery in children compared with continuous epidural blocks. 5 However, only one trial has been published with a high number of pediatric cases.…”

“…[4][5][6] CPNBs are associated with fewer side effects after lower limb surgery in children compared with continuous epidural blocks. 5 However, only one trial has been published with a high number of pediatric cases. 6 Moreover, it has recently been reported that CPNB carries a low rate of complications in adult orthopedic patients, and major neurological and infectious adverse events are rare.…”

Acute Pain Management in a Child: A Case Report of 46-Days of Popliteal Sciatic Nerve Catheter

“…This can lead to systematic withdrawal. However, previous pediatrics studies have qualified this 3-days rule, both in the surgical setting [6], and for chronic or cancer pain control [7]. Obviously, the maintenance of a PNBC should be evaluated according to the benefit-risk ratio specific to each patient and medical issue.…”