Continuous thoracic paravertebral nerve blocks in pediatric patients
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Studies that evaluate the use of ultrasound-guided continuous paravertebral nerve blocks in pediatric patients are scarce, although the use of peripheral nerve blocks has indeed increased in popularity in the adult demographic. The present study aims to describe the epidemiology, safety and efficacy of ultrasound-guided continuous thoracic paravertebral nerve blocks as an everyday practice on a large scale in pediatric patients at a busy, academic, tertiary-care hospital. In all patients studied, a linear ultrasound transducer was used via the transverse in-line technique for catheter placement. Transducer configuration (frequency of oscillation and probe length) was varied based on individual patient factors, such as age, weight and body mass index. A descriptive, retrospective chart review of all patients who received a continuous paravertebral nerve block within a two-year time frame, from 10/2012 to 10/2014, was conducted, resulting in a sample size of 238 paravertebral catheters placed in 214 patients. In regards to patient demographics, the median age was 2 years (IQR 0.8 years - 12 years), with a range of 1 day to 18 years; and the average weight was 25.3 kg ± 23.6 kg, with a range of 1.8 kg to 113.7 kg. The median catheter duration was 3 days (IQR 2 days - 5 days), with 88.8% of catheters placed unilaterally, and 11.2% placed bilaterally. Median postoperative pain scores, intubation time, morphine equivalent consumption, and midazolam consumption were measured for all patients. The overall complication rate was 16.8% (n = 36 patients) with a minor catheter complication rate of 16.4% (n = 35). 6.1% (n = 13) of complications were due to catheter leakage, 4.7% (n = 10) due to catheter dislodgement, 2.8% (n = 6) due to skin irritation, 1.9% (n = 4) due to catheter occlusion and 0.9% (n = 2) due to minor bleeding at the site of catheter insertion. Only one patient experienced a major complication (0.5% of total patients), manifested as a self-resolving, 30-second seizure after a bolus administration of 2% chloroprocaine to manage postoperative pain. The patient was bag-mask ventilated for 60 seconds and the catheter was discontinued. No long-term sequelae were present in this case. Lastly, 98.1% (n = 210) of patients experienced sufficient pain coverage, yielding a failed block rate of 1.9% (n = 4). These results demonstrate safety and efficacy of ultrasound-guided transverse in-line continuous, thoracic paravertebral nerve block in pediatric patients, especially small infants and children. This technique provides an analgesic alternative to the thoracic epidural for postoperative pain treatment in pediatric patients.