Ultrasound-guided regional anesthesia appears to be the superior treatment for supracondylar fractures in the pediatric population when compared with IV opioids.
According to a recent pediatric study, regional anesthesia for closed reduction and percutaneous pinning demonstrated superior pain scores throughout hospitalization and at home when compared with standard therapy. The authors also reported decreased opioid consumption and a smaller range of pain scores in patients who received an ultrasound-guided block under general anesthesia.
“The regional anesthetic technique we performed in this small patient cohort seemed to be a superior treatment to IV opioids, as defined by superior pain scores, a smaller range of pain scores and decreased opioid consumption when compared between groups,” said Chris Darrel Glover, MD, MBA, associate professor of pediatrics and anesthesiology at Baylor College of Medicine and chief of the Division of Community Anesthesia Services at Texas Children’s Hospital, in Houston. “There was also higher satisfaction reported by parents and families.
“We’re hoping that this will further increase the utilization of regional anesthesia in the pediatric population,” Dr. Glover added.
Although opioids are considered the primary agents for pain control in supracondylar fractures of the humerus, as Dr. Glover reported at the American Society of Regional Anesthesia and Pain Medicine 2016 annual meeting (abstract 3069), they’re also associated with undesirable side effects, including itching, respiratory depression, sedation and urinary retention.
The introduction of ultrasound in regional anesthesia has resulted in increased success rates for blockade in pediatric patients, Dr. Glover said, but prospective trials comparing IV opioids with regional anesthesia in pediatric patients are limited.
Pain Control Success
In this prospective, double-blind, randomized controlled trial, Dr. Glover and his colleagues compared pain scores and perioperative outcomes between ultrasound-guided regional anesthesia of the brachial plexus and IV opioids for children undergoing reduction of supracondylar fractures.
The researchers approached over 339 patients with American Society of Anesthesiologists physical status class I or II between January 2011 and September 2015, and randomly assigned 115 patients for comparison.
“When you look at the length of time it took us to recruit these patients, this was a labor of love from a committed group of care providers,” Dr. Glover observed.
Not surprisingly, children randomly assigned to ultrasound-guided regional anesthesia took on average five minutes longer from induction to surgery. As Dr. Glover noted, however, time from end of surgery to PACU discharge readiness in the block group was approximately 12 minutes faster.
Given the wide range of age (3-16 years) of patients enrolled in this study, researchers used varying pain scales. Regardless of the pain scale used, however, peak and mean pain scores in the PACU phase were lower in the regional anesthetic group than in the IV opioid group (P<0.01). Total opioid consumption also was significantly lower in the regional anesthetic group (P<0.01), along with incidence of rescue opioid administration in recovery (P<0.01).
Statistical significance also carried over from the hospital.
Patients were sent home with a diary, in which they recorded their symptoms over a 48-hour period.
“The diary yielded some interesting data sets,” Dr. Glover said. “Peak and mean scores were lower in the regional anesthesia group throughout the time periods tested, except the 12-hour mark, which implies when the block wore off more than anything else.”
That one-time point aside, researchers observed a consistent decreasing of opioid consumption in the regional anesthesia group. Regardless of the number of pain medications used throughout their post-op home stay, patient satisfaction also was highest in the group that received the block.
“When you look at the Kaplan-Meier survival curve,” Dr. Glover said, “it’s interesting to see that a large proportion of patients on IV opioids received rescue medications throughout their recovery period, while those that received a regional block did not.”
Incidences of nausea, vomiting, pruritus and respiratory depression also were significantly higher in patients receiving IV opioids.
Moderator James C. Eisenach, MD, president and CEO of the Foundation for Anesthesia Education and Research, in Schaumburg, Ill., inquired as to whether the hospital’s surgeons were convinced by these results.
“This couldn’t have been done without our surgical colleagues,” Dr. Glover stressed. “In fact, one of our surgeons just presented these data at a Pediatric Orthopaedic Society of North America meeting.
“While everyone seemed convinced by the pain scores,” Dr. Glover added, “nobody could believe that the block took only five minutes. Go figure.”