Ultrasound-Guided Axillary Plexus Block in a Child with Dystrophic Epidermolysis Bullosa

Abstract

We report the use of ultrasound-guided axillary brachial plexus block in a child with dystrophic epidermolysis bullosa needing surgical treatment of the right hand. The regional anaesthesia was used in association with sedation/anaesthesia. This technique is suitable for these difficult patients because it can minimise the risk of new bullae formation due to palpation of landmarks or unintentional intra- or subcutaneous injections. Initial anaesthesia/sedation was provided with sevoflurane until intravenous access was obtained, following which intravenous propofol infusion with ketamine boluses without any invasive airway management was continued for performance of the block and the procedure. This management plan provided good surgical conditions, early postoperative analgesia, minimised stress for the patient and avoided the need to manipulate the airway with instruments and the associated risk of mucosal bullae. The classification and breadth of clinical manifestation of epidermolysis bullosa is complex and briefly summarised. The anaesthetist should clarify the details of a particular patient's form of epidermolysis bullosa, especially in terms of mucosal involvement, as this may greatly influence planning for a procedure.

Pain care for patients with epidermolysis bullosa: best care practice guidelines

“…Some common procedures (and the corresponding regional anesthesia technique used) in EB patients include: fundoplication (epidural) [ 48 ]-[ 50 ], hand and foot surgery (peripheral nerve block, either single shot or continuous peripheral nerve catheter infusion following bolus injection) and hand surgery (both axillary and infraclavicular approaches have been used for brachial plexus block) [ 51 ],[ 52 ].…”

“… Basic perioperative assessment and pain treatments should be used as for non-EB patients, with modification A All Goldschneider 2010 [ 41 ] (5a), Goldschneider 2010b [ 42 ] (5a) Transmucosal (including intranasal fentanyl and transbuccal opioids) should be considered for short procedures and pain of brief duration when intravenous and enteral routes are unavailable B All Manjushree et al ., 2002 [ 45 ] (2b); Borland et al ., 2007 [ 46 ] (2b); Desjardins et al ., 2000 [ 47 ] (2a) Perioperative opioid use must account for preoperative exposure, with appropriate dose increases to account for tolerance B All Hartrick 2008 [ 56 ] (1a), Mhuircheartaigh 2009 [ 55 ] (1a), Viscusi 2005 [ 54 ] (2a) Regional anesthesia is appropriate for pain resulting from a number of major surgeries. Dressing of catheters must be non-adhesive and monitored carefully C All Diwan 2001 [ 51 ] (5a), Doi 2006 [ 53 ] (5b), Englbrecht 2010 [ 52 ] (5a), Kelly 1988 [ 48 ] (5b), Sopchak 1993 [ 49 ] (5a), Yee 1989 [ 50 ] (5a) C. Skin wounds and related pain are the hallmark of EB of most subtypes. Prevention and rapid healing of wounds through activity pacing, optimal nutrition and infection control are important.…”

Anesthetic Management in Patients with Epidermolysis Bullosa: Two Case Reports

“…Yet again, contrary to the prevailing belief, the fact that regional anaesthesia does not cause the development of bullae and the fact that it provides appropriate anaesthesia with sedation, even in children, regional anesthesia is more preferred nowadays. 6 In a study involving 19 patients, including children, regional anaesthesia was performed with axillary block anaesthesia such as pseudosyndactyly without any complications. 7,8 In cases where intubation is difficult, fiberoptic nasal intubation is preferred.…”

Interventional Procedures for Chronic Pain in Children and Adolescents: A Review of the Current Evidence

“…Brachial plexus blockade is frequently utilized to provide intraoperative and postoperative analgesia in children . These techniques may be successfully applied to the treatment of chronic pain states, including adjuvant management of CRPS I, neuropathic pain of the upper extremity, phantom limb pain, and cancer‐related pain .…”