Ultrasound-Guided Regional Anesthesia for Pediatric Burn Reconstructive Surgery

Abstract

Pediatric patients face multiple reconstructive surgeries to re-establish function and aesthetics post burn injury. Often, the site of the harvested graft for these reconstructions is reported to be the most painful part of the procedure and a common reason for deferring these reconstructive procedures. This study in pediatric burn patients undergoing reconstructive procedures examined the analgesia response to local anesthetic infiltration versus either a single ultrasound guided regional nerve block of the lateral femoral cutaneous nerve, or a fascia-iliaca compartment block with catheter placement and continuous infusion. Methods 19 patients were randomized to one of three groups (infiltration, single shot nerve block, or compartment block with catheter) and received intraoperative analgesia intervention. Post-operatively, visual analog scale pain scores were recorded –for pain at the donor site—every four hours while awake—for forty-eight hours. Results This non-parametric data was analyzed using a two way ANOVA, Friedman's test, and Kruskal-Walllis test, with significance determined at p<0.05. The analysis demonstrated that the patients in the regional anesthesia groups were significantly more comfortable over the 48 hour hospital course than the patients in the control group. The patients receiving a single shot block of the LFCN were more comfortable on post-operative day (POD) 0 while the catheter patients were more comfortable on POD 1 and POD 2. There was not a statistically significant difference in opioid requirements in any group. Conclusions Regional anesthetic block of the lateral femoral cutaneous nerve, with or without catheter placement, provides an improved postoperative experience for the pediatric patient undergoing reconstructive surgery with lateral/anterolateral skin graft versus local anesthesia infiltration of donor site. For optimal comfort throughout the postoperative period, an ultrasound guided block with continuous catheter may be beneficial.

Regional anesthesia to ameliorate postoperative analgesia outcomes in pediatric surgical patients: an updated systematic review of randomized controlled trials

“…Shank et al compared surgical site infiltration (0.25% bupivacaine), ultrasound-guided single-shot lateral femoral cutaneous nerve block, and ultrasound-guided continuous infusion fasciailiaca compartment block on postoperative pain in children undergoing reconstructive skin grafting. 47 The authors reported that patients who received regional anesthesia via single-shot lateral femoral cutaneous nerve block (LFCNB) or catheter infusion fascia iliaca compartment block (FICB) experienced less pain than those in the surgical site infiltration group. The patients in the LFCNB group reported significantly less postoperative pain upon arrival to the post-anesthesia care unit until discharge to the floor compared with the FICB group or the control group.…”

Acute and Perioperative Care of the Burn-injured Patient

“…Regional anesthesia in its simplest form may be tumescent local anesthesia injected into a donor site prior to harvesting 75 or it can take the form of subcutaneous catheter infusions, 76 peripheral nerve, or central neuraxial blocks. 77 …”

Acute and Perioperative Care of the Burn-Injured Patient

“…Sometimes there is a need to cover the anterior and medial thigh due to the extent of skin harvest, and therefore a fascia iliaca block can also be performed. [76][77][78] …”

“…Regional anesthesia in its simplest form may be tumescent local anesthesia injected into a donor site prior to harvesting 75 or it can take the form of subcutaneous catheter infusions, 76 peripheral nerve, or central neuraxial blocks. 77 Central neuraxial techniques (spinals, epidurals) have been utilized with good effect as both primary anesthetics and postoperative adjuncts in burn injured patients. There are no reports suggesting epidural abscesses are more common in burn patients, but reports have suggested that intravascular catheters are more likely to become infected if placed in or near burned tissue; 78 similarly caution is likely reasonable in selecting appropriate burn patients for central neuraxial techniques.…”