Gurnaney, Harshad MBBS, MPH; Kraemer, F. Wickham MD; Maxwell, Lynne MD; Muhly, Wallis T. MD; Schleelein, Laura MD; Ganesh, Arjunan MBBS.
It’s a pleasure to begin this journal club with an outstanding article from my own group here at The Children’s Hospital of Philadelphia. Several years ago, they began inserting continuous peripheral nerve catheters (CNPB) in children undergoing orthopedic procedures. These children were then discharged home (usually the same day) with the nerve catheter attached to a source of local anesthetic solution, with the goal of attaining pain relief over the first several days. When the local anesthetic was depleted, the child’s parent would pull out the catheter. The article is noteworthy because of the large size (n = 1,285) of the numbers of patients included in the analysis. All patients received intraoperative infusion of ropivacaine, followed by postoperative infusion of either ropivacaine or bupivacaine. Nurses or physicians assigned to the acute pain service contacted all patients by telephone once or twice daily following discharge to document efficacy and complications.
The results were outstanding: The mean duration of the CPNB was 50.7 ± 14.4 hours (mean ± SD). Among patients discharged home with the CPNBs, 969 (75.4%) of the patients required either no supplemental opioids or oral opioids only on an “as needed” basis in the postoperative period (confidence interval, 73.0%–77.8%). Two patients were readmitted for IV pain management after they were discharged home with the CPNB catheters. No neurological deficit related to the CPNBs was identified in any of the patients at their 6-month follow-up with the orthopedic surgeon (confidence interval, 0%–0.29%).
A list of complications are described in Table 3:
An accompanying editorial by Krane and Polaner points out the limitations of the retrospective approach, but concedes that this data adds to the existing knowledge of the safety of pediatric regional anesthesia. In my opinion, the most important limitation of the study is the lack of a comparative control group, that is, a group of children without peripheral nerve catheters. Would they have fared as well? How many would have suffered from pain and/or opioid-related complications in the postoperative period? How would they compare in return to their activities of daily living? This type of prospective study does not exist, nor would it be feasible with a large number of patients, at least in a single center. I wonder what the comparative costs would be.