Background & Aims

Lower extremity nerve blocks are infrequently used in pediatric age group, due to alternate simple and reliable caudal epidural block. The goal of peripheral regional anesthesia to target drug delivery at respective nerves leading to prolonged analgesia for site of surgery, hence decreasing requirement of peri-operative opioids and enhance early mobility and discharge.
Aims:
1. To compare seven approaches of sciatic nerve blocks in pediatric patients for unilateral lower limb surgeries
2. To compare ease of locating the sciatic nerve with a peripheral nerve stimulator device.
3. To assess the duration of analgesia
4. To assess the patient and care-giver satisfaction rates among different age groups.

Methods

Hospital ethical committee approval was sought.
140 blocks were performed in eligible children of either sex (age 2 years to 15 years) scheduled for lower limb surgeries via Parasacral (PS), Labat (LB), Subgluteal (SG), Raj (RJ), Lateral Greater Trochanter (GT), Posterior Popleteal (PP), and Lateral Popleteal (LP) approaches in children (20 per group). Two paediatric anesthesiologists trained in peripheral regional anaesthesia were involved in the study.
Parental consent was taken.
General anaesthesia was conducted according to standard protocol maintained with oxygen, nitrous oxide and halothane and spontaneous respiration.
Sciatic nerve was localised using Peripheral Nerve Stimulator. Plantar flexion/ inversion of foot or dorsi-flexion/ eversion accepted at 0.4 mA.
Variables assessed: Performance time, Number of needle insertion attempts, Depth of nerve, Block failure, Duration analgesia, parental satisfaction, time for rescue analgesia, complications.

Results

Data was collected and noted in excel sheet format. Data analysis was carried out using SPSS software (version 24).
Demographic data, duration of analgesia and complications were comparable in all groups. Number of attempts, performance time were higher in PS, followed by GT approach. Plantar Flexion was achieved most frequently in all groups. Failure was noted in 1 case each in PS and LB groups. 90 % parents in PS group were satisfied. All patients received multimodal analgesia (IV/ oral paracetamol, diclofenac). Time to first rescue analgesia was favorable for PS group (18.02+/-2.03 hours). No complication were observed till the time patients were discharged from hospital.
Parental satisfaction was comparable.

Conclusions

Considering the advantages offered by distal (posterior popliteal, subgluteal, lateral popliteal) approaches, sciatic nerve blocks definitely helps in reducing operating room costs, PACU stay, allows fast tracking, and allows early mobilization.
Proximal approaches (PS and LB) are technically more challenging, requiring a 3 dimensional orientation of sciatic nerve along with musculo-skeletal relations. The use of peripheral nerve stimulator allows for targeted drug delivery and improves the outcome of regional anesthesia.
The limited availability of ultrasound machines in the resource limited regions still is a big challenge. The incidence of kids with congenital bony malformations is still significant and multiple surgeries are warranted for the same. The use of peripheral regional anesthesia in multi-modal analgesia regime improves the overall hospital experience and acceptance among this tender group of patients.

References

1. Frawley G, Marchesini V, Loh B, Koziol J. Pediatric lower limb peripheral nerve blocks: Indications, effectiveness, and the incidence of adverse events. Paediatr Anaesth. 2022 Aug;32(8):946-953.
2. Dalens, Bernard MD; Tanguy, Alain MD; Vanneuville, Guy MD. Sciatic Nerve Blocks in Children: Comparison of the Posterior, Anterior, and Lateral Approaches in 180 Pediatric Patients. Anesthesia & Analgesia 70(2):p 131-137, February 1990.
3. Pearson, A.M.E., Roberts, S. and Turbitt, L.R. (2023), New blocks on the kids: core basic nerve blocks in paediatric anaesthesia. Anaesthesia, 78: 3-8.
4. Reinoso-Barbero F, Saavedra B, Segura-Grau E, Llamas A. Anatomical comparison of sciatic nerves between adults and newborns: clinical implications for ultrasound guided block. J Anat. 2014 Feb;224(2):108-12.
5. R. D. Shah, S. Suresh, Applications of regional anaesthesia in paediatrics, BJA: British Journal of Anaesthesia, Volume 111, Issue suppl_1, December 2013, Pages i114–i124.

Presenting Author

Samiksha Mehra

Poster Authors

Samiksha Mehra

MBBS, DNB

Kailash group of hospitals, NOIDA, India

Lead Author

Topics

  • Treatment/Management: Interventional Therapies – Injections/Blocks