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      Regional Anesthesia for Pain Management After Orthopedic Procedures for Treatment of Lower Extremity Length Discrepancy

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          Abstract

          Introduction

          The use of regional anesthesia techniques continues to expand in a wide variety of surgical procedures as the benefits and safety are increasingly appreciated. Limb-lengthening procedures are often associated with significant postoperative pain and high opioid requirements which may impact patient’s recovery and increase risk of chronic pain and long-term opioid use.

          Methods

          The current study retrospectively reviews our experience utilizing a novel peripheral nerve catheter (PNC) protocol for postoperative pain management in patients undergoing elective limb-lengthening procedures. We measure total opioid consumption following 48 hrs in the postoperative period between groups.

          Results

          A total of 70 patients were included from which 41 received general plus regional anesthesia (RA) and 29 were managed with general anesthesia alone (NORA). Postoperative pain needs were calculated as morphine equivalents (ME). There were no differences in the demographic characteristics between the groups. Over the first 48 postoperative hours, opioid use was 0.5 mg/kg ME (IQR 0.3, 0.9) in the RA group versus 1.7 mg/kg ME (IQR 1.1, 3.1) in the NORA group (p<0.001). Subgroup analysis between femoral lengthening and tibial-fibular lengthening procedures demonstrated the same opioid-sparing effect favoring the RA group compared to the NORA group. Hospital length of stay was significantly shorter in the femoral lengthening RA group compared to NORA group (32 hrs [IQR 29, 35] versus 53 hrs [IQR 33, 55], respectively). There was no significant difference in length of stay between the RA group and NORA group after tibial-fibular lengthening procedures.

          Discussion

          Regional anesthesia via continuous catheter infusions has a clinically significant opioid-sparing effect for postoperative pain management after limb-lengthening procedures and may facilitate earlier hospital discharge.

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          Most cited references 16

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          Continuous peripheral nerve blocks: a review of the published evidence.

           Brian Ilfeld (2011)
          A continuous peripheral nerve block, also termed "perineural local anesthetic infusion," involves the percutaneous insertion of a catheter adjacent to a peripheral nerve, followed by local anesthetic administration via the catheter, providing anesthesia/analgesia for multiple days or even months. Continuous peripheral nerve blocks may be provided in the hospital setting, but the use of lightweight, portable pumps permits ambulatory infusion as well. This technique's most common application is providing analgesia after surgical procedures. However, additional indications include treating intractable hiccups; inducing a sympathectomy and vasodilation to increase blood flow after a vascular accident, digit transfer/replantation, or limb salvage; alleviating vasospasm of Raynaud disease; and treating peripheral embolism and chronic pain such as complex regional pain syndrome, phantom limb pain, trigeminal neuralgia, and cancer-induced pain. After trauma, perineural infusion can provide analgesia during transportation to a distant treatment center, or while simply awaiting surgical repair. Catheter insertion may be accomplished using many possible modalities, including nerve stimulation, ultrasound guidance, paresthesia induction, fluoroscopic imaging, and simple tactile perceptions ("facial click"). Either a nonstimulating epidural-type catheter may be used, or a "stimulating catheter" that delivers electrical current to its tip. Administered infusate generally includes exclusively long-acting, dilute, local anesthetic delivered as a bolus only, basal only, or basal-bolus combination. Documented benefits appear to be dependent on successfully improving analgesia, and include decreasing baseline/breakthrough/dynamic pain, supplemental analgesic requirements, opioid-related side effects, and sleep disturbances. In some cases, patient satisfaction and ambulation/functioning may be improved; an accelerated resumption of passive joint range-of-motion realized; and the time until discharge readiness as well as actual discharge from the hospital or rehabilitation center achieved. Lastly, postoperative joint inflammation and inflammatory markers may be decreased. Nearly all benefits occur during the infusion itself, but several randomized controlled trials suggest that in some situations there are prolonged benefits after catheter removal as well. Easily rectified minor complications occur somewhat frequently, but major risks including clinically relevant infection and nerve injury are relatively rare. This article is an evidence-based review of the published literature involving continuous peripheral nerve blocks.
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            Prevalence of moderate-severe pain in hospitalized children.

              Acute pain management in children is often inadequate. The prevalence of pain in hospitalized children in the US is unknown.
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              Acute to chronic postoperative pain in children: preliminary findings.

              Chronic postoperative pain is a well-established clinical phenomenon that is associated with adverse outcomes. The incidence of this clinical phenomenon in children, however, is not well established. The purpose of this study was to identify the incidence of chronic pain in children after surgery.
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                Author and article information

                Journal
                J Pain Res
                J Pain Res
                JPR
                jpainres
                Journal of Pain Research
                Dove
                1178-7090
                16 March 2020
                2020
                : 13
                : 547-552
                Affiliations
                [1 ]Department of Anesthesiology & Pain Medicine, The Ohio State University College of Medicine , Columbus, OH, USA
                [2 ]Department of Anesthesiology & Pain Medicine, Nationwide Children’s Hospital , Columbus, OH, USA
                [3 ]Department of Orthopedic Surgery, Nationwide Children’s Hospital and The Ohio State University College of Medicine , Columbus, OH, USA
                Author notes
                Correspondence: Mauricio Arce Villalobos Department of Anesthesiology & Pain Medicine, Nationwide Children’s Hospital , 700 Children’s Drive, Columbus, OH43205, USA Tel +1614 722-4200 Fax +1614 722-4203 Email Mauricio.ArceVillalobos@osumc.edu
                Article
                233617
                10.2147/JPR.S233617
                7083638
                © 2020 Arce Villalobos et al.

                This work is published and licensed by Dove Medical Press Limited. The full terms of this license are available at https://www.dovepress.com/terms.php and incorporate the Creative Commons Attribution – Non Commercial (unported, v3.0) License ( http://creativecommons.org/licenses/by-nc/3.0/). By accessing the work you hereby accept the Terms. Non-commercial uses of the work are permitted without any further permission from Dove Medical Press Limited, provided the work is properly attributed. For permission for commercial use of this work, please see paragraphs 4.2 and 5 of our Terms ( https://www.dovepress.com/terms.php).

                Page count
                Tables: 4, References: 17, Pages: 6
                Categories
                Original Research

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