ASA Abstract Reviews

Enhanced Perioperative Pain Management in Children With Disabilities Undergoing Lower Extremity Orthopedic Surgery: Does the Addition of Steroids Prolong the Effectiveness of Regional Blocks?

Peter R. Lichtenthal, MD, Helen Chan, MD, Francisco Valencia, MD
University of Arizona, Tucson, Arizona, United States
(Summarized and submitted by Peter Lichtenthal, MD)

Background and Design
Parental and patient feedback has brought attention to the anxiety and pain children experience while undergoing orthopedic surgery. This is particularly important to families and children with chronic musculoskeletal conditions that require multiple procedures. As a result, there is an increasing interest among anesthesiologists and orthopedic surgeons to provide safe and effective pain management. Regional blocks, while becoming increasingly popular, are limited by the duration of action of the agent, leading to the abrupt onset of significant pain. The addition of dexamethasone has been shown to potentiate the duration of blocks in the adult population but has not been reported in the pediatric population. We hypothesize that the addition of steroids can provide safe, effective overnight pain relief and decrease hospital expenses with high patient satisfaction. Utilizing an IRB-approved protocol, ultrasound-guided lower extremity single shots were performed after the induction of general anesthesia. In the control group, the block consisted of bupivacaine 0.25% (2.5-4.0 mg/kg). In the experimental group, bupivacaine 0.25% (2.5-4.0 mg/kg) plus dexamethasone 2-8 mg was injected.

Results and Conclusion
Fifty-three consecutive children with diverse chronic musculoskeletal conditions undergoing lower extremity orthopedic procedures were recruited. The time to first pain medication was recorded. In patients discharged home, parents were asked to document the time to first pain medication. Furthermore, the experimental group was asked to complete a satisfaction survey outlining the patients’ satisfaction with the pain control and anxiety over future procedures. There were 30 males and 23 females with an average age of 12.9 years and average weight of 42.6 kgs. Seventy-eight percent of the cases included a bony procedure. Eighty-three percent, 45 of 53, of the patients were discharged home from the recovery room. There were no readmissions for pain management or surgical complications. In the control group, the blocks lasted an average of 11.4 hours to the first pain medication versus 30 hours in the experimental group. Mann-Whitney analysis indicated P<.005. Parental satisfaction was rated at 3.6/4.0 with decreased family disruption being noted a major factor. Anxiety over future procedures was rated at 1.1/4.0. Patients rated pain control satisfaction at 3.5/4.0 and anxiety over future procedures at 0.97/4.0. In conclusion, the addition of dexamethasone ($0.71/vial) to lower extremity regional blocks provided safe, extended, and cost-effective pain management with high patient/family satisfaction. This allowed the majority of cases to be done on an outpatient basis, which minimized family disruption and eliminated an overnight hospital stay.