Background:
Parental and patient feedback has brought attention to the anxiety and pain pediatric patients experience while undergoing orthopedic surgery. This is particularly important to families and children with chronic musculoskeletal conditions and special needs who require multiple procedures. We wanted a way to safely provide effective pain management in order to improve the experience our patients and their parents encounter. Regional blocks are usually limited by the duration of the local anesthetic. 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 dexamethasone can provide safe and effective pain relief overnight with the benefit of decreasing hospital expenses with high patient satisfaction.
Methods:
Utilizing an IRB-approved protocol, ultrasound-guided lower extremity single shot blocks were performed after the induction of general anesthesia. In the control group, the block solution consisted of 0.25% bupivacaine (2.5-4.0 mg/kg). In the experimental group, 0.25% bupivacaine (2.5-4.0 mg/kg) plus dexamethasone 2-8 mg was added. The control group is established from a retrospective chart review over a 6 month period of 17 patients who received lower extremity blocks.
In the experimental group, 43 children with diverse chronic musculoskeletal conditions and/or special needs undergoing lower extremity orthopedic procedures received lower extremity peripheral nerve blocks with intraneural dexamethasone. They included cerebral palsy (16), spina bifida (9), osteogenesis imperfecta (3), and developmental delay (28). Some with chronic musculoskeletal condition may also have developmental delay. Patients underwent soft tissue, bony, or combination of procedures. The experimental group was asked to complete a blinded survey outlining the patient’s satisfaction with pain control and anxiety over future procedures as well as time to first pain medication.
Results:
Of the 43 patients, 21 were female and 22 were male with average of 11.5 years old and average weight of 39.3 kg. Of the 43 surgeries, 9 soft tissue, 19 bony, and 15 combination procedures. 34 out of 43 were discharged from the recovery room while 9 were admitted inpatient. There were no readmissions for pain management or surgical complications. At post-op visit, no complications from nerve block was seen. In the control group, the block lasted an average of 11.4 hours to the first pain medications versus average of 29.9 hours in the experimental group. Patient satisfaction with post-op pain relief was rated at 3.6/4.0 and anxiety over future visit was 1.2/5. Parental satisfaction with overall experience was rated at 3.6/4.0 and anxiety over future visit was 0.8/5.
Conclusions:
The addition of dexamethasone ($0.71/4mg vial) to lower extremity peripheral nerve blocks provided a 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, minimizing family disruption which is especially important for families of patients who need multiple surgeries.
