Pediatric Anesthesia Concerns and Management for Orthopedic Procedures

Jeffrey P Wu, Jeffrey P Wu

Abstract

Anesthetic management of pediatric orthopedic patients is uniquely challenging. Approach to the pediatric patient must consider heightened preoperative anxiety and its postoperative behavioral and pain effects. Frequent respiratory infections can complicate timing of surgery and anesthetic care. Perioperative pain management usually involves a multimodal pharmacologic approach with the goal of minimizing opioid requirements. Regional anesthesia is valuable for postoperative pain control. Safety of its use in the pediatric population has been confirmed in recent studies. Included for discussion are fractures, slipped capital femoral epiphysis, club foot, and scoliosis.

Keywords: Caudal; Club foot; Local anesthetic; Pediatric anesthesia; Pediatric fracture; Peripheral nerve block; SCFE; Scoliosis.

Copyright © 2019 Elsevier Inc. All rights reserved.

References

    1. Kain Z.N., Mayes L.C., Weisman S.J., et al. Social adaptability, cognitive abilities, and other predictors for children’s reactions to surgery. J Clin Anesth. 2000;12(7):549–554.
    1. Davidson A.J., Shrivastava P.P., Jamsen K., et al. Risk factors for anxiety at induction of anesthesia in children: a prospective cohort study. Paediatr Anaesth. 2006;16(9):919–927.
    1. Kain Z.N., Wang S.M., Mayes L.C., et al. Distress during the induction of anesthesia and postoperative behavioral outcomes. Anesth Analg. 1999;88(5):1042–1047.
    1. Kain Z.N., Mayes L.C., O'Connor T.Z., et al. Preoperative anxiety in children: predictors and outcomes. Arch Pediatr Adolesc Med. 1996;150(12):1238–1245.
    1. Kain Z.N., Mayes L.C., Caldwell-Andrews A.A., et al. Preoperative anxiety, postoperative pain, and behavioral recovery in young children undergoing surgery. Pediatrics. 2006;118(2):651–658.
    1. Kain Z.N., Mayes L.C., Wang S.M., et al. Postoperative behavioral outcomes in children: effects of sedative premedication. Anesthesiology. 1999;90(3):758–765.
    1. Gulur P., Kain Z.N., Fortier M.A. In: Smith’s anesthesia for infants and children. 9th edition. Davis P.J., Cladis F.P., editors. Elsevier; St Louis (MO): 2017. Psychological aspects of pediatric anesthesia; pp. 275–277.
    1. Becke K. Anesthesia in children with a cold. Curr Opin Anaesthesiol. 2012;25(3):333–339.
    1. Regli A., Becke K., von Ungern-Sternberg B.S. An update on the perioperative management of children with upper respiratory tract infections. Curr Opin Anaesthesiol. 2017;30(3):362–367.
    1. Tait A.R., Malviya S., Voepel-Lewis T., et al. Risk factors for perioperative adverse respiratory events in children with upper respiratory tract infections. Anesthesiology. 2001;95(2):299–306.
    1. Tait A.R., Malviya S. Anesthesia for the child with an upper respiratory tract infection: still a dilemma? Anesth Analg. 2005;100(1):59–65.
    1. Deutsch N., Ohliger S., Motoyama E.K., et al. In: Smith’s anesthesia for infants and children. 9th edition. Davis P.J., Cladis F.P., editors. Elsevier; St Louis (MO): 2017. Induction, maintenance, and recovery; pp. 375–376.
    1. Schwartz D., Connelly N.R., Gutta S., et al. Early intravenous cannulation in children during sevoflurane induction. Paediatr Anaesth. 2004;14(10):820–824.
    1. Kraemer F.W., Rose J.B. Pharmacologic management of acute pediatric pain. Anesthesiol Clin. 2009;27:241–268.
    1. Jozwiak-Bebenista M., Nowak J.Z. Paracetamol: mechanism of action, applications and safety concern. Acta Pol Pharm. 2014;71(1):11–23.
    1. Kokki H. Nonsteroidal anti-Inflammatory drugs for postoperative pain. a focus on children. Paediatr Drugs. 2003;5(2):103–123.
    1. Vitale M.G., Choe J.C., Hwang M.W., et al. Use of ketorolac tromethamine in children undergoing scoliosis surgery. an analysis of complications. Spine J. 2003;3(1):55–62.
    1. Monitto C.L., yaster M., Kost-Byerly S. In: Smith’s anesthesia for infants and children. 9th edition. Davis P.J., Cladis F.P., editors. Elsevier; St Louis (MO): 2017. Pain management; pp. 437–438.
    1. Crews K.R., Gaedigk A., Dunnenberger H.M., et al. Clinical pharmacogenetics implementation consortium guidelines for cytochrome P450 2D6 genotype and codeine therapy: 2014 update. Clin Pharmacol Ther. 2014;95(4):376–382.
    1. US Food and Drug Administration Safety review update of codeine use in children; new Boxed Warning and Contraindication on use after tonsillectomy and/or adenoidectomy. In: FDA Drug Safety Communications. 2013. Available at: Accessed February 14, 2019.
    1. US Food and Drug Administration FDA restricts use of prescription codeine pain and cough medicines and tramadol pain medicines in children; recommends against use in breastfeeding women. In: FDA Drug Safety Communication. 2017. Available at: Accessed February 14, 2019.
    1. Walker B.J., Long J.B., Sathyamoorthy M., et al. Complications in pediatric regional anesthesia: an analysis of more than 100,000 blocks from the Pediatric Regional Anesthesia Network. Anesthesiology. 2018;129(4):721–732.
    1. Suresh S., Long J., Birmingham P.K., et al. Are caudal blocks for pain control safe in children? An analysis of 18,650 caudal blocks from the Pediatric Regional Anesthesia Network (PRAN) database. Anesth Analg. 2015;120(1):151–156.
    1. Kao S.C., Lin C.S. Caudal epidural block: an updated review of anatomy and techniques. Biomed Res Int. 2017;2017:9217145.
    1. Bernards C.M. In: Clinical anesthesia. 6th edition. Barash P.G., Cullen B.F., Stoelting R.K., et al., editors. Lippincott Williams & Wilkins; Philadelphia: 2009. Epidural and spinal anesthesia; pp. 934–936.
    1. Lam D.K., Corry G.N., Tsui B.C. Evidence for the use of ultrasound imaging in pediatric regional anesthesia: a systematic review. Reg Anesth Pain Med. 2016;41(2):229–241.
    1. Guay J., Suresh S., Kopp S. The use of ultrasound guidance for perioperative neuraxial and peripheral nerve blocks in children: a cochrane review. Anesth Analg. 2017;124(3):948–958.
    1. Flack S., Lang R.S. In: Smith’s anesthesia for infants and children. 9th edition. Davis P.J., Cladis F.P., editors. Elsevier; St Louis (MO): 2017. Regional anesthesia; pp. 487–506.
    1. Gray A.F., Collins A.B., Eilers H. In: Basics of anesthesia. 5th edition. Stoelting R.K., Miller R.D., editors. Churchill Livingstone; Philadelphia: 2007. Peripheral nerve blocks; pp. 276–286.
    1. Neal J.M., Bernards C.M., Hadzic A., et al. ASRA practice advisory on neurologic complications in regional anesthesia and pain medicine. Reg Anesth Pain Med. 2008;33(5):404–415.
    1. Taenzer A.H., Walker B.J., Bosenberg A.T., et al. Asleep versus awake: does it matter?: pediatric regional block complications by patient state: a report from the Pediatric Regional Anesthesia Network. Reg Anesth Pain Med. 2014;39(4):279–283.
    1. Liu S.S., Lin Y. In: Clinical anesthesia. 6th edition. Barash P.G., Cullen B.F., Stoelting R.K., et al., editors. Lippincott Williams & Wilkins; Philadelphia: 2009. Local anesthetics; pp. 542–544.
    1. Suresh S., Polaner D.M., Cote C.J. In: A practice of anesthesia for infants and children. 6th edition. Cote C.J., Lerman J., Anderson B.J., editors. Elsevier; Philadelphia: 2019. Regional anesthesia; pp. 943–945.
    1. Lönnqvist P.A. Toxicity of local anesthetic drugs: a pediatric perspective. Paediatr Anaesth. 2012;22(1):39–43.
    1. Polaner D.M., Zuk J., Luong K., et al. Positive intravascular test dose criteria in children during total intravenous anesthesia with propofol and remifentanil are different than during inhaled anesthesia. Anesth Analg. 2010;110(1):41–45.
    1. Lin J.S., Balch Samora J. Pediatric acute compartment syndrome: a systematic review and meta-analysis. J Pediatr Orthop B. 2019 Available at: Accessed February 14, 2019.
    1. Gadsden J., Warlick A. Regional anesthesia for the trauma patient: improving patient outcomes. Local Reg Anesth. 2015;8:45–55.
    1. Lönnqvist P.A., Ecoffey C., Bosenberg A., et al. The European society of regional anesthesia and pain therapy and the American society of regional anesthesia and pain medicine joint committee practice advisory on controversial topics in pediatric regional anesthesia I and II: what do they tell us? Curr Opin Anaesthesiol. 2017;5:613–620.
    1. Naranje S.M., Erali R.A., Warner W.C., Jr., et al. Epidemiology of pediatric fractures presenting to emergency departments in the United States. J Pediatr Orthop. 2016;36(4):e45–e48.
    1. Galano G.J., Vitale M.A., Kessler M.W., et al. The most frequent traumatic orthopaedic injuries from a national pediatric inpatient population. J Pediatr Orthop. 2005;25(1):39–44.
    1. Flaherty E.G., Perez-Rossello J.M., Levine M.A., et al. Evaluating children with fractures for child physical abuse. Pediatrics. 2014;133(2):e477–e489.
    1. Purcell D., Varthi A., Lee M.C. Slipped capital femoral epiphysis: current concepts review. Curr Orthop Pract. 2011;22(1):81–89.
    1. Aronsson D.D., Loder R.T., Breur G.J., et al. Slipped capital femoral epiphysis: current concepts. J Am Acad Orthop Surg. 2006;14(12):666–679.
    1. Aversano M.W., Moazzaz P., Scaduto A.A., et al. Association between body mass index-for-age and slipped capital femoral epiphysis: the long-term risk for subsequent slip in patients followed until physeal closure. J Child Orthop. 2016;10(3):209–213.
    1. Radler C. The Ponseti method for the treatment of congenital club foot: review of the current literature and treatment recommendations. Int Orthop. 2013;37(9):1747–1753.
    1. Parada S.A., Baird G.O., Auffant R.A., et al. Safety of percutaneous tendoachilles tenotomy performed under general anesthesia on infants with idiopathic clubfoot. J Pediatr Orthop. 2009;29(8):916–919.
    1. Tobias J.D., Mencio G.A. Regional anesthesia for clubfoot surgery in children. Am J Ther. 1998;5(4):273–277.
    1. AlSuhebani M., Martin D.P., Relland L.M., et al. Spinal anesthesia instead of general anesthesia for infants undergoing tendon Achilles lengthening. Local Reg Anesth. 2018;3(11):25–29.
    1. Ghazal E.A., Vadi M.G., Mason L.J., et al. In: A practice of anesthesia for infants and children. 6th edition. Cote C.J., Lerman J., Anderson B.J., editors. Elsevier; Philadelphia: 2019. Preoperative evaluation, premedication, and induction of anesthesia; pp. 64–66.
    1. Murphy R.F., Mooney J.F., III Complications following spine fusion for adolescent idiopathic scoliosis. Curr Rev Musculoskelet Med. 2016;9(4):462–469.
    1. Strike S.A., Hassanzadeh H., Jain A., et al. Intraoperative neuromonitoring in pediatric and adult spine deformity surgery. Clin Spine Surg. 2017;30(9):E1174–E1181.
    1. Wahlquist S., Wongworawat M., Nelson S. When does intraoperative blood loss occur during pediatric scoliosis correction? Spine Deform. 2017;5(6):387–391.
    1. Shapiro F., Sethna N. Blood loss in pediatric spine surgery. Eur Spine J. 2004;13(Suppl 1):S6–S17.
    1. Ialenti M.N., Lonner B.S., Verma K., et al. Predicting operative blood loss during spinal fusion for adolescent idiopathic scoliosis. J Pediatr Orthop. 2013;33(4):372–376.
    1. Yu X., Xiao H., Wang R., et al. Prediction of massive blood loss in scoliosis surgery from preoperative variables. Spine. 2013;38(4):350–355.
    1. Kim H.J., Park H.S., Jang M.J., et al. Predicting massive transfusion in adolescent idiopathic scoliosis patients undergoing corrective surgery: association of preoperative radiographic findings. Medicine. 2018;97(22):e10972.
    1. Oetgen M.E., Litrenta J. Perioperative blood management in pediatric spine surgery. J Am Acad Orthop Surg. 2017;25(7):480–488.
    1. Wilton N.C., Anderson B.J. In: A practice of anesthesia for infants and children. 6th edition. Cote C.J., Lerman J., Anderson B.J., editors. Elsevier; Philadelphia: 2019. Orthopedic and spine surgery; pp. 741–743.
    1. Schwartz D.M., Drummond D.S., Hahn M., et al. Prevention of positional brachial plexopathy during surgical correction of scoliosis. J Spinal Disord. 2000;13(2):178–182.
    1. Kamel I., Barnette R. Positioning patients for spine surgery: avoiding uncommon position-related complications. World J Orthop. 2014;5(4):425–443.
    1. Lee L.A., Roth S., Posner K.L., et al. The American Society of Anesthesiologists Postoperative Visual Loss Registry: analysis of 93 spine surgery cases with postoperative visual loss. Anesthesiology. 2006;105(4):652–659.
    1. Patil C.G., Lad E.M., Lad S.P., et al. Visual loss after spine surgery: a population-based study. Spine. 2008;33(13):1491–1496.
    1. De la Garza-Ramos R., Samdani A.F., Sponseller P.D., et al. Visual loss after corrective surgery for pediatric scoliosis: incidence and risk factors from a nationwide database. Spine J. 2016;16(4):516–522.

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