Error Traps in Pediatric Regional Anesthesia
Lynne Maxwell MD and Myron Yaster MD
During my anesthesia residency and fellowship in the late 1970s, the use of regional anesthesia in pediatrics was as rare as a full spare tire is in a new car today. “Why use a regional technique if you have to use a general anesthetic to place the needle in the right spot”? or “Is it safe”? Indeed, when Estela Melman(1), the mother of pediatric anesthesia in Mexico, wrote up one of the first case series of the use of pediatric caudal anesthesia in the 1960s, the editor of the journal didn’t want to publish it thinking that regional anesthetics were of no use in American anesthetic practice and would be limited to the less developed world! How times have changed!
The last two decades have been notable for great advances in both the techniques and utilization of peripheral nerve and neuraxial blocks in pediatric patients as adjunctive analgesic modalities to improve pain control while reducing opioid administration during and after surgery. Despite these advances, these techniques require meticulous education and practice to maintain competence, ensure efficacy and avoid adverse outcomes. The success of these techniques has been facilitated by the increasing use of ultrasound. The authors of the article discussed in today’s PAAD discuss sources of possible error (error traps) which may lead to less than optimal outcomes for these pediatric regional anesthetic techniques. It is another in series of error trap articles being published in the Journal of Pediatric Anesthesia. We’ll try to publish them in forthcoming PAADs. Myron Yaster MD
Original article
Melissa M. Masaracchia, Rani A. Sunder, David M. Polaner. Error traps in pediatric regional anesthesia. Pediatric Anesthesia 2021; 31:1161-69. doi: 10.1111/pan.14275. PMID: 34396637
Error traps are circumstances that lead to erroneous actions. The senior author of today’s article, Dr. David Polaner, is truly one of the giants in our profession and to paraphrase an old commercial: “When David Polaner speaks, people listen”! One of the crucial questions concerning pediatric regional anesthesia is: “Is it safe”? David was one of the key players in developing the Pediatric Regional Anesthesia Network (PRAN)(2) which has provided many of the answers to this fundamental question.
The authors of this article are very experienced practitioners of pediatric regional anesthesia techniques, and are familiar with many of the pitfalls which may result in less than optimal outcomes of even well-intentioned use of these techniques.
The error traps discussed range from the basic failure to perform a “time out” to confirm the intended block site to their use in rare diseases like arthrogryposis. Failure to perform a time out prior to performing peripheral nerve blocks may be more common than wrong side surgery, but also may itself lead to wrong side surgery. Other errors discussed include poor familiarity with technology (failure of ultrasound image optimization) which may result in failure to identify the target neural structures, to knowledge gaps (medical conditions in which various regional anesthetic techniques may worsen underlying pathology, those in which alternative blocks might be preferable, or lack of knowledge of adjunctive imaging techniques whose use may improve the success of certain blocks (such as the use of ultrasound or fluoroscopy to ensure the optimal location of epidural catheter tip).
The authors give detailed examples of both potential for error and ways to avoid these errors in both the performance of peripheral nerve blocks with ultrasound as well as neuraxial techniques.
As with other skills that we use daily in the practice of pediatric anesthesiology, maintenance of competence in the performance of peripheral and neuraxial blocks requires constant attention to utilization and interpretation of the tools at our disposal and our knowledge base to ensure optimal outcomes for our patients and informs our discussion of benefits and risks with the families of our patients.
We have one concern with this paper though, namely, the lack of discussion of the prevention and treatment of local anesthetic toxicity (LAST). As we like to say and teach: “Common things happen commonly, that’s why they are common”! One of the most common complications of regional anesthesia is the development of LAST and is often caused by the speed and quantity of local anesthetic administration. Remember to think about the dose, fractionate it when administering it, and always watch the ECG for T wave elevation. Finally, if LAST does occur, don’t rely on your memory when treating! Always open the Society for Pediatric Anesthesia’s PEDI-CRISIS v 2 app on your cell phone as one of the first things you do! And if you don’t have it on your cell phone go to the app store or the SPA website and download it now!
Lynne Maxwell MD and Myron Yaster MD
References
1. Ahmed Z, Mai C, Skinner KG, Yaster M. At the birth of pediatric anesthesia in Mexico: An interview with Dr. Estela Melman, a pioneering woman in medicine. Paediatr Anaesth 2018;28:1066-70.
2. Walker BJ, Long JB, Sathyamoorthy M, Birstler J, Wolf C, Bosenberg AT, Flack SH, Krane EJ, Sethna NF, Suresh S, Taenzer AH, Polaner DM, Martin L, Anderson C, Sunder R, Adams T, Martin L, Pankovich M, Sawardekar A, Birmingham P, Marcelino R, Ramarmurthi RJ, Szmuk P, Ungar GK, Lozano S, Boretsky K, Jain R, Matuszczak M, Petersen TR, Dillow J, Power R, Nguyen K, Lee BH, Chan L, Pineda J, Hutchins J, Mendoza K, Spisak K, Shah A, DelPizzo K, Dong N, Yalamanchili V, Venable C, Williams CA, Chaudahari R, Ohkawa S, Usljebrka H, Bhalla T, Vanzillotta PP, Apiliogullari S, Franklin AD, Ando A, Pestieau SR, Wright C, Rosenbloom J, Anderson T. Complications in Pediatric Regional Anesthesia: An Analysis of More than 100,000 Blocks from the Pediatric Regional Anesthesia Network. Anesthesiology 2018;129:721-32.