From Britta S von Ungern-Sternberg, David Sommerfield & Aine Sommerfield
We read with interest the Pediatric Anesthesia Article of the Day on 29 January on the intersections between parental distress and childhood pain [Beveridge et al. PAIN 2023. http://dx.doi.org/10.1097/j.pain.0000000000003125)]. Our multidisciplinary team in Perth, Australia, is interested in the development of chronic post surgical pain in children. While the association of parental mental health and pediatric chronic pain is undeniable, there are other complex factors involved in the transition of acute to chronic pain, including patient (pre-surgical) psychosocial and genetic factors, surgical factors and quality of perioperative pain management which all play roles in the development of complex post-surgical pain.
At Perth Children’s Hospital, in close collaboration with paediatric clinical psychologists, we are leading an international, multicenter, longitudinal prospective study (POPSICLE) which has been designed to assess the prevalence of chronic post-surgical pain in children, to identify risk factors and consequences of persistent pain following common paediatric surgeries. POPSICLE will assess child, parent and surgical factors and their interaction in the development of persistent postsurgical pain. Further, we will also assess the speed of return to normal function. We are attempting to add further pieces to the overall puzzle. Included sites will be in South Australia, Europe, New Zealand, USA and Canada. Further sites in are being actively recruited, . We strongly believe that we have to all work together to answer these important questions – if you would like to join our quest and be sent more information, please don’t hesitate to contact
Britta britta.regli-vonungern@health.wa.gov.au
or
scan the QR-code
From Joseph T. Sofia MD, Jennifer L. Chiem MD, Daniel K. Low MD, Lynn D. Martin MD MBA University of Washington, Seattle Children’s Hospital on the implications of caudal anesthesia for hypospadias repair.
We found great interest in the questions “Have you stopped doing caudals for hypospadias repair?” and “[..] what (if any) regional technique did you use in its place?”. Following Dr. Cravero’s SPA presentation reviewing the evidence base for ultrasound guided pudendal nerve blocks in 2018, we at Seattle Children’s Hospital transitioned away from caudal analgesia for all penile procedures, including hypospadias repair.1 In fact, since January 2021, over 94% of these cases performed in patients less than 3 years old at our ambulatory surgery center receive analgesia by pudendal nerve block.
We recently reviewed retrospective observational data to evaluate this change in practice across 2,768 patients between January 2015 and June 2023. After our practice implemented pudendal nerve blocks in >75% of all penile procedures performed, we experienced a reduction in average PACU max pain scores (average 1.94 on NRS), morphine rescue rates (average 1.43%), and incidence of PONV (0%). Despite a learning curve when adopting pudendal nerve blocks, the technique also had a higher rate of first-attempt success (98.97%) compared with caudals (80.8%) over the studied timeframe. We look forward to sharing these results in further detail at the upcoming SPA-AAP meeting in April.
Caudal analgesia is not without inherent risk, including prolonged motor blockade, urinary retention, accidental intrathecal injection, epidural hematoma, and infection. At our institution, we have found pudendal nerve blocks provide significant advantages with a lower risk profile and have become the standard method of analgesia for pediatric urologic procedures. We hope that by sharing this information, more institutions consider a similar evolution of practice.
References
1. Gaudet-Ferrand I, De La Arena P, Bringuier S, Raux O, Hertz L, Kalfa N, Sola C, Dadure C. Ultrasound-guided pudendal nerve block in children: A new technique of ultrasound-guided transperineal approach. Paediatr Anaesth. 2018 Jan;28(1):53-58. doi: 10.1111/pan.13286. Epub 2017 Dec 5. PMID: 29205687.
PS from Myron: Keep your posted on the PAAD. We will be reviewing 2 new papers on pediatric regional anesthesia in the next 2 weeks.