Philosophy
While perioperative pain management can and is managed any number of ways, our philosophy is simple: preemptively block everything. Single shot. Multiple blocks. Catheters. Whatever you have at your disposal and makes sense given your institutional idiosyncrasies and infrastructure. Though this philosophy is clearly at one end of the spectrum, we know that this is not how the vast majority of people practice.
A recent survey of Society of Pediatric Anesthesia (SPA) and Association of Pediatric Anaesthetists of Great Britain (APA) members evaluated the perioperative management of patients with pyloric stenosis, not a procedure that many would consider needing a regional anesthetic. The majority of practitioners used acetaminophen or ketorolac and local anesthetic infiltration of the incision by the surgeon before skin closure—the mainstay when I started clinical practice.
As you can see from the graphics above, only 7% of SPA members and 20% of APA members used supplemental regional anesthesia. An even smaller number of patients were done under spinal only. While one might argue that performing a regional anesthetic for pylorics is like “using a sledgehammer to crack a nut,” nearly 25% of these patients required opioids post-operatively. Unfortunately, because this was a survey of anesthetic practice, there is no information regarding whether the procedure was performed open vs laparoscopic. There is also no data looking at cumulative post-op narcotic use, so we don’t exactly know if these patients required one dose or 10 doses of opioids post-operatively. Moreover, surgical practice may differ geographically, and open pyloromyotomy may be associated with increased postoperative pain and opioid use. Having said all that, some might argue that this is still an area of clinical care that might be improved upon. These kids are at in increased risk of perioperative apneic events and reducing concomitant respiratory depression from opioids by additional means should at least be considered.
And don’t think this conservative mentality is limited to minor, relatively painless procedures in children. Two recent studies looked at the use of regional anesthesia in total knee replacements in adults —not something most people would consider minor or relatively painless. In these studies, the researchers found only a fraction of patients received any long-acting regional anesthetic. In one study, only 27% of patients received a femoral nerve block for their post-operative pain management, at the time the PNB of choice for knee surgery. Another study found only 12% received a PNB of any kind for their procedure. Even in procedures where there would clearly be an analgesic benefit, especially compared to a pyloromyotomy, practitioners are still opting for more conservative management. Mind you, this is almost 20 years after Singelyn et al showed superior analgesia, along with earlier and better rehabilitation with continuous femoral nerve blockade. Whether it is ambivalence or lack of comfort performing a regional technique, perhaps it is time to reconsider our approach and move the needle forward (pun intended).
In our clinical pediatric practice, regional blocks are the norm, the expectation. We typically perform them pre-incision. Rarely, do the surgeons need to place additional LA at incision sites, unless an unanticipated incision or an additional trocar is added—something not covered by our initial block(s). The majority of our patients, pylorics or otherwise, require little to no intraoperative narcotics, and considerably reduced perioperative narcotics.
Given the current opioid epidemic, I believe we are at the brink of a paradigm shift in perioperative pain management, something that has already filtered through the intelligentsia. While one may argue that the biggest impact is still discharge prescriptions (especially for dental procedures), of which anesthesiologists have little direct control over, the perioperative use of regional anesthesia and reduction of intraoperative opioids can change a surgeon’s mentality about what is possible and how patients can look post-operatively. Furthermore, considerable publicity about the opioid epidemic has also made clinicians reevaluate their practice and look for way to integrate multimodal therapy, regional anesthesia, and reduce opioid exposure.
While the current studies on opioid-free and opioid-sparing are limited, some suggest improved patient outcomes, fewer intraoperative analgesics, reduced need for postoperative opioids in the PACU, improved quality of recovery after surgery and less serious adverse events in the PACU.
More work is needed to show this not only can be done, but perhaps should be done.
In our clinical pediatric practice, regional blocks are the norm, the expectation. We typically perform them pre-incision. Rarely, do the surgeons need to place additional LA at incision sites, unless an unanticipated incision or an additional trocar is added—something not covered by our initial block(s). The majority of our patients, pylorics or otherwise, require little to no intraoperative narcotics, and considerably reduced perioperative narcotics.
Given the current opioid epidemic, I believe we are at the brink of a paradigm shift in perioperative pain management, something that has already filtered through the cognoscenti. While one may argue that the biggest impact is still discharge prescriptions (especially for dental procedures), of which anesthesiologists have little direct control over, the perioperative use of regional anesthesia and reduction of intraoperative opioids can change a surgeon’s mentality about what is possible and how patients can look post-operatively. Furthermore, considerable publicity about the opioid epidemic has also made clinicians reevaluate their practice and look for way to integrate multimodal therapy, regional anesthesia, and reduce opioid exposure.
While the current studies on opioid-free and opioid-sparing are limited, some suggest improved patient outcomes, fewer intraoperative analgesics, reduced need for postoperative opioids in the PACU, improved quality of recovery after surgery and less serious adverse events in the PACU.
More work is needed to show this not only can be done, but perhaps should be done.
Food for thought: Common clinical practice 20 years ago was the routine use of awake endotracheal intubation in pylorics. Current awake intubation rates from the previously mentioned survey above vary between 0.7-2.5%.
Dramatic change in clinical practice is possible.
Cartabuke, R.S., Tobias, J.D., Rice, J. and Tumin, D., 2018. Current perioperative care of infants with pyloric stenosis: comparison of survey results. Journal of Surgical Research, 223, pp.244-250.
Mulier, J.P., Wouters, R., Dillemans, B. and De Kock, M., 2018. A randomized controlled, double-blind trial evaluating the effect of opioid-free versus opioid general anaesthesia on postoperative pain and discomfort measured by the QoR-40. of, 6, p.2.
Leclair, M.D., Plattner, V., Mirallie, E., Lejus, C., Nguyen, J.M., Podevin, G. and Heloury, Y., 2007. Laparoscopic pyloromyotomy for hypertrophic pyloric stenosis: a prospective, randomized controlled trial. Journal of pediatric surgery, 42(4), pp.692-698
Hall, N.J., Pacilli, M., Eaton, S., Reblock, K., Gaines, B.A., Pastor, A., Langer, J.C., Koivusalo, A.I., Pakarinen, M.P., Stroedter, L. and Beyerlein, S., 2009. Recovery after open versus laparoscopic pyloromyotomy for pyloric stenosis: a double-blind multicentre randomised controlled trial. The Lancet, 373(9661), pp.390-398.
Singelyn, F.J., Deyaert, M., Joris, D., Pendeville, E. and Gouverneur, J.M., 1998. Effects of intravenous patient-controlled analgesia with morphine, continuous epidural analgesia, and continuous three-in-one block on postoperative pain and knee rehabilitation after unilateral total knee arthroplasty. Anesthesia & Analgesia, 87(1), pp.88-92.
Sultana, A., Torres, D. and Schumann, R., 2017. Special indications for Opioid Free Anaesthesia and Analgesia, patient and procedure related: Including obesity, sleep apnoea, chronic obstructive pulmonary disease, complex regional pain syndromes, opioid addiction and cancer surgery. Best practice & research. Clinical Anaesthesiology, 31(4), pp.547-560.
Mulier, J. and Dekock, M., 2017. Opioid free general anesthesia, a new paradigm?. Best practice & research. Clinical Anaesthesiology, 31(4), p.441.
Hagen, J.G., Barnett, N., Kars, M.S., Padover, A. and Bunnell, A.M., 2019. Rectus sheath blocks in the extremes of body habitus. J Clin Anesth, 57.