1. Giorgio Ivani, Italy Continuous Peripheral Nerve Blockade in Children Giorgio Ivani Giorgio Ivani Regina Margherita Children’s Hospital Turin Italy gioivani@libero.it

2. Giorgio Ivani, Italy Postoperative Pain Control and RA Single shot analgesia, even with the addition of adjuvants is not enough for: - long-term surgery - long-term pain

3. Giorgio Ivani, Italy Postoperative Pain Control and RA: techniques ä Single Shot : minor surgery ä Continuous Infusion: - long-term surgery surgery - painful postop. - painful postop.

4. Giorgio Ivani, Italy Postoperative Pain Control and RA When a long-term pain control is required pain treatment becomes a challenge: - complete pain relief - without interference with the daily life - drugs with as few side effects as possible patient well-being

5. Giorgio Ivani, Italy Continuous Infusion and Outcome l Surgical Stress Control:oesophageal atresia l Optimal Pain Control l Reduced Need of Opioids l Reduced Need of Muscle Relaxants l Ventilatory Support Reduction Bosenberg A et al. Pediatr Surg Int 1992;7:289-91

6. Giorgio Ivani, Italy Is epidural analgesia associated with an improved outcome following open Nissen fundoplication? retrospective study, 104 open Nissen iv morphine infusion:10-40 mcg/kg/h vs epi 0.125% bupivacaine/fentanyl 4 mcg/ml 0.4 ml/kg/h Wilson et al. Paediatr Anaesth 2001;11:65-70

7. Giorgio Ivani, Italy Is epidural analgesia associated with an improved outcome following open Nissen fundoplication? Hospital stay: GA 13 days vs RA 8 days over 7 days discharge: GA 44% vs RA 25% ICU stay: GA 33% vs RA 17% ICU ventilation: GA 21% vs RA 8%

8. Giorgio Ivani, Italy Peripheral Pain Control several techniques/ routes can be used - intramuscolar pain, some drug absorption unpredictability -iv opioids nausea,vomiting,pruritus,urinary retention, GI impairment,respiratory depression -epidural infusion anaesthesia/analgesia also in controlateral leg

9. Giorgio Ivani, Italy Postoperative Pain Control and RA As continuous epidural infusion is a technique of choice when there is a prolonged operation or an intense postoperative pain, why not a peripheral infusion for a peripheral pain?

10. Giorgio Ivani, Italy Continuous Peripheral Blocks In adults it is a well established and commonly performed technique

11. Giorgio Ivani, Italy Peripheral Catheter Positioning - as efficient as epidural continuous infusion - easy to perform - long-term analgesia

12. Giorgio Ivani, Italy Pediatric Data Very Few Papers Mainly Case Reports Usually short term infusion (48h) A review of CPNB in Children Syngelyn. TRAPM 2002,vol 6 n3;108-114

13. Giorgio Ivani, Italy Matuszczak et al.Anesthesiology 2001;95:A1236 brachial plexus block 36 patients; age 2-16 years catheter lasting 2-13 days, mean 4 days arm/and trauma, vascular/congenital surgery,complicated fractures optimal analgesia no complications

14. Giorgio Ivani, Italy Pediatric Data 25 children, major orthopedic surgery CPNB with elastomeric pumps 0.2% ropivacaine 0.1 ml/kg/h mean age 10 yrs mean duration 45 h no complications,no accidental removal Dadure et al. Anesth Analg 2003;97:687-690

15. Giorgio Ivani, Italy Continuous infusions: Safety/Efficacy   Asepsis   Dedicated Pediatric Tools   Nerve Stimulator   Strictly observed Drugs Guide-Lines   Continuous monitoring : instrumental   nurses

16. Giorgio Ivani, Italy Material: needles and catheteres   radial artery catheterization set for axillary block (Tan et al.Anesth Analg1995;80:640-641)   epidural kit for femoral block (Johnson.Anaesth Int Care 1994;22:281- 283)   central venous catheter set for femoral block (Tobias. Anaesth Int Care 1994;22:616-618 )

17. Giorgio Ivani, Italy Case Report 1 3 1/2 y, left foot semiamputation sciatic block 15 days of continuous infusion

18. Giorgio Ivani, Italy Case Report 2 3 y old boy right foot semiamputation sciatic block 21 days of continuous infusion Ivani et al. Paediatr Anaesth 2003 ; in press

19. Giorgio Ivani, Italy Case Report 2 bolus dose: 0.2% ropivacaine 0.6 ml/kg + clonidine 2 mcg/kg continuous infusion: 0.2% ropivacaine 0.4 mg/kg/h + clonidine 3 mcg/kg/24h

20. Giorgio Ivani, Italy Case Report 2 J J better blood flow J J daily wound treatments ( 2-3 times per day) and surgical cleaning without any additional pain killer

21. Giorgio Ivani, Italy Peripheral Catheter Positioning axillary sciatic femoral (fascia iliaca) bl. starting dose 0.25% bupiv., 0.2% ropivacaine 0.4-0.6 ml/kg (Syngelin) 1.5% lidocaine+0.2% ropivacaine (Matuszczack) 0.2% ropiv/levob. 0.3-0.6 ml/kg+ clonidine 2mcg/kg (Ivani)

22. Giorgio Ivani, Italy Peripheral Catheter Positioning continuous infusion 0.125%- 0.25% levobupivacaine, 0.1%-0.2% ropivacaine 0.1-0.3 ml/kg/h 0.2-0.4 mg/kg/h + clonidine 3 mcg/kg/24h 30% reduction for infants < 6 mo

23. Giorgio Ivani, Italy Pediatric Regional Anesthesia: the Future Continuous Infusion: Technical difficulties have been overcome Pediatric tools availability for peripheral continuous infusion: can provide effective analgesia optimizing drugs administration and pain management