Pediatric Anesthesia ISSN 1155-5645
CASE REPORT
Inferior alveolar nerve blocks for postoperative pain control after mandibular distraction with osteotomies in a neonate David J. Krodel1,2, Dawn Belvis1,2 & Santhanam Suresh1,2 1 Department of Pediatric Anesthesiology, Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, IL, USA 2 Department of Anesthesiology, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
Keywords newborn; airway management; acute pain; nerve block; postoperative pain; Pierre Robin syndrome Correspondence David J. Krodel, Department of Pediatric Anesthesiology, Ann & Robert H. Lurie Children’s Hospital of Chicago, 225 East Chicago Avenue, Box 19, Chicago, IL 60611, USA. Email: [email protected] Section Editor: David Polaner
Summary We describe the use of inferior alveolar nerve blocks (IANBs) for postoperative pain control for a neonate undergoing mandibular distraction and osteotomies. In this case, bilateral IANBs were effective in keeping low pain scores as assessed on the neonatal infant pain scale (NIPS) and the amount of opioid and adjuvant analgesics used. The blocks were assessed to have lasted approximately 24 h making serial blocks for pain control logistically feasible. Additionally, pain control was improved throughout the period of distractor advancement (approximately 7 days). We propose the routine use of this regional technique for improved pain control after this procedure in neonates and suggest that improved pain control may facilitate earlier extubation in this challenging population.
Accepted 1 February 2014 doi:10.1111/pan.12379
Introduction Peripheral nerve blocks of the head and neck have been an anesthetic mainstay for oral and maxillofacial procedures, as a primary anesthetic, an adjunct to general anesthesia, and for pain relief in the immediate postoperative period (1). They have been infrequently described for the management of ongoing postoperative pain. Serial nerve blocks while effective have several drawbacks in most populations. From the patient’s perspective, it can be difficult to undergo repeated uncomfortable procedures on a daily or more frequent basis to maintain good pain control. In some situations, however, the potential benefits of serial nerve blocks of the head and neck may outweigh these concerns. This may be true in the very young, and in patients with difficult airways that would be at great risk from respiratory depression from opioids. Case The pediatric acute pain service was consulted regarding an 8-week-old, full-term, 2.6-kg, male infant with © 2014 John Wiley & Sons Ltd Pediatric Anesthesia 24 (2014) 635–637
mandibular hypoplasia of the Pierre Robin sequence and a constellation of other (noncraniofacial) genetic anomalies who had undergone mandibular distraction and osteotomies (2) 1 day prior. The infant remained intubated in the neonatal intensive care unit (NICU) due to the difficulty of intubation, local edema after surgery, as well as the need to provide pain control with opioids that were likely to cause respiratory depression. On postoperative day 1, he was receiving a continuous infusion of morphine, which had been increased from 50 to 100 mcgkg 1h 1. He had also been provided fentanyl as needed, requiring 1.5 mcgkg 1 every 3 h since the night before. Despite this, the patient remained agitated and his neonatal infant pain scale (NIPS) scores (3) were elevated. The acute pain service offered bilateral blocks of the inferior alveolar branches of the mandibular nerves (1). After negative aspiration, 0.2 ml of 0.25% bupivacaine was injected with a 27 G needle into each side (Figure 1). Within minutes, the patient appeared more comfortable and his respirations declined below the backup rate of the ventilator. Following this first
635
D.J. Krodel et al.
Regional analgesia for mandibular distraction
nerve block, his morphine infusion was lowered to 50 mcgkg 1h 1 and he only received two additional doses of fentanyl over 24 h. Additionally, his agitation was greatly improved as assessed by the bedside nurse with NIPS scores ≤1 (minimum of 0, maximum of 7) throughout the next 24 h (Figure 2). Both his surgeon and neonatologist requested that we repeat the block daily if the infant began to appear uncomfortable as well as in anticipation of painful turning of the distraction screws for mandibular advancement. Screw turning typically increases pain and agitation, but was well tolerated with the analgesia provided by the blocks. His morphine and fentanyl were further decreased, and he was extubated on postoperative day 3. He underwent a total of four blocks daily from postoperative day 1 to postoperative day 5. He did not receive one on the day of extubation. His NIPS scores continued to be low after the initial block placement. He was discharged home on postoperative day 12. Discussion Pain and sedation can be difficult to manage in small infants and more so in the setting of a difficult airway and recent mandibular or other maxillofacial surgery (4). Even after improvement of an obstructed airway by distraction osteotomy, ongoing pain and its treatment with opioids that depress the respiratory drive can prolong the need for intubation. Despite the use of opioids, pain control and agitation can be problematic in the NICU as seen in this case prior to the administration of regional analgesia. In this case, we described the use of inferior alveolar nerve blocks to provide excellent pain control to the
Figure 2 Postoperative course consisting of NIPS score in temporal relation to the provision of bilateral inferior alveolar mandibular nerve blocks. The second block was provided in anticipation of painful distractor advancement, not observed discomfort.
infant after mandibular surgery. Large prospective pediatric cohorts have shown that peripheral nerve blocks have extremely low complication rates (5). We were able to use a small fraction of the toxic dose of local anesthetic to achieve pain relief. While expert providers supervised the blocks, multiple novice trainees performed them, suggesting that the technique is relatively easy to learn and administer effectively. In addition to the objective data reported, the neonatologists, surgeon, and the mother of the child reported satisfaction with the technique and were eager to have serial daily blocks performed. We submit that this technique may be an effective approach to postoperative pain control in neonates undergoing mandibular surgery and possibly superior to pain control with opioids and other systemic adjuncts alone. Learning points
Figure 1 Inferior alveolar nerve block performed on an intubated neonate with mandibular distractors in situ.
636
1. Inferior alveolar nerve blocks are effective for managing pain after mandibular surgery in neonates. 2. Inferior alveolar nerve blocks in neonates were easily performed by novices. 3. Regional analgesia techniques including serial nerve blocks are important to consider when formulating plans for postoperative pain control after head and neck surgery in infants. © 2014 John Wiley & Sons Ltd Pediatric Anesthesia 24 (2014) 635–637
D.J. Krodel et al.
Regional analgesia for mandibular distraction
Acknowledgments
Conflict of interests
The authors thank Kate Schaldenbrand, MPH for her help with data collection and Gildasio De Oliveira, MD for his helpful guidance. This research was carried out without funding.
No conflict of interests declared.
References 1 Suresh S, Voronov P. Head and neck blocks in infants, children, and adolescents. Pediatr Anesth 2012; 22: 81–87. 2 Frawley G, Espenell A, Howe P et al. Anesthetic implications of infants with mandibular hypoplasia treated with mandibular distraction osteogenesis. Pediatr Anesth 2013; 23: 342–348.
© 2014 John Wiley & Sons Ltd Pediatric Anesthesia 24 (2014) 635–637
3 Lawrence J, Alcock D, McGrath P et al. The development of a tool to assess neonatal pain. Neonatal Netw 1993; 12: 59–66. 4 Suresh S, Birmingham PK, Kozlowski RJ. Pediatric pain management. Anesthesiol Clin 2012; 30: 101–117. 5 Polaner DM, Taenzer AH, Walker BJ et al. Pediatric Regional Anesthesia Network
(PRAN): a multi-institutional study of the use and incidence of complications of pediatric regional anesthesia. Anesth Analg 2012; 115: 1353–1364.
637
CASE REPORT
Inferior alveolar nerve blocks for postoperative pain control after mandibular distraction with osteotomies in a neonate David J. Krodel1,2, Dawn Belvis1,2 & Santhanam Suresh1,2 1 Department of Pediatric Anesthesiology, Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, IL, USA 2 Department of Anesthesiology, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
Keywords newborn; airway management; acute pain; nerve block; postoperative pain; Pierre Robin syndrome Correspondence David J. Krodel, Department of Pediatric Anesthesiology, Ann & Robert H. Lurie Children’s Hospital of Chicago, 225 East Chicago Avenue, Box 19, Chicago, IL 60611, USA. Email: [email protected] Section Editor: David Polaner
Summary We describe the use of inferior alveolar nerve blocks (IANBs) for postoperative pain control for a neonate undergoing mandibular distraction and osteotomies. In this case, bilateral IANBs were effective in keeping low pain scores as assessed on the neonatal infant pain scale (NIPS) and the amount of opioid and adjuvant analgesics used. The blocks were assessed to have lasted approximately 24 h making serial blocks for pain control logistically feasible. Additionally, pain control was improved throughout the period of distractor advancement (approximately 7 days). We propose the routine use of this regional technique for improved pain control after this procedure in neonates and suggest that improved pain control may facilitate earlier extubation in this challenging population.
Accepted 1 February 2014 doi:10.1111/pan.12379
Introduction Peripheral nerve blocks of the head and neck have been an anesthetic mainstay for oral and maxillofacial procedures, as a primary anesthetic, an adjunct to general anesthesia, and for pain relief in the immediate postoperative period (1). They have been infrequently described for the management of ongoing postoperative pain. Serial nerve blocks while effective have several drawbacks in most populations. From the patient’s perspective, it can be difficult to undergo repeated uncomfortable procedures on a daily or more frequent basis to maintain good pain control. In some situations, however, the potential benefits of serial nerve blocks of the head and neck may outweigh these concerns. This may be true in the very young, and in patients with difficult airways that would be at great risk from respiratory depression from opioids. Case The pediatric acute pain service was consulted regarding an 8-week-old, full-term, 2.6-kg, male infant with © 2014 John Wiley & Sons Ltd Pediatric Anesthesia 24 (2014) 635–637
mandibular hypoplasia of the Pierre Robin sequence and a constellation of other (noncraniofacial) genetic anomalies who had undergone mandibular distraction and osteotomies (2) 1 day prior. The infant remained intubated in the neonatal intensive care unit (NICU) due to the difficulty of intubation, local edema after surgery, as well as the need to provide pain control with opioids that were likely to cause respiratory depression. On postoperative day 1, he was receiving a continuous infusion of morphine, which had been increased from 50 to 100 mcgkg 1h 1. He had also been provided fentanyl as needed, requiring 1.5 mcgkg 1 every 3 h since the night before. Despite this, the patient remained agitated and his neonatal infant pain scale (NIPS) scores (3) were elevated. The acute pain service offered bilateral blocks of the inferior alveolar branches of the mandibular nerves (1). After negative aspiration, 0.2 ml of 0.25% bupivacaine was injected with a 27 G needle into each side (Figure 1). Within minutes, the patient appeared more comfortable and his respirations declined below the backup rate of the ventilator. Following this first
635
D.J. Krodel et al.
Regional analgesia for mandibular distraction
nerve block, his morphine infusion was lowered to 50 mcgkg 1h 1 and he only received two additional doses of fentanyl over 24 h. Additionally, his agitation was greatly improved as assessed by the bedside nurse with NIPS scores ≤1 (minimum of 0, maximum of 7) throughout the next 24 h (Figure 2). Both his surgeon and neonatologist requested that we repeat the block daily if the infant began to appear uncomfortable as well as in anticipation of painful turning of the distraction screws for mandibular advancement. Screw turning typically increases pain and agitation, but was well tolerated with the analgesia provided by the blocks. His morphine and fentanyl were further decreased, and he was extubated on postoperative day 3. He underwent a total of four blocks daily from postoperative day 1 to postoperative day 5. He did not receive one on the day of extubation. His NIPS scores continued to be low after the initial block placement. He was discharged home on postoperative day 12. Discussion Pain and sedation can be difficult to manage in small infants and more so in the setting of a difficult airway and recent mandibular or other maxillofacial surgery (4). Even after improvement of an obstructed airway by distraction osteotomy, ongoing pain and its treatment with opioids that depress the respiratory drive can prolong the need for intubation. Despite the use of opioids, pain control and agitation can be problematic in the NICU as seen in this case prior to the administration of regional analgesia. In this case, we described the use of inferior alveolar nerve blocks to provide excellent pain control to the
Figure 2 Postoperative course consisting of NIPS score in temporal relation to the provision of bilateral inferior alveolar mandibular nerve blocks. The second block was provided in anticipation of painful distractor advancement, not observed discomfort.
infant after mandibular surgery. Large prospective pediatric cohorts have shown that peripheral nerve blocks have extremely low complication rates (5). We were able to use a small fraction of the toxic dose of local anesthetic to achieve pain relief. While expert providers supervised the blocks, multiple novice trainees performed them, suggesting that the technique is relatively easy to learn and administer effectively. In addition to the objective data reported, the neonatologists, surgeon, and the mother of the child reported satisfaction with the technique and were eager to have serial daily blocks performed. We submit that this technique may be an effective approach to postoperative pain control in neonates undergoing mandibular surgery and possibly superior to pain control with opioids and other systemic adjuncts alone. Learning points
Figure 1 Inferior alveolar nerve block performed on an intubated neonate with mandibular distractors in situ.
636
1. Inferior alveolar nerve blocks are effective for managing pain after mandibular surgery in neonates. 2. Inferior alveolar nerve blocks in neonates were easily performed by novices. 3. Regional analgesia techniques including serial nerve blocks are important to consider when formulating plans for postoperative pain control after head and neck surgery in infants. © 2014 John Wiley & Sons Ltd Pediatric Anesthesia 24 (2014) 635–637
D.J. Krodel et al.
Regional analgesia for mandibular distraction
Acknowledgments
Conflict of interests
The authors thank Kate Schaldenbrand, MPH for her help with data collection and Gildasio De Oliveira, MD for his helpful guidance. This research was carried out without funding.
No conflict of interests declared.
References 1 Suresh S, Voronov P. Head and neck blocks in infants, children, and adolescents. Pediatr Anesth 2012; 22: 81–87. 2 Frawley G, Espenell A, Howe P et al. Anesthetic implications of infants with mandibular hypoplasia treated with mandibular distraction osteogenesis. Pediatr Anesth 2013; 23: 342–348.
© 2014 John Wiley & Sons Ltd Pediatric Anesthesia 24 (2014) 635–637
3 Lawrence J, Alcock D, McGrath P et al. The development of a tool to assess neonatal pain. Neonatal Netw 1993; 12: 59–66. 4 Suresh S, Birmingham PK, Kozlowski RJ. Pediatric pain management. Anesthesiol Clin 2012; 30: 101–117. 5 Polaner DM, Taenzer AH, Walker BJ et al. Pediatric Regional Anesthesia Network
(PRAN): a multi-institutional study of the use and incidence of complications of pediatric regional anesthesia. Anesth Analg 2012; 115: 1353–1364.
637
