Patients need to be prepared for increase in pain when block wears off
According to a paper presented during the 2016 annual meeting of the Pediatric Orthopaedic Society of North America (POSNA), using a regional nerve block can reduce opioid use in children with supracondylar humerus (SCH) fractures who are treated with closed reduction and percutaneous pinning (CRPP). The Level 1 therapeutic study compared the impact of ultrasound-guided regional anesthesia (UGRA), specifically a supraclavicular nerve block, and postoperative intravenous (IV) opioids on a variety of outcomes.

Presenter Scott B. Rosenfeld, MD, of Texas Children's Hospital in Houston, Texas, noted that SCH fractures are the most common fracture requiring surgery in children. Although CRPP is a minimally invasive treatment, postoperative pain can delay discharge, increase anxiety, and decrease both patient and parent satisfaction. Using opioids to control the pain, however, may result in significant side effects, including nausea, vomiting, respiratory depression, and dysphoria.

"The goal of this IRB-approved, prospective, randomized, double-blinded trial was to compare postoperative pain scores and narcotic consumption in children with SCH fractures who received ultrasound-guided supraclavicular nerve blocks versus those who received IV opioids," explained Dr. Rosenfeld.

The study involved 111 children ages 3 to 17 years who were treated with CRPP for a SCH fracture under general anesthesia. Neurovascular compromise on the preoperative exam, allergies to anesthetics, bleeding diathesis, sleep apnea, an ASA (American Society of Anesthesiologists) status greater than 4, and treatment with open reduction were among the exclusion criteria.

Using student t-test, nonparametric tests, and chi-squared tests for statistical analysis, researchers assessed several outcomes, including the following:

• verbal pain scores
• FLACC (Face, Legs, Activity, Cry, and Consolability) pain scores
• PAED (Pediatric Anesthesia Emergence Delirium) scores at 15 and 30 minutes, as well as at 1, 2, 6, 12, 24, and 48 hours
• morphine-equivalent opioid consumption
• time to first analgesia request
• incidence of nausea, vomiting, itching, and respiratory depression
• time in recovery room

As shown in Table 1, both intraoperative opioid use and postoperative morphine use were significantly less in the nerve block group. In addition, the need for opioid rescue in the post-anesthesia care unit was significantly lower in the nerve block group, and children who received nerve blocks were ready for discharge in half the time of that required by children who received IV opioids.

"There was no difference between the groups in the incidence of nausea, vomiting, pruritus, or respiratory depression," noted Dr. Rosenfeld.

Nerve blocks were also effective in controlling pain. Pain scores were significantly lower in the nerve block group through the first 48 hours following the procedure. However, pain scores were significantly greater at 12 hours postoperative in the nerve block group than in the IV opioid group. This is presumably due to the block wearing off after discharge home.

"UGRA provided superior analgesia for CRPP of SCH fractures when compared to IV opioids," concluded Dr. Rosenfeld, "as evidenced by decreased opioid consumption, decreased pain scores, and decreased time to discharge. This option should be considered as an alternative to opioids in the perioperative management of children with SCH fractures.

"However, educating the family about the increase in pain after the block wears off is important. This will enable them to prepare properly and will reduce the impact of pain on patient and parent satisfaction," he concluded.

Dr. Rosenfeld's coauthors for "Ultrasound Guided Supraclavicular Nerve Block in Closed Reduction Percutaneous Pinning of Pediatric Supracondylar Humerus Fractures" are Chris Glover, MD; Yang Liu, MD; Kim P. Nguyen, MD; Nihar Patel, MD; Thomas Shaw, MD; Eduardo Medellin, BS; Jonathan A. Guzman, BA; Samantha Capehart, RN; Mehernoor F. Watcha, MD; and Henry Huang, MD.  

Bottom Line

• Pediatric patients with SCH fractures who undergo CRPP may experience significant postoperative pain.
• Use of opioids to control the pain, however, may result in unwanted side effects.
• This therapeutic study evaluated the impact of UGRA, specifically a supraclavicular nerve block, and postoperative IV opioids on postoperative pain scores and narcotic consumption in children with SCH fractures.
• The researchers found that UGRA was associated with decreased opioid consumption, pain scores, and time to discharge, compared to IV opioids.