Pain and Regional Anesthesia

Background: Recurrent complex regional pain syndrome I is not rare in the pediatric population. The authors conducted this study to evaluate the efficacy of continuous peripheral nerve blocks with elastomeric disposable pumps associated with initial Bier blocks for the treatment of recurrent complex regional pain syndrome I in children. Methods: After parental informed consent, 13 children who did not respond to conventional complex regional pain syndrome treatment were included (mean age, 13 yr; range, 9– 16 yr). After general anesthesia, peripheral nerve block was performed using 0.5 ml/kg lidocaine, 1%, with epinephrine and 0.5% ropivacaine injected in the peripheral nerve block catheter. Then, a 20-min Bier block was performed using a tourniquet and 0.2 ml/kg lidocaine, 1%; 3 ml/kg hydroxyethyl starch 130/06; and 5 mg/kg buflomedil injected intravenously. A solution of 0.1 ml · kg 1 · h 1 continuous ropivacaine, 0.2%, was infused through the catheter using an elastomeric pump for 96 h. Need for rescue analgesia, occurrence of side effects, and status of motor and sensory block were recorded at hours 1, 6, 12, 24, 48, 72, and 96. Children and parents completed a satisfaction assessment. All of the children had follow-up visits after 2 months. Results: Postoperative analgesia was excellent. The median pain score was 0 for each period studied. Motor blockade was minimal before 12 h (median, 1) and absent thereafter. One child needed rescue analgesia. All children were able to walk easily after the initial 24-h period (walking score, > 4). Children and parents were all satisfied. Children returned home under parental surveillance beginning in the 24th hour. Neither peripheral nerve block nor Bier block caused side effects. After 2 months, none of the children exhibited any clinical symptom of recurrent complex regional pain syndrome. Conclusion: Ambulatory continuous peripheral nerve block associated with an initial Bier block seems to be a significant and novel contribution to treat recurrent pediatric complex regional pain syndrome I. It allows complete pain relief, early mobilization, and rapid return home, representing a psychological advantage for these children. COMPLEX regional pain syndrome (CRPS) type I is defined as a painful, disabling syndrome accompanied by edema and sudomotor and vasomotor dysfunction. Various treatments in adults have been reported, but no technique has shown superiority for treating or preventing CRPS I. The reported methods include physical therapy, behavioral measures, and use of antidepressants, anticonvulsants, or transcutaneous electrical nerve stimulation. Other authors have proposed regional anesthesia with intravenous local anesthetics, guanethidine, reserpine, bretylium, nonsteroidal antiinflammatory drugs, droperidol or calcium-regulating drugs, or blockade of sympathetic activity by epidural analgesia or peripheral nerve blocks. Complex regional pain syndrome type I has also been described in a pediatric population. The pathophysiology of CRPS I is not clear. A treatment using Bier block with local anesthetics, physical therapy, and cognitive– behavioral treatment should be recommended. Unfortunately, recurrent episodes have been reported in 50% of children. The median time to recurrence was 2 months with physical therapy alone. One of the key elements of CRPS I treatment is intense physiotherapy. Intense exercise therapy has been proposed for initial treatment of childhood CRPS I, but this treatment is very painful. The use of ambulatory continuous peripheral nerve blocks (CPNBs) to alleviate pain, allow intense physiotherapy, and treat CRPS I has not been prospectively studied in children with this syndrome. Ambulatory elastomeric or electronic pumps have been often used at home for the postoperative period after orthopedic surgery in adults. The use of such devices to restore optimal autonomy in children has recently been demonstrated in the postoperative period. The aim of the current study was to evaluate the feasibility and efficacy of CPNB at home by means of disposable elastomeric pumps associated with an initial Bier block in the treatment of recurrent CRPS I in children.