title: Regional anesthesia approaches to pain management in pediatric palliative care: a review of current knowledge.
abstract: BACKGROUND
  Although systemic analgesic therapies are the mainstay of pain treatment in pediatric palliative care, there are cases where they fail to adequately relieve symptoms or produce side effects that undermine effectiveness. Regional anesthesia may be considered as a potential therapy for these patients.
  
  
  OBJECTIVE
  To review the literature on regional techniques in pediatric patients with life-limiting and chronic conditions, including pain from tumor infiltration, chest pain in advanced pulmonary disease, chronic abdominal pain, phantom limb pain, and spasticity and dystonia. Where relevant, the authors' clinical experiences are included.
  
  
  METHODS
  References were identified by searches of PubMed from 1980 until June 2012 with related terms.
  
  
  RESULTS
  Case reports and case series were identified for each condition. Regional anesthesia techniques performed included central neuraxial infusions, peripheral nerve and plexus blocks or infusions, neurolytic blocks, and implanted intrathecal ports and pumps for baclofen, opioids, local anesthetics, and other adjuvants. The reports described positive contributions to the management of moderate-to-severe pain. Clinical context for these techniques frequently included the failure of systemic treatments and/or intolerable medication side effects. Complications varied according to the procedure and the underlying patient pathology; however, these risks were often acceptable when the potential benefits were consistent with the overall goals of care.
  
  
  CONCLUSIONS
  The present medical literature on regional anesthesia techniques in children receiving palliative care is limited to case reports and case series. Based on this evidence, recommendations must be provisional. Careful thought and discussion with pain management specialists are encouraged when pain symptoms are inadequately managed or the treatments produce deleterious side effects.
authors.affiliation: Harvard Medical School, Boston, Massachusetts, USA.
authors.forename: Jillian F
authors.initials: JF
authors.lastname: Rork
authors.forename: Charles B
authors.initials: CB
authors.lastname: Berde
authors.forename: Richard D
authors.initials: RD
authors.lastname: Goldstein
mesh_terms: D000765:Anesthesia, Conduction / Q000379:methods*; D000779:Anesthetics, Local / Q000627:therapeutic use*; D002648:Child; D006801:Humans; D009407:Nerve Block / Q000379:methods*; D010146:Pain / Q000451:nursing / Q000517:prevention & control*; D059408:Pain Management / Q000379:methods*; D010166:Palliative Care / Q000379:methods*; D010372:Pediatrics / Q000379:methods*; D016896:Treatment Outcome
chemical_list: D000779:Anesthetics, Local
keywords: Palliative care; adolescent; child; nerve block; neuraxial blockade; pain management; regional anesthesia