Paravertebral nerve block catheters using chloroprocaine in infants with prolonged mechanical ventilation for treatment of long-gap esophageal atresia.
BACKGROUND
Infants with long-gap esophageal atresia (LGEA) undergo repeated thoracotomies for staged surgical repair known as the Foker process (FP). Associated prolonged mechanical ventilation results in exposure to high doses of opioids and benzodiazepines, and prolonged weaning times and ICU stays.


OBJECTIVE
The aim of this study was to determine the effectiveness of short-term paravertebral nerve block (PVNB) catheters in reducing opioid/benzodiazepine exposure and effects on clinical variables.


METHODS
The medical records of seventeen infants were retrospectively reviewed; 11 with PVNB and six without (CG). PVNB were placed using ultrasound-guidance and chloroprocaine infusions implemented in the ICU. Opioids and benzodiazepines were administered via the protocol for 5 days following thoracotomies for Foker-I and Foker-II.


RESULTS
Foker-I: Average reduction in morphine and midazolam consumption was 36% (2.18 vs 3.40 mg·kg(-1) ·day(-1) ; P < 0.001) and 31% (2.25 vs 3.25 mg·kg(-1) ·day(-1) ; P = 0.033), respectively, in the PVNB compared with CG. Foker-II: Average reduction in morphine and midazolam consumption was 39% (3.19 vs 5.27 mg·kg(-1) ·day(-1) ) and 38% (3.46 mg·kg(-1) ·day(-1) vs 5.62; P < 0.001), respectively in the PVNB compared with CG. 24-h prior to extubation: Average reduction in morphine and midazolam consumption was 50% (2.91 vs 5.85 mg·kg(-1) ·24 h(-1) ; p = 0.023) and 61% (2.27 vs 5.83 mg·kg(-1) ·24 h(-1) ; P = 0.004), respectively, in the PVNB compared with CG. Infusion wean time, (independence from opioid/midazolam infusions) following extubation was 5 days in the PVNB group and 15 days in CG (P = 0.005). Median ICU stay (IQR) was 40 days (34-45 days) in PVNB patients and 71 days (42-106 days) in controls (P = 0.02). PVNB catheters were left an average of 7 days and there were no complications associated with the nerve blocks.


CONCLUSIONS
Short-term PVNB placement decreases opioid and benzodiazepine exposure, weaning days and ICU stay in infants undergoing prolonged mechanical ventilation for LGEA repair in this small pilot study. Larger studies are warranted to confirm results.
Department of Pediatric Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA.
Sigrid
http://orcid.org/0000-0001-9741-6130
S
Bairdain
Department of Pharmacy, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA.
Brenda
B
Dodson
Department of Pediatric Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA.|Department of Anesthesia, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA.
David
D
Zurakowski
Department of Anesthesia, Perioperative and Pain Medicine, Division of Critical Care Medicine, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA.
David B
DB
Waisel
Department of Pediatric Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA.
Russell W
RW
Jennings
Department of Anesthesia, Perioperative and Pain Medicine, Division of Critical Care Medicine, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA.
Karen R
KR
Boretsky
D000701:Analgesics, Opioid; D000779:Anesthetics, Local / Q000008:administration & dosage; D001569:Benzodiazepines; D057785:Catheters; D004933:Esophageal Atresia / Q000601:surgery*; D005260:Female; D006801:Humans; D007223:Infant; D007902:Length of Stay / Q000706:statistics & numerical data; D008297:Male; D009407:Nerve Block / Q000295:instrumentation* / Q000379:methods*; D011343:Procaine / Q000008:administration & dosage / Q000031:analogs & derivatives*; D012121:Respiration, Artificial / Q000706:statistics & numerical data*; D012189:Retrospective Studies; D013908:Thoracotomy; D016896:Treatment Outcome; D018084:Ultrasonography, Interventional
D000701:Analgesics, Opioid; D000779:Anesthetics, Local; D001569:Benzodiazepines; D011343:Procaine; C004616:chloroprocaine
infants; long-gap esophageal atresia; pain; paravertebral nerve block; regional anesthesia