|Year : 2007 | Volume
| Issue : 3 | Page : 220-224
Role of regional anaesthesia in major limb operations in children with cerebral palsy
Vrushali C Ponde1, BD Athani2
1 MD, DA, All India Institute of physical medicine and rehabilitation centre, Haji Ali, Mumbai, Maharashtra, India
2 M.S (Ortho), DNB (Rehab), All India Institute of physical medicine and rehabilitation centre, Haji Ali, Mumbai, Maharashtra, India
|Date of Acceptance||18-Mar-2007|
|Date of Web Publication||20-Mar-2010|
Vrushali C Ponde
MD, DA, Amit Apartments, 401, Veronica road bandra west, Mumbai 400050
Source of Support: None, Conflict of Interest: None
There are several issues that influence the anaesthetic care of children with cerebral palsy such as seizures, spasticity, and sensitivity to pain medications, scoliosis, mental retardation, inability to communicate, respiratory infections, variable patterns of breathing, excessive drooling and other associated medical conditions. A series of 62 cases of cerebral palsy scheduled for limb deformity correction is described.
Midazolam 0.5mg.kg -1 was given orally half an hour prior to induction. Glycopyrrolate 0.02 mg.kg -1 IV was administered. Propofol 3 mg.kg -1 was given to facilitate LMA placement. They breathed nitrous oxide and oxygen spontaneously through the LMA. Subsequent to this, infusion of propofol 2 mg.kg -1 .min -1 was commenced. They received regional blocks such as continuous lumbar epidural for bilateral lower limb procedures, continuous sciatic& fascia iliaca compartment block for unilateral lower limb procedures and single shot infraclavicular block for upper limb, for below the elbow surgeries . Adequacy of the block was assessed by the necessity of any rescue analgesic, recovery was evaluated by Alderte score on table, and the time of first feed was noted. Postoperative analgesia was assessed by CHEOPS pain score.
Aldrete score was 8 (SD=0.7) by the end of plaster application. Additional drugs for the analgesia were not required in any of the patients. First oral feed was possible 1 ½ hr (SD=1.1) after the procedure. CHEOPS score of 4-6 (Satisfactory levels of analgesia) was achieved into the postoperative period by top ups.
Keywords: Cerebral palsy; Regional anaesthesia.
|How to cite this article:|
Ponde VC, Athani B D. Role of regional anaesthesia in major limb operations in children with cerebral palsy. Indian J Anaesth 2007;51:220-4
|How to cite this URL:|
Ponde VC, Athani B D. Role of regional anaesthesia in major limb operations in children with cerebral palsy. Indian J Anaesth [serial online] 2007 [cited 2019 Dec 16];51:220-4. Available from: http://www.ijaweb.org/text.asp?2007/51/3/220/61146
| Introduction|| |
Cerebral palsy (CP) is an umbrella diagnostic term used to describe a group of motor syndrome resulting from early brain damage. It covers a group of non-progressive, but often changing, motor impairment syndromes secondary to brain lesions or anomalies arising in early stages of development. The result is a fixed anatomical deficit that leads to a progressive deformity in a growing child  . Surgery is necessary to improve function, reestablish the balance of muscle forces through soft tissue releases and transfers.
Besides motor handicap, other problems associated with CP are mental retardation, seizures, ocular deficits, and hearing and speech problems leading to difficulty in communication and behavior problems. Moreover, quadriplegics have a tendency of respiratory infection, excessive drooling and gastro-esophageal reflux.
Taking into account all the associated problems and the need for postoperative pain relief regional techniques become an appropriate option.
The aim of this study was to assess the feasibility of regional blocks and sedation in CP children and to evaluate its impact on recovery and the postoperative pain control offered by these techniques.
We herewith present a data of 62 patients of cerebral palsy, aged 4 years to 14 years operated for various limb surgeries performed solely under the combination of sedation and regional anaesthesia.
| Methods|| |
Sixty two consecutive children with CP were selected. The patients were in the age group of 4 to 14 year belonging to ASA status 1 & 2, 14-28 kg in weight. Thirty nine of 62 cases had diplegia, 10 were quadriplegics 13 had cerebral hemiplegia. Forty eight children had mild to moderate mental retardation, 14 children had severe mental retardation. Forty six patients had seizures which were controlled with medications.
The single shot infraclavicular blocks were performed in supine position using the coracoid process as landmark, the upper arm being adducted to the trunk and the elbow flexed at 90 degree with the forearm placed on the abdomen. Following aseptic preparation, the coracoid process was palpated, then a 24-gauge 40 mm Braun needle connected to a peripheral nerve stimulator (inmed) was inserted in a vertical direction. Once a distal motor response like finger flexion, wrist movements was obtained at 0.5 mA, the site was aspirated to check whether any vessels had been inadvertently punctured, followed by injection of 0.25% bupivacaine 1 ml.kg -1 + ketamine (preservative free) 0.5mg.kg -1.
The continuous sciatic nerve block was performed by the loss of resistance method. 
The approximate duration of these procedures was 45 min to 120 minutes.
Patients were kept NPO, 6 hours for milk and solids and 2 hours for clear fluids .Premedication consisted of oral midazolam 0.5 mg.kg -1 given 25 - 30 minutes prior to surgery.
Venous access was secured, Ringer lactate was commenced. Glycopyrrolate 0.02mg.kg -1 IV was administered. Bolus dose of 3 mg.kg -1 of propofol followed by infusion of 2 mg.kg -1 .hour -1 was given. LMA (Proseal, Intravent) was inserted. They all breathed O2 and N2O through LMA. Routine intraoperative monitors were placed (pulseoximetry, NIBP, electrocardiography& end tidal carbon dioxide).
Infusion of propofol 2 mg.kg -1 .hr -1 was stopped at the end of the surgery, tramadol bolus of 0.5 mg.kg -1 was reserved as rescue analgesic for pain response. LMA was subsequently removed at the end of the surgery. After plaster application the children were shifted in the recovery area. Aldrete score [Table 7]  was recorded on the operating table and before shifting to the wards. In cases of single shot blocks diclofenac 2mg.kg -1 suppository was inserted. CHEOPS Score [Table 8]  was recorded in the wards at 1h, 6h, 12h, 18h, 24h, 30h, 36h, 42h and 48h. The catheters were removed after 48 hours.
| Results|| |
Demographic data is as shown in [Table 1] and [Table 2]. [Table 3] gives the details of the number of surgeries and the respective regional technique used. Drugs and dosages for each block and their respective top ups in the postoperative period are given in [Table 4].
There were 62 children of 4 year to 14 year (mean + SD =8 + 0.2) of age .Their weight ranged from 14-28 kg (mean + SD = 19+ 1.1). The duration of surgery varied from 40 minutes to 140minutes (mean + SD =110 + 1.2).
One of 62 children with cerebral quadriplegia had laryngospasm after removal of LMA, which was managed by CPAP and relieved spontaneously. One of the CP diploid children with continuous lumbar epidural block developed urinary retention and had to be catheterised.
[Table 5] and [Table 6] represent the CHEOPS pain score in child with continuous lumbar epidural blocks and continuous sciatic blocks respectively. Additional drugs for the analgesia were not required in any of the children. Aldrete score was 8 (SD=0.7) on table by the end of plaster application and 10(SD=1.2) while shifting to the wards. First oral feed with clear liquid was possible in all children at 1 ½ hr (SD=1.1) after the procedure.
| Discussion|| |
Cerebral palsy is a term, which covers a group of non-progressive but often changing motor impairment syndromes secondary to lesions of brain in the early phases of development.
Our institute is a rehabilitation center mainly dealing with surgical procedures, which improve function, reestablish the balance of muscle forces through soft tissue releases and transfers. These are promptly followed by postoperative physiotherapy. It is imperative to keep these children pain free in the immediate postoperative period due to their inherent tendency towards spasticity which can be exaggerated due to pain.
Besides orthopaedic surgery we have a multidisciplinary team comprising of paediatrician, physiotherapist, occupational therapist and clinical psychologist. The clinical psychologist helps with management of behavior problems using behavior modification techniques, psychotherapy, family counseling etc.
The prevalence of cerebral palsy varies from 1.5 to 2.5 per 1000 live birth. Exact incidence and prevalence figures from our country are not available  Induction is challenging due to several factors such as communication difficulties compounded by lack of cooperation. Obtaining an intravenous access is thus difficult, presence of a primary care taker is helpful while securing a vein especially in mentally retarded children. Gaseous induction can be messy due to high incidence of drooling, especially in severely affected individuals. In view of gastroesophageal reflux gaseous induction can also be risky. Preoperative history of night awakening may indicate reflux or esophageal spasms.
Poranee et al  have described a study in which they have evaluated that the cerebral palsy patients do need a lower dosage of propofol for induction than normal children using bispectral index (BIS) monitoring criteria. However these authors have not used regional techniques.
The main purpose of our study was to evaluate the feasibility of regional techniques and sedation in children with cerebral palsy, its impact on recovery and the postoperative pain control offered by these techniques.
Regional blocks formed the mainstay of our anaesthesia management as the surgery was carried out under propofol infusion of 2mg.kg -1 .hr -1 which is a sedative dose 7 and far below than required for maintenance of general anaesthesia viz 7.5 to 12 mg.kg -1 .hr -1 . , The use of a narcotic analgesic was not necessary.
Nolan et al , have highlighted the use of epidural analgesia in these patients and have mentioned that it is particularly valuable when major orthopaedic procedures are performed. Though they have not used other regional techniques such as in our case series.
In the post operative period top ups were given 4 - 6 hourly [Table 4] for 48 hours. CHEOPS ,, score of 4-6 (pain free state) as represented in [Table 5] and [Table 6] could be achieved in most of them.
In mild to moderate mental retardation the assessment of pain score did not pose a big problem.
Out of 62 children 14 were severely mentally retarded. It was practically almost impossible to assess pain scale in the postoperative period in these children because of intellectual disability and poor verbal communication. More over behavioral patterns such as groaning and moaning may not necessarily arise because of pain  . Here a primary care taker who understood the responses, was of help in assessing pain. They do form an indispensable asset in the postoperative pain management for children specially in the case of non verbal, non communicative children. Our top ups in these cases hence were also guided by the opinion of the primary care taker who was usually the mother. Children were discharged on the third postoperative day.
The most important advantage, that we wish to highlight with this technique is an awake and pain free child at the end of the surgery. Children were fully awake, able to breathe deeply& cough freely before shifting to the recovery room. They were ready to be shifted to the wards on OR table itself .This is an ideal scenario for any set up where the number of cases is large and the turnover is rapid.
One limitation of this study that we wish to highlight is the intermittent nature of the postoperative boluses. Continuous infusion perhaps would have avoided a pain score of more than 4-6 by providing a continuous basal analgesia level.
Total avoidance of narcotics and muscle relaxants, an awake and pain free child at the end of the surgery is a more than favorable picture especially in our setup.
To conclude, regional techniques hence form an important tool in management of perioperative pain in children with cerebral palsy .Regional techniques can form the mainstay of anaesthesia management and postoperative pain relief in children with cerebral palsy. The combination of regional blocks and sedation has a favorable impact on the recovery as the oral feeds can be given as early as 1½-2 hours. In children with severe mental retardation it is almost impossible to gauge analgesia. The primary care taker is definitely an asset in understanding their responses and behavior.
| References|| |
|1.||Mutch I, Alberman E, Hager B, et al. Cerebral palsy epidemiology:where are we now and where we are going? Dev Med Child Neurol 1992; 34:547-555. |
|2.||L. Vas. Continuous sciatic block for leg and foot surgery. Paediatric Ana0esthesia 2005; 15 : 971-978. |
|3.||Aldrete J A, Kroulik D A. Post anaesthetic recoveryscore. Anesth Analg 1970 ; 9:924-928 |
|4.||Johnson G, Goodman G J, et al. A behavioral scale to measure postoperative pain in children. In : Advances in the Pain Research& therapy . New York Raven Press 1985 ;395. |
|5.||IAP text book of pediatrics, chapter 18.2 P.D Singh, Page 598 |
|6.||Poranee Wgprasartsuk, John Stevens.Cerebral palsy and anaesthesia. Paediatric Anaesthesia 2002;12: 296-303. |
|7.||Peter .D. Booker Intravenous Anaesthetics Chapter 14 page 246-247, Pediatric Anaesthesia, Principles and practice Bruno Bissonnette and Bernarld Dalens 2002. |
|8.||Norreslet J, Wahlgreen. Propofol infusion for sedation of children. Crit Care Med 1990 ; 18 :890-2. |
|9.||J.Nolan, G. A. Chalkiadis, J.Low, C.A.Olesch and T.C.K Brown. Anaesthesia and Pain management in cerebral palsy. Anaesthesia 2000; 55: 32-41. |
|10.||Batra YK. Intraoperative small dose Ketamine does not reduce pain or analgesic consumption during perioperative opioids analgesics in children after tonsillectomy.Int J Pharmacol Ther 2007;45:155-60. |
|11.||Klein EJ. A randomized clinical trial of oral midazolam versus oral midazolam plus transmucosal fentanyl for sedation during laceration repair. Pediatrics 2002; 109: 894-7. |
|12.||Issac LA. A pilot study of the rectus sheath block for pain control after umbilical hernia repair. Paediatr Anaesth 2006;16: 406-9. |
[Table 7], [Table 8], [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]