PEDIATRIC REGIONAL ANESTHESIA NETWORK (PRAN)

Safety Data From PRAN: A review of two articles published in 2014

By Martha Pankovich, MD
Seattle Children’s Hospital
Seattle, WA

The Pediatric Regional Anesthesia Network (PRAN) is a multi-institutional project aiming to prospectively collect data on every regional anesthetic performed on children 0-18 years of age at participating centers.  It was developed in 2006 and since data collection began, over 80,000 blocks have now been performed.  One of the key intentions for collecting this data is to provide safety information about performing regional anesthesia in children1,2 as demonstrated by two articles published in 2014.

In the first article, Asleep Versus Awake: Does It Matter? Pediatric Regional Block Complications by Patient State: A Report From the Pediatric Regional Anesthesia Network3, the authors note that the anesthesia community remains divided as to the safety of performing regional anesthesia in patients under general anesthesia. I believe the authors may have finally put this concern to rest.  This paper analyzed PRAN data on more than 50,000 regional anesthetics.  They separated blocks by patient state at the time of block placement: awake (1.5% cases), sedated (4% cases), under General Anesthesia (GA) with neuromuscular blockade (NB) (19% cases), or GA without NB (75% cases).  They also looked at these categories by age group to see if age had any effect on the number of complications found, the state of the patient at the time of block placement and types of blocks performed in the different age groups.  The complications they specifically looked at were postoperative neurological symptoms (PONS) and local anesthetic systemic toxicity (LAST).  They also looked at cases in which a complication associated with a regional anesthetic led to an extended hospital stay.

The authors found that the incidence of complications was less than previously reported for children and for adults. The overall complication rate was 11.9/1000 (CI 11.0-12.8). PONS was observed in 70 cases, with the incidence under GA being 0.93/1000 (CI, 0.7-1.2) and in awake or sedated children, 6.82/1000 (CI, 0.4-0.92).  There were five cases of LAST, or 0.08/1000 (CI, 0.02-0.2) under GA and 0.34/1000 (CI, 0 – 1.9) in awake or sedated patients (CI, 0-1.9).  The authors noted 18 cases of extended hospital stay or 0.33/1000 (CI, 0.2-0.53) overall.

The numbers suggest it might be safer to perform regional anesthesia under GA.  However, the authors note several limitations when interpreting this data.  These include an uneven distribution of blocks in the different categories of state at time of block placement, the vast majority being done under GA, the PRAN institutions being all pediatric academic centers, and an uneven distribution of block types in different age groups with more neuraxial blocks in younger children and more peripheral nerve blocks in older children.  Finally, the majority of awake patients were either very young or older teenage children. 

The authors ultimately conclude that performing regional anesthesia in children under general anesthesia is a safe practice, as safe as or safer than performing regional anesthesia in awake or sedated patients, and should remain our standard of care for pediatric patients.

In a second article published by Taenzer et al, Interscalene Brachial Plexus Blocks under General Anesthesia in Children:  Is This Safe Practice,4 the authors look at another safety issue that has been a topic of discussion in recent years.  In 2008, a regional anesthesia practice advisory was published in Regional Anesthesia and Pain Medicine5 that upheld the safety of performing regional anesthesia in children under general anesthesia.  However, given expert opinion, they excluded the Interscalene block (ISB) based on limited evidence collected from several adult case reports of complications from ISBs performed in either heavily sedated patients or patients under GA. 

Taenzer et al queried the PRAN database to determine the incidence of complications associated with ISBs in children.  Between 2007 and May of 2013, a total of 518 ISBs were peformed, 390 under GA.  They found no cases of PONS, LAST or dural puncture (95% CI, 0-7.7/1000 under GA). This finding is interestingly comparable to rates of LAST or PONS with other blocks performed under GA in children.  The complications they did find with ISBs were one case of local infection and another case of vascular puncture.  Neither of these complications resulted in any long term sequelae.  The authors go on to site other published reports of ISBs in children that have also reported no serious complications.  The majority of serious complications from ISBs are noted in the adult literature.

The authors note several limitations to their study.  One is that the vast majority (88%) of the ISBs performed were in children 10 to 18 years old.  Another, which is common to research involving safety of regional anesthesia in children, is that small children, neonates and infants and children who are developmentally delayed, are unable to report any sensory deficits (while a motor deficit would likely be self-evident).  In addition to these limitations, the participating centers in PRAN are all academic pediatric institutions and it can be assumed that pediatric anesthesiologists with experience either supervise or perform these blocks.

One fact the authors mention that may limit overall safety data extracted from the PRAN database is that “PRAN does not have a structured follow-up process….beyond a routine follow-up in the first 72 hours after discharge.”  By not having a clear method for capturing complications, some might go undetected.  The authors do note, however, that should a serious complication occur such as PONS, it is more than likely that the patient would return to the institution and the complication would be noted.

Ultimately, the authors conclude that based upon available evidence, ISBs may be safely placed in children under GA, and that the complication rate is no higher than when performing other regional blocks.  They suggest that the advisory set forth by the American Society of Regional Anesthesia and Pain Medicine against this practice may need to be reevaluated.

REFERENCES

  1. Polaner DM, Martin LD; PRAN Investigators. Quality assurance and improvement: the Pediatric Regional Anesthesia Network.  Paediatr Anaesth. 2012 Jan;22(1):115-9.
  2. Polaner DM, Taenzer AH, Walker BJ, Bosenberg A, Krane EJ, Suresh S, Wolf C, Martin LD.,. Pediatric Regional Anesthesia Network (PRAN): A multi-institutional study of the use and incidence of complications of pediatric regional anesthesia. Anesth Analg. 2012 Dec;115(6):1353-64.
  3. Taenzer AH, Walker BJ, Bosenberg AT, Martin L, Suresh S, Polaner DM, Wolf C, Krane EJ., Asleep versus awake: does it matter?: Pediatric regional block complications by patient state: a report from the Pediatric Regional Anesthesia Network., Reg Anesth Pain Med. 2014 Jul-Aug;39(4):279-83.
  4. Taenzer A, Walker BJ, Bosenberg AT, Krane EJ, Martin LD, Polaner DM, Wolf C, Suresh S., Interscalene brachial plexus blocks under general anesthesia in children: is this safe practice?: A Report from the Pediatric Regional Anesthesia Network (PRAN).  Reg Anesth Pain Med. 2014 Nov-Dec;39(6):502-5.
  5. Bernards CM, Hadzic A, Suresh S, Neal JM. Regional anesthesia in anesthetized or heavily sedated patients. Reg Anesth Pain Med. 2008;33:449–460.

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