Approaching trauma analgesia using prolonged and novel continuous peripheral nerve blocks - A case report -

Background A supraclavicular brachial plexus nerve block provides analgesia for the shoulder, arm, and hand; however, the maximum safe duration for a continuous infusion remains controversial. A novel continuous peripheral nerve block (CPNB) technique combining the Lateral, Intermediate, and Medial femoral cutaneous nerves (termed the ‘LIM’ block) to provide analgesia to the lateral, anterior, and medial cutaneous areas of the thigh while preserving quadriceps strength will also be described in detail here. CaseWe present a complex case in which simultaneous utilization of an unilateral supraclavicular CPNB (5 weeks) and bilateral LIM CPNB (5 days) are successfully performed to provide analgesia for a traumatic degloving injury resulting in multiple surgeries.Conclusions The analgesic plan in this case study eliminated previous episodes of opioid-induced delirium, facilitated participation in recovery, and removed concerns for respiratory depression and chronic opioid use in a patient at particular risk for both issues.

DOES A CONTINUOUS PERIPHERAL NERVE BLOCK REDUCE HOME OPIOID USE IN CHILDREN AND ADOLESCENTS FOLLOWING ANTERIOR CRUCIATE LIGAMENT RECONSTRUCTION? THE ENVELOPE PLEASE.

Background: Anterior cruciate ligament reconstruction (ACLR) is commonly performed in youth athletes. Opioid misuse and addiction have reached alarming proportions. Purpose: To evaluate whether a continuous peripheral nerve block (CPNB) with placement of an elastomeric reservoir ball would decrease the need for home opioid analgesia when compared to a single-shot peripheral nerve block (SPNB) following ACLR in children and adolescents. Methods: A continuous cohort was analyzed via retrospective review of prospectively collected data following ACLR by a single surgeon. Group 1 had ACLR at our in-patient hospital and received a 72-hour CPNB. Group 2 had ACLR at our outpatient surgery centers and received a SPNB. Post-operative pain management included cryotherapy, oral acetaminophen and ibuprofen. A prescription for 10 doses of hydrocodone/acetaminophen (5/325mg) was provided in a sealed envelope with instructions to only be used for uncontrolled pain. On a three-day written log all children recorded their post-op Visual Analog Scale (VAS), amount of ibuprofen, acetaminophen and hydrocodone taken. Those reporting no narcotics needed to provide the unopened envelope and unfilled prescription. Hydrocodone utilization was converted to morphine milligram equivalents (MME). 1 mg hydrocodone = 1 MME. A state Controlled Substance Utilization Review and Evaluation System (CURES) inquiry was made on all participants in the peri-operative period. Demographic and operative data were collected. This study was powered to detect a difference of 20% in rate of narcotic consumption, should one exist, at beta=0.80, alpha<0.05. All analyses were performed using SPSS v. 26 with alpha set at p<0.05 to declare significance. Results: One hundred ninety-six patients were included in the study with an average age of 15 years (range 10-19y). 58 (30%) took hydrocodone/acetaminophen post ACLR, 39 female (67.2%) 19 male (32.8%). The CPNB group consumed 4.7 MME 95 % Confidence Interval (CI) 2.5-6.9 vs 6.5 MME 95 % CI 4.3-8.7 in the SPNB group (p=0.427) There were no significant differences in demographics, operative data or VAS scores. (Table). Conclusion: Home narcotic use can be negated in 70% of children and adolescents following ACLR regardless of duration of peripheral nerve block. In those requiring narcotics, the average utilization was only 1.3 pills of hydrocodone/acetaminophen with no child using more than 10 pills. The MME can be diminished with a CPNB however not significant enough to recommend routine use. We postulate the sealed envelope was as a barrier and psychological deterrent to filling the opioid prescription. [Table: see text]