Nigerian Journal of Paediatrics

8Usefulness of peripheral nerve block as an aneasthetic technique in a critically ill Child A case report

Niger J Paediatr 2017; 44 (1): 39 – 41

CASE REPORT

Fatungase OM

Usefulness of peripheral nerve block

Ogundipe AA

Adebanjo AA

as an aneasthetic technique in a criti-

cally ill Child – A case report

DOI:http://dx.doi.org/10.4314/njp.v44i1.8

Accepted: 6th December 2016

Abstract : Regional anaesthesia in

regional anaesthesia. This case is

children is a growing field of in-

reported to highlight the prospect

Fatungase OM

(

)

terest in current anaesthesia prac-

of regional anaesthesia for criti-

Ogundipe AA

tice. We report a case of brachial

cally ill children who require sur-

Department of Anaesthesia,

Olabisi Onabanjo University,

plexus block for a child with se-

gical interventions in resource-

Email: mamafat40@gmail.com

vere forearm necrotizing fasciitis

poor settings.

and septicaemia. The need to

Adebanjo AA

avoid the multiple shortcomings

Keywords: brachial plexus block,

Department of surgery,

of general anaesthesia in a criti-

children, critical illness, septicae-

Olabisi Onabanjo University,

cally ill child prompted the use of

mia, regional anaesthesia

Ago-iwoye.

Introduction

in a sick child who is not suitable for general anaesthe-

sia.

The growing use of regional anaesthesia in infants, chil-

dren and adolescents has increased the popularity of

Case report

peripheral nerve blocks (PNB) in children. PNB is a

Presentation, admission and treatment

form of regional anaesthesia which is accomplished by

injecting a local anaesthetic near a nerve/nerves that

A 9 year old presented in the children emergency ward

controls sensation and movement to a specific part of

of Olabisi Onabanjo University Teaching Hospital, Sa-

the body. This causes temporary numbness in the area.

gamu, Nigeria on referral from a private hospital where

The growing use of the technique is a result of the in-

he had presented with a 6 day history of fever, body

creased confidence of anaesthetists in performing pe-

pains and general malaise. He was admitted at the pri-

ripheral nerve blocks. PNB are typically used for surger-

vate hospital and given intravenous medications through

ies of the upper and lower extremities, also for some

the dorsum of the left arm. After three days the left arm

procedures around the neck and groin.

subsequently became swollen, tender with limitations of

Peripheral regional anaesthesia is of great utility in chil-

active movements, with blister formation. These, cou-

dren undergoing surgeries of the upper extremities. In

pled with the persistence of the symptoms necessitated

contrast to general anaesthesia, it avoids airway instru-

his referral to the teaching hospital.

mentation and the use of many drugs. The peculiarities

of this technique include the meticulous attention to dos-

On admission he was acutely ill looking, pale and febrile

ing as a result of the poor development of connective

(39ºC). He was in respiratory distress, tachypneic,

tissues and the likelihood of extensive spread of locally

tachycardic with a tender hepatomegaly. The left arm

administered drugs. Other important considerations in-

was swollen, tender with coalescing blisters, necrotic

clude the risk of rapid absorption with attendant sys-

eschar and copious purulent exudates. The packed cell

temic toxicity, reduced duration of action and age-

volume was 15% and chest x-ray showed evidence of

related anatomic variations.

pulmonary oedema. generalized widespread fluffy exu-

dates. A diagnosis of septicaemia with focus in necrotiz-

The use of ultrasound guidance during axillary approach

ing fasciitis of the left upper limb, severe anaemia and

to brachial plexus blockade allows for real-time visuali-

congestive cardiac failure was made. He was resusci-

zaion of anatomical structures; however some anaesthe-

tated, commenced on parenteral antibiotics, diuretics,

tists prefer nerve stimulation to guide peripheral block-

digitalis and blood transfusion. Bacteriological culture

ade, while some use both methods for greater accuracy

of pus aspirate yielded Proteus sp. He was planned for

and safety. However, the use of ultrasound scan and / or

extensive wound debridement three days after admission

peripheral nerve stimulator is subject to availability. Our

to remove focus of sepsis.

centre does not have the capacity for either. Complica-

tions of axillary approach include infection at the punc-

Pre-anaesthesia Review

ture site, axillary tenderness, heamatoma, intravascular

injection and nerve damage . This case report is to enu-

1,2

When he was reviewed on the morning of surgery he

merate the prospects of blind axillary approach to pe-

was still having temperature spikes despite intravenous

ripheral brachial nerve block, in a low-resource setting,

antibiotics. Urinary output was adequate. There were no

known allergies. He had been on nil per oris for 12

hours. He was mildly pale and weighed 28kg which was

Fig 3: Blockage of the

appropriate for age. The respiratory and heart rates,

musculo-cutaneous

blood pressure and precordial activities were normal.

nerve.

Airway assessment for ease of intubation and mask ven-

tilation showed no abnormality. He had Mallampati 2

class with adequate mouth opening.

Abdominal examination revealed minimal ascites and

hepatomegaly of 4cm below costal margin. The left el-

bow was in gauze and bandaged dressing. The initial

laboratory findings included PCV 30%, negative retrovi-

ral screening, normal haemoglobin genotype and INR of

The debridement lasted 15minutes, with an estimated

1.0.

blood loss of 50mls. He had 100mls of 4.3% dextrose in

Assessment was resolving septicaemia, resolving con-

5th saline. The pulse rate ranged between 120 and 135

gestive cardiac failure. An American Society of Anaes-

beat per minutes during the procedure. There were no

thesiologist (ASA) physical status class assessment of

critical incidences or complications intra-operatively

IIIE was made.

Post operatively the arm was put in a POP back slab for

The mother consented to the use of peripheral nerve

support, and patient was transferred to the recovery

block with sedation following adequate patient informa-

room and later back to the ward. He made full recovery

tion.

and was discharged a month later.

Procedure In theatre

The child was placed supine. Pulse oximeter and pre-

Discussion

cordial stethoscope and Non- Invasive Blood Pressure

(NIBP) measurement apparatus were attached. Baseline

Although the clinical diagnosis of septicaemia was bac-

parameters were; PR 107bpm, Bp 106/67mmHg, SpO2

teriologically confirmed, it was unresolved whether cel-

was 97% at room air.

lulitis of the arm resulted to septicaemia or the reverse

He was pre-medicated with IV hydrocortisone 100mg,

occurred. The cellulitis could also have been due to drug

sedated with IV 2.5mg midazolam with IV Paracetamol

-induced tissue injury with subsequent bacterial coloni-

50mg for analgesia. The injectate for the nerve block

zation. However the removal of pus and eschar in this

patient was essential for infection control. Anaesthetists

was made by mixing 5mls of 0.5% plain bupivacaine,

plus 10mls of lignocaine in adrenaline and 10mls of

are involved in the care of septic patients for resuscita-

sterile water.

tion, intensive care and anaesthesia for infection source

A 22G hypodermic needle, first made blunt by passing it

control. The latter includes drainage of abscess, debride-

through the sterile plastic sheath, was used for the axil-

ment of necrotic tissue, removal of infected devices and

lary block. The patient’s arm was abducted to 90 de-

foreign bodies. The anaesthesia of septicaemic patient

grees (Fig 1) and the palpation method was used to iden-

for infection source control poses some challenges be-

tify the axillary artery. Skin infiltration was done with

cause of the gross heamodynamic instability and these

plain lidocaine. Test aspirate was done and 20mls of the

risks are higher in children.

injectate was used for the axillary block and 5mls for the

blockage of the musculocutanoeus nerve (Fig 2 and 3).

The available anaesthetic technique options include gen-

Efficacy was confirmed with loss of pain to surgical

eral anaesthesia or a brachial plexus block. The advan-

stimulation after 10 minutes. Supplemental 100% oxy-

tages of the use of regional anaesthesia as opposed to

gen was administered by face mask at 6l/minute flow

general anaesthesia include avoidance of the airway,

rate.

reduced postoperative nausea and vomiting, improved

tissue perfusion during re-implantations and the ability

Fig 1: Palpation method

to provide a continuous technique for repeated proce-

dures, and early hospital discharge. Brachial plexus

of locating the axillary

artery prior to anaesthes-

block was chosen in this case because a full general an-

tic infiltration

aesthesia will lead to administration of anaesthetic

agents that may further depress the myocardium thus

worsening the heart failure. It is also important to avoid

the airway and the chest due to the accompanying pul-

monary oedema. Peripheral nerve blocks in septic pa-

tients cause less haemodynamic instability and less im-

munosuppression but also carry the risk of nerve dam-

Fig 2: Injection of local

age, allergic reaction, intravascular injection and risk of

anaesthetic into the axil-

toxicity. The index case had none of these complica-

lary sheath

tions.

Various approaches can be used for the brachial plexus

block; interscalene, supraclavicular, infraclavicular and

axillary approaches. Axillary approach is the common-

nes and short acting opioids are useful in this regard.

est, easiest and safest approach in all age groups espe-

Midazolam, a short acting benzodiazepine was used in

cially if it is done under the palpation method alone.

1,2,5

the index case. It provided sedation, hypnosis and an-

The continuous axillary block variant involves inserting

terograde amnesia without compromising the airway or

a peripheral block catheter in the perineural space for

the cardiovascular status of the patient. Paracetamol was

intermittent injections of the local anaesthetic solutions.

used for pre-emptive analgesia after the effect of the

This improves outcomes after microvascular sur-

nerve block must have worn off. This also avoided the

gery. Another safe method is the lateral infraclavicular

respiratory depressant effect of opioids.

approach which reduces the risk of pneumothorax . The

latter method is new in children, but gives a wider de-

gree of blockage, and can be done with the patient’s arm

at the sides thus minimizing pain. Both can be made

Conclusion

safer and easier with the use of peripheral nerve stimula-

tor and / or ultrasound scan.

6,7.

Unfortunately, in low

The case highlights the usefulness of peripheral nerve

resource centres where peripheral nerve stimulator and

block, in a septic peadiatric patient undergoing infection

an ultrasound are not routinely available, the blind tech-

source control surgery. It is a viable option to consider

nique by palpation becomes extremely useful and handy.

when the patient is unstable for general anaesthesia. It is

safe, cost friendly and effective.

There are no published studies comparing general anaes-

thesia to upper limb regional anaestheisa . There are also

none comparing general anaesthesia with or without

Conflict of interest: None

upper limb blockade. Performing a nerve block in chil-

Funding: None

dren usually requires the use of sedation. Benzodiazepi-

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