Friday February 23, 1996

IV anesthesia preferred treatment for pediatric fractures

Using intravenous regional anesthesia to treat extremity fractures in children is preferable to other methods because it is safe, easy, and convenient according to scientific paper 15 presented Thursday.

Of the 470 consecutive emergency room cases studied, 467 were effectively treated using intravenous regional anesthesia, said R. Dale Blasier, MD, director of pediatric orthopaedic traumatology at Arkansas Children's Hospital, Little Rock. The children in the study were ages two to 19 years, with the mean age being 9.4 years.

"Although intravenous regional anesthesia is commonly used in the treatment of adult extremity fractures, it is not often used in as an anesthetic for children in an outpatient setting," said Dr. Blasier.

The procedure involves using a pneumatic tourniquet that is applied to the child's extremity and that is inflated to 200 to 250 mmHg pressure. The child is then given 0.5 percent lidocaine intravenously at 3 to 5 milligrams per kilogram of weight, rather than basing the medication dosage on age. During the procedure the child is monitored visually and by EKG. After fracture reduction, radiographs are taken so, if necessary, a repeat reduction maneuver can take place under the same anesthetic.

A splint or cast is applied, and the tourniquet is slowly released in a "cycled" manner, being deflated then reinflated for a few seconds to prevent a large dose of lidocaine from entering the systemic circulation all at once. Following the tourniquet release, the patient is closely monitored for about five minutes before being discharged a half hour later. Fracture follow-up occurs in the outpatient clinic in one week.

Eighty-one percent of the patients had their fractures reduced to an acceptable position in one attempt; 66 percent, two attempts; and 4 percent in three attempts. Only one patient had to have the reduction attempted four times before it was successful. Three patients could not have an intravenous regional anesthetic, due to the inability to access a vein in the injured limb. Nine patients had to be taken to the operating room for further treatment. "However," said Dr. Blasier, "none of these failed reductions were believed to be secondary to inadequate anesthesia."

In addition, he said, no adverse effects, such as hypotension, tachycardia, seizure, or arrhythmia were noted from the injection of lidocaine or tourniquet release.

A few previous studies have described the use of intravenous regional anesthesia in children for treatment of extremity fractures, said Dr. Blasier, who said his results were comparable because there was no failure of reduction secondary to inadequate anesthesia and no complications.

"We do recommend the tourniquet remain elevated for at least 30 minutes, where other studies have averaged 15 to 20 minutes," said Dr. Blasier. "This allows extra time for the lidocaine to fix to the tissues before cuff deflation and we use this time to apply plaster and obtain radiographs. Also, we release the cuff in cycles, reinflating within seconds after first deflating the tourniquet, and we believe this staged release also may decrease the risk of complications."

Co-author of the paper with Dr. Blasier is Rosalind White, RN, orthopaedic specialty nurse, department of orthopaedics, Arkansas Children's Hospital.

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