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The updated regional time out: Now is the time to add neuromuscular blockade to the checklist
Session: MP-05a
Fri, Nov. 17, 8:00-10:00 am
Hampton Room

Please note, medically challenging cases are removed three months after the meeting and scientific abstracts after three years.

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Introduction:

•Historically, regional blocks in pediatric anesthesia have proven efficacy and safety records, often being performed under general anesthesia with and without neuromuscular blockade (NMB). In this way, pediatric regional anesthesia is different from adult regional anesthesia as many nerve blocks are done under general anesthesia. [1, 2]
•It has been reported that pediatric institutions across the country have implemented a time out with a check list prior to regional anesthesia. [3]
•Both Seattle Children’s Hospital and Children’s Hospital Colorado have checklists in place. Despite a checklist in place, it is important to recognize errors may still occur and thus may necessitate modifications. We believe after reviewing two cases from high volume pediatric institutions, that it is important to consider adding NMB into the time out checklist.  This information is essential in situations in which the provider performing the block may elect to use nerve stimulation to aid in successful block placement.  
 

Material and Methods:

•Two cases involving regional anesthesia at two pediatric academic centers were discussed amongst colleagues. The use of NMB during or prior to regional anesthesia was not discussed as part of the time out.  Both cases involved lumbar plexus blocks.  Neither center incorporated NMB in their time out. However, they do report in their electronic medical record if NMB was used during the block.
•Both cases presented were covered by the global consent done prior to surgery at these academic institutions.

Case Report 1:

•A 16 year old male presented to the operating room for limb lengthening surgery, and the desire was to perform a lumbar plexus block with infusion catheter placement. 
•BMI was 40.
•After induction of anesthesia, an endotracheal tube was placed, facilitated by the use of rocuronium.
•The regional team was not in the room when rocuronium was administered.
•The full timeout, including regional timeout, was performed prior to performing the block.  Neuromuscular blockade was not included in the time out.
•Due to size of the child, the acute pain service (APS) elected to perform the block using only stimulation. 
•The needle was advanced over the transverse process and was unable to elicit a twitch response. The entire stimulation circuit was checked and no faults were noted.
•After about 2 minutes, the anesthesia team recognized the reason for no twitch response was due to NMB.
•Twitches were checked and none were present.
•15 minutes passed until a twitch came back permitting reversal of the NMB with neostigmine and glycopyrrolate.  (Suggamadex was not yet available)
•Stimulation worked and the catheter was successfully placed.
 

Case Report 2:

•A 14 year old male, presented to the operating room for hardware removal and internal fixation of the femur.  The family requested a single shot lumbar plexus block as this provided good pain control for a prior similar surgery. This was previously achieved using a combination of ultrasound and stimulation.
•The APS attending agreed to do the block and the on call attending provided anesthesia for the case.
•Prior to induction, during the surgical time out, Orthopedics stated they would not be performing nerve monitoring and NMB was acceptable. After induction of anesthesia, an endotracheal tube was placed, facilitated by the use of NMB. 
•The OR anesthesia attending and the APS attending were present for a regional time out. The APS attending elected to utilize both ultrasound and nerve stimulation.  The proper anatomy was identified on ultrasound. A 22 G Bevel needle was then inserted and stimulation was attempted, but no twitch was elicited. Multiple stimulation needles were used and the the twitch monitor was self-tested on the provider. After 20 min of attempting the block, it was eventually decided  to solely use ultrasound, since visualization on ultrasound was adequate.
•After injection of the local anesthetic it was recalled that the patient received NMB.
•The block was successful intra-operatively and post-operatively.
 

Discussion:

•Both cases represent situations where neuromuscular blockade led to significant delays in the placements of the nerve blocks, with increased time in the operating room.
•Fortunately, neither patient experienced any adverse events.
•There is the possibility that the needle could be inserted too deep or in the wrong location if one were to assume that they had not placed the needle far enough to get a response.
•Knowing the proper NMB status of the patient is important with the lumbar plexus, as the nerve bundle is deeper to most resolution from ultrasound, especially in larger patients
•Performing a time out prior to regional anesthesia is important to provide a safe environment for the patient. 
•Adding NMB to the regional checklist would provide the regional anesthesiologist performing the nerve block vital information. This would allow modifications to be made prior to the start of the procedure; specifically if reversal should be used or if using ultrasound by itself would be sufficient.  This becomes crucial, if there are different providers doing the nerve block and the general anesthesia.  
 

Conclusions:

•The use of neuromuscular blockade prior to placement of a nerve block is an important topic to discuss in a pre-procedure timeout and checklist.
•It provides the proceduralist with information that is critical if reversal may be necessary to allow adequate nerve stimulation or if the procedure should be done solely with ultrasound.
•It is unclear if Pediatric Regional Anesthesia Network (PRAN) currently has a method to systematically review case complications such as these described. [3] 
•With the use of undisclosed NMB, there is a potential for complications to occur.
•After review of these cases we propose to add neuromuscular blockade to the pre-procedure timeout checklist. 
 

References:

1.Bosenberg A. Pediatric regional anesthesia update. PaediatrAnaesth. 2004; 14:398–402.
2.Polaner DM, Taenzer AH, Walker BJ, et al. Pediatric Regional Anesthesia Network (PRAN): a multi-institutional study of the use and incidence of complications of pediatric regional anesthesia. AnesthAnalg. 2012;115:1353–1364.
3.A Time-Out Checklist for Pediatric Regional Anesthetics.  Clebone, Anna MD; Burian, Barbara K. PhD; Polaner, David M. MD.  Regional Anesthesia & Pain Medicine; January/Feburary 2017. Volume 42.  Issue 1. 105.108.
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