Regional anaesthesia for awake urgent upper limb surgery in children: a prospective cohort study

Peripheral regional anaesthesia is used rarely as the sole anaesthetic technique in children and is often combined with deep sedation or general anaesthesia for analgesic purposes. No literature addresses the minimum age at which regional anaesthesia can be considered to facilitate awake surgery in children. We hypothesised that children of school age could undergo awake urgent upper limb surgery with regional anaesthesia supported by anxiety-reduction strategies.

We recruited children aged 6-12 y who required urgent upper limb surgery. Peripheral regional anaesthesia with 0.35% ropivacaine was administered with ultrasound guidance and without neurostimulation. To reduce anxiety, patients watched cartoons on touchscreen tablets throughout the procedure. Sedatives or general anaesthesia were administered only if necessary. Anxiety was assessed during regional anaesthesia and surgery using the short form of the Modified Yale Pre-operative Anxiety Scale. Behavioural changes were evaluated on postoperative day 14 using the post-hospitalisation behaviour questionnaire.

Of the 99 patients studied, 81 (82%) underwent successful awake surgery with peripheral regional anaesthesia. The success rate increased with age, from 12 (67%) in 6-year-olds to 10 (100%) in 12-year-olds. No serious adverse events or significant behavioural disturbances were observed at 2-week follow-up. The staff ratings showed low difficulty ratings in the regional anaesthesia alone group, apart from during catheter insertion in two patients. The administration of peripheral regional anaesthesia was rated to be difficult for six (41%) of the patients in the regional anaesthesia with sedation and/or general anaesthesia subgroup.

Using regional anaesthesia to facilitate awake surgery is feasible in children of school age undergoing urgent upper limb surgery. Further investigations are needed to compare regional anaesthesia with general anaesthesia in this context.