Mazlila Meor Ahmad Shah1, Mas Mazlila1, Ng KS1, Mary S Cardosa1, Subakhi Faizah1
1) Malaysia
Providing good analgesia for effective management of large wounds is challenging, especially in paediatric patients. We report a case where a continuous peripheral nerve block was successfully used.
A 12 year-old boy was admitted to hospital with septic arthritis of his left ankle and a large infected wound following an injury to his left big toe. Wound debridement, arthrotomy and washout of his left ankle was performed, resulting in a large wound requiring daily dressing. Pain control was initially adequate using a combination of aqueous morphine, paracetamol and ibuprofen given regularly plus additional aqueous morphine prior to dressing; patient’s pain scores were 2 at rest and 4 on movement on a scale of zero to 10 (zero = no pain, 10 = worst pain imaginable).
After a second wound debridement was done, he experienced severe pain (pain score 7) despite increasing the pre-dressing oral morphine dose up to 30 mg, and nurses were unable to do the required daily dressing.
We inserted a sciatic nerve block catheter with a continuous infusion of local anaesthetic (LA) (levobupivacaine 0.2%) with additional boluses of LA prior to dressing. This resulted in much better pain relief and we were able to reduce the pre-dressing dose of aqueous morphine. The peripheral nerve catheter was removed after 15 days. By this time adequate analgesia for dressing was provided by aqueous morphine, and the dose of morphine was weaned down gradually and the patient was discharged after 90 days in hospital.
Continuous peripheral nerve block for wound management in paediatric patients should be considered as part of a multimodal analgesic regime when oral and/or parenteral analgesics provide inadequate analgesia.
