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Abstract
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Background and Aims Pediatric regional anaesthesia lacks evidence-based clinical practice, prompting ESRA and ASRA to provide practice advisories. However, selecting the safest strategy for complex cases remains challenging.
Methods Description of the intraoperative analgesic-anaesthetic management of a multiple limb amputation.
Results A 13-year-old, BMI 12.7, 29kg patient diagnosed with acral necrosis post-septic shock underwent minor amputations in both upper extremities, with a more aggressive approach on the right side, and transmetatarsal and infracondylar amputations on the left foot and right lower extremity. Combined anaesthesia was performed and included intravenous dexamethasone, dexketoprofen and paracetamol. An epidural catheter was placed at 8 hours, followed by fractionated administration of ropivacaine 12mg. At 11 hours, a left axillary block was performed with ropivacaine 20mg and dexamethasone. Subsequently, at 13 hours, a right supraclavicular catheter was placed, administering ropivacaine 20mg and dexamethasone. Precautions were taken to avoid systemic toxicity, such as dose fractionation and staggered blocks as different surgical areas were addressed. However, the total doses exceeded the theoretical toxic dose. Another approach involves reducing the local anesthetic concentration. Recommendations are available for continuous infusions of a single block, not two as presented in this case. Two infusions were maintained at the safety limit established for 24 hours, but this limit does not consider simultaneous blocks. Subsequently, only the epidural infusion was continued.
Conclusions Diligence is crucial to avoid iatrogenic effects with single-injection multiple blocks in paediatrics. Continuous multiple blocks need further evidence on cumulative dose safety. Dose fractionation and staggered blocks help prevent peak plasma levels of local anaesthetic.
