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Variation in pediatric local anesthetic dosing for peripheral nerve blocks: an analysis from the Pediatric Regional Anesthesia Network (PRAN)
  1. Andreas H Taenzer1,
  2. Michael Herrick2,
  3. Matthew Hoyt3,
  4. R J Ramamurthi4,
  5. Benjamin Walker5,
  6. Sean H Flack6,
  7. Adrian Bosenberg7,
  8. Andrew Franklin8 and
  9. David M Polaner9
  10. for the PRAN investigators
    1. 1Anesthesiology, Dartmouth Medical School, Hanover, New Hampshire, USA
    2. 2Anesthesiology, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, USA
    3. 3Anesthesiology, Riley Hospital for Children at Indiana University Health, Indianapolis, Indiana, USA
    4. 4Department of Anesthesia, Stanford University School of Medicine, Stanford, California, USA
    5. 5Anesthesiology, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
    6. 6Anesthesiology and Pain Medicine, Univ Washington, Seattle, Washington, USA
    7. 7Anesthesiology, University of Washington and Seattle Children's Hospital, Seattle, Washington, USA
    8. 8Anesthesiology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
    9. 9Anesthesiology, Seattle Children's Hospital, Seattle, Washington, USA
    1. Correspondence to Professor Andreas H Taenzer, Anesthesiology, Dartmouth Medical School, Hanover, NH 03755, USA; andreas.h.taenzer{at}


    Background Variation of local anesthetic dosing has been reported for adult peripheral nerve blocks (PNBs) and infant caudal blocks. As higher doses of local anesthetics (LA) are potentially associated with increased risk of complications (eg, local anesthetic systemic toxicity), it is important to understand the source of LA dose variation. Using the Pediatric Regional Anesthesia Network (PRAN) database, we aimed to determine if variation in dosing exists in pediatric single-injection PNBs, and what factors influence that variation.

    The primary aim of this study was to determine the factors associated with dosing for the 10 most commonly performed PNBs, with the secondary aim of exploring possible factors for variation such as number of blocks performed versus geographic location.

    Methods The PRAN database was used to determine the 10 most common pediatric PNBs, excluding neuraxial regional anesthetics. The 10 most common pediatric PNBs in the PRAN database were analyzed for variation of LA dose and causes for variation.

    Results In a cohort of 34 514 children receiving PNBs, the mean age was 10.38 (+/-5.23) years, average weight was 44.88 (+/-26.66) kg and 61.8% were men. The mean bupivacaine equivalent (BE) dose was 0.86 (+/-0.5) mg kg−1 and ropivacaine was used in 65.4% of blocks. Dose decreases with age (estimate −0.016 (−0.017, –0.015; p<0.001)). In all blocks for all age groups, the range of doses that make up the central 80% of all doses exceeds the mean BE dose for the block. Variation is not related to the number blocks performed at an institution (p=0.33 (CI −0.42 to 0.15)). The dose administered for a PNB is driven in order of impact by the institution where the block was performed (Cohen’s ƒ=0.45), then by weight (0.31), type of block (0.27), LA used (0.15) and age (0.03).

    Conclusions Considerable variation in dosing exists in all age groups and in all block types. The most impactful driver of local anesthetic dose is the institution where the block was performed, indicating the dosing of a potentially lethal drug is more based on local culture than on evidence.

    • regional anesthesia
    • pediatrics
    • pain
    • postoperative

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    • Collaborators The PRAN investigators: Adrian Bosenberg, Sean Flack, David Polaner, Patrick Fernandez, Andreas Taenzer, Patrick Birmingham, RJ Ramamurthi, Anthony Anderson, Galit Kastner, Sara Lozano, Maria Matuszczak, Navil Sethna, Tim Petersen, Karla Wyat, Jorge Pineda, Benjamin Walker, Jacob Hutchins, Aali Shah, Madhankumar Sathyamoorthy, Claudia Venable, Vidya Yalamanchili, Naomi Dong, Katherine Del Pizzo, Reena Chaudhari, Andrew Franklin, Akiko Ando, Nikhil Patel, Sophie Pestieau, Julia Rosenbloom, Victoria Bradford.

    • Contributors AHT: helped design the study, prepared and analyzed the data, performed statistical analysis, wrote, reviewed and approved the manuscript. MH: helped to write, review, review and approve the manuscript. MaHo: helped design the study, reviewed, revised and approved the manuscript. RJR: helped to design the study, reviewed, revised and approved the manuscript. BW: helped to design the study, reviewed, revised and approved the manuscript. SHF: helped to design the study, reviewed, revised and approved the manuscript. AB: helped to design the study, reviewed, revised and approved the manuscript. AF: helped to design the study, reviewed, revised and approved the manuscript. DMP: helped design the study, reviewed statistical analysis, reviewed, revised and approved the manuscript.

    • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

    • Competing interests None declared.

    • Patient consent for publication Not required.

    • Ethics approval The study proposal was reviewed and accepted by PRAN’s steering committee and the manuscript was approved by PRAN’s publication committee.

    • Provenance and peer review Not commissioned; externally peer reviewed.

    • Data availability statement No data are available. While data is anonymously collected and stored, public access is not available.