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Local anesthetic dosing and toxicity of pediatric truncal catheters: a narrative review of published practice
  1. Michael Fettiplace1,2,
  2. Lana Joudeh1,2,
  3. Brittani Bungart1,2 and
  4. Karen Boretsky2,3
  1. 1Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
  2. 2Department of Anaesthesia, Harvard Medical School, Boston, Massachusetts, USA
  3. 3Department of Anesthesiology, Critical Care and Pain Medicine, Boston Childrens Hospital, Boston, Massachusetts, USA
  1. Correspondence to Dr Michael Fettiplace, Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts, 02114, USA; fettiplace{at}


Background/importance Despite over 30 years of use by pediatric anesthesiologists, standardized dosing rates, dosing characteristics, and cases of toxicity of truncal nerve catheters are poorly described.

Objective We reviewed the literature to characterize dosing and toxicity of paravertebral and transversus abdominis plane catheters in children (less than 18 years).

Evidence review We searched for reports of ropivacaine or bupivacaine infusions in the paravertebral and transversus abdominis space intended for 24 hours or more of use in pediatric patients. We evaluated bolus dosing, infusion dosing, and cumulative 24-hour dosing in patients over and under 6 months. We also identified cases of local anesthetic systemic toxicity and toxic blood levels.

Findings Following screening, we extracted data from 46 papers with 945 patients.

Bolus dosing was 2.5 mg/kg (median, range 0.6–5.0; n=466) and 1.25 mg/kg (median, range 0.5–2.5; n=294) for ropivacaine and bupivacaine, respectively. Infusion dosing was 0.5 mg/kg/hour (median, range 0.2–0.68; n=521) and 0.33 mg/kg/hour (median, range 0.1–1.0; n=423) for ropivacaine and bupivacaine, respectively, consistent with a dose equivalence of 1.5:1.0. A single case of toxicity was reported, and pharmacokinetic studies reported at least five cases with serum levels above the toxic threshold.

Conclusions Bolus doses of bupivacaine and ropivacaine frequently comport with expert recommendations. Infusions in patients under 6 months used doses associated with toxicity and toxicity occurred at a rate consistent with single-shot blocks. Pediatric patients would benefit from specific recommendations about ropivacaine and bupivacaine dosing, including age-based dosing, breakthrough dosing, and intermittent bolus dosing.

  • Drug-Related Side Effects and Adverse Reactions
  • Nerve Block
  • Pain, Postoperative
  • Postoperative Complications

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  • Twitter @mfettiplace, @BrittaniBungart

  • Contributors MF conceived the project and designed the extraction. BB, LJ and MF contributed to literature screening, data extraction, data preparation, manuscript drafting and manuscript editing. KB contributed to data interpretation, manuscript drafting and manuscript editing.

  • Funding MF was supported by an National Institutes of Health T32 training grant (grant number 5T32GM007592-42).

  • Competing interests None declared.

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

  • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.

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