Transcript
Society for Pediatric Anesthesia
Section Editor: Peter J. Davis
Pediatric Regional Anesthesia Network (PRAN):
A Multi-Institutional Study of the Use and Incidence
of Complications of Pediatric Regional Anesthesia
David M. Polaner, MD, FAAP,*† Andreas H. Taenzer, MD, MS, FAAP,‡§ Benjamin J. Walker, MD,||
Adrian Bosenberg, MB, ChB, FFA,|| Elliot J. Krane, MD,¶# Santhanam Suresh, MD,**††
Christine Wolf, MBS,‡‡ and Lynn D. Martin, MD, MBA, FAAP, FCCM||§§
BACKGROUND: Regional anesthesia is increasingly used in pediatric patients to provide postoperative analgesia and to supplement intraoperative anesthesia. The Pediatric Regional Anesthesia
Network was formed to obtain highly audited data on practice patterns and complications and to
facilitate collaborative research in regional anesthetic techniques in infants and children.
METHODS: We constructed a centralized database to collect detailed prospective data on all
regional anesthetics performed by anesthesiologists at the participating centers. Data were
uploaded via a secure Internet connection to a central server. Data were rigorously audited
for accuracy and errors were corrected. All anesthetic records were scrutinized to ensure that
every block that was performed was captured in the database. Intraoperative and postoperative complications were tracked until their resolution. Blocks were categorized by type and as
single-injection or catheter (continuous) blocks.
RESULTS: A total of 14,917 regional blocks, performed on 13,725 patients, were accrued from
April 1, 2007 through March 31, 2010. There were no deaths or complications with sequelae
lasting >3 months (95% CI 0–2:10,000). Single-injection blocks had fewer adverse events than
continuous blocks, although the most frequent events (33% of all events) in the latter group
were catheter-related problems. Ninety-five percent of blocks were placed while patients were
under general anesthesia. S
ingle-injection caudal blocks were the most frequently performed
(40%), but peripheral nerve blocks were also frequently used (35%), possibly driven by the widespread use of ultrasound (83% of upper extremity and 69% of lower extremity blocks).
CONCLUSIONS: Regional anesthesia in children as commonly performed in the United States has
a very low rate of complications, comparable to that seen in the large multicenter European studies. Ultrasound may be increasing the use of peripheral nerve blocks. Multicenter collaborative
networks such as the Pediatric Regional Anesthesia Network can facilitate the collection of detailed
prospective data for research and quality improvement. (Anesth Analg 2012;115: 1353–64)
R
egional anesthesia is increasingly used in pediatric patients to provide postoperative analgesia and
intraoperative anesthesia. There is a large body of
literature describing the techniques of regional blockade
in children, the pharmacokinetics and pharmacodynamics
of local anesthetics, use of adjunctive drugs, and reports
Author affiliations are provided at the end of the article.
Accepted for publication April 10, 2012.
The authors declare no conflicts of interest.
This report was previously presented, in part, at the Annual Meetings of the
Society for Pediatric Anesthesia/American Academy of Pediatrics Section
on Anesthesiology and Pain Management and the American Society of
Anesthesiologists 2009 and 2010.
Benjamin J. Walker, MD, is currently affiliated with the Department of
Anesthesiology, University of Wisconsin School of Medicine and Public
Health, Madison, WI.
Reprints will not be available from the authors.
Address correspondence to David M. Polaner, MD, FAAP, Departments
of Anesthesiology and Pediatrics, Children’s Hospital Colorado, 13123
East 16th Ave., B090, Aurora, CO 80045. Address e-mail to david.polaner@
ucdenver.edu
Copyright © 2012 International Anesthesia Research Society
DOI: 10.1213/ANE.0b013e31825d9f4b
December 2012 • Volume 115 • Number 6
of complications and pitfalls of various techniques, but
detailed and complete information on complication rates
and safety, particularly prospectively collected data, is limited.1,2 There are only 3 large detailed prospective studies
of complication rates in pediatric regional anesthesia,
2 from the F
rench-
Language Society of Pediatric
Anesthesiologists (ADARPEF) and 1, limited to epidural
anesthesia, from the United Kingdom (UK) and Ireland.3–5
The French prospective studies are the largest and most
comprehensive. The initial study was published in 1996,
before the common use of ultrasound guidance. The most
recent ADARPEF study, using the same methodology,
comprised 31,132 regional blocks. It reported that the use
of peripheral nerve blocks and continuous nerve blocks
increased compared with the earlier study, although information regarding imaging and localizing techniques was
not presented, and it was unclear whether there was a validation or auditing process to ensure the capture of the total
number of blocks performed, which is essential to accurately determine rates.
Other studies were retrospective in design, may not
have had accurate denominators, or had total numbers of
www.anesthesia-analgesia.org 1353
PRAN Database of Pediatric Regional Anesthetics
subjects too small to generate accurate incidence data.6–8 Yet
others reflect the practice of a particular institution and cannot be easily generalized to a broader population.9 Because
the incidence of complications in regional anesthesia is
relatively small, accurate and meaningful data can only
be obtained by enrolling large numbers. This is virtually
impossible even at large children’s hospitals.
We therefore established a consortium of institutions
in the United States (US) where pediatric regional anesthetics are frequently performed (the Pediatric Regional
Anesthesia Network [PRAN]) to collect data prospectively and to facilitate large-scale, multicenter collaborative research and quality improvement in pediatric regional
anesthesia.10 Data on all regional blocks performed at each
hospital were entered locally into a central database using
a web-based data-reporting tool. This report describes the
practice patterns, adverse events, and complications in
nearly 15,000 regional anesthetics administered to children.
We also describe details of the database and data collection
tool to serve as a methodological reference for subsequent
investigations that report data from PRAN.
METHODS
The PRAN was organized in 2006. Database and web data
collection tools were developed with assistance from Axio
Research, LLC (Seattle, WA). Data accrual began on April
1, 2007, using 6 pilot centers (Children’s Hospital Colorado,
Aurora, CO; Seattle Children’s Hospital; Children’s
Hospital of Philadelphia; Children’s Memorial Hospital,
Chicago, IL; Lucile Packard Children’s Hospital at Stanford
University, Palo Alto, CA; and Children’s Hospital at
Dartmouth-Hitchcock Medical Center, Lebanon, NH). This
preliminary phase of the study was used to troubleshoot
data collection, to test the web instrument, and to acquire
pilot data to demonstrate the effectiveness of the study
methodology for collecting large-
scale information. One
center (Philadelphia) dropped out of the Network because of
resource issues; the investigators were not able to ensure that
all blocks could be collected and entered into the database,
and their data have been excluded from the study results.
After the first year of data collection, additional centers were
added to the Network. Study centers in the PRAN that contributed data to this report are listed in the Appendix.
Approval for the study was obtained from the human
subjects review board at each center. All centers were granted
waivers of consent and Health Insurance Portability and
Accountability Act of 1996 (HIPAA) by their review boards,
because data were collected without any alteration in routine patient care, and no patient identifiers were uploaded
to the database.
The Network is governed by a Steering Committee, comprised of 2 chairpersons (LDM and DMP) and a representative from each of the pilot centers, that meets monthly by
teleconference and biannually in person. The project manager from Axio (CW) is an e x-officio representative on the
committee.
Data Collection
Each PRAN study center collected data on every regional
anesthetic performed by an anesthesiologist. Blocks
performed by others (surgeons, emergency medicine
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physicians, etc.) were not included, but therapeutic and
diagnostic nerve blocks performed by pain service anesthesiologists were entered. These comprised the intraoperative dataset. Data were also collected on continuous
blocks during the period of infusion after the patient left the
operating room. These variables comprised the postoperative dataset. Complications and adverse events were noted
separately during both periods. The anesthesiologist performing the block entered the intraoperative data either
on the anesthesia record or on a separate data form; data
forms were used when there were not mandatory fields for
all required variables on the anesthesia record itself. For
single-injection blocks, either the anesthesiologist or their
surrogate at follow-up recorded postoperative events. For
continuous blocks, the clinicians on the hospital’s acute
pain service collected the postoperative data. Complications
reported after discharge or at follow-up were also recorded
where appropriate in the postoperative dataset. If a complication or adverse event was identified, it was followed until
its resolution, usually by the clinicians on the pain service.
That file remained open until follow-up data were completed and entered in the database.
Data Entry
Data from each center were entered into a centralized
database maintained by Axio Research, LLC, using a
web-based tool developed by the investigators in collaboration with Axio. The website is secure and password protected (each site has its own identity and each user has a
unique username and password). No patient identifiers
were uploaded or stored on the central server. Study centers, which needed to keep patient identifiers linked to each
data file for follow-up until the file was complete, did so
with either local paper data sheets or by using software that
stored patient data in a “desktop registry” and uploaded
the completed data to the central server only after stripping
the file of patient identifiers. The website was designed to
both maximize the efficiency and ease of data entry and to
minimize data entry errors. For an individual data file to
be considered complete, all required fields had to be filled
in. “Orphan pages” were data files with no demographic
information, those with demographics but missing block
data, or complication pages with either no demographics
or block data; these were detected initially by manual auditing at Axio until this function was automated in the database software. Required pages (web pages that contained
data that could not be left blank) looked at “upstream” and
“downstream” orphan pages; the software prevented block
pages from being created unless a demographics page had
been created, and complication pages could not be created
unless at least 1 block was submitted. Demographics pages
that were left with no block page ever created were also
automatically detected. All of these were flagged and listed
on the home page for each study center until they were
completed or corrected.
Each institution had access to its own data, as well as the
aggregate data, to enable comparisons and benchmarking
for internal quality assurance and improvement purposes.10
Individual centers were not able to view data stratified by
center or identify their source, but could only see pooled
data from other centers.
ANESTHESIA & ANALGESIA
Data Auditing and Accuracy
Two data audits were performed: the first to confirm that
every block performed was collected for entry into the
database, ensuring the accuracy of the denominator, and
the second to detect transcription errors, confirming and
ensuring the accuracy of the data in the database. For the
first audit, a member of the research team at each center
reviewed every anesthesia record. In some institutions, a
redundant list of all anesthetic records that were submitted for billing with a regional block was matched with the
cases already identified, and provided an additional confirmation that no cases were missed. In institutions that used
data sheets, those data were compared with the anesthesia
record. If there were discrepancies or ambiguities that could
not be resolved, the anesthesiologist of record was contacted
to resolve them. If this audit detected a block that had not
been reported on a data sheet, the data were obtained from
the anesthesia record, or when necessary, from the anesthesiologist who performed the block.
The second audit, for data accuracy, was performed
monthly. Initially, each center randomly selected 10% of that
month’s cases; if fewer than 50 cases were accrued, 5 cases
were randomly selected. In the second year of the project,
Axio developed software that randomly selected the cases
for auditing. An investigator at each site examined the
entries in the database and compared those data with the
original source data. Any errors were corrected, and a
record was maintained of the number of errors. Every complication and adverse event (rather than a selected sample)
was audited for accuracy.
When multiple blocks were performed during a single
operation and a complication or adverse event occurred, in
rare instances it was not clear during data analysis which
block was associated with the complication. These cases were
independently reviewed and adjudicated by 3 steering committee members to associate the complication with the correct block. Unanimity was required to assign a complication
to a particular block. In 3 instances, the data were ambiguous and a definitive assignment was not possible. In these
few cases, the complication was assigned to both blocks in
question to achieve the most conservative estimate of risk for
each specific block, but was not “double counted” in the total
number of block complications in that general category.
Data Parameters
Demographics collected included the date of database
entry, the age (in months and years), the subject’s weight
(in kilograms), ASA physical status (including emergency),
and gender.
Blocks were categorized as single-injection or continuous
(catheter) blocks, and stratified by anatomical region. If more
than 1 block or bilateral blocks were placed, a separate record
was entered for each block, because each block was an independent event, each with its own risk of complications and
failure. A rectus sheath block was the only exception because
the steering committee considered it unlikely that a unilateral rectus sheath block would ever be performed.
Dosing and technical data collected included the physical status of the patient during the block placement (awake,
sedated, anesthetized, presence or absence of neuromuscular blockade), the technology used to locate the nerve or
December 2012 • Volume 115 • Number 6
confirm catheter placement (none, nerve stimulator, fluoroscopy, ultrasound, or epidurogram), and whether a test
dose was administered.
The local anesthetic administered and its c oncentration,
volume, and epinephrine content were recorded, as were
the doses of any adjunctive drugs (opioids, clonidine).
Related variables, including the starting infusion rate, and
the date of catheter removal and reason for removal (no
longer needed, dislodgement, development of a complication) were collected for catheter blocks in the postoperative
period. Some of these data are not included in this initial
report, and will be analyzed and reported in subsequent
papers from PRAN.
Table 1a. Intraoperative Complications Measured
Whenever “other” was an option, its details were specified
Positive test dose and method of detection (heart rate increase,
arterial blood pressure change, electrocardiogram change, other)
Inadvertent dural puncture (cerebrospinal fluid aspirate)
Inadvertent vascular puncture (blood aspirate)
Abandoned block (unable to place)
Failed block (completed but not successful)
Respiratory: pneumothorax, diaphragmatic paralysis, other
Cardiovascular: arrhythmia, hypotension, cardiac arrest, other
Neurological: seizure, paresthesia, other
Other complications
Interventions needed: none, repeated block in same location,
repeated block in different location (specified), altered anesthetic
medications (specified), administered other medications (specified),
canceled surgery, other
Outcome: resolved without sequelae—no change in treatment;
resolved without sequelae—change in treatment (specified);
resolved with sequelae lasting <3 mo; resolved with sequelae
lasting >3 mo (specified); death
Was length of hospitalization increased as a result of the complication?
Table 1b. Postoperative Complications Measured
Whenever “other” was an option, its details were specified
Unintentional unilateral block
Prolonged block (>12 h for single-injection)
Excessive motor blockade
Catheter problem: occluded, kinked, accidental dislodgement, other
Adverse drug reaction: nausea/vomiting, pruritus, other
Respiratory: respiratory depression, apnea, diaphragm paralysis, other
Neurological: seizure, paresthesia, dysesthesia, paralysis, postdural
puncture headache, altered mental status, Horner syndrome, other
Hematoma
Infection: insertion site, deep tissue, other
Other
Location where complication was identified: postanesthesia care unit,
intensive care unit, ward, home, other
Days between placement and complication
Intervention: none; change in infusate, rate, or contents; remove
catheter; diagnostic test (computed tomography, magnetic
resonance imaging, electromyogram, nerve conduction, other);
consultation (neurology, neurosurgery, infectious disease, rehab
medicine, other); medication (antibiotics, anticonvulsants, other);
other
Outcome: resolved without sequelae—no change in treatment;
resolved without sequelae—change in treatment (specify); resolved
with sequelae lasting <3 mo; resolved with sequelae lasting >3 mo
(specify); death
Was length of hospitalization increased as a result of the
complication?
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PRAN Database of Pediatric Regional Anesthetics
The presence or absence of adverse events and complications was recorded for every block, and categorized
as intraoperative or postoperative dependent on when
the complication occurred (Table 1, a and b). Definitions
were specified by the Steering Committee. A complication
describes a serious event (nerve injury, local anesthetic
toxicity, postdural puncture headache, serious cardiac or
respiratory events, deep infection). Adverse events describe
undesirable side effects (Horner syndrome, pruritus) and
events (unintended unilateral block, inability to place a
block, failed block, positive test dose, or aspiration of blood
from a needle or catheter) that did not result in patient harm
or sequelae. The nature of each complication or event and
whether an intervention was necessary and its outcome
were recorded. A failed block was defined as one that was
completed but resulted in no apparent analgesia or blockade. This includes epidural blocks in which epidurography
demonstrated the catheter outside the epidural space. An
abandoned block was one that could not be placed and the
operator aborted further attempts.
Data Analysis
All cases entered into the PRAN database from April 1, 2007,
when data collection commenced, through March 31, 2010,
are included in this report. The dataset was analyzed only
after audits described above were completed. The data in this
initial report are descriptive, and are presented in the aggregate. Individual data from each center were not analyzed
separately. The incidence of complications is reported in raw
numbers and then calculated as percentage rates or occurrences per 1000 or 10,000 where appropriate. When indicated,
the data are described with summary statistics including
mean ± SD for normally distributed data and median (interquartile range) for non-normally distributed data. Exact binomial 95% confidence intervals (CIs) were calculated for some
incidence rates, and are reported in parentheses. Statistical
analysis was performed using STATA software (version 11.1;
StataCorp LP, College Station, TX). In analyzing the use of
imaging and localizing techniques, blocks were divided
according to the following variables:
• Regional anesthetic techniques were analyzed by location and by single-
injection or continuous catheter
techniques.
•• Nerve blocks performed >100 times were analyzed
individually.
•• Nerve blocks performed <100 times were grouped
with similar blocks (e.g., upper extremity catheters of
all types).
•• The most common localizing technique was listed
when it was used to perform >3% of the nerve blocks.
Those nerve blocks performed using >1 technique
(ultrasound, nerve stimulator) were also analyzed, and
thus those numbers may add up to >100%.
RESULTS
Fourteen thousand nine hundred seventeen regional blocks,
performed on 13,725 patients, were accrued during this initial
3-year study period. The majority of blocks were performed
for elective surgery (96%). The demographics are presented
in Figure 1. F
ifty-three percent of the blocks were performed
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4500
4000
3500
3000
2500
2000
Female
1500
Male
1000
500
0
<1 Month
1 Month 6 Months 1 Year to 3 Years to 10 Years Unknown
to <6
to < 1 <3 Years <10 Years or greater
Age
Months
Year
Figure 1. Demographics for 13,725 patients in the Pediatric
Regional Anesthesia Network (PRAN) database.
in ASA physical status I, 30% in ASA II, 15% in ASA III, and
0.76% in ASA IV patients. Only 1 block was placed in an ASA
physical status V patient. Block type, numbers, and incidences of complications are detailed in Tables 2 and 3. There
were no deaths and no serious complications with sequelae
lasting >3 months (95% CI 0–2:10,000). The distribution of
block types among centers is shown in Figure 2.
Data Audits
The audits for data accuracy detected an error rate of 0.3%
of case records, yielding an upper error margin of 0.5%.
Each record contained at least 17 and potentially as many
as 70 data fields, and the errors were usually confined to a
single data field. All detected errors were corrected before
data analysis. A small number of cases (0%–4%, depending
on block type) had missing data in the imaging and technology field.
Single-Injection Group
Neuraxial Blocks
There were 6210 blocks in this category, of which the majority
(6011, or 97%) were caudals and 83 were subarachnoid blocks
(Table 2). The vast majority of caudal blocks were performed
in young children, predominantly 3 years and younger (Fig.
3). No complications were reported in the caudal group
(95% CI 0–6:10,000) or in the other single-injection neuraxial
groups with the exception of a teenager who had hypotension from a subarachnoid block. There were 183 adverse
events, an incidence of 3% (95% CI 26–35:1000) (Table 3).
The most common adverse event (104, or 2% of the total and
57% of all events) was the inability to place the block or block
failure. S
ingle-injection caudal blocks were predominantly
performed without any technical aids or imaging (93%);
ultrasound guidance was used in 3% of cases.
Upper Extremity Blocks
The greatest variation in practice among study centers
occurred with upper extremity blocks. Four hundred
fifty-five blocks were performed, but 3 sites accounted for
nearly all, and 1 site nearly half, of these blocks (Fig. 2).
Supraclavicular blocks were performed more often than
any other technique. Inability to place the block or a failed
block was the most common adverse event. Two (of 164)
supraclavicular blocks lasted >12 hours; these were considered prolonged beyond their expected duration. Most
upper extremity blocks were placed using ultrasound guidance (82%) (Table 4).
ANESTHESIA & ANALGESIA
Table 2. Summary of S
ingle-Injection Blocks and
Adverse Event Rates for All Centers
No
Total
sequelae—
Total
adverse
No
change in
procedures events (%) sequelae treatment
Neuraxial
Caudal
6011
172 (3)
60
112
Lumbar
103
5 (5)
1
4
Thoracic
13
2 (15)
0
2
Subarachnoid
83
5 (6)
4
1
Total neuraxial
6210
183 (3)
64
119
Upper extremity
Interscalene
80
0
0
0
Supraclavicular
164
6 (4)
2
4
Infraclavicular
40
0
0
0
Axillary
99
2 (2)
1
1
Musculocutaneous
5
0
0
0
Elbow
1
0
0
0
Wrist
7
0
0
0
Other
58
0
0
0
Total
455
8 (2)
3
5
Lower extremity
Lumbar plexus
78
6 (8)
4
2
Fascia iliaca
221
1 (0.5)
0
1
Femoral
872
6 (0.7)
3
3
Sciatic
413
14 (3)
3
11
Popliteal fossa
319
2 (0.6)
0
2
Saphenous
78
0
0
0
Other
325
5 (2)
2
3
Total
2307
33 (1)
11
22
Head and neck
Supraorbital/
58
0
0
0
supratrochlear
Infraorbital
139
0
0
0
Greater auricular/
157
0
0
0
superficial
cervical
Occipital
101
0
0
0
Greater palatine
11
0
0
0
Other
89
0
0
0
Total
556
0
0
0
Other block type
Intercostal
39
0
0
0
Ilioinguinal/
737
3 (0.4)
1
2
iliohypogastric
Rectus sheath
294
0
0
0
Paravertebral
14
1 (7)
0
1
Penile
230
0
0
0
TAP
140
1 (0.7)
0
1
Other
395
0
0
0
Total
1849
5 (0.3)
1
4
Total adverse event rates reported in parentheses. Rates <1% reported as
decimals and >1% rounded to nearest whole number.
Note that in the neuraxial category and the lower extremity category, the total
number of complications are fewer than the cumulative sums of the individual
types. This is because there were 3 cases in which 2 blocks were done in
a single patient, 1 successful block after a complication in the other, and
because of ambiguity in the data entry, it was impossible to determine which
block was placed first. To assign the most conservative complication rate to
the specific block category, the complication was counted against both blocks,
but the total number of complications in that general block type is accurate.
See text for more details.
There were no serious complications or sequelae reported in any s
ingle-
injection group.
TAP = transversus abdominis plane.
Lower Extremity Blocks
Two thousand three hundred seven blocks were performed.
Adverse events were detected in 33 (1%, 95% CI 1–2:100),
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and although 22 required a change in m
anagement,
all resolved without therapy or sequelae. In 14 cases
(6:1000), the block failed or could not be placed. Nearly
three-
quarters (70%) were performed with ultrasound
guidance, with only fascia iliaca and lumbar plexus blocks
having low ultrasound utilization rates (Table 5).
Head and Neck Blocks
There were 556 blocks in this group, with no complications
or adverse events (95% CI 0–7:1000). There were minor differences among sites that frequently performed these blocks
regarding the quantity and distribution of each head and
neck block, but 2 sites did not perform any head and neck
blocks, and 2 others, which joined the PRAN later than the
pilot centers, only performed a total of 5 (Fig. 2).
Other Single-Injection Blocks
This group comprised intercostal and truncal blocks. There
were 1849 blocks entered into the database, including 737
ilioinguinal-iliohypogastric blocks. There were 5 adverse
events and no complications reported. Three blocks failed
or could not be placed, a paravertebral block had a positive test dose, and an ilioinguinal block had a positive blood
aspiration. Ultrasound imaging was very often used in this
group, especially for ilioinguinal, intercostal, rectus sheath,
and transversus abdominis plane blocks (Table 6).
Catheter Group
Adverse events occurred more often in the catheter group
(Table 7). Nearly 43% were catheter related (265 of 623);
by far, the most common (210) were catheter malfunctions
(kink, disconnect, or inadvertent dislodgement) in the postoperative period. In 56 instances (9%), the block could not
be placed or failed.
Neuraxial Blocks
Two thousand nine hundred
forty-
six neuraxial catheter
blocks were performed. There was a relationship between
age and catheter insertion site (Fig. 4). There were 520 adverse
events (18%, 95% CI 160–190:1000) and 21 complications
(0.7%, 95% CI 4–11:1000), but no complications had sequelae
lasting >3 months. Most adverse events (140 or 26%) were
catheter-related (dislodgement or kinking) (Table 8, a and b).
The cumulative failure rate in this group was 2%. The highest
failure rate occurred in thoracic catheters; 3% (5 of 195, 95%
CI 10–60:1000) of caudally threaded thoracic catheters and
2% of thoracic catheters (15 of 695, 95% CI 10–40:1000) could
not be placed, whereas 1.3% (20 of 1518, 95% CI 8–20:1000)
of lumbar catheters and 0.8% (2 of 261, 95% CI 1–27:1000) of
caudally advanced lumbar catheters failed. Just over half of
these (51%) were completed successfully at either the same
or a different level. Thoracic epidurals were associated with a
higher incidence of catheter problems (8%) than caudal (2%)
or lumbar (5%) epidurals. In addition, there were 40 unintentional unilateral blocks, which were more common with lumbar (23 of 1518, 1.5%) and thoracic (15 of 695, 2.2%) catheters
compared with caudal catheters (2 of 730, 0.3%).
There were 46 positive test doses or vascular punctures (2%, 95% CI 12–21:1000). Accidental dural puncture
occurred in 26 instances (0.9%, 95% CI 6–13:1000), during 4
caudal, 14 lumbar, and 8 thoracic placements. Four of these
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PRAN Database of Pediatric Regional Anesthetics
Table 3. Single-Injection Neuraxial Block Complications and Adverse Events by Type
Caudal
Lumbar
Thoracic
Subarachnoid
Total
TD
DP
VP
AB
FB
C
R
N
Other
Total
events
Total
procedures
18
0
0
n/a
18
5
2
1
n/a
7
38
0
0
0
38
71
2
1
2
76
26
0
0
2
28
1
0
0
1
2
0
0
0
0
0
0
0
0
0
0
13
1
0
1
15
172
5
2
6
184
6011
103
13
83
6210
TD = positive test dose; DP = dural puncture; VP = vascular puncture; AB = abandoned block; FB = failed block; C = cardiovascular; R = respiratory; N =
neurological.
2500
2000
1500
Figure 2. Distribution of blocks by study site. Each
letter refers to a single study center and was assigned
randomly (i.e., the order does not correspond to the
H list of study centers in the Appendix).
1000
500
0
A
Number of caudals
2500
2169
2000
1494
1500
1260
918
1000
500
89
78
0
<1
month
3
1 month 6 month 1 year to 3 year to 10 year unknown
to <6
to <12 <3 year <10 year
and
month
month
greater
Age (years)
Figure 3. Single-injection caudal placement by age. Age data are
missing for 3 patients.
patients developed postdural puncture headaches, and all
required epidural blood patches after failing conservative
therapy. The onset of headache in those patients who had a
successful epidural catheter placed on a second attempt was
delayed until after the infusion was stopped. One epidural
catheter eroded through the dura on the second day of infusion; this also required a blood patch.
Neurological events were noted only in patients with
lumbar or thoracic catheters. Four cases of Horner syndrome (0.6%, 95% CI 2–14:1000) were noted in patients
with thoracic catheters; all resolved when the infusion rate
was reduced. Three patients (0.1%, 95% CI 0.2–3:1000) had
1358
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B
C
D
E
F
G
paresthesiae in the postoperative period, all of which
resolved without sequelae. One patient with paresthesia
also had allodynia and was prescribed gabapentin in the
immediate postoperative period; the symptoms resolved by
the time of hospital discharge.
Thirty-
two local inflammations or infections were
reported, resulting in an incidence of 11% (95% CI 8–17:1000).
Most infections were localized to the insertion site
and treated by removal of the catheter. Antibiotics were
prescribed in only 3 patients, and all cases resolved without sequelae. There were no cases of deep infection, abscess,
or meningitis reported (95% CI 0–13:10,000). Superficial
infections requiring antibiotic treatment were diagnosed
at a median of 3 days (2–4 days) after catheter placement.
In addition, 8 caudal catheters were removed because the
dressings were soiled with fecal matter and 10 were removed
because of the presence of fever without an evident source.
In all these patients, there was no concomitant evidence of
infection related to the epidural catheter. Lumbar epidurals
(0.6%, 95% CI 3–11:1000) were associated with a lower rate of
infection than caudal (0.15%, 95% CI 8–27:1000) or thoracic
(0.17%, 95% CI 9–30:1000) epidurals. Central neuraxial catheters were left in place for a mean of 2.2 days (median 2 days,
range 0–20 days, SD 1.64 days).
Six postoperative respiratory complications were
recorded, 5 of which were related to respiratory depression, for an incidence of 0.2% (95% CI 1–5:1000). These
events occurred in a wide range of ages: one neonate, one
ANESTHESIA & ANALGESIA
Table 4. Use of Localizing Techniques for S
ingle-Injection Upper Extremity Blocks
Total
80
164
40
99
5
1
7
58
455
Interscalene/parascalene
Supraclavicular
Infraclavicular
Axillary
Musculocutaneous
Elbow
Wrist
Other
Totals
None
2
2
1
14
2
0
7
33
61
Nerve stimulator
16 (20%)
22 (13%)
11 (28%)
12 (12%)
0
0
0
2 (3%)
64 (14%)
Fluoroscopy
0
0
0
1
0
0
0
3
4
Ultrasound
78 (98%)
158 (96%)
38 (95%)
77 (78%)
3 (60%)
1 (100%)
0
19 (33%)
375 (82%)
More than 1 technology can be used for a block, thus totals may exceed 100%.
Table 5. Use of Localizing Techniques for S
ingle-Injection Lower Extremity Blocks
Lumbar plexus/psoas
compartment
Fascia iliaca
Femoral
Sciatic
Popliteal fossa
Saphenous
Other
Totals
Total
78
None
8
Nerve stimulator
60 (77%)
221
872
413
319
78
325
2307
166
35
13
11
9
119
361
4 (2%)
313 (36%)
195 (47%)
151 (47%)
5 (6%)
36 (11%)
764 (33%)
Fluoroscopy
9 (12%)
Ultrasound
9 (12%)
0
1 (0.1%)
0
2 (0.6%)
0
20 (6%)
32 (1%)
48 (22%)
760 (87%)
303 (73%)
265 (83%)
65 (83%)
169 (52%)
1619 (70%)
Other
1 (1%)
0
0
0
0
0
0
1 (0.4%)
More than 1 technology can be used for a block, thus totals may exceed 100%.
Table 6. Use of Localizing Techniques for S
ingle-Injection Other Block Types
Intercostal
Ilioinguinal/iliohypogastric
Rectus sheath
Paravertebral
Penile
TAP
Other
Totals
Total blocks
39
737
294
14
230
140
395
1849
None
8
158
32
8
224
2
198
630
Nerve stimulator
0
2
2
0
0
0
3
7
Fluoroscopy
0
3
0
1
0
0
44
48
Ultrasound
30 (77%)
563 (76%)
256 (87%)
4 (29%)
2 (0.9%)
129 (92%)
147 (37%)
1131 (61%)
TAP = transversus abdominis plane.
2-month-old, one 35-month-old, one 4-year-old, and a
15-year-old patient. They were remedied by decreasing the
concentration of, or completely removing, the opioid component of the epidural infusate.
Seven cases of postoperative hypotension possibly
related to continuous epidural infusions were reported, for
an incidence of 2:1000. All were treated with a change or
decrease in infusion rate. Six were teenagers and the other 5
years of age. All but one had a thoracic epidural.
Most epidural catheters were placed without subsequent verification of the position of the catheter tip (88%
of caudal-sacral and 77% of caudal-lumbar) with the exception of just over half (55%) of the catheters threaded from
the sacral hiatus to the thoracic level. Epidurograms were
used to verify correct catheter placement in 9% of catheters
advanced from the sacral hiatus to the sacral or lumbar
region and in 25% of those threaded to the thoracic level.
Ultrasound was used to verify placement in 11% of caudal-
to-thoracic epidural catheter placements and stimulating
catheters in 0.5% (Table 9).
Upper Extremity Catheters
Only 26 upper extremity catheters were placed. Adverse
events were noted in 6 (23%, 95% CI 90–440:1000), but no
December 2012 • Volume 115 • Number 6
complications were reported (95% CI 0–13:100). There were
3 catheter problems (50%), 2 failed blocks, and 1 prolonged
block. Most (24 of 26, 92%) continuous upper limb blocks
were placed with ultrasound guidance. In 5 of those, nerve
stimulation was also used.
Lower Extremity Catheters
Five hundred forty-four lower extremity catheters were
placed; some of these were continuous ambulatory
catheters using elastomeric infusion devices in patients
discharged home with outpatient f ollow-up, but the database does not distinguish between outpatient and inpatient catheters. There was 1 possible complication (95%
CI 0–1:100), a case of prolonged paresthesia or numbness of the foot after a lumbar plexus block in a patient
with spina bifida. The paresthesia resolved in <3 months;
however, some of the symptoms might have been present
preoperatively. There were 98 adverse events (18%, 95%
CI 150–210:1000), of which 65 (67% or 12% of all catheters) were catheter-related problems. Vascular punctures
occurred in 6 (3%, 95% CI 10–70:1000) lumbar plexus and
4 (2%, 95% CI 10–60:1000) femoral catheter placements.
Seven blocks (5 sciatic, a lumbar plexus and a popliteal
fossa) were judged to have excessive motor blockade. In 8
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PRAN Database of Pediatric Regional Anesthetics
Table 7. Summary of Continuous Catheters and
Complication/Adverse Event Rates for All Centers
No
No
Total
sequelae— sequelae—
Total
adverse
no change change in
procedures events (%) in treatment treatment
Caudal
Sacral
Lumbar
Thoracic
Epidural
Lumbar
Thoracic
All neuraxial
catheters
Upper extremity
Interscalene
Supraclavicular
Infraclavicular
Axillary
Other
Total
Lower extremity
Lumbar plexus
Fascia iliaca
Femoral
Sciatic
Popliteal
Other
Total
Other catheter
Intercostal
Ilioinguinal
Fascia iliaca
Rectus sheath
Paravertebral
Other
Total
274
261
195
1518
695
2946
36 (13)
38 (15)
26 (13)
243 (16)
177 (25)
520 (18)
12
10
12
57
23
114
24
28
14
cases, catheters could not be placed or the block failed.
There were 3 superficial infections, 1 each with a femoral nerve, sciatic, and popliteal fossa catheter, all of which
resolved completely with antibiotics, local care, or removal
of the catheter. Continuous peripheral nerve blocks of the
lower limbs were frequently placed with ultrasound guidance (64%) and/or nerve stimulation (63%), and rarely
without any localizing technique (6%) (Table 10).
Truncal and Other Blocks
There were 24 catheters placed for paravertebral, transversus abdominis plane, or other truncal locations. Only 1
adverse event was noted, a catheter-related problem.
186
154
406
DISCUSSION
9
7
8
0
1
26
4 (44)
1 (14)
0
0
1 (100)
6 (23)
181
0
169
150
33
8
544
36 (20)
0
29 (17)
29 (19)
3 (9)
0
97 (18)
1
1
0
0
3
19
24
0
0
0
0
0
1 (5)
1 (4)
0
0
0
1
1
1
Total adverse event rates reported in parentheses. Rates <1% reported as
decimals and >1% rounded to nearest whole number.
Level of insertion data is missing for 3 neuraxial patients, none of whom had
complications.
There were no deaths or complications with sequelae lasting >3 mo.
This is the first prospective, observational, multicenter
study of the practice of pediatric regional anesthesia and its
complications from the US. The PRAN database, corroborating the findings of European investigators, suggests that
regional anesthesia in pediatrics is remarkably safe, with
a very low rate of complications. Our data also show that
peripheral nerve blocks are very often used for infants and
children in the US, and that the use of ultrasound guidance
may be driving that practice for many of these blocks.
The intent of the PRAN is to accrue large numbers on
regional anesthetics of all types in children so that assessments of practice patterns, risks, and complications can be
obtained. The study methodology was designed to establish
an accurate denominator for the data by subjecting the data
to multiple audits so that rates of complications could be
determined with certainty.
Since the inception of the network, several minor revisions of the website and database occurred. The majority
did not affect the data collected and were made to improve
clarity and ease of use. One exception, however, was the
elimination of the “inadequate analgesia” complication
data field. This was originally intended to measure block
efficacy and was defined as a pain score higher than 5. The
PRAN steering committee, upon interim examination of the
Figure 4. Continuous catheter placement by
age and level of insertion. Age or insertion
level data are missing for 6 patients.
Neonate
Infant
1-4 years 5-8 years
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thoracic
lumbar
caudal
9-12
years
>12
years
ANESTHESIA & ANALGESIA
Table 8a. Continuous Neuraxial Blocks: Intraoperative Adverse Events and Complications
Caudal-sacral
Caudal-lumbar
Caudal-thoracic
Lumbar
Thoracic
Totals
TD
3
4
3
1
2
13
DP
2
2
0
14
8
26
VP
11
4
0
8
10
33
AB
2
1
4
12
5
24
FB
2
1
1
8
10
22
R
0
0
0
0
0
0
C
0
0
0
1
0
1
N
0
0
0
0
0
0
IO
5
2
2
7
3
19
TD = positive test dose; DP = dural puncture; VP = vascular puncture; AB = abandoned block; FB = failed block; R = respiratory; C = cardiovascular; N =
neurological; IO = infection other.
Level of insertion data missing for 3 patients (no complications).
Table 8b. Continuous Neuraxial Blocks: Postoperative Adverse Events and Complications
Caudal-sacral
Caudal-lumbar
Caudal-thoracic
Lumbar
Thoracic
Totals
UUB
PB
EMB
CP
ADR
RP
NP
H
I
PO
1
1
0
23
15
40
0
0
0
1
0
1
1
4
1
35
9
50
5
6
5
71
54
141
1
8
2
30
26
67
1
0
0
5
0
6
0
0
0
8
15
23
0
0
0
0
0
0
2
2
7
9
12
32
2
3
1
23
14
43
UUB = unintentional unilateral blockade; PB = prolonged blockade; EMB = excessive motor blockade; CP = catheter problem (dislodgment, occlusion); ADR =
adverse drug reaction; RP = respiratory problem; NP = neurological problem; H = hematoma; I = infection; PO = postoperative other.
Table 9. Use of Localizing Techniques for Continuous Neuraxial Blocks
Total blocks
Caudal-sacral
Caudal-lumbar
Caudal-thoracic
Lumbar
Thoracic
Totals
None
274
261
195
1518
695
2946
241
200
107
1337
587
2475
Nerve stimulator
0
2
1
5
3
11
Fluoroscopy
Ultrasound
8 (3%)
10 (4%)
25 (13%)
30 (2%)
23 (3%)
96 (3%)
14 (5%)
20 (8%)
22 (11%)
24 (2%)
19 (3%)
99 (3%)
Epidurogram
15 (5%)
31 (12%)
48 (25%)
93 (6%)
58 (8)
245 (8%)
Other
0
0
1
0
0
1
Table 10. Use of Localizing Techniques for Continuous Lower Extremity Blocks
Lumbar plexus/psoas
compartment
Fascia iliaca
Femoral
Sciatic
Popliteal fossa
Other
Totals
Total blocks
None
181
22 (12)
153 (85)
9 (5)
23 (13)
0
169
150
33
8
544
0
5 (3)
5 (3)
0
0
33 (6)
0
102 (60)
72 (47)
13 (39)
1
342 (63)
0
1
1
0
0
11 (2)
0
156 (92)
131 (85)
31 (94)
7 (88)
349 (64)
data, decided that the measurement criteria of inadequate
analgesia were not adequately defined to preclude inaccuracies and ambiguities. These data were therefore not analyzed and are not reported, limiting our ability to delineate
an incidence of “block ineffectiveness,” that is, how many
blocks were technically successful but provided suboptimal
or inadequate analgesia.
Limitations
This study was prospective and observational in nature.
The study population was accrued from a limited number of academic medical centers with corresponding geographic and demographic diversity; the participating
centers were not a random sample of hospitals providing
pediatric regional anesthetic care in the US. Therefore, it
December 2012 • Volume 115 • Number 6
Nerve stimulator
Fluoroscopy
Ultrasound
should be noted that the reported complication rates are
subject to selection and study population bias, design effect,
and multiple other confounding variables that may not
only impact the reported rate of adverse events, but also
the reported CIs. Hence, we did not attempt to draw direct
cause and effect from these data with respect to adverse
outcomes. This large dataset will allow the identification of
important adverse events to be researched further and will
generate future prospective, randomized trials in the areas
of concern that have been identified. PRAN was founded
to provide a platform to conduct such studies that will
address questions generated by observational data.
In most cases, a team of faculty and residents or fellows
performed the regional blocks. Although we did not collect
information on the level of training, we believe that, because
www.anesthesia-analgesia.org 1361
PRAN Database of Pediatric Regional Anesthetics
of the nature of the participating institutions, most faculty
had subspecialty training in pediatric anesthesiology. The
relatively small number of study centers, as compared with
the ADARPEF and UK studies, may also impose some limitation of diversity of practice on our results, although the
character of the centers was fairly diverse.
Although our study design was prospective, it still
relied on s elf-reporting, as have other multicenter, prospective, observational studies.3–5 Voluntary reporting carries a
significant risk of underreporting,11 but other prospective
studies have suggested that this probably has little effect on
the true incidence of complications.12 The PRAN data differ significantly from other studies in that there is rigorous
auditing to ensure that all regional anesthetics at each study
center are collected and reported. As a consequence, the
denominators of this dataset are highly accurate and may
be the most precise incidence information to date.
In analyzing the complications it must be noted that
although the total number of cases in the database is large,
the quantity of some individual blocks remains relatively
small. Thus, risk data on these blocks remain tentative and
of speculative accuracy until a larger number are accumulated. Similarly, although a wide distribution of ages is
represented, the number of cases in the youngest cohorts
remains relatively small, and until greater numbers of very
young patients are accrued, valid conclusions cannot be
drawn with regard to safety for any specific block in these
age groups. The same is true for weight; only 1 block was
reported in a premature infant weighing <1000 g. The reason for the low neonatal numbers compared with the UK
and ADARPEF is uncertain but may reflect practice in the
US. Without a denominator for all neonatal operations
performed with or without regional blockade, it is unclear
whether this is an avoidance of regional anesthesia in neonates or simply a lower case volume performed in this age
group at the PRAN institutions. Because the PRAN is an
ongoing project, enough data should eventually be collected to make more confident and meaningful estimates of
the complication rates in all regional anesthesia procedures
in all age groups.
Many complications (e.g., paresthesia) are difficult to
diagnose in infants and nonverbal children who cannot
describe their symptoms accurately or even alert clinicians to their presence. Nevertheless, the incidence of serious complications that were detected in this prospectively
acquired unselected population is extremely small, and no
sequelae lasting >3 months were reported in close to 15,000
regional anesthetics. There were no serious complications
such as epidural abscess, epidural hematoma, or persistent
neurological deficit. In these instances, we must rely on CIs
to provide an upper limit of possible incidence rates.13 For
example, although there was no mortality reported in 9156
neuraxial blocks, a mortality of 0 to 3.3:10,000 is still consistent with our data.
A final limitation of our methodology is that despite
our best attempts at complete reporting, we cannot be sure
that some late complications did not develop after patients
were discharged from our care and thus escaped detection.
Although all centers followed up on known complications
until their resolution, there was no uniform or mandated
system to actively query all patients without complications
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at discharge to determine whether new late complications
developed beyond the proximate perioperative period. This
is particularly relevant for single-injection blocks in patients
who were discharged home on the day of surgery. Although
each patient’s parents or guardians were queried by telephone within several days of discharge, the specificity and
rigor of those calls were not uniform, and it is possible
(although unlikely) that some complications might have
gone unreported.
Complications and Adverse Events
Catheter problems (dislodgement, kinking, malfunction)
were especially common, accounting for approximately
one-third of all postoperative adverse events. This problem
has only been reported with upper extremity blocks, but
we found that it occurs with all kinds of catheters, suggesting that devising better methods of placement and fixation
should be a high priority.14
Similar to the ADARPEF studies and the UK epidural
audit, the incidence of neurological complications was very
low.3–5 The number of dural punctures, however, was higher
than expected. The second ADARPEF study reported a dural
puncture rate of 0.1%, most often occurring during caudal
blocks in infants, with only one during a thoracic epidural
placement; none had postdural puncture headaches. Our
incidence of dural puncture was more than twice that, and
postdural puncture headaches were more common. The
number of dural punctures during thoracic epidural placement is of particular concern, even though none resulted in
any reported neurological sequelae.
Although we did not detect any deep neuraxial infections, the 95% CI for serious infection based on this PRAN
data analysis and sample size is 0 to 13:10,000, similar to the
findings in previous studies.3,4,13,15 The UK audit reported 25
local and 3 serious (epidural abscess and meningism) infections,4 for an overall incidence of 0.3% for local and 0.02% for
serious infection. Another review from a single institution
examined >10,000 epidurals placed during a 17-year period
and found a low infection rate (0.06%, 95% CI 0.03–0.13) in
epidurals placed for postoperative analgesia. The criteria
for infection in that study were strict, and did not include
local erythema or induration that resolved spontaneously.16
Respiratory complications were noted in several patients
receiving central neuraxial opioids, but all cases were
detected by respiratory monitoring before serious consequences developed and responded to a reduction in the
infusion rate or opioid concentration. This highlights the
importance and efficacy of careful and vigilant monitoring
of respiratory status in these patients.
No local anesthetic toxicity was reported in any block.
The 95% CI of 0–2:10,000 is consistent with rates in the
ADARPEF and UK audits.3–5 However, positive test doses
were noted in several types of blocks, as was aspiration of
blood through the needle or catheter. This suggests that test
dosing and incremental injection whenever large volumes
of local anesthetic are used remain important safety measures to detect intravascular injection and prevent toxicity.
Practice Patterns
The PRAN database offers an opportunity to examine
practice patterns and complications. The common use of
ANESTHESIA & ANALGESIA
peripheral nerve blocks, which comprised nearly o
ne-third
of all blocks in the PRAN database, mirrors the findings of
the most recent ADARPEF study.5 This may reflect a change
in surgical practice (more laparoscopic surgery) or change
in anesthetic practice (ultrasound) toward the perceived
safer option of peripheral nerve block and away from the
putative risks associated with neuraxial blocks.17–19 The
ADARPEF study did not report the frequency of ultrasound
use, but our data enable us to speculate that the availability of ultrasound guidance for peripheral nerve blocks in
particular may be driving the increased use of these blocks
in pediatric practice compared with historical data.20–22 This
is not surprising, because good visual definition of most
peripheral nerves can be obtained with portable ultrasound
probes.
Real-
time ultrasound imaging can verify correct
needle placement and local anesthetic delivery around the
nerve.23 We also document a shift in the practice of upper
extremity blocks, most likely attributable to the advent
of ultrasound guidance. In the past, axillary blocks were
reported to be the most common upper extremity block
in pediatric practice; however, 74% of the brachial plexus
blocks in the PRAN database are supraclavicular, infraclavicular, or interscalene. More than 96% were placed using
ultrasound guidance, as were nearly 83% of femoral, sciatic,
popliteal fossa, and saphenous nerve blocks. Nerve stimulation seems to have a lesser role in pediatric regional techniques in the PRAN network, but remained commonly used
for deeper blocks of the lower extremity as an adjunct to
ultrasound. We postulate that this might be because deeper
nerves at the limit of ultrasound penetration are less well
defined and practitioners resorted to stimulation to confirm
nerve location, or perhaps in some cases because of lack of
ultrasound skills or training.
Although new data suggest that epidurography detects a
much higher rate of unsuspected misplacement of epidural
catheters than previously assumed, this information was published toward the end of the study period in this report.24,25
CONCLUSIONS
Regional anesthesia can be performed safely in children
with a relatively low risk of complications. In this large
prospective cohort of nearly 15,000 blocks in children from
several academic medical centers, the majority of complications or adverse events were detected at the time of needle
or catheter placement. There were no long-term sequelae.
The PRAN data from pediatric institutions in the US compares favorably with those of other audits supporting the
safety of regional anesthesia in children.
The high incidence of c atheter-related issues may be a
consequence of the catheter size, the connectors used, methods of fixation, or simply the novelty of peripheral nerve
catheters. It is clear from these data that improved catheter
stability is an important advance that must be achieved for
more effective continuous neural blockade in children.
We believe that because of the rigorous auditing,
these data represent one of the most accurate attempts at
a
large-
scale estimate of complication rates in pediatric
regional anesthesia. As more institutions and larger numbers of patients are enrolled, the PRAN database project may
be the best way to achieve meaningful risk assessment in
December 2012 • Volume 115 • Number 6
pediatric regional anesthesia, and may be a mechanism to
organize future l arge-scale clinical comparison studies. E
APPENDIX: PRAN Participating Institutions and
Investigators as of January 2012
Seattle Children’s Hospital, Seattle, WA* (Lynn Martin,
Adrian Bosenberg, Sean Flack)
Children’s Hospital Colorado, Aurora, CO (Denver
Children’s)* (David Polaner)
Children’s Hospital at Dartmouth, Lebanon, NH* (Andreas
Taenzer)
Children’s Memorial Hospital, Chicago, IL* (Santhanam
Suresh, Carmen Simion, Polina Voronov)
Lucile Packard Children’s Hospital at Stanford University,
Palo Alto, CA* (Elliot Krane)
Children’s Medical Center, Dallas, TX (Peter Szmuk)
Columbia University, New York, NY (Susumu Ohkawa)
The Cleveland Clinic, Cleveland, OH (Sara Lozano)
University of Texas- Houston, TX† (Maria Matuszczak,
Ranu Jain)
Children’s Hospital, Boston, MA† (Hyun Kee Chung,
Navil Sethna, Christopher Lee)
Texas Children’s Hospital, Houston, TX† (Robert Power,
Kim Nguyen, Nancy Glass)
University of New Mexico, Albuquerque, NM† (Nicholas
Lam, Tim Peterson)
Oregon Health Sciences University/ Doernbecher
Children’s Hospital, Portland, OR† (Jorge Pineda)
Nationwide Children’s Hospital, Columbus, OH (Tarun Bhalla)
* Denotes a pilot institution.
† Denotes an institution that has joined the network after the closing date of
the data set included in this report.
AUTHOR AFFILIATIONS
From the Departments of *Anesthesiology and †Pediatrics,
University of Colorado School of Medicine and Children’s
Hospital Colorado, Aurora, Colorado; Departments of
‡Anesthesiology and §Pediatrics, Dartmouth Medical School and
Children’s Hospital at Dartmouth, Lebanon, New Hampshire;
Departments of ‖Anesthesiology and §§Pediatrics, University
of Washington School of Medicine and Seattle Children’s
Hospital, Seattle, Washington; Departments of ¶Anesthesia and
#Pediatrics, Stanford University School of Medicine and Lucile
Packard Children’s Hospital, Palo Alto, California; Departments
of **Anesthesiology and ††Pediatrics, Northwestern University
Feinberg School of Medicine and Children’s Memorial Hospital,
Chicago, Illinois; and ‡‡Axio Research, LLC, Seattle, Washington.
DISCLOSURES
Name: David M. Polaner, MD, FAAP.
Contribution: This author helped design the study, conduct the
study, collect and analyze the data, and write the manuscript.
Attestation: David M. Polaner has seen the original study
data, reviewed the analysis of the data, and approved the final
manuscript.
Name: Andreas H. Taenzer, MD, MS, FAAP.
Contribution: This author helped design the study, conduct the
study, analyze the data, and write the manuscript.
Attestation: Andreas H. Taenzer has seen the original study
data, reviewed the analysis of the data, and approved the final
manuscript.
www.anesthesia-analgesia.org 1363
PRAN Database of Pediatric Regional Anesthetics
Name: Benjamin J. Walker, MD.
Contribution: This author helped analyze the data, and write
the manuscript.
Attestation: Benjamin J. Walker has seen the original study
data, reviewed the analysis of the data, and approved the final
manuscript.
Name: Adrian Bosenberg, MB, ChB, FFA.
Contribution: This author helped design the study, conduct the
study, analyze the data, and write the manuscript.
Attestation: Adrian Bosenberg has seen the original study
data, reviewed the analysis of the data, and approved the final
manuscript.
Name: Elliot J. Krane, MD.
Contribution: This author helped design the study, conduct the
study, analyze the data, and write the manuscript.
Attestation: Elliott J. Krane has seen the original study data,
reviewed the analysis of the data, and approved the final
manuscript.
Name: Santhanam Suresh, MD.
Contribution: This author helped design the study, conduct the
study, analyze the data, and write the manuscript.
Attestation: Santhanam Suresh has seen the original study
data, reviewed the analysis of the data, and approved the final
manuscript.
Name: Christine Wolf, MBS.
Contribution: This author helped design the study, conduct the
study, analyze the data, and write the manuscript.
Attestation: Christine Wolf has seen the original study data,
reviewed the analysis of the data, approved the final manuscript, and is the author responsible for archiving the study
files.
Name: Lynn D. Martin, MD, MBA, FAAP, FCCM.
Contribution: This author helped design the study, conduct the
study, analyze the data, and write the manuscript.
Attestation: Lynn D. Martin has seen the original study data,
reviewed the analysis of the data, and approved the final
manuscript.
This manuscript was handled by: Peter J. Davis, MD.
ACKNOWLEDGMENTS
The Society for Pediatric Anesthesia generously provides logistical and administrative support and financial assistance to the
PRAN. PRAN thanks Axio Research, LLC, for their generous
assistance to PRAN in startup development and ongoing data
management and website support. PRAN is endorsed by the
American Academy of Pediatrics Section on Anesthesiology
and Pain Management.
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ANESTHESIA & ANALGESIA