Regulation and Selective Utilization of Peripheral Nerve Blocks Decrease Residual Neurological Symptoms After Pediatric Knee Surgery

Background: Peripheral nerve blocks (PNBs) are an essential tool for reducing postoperative pain, but they have recently been associated with a higher incidence of complications than previously thought. Hypothesis/Purpose: We compared 1) incidence of PNB-related postoperative neurological symptoms and 2) patient selection, operative practices, and anesthetic practices regarding PNBs for pediatric patients who underwent knee surgery before and after changes in administration of PNBs at our institution. Methods: We compared data from pediatric patients who underwent knee surgery with PNBs at our institution during 2 periods: 2014–2016 (Cohort 1; 100 patients) and 2017–2019 (Cohort 2; 104 patients). Cohort 1 was described in a previous study, and Cohort 2 consisted of consecutive patients treated by 1 orthopaedic surgeon after recognition of the higher rate of complications and limiting use of PNBs to an anesthesia service at our institution. We compared cohorts using Student t-tests and chi-squared tests. P < 0.05 was considered significant. Results: The incidence of PNB-related neurological complications was significantly lower in Cohort 2 (0.96%; n = 1) than in Cohort 1 (6%; n = 6) (p = 0.045). The 1 patient in Cohort 2 had numbness proximal to the knee, which resolved by 9.5 weeks postoperatively. Of the 6 patients in Cohort 1, 5 also had numbness proximal to the knee, and 1 had shooting pains down the leg upon palpation of the femoral block site. Three of these patients had unresolved symptoms at final follow-up. There was a greater proportion of female patients in Cohort 2 (57%) than in Cohort 1 (36%) (p = 0.01), with no significant differences in age or BMI. The Cohort 2 surgeries also had significantly longer average operating times and a higher proportion using tourniquets (p<0.01). More fellows (67% vs. 55%) and fewer residents (6.9% vs. 16%) performed PNBs in Cohort 2 than in Cohort 1 (p = 0.01). The most common anatomical site for PNBs was the femoral nerve (51%; n = 85) in Cohort 1 and the saphenous nerve (51%; n = 90) in Cohort 2 (p < 0.01). Conclusions: The incidence of PNB-related complications after pediatric knee surgery was significantly lower after our institution implemented changes in the regulation of PNB use. This reduction may be explained by a shift toward more experienced providers administering PNBs and preference for distal anatomic sites, which may suggest actionable items for other institutions aiming to lower their PNB complication rate. [Table: see text][Table: see text]