Combination of neuraxial and peripheral regional anaesthetic techniques in a multimodal analgesia regimen – case report

Dear Editor,
Choosing the right anaesthetic technique and postoperative analgesia after major surgery can be a great challenge for paediatric anaesthetists, especially when younger children are concerned. The simultaneous use of systemic analgesics with adjuncts in combination with single-shot blocks performed at the right time may facilitate the patient’s recovery and result in a comfortable postoperative period.
Current guidelines recommend individualised pain management strategies and support the use of multimodal regimens offering effective pain relief, reduced incidence of postoperative respiratory complications, and promoting faster return of gut function and feeding [1–3]. Potentially, these goals can be achieved with the use of continuous epidural anaesthesia. However, in young children, it requires the addition of sedatives. Different combinations of multimodal techniques have been proposed, but only a few have been evaluated in high-quality trials [1, 4]. Through this paper, we would like to report a successful selection of multimodal therapy for an extensive orthopaedic procedure affecting both legs.
This case report describes an 18-month-old female, weighing 9.2 kg, with bilateral fibular hemimelia Paley type 3c with a fixed equinovalgus deformity and shortening of both lower limbs. The SUPERankle technique, which is a combination of bone and soft tissue procedures, was selected to address all deformities and stabilise the feet. The surgery was performed under tourniquet control and comprised tarsal tunnel decompression and distal tibial osteotomy with shortening osteoplasty and tibiofibular syndesmosis reconstruction to realign the ankle joint. The osteotomy was fixed with a plate and screws (Figure 1), wounds were closed in layers.
After the induction of general anaesthesia, a single-shot caudal epidural anaesthesia was attempted. Following skin disinfection with the patient in the lateral decubitus position, the caudal epidural anaesthesia was accomplished using anatomical landmarks. Nine millilitres of 0.2% ropivacaine was injected via a 22G paediatric needle with a 32° Crawford type bevel. According to the multimodal paradigm, despite the successful neuraxial block, 100 mg acetaminophen, 100 mg metamizole (Metamizole Kalceks, Akciju sabiedrība “Kalceks”, Rīga, Latvia), and 2 mg dexamethasone were administered in adjuncts. In total 90 mcg of fentanyl was used for induction (30 mcg) and maintenance (60 mcg) of...


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