Lower socioeconomic status and minority race were associated with decreased use of regional anesthesia in pediatric patients undergoing common ambulatory orthopedic procedures, according to researchers at Hospital for Special Surgery (HSS) presenting at the 2019 ASRA Annual Meeting.¹

Recent research has shown an increase in ambulatory pediatric orthopedic surgery in the United States.^2,3 Although there is evidence suggesting that regional anesthesia benefits this population, this topic remains understudied.

"We undertook this large-scale study with the notion that regional anesthesia benefits children. However, we were aware that it is underutilized in this population and wanted to identify factors that were associated with its use," said anesthesiologist Kate DelPizzo, MD. "Overall, children have been less likely to receive regional anesthesia than adults, but that has changed due to widespread use of ultrasound and due to more formal training practices on regional anesthesia. At our institution, the majority of children receive regional anesthesia, but we are aware that we practice at a highly specialized place, so we wanted to find out what other institutions around the state are doing."

To examine this subject, as well as what factors might be associated with decreased use of regional anesthesia, Dr. DelPizzo and colleagues at HSS analyzed a large population-based cohort of patients below age 21.

Researchers identified pediatric patients who underwent anterior cruciate ligament repair or reconstruction, knee arthroscopy, or shoulder arthroscopy. Patient and healthcare system information was analyzed to determine whether regional anesthesia was used, including spinal anesthesia, epidural anesthesia, caudal anesthesia, and other peripheral nerve blocks.

Out of 87,273 pediatric patients undergoing anterior cruciate ligament repair or reconstruction (n=28,226), shoulder arthroscopy (n=18,155) or knee arthroscopy (n=40,892), only 11,404 (13.07%) received regional anesthesia as the primary anesthetic for their surgery.

"Our main conclusions are that the majority of patients under 18 having ambulatory (same-day release) surgery are not receiving regional anesthesia. The older you are, the higher your chance receiving regional anesthesia, which makes sense because it is always easier to perform regional anesthesia on an older child," said Dr. DelPizzo.

Dr. DelPizzo and her colleagues also found that Hispanic race and Medicaid insurance were associated with decreased odds of receiving regional anesthesia. "Disparities in healthcare are known to exist but remain relatively understudied in the field of anesthesia. This represents a problem, especially when we know that a certain intervention like regional anesthesia is associated with better outcomes but does not get applied equally to all groups of the population."

"It is difficult to draw conclusions as to why we see what we see from this type of data, but it forces us to ask questions and design studies that could determine that a mechanism," Dr. DelPizzo said.

The results from this study have potentially wide-reaching takeaways for parents, clinicians, and policymakers.

"Regional anesthesia used to be something that was only performed at large medical centers where there is a focus on teaching and where there are more resources available, but over the past decade, an increasing number of clinicians have learned how to perform these techniques," said Dr. DelPizzo. "However, even with that knowledge, they need to be in an environment with support systems enabling them to do so. Policymakers and administrators should provide an environment that facilitates this type of practice. The more successful a hospital is in providing an infrastructure, the more likely it is for patients to receive regional anesthesia."

"Patients are also becoming savvier and may ask for regional anesthesia, and we as physicians should be able to deliver it no matter where they live and who they are," Dr. DelPizzo added.

Parents of patients whose children require surgery that are amenable to regional anesthesia can also take away some tips from this research.

"If patients are able to choose where to have surgery, they should do some research to see if regional anesthesia is offered," she said.

References

1. Kathryn DelPizzo MD, Megan Fiasconaro MS, Jiabin Liu MD PhD, Lauren A. Wilson MPH, Janis Bekeris MD, Jashvant Poeran MD PhD, Stavros G. Memtsoudis MD PhD. “Low socioeconomic status and minority race decrease the odds of the provision of regional anesthesia in pediatric patients undergoing common ambulatory orthopedic procedures.” Presented at: 44th Annual Regional Anesthesiology and Acute Pain Medicine Meeting of the American Society of Regional Anesthesia and Pain Medicine (ASRA), April 11-13, 2019; Las Vegas, NV.

2. Dodwell ER, LaMont LE, Green DW, Pan TJ, Marx RG, Lyman S. 20 years of pediatric anterior cruciate ligament reconstruction in new york state. The American Journal of Sports Medicine. 2014;42(3):675-680.

3. Tepolt F, Feldman L, Kocher M. Trends in pediatric ACL reconstruction from the PHIS database. Journal of Pediatric Orthopaedics. 2018;38(9):e494.