Schlechter John A, Tholcke Loren C, Lum Trenton G, Thomas Evelyn S, Gornick Bryn R, Ignacio Gian C, McMichael Jessica C
Riverside University Health System - Medical Center, Department of Orthopaedic Surgery, Moreno Valley, CA, USA.
CHOC Children's Hospital, Orange, CA, USA.
J Pediatr Soc North Am. 2024 Apr 4;7:100035. doi: 10.1016/j.jposna.2024.100035. eCollection 2024 May.
Paralytic agents are occasionally used during the surgical treatment of type III (OTA 13A2) supracondylar humerus fractures (SCHFx) in children depending on surgeon preference. Paralytic agents create a neuromuscular blockade and therefore may potentially help with ease of fracture reduction. Controversy regarding the use of a paralytic agent as an adjunct to anesthesia exists due to potential associated adverse drug reactions, including prolonged paralysis, cardiovascular effects, or electrolyte abnormalities.The purpose of this study was to investigate intraoperative paralytic use in pediatric type III SCHFx and to report survey responses of members of the Pediatric Orthopaedic Society of North America (POSNA) on paralytic use in SCHFx management.
A retrospective chart review identified 319 type III SCHFx treated at our institution (January 2016-May 2019). Patients were assigned to 3 groups: group 1, surgical treatment without a paralytic agent ( = 240); group 2, treatment with rocuronium ( = 43); group 3, treatment with succinylcholine ( = 36). POSNA members were surveyed regarding paralytic use intraoperatively for type III SCHFx (November-December 2021) on paralytic use frequency, request for paralytics, reversal agent use, average time to surgery after injury and/or presentation, effect of time to surgery after injury and/or presentation on when to use a paralytic, annual number of SCHFx surgeries performed, awareness of paralytic complications, and years of surgeon experience. Statistical analysis was performed.
Average patient age was 5.2 ± 2.2 years. Group 2 had significant increases in anesthesia duration, surgical duration, fluoroscopic time, and radiation exposure compared to group 1. Group 2 had a higher conversion rate to open reduction than other groups. No statistically significant difference was found among groups in terms of sex, body mass index (BMI), laterality, radiographic measurements, or rates of open procedures or complications. Survey results indicated 32% (24/76) routinely use paralytics during closed reduction maneuvers; 71% (17/24) request administering paralytics at the beginning/before the case; and 33% (8/24) use paralytics in all type III SCHFx.
Surgeons at our center reported paralytic use for closed reduction in 25% of patients; similarly, one-third of POSNA survey respondents reported paralytic use during operative management. Although paralytic agents are used during the treatment of supracondylar humerus fractures in children this study was unable to demonstrate an association of advantageous outcomes, such as shorter surgical times. Routine paralytic use to facilitate closed reduction of supracondylar humerus fractures in children warrants further study.
(1)Paralytic agents may be utilized in pediatric supracondylar humerus fracture (SCHFx) surgeries, but their efficacy remains controversial due to associated adverse reactions.(2)Administration of rocuronium during surgery was associated with prolonged anesthesia and surgical durations, as well as increased fluoroscopic time and radiation exposure, suggesting potential drawbacks to its use.(3)Despite common use, the study found no significant correlation between paralytic agent administration and beneficial outcomes such as shorter surgical times.(4)Survey responses revealed varying practices among orthopaedic surgeons regarding paralytic agent use during closed reduction maneuvers for SCHFx.(5)Understanding variations in paralytic agent use among orthopaedic surgeons underscores the importance of future research to guide clinical decision-making.(6)The study highlights the need for standardized protocols and evidence-based practices in the use of paralytic agents for pediatric SCHFx.(7)The findings underscore the need for further research to establish the efficacy and safety of routine paralytic use in pediatric SCHFx surgeries and inform standardized protocols.
III, Retrospective chart review; Therapeutic study.
根据外科医生的偏好，在儿童III型（OTA 13A2）肱骨髁上骨折（SCHFx）的手术治疗中偶尔会使用麻痹剂。麻痹剂会产生神经肌肉阻滞，因此可能有助于更轻松地进行骨折复位。由于潜在的相关药物不良反应，包括麻痹时间延长、心血管影响或电解质异常，关于将麻痹剂作为麻醉辅助药物的使用存在争议。本研究的目的是调查小儿III型SCHFx术中麻痹剂的使用情况，并报告北美小儿骨科学会（POSNA）成员对SCHFx治疗中麻痹剂使用的调查回复。
通过回顾性病历审查，确定了在我们机构治疗的319例III型SCHFx（2016年1月至2019年5月）。患者被分为3组：第1组，不使用麻痹剂的手术治疗（n = 240）；第2组，使用罗库溴铵治疗（n = 43）；第3组，使用琥珀酰胆碱治疗（n = 36）。就III型SCHFx术中麻痹剂的使用情况对POSNA成员进行了调查（2021年11月至12月），内容包括麻痹剂使用频率、对麻痹剂的需求、逆转剂的使用、受伤和/或就诊后至手术的平均时间、受伤和/或就诊后至手术的时间对何时使用麻痹剂的影响、每年进行的SCHFx手术数量、对麻痹剂并发症的认识以及外科医生的经验年限。进行了统计分析。
患者平均年龄为5.2±2.2岁。与第1组相比，第2组的麻醉持续时间、手术持续时间、透视时间和辐射暴露显著增加。第2组切开复位的转化率高于其他组。在性别、体重指数（BMI）、侧别、影像学测量、切开手术率或并发症发生率方面，各组之间未发现统计学上的显著差异。调查结果表明，32%（24/76）的人在闭合复位操作中常规使用麻痹剂；71%（17/24）的人要求在病例开始时/之前给予麻痹剂；33%（8/24）的人在所有III型SCHFx中使用麻痹剂。
我们中心的数据显示25%的患者在闭合复位时使用了麻痹剂；同样，三分之一的POSNA调查受访者表示在手术治疗期间使用了麻痹剂。尽管在儿童肱骨髁上骨折的治疗中使用了麻痹剂，但本研究未能证明其与有利结果（如缩短手术时间）之间存在关联。在儿童肱骨髁上骨折闭合复位中常规使用麻痹剂有待进一步研究。
（1）麻痹剂可用于小儿肱骨髁上骨折（SCHFx）手术，但由于相关不良反应，其疗效仍存在争议。（2）手术期间使用罗库溴铵与麻醉和手术时间延长以及透视时间和辐射暴露增加有关，表明其使用可能存在潜在缺点。（3）尽管普遍使用，但该研究发现麻痹剂的使用与缩短手术时间等有益结果之间无显著相关性。（4）调查回复显示，骨科医生在SCHFx闭合复位操作中使用麻痹剂的做法各不相同。（5）了解骨科医生在麻痹剂使用上的差异凸显了未来研究指导临床决策的重要性。（6）该研究强调了在小儿SCHFx中使用麻痹剂时制定标准化方案和循证实践的必要性。（7）研究结果强调需要进一步研究以确定小儿SCHFx手术中常规使用麻痹剂的疗效和安全性，并为标准化方案提供依据。
III，回顾性病历审查；治疗性研究。
