V. Thwaites1, S. Y. Ong2, N. Record3

1NHS Lothian, Edinburgh, UK

2Royal Hospital For Children and Sick Kids, Edinburgh, UK

3NHS Tayside, Dundee, UK


Surgery for congenital developmental dysplasia of the hip (DDH) is complex and painful. In our centre, children undergoing hip reconstruction, pelvic and femoral osteotomies and open reduction of the hip have traditionally received a combination of caudal anaesthesia and intraoperative and postoperative intravenous morphine.


Evidence suggest that peripheral nerve blocks have a better safety profile than central neuraxial blockade1. Furthermore, peripheral blocks have a longer duration of action than caudal blocks2, can be given unilaterally, and eliminate the risk of post-operative urinary retention. Similarly, from a safety perspective, oral opioids are preferable to intravenous opioids3 and removes the need for post-operative intravenous cannulation.

Strategy for change:

Over four years we gradually modified the DDH intraoperative regional anaesthesia from caudal anaesthesia to a combination of single shot anterior quadratus lumborum (QL) blocks, lateral QL blocks, and femoral nerve blocks. Simultaneously we implemented a change from post-operative morphine infusions to nurse controlled intravenous morphine boluses (NCA), and then to oral morphine.

Measure of improvement:

Our primary measure of improvement was a reduction in post-operative opioid requirement. We also measured highest pain score in order to ensure patients were not experiencing greater discomfort.  Our secondary measure of improvement was time until discharge. Patients were followed up by the paediatric pain team and their IV and oral morphine consumption recorded, alongside FLACC pain score and date of discharge.

Lessons learnt:

The combination of peripheral regional anaesthesia and oral morphine resulted in a substantial reduction in overall post-operative opioid consumption. Previously, patients receiving a caudal block and a morphine infusion had a total oral morphine equivalent of 927mcg/kg in those (N=11), with a mean highest pain score of 2.6 out of 5. This was then changed to peripheral regional anaesthesia and a bolus only NCA (N=3) with a mean total oral morphine equivalent of 613mcg/kg. It was noted that these patients only required 0-4 boluses in 24 hours. Therefore, we trialled oral morphine. Following this change, patients receiving peripheral regional anaesthesia and oral morphine had a total oral morphine equivalent of 451mcg/kg (N=6), with a mean highest reported pain score of 2.


Message for others:

Our experience shows that it is possible to perform DDH surgery using a combination of peripheral lower limb nerve blocks and post-operative oral morphine, resulting in a significant reduction in total opioid consumption, without a compromise in pain management. Performing DDH surgery as a day case has been implemented by some centres, using caudal blocks and oral morphine to reduce the number of overnight stays in this group of patients4. We suggest that an analgesia model utilising QL blocks and/or femoral nerve blocks, in conjunction with oral morphine post-operatively, could facilitate this.


1 Walker BJ, Long JB, Sathyamoorthy M,  Birstler J,  Wolf C,  Bosenberg AT, et al. An Analysis of More than 100,000 Blocks from the Pediatric Regional Anesthesia Network. Anesthesiology. 2018 Nov 1; 129:721–732 Available from: https://doi.org/10.1097/ALN.0000000000002372

2 Öksüz G, Arslan M, Urfalioglu A, Guler AG, Teksen S, Bilal B and Oksuz H. Comparison of quadratus lumborum block and caudal block for postoperative analgesia in pediatric patients undergoing inguinal hernia repair and orchiopexy surgeries: a randomized controlled trial Reg Anesth Pain Med. 2020 Mar 1; 45(3):187-191. Available from: doi: 10.1136/rapm-2019-101027.

3 Gai N, Naser B, Hanley J, Peliowski A, Hayes J, Aoyama H. A practical guide to acute pain management in children. Journal of Anaesthesia. 2020 March 31; 34:421–433. Available from: https://doi.org/10.1007/s00540-020-02767-x

4 Moore DM, Sheridan GA, Kelly PM, Moore DP. Day-case pelvic osteotomy for developmental dysplasia of the hip. J Child Orthop. 2020 Dec 1; 14(6): 508–512. Available from: doi: 10.1302/1863-2548.14.200164

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