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Local and Regional Anesthesia in Pediatrics

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Book cover Complications of Regional Anesthesia

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Key Points

  • Over the past 30 years, practice of pediatric regional anesthesia and analgesia has expanded rapidly. There are now a substantial number of studies, publications, and chapters in textbooks regarding the techniques, pharmacokinetics, clinical outcomes, and dosing guidelines in children.

  • Regional anesthesia in children requires special consideration due to generally smaller anatomy and the fact that the vast majority of blocks are administered under general anesthesia or heavy sedation.

  • Multiple studies of data collected by regional anesthesia centers have found a low incidence of complications in pediatric patients receiving nerve blocks. Permanent or severe complications are extremely rare.

  • Specific complications that may hinder pediatric nerve blocks include nerve injury, inadvertent dural puncture, improper catheter tip placement, high doses with risk of local anesthetic toxicity, infection, and compartment syndrome.

  • Ultrasound-guided approaches increase efficacy of blocks and may reduce the risk of complications associated with injection of large volumes of local anesthetic.

  • As with regional practice in adults, aseptic technique and use of appropriate equipment (e.g., needle size, ultrasound probes) are critical for performance of safe nerve blockade in the pediatric population.

  • At the end of the chapter, the reader will find some personal suggestions and “pediatric common sense” safety considerations the present author considers necessary for the practice of safe pediatric regional anesthesia.

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Abbreviations

ACS:

Acute compartment syndrome

ADARPEF:

French-Language Society of Pediatric Anesthesiologists

AGP:

Alpha1-acid glycoprotein

ASRA:

American Society of Regional Anesthesia and Pain Medicine

ECG:

Electrocardiogram

EIA:

Epidural infusion analgesia

GAs:

General anesthesia

ILE:

Intravenous lipid emulsion

LAST:

Local anesthetic systemic toxicity

PDPH:

Postdural puncture headache

PRAN:

Pediatric Regional Anesthesia Network

RCTs:

Randomized controlled trials

TAP:

Transversus abdominis plane

USG:

Ultrasound guidance

References

  1. Broadman LM, Holt RA: The evidence-based safety of pediatric regional anesthesia and complications. In: Finucane BT (ed.), Complications of regional anesthesia, 2nd ed. Springer, New York 2007, pp. 224–241

    Chapter  Google Scholar 

  2. Giaufre E, Dalens B, Gombert A. Epidemiology and morbidity of regional anesthesia in children: a one-year prospective survey of the French-Language Society of Pediatric Anesthesiologists. Anesth Analg. 1996;83:904–12.

    Article  CAS  PubMed  Google Scholar 

  3. Cheney FW, Domino KB, Caplan RA, Posner KL. Nerve injury associated with anesthesia: a closed claims analysis. Anesthesiology. 1999;90:1062–9.

    Article  CAS  PubMed  Google Scholar 

  4. Fox MA, Webb RK, Singleton R, Ludbrook G, Runciman WB. The Australian incident monitoring study. Problems with regional anaesthesia: an analysis of 2000 incident reports. Anaesth Intensive Care. 1993;21:646–9.

    CAS  PubMed  Google Scholar 

  5. Zadra N, Giusti F. Il blocco caudale in pediatria. Minerva Anestesiol. 2001;67(Suppl 1):126–31.

    CAS  PubMed  Google Scholar 

  6. Puncuh F, Lampugnani E, Kokki H. Use of spinal anaesthesia in paediatric patients: a single centre experience with 1132 cases. Paediatr Anaesth. 2004;14:564–7.

    Article  PubMed  Google Scholar 

  7. Kokki H. Spinal blocks. Ped Anesth. 2012;22:56–64.

    Article  Google Scholar 

  8. Llewellyn N, Moriarty A. The national pediatric epidural audit. Paediatr Anaesth. 2007;17:520–33.

    Article  CAS  PubMed  Google Scholar 

  9. Ecoffey C, Lacroix F, Giaufre E, Orliaguet G, Courreges P. Epidemiology and morbidity of regional anesthesia in children: a follow-up one-year prospective survey of the French-Language Society of Paediatric Anaesthesiologists (ADARPEF). Paediatr Anaesth. 2010;20:1061–9.

    Article  PubMed  Google Scholar 

  10. Polaner DM, Taenzer AH, Walker BJ, Bosenberg A, Krane EJ, Suresh S, Wolf C, Martin LD. Pediatric Regional Anesthesia Network (PRAN): a multi-institutional study of the use and incidence of complications of pediatric regional anesthesia. Anesth Analg. 2012;115:1353–64.

    Article  CAS  PubMed  Google Scholar 

  11. Long JB, Birmingham PK, De Oliveira GSJ, Schaldenbrand KM, Suresh S. Transversus abdominis plane block in children: a multicenter safety analysis of 1994 cases from the PRAN (Pediatric Regional Anesthesia Network) database. Anesth Analg. 2014;119:395–9.

    Article  CAS  PubMed  Google Scholar 

  12. Suresh S, Long J, Birmingham PK, De Oliveira GSJ. Are caudal blocks for pain control safe in children? An analysis of 18,650 caudal blocks from the Pediatric Regional Anesthesia Network (PRAN) database. Anesth Analg. 2015;120:151–6.

    Article  PubMed  Google Scholar 

  13. Na EH, Han SJ, Kim MH. Delayed occurrence of spinal arachnoiditis following a caudal block. J Spinal Cord Med. 2011;34:616–9.

    Article  PubMed  PubMed Central  Google Scholar 

  14. Symons JA, Palmer GM. Neuropathic pain and foot drop related to nerve injury after short duration surgery and caudal analgesia. Clin J Pain. 2008;24:647–9.

    Article  PubMed  Google Scholar 

  15. Weinberg L, Harvey WR, Marshall RJ. Post-operative paraplegia following spinal cord infarction. Acta Anaesthesiol Scand. 2002;46:469–72.

    Article  CAS  PubMed  Google Scholar 

  16. Neal JM. Anatomy and pathophysiology of spinal cord injury associated with regional anesthesia and pain medicine. Reg Anesth Pain Med. 2008;33:423–34.

    Article  PubMed  Google Scholar 

  17. Meyer MJ, Krane EJ, Goldschneider KR, Klein NJ. Case report: neurological complications associated with epidural analgesia in children: a report of 4 cases of ambiguous etiologies. Anesth Analg. 2012;115:1365–70.

    Article  PubMed  Google Scholar 

  18. Berde C, Greco C. Pediatric regional anesthesia: drawing inferences on safety from prospective registries and case reports. Anesth Analg. 2012;115:1259–62.

    Article  PubMed  Google Scholar 

  19. Taenzer A, Walker BJ, Bosenberg AT, Krane EJ, Martin LD, Polaner DM, Wolf C, Suresh S. Interscalene brachial plexus blocks under general anesthesia in children: is this safe practice?: A report from the Pediatric Regional Anesthesia Network (PRAN). Reg Anesth Pain Med. 2014;39:502–5.

    Article  CAS  PubMed  Google Scholar 

  20. Wee LH, Lam F, Cranston AJ. The incidence of post dural puncture headache in children. Anaesthesia. 1996;51:1164–6.

    Article  CAS  PubMed  Google Scholar 

  21. Tobias JD. Postdural puncture headache in children. Etiology and treatment. Clin Pediatr (Phila). 1994;33:110–3.

    Article  CAS  Google Scholar 

  22. Janssens E, Aerssens P, Alliet P, Gillis P, Raes M. Post-dural puncture headaches in children. A literature review. Eur J Pediatr. 2003;162:117–21.

    Article  PubMed  Google Scholar 

  23. Ylonen P, Kokki H. Management of postdural puncture headache with epidural blood patch in children. Paediatr Anaesth. 2002;12:526–9.

    Article  PubMed  Google Scholar 

  24. Oliver A. Dural punctures in children: what should we do? Paediatr Anaesth. 2002;12:473–7.

    Article  PubMed  Google Scholar 

  25. Bosenberg AT, Bland BA, Schulte-Steinberg O, Downing JW. Thoracic epidural anesthesia via caudal route in infants. Anesthesiology. 1988;69:265–9.

    Article  CAS  PubMed  Google Scholar 

  26. Blanco D, Llamazares J, Rincon R, Ortiz M, Vidal F. Thoracic epidural anesthesia via the lumbar approach in infants and children. Anesthesiology. 1996;84:1312–6.

    Article  CAS  PubMed  Google Scholar 

  27. Gunter JB, Eng C. Thoracic epidural anesthesia via the caudal approach in children. Anesthesiology. 1992;76:935–8.

    Article  CAS  PubMed  Google Scholar 

  28. Tsui BC, Gupta S, Finucane B. Confirmation of epidural catheter placement using nerve stimulation. Can J Anaesth. 1998;45:640–4.

    Article  CAS  PubMed  Google Scholar 

  29. Tsui BC, Guenther C, Emery D, Finucane B. Determining epidural catheter location using nerve stimulation with radiological confirmation. Reg Anesth Pain Med. 2000;25:306–9.

    CAS  PubMed  Google Scholar 

  30. Tsui BC, Gupta S, Finucane B. Detection of subarachnoid and intravascular epidural catheter placement. Can J Anaesth. 1999;46:675–8.

    Article  CAS  PubMed  Google Scholar 

  31. Tsui BC, Gupta S, Emery D, Finucane B. Detection of subdural placement of epidural catheter using nerve stimulation. Can J Anaesth. 2000;47:471–3.

    Article  CAS  PubMed  Google Scholar 

  32. Tsui BC. Thoracic epidural catheter placement in infants via the caudal approach under electrocardiographic guidance: simplification of the original technique. Anesth Analg. 2004;98:273.

    Article  PubMed  Google Scholar 

  33. Neal JM, Bernards CM, Butterworth JF, Di GG, Drasner K, Hejtmanek MR, Mulroy MF, Rosenquist RW, Weinberg GL. ASRA practice advisory on local anesthetic systemic toxicity. Reg Anesth Pain Med. 2010;35:152–61.

    Article  PubMed  Google Scholar 

  34. Lin EP, Aronson LA. Successful resuscitation of bupivacaine-induced cardiotoxicity in a neonate. Paediatr Anaesth. 2010;20:955–7.

    Article  PubMed  Google Scholar 

  35. Neal JM, Mulroy MF, Weinberg GL. American Society of Regional Anesthesia and Pain Medicine checklist for managing local anesthetic systemic toxicity: 2012 version. Reg Anesth Pain Med. 2012;37:16–8.

    Article  PubMed  Google Scholar 

  36. Shenoy U, Paul J, Antony D. Lipid resuscitation in pediatric patients—need for caution? Paediatr Anaesth. 2014;24:332–4.

    Article  PubMed  Google Scholar 

  37. Hojsak I, Kolacek S. Fat overload syndrome after the rapid infusion of SMOFlipid emulsion. JPEN J Parenter Enteral Nutr. 2014;38:119–21.

    Article  PubMed  Google Scholar 

  38. Lonnqvist PA. Toxicity of local anesthetic drugs: a pediatric perspective. Paediatr Anaesth. 2012;22:39–43.

    Article  PubMed  Google Scholar 

  39. Sethna NF, Clendenin D, Athiraman U, Solodiuk J, Rodriguez DP, Zurakowski D. Incidence of epidural catheter-associated infections after continuous epidural analgesia in children. Anesthesiology. 2010;113:224–32.

    Article  PubMed  Google Scholar 

  40. Kost-Byerly S, Tobin JR, Greenberg RS, Billett C, Zahurak M, Yaster M. Bacterial colonization and infection rate of continuous epidural catheters in children. Anesth Analg. 1998;86:712–6.

    Article  CAS  PubMed  Google Scholar 

  41. Wittum S, Hofer CK, Rolli U, Suhner M, Gubler J, Zollinger A. Sacral osteomyelitis after single-shot epidural anesthesia via the caudal approach in a child. Anesthesiology. 2003;99:503–5.

    Article  PubMed  Google Scholar 

  42. Bubeck J, Boos K, Krause H, Thies KC. Subcutaneous tunneling of caudal catheters reduces the rate of bacterial colonization to that of lumbar epidural catheters. Anesth Analg. 2004;99:689–93, table.

    Google Scholar 

  43. Staudt JM, Smeulders MJ, van der Horst CM. Normal compartment pressures of the lower leg in children. J Bone Joint Surg Br. 2008;90:215–9.

    Article  CAS  PubMed  Google Scholar 

  44. Dunwoody JM, Reichert CC, Brown KL. Compartment syndrome associated with bupivacaine and fentanyl epidural analgesia in pediatric orthopaedics. J Pediatr Orthop. 1997;17:285–8.

    CAS  PubMed  Google Scholar 

  45. Johnson DJ, Chalkiadis GA. Does epidural analgesia delay the diagnosis of lower limb compartment syndrome in children? Paediatr Anaesth. 2009;19:83–91.

    Article  PubMed  Google Scholar 

  46. Bhatia A, Brull R. Review article: is ultrasound guidance advantageous for interventional pain management? A systematic review of chronic pain outcomes. Anesth Analg. 2013;117:236–51.

    Article  PubMed  Google Scholar 

  47. Kent ML, Hackworth RJ, Riffenburgh RH, Kaesberg JL, Asseff DC, Lujan E, Corey JM. A comparison of ultrasound-guided and landmark-based approaches to saphenous nerve blockade: a prospective, controlled, blinded, crossover trial. Anesth Analg. 2013;117:265–70.

    Article  PubMed  Google Scholar 

  48. Schnabel A, Meyer-Friessem CH, Zahn PK, Pogatzki-Zahn EM. Ultrasound compared with nerve stimulation guidance for peripheral nerve catheter placement: a meta-analysis of randomized controlled trials. Br J Anaesth. 2013;111:564–72.

    Article  CAS  PubMed  Google Scholar 

  49. Gelfand HJ, Ouanes JP, Lesley MR, Ko PS, Murphy JD, Sumida SM, Isaac GR, Kumar K, Wu CL. Analgesic efficacy of ultrasound-guided regional anesthesia: a meta-analysis. J Clin Anesth. 2011;23:90–6.

    Article  PubMed  Google Scholar 

  50. Neal JM, Brull R, Chan VW, Grant SA, Horn JL, Liu SS, McCartney CJ, Narouze SN, Perlas A, Salinas FV, Sites BD, Tsui BC. The ASRA evidence-based medicine assessment of ultrasound-guided regional anesthesia and pain medicine: executive summary. Reg Anesth Pain Med. 2010;35:S1–9.

    Article  PubMed  Google Scholar 

  51. Barrington MJ, Kluger R. Ultrasound guidance reduces the risk of local anesthetic systemic toxicity following peripheral nerve blockade. Reg Anesth Pain Med. 2013;38:289–99.

    Article  PubMed  Google Scholar 

  52. Sites BD, Taenzer AH, Herrick MD, Gilloon C, Antonakakis J, Richins J, Beach ML. Incidence of local anesthetic systemic toxicity and postoperative neurologic symptoms associated with 12,668 ultrasound-guided nerve blocks: an analysis from a prospective clinical registry. Reg Anesth Pain Med. 2012;37:478–82.

    Article  CAS  PubMed  Google Scholar 

  53. Orebaugh SL, Kentor ML, Williams BA. Adverse outcomes associated with nerve stimulator-guided and ultrasound-guided peripheral nerve blocks by supervised trainees: update of a single-site database. Reg Anesth Pain Med. 2012;37:577–82.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  54. Ecoffey C, Oger E, Marchand-Maillet F, Cimino Y, Rannou JJ, Beloeil H. Complications associated with 27031 ultrasound-guided axillary brachial plexus blocks: a web-based survey of 36 French centres. Eur J Anaesthesiol. 2014;31:606–10.

    Article  PubMed  Google Scholar 

  55. Oberndorfer U, Marhofer P, Bosenberg A, Willschke H, Felfernig M, Weintraud M, Kapral S, Kettner SC. Ultrasonographic guidance for sciatic and femoral nerve blocks in children. Br J Anaesth. 2007;98:797–801.

    Article  CAS  PubMed  Google Scholar 

  56. Tsui BC, Pillay JJ. Evidence-based medicine: Assessment of ultrasound imaging for regional anesthesia in infants, children, and adolescents. Reg Anesth Pain Med. 2010;35:S47–54.

    Article  PubMed  Google Scholar 

  57. Rubin K, Sullivan D, Sadhasivam S. Are peripheral and neuraxial blocks with ultrasound guidance more effective and safe in children? Paediatr Anaesth. 2009;19:92–6.

    Article  PubMed  Google Scholar 

  58. Boretsky KR. Regional anesthesia in pediatrics: marching forward. Curr Opin Anaesthesiol. 2014;27:556–60.

    Article  CAS  PubMed  Google Scholar 

  59. Ecoffey C. Safety in pediatric regional anesthesia. Paediatr Anaesth. 2012;22:25–30.

    Article  PubMed  Google Scholar 

  60. Lam DK, Corry GN, Tsui BC. Evidence for the use of ultrasound imaging in pediatric regional anesthesia: a systematic review. Reg Anesth Pain Med. 2016;41(2):229–41.

    Article  CAS  PubMed  Google Scholar 

  61. Perlas A. Evidence for the use of ultrasound in neuraxial blocks. Reg Anesth Pain Med. 2010;35:S43–6.

    Article  PubMed  Google Scholar 

  62. Roberts S. Ultrasonographic guidance in pediatric regional anesthesia. Part 2: techniques. Paediatr Anaesth. 2006;16:1112–24.

    Article  PubMed  Google Scholar 

  63. Willschke H, Marhofer P, Bosenberg A, Johnston S, Wanzel O, Sitzwohl C, Kettner S, Kapral S. Epidural catheter placement in children: comparing a novel approach using ultrasound guidance and a standard loss-of-resistance technique. Br J Anaesth. 2006;97:200–7.

    Article  CAS  PubMed  Google Scholar 

  64. Willschke H, Bosenberg A, Marhofer P, Willschke J, Schwindt J, Weintraud M, Kapral S, Kettner S. Epidural catheter placement in neonates: sonoanatomy and feasibility of ultrasonographic guidance in term and preterm neonates. Reg Anesth Pain Med. 2007;32:34–40.

    PubMed  Google Scholar 

  65. Roberts SA, Guruswamy V, Galvez I. Caudal injectate can be reliably imaged using portable ultrasound—a preliminary study. Paediatr Anaesth. 2005;15:948–52.

    Article  PubMed  Google Scholar 

  66. Triffterer L, Machata AM, Latzke D, Willschke H, Rebhandl W, Kimberger O, Marhofer P. Ultrasound assessment of cranial spread during caudal blockade in children: effect of the speed of injection of local anaesthetics. Br J Anaesth. 2012;108:670–4.

    Article  CAS  PubMed  Google Scholar 

  67. Lundblad M, Lonnqvist PA, Eksborg S, Marhofer P. Segmental distribution of high-volume caudal anesthesia in neonates, infants, and toddlers as assessed by ultrasonography. Paediatr Anaesth. 2011;21:121–7.

    Article  PubMed  Google Scholar 

  68. Lundblad M, Eksborg S, Lonnqvist PA. Secondary spread of caudal block as assessed by ultrasonography. Br J Anaesth. 2012;108:675–81.

    Article  CAS  PubMed  Google Scholar 

  69. Mossetti V, Ivani G. Controversial issues in pediatric regional anesthesia. Paediatr Anaesth. 2012;22:109–14.

    Article  PubMed  Google Scholar 

  70. Ala-Kokko TI, Karinen J, Raiha E, Kiviluoma K, Alahuhta S. Pharmacokinetics of 0.75 % ropivacaine and 0.5 % bupivacaine after ilioinguinal-iliohypogastric nerve block in children. Br J Anaesth. 2002;89:438–41.

    CAS  PubMed  Google Scholar 

  71. Karmakar MK, Aun CS, Wong EL, Wong AS, Chan SK, Yeung CK. Ropivacaine undergoes slower systemic absorption from the caudal epidural space in children than bupivacaine. Anesth Analg. 2002;94:259–65, table.

    Google Scholar 

  72. Dadure C, Capdevilla X. Peripheral catheter techniques. Ped Anesth. 2012;22:93–101.

    Article  Google Scholar 

  73. de Jose Maria B, Banus E, Navarro-Egea M, Banchs RJ. Tips and tricks to facilitate ultrasound-guided placement of peripheral nerve catheters in children. Paediatr Anaesth. 2011;21:974–9.

    Article  PubMed  Google Scholar 

  74. Gurnaney H, Kraemer FW, Maxwell L, Muhly WT, Schleelein L, Ganesh A. Ambulatory continuous peripheral nerve blocks in children and adolescents: a longitudinal 8-year single center study. Anesth Analg. 2014;118:621–7.

    Article  PubMed  Google Scholar 

  75. Hall Burton DM, Boretsky KR. A comparison of paravertebral nerve block catheters and thoracic epidural catheters for postoperative analgesia following the Nuss procedure for pectus excavatum repair. Paediatr Anaesth. 2014;24:516–20.

    Article  PubMed  Google Scholar 

  76. Ivani G, Mossetti V. Continuous central and perineural infusions for postoperative pain control in children. Curr Opin Anaesthesiol. 2010;23:637–42.

    Article  PubMed  Google Scholar 

  77. Muhly W, Gurnaney H, Hosalkar H, Kraemer F, Davidson R, Ganesh A. Continuous perineural infusion after lower extremity osteotomies in children: a feasibility and safety analysis. Br J Anaesth. 2013;110:851–2.

    Article  CAS  PubMed  Google Scholar 

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Author information

Authors and Affiliations

  1. Department of Pediatric Anesthesiology, Hospital Sant Joan de Déu, University of Barcelona, Barcelona, Spain

    Belen De Jose Maria MD, PhD

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  1. Belen De Jose Maria MD, PhD
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Correspondence to Belen De Jose Maria MD, PhD .

Editor information

Editors and Affiliations

  1. Department of Anesthesiology and Pain Medicine University of Alberta, Edmonton, Alberta, Canada

    Brendan T. Finucane

  2. Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, California, USA

    Ban C.H. Tsui

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De Jose Maria, B. (2017). Local and Regional Anesthesia in Pediatrics. In: Finucane, B., Tsui, B. (eds) Complications of Regional Anesthesia. Springer, Cham. https://doi.org/10.1007/978-3-319-49386-2_20

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  • DOI: https://doi.org/10.1007/978-3-319-49386-2_20

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