Advertisement

Stellenwert der Regionalanästhesie in der Kinderchirurgie

  • H. Kaiser
  • H. C. Niesel
Conference paper

Summary

Indications for different forms of regional anaesthesia in paediatric surgery, advantages and disadvantages of the various methods, and techniques of plexus and peripheral nerve blocks are presented and discussed in some detail. It is generally accepted that regional anaesthesia is indicated in children in the following situations: acute care of non-fasted patients, difficulties or high risks with intubation, family history of malignant hyperthermia, chronic airways disease, reduced respiratory reserve, underdeveloped pharyngeal or laryngeal reflexes and fear of loss of self-control during unconsciousness. The dosage of local anaesthetic agents should be based on the expected and possible plasma level curves, and technical and temporal monitoring should be decided on with reference to the administration technique. Whenever possible regional anaesthesia in children should be applied if adequate sedation is induced or during general anaesthesia. Regional anaesthetic agents, particularly when administered before the operation, reduce the amounts of inhalation anaesthetics, opioids and muscle relaxants required and also attenuate the metabolic stress reaction. Earlier and less difficult recovery, a lower incidence of apnoeic episodes and less frequent postnarcotic vomiting are further advantages of regional anaesthesia. Postoperatively, regional anaesthesia can be maintained with the aid of the catheter technique for several hours or even days with no danger of respiratory depression.

The different indications for plexus and peripheral nerve blocks and the appropriate techniques are listed. The axillary access is preferred for blockade of the brachial plexus because of the lower complication rate. The perivascular subclavian technique is especially suitable when there are injuries in the area of the elbow and upper arm, while the interscalene approach is the access route of choice for shoulder dislocations. Peripheral electrical nerve stimulation is helpful in the localization of the plexus. The local anaesthetic agent selected depends on what is expected of the blockade. There are no specific preferences for a particular agent for use in paediatric surgery. The dose of any local anaesthetic agent should be based on the child’s body weight. Continuous blockade of the brachial plexus by means of a catheter is indicated for long operations, particularly reconstructive surgery, postoperative analgesia and prolonged blockade of the sympathetic nervous system to improve the situation with regard to perfusion. Individual peripheral nerves can be blocked to supplement incomplete plexus blockades. For the lower extremities, blockade of the lumbosacral plexus rivals caudal anaesthesia in children. Peripheral electrical nerve stimulation is essential for precise localization of the nerve. Indications for intercostal blockade are rib fractures, postoperative analgesia following thoracotomy, and upper abdominal interventions with incision along the costal arch. Providing always that very strict cardiovascular monitoring is maintained, interpleural analgesia can also be a very helpful technique for the treatment of postthoracotomy pain in paediatric patients.

Preview

Unable to display preview. Download preview PDF.

Unable to display preview. Download preview PDF.

Literatur

  1. 1.
    Auberger HG, Niesel HC (1990) Praktische Lokalanästhesie - regionale Schmerztherapie, 5. Aufl. Thieme, Stuttgart New YorkGoogle Scholar
  2. 2.
    Arthur DS, McNicol LR (1986) Local anaesthetic techniques in paediatric surgery. Br J Anaesth 58: 760PubMedCrossRefGoogle Scholar
  3. 3.
    Astra Chemicals (1989) Regionalanästhesie, 3. Aufl. Fischer, Stuttgart New YorkGoogle Scholar
  4. 4.
    Beck GP (1963) Anterior approach to sciatic nerve block. Anesthesiology 24: 222PubMedCrossRefGoogle Scholar
  5. 5.
    Chayen D, Nathan H, Chayen M (1976) The psoas compartment block. Anesthesiology 45: 95PubMedCrossRefGoogle Scholar
  6. 6.
    Clayton ML, Turner DA (1959) Upper arm block anesthesia in children with fractures. JAMA 169: 99CrossRefGoogle Scholar
  7. 7.
    Dalens B, Tanguy A, Vanneuville G (1990) Sciatic nerve block in children: comparison of the posterior, anterior and lateral approach in 180 patients. Anesth Analg 70: 131–137PubMedCrossRefGoogle Scholar
  8. 8.
    Duncan PG, Kobrinsky N (1983) Prilocaine-induced methemoglobinemia in a newborn infant. Anesthesiology 59: 75PubMedCrossRefGoogle Scholar
  9. 9.
    Eriksson E (1965) Axillary brachial plexus anaesthesia in children with citanest. Acta Anaesthesiol Scand [Suppl] XVI: 291CrossRefGoogle Scholar
  10. 10.
    Feig SA in Nathan DG, Oski FA (1974) Methemoglobinemia, hematology of infancy and childhood. Saunders, Philadelphia, pp 378–389Google Scholar
  11. 11.
    Gottschall V, Matysek R (1989) Plexusanästhesie bei Kindern ab dem 6. Lebensjahr. In: Kretz FJ, Eyrich K (Hrsg) Kinderanästhesie-Symposium. Springer, Berlin Heidelberg New York Tokyo, S 219CrossRefGoogle Scholar
  12. 12.
    Hoffmann P, Schockendorff B, Wagner U (1983) Axilläre Blockade des Plexus brachialis im Kindesalter. Regionalanaesthesie 6: 86Google Scholar
  13. 13.
    Ichiyanagi K (1959) Sciatic nerve block: lateral approach with the patient supine. Anesthesiology 20: 601CrossRefGoogle Scholar
  14. 14.
    Ilias W, Zimpfer M, Mutz N (1981) Plexusanästhesie im Kindesalter. Anaesth Intensivmed 140: 6Google Scholar
  15. 15.
    Ilias W, Fitzal S, Mutz N, Scherzer W, Tonczar L (1978) Die kontinuierliche perivasculäre axilläre Plexus-Blockade bei Replantationen an der Hand. Regionalanaesthesie 1: 79Google Scholar
  16. 16.
    Kaiser H, Niesei HC, Klimpel L (1988) Einfluß der Reizstromstärke der Nervenstimulation auf Latenz und Erfolg der hinteren Ischiadikusblockade. Regionalanästhesie 11: 92Google Scholar
  17. 17.
    Kaiser H, Niesei HC, Hans V (1990) Grundlagen und Anforderungen der peripheren elektrischen Nervenstimulation. Regionalanaesthesie 13: 143Google Scholar
  18. 18.
    Kaiser H, Niesel HC, Hans V, Klimpel L (1990) Untersuchungen zur Funktion peripherer Nervenstimulatoren für die Durchführung von Nerven und Plexusblockaden. Regionalanaesthesie 13: 172Google Scholar
  19. 19.
    Kulenkampff D (1912) Die Anästhesierung des Plexus brachialis. Beitr Klin Chir 79: 550Google Scholar
  20. 20.
    Kvalheim L, Reiestad F (1984) Interpleural catheter in the management of postoperative pain. Anesthesiology 61: 231CrossRefGoogle Scholar
  21. 21.
    Labat G (1929) Regional anesthesia. Its technic and clinical application. Saunders, PhiladelphiaGoogle Scholar
  22. 22.
    McIlvain WB, Knox RF, Fennessey PV, Goldstein M (1988) Continuous infusion of bupivacaine via intrapleural catheter for analgesia after thoracotomy in children. Anesthesiology 69: 261CrossRefGoogle Scholar
  23. 23.
    McNicol LR (1986) Lower limb block for children. Anaesthesia 41: 27PubMedCrossRefGoogle Scholar
  24. 24.
    Niesel HC, Rodriguez P, Wilsmann J (1974) Regionalanästhesie der oberen Extremität bei Kindern. Anaesthesist 23: 178PubMedGoogle Scholar
  25. 25.
    Niesel HC, Klimpel L, Kaiser H, Al-Rafai S (1989) Die einzeitige Intercostalblockade — operative und therapeutische Indikationen. Regionalanästhesie 12: 1Google Scholar
  26. 26.
    Niesel HC, Kaiser H (1991) Grenzdosis für Lokalanästhetika. Empfehlungen nach toxikologischen und pharmakokinetischen Daten. Regionalanästhesie 14: 79Google Scholar
  27. 27.
    Pilling L (1983) Die subaxilläre Plexusanästhesie im Kindesalter. Zentralbl Chir 108: 815PubMedGoogle Scholar
  28. 28.
    Pitkin GB (1953) Conduction anaesthesia, 2nd edn. Lippincott, PhiladelphiaGoogle Scholar
  29. 29.
    Rothstein P, Arthur GR, Feldman H, Barash PG, Kopf G, Sudan N, Covino BG (1982) Pharmacokinetics of bupivacaine in children following intercostal block. Anesthesiology 57: A426CrossRefGoogle Scholar
  30. 30.
    Saint Maurice C (1990) Intercostal nerve block. In: Saint Maurice C, Schulte Steinberg O (eds) Regional anesthesia in children. Appleton & Lange/Mediglobe, Norwalk San Mateo FribourgGoogle Scholar
  31. 31.
    Selander D (1987) Axillary plexus block: paresthetic or perivascular. Anesthesiology 66: 726PubMedCrossRefGoogle Scholar
  32. 32.
    Semsroth M, Haumer H, Kassal H (1991) Interpleurale Analgesie nach Thoracotomien im Kindesalter. Anaesthesist 40 [Suppl2]: 9Google Scholar
  33. 33.
    Serlo W, Haapanemi L (1985) Regional anaesthesia in paediatric surgery. Acta Anaesthesiol Scand 29: 283PubMedCrossRefGoogle Scholar
  34. 34.
    Shelly MP, Park GR (1987) Intercostal nerve blockade for children. Anaesthesia 42: 541PubMedCrossRefGoogle Scholar
  35. 35.
    Small GA (1951) Brachial plexus block anesthesia in children. JAMA 147: 1648CrossRefGoogle Scholar
  36. 36.
    Winnie AP (1970) Interscalene brachial plexus block. Anesth Analg 49: 455PubMedCrossRefGoogle Scholar
  37. 37.
    Winnie AP, Collins VJ (1964) The subclavian perivascular technique of brachial plexus anesthesia. Anesthesiology 25: 353PubMedCrossRefGoogle Scholar
  38. 38.
    Winnie AP, Ramamurthy S, Durrani Z (1973) The inguinal paravascular technic of lumbar plexus anesthesia: the „3-in-1 block“. Anesth Analg 52: 989PubMedGoogle Scholar

Copyright information

© Springer-Verlag Berlin Heidelberg 1993

Authors and Affiliations

  • H. Kaiser
    • 1
  • H. C. Niesel
    • 1
  1. 1.AnästhesieSt. Marien- und St. AnnastiftskrankenhausLudwigshafenDeutschland

Personalised recommendations