Stellenwert der Regionalanästhesie in der Kinderchirurgie

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.