Performance of regional anesthesia in children

Arjunan Ganesh; Wallis T. Muhly

doi:10.1017/CBO9781316162538.002

2 - Performance of regional anesthesia in children

from Section 1 - Principles and practice

Published online by Cambridge University Press: 05 September 2015

Arjunan Ganesh and

Edited by

Mark D. Reisbig and

Arjunan Ganesh: Affiliation:
University of Pennsylvania, Philadelphia, PA, USA
Wallis T. Muhly: Affiliation:
University of Pennsylvania, Philadelphia, PA, USA
Stephen Mannion: Affiliation:
University College Cork
Gabrielle Iohom: Affiliation:
University College Cork
Christophe Dadure: Affiliation:
Hôpital Lapeyronie, Montpellier
Mark D. Reisbig: Affiliation:
Creighton University Medical Center, Omaha, Nebraska
Arjunan Ganesh: Affiliation:
Children’s Hospital of Philadelphia

Book contents

Get access

Summary

Introduction

The use of regional anesthesia for post-operative analgesia in children has gained popularity over time. While the caudal block is still the most commonly performed regional anesthetic technique in children, the performance of peripheral nerve blocks is growing. Advances in ultrasound technology have certainly contributed to the increase in the use of regional anesthetic techniques in children. The ability to view the anatomy and the use of real-time needle guidance has increased the confidence among anesthesiologists to perform a variety of regional anesthetic procedures in anesthetized children.

A successful regional anesthetic block requires adequate distribution of local anesthetic (LA) around the target neural structures (Marhofer et al., 2005). The ability to visualize the spread of LA adjacent to the neural structures has improved the success of regional anesthetic techniques. In addition, variations in anatomy can be recognized with the use of ultrasound, which in turn has the potential to increase the safety and success of regional anesthetic techniques.

This chapter describes the key principles necessary for performing safe and effective ultrasound-guided regional anesthesia in children – a number of the topics are considerably expanded on in subsequent chapters.

Anatomy and physiology

Chapter 6 describes the relevant anatomy for the blocks described in this book – below is a brief outline of the key anatomic differences between children and adults.

With regard to peripheral nerve blocks anatomic differences between children and adults may not be significant, although the smaller size of infants and children (structures are more superficial compared to adults) allow the use of higher frequency ultrasound probes resulting in a higher resolution image. However, one needs to appreciate the differences with neuraxial blockade. In a study using ultrasound guidance for epidural placement in children, the median value for the termination of the spinal cord was noted to be L2, but was as low as L3/L4 in some neonates (Willschke et al., 2007). Also, the dural sac in infants extends up to the S3 level. This is in contrast to adults where the spinal cord ends at the level of L1 and the dural sac at S1. Practitioners need to keep this in mind when performing neuraxial blockade in order to avoid injury to the spinal cord or an unintentional intrathecal injection.

Type: Chapter
Information: Ultrasound-Guided Regional Anesthesia in Children
A Practical Guide
, pp. 5 - 12

DOI: https://doi.org/10.1017/CBO9781316162538.002 [Opens in a new window]

Publisher: Cambridge University Press

Print publication year: 2015

Access options

Get access to the full version of this content by using one of the access options below. (Log in options will check for institutional or personal access. Content may require purchase if you do not have access.)

References

Auroy, Y, Benhamou, D, Bargues, L., et al. (2002) Major complications of regional anesthesia in France: the SOS Regional Anesthesia Hotline Service. Anesthesiology. 97,1274–80.Google Scholar

Benumof, JL. (2000) Permanent loss of cervical spinal cord function associated with interscalene block performed under general anesthesia. Anesthesiology. 93,1541–4.Google Scholar

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

Bernards, CM, Hadzic, A, Suresh, S, Neal, JM. (2008) Regional anesthesia in anesthetized or heavily sedated patients. Reg Anesth Pain Med. 33,449–60.Google Scholar

Bosenberg, AT, Thomas, J, Cronje, L, et al. (2005) Pharmacokinetics and efficacy of ropivacaine for continuous epidural infusion in neonates and infants. Paediatr Anaesth. 15,739–49.Google Scholar

Broome, ME, Kodish, E, Geller, G, Siminoff, LA. (2003) Children in research: new perspectives and practices for informed consent. IRB. Suppl 25(5),S20–3.Google Scholar

Casati, A, Baciarello, M, Di Cianni, S, et al. (2007) Effects of ultrasound guidance on the minimum effective anaesthetic volume required to block the femoral nerve. Br J Anaesth. 98,823–7.Google Scholar

Dohi, S, Seino, H. (1986). Spinal anesthesia in premature infants: dosage and effects of sympathectomy. Anesthesiology. 65,559–61.Google Scholar

Dohi, S, Naito, H, Takahashi, T. (1979) Age-related changes in blood pressure and duration of motor block in spinal anesthesia. Anesthesiology. 50,319–23.Google Scholar

Dony, P, Dewinde, V, Vanderick, B, et al. (2000). The comparative toxicity of ropivacaine and bupivacaine at equipotent doses in rats. Anesth Analg. 91,1489–92.Google Scholar

Ecoffey, C. (2012) Safety in pediatric regional anesthesia. Paediatr Anaesth. 22,25–30.Google Scholar

Ecoffey, C, Dalens, B. (2003). Informed consent for children. Curr Opin Anaesthesiol. 16,205–8.Google Scholar

Feldman, HS, Arthur, GR, Covino, BG. (1989) Comparative systemic toxicity of convulsant and supraconvulsant doses of intravenous ropivacaine, bupivacaine, and lidocaine in the conscious dog. Anesth Analg. 69,794–801.Google Scholar

Fredrickson, MJ, Kilfoyle, DH. (2009) Neurological complication analysis of 1000 ultrasound guided peripheral nerve blocks for elective orthopaedic surgery: a prospective study. Anaesthesia. 64,836–44.Google Scholar

Ganesh, A, Rose, JB, Wells, L, et al. (2007) Continuous peripheral nerve blockade for inpatient and outpatient postoperative analgesia in children. Anesth Analg. 105,1234–42.Google Scholar

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

Griffin, J, Nicholls, B. (2010) Ultrasound in regional anaesthesia. Anaesthesia. 65 (Suppl 1),1–12.Google Scholar

Gurnaney, H, Kraemer, FW, Maxwell, L, et al. (2014) Ambulatory continuous peripheral nerve blocks in children and adolescents: a longitudinal 8-year single center study. Anesth Analg. 118,621–7.Google Scholar

Krane, EJ, Polaner, D. (2014) The safety and effectiveness of continuous peripheral nerve blockade in children. Anesth Analg. 118,499–500.Google Scholar

Krane, EJ, Dalens, BJ, Murat, I, Murrell, D. (1998) The safety of epidurals placed during general anesthesia. Reg Anesth Pain Med. 23,433–8.Google Scholar

Kriss, VM, Desai, NS. (1998) Occult spinal dysraphism in neonates: assessment of high-risk cutaneous stigmata on sonography. AJR Am J Roentgenol. 171,1687–92.Google Scholar

Lei, SY, Hache, M, Loepke, AW. (2014). Clinical research into anesthetic neurotoxicity: does anesthesia cause neurological abnormalities in humans? J Neurosurg Anesthesiol. 26,349–57.Google Scholar

Llewellyn, N, Moriarty, A. (2007). The national pediatric epidural audit. Paediatr Anaesth. 17,520–33.Google Scholar

Marhofer, P, Schrogendorfer, K, Wallner, T, et al. (1998). Ultrasonographic guidance reduces the amount of local anesthetic for 3-in-1 blocks. Reg Anesth Pain Med. 23,584–8.Google Scholar

Marhofer, P, Greher, M, Kapral, S. (2005). Ultrasound guidance in regional anaesthesia. Br J Anaesth. 94,7–17.Google Scholar

Neal, JM, Bernards, CM, Butterworth, JFT, et al. (2010) ASRA practice advisory on local anesthetic systemic toxicity. Reg Anesth Pain Med. 35,152–61.Google Scholar

Neal, JM, Mulroy, MF, Weinberg, GL. (2012) American Society of Regional Anesthesia and Pain Medicine checklist for managing local anesthetic systemic toxicity: 2012 version. Reg Anesth Pain Med. 37,16–18.Google Scholar

Polaner, DM, Taenzer, AH, Walker, BJ, et al. (2012) Pediatric Regional Anesthesia Network (PRAN): a multi-institutional study of the use and incidence of complications of pediatric regional anesthesia. Anesth Analg. 115,1353–64.Google Scholar

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

Rodriguez, J, Taboada, M, Garcia, F, et al. (2011) Intraneural hematoma after nerve stimulation-guided femoral block in a patient with factor XI deficiency: case report. J Clin Anesth. 23,234–7.Google Scholar

Sandhu, NS, Sidhu, DS, Capan, LM. (2004) The cost comparison of infraclavicular brachial plexus block by nerve stimulator and ultrasound guidance. Anesth Analg. 98,267–8.Google Scholar

Sripada, R, Reyes, JJ, Sun, R. (2009) Peripheral nerve blocks for intraoperative management in patients with hemophilia A. J Clin Anesth. 21,120–3.Google Scholar

Taenzer, AH, Walker, BJ, Bosenberg, AT, et al. (2014a) 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. 39,502–5.Google Scholar

Taenzer, AH, Walker, BJ, Bosenberg, AT, et al. (2014b). Asleep versus awake: does it matter? Pediatric regional block complications by patient state: a report from the Pediatric Regional Anesthesia Network. Reg Anesth Pain Med. 39,279–83.Google Scholar

Weinberg, GL. (2010) Treatment of local anesthetic systemic toxicity (LAST). Reg Anesth Pain Med. 35,188–93.Google Scholar

Willschke, H, Marhofer, P, Bosenberg, A, et al. (2005) Ultrasonography for ilioinguinal/iliohypogastric nerve blocks in children. Br J Anaesth. 95,226–30.Google Scholar

Willschke, H, Marhofer, P, Bosenberg, A, et al. (2006) Epidural catheter placement in children: comparing a novel approach using ultrasound guidance and a standard loss-of-resistance technique. Br J Anaesth. 97,200–7.Google Scholar

Willschke, H, Bosenberg, A, Marhofer, P, et al. (2007) Epidural catheter placement in neonates: sonoanatomy and feasibility of ultrasonographic guidance in term and preterm neonates. Reg Anesth Pain Med. 32,34–40.Google Scholar

Book contents

2 - Performance of regional anesthesia in children

Summary

Access options

References

Save book to Kindle

Save book to Dropbox

Save book to Google Drive