202406151710

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Tags: Paed, Regional Anaesthesia

Paediatric regional anaesthesia

for many years it was presumed that neonates and infants had underdeveloped nervous systems, and thus did not feel pain or remember painful experiences. Landmark studies clearly refuted these longstanding fallacies

Caudal anaesthesia

ADAPREF study

benefits of RA

Controversies

Compartment syndrome

The European Society of Regional Anaesthesia and Pain Therapy and the American Society of Regional Anesthesia and Pain Medicine Joint Committee released a joint statement that supported the safe use of regional anesthesia in pediatric patients with no evidence that it may increase the risk of acute compartment syndrome or delay its diagnosis

Local Anesthetic Concentration Single shot (Peripheral and neuraxial):
Use 0.1%–0.25% bupivacaine, levobupivacaine, or ropivacaine concentrations
Continuous Infusions
Use 0.1% of Bupivacaine, levobupivacaine, or ropivacaine concentration
High Risk Surgery for Compartment Syndrome These include tibial compartment surgery, advised to restrict both volume and concentration in sciatic catheters to avoid overly dense nerve blockade
Local anesthetic additives Use with caution as additives can increase duration and/or density of block
Monitoring Patients at higher risk for compartment syndrome who have received a regional anesthetic should be followed by an acute pain service to allow for early detection
Urgent Workup If compartment syndrome is suspected, compartment pressure should be urgently measured

test dose

The test dose should contain 0.1 ml/kg of local anesthetic with 5 μg/mL of epinephrine. The dose of epinephrine is considered sufficient to detect hemodynamic changes, yet small enough that it would not be detrimental to the patient

Several factors that have been hypothesized to alter the reliability of a test dose: a) general anesthesia, including premedication, during the time of the test dose administration; b) higher basal heart rate in pediatric patients; c) variation based on age and the cardiovascular response to epinephrine.

LOR

Less than 1 mL of air is recommended for use in infants when utilizing air. A lower volume of saline will avoid dilution of the local anesthetic, which may impact block efficacy, and to allow for better identification of a dural puncture

Caudal block & hypospadias

researchers hypothesized that the sympathetic block resulting from CEB can lead to penile sinus vasodilation, venous pooling causing penile engorgement and impaired wound healing

Given available data and literature, it is unlikely that the type of regional anesthesia is associated with postoperative complications following hypospadias repair. Age, severity of hypospadias, and surgical repair technique and surgeon experience are more likely contributing risk factors.

block after GA vs awake

One of the biggest identifiable differences between adult and pediatric regional anesthesia is the propensity to perform blocks, both peripheral and neuraxial, after the induction of general anesthesia in the pediatric population, as opposed to awake or with minimal sedation as in adults. Therefore, one of the primary challenges in recent times has been addressing safety concerns, particularly when performing regional techniques in conjunction with general anesthesia. This combination raises concerns about the loss of critical sensory feedback, which typically serves as an alert for unintentional intravascular injection or paresthesias, signaling potential nerve injury.

The risk for neurologic or severe local anesthetic toxicity was found to be higher for awake or sedated blocks than under general anesthesia, even when adjusted for age

References

Pediatric Regional Anesthesia and Acute Pain Management State of the Art