Pediatric Regional Anesthesia and Acute Pain Management: State of the Art

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Metadata

Author: sciencedirect.com
Full Title: Pediatric Regional Anesthesia and Acute Pain Management: State of the Art
Category: #articles
Document Tags: paed part 2 regional
Summary: Pediatric regional anesthesia has evolved significantly in recent decades with the help of ultrasound guidance. Safety concerns remain a challenge, especially when combining regional techniques with general anesthesia. Studies show that performing regional anesthesia on children under general anesthesia is as safe as or safer than in awake adults.
URL: https://www.sciencedirect.com/science/article/pii/S1521689624000296

Highlights

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. (View Highlight)
prominent figures in pediatric anesthesia argued that the standard of care in medicine is “ultimately determined by the common practice of physicians and by common sense--an element that seemed to be lacking in the case report by Bromage and Benumof.” [18] They emphasized that performing regional anesthesia in awake or lightly sedated children might be even riskier, and instead recommend that they must be sedated or anesthetized to ensure the safe administration of a regional block while the child remains still and calm (View Highlight)
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 (View Highlight)
One key advantage of regional anesthesia is providing profound analgesia while causing only minor physiological disturbances (View Highlight)
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 (View Highlight)
Regional anesthesia also decreases opioid consumption and/or lower postoperative pain scores (View Highlight)
Regional anesthesia may also offer cardiovascular and respiratory benefits, such as a reduced risk of early post-operative apneic events when compared to general anesthesia (View Highlight)
patients receiving regional anesthesia may require less postoperative ventilatory support [22,34,38]. This may be attributed to the effective relief of pain without opioid-induced respiratory depression, as well as improved ventilatory efficiency (View Highlight)
an often reported benefit of spinal anesthesia is the avoidance of airway manipulation in patients in whom the anesthesiologist wishes to avoid general anesthesia, such as in the setting of upper respiratory infection or known difficult airway. This indication should be used in caution as the “backup” to spinal for a procedure would be general, unless the surgeon and anesthesiologist agree with the family beforehand that in the instance of spinal failure the case would be postponed or canceled. (View Highlight)
Infants and neonates, including premature infants as well as young children, tolerate spinal anesthesia well without significant change in heart rate, blood pressure, and respiration [13,43]. This is most likely due to balanced autonomic changes, a sympatholysis with withdrawal of cardiac vagal activity (View Highlight)
Economically, regional anesthesia offers several advantages. It facilitates same-day surgery discharge, prevents unplanned hospital admissions, reduces length of stay and significantly lowers healthcare costs (View Highlight)
Embracing Enhanced Recovery After Surgery (ERAS) protocols, where regional anesthesia plays a central role, can result in several benefits. These include shorter stays in the intensive care unit (ICU), reduced overall hospitalization duration, and cost savings (View Highlight)
Compartment syndrome is an acute emergency characterized by inter-compartmental tissue pressure >30 mm Hg (View Highlight)
Compartment syndrome is often associated with trauma, fractures, malpositioning during surgery or ischemia-reperfusion injury. The abnormally high pressure in a closed, non-compliant muscle compartment leads to decreased circulation, ischemia, and eventually myonecrosis. There is risk to loss of limb if treatment is delayed beyond 4 h from symptom onset (View Highlight)
some have argued that a comfortable patient with a nerve block who has sudden breakthrough pain would be more easily identified as having early symptoms of compartment syndrome (View Highlight)
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 (View Highlight)
The test dose should contain 0.1 ml/kg of local anesthetic with 5 μg/mL of epinephrine (View Highlight)
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. (View Highlight)
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 (View Highlight)
These researchers hypothesized that the sympathetic block resulting from CEB can lead to penile sinus vasodilation, venous pooling causing penile engorgement and impaired wound healing (View Highlight)
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. (View Highlight)