Aplication in Regional Anethesia in Pediatric

7/25/2019 Aplication in Regional Anethesia in Pediatric

1/11

Applications of regional anaesthesia in paediatrics

R. D. Shah and S. Suresh*

Department of Pediatric Anesthesiology, Ann & Robert H. Lurie Childrens Hospital, Feinberg School of Medicine, Northwestern University,

Chicago, IL 60611, USA

* Corresponding author. E-mail:[email protected];[email protected]

Editors key points

Regional anaesthetic techniques are

increasingly used for both acute and chronic

pain management in children.

Advantages in ultrasound guidance and

tailored dosing regimens have facilitated their

widespread use in paediatrics.

Evidence supportsthe safety and efficiencyof a

numberof regionalanaesthetictechniquesand

drug combinations.

Summary. Advances in the fieldof paediatric regional anaesthesia have specific

applications to both acute and chronic pain management. This review

summarizes data regarding the safety of paediatric regional anaesthetic

techniques. Current guidelines are provided for performing paediatric regional

techniques, with a focus on applications for postoperative pain management.

Brief descriptions of relevant anatomy followed by indications for commonly

performed blocks are highlighted along with the potential of adverse side-

effects.

Keywords: caudal analgesia; complications; paediatric anaesthesia,

peripheral; regional anaesthesia

Increased use of regional anaesthesia in infants, children, and

adolescents has significantly improved the scope of paediatric

painmanagement.Regionalanaesthesiaisgenerallyaccepted

as an integral component of postoperative pain relief in paedi-

atric patients.1 Several regional anaesthetic techniques are

also playing emerging roles in managing chronic paediatric

pain syndromes. Performance of regional anaesthesia can be

safely and effectively applied to paediatric patients, and

these techniques are becoming increasingly popular.2 3

Regional anaesthetic techniques are commonly performed

in paediatric patients4; largeprospective databases and expert

opinion have demonstrated the ability to safely perform re-

gionalanaesthesia in childrenwith minimal riskof neurological

damage.5 The use of ultrasoundguidanceand its incorporation

into the practice of regional anaesthesia has dramatically

improved routine paediatric perioperative care.

Safety of regional anaesthesia in children

Most regional anaesthetic techniques in adults are performed

awakeor with mild sedation,allowing patients to report pares-

thesias or pain during block placement, symptoms of local an-

aesthetic systemic toxicity (LAST), and progression of sensory

or motor block after injection.6

Although several authorshave criticized the practice of performing major neuraxial or

peripheral nerve blocks in adults under deep sedation or

general anaesthesia, this is commonly utilized in infants and

children to facilitate patient cooperation while performing

the block.7

In contrastto adult practice, themajority of regionalanaes-

thesia in children and infants is performed under either deep

sedation or general anaesthesia. Prospective and retrospective

safety studies support the notion that performing regional

anaesthesia under general anaesthesia is safe practice.5 8 9

The Pediatric Regional Anesthesia Network (PRAN), a multi-

centre collaborative effort, has facilitated the collection of

detailed prospective data for research and quality improve-

ment. Polaner and colleagues10 recently reported on the first

3 yr of data registry, giving an overall favourable impression

of the safety of modern paediatric regional anaesthesia prac-

tice (Table1).

Pharmacology and toxicity of local

anaesthetics in infants and childrenSafe dosing guidelines and age-related trends in local anaes-

thetic pharmacokinetics and pharmacodynamics have been

characterized and have facilitated expansion of paediatric re-

gional anaesthesia practice.11 12 Neurologic or cardiac toxicity

related to excessive local anaesthetic blood concentration is

more likely to occur in infants than in adults because of low

protein binding and decreased intrinsic clearance.13

Resuscitation measures mustbe initiated immediatelyafter

LAST. Neurotoxicity (seizures) can be treated with barbiturates,

benzodiazapines or propopfol. Recent evidence indicates that

the most successful treatment for LAST-related cardiotoxicity

is the administration of a lipid emulsion, which is now consid-ered first-line therapy.14 An emerging number of case reports

demonstrate that rapid bolus injections of lipid emulsion

reverse the toxic effects of local anaesthetics in paediatric

patients.15 Safe dosing limits for lipid resuscitation are import-

ant to establish in neonates and children because complica-

tions from lipid overload have been reported in neonates

receiving i.v. nutritional support.16 The recommended dose of

20% Intralipidw for paediatric patients is 25 ml kg21. This

dose is repeated (up to 10 ml kg21) if cardiac function does

not return (Table2).17 Although the exact mechanism of lipid

British Journal of Anaesthesia 111 (S1): i114i124 (2013)

doi:10.1093/bja/aet379

& The Author [2013]. Published by Oxford University Press on behalf of the British Journal of Anaesthesia. All rights reserved.

For Permissions, please email: [email protected]
mailto:[email protected]:[email protected]:[email protected]:[email protected]:[email protected]:[email protected]


2/11

Table1 Summaryof Single-injectionblocks andadverse event rates forall centres. Totaladverse event ratesreported inparentheses. Rates,1%

reported as decimals and.1% rounded to nearest whole number.Notethat in theneuraxial categoryand thelowerextremity category,the total

numberof complications arefewer than thecumulativesumsofthe individual types.Thisis because therewere3 casesin which2 blocksweredone

in a singlepatient, 1 successful block after a complicationin theother, andbecause of ambiguityin thedata entry,it wasimpossible to determine

which block was placed first. To assign the most conservative complication rate to the specific block category, the complication was counted

againstboth blocks, but the total number of complications in that general block type is accurate.See textfor more details. There were no serious

complications or sequelae reported in any single-injection group. TAP, transversus abdominis plane. Table reproduced from Polaner and

colleagues10 with permission from Lippincott Williams and Wilkins/Wolters Kluwer Health (&2012)

Total procedures Total adverse events (%) No sequelae No sequelaechange in treatment

Neuraxial

Caudal 6011 172 (3) 60 112

Lumbar 103 5 (5) 1 4

Thoracic 13 2 (15) 0 2

Subarachnoid 83 5 (6) 4 1

Total neuraxial 6210 183 (3) 64 119

Upper Extremity

Interscalene 80 0 0 0

Supraclavicular 164 6 (4) 2 4

Infraclavicular 40 0 0 0

Axillary 99 2 (2) 1 1

Musculocutaneous 5 0 0 0

Elbow 1 0 0 0

Wrist 7 0 0 0

Other 58 0 0 0

Total 455 8 (2) 3 5

Lower Extremity

Lumbar plexus 78 6 (8) 4 2

Fascia iliaca 221 1 (0.5) 0 1

Femoral 872 6 (0.7) 3 3

Sciatic 413 14 (3) 3 11

Popliteal fossa 319 2 (0.6) 0 2

Saphenous 78 0 0 0

Other 325 5 (2) 2 3

Total 2307 33 (1) 11 22

Head and neck

Supraorbital/supratrochlear 58 0 0 0

Infraorbital 139 0 0 0

Greater auricular/superficial cervical 157 0 0 0

Occipital 101 0 0 0

Greater palatine 11 0 0 0

Other 89 0 0 0

Total 556 0 0 0

Other block type

Intercostal 39 0 0 0

Ilioinguinal/iliohypogastric 737 3 (0.4) 1 2

Rectus sheath 294 0 0 0Paravertebral 14 1 (7) 0 1

Penile 230 0 0 0

TAP 140 1 (0.7) 0 1

Other 395 0 0 0

Total 1849 5 (0.3) 1 4

Paediatric regional anaesthesia BJA

i115


3/11

emulsion therapy is unknown, when administered rapidly after

the diagnosis of LAST, lipid resuscitation can be a life-saving

measure in paediatric patients, as has been reported to the

LipidRescue registry (www.lipidrescue.org).

Regional anaesthesia for paediatric acutepain management

A substantialbody of literature supports the safetyand efficacyof performing regional anaesthetic techniques in children.

Evidence-based literature shows that combined regional

and general anaesthesia can decrease hospital stay and

improve outcomes in paediatric patients.18 Despite some con-

troversy regarding the performance of regional anaesthesia in

sedated children, there is consensus among paediatric anaes-

thesiologists regarding the importance and feasibilityof safely

providing regional anaesthetic techniques under general an-

aesthesia.8

Central neuraxial techniques

Caudal analgesia

Caudal block is one of the most commonly used paediatric re-

gional anaesthetic techniques for postoperative analgesia.

Caudal block is performed in children undergoing surgery of

the lumbosacral to midthoracic dermatomal levels with antici-

pated moderate-to-severe postoperative pain. Its popularity

originates in part from easily palpable landmarks and relative

ease of placement. A styletted needle with a blunt tip is

passed through the sacrococcygeal ligament into the caudal

space. A distinct pop is felt when the caudal block space is

entered. Nerve stimulation and ultrasonography have been

describedas tools to assistin caudalplacement.1 9 2 0 Common-

ly used local anaesthetics include bupivacaine (0.125 0.25%)

or ropivacaine (0.1 0.375%) with 1:200 000 epinephrine at a

dose of 11.5 ml kg21 (maximum dosage 30 ml).

Continuous neuraxial catheters

Continuous epidural analgesia is commonly used to manage

post-surgical painin infants and children.21 Epidural catheters

can be placed in the thoracic, lumbar, or caudal regions. It is

also possible to inserta caudalcatheterand threadit cephaladto the desired dermatomal level. Bupivacaine and ropivacaine

arefrequently used localanaesthetic solutions.Common addi-

tives include opioids anda2-agonists, including fentanyl, mor-

phine, hydromorphone, and clonidine. It is imperative that

standardized dosing parameters for a single injection, and for

continuous infusion,be used in neonates,infants,and children

to avoid LAST.22 Suggested paediatric dosing regimens are

listed in Table3.

Peripheral nerve block

Peripheral and truncal nerve blocks are playing an emerging

role in paediatric postoperative pain management.

23

Severalperipheral blocks have also been described as effective in

achieving analgesia in paediatric trauma.24 These techniques

are typically performed under general anaesthesia and are

often performed utilizing ultrasound guidance. Head and neck,

transversus abdominis plane (TAP), rectus sheath, ilioinguinal/

iliohypogastric (IL/IH), and upper and lower extremity blocks

are commonly performed.25 35 Common dosing guidelines have

been included as a reference point for practitioners (Table 4).

Peripheral nerve blocks are also increasingly utilized in

paediatric chronic pain management to facilitate physical

therapy while providing sympathectomy; such interventional

approaches have become more plausiblewith the use of ultra-

sound guidance.36

Serial peripheral nerve blocks can be per-formed to treat chronic neuropathic pain in children. In such

circumstances, the pain relief often outlasts the duration of

conduction block, which might be attributable to reduced

central sensitization, and interruption of the circuit established

between nociceptor,centralnervoussystem,and motorunit.37

Concomitant corticosteroid administration can contribute to

this effect via anti-inflammatory action and suppression of

ectopicneuronaldischarge.38 We have noted that themajority

of patients with neuropathic pain who undergo serial periph-

eral nerve blocks experience pain relief that increases in dur-

ation after each block.

Table 3 Paediatric epidural dosing guidelines

Medication Initial bolus Infusion solution Infusion limits

Bupivicaine 2.53 mg kg21 0.06250. 1% 0.40. 5 mg kg21 h21

Ropivicaine 2.53 mg kg21 0.10. 2% 0.40.5 mg kg21 h21

Fentanyl 1 2 mg kg21 2 5 mg ml21 0.52 mg kg21 h21

Morphine 10 30 mg kg21 510 mg ml21 1 5 mg kg21 h21

Hydromorphone 2 6 mg kg21 2 5 mg ml21 12.5 mg kg21 h21

Clonidine 1 2 mg kg21 0.51 mg ml21 0.51 mg kg21 h21

Table 2 Treatment of LAST

Dosing guidelines for lipid resuscitation of paediatric

local anaesthetic toxicity

Administer1 mlkg21 of20% lipidemulsioni.v.overmorethan1 min

Repeat dose every 35 min to a maximum of 3 ml kg21

(up to total dose 10 ml kg21)

Maintenance infusion of 0.25 ml kg21 min21 until

circulation restored

BJA Shah and Suresh

i116
http://www.lipidrescue.org/http://www.lipidrescue.org/http://www.lipidrescue.org/http://www.lipidrescue.org/


4/11

Nerve block techniques utilized in adult pain management

have, in some instances, been applied to paediatric patients.

Mesnil and colleagues39 described the suprazygomatic ap-

proach to the maxillary nerve block, an effective procedure

for adults with trigeminal neuralgia, as useful to control post-

operative pain and facilitate early feeding resumption after

cleft palate repair in infants.

Continuous peripheral nerve block

Continuous peripheral nerve blocks (CPNBs) are increasingly

usedinpaediatricsasamethodofprovidingextendedduration

of pain relief40

and facilitating physical therapy in childrenwith chronic pain syndromes.41 CPNBs have been reported to

be effective in both reducing pain and enabling participation

in physical therapy in children with CRPS.41 Despite such re-

ports, limited data exist regarding the safety, feasibility, and

efficacy of CPNBs in children.42

Perineural catheters can be placed at various locations to

ensure site-specific analgesia. Brachial plexus catheters are

useful for surgical procedures of the shoulder, elbow, forearm,

and hand. Perineural catheter placement in the axillary region

can provide pain control, but concerns over catheter sterility

and migration exist.43 Catheters placed in the supraclavicular

region are effective and reduce these concerns. Placement of

a catheter into the TAP provides continuous analgesia anddecreases supplemental postoperative systemic opioid require-

ments.44 In addition, use of continuous TAP catheters in paedi-

atric patients can serve as an alternative to conventional

neuraxial catheters.45 TAP catheters can also provide analgesia

in patients with severe spinal deformitiesthat preclude neurax-

ial anaesthesia.46

CPNBsare alsousefulin providinglower extremityanalgesia

for extended periods. Femoral catheters have been used safely

and effectively in children.47 Continuous femoral nerve blocks

are commonly used to treat pain from surgery on the distal

femur and anterior knee and to treat complex regional

pain syndrome and cancer-related pain. Risks associated

with indwelling catheter placement include infection, nerve

damage, and falls as a result of block-induced quadriceps

motor weakness. Continuous sciatic nerve block can also be

used to provide analgesia to the lower extremity in infants

and children, with fewer adverse effects than epidural anaes-

thesia in children undergoing major foot and ankle surgery.48

CPNBs are evolvingas a novel extended analgesicmodality inpaediatrics. Ultrasound guidance can facilitate and confirm

placementof thecatheter, whichcan reducepainand potentially

eliminate the need for opioids and theirundesirable side-effects.

Ultrasound-guided peripheral nerve blocktechniques

Advances in ultrasonography have expanded the scope of re-

gional anaesthesia practice in paediatrics. Ultrasound guid-

ance improves the ease and safety of peripheral nerve block.

This section reviews some of the more common peripheral

nerve blocks in children and provides a straightforward ap-

proach to performing these blocks.

Upper extremity blocks

Brachialplexusblockcanbeperformedatvariouslocationsand

is applicable to upper extremity surgical procedures. Axillary,

infraclavicular, interscalene, and supraclavicular approaches

are possible, supraclavicular brachial plexus block being the

mostcommonupperextremityblockperformedinchildren(per-

sonal communication, PRAN database). The use of ultrasound

guidance when performing regional anaesthesia allows per-

formance of brachial plexusblocksat any locationsafelyand ef-

fectively by allowing better recognition of brachial plexus

anatomy and improved localization of adjacent structuresduring needle placement.

Axillary block

Anatomy and indications The axillary approach to the

brachial plexus block supplies analgesia to the elbow, forearm,

and hand via the radial, median, and ulnar nerves. The radial

nerve most commonly lies posterior to the axillary artery, and

the ulnar nerve lies anterior and inferior to the artery. The

median nerve is most often located anterior and superior to

the axillary artery. The musculocutaneous nerve is situated

outside of the axillary neurovascular sheath between the

biceps brachii and coracobrachilias muscles, and must be

blocked separately from the radial, median, and ulnar nerves.

Technique Although axillary block techniques are not welldescribed in the literature, ultrasound-guided axillary techniques

used in adults can be applied in children.49 50 An in-plane tech-

nique is utilized with the ultrasound probe positioned transverse

to the humerus (Fig.1). Multiple injections with needle repos-

itioning facilitate circumferential spread of the local anaesthetic

aroundeach nerve.51Carefulultrasound-guidedneedle advance-

ment should be completed because of the superficial depth of

the axillary sheath.

Table 4 Suggested dosing of local anaesthetics for peripheral

nerve blocks

Block technique Dose (ml

kg21)

Maximum

volume (ml)

Head and neck 0.1 5

Axillary 0.1 0.2 10

Infraclavicular 0.2 0.3 15

Intercostal 0.05 0.1 5

Rectus sheath 0.1 0.2 5

Ilioinguinal 0.1 0.2 10

Femoral nerve 0.2 0.3 15

Sciatic nerve 0.2 0.3 20

Popliteal fossa 0.2 0.3 15

Lumbar plexus 0.2 0.3 20

Penile 0.1 10

Digital nerve 0.05 0.1 5

Transversus abdominus p lane

(TAP)

0.2 (per side) 10 (perside)


i117


5/11

Complications Potential complications include neural injury,

intravascular injection, haematoma, skin puncture site infec-

tion, and skin tenderness. Utilization of ultrasound guidance

to facilitate needle advancement can help to reduce the

likelihood of haematoma formation from inadvertent vascular

puncture, intravascular injection, or nerve injury.

Interscalene block

Anatomy and indications Analgesia of the shoulder and

proximal humerus is achieved by blocking the brachial plexus

at the level of the interscalene groove. At this site, the trunks

and roots of the brachial plexus lie posterior to the

sternocleidomastoid muscle and are situated between the

anterior and middle scalene muscles. The C5, C6, and C7

nerve roots are easily seen between the anterior and middle

scalene muscles using this approach.

Technique Theultrasoundprobeispositionedinthetransverseoblique plane at the level of the cricoid cartilage at the lateral

border of the sternocleidomastoid muscle (Fig. 2). The

anterior and middle scalene muscles, which make up the

interscalene groove, lie deep to the sternocleidomastoid

muscle and lateral to the subclavian artery. The hyperechoic

structures that comprise the neurovascular bundle of the C5,

C6, and C7 nerve roots are contained within this groove.

Nerve stimulation can be used to guide local anaesthetic

delivery to the brachial plexus at this level; however,

ultrasound guidance might decrease the required total

amount of local anaesthetic.52 53

Complications Successful interscalene block is associatedwith hemidiaphragmatic paralysis, recurrent laryngeal nerve

block, and Horner syndrome; such side-effects should not be

mistaken for complications.54 The interscalene block should

be used with caution in children because of potential risks of

pneumothorax, vertebral artery injection, and intrathecal

injection.40

Supraclavicular block

Anatomy and indications The supraclavicular approach,which provides analgesia to the upper arm and elbow, facilitates

block of the trunks and divisions of the brachial plexus, whichare located lateral and superficial to the subclavian artery.

An important sonographic landmark is the first rib, which is

posterior and medial to the brachial plexus; the cervical

pleura is situated deep to these structures.

Technique Few techniqueshave beendescribedfor paediatric

patients.55 The ultrasound probe is positioned in the coronal-

oblique plane, just superior to the upper border of the

mid-clavicle. The subclavian artery, which is identified as a

hypoechoic and pulsatile structure, lies adjacent to the

brachial plexus. The needle is advanced medially towards the

brachial plexus, just superior and lateral to the subclavian

artery, using an in-plane approach. Potential risk ofintraneural injection or vascular puncture is minimized by

directing the needle in a lateral-to-medial fashion.

Complications Pneumothorax, haematoma, infection, andintravascular injection are possible complications of the

supraclavicular block. The potential for pneumothorax is

present as the lung parenchyma is located just medial to the

first rib. Direct visualization of the needle tip with

ultrasonography might decrease the likelihood of this

complication.

Infraclavicular block

Anatomy and indications Like the supraclavicular block, theinfraclavicular block provides analgesia to the upper arm and

elbow. This approach to the brachial plexus allows nerve

block at the level of the cords of the plexus that lie medial

and inferior to the coracoid process. The axillary artery and

vein are deep to the cords. The pectoralis major and minor

muscles are superficial to the brachial plexus. The lateral cord

of the plexus is seen on ultrasound as a hyperechoic

structure. The posterior cord is situated deep to the axillary

artery. The medial cord can be difficult to identify because of

its anatomical position between the axillary artery and vein.

MNAA

UN

RN

Fig1 Axillarynerveblocksonoanatomy.MN,mediannerve;AA,ax-

illary artery; UN, ulnar nerve; RN, radial nerve.

SCM

ASM

C5

C6

C7

MSM

Fig2 Interscalene blocksonoanatomy. SCM,sternocleidomastoid;

ASM, anterior scalene muscle; MSM, middle scalene muscle.

BJA Shah and Suresh

i118


6/11

Technique A lateral approach for performing the ultrasound-

guided infraclavicular block is described in the paediatric

literature.56 The ultrasound probe is positioned in a transverse

orientation below the clavicle to identify the brachial plexus.

The needle is inserted inferior to the probe and advanced

using an out-of-plane technique. The needle is directed lateral

to the cords of the brachial plexus; careful attention is needed

to avoid vascular structures as the local anaesthetic is

deposited into the deeper portions of the neurovascularsheath. De Jose Maria and colleagues55 described an

alternative technique in which the probe is positioned parallel

to the clavicle in a parasagittal plane, and the needle is

directed cephalad towards the brachial plexus.

Complications The infraclavicular block confers risks similar

to those of the supraclavicular block, including the risk of a

pneumothorax because of the close proximity of the cervical

pleura. The close location of the axillary artery and vein make

haematoma because of vascular puncture a potential

complication.

Truncal blocksThe frequent use of ultrasonography has increased the success

and safety of truncal blocks in paediatric regional anaesthesia

practice.The emerging role of minimallyinvasive surgical tech-

niques in children has expanded the spectrum of patients that

benefit from these blocks.

Transversus abdominus plane block

Anatomy and indications The TAP block supplies analgesiato the anterior abdominal wall and facilitates effective

postoperative pain control, but does not provide surgical

analgesia.44 This block is frequently utilized for laparoscopic

procedures to provide analgesia at port placement sites andfor larger abdominal incisions.57 58 Three muscle layers are

identified lateral to the rectus abdominis: the external

oblique, internal oblique, and the transversus abdominis

(Fig. 3). The TAP plane, which lies between the internal

oblique and transversus abdominis muscles, encases the

thoracolumbar nerve roots (T8 L1), which deliver sensory

innervation to the skin and muscles of the anterior

abdominal wall.

Technique An ultrasound-guided in-plane approach is used

to advance the needle into the TAP plane.59 The ultrasound

probe is positioned adjacent to the umbilicus and moved

laterally, away from the rectus abdominus, to facilitate

visualization of the three muscle layers of the abdominal

wall. The needle is advanced in-plane starting from either the

lateral or medial side. Injection of the local anaesthetic

creates an elliptical pocket within the TAP plane.

Complications Potential complications include infection,

peritoneal, bowel puncture, or both, and intravascular injection.

IL/IH nerve block

Anatomy and indications The IL/IH nerves originate fromT12 and L1 of the thoracolumbar plexus and provide

sensation to the inguinal area and the anterior scrotum. The

IL/IH nerves are blocked medial to the anterior superior iliac

spine where they traverse the internal oblique aponeurosis.

Successful IL/IH nerve block can provide equivalent relief to

caudal block for inguinal surgery with the benefit of

increased duration of postoperative analgesia.60 61

Technique The ultrasound probe is positioned medial to theanterior superior iliac spine, in-line with the umbilicus (Fig.4).

Three abdominal muscle layers are identified (internal oblique,

external oblique, and transversus abdominus). At this level,the external oblique muscle layer can be aponeurotic and

only two muscle layers may be seen.62 The IL/IH nerves

appear as oval structures that lie between the internal oblique

and transverse abdominal muscles. The needle is advanced

in-plane to the IL/IH nerves and the local anaesthetic is

injected. In children, ultrasound-guided block dramatically

reduces the volume of local anaesthetic required to produce

analgesia compared with landmark-based techniques.63 64

Complications Complications associated with IL/IH nerveblock are rare but include needle-insertion site infection,

intravascular injection, bowel puncture, pelvic haematoma,

and femoral nerve palsy.

Rectus sheath block

Anatomy and indications The rectus sheath block provides

analgesia along the midline of the anterior abdominal wall.

The rectus abdominis muscle, lying on the anterior abdominal

wall, is divided by the linea alba. The thoracolumbar nerves

(T7T11) lie posterior to rectus abdominis, immediately

anterior to the posterior sheath. The rectus sheath block is

commonly utilized to provide postoperative pain relief for

umbilical hernia and single-incision laparoscopic surgery.65

EO

IO

TA

Fig 3 TAP block sonoanatomy. EO, external oblique; IO, internaloblique; TA, transversus abdominis.


i119


7/11

Technique The ultrasound probe is placed lateral to theumbilicus and the rectus abdominis is identified. The

posterior rectus sheath lies immediately under the rectus

abdominis and sits above the peritoneum. The needle is

advanced in-plane from lateral to medial, and the local

anaesthetic is placed between the rectus abdominis and the

posterior rectus sheath.66

Complications Potential complications of the rectus sheath

block include infection, intravascular injection, and bowel

puncture.

Lower extremity blocks

Femoral nerve blockAnatomy and indications The femoral nerve, whichinnervates the anterior thigh and the knee, originates from

the L2, L3, and L4 nerve roots and is commonly blocked in

paediatrics for surgical interventions of the knee. The femoral

nerve sits lateral to the femoral artery and vein and is

encased in a neurovascular bundle that is easily seen with

ultrasonography.67 In addition to performing a single-shot

block, a perineural catheter can be safely placed to provide

extended analgesia.

Technique With the patient in the supine position, thefemoral nerve, artery, and vein are located within the

inguinal crease. The femoral nerve is identified lateral to theartery and the femoral vein is seen just medial to the artery

as a collapsible vessel. An in-plane or out-of-plane approach

can be used to guide the needle towards the lateral portion

of the femoral nerve. The local anaesthetic circumferentially

surrounds the nerve as it is injected.50 Careful needle

visualization with advancement decreases the likelihood of

inadvertent puncture of the femoral vessels.

Complications Potential complications of the femoral nerve

block include infection, nerve injury, and haematoma

formation secondary to femoral vessel puncture.

Saphenous nerve block

Anatomy and indications The saphenous nerve innervates

the knee and the medial portion of the leg below the knee. Itis a branch of the femoral nerve and courses within the

adductor canal, running adjacent to the sartorius muscle

before continuing onto the medial aspect of the knee (Fig.5).

It can be blocked proximally to provide sensory analgesia to

the anterior knee or can be blocked more distally to provide

analgesia solely to the medial aspect of the lower extremity.

Technique With the patient in the supine position, the leg is

abducted and laterally rotated as the probe is placed on the

medial aspect of the knee. The sartorius muscle is identified;

the saphenous nerve lies adjacent to this structure. The

needle is directed using an in-plane technique towards the

saphenous nerve and the local anaesthetic is injected.Complications Potential complications of saphenous nerveblock include nerve injury, haematoma formation from

arterial puncture, and infection at the needle-insertion site.

Sciatic nerve block

Anatomy and indications The sciatic nerve, whichoriginates from the nerve roots of L4 to S3, innervates the

posterior thigh and the portion of the leg distal to the knee

(excluding the medial component). The nerve exits the pelvis

via the greater sciatic foramen and courses inferior to the

gluteus maximus muscle, travelling distally through the

posterior popliteal fossa, where it splits into the tibial andcommon peroneal nerves. The nerve can be blocked via the

subgluteal, anterior thigh, or popliteal approaches in

children. Continuous sciatic nerve block, and a single-shot

technique, can provide extended analgesia in children.68 69

Technique The subgluteal approach to the sciatic nerverequires the patient to lie either in the lateral decubitus

position, with the hip and knee flexed, or in the prone

position. The ultrasound probe is placed between the greater

trochanter and the ischial tuberosity and the gluteus

maximus muscle is identified; the sciatic nerve is situated

EO

IO

IL/IH

TA

Fig 4 Ilioinguinal/iliohypogastric nerve block sonoanatomy. EO,

external oblique; IO, internal oblique; IL/IH, ilioinguinal/iliohypo-

gastric nerves; TA, transversus abdominis.

Anterior

Sartorius

SN

Posterior

Fig 5 Saphenous nerve block sonoanatomy. SN, saphenous nerve.

BJA Shah and Suresh

i120


8/11

deep to this structure. An in-plane or out-of-plane technique

can be utilized for needle guidance. The local anaesthetic is

injected until it circumferentially surrounds the nerve. A

perineural catheter can also be placed to deliver continuous

nerve block.

An anterior approach to sciatic nerve block can be per-

formed with an ultrasound-guided approach.70 This technique

is ideal for the non-anesthetized patient with lower extremity

discomfort, as the block is performed in the supine positionwith the patients leg abducted and laterally rotated. The

probe is placed inferior to the inguinal crease and the femur

is identified; the probe is moved medially to reveal the sciatic

nerve in its location deep and medial to the femur. The nerve

often lies deeper in larger patients, which can make this ap-

proach technically challenging to complete in older children.

The sciatic nerve can also be blocked more distally in the

popliteal fossa.71 The patient is positioned prone or can

remain supineand theultrasoundprobeis placedin thepoplit-

eal crease. The popliteal artery is seen; the tibial nerve, which

lies adjacentto theartery,canbe followedproximalto thejunc-

tion with the common peroneal nerve, merging together to

form the sciatic nerve. The sciatic nerve can be blocked here

or the tibial and common peroneal nerves can be individually

targeted at this location.

Complications Complications of sciatic nerve block includeskin puncture site infection, haematoma formation from

vessel puncture, and local anaesthetic toxicity.

Lumbar plexus block

Anatomy and indications The lumbar plexus originatesfrom the T12 to L5 nerve roots. Its branches, which include

the femoral, genitofemoral, lateral femoral cutaneous, andobturator nerves, innervate the lower abdomen and the

upper leg. The plexus is located within the psoas muscle,

deep to the paravertebral muscles, and can be blocked with

the ipsilateral sciatic nerve to achieve complete analgesia to

the lower extremity. Lumbar plexus block can be safely

performed in children.72

Technique The patient is positioned lateral decubitus and

the iliac crest and spinous processes are identified. The

ultrasound probe is placed lateral to the midline and the L4

or L5 transverse process is located. The erector spinae and

quadratus lumborum muscles lie deep to the transverseprocess, and deep to these, within the psoas major muscle, is

the lumbar plexus. Because of this anatomical location, the

plexus is often difficult to demarcate from the similar

echogenicity to muscle. Nerve stimulation can be used in

conjunction with ultrasonography to confirm needle

positioning near the plexus.

Complications Complications include infection, haema-

toma, and retroperitoneal bleeding because of the location

of the plexus.

Paravertebral block

Anatomy and indications The paravertebral space is a

potential wedge-shaped area that contains intercostal and

sympathetic nerve fibres. Boundaries of the paravertebral

space include the superior costotransverse ligament

posteriorly, the parietal pleura anteriorly, intervertebral discs

medially, and the head and neck of the ribs superiorly.

Paravertebral block has been described as an effectivemodality for achieving postoperative analgesia with fewer

adverse effects and fewer contraindications than central

neuraxial block.73 Indications include thoracotomy, breast

surgery, cholecystectomy, renal surgery, and inguinal

herniorraphy.74 Ultrasound-guided paravertebral block has

been utilized for postoperative pain management in children

undergoing thoracic and cardiac surgery procedures.75

Lonnqvist described continuous paravertebral block as a

viable option for extended postoperative analgesia.76

Technique The patient is placed in the lateral or proneposition. A linear array transducer is placed at the appropriate

spinous process and moved longitudinally in the cephalo-

caudad direction until the corresponding transverse process is

identified. The ultrasound probe is then rotated 908until it lies

perpendicular to the spinal column. The transverse process

and the pleura can both be seen at this point. A needle is

advanced in-plane until it traverses the intercostal muscles to

a point superficial to the pleural border (Fig. 6). A local

anaesthetic solution can be injected, a catheter placed into

this space, or both.

Cephalad

Needle

Transverse processat T3

Pleura

Paravertebralspace

Superior costo-transverse ligament

Fig 6 Sonoanatomy of the paravertebral space.


i121


9/11

Complications Potential complications of paravertebral

block include accidental pleural puncture, hypotension from

local anaesthetic spread centrally with sympathetic block,

neurological injury because of intrathecal or epidural entry,

and paravertebral haematoma formation.

Discussion

The practice of paediatric regional anaesthesia has made tre-mendous strides in recent years. Advances in ultrasonography

and precisedosing regimenshave facilitated widespread appli-

cations of regional anaesthetic techniques in infants, children,

and adolescents. Prospective studies indicate that these tech-

niques can be safely performed and positively impact on the

outcomes of paediatric patients undergoing painful proce-

dures and those who suffer from chronic pain. Large prospect-

ive databases in the USA and Europe will allow ongoing

monitoringof regionaltechniques in children andallow mean-

ingful decisions regarding their safety and efficacy.

Authors contributions

R.D.S.and S.S.: responsible for the conception of this review, in-

terpretation of thedata, drafting thereview, andfinal approval

of the published version.

Declaration of interest

None declared.

Funding

None.

References

1 Johr M. Practical pediatric regional anesthesia.Curr Opin Anaesth2013; 26: 32732

2 Good practice in postoperative and procedural pain management,

2nd edn.Paediatr Anaesth2012; 22Suppl 1: 179

3 Ecoffey C. Local anesthetics in pediatric anesthesia: an update.

Minerva Anestesiol2005; 71: 35760

4 Ecoffey C. Safety in pediatricregionalanesthesia. Paediatr Anaesth

2012; 22: 2530

5 Giaufre E, Dalens B, Gombert A. Epidemiology and morbidity of re-

gional anesthesia in children: a one-year prospective survey of

the French-Language Society of Pediatric Anesthesiologists.

Anesth Analg 1996; 83: 90412

6 Berde C, Greco C. Pediatric regional anesthesia: drawing inferences

onsafetyfrom prospectiveregistriesand casereports.AnesthAnalg

2012; 115: 1259627 Bernards CM, Hadzic A, Suresh S, Neal JM. Regional anesthesia in

anesthetized or heavily sedated patients. Reg Anesth Pain Med

2008; 33: 44960

8 KraneEJ,DalensBJ, MuratI, MurrellD. Thesafetyofepidurals placed

during general anesthesia.Reg Anesth Pain Med1998; 23: 4338

9 Llewellyn N, Moriarty A. The national pediatric epidural audit.Pae-

diatr Anaesth2007; 17: 52033

10 PolanerDM,TaenzerAH,WalkerBJ, etal. Pediatricregional anesthe-

sia network (PRAN): a multi-institutional study of the use and inci-

dence of complications of pediatric regional anesthesia. Anesth

Analg 2012; 115: 135364

11 Mazoit JX. Local anesthetics and their adjuncts.Paediatr Anaesth

2012; 22: 318

12 Mazoit JX. [Regional analgesia: things are moving ahead].Ann Fr

Anesth Reanim2012; 31: 1056

13 Di Gregorio G, Neal JM, Rosenquist RW, Weinberg GL. Clinical

presentation of local anesthetic systemic toxicity: a review

of published cases, 1979 to 2009.Reg Anesth Pain Med2010;35:

1817

14 Weinberg G. Lipid rescue resuscitation from local anaesthetic

cardiac toxicity.Toxicol Rev2006; 25: 13945

15 Weinberg GL. Treatment of local anesthetic systemic toxicity

(LAST). Reg Anesth Pain Med2010; 35: 18893

16 Barson AJ, Chistwick ML, Doig CM. Fat embolism in infancy

after intravenous fat infusions. Arch Dis Child 1978; 53:

21823

17 Suresh S, Birmingham PK, Kozlowski RJ. Pediatric pain manage-

ment.Anesthesiol Clin2012; 30: 10117

18 McNeely JK, Farber NE, Rusy LM, Hoffman GM. Epidural analgesia

improvesoutcomefollowingpediatricfundoplication.Aretrospect-

ive analysis.Reg Anesth1997; 22: 1623

19 Tsui BC, Tarkkila P, Gupta S, Kearney R. Confirmation of caudal

needle placement using nerve stimulation. Anesthesiology1999;

91: 374 820 Rapp HJ, Folger A, Grau T. Ultrasound-guided epidural catheter in-

sertion in children.Anesth Analg2005;101: 3339, table of con-

tents

21 Tsui BC, Suresh S. Ultrasound imaging for regional anesthesia in

infants, children, and adolescents: a review of current literature

and its application in the practice of neuraxial blocks. Anesthesi-

ology2010; 112: 71928

22 Berde C. Epidural analgesia in children. Can J Anaesth 1994; 41:

55560

23 Rapp HJ,Grau T. Ultrasound imaging in pediatricregionalanesthe-

sia.Can J Anaesth2004; 51: 2778

24 Wathen JE, Gao D, Merritt G, Georgopoulos G, Battan FK. A rando-

mized controlled trial comparing a fascia iliaca compartment

nerve block to a traditional systemic analgesic for femur fracturesin a pediatric emergency department.Ann Emerg Med2007; 50:

16271

25 Aunac S, Carlier M, Singelyn F, De Kock M. The analgesic efficacy of

bilateralcombined superficialand deepcervicalplexusblock admi-

nistered before thyroid surgery under general anesthesia.Anesth

Analg 2002; 95: 746 50, table of contents

26 Broadman LM. Blocks and other techniques pediatricsurgeonscan

employ to reduce postoperative pain in pediatric patients. Semin

Pediatr Surg1999; 8: 303

27 de Jose MariaB, Gotzens V, Mabrok M. Ultrasound-guided umbilical

nerve block in children: a brief description of a newapproach. Pae-


28 Khan ML, Hossain MM, Chowdhury AY, Saleh QA, Majid MA. Lateral

femoral cutaneous nerve block for split skin grafting. BangladeshMed Res Counc Bull1998; 24: 324

29 KonradC,JohrM.Blockadeofthesciaticnerveinthepoplitealfossa:

a system for standardization in children. Anesth Analg 1998;87:

12568

30 Molliex S, Navez M, Baylot D, Prades JM, Elkhoury Z, Auboyer C. Re-

gional anaesthesia for outpatient nasal surgery. Br J Anaesth

1996; 76: 1513

31 Suresh S, Barcelona SL, Young NM, Seligman I, Heffner CL, Cote CJ.

Postoperative pain relief in children undergoing tympanomastoid

surgery: is a regional block better than opioids? Anesth Analg

2002; 94: 85962, table of contents

BJA Shah and Suresh

i122


10/11

32 Suresh S, Bellig G. Regional anesthesia in a very low-birth-weight

neonate for a neurosurgical procedure. Reg Anesth Pain Med

2004; 29: 589

33 Tobias JD. Continuous femoral nerve block to provide analgesia

following femur fracture in a paediatric ICU population. Anaesth

Intensive Care 1994; 22: 6168

34 TobiasJD. Brachialplexusanaesthesiain children.PaediatrAnaesth

2001; 11: 26575

35 Willschke H, Bosenberg A, Marhofer P, et al. Ultrasonographic-

guided ilioinguinal/iliohypogastric nerveblock in pediatricanesthe-

sia: what is the optimal volume?Anesth Analg 2006; 102: 1680 4

36 Kato J, Gokan D, Ueda K, Shimizu M, Suzuki T, Ogawa S. Successful

pain management of primary and independent spread sites in a

child with CRPS type I using regional nerve blocks. Pain Med

(Malden, Mass)2011; 12: 174

37 Naja ZM,Al-Tannir MA,Zeidan A, El-Rajab M, Ziade F, BarakaA. Nerve

stimulator-guided repetitive paravertebral blockfor thoracicmyofas-

cial pain syndrome. Pain Pract 2007; 7: 34851

38 Vlassakov KV, Narang S, Kissin I. Local anesthetic blockade of per-

ipheral nerves for treatment of neuralgias: systematic analysis.

Anesth Analg 2011; 112: 148793

39 Mesnil M, Dadure C, Captier G, et al. A new approach for peri-

operative analgesia of cleft palate repair in infants: the bilateral

suprazygomatic maxillary nerve block. Paediatr Anaesth 2010;

20: 343 9

40 Mariano ER,Ilfeld BM,Cheng GS, NicodemusHF, SureshS. Feasibility

of ultrasound-guided peripheral nerve block catheters for pain

control on pediatricmedical missionsin developingcountries. Pae-


41 DadureC,MotaisF,RicardC,RauxO,TroncinR,CapdevilaX.Continu-

ous peripheral nerve blocks at home for treatment of recurrent

complex regional pain syndrome I in children. Anesthesiology

2005; 102: 38791

42 GaneshA, RoseJB, Wells L, etal. Continuous peripheralnerveblock-

ade for inpatient and outpatient postoperative analgesia in chil-

dren.Anesth Analg 2007; 105: 1234 42, table of contents

43 Dadure C, Raux O, Troncin R, Rochette A, Capdevila X. Continuous

infraclavicular brachial plexus block for acute pain management

in children.Anesth Analg2003; 97: 6913

44 Suresh S, Chan VW. Ultrasound guided transversus abdominis

plane block in infants, children and adolescents: a simple proced-

ural guidance for their performance. Paediatr Anaesth 2009; 19:

2969

45 Visoiu M, Boretsky KR, Goyal G, Cladis FP, Cassara A. Postoperative

analgesia via transversus abdominis plane (TAP) catheter for

small weight childrenour initial experience. Paediatr Anaesth

2012; 22: 2814

46 TaylorLJ, Birmingham P,Yerkes E, SureshS. Childrenwithspinaldys-

raphism: transversus abdominis plane (TAP) catheters to the

rescue!Paediatr Anaesth2010; 20: 9514

47 Johnson CM. Continuous femoral nerve blockade for analgesia in

children with femoral fractures. Anaesth Intensive Care 1994;22:

2813

48 Dadure C, Bringuier S, Nicolas F,et al. Continuous epidural block

versus continuous popliteal nerve block for postoperative pain

relief after major podiatric surgery in children: a prospective, com-

parative randomized study.Anesth Analg2006; 102: 7449

49 Roberts S. Ultrasonographic guidance in pediatric regional anes-

thesia. Part 2: techniques.Paediatr Anaesth2006; 16: 111224

50 Oberndorfer U, Marhofer P, Bosenberg A,et al. Ultrasonographic

guidance for sciatic and femoral nerve blocks in children. Br J

Anaesth2007; 98: 797801

51 ODonnell BD, Iohom G. An estimation of the minimum effective

anesthetic volume of 2% lidocaine in ultrasound-guided axillary

brachial plexus block. Anesthesiology2009; 111: 259

52 Jan van Geffen G, Tielens L, Gielen M. Ultrasound-guided intersca-

lene brachial plexus block in a child with femur fibula ulna syn-

drome.Paediatr Anaesth2006; 16: 3302

53 McNaught A, Shastri U, Carmichael N, etal. Ultrasound reduces the

minimum effective local anaesthetic volume compared with per-

ipheral nerve stimulation for interscalene block. Br J Anaesth

2011; 106: 12430

54 Fredrickson MJ. Ultrasound-assisted interscalene catheter place-

ment in a child.Anaesth Intensive Care2007; 35: 8078

55 De Jose Maria B, Banus E, Navarro Egea M, Serrano S, Perello M,

Mabrok M. Ultrasound-guided supraclavicular vs infraclavicular

brachial plexus blocks in children. Paediatr Anaesth 2008; 18:

83844

56 Marhofer P, Sitzwohl C, Greher M, Kapral S. Ultrasound guidance

for infraclavicular brachial plexus anaesthesia in children. Anaes-

thesia2004; 59: 6426

57 McDonnellJG,ODonnellB,CurleyG,HeffernanA,PowerC,LaffeyJG.

The analgesic efficacy of transversus abdominis plane block after

abdominal surgery: a prospective randomized controlled trial.

Anesth Analg 2007; 104: 1937

58 Pak T, Mickelson J, Yerkes E, Suresh S. Transverse abdominis plane

block: a new approach to the management of secondary hyper-

algesia following major abdominal surgery. Paediatr Anaesth

2009; 19: 546

59 FredricksonM, Seal P, Houghton J. Early experience with thetrans-

versus abdominis plane block in children. Paediatr Anaesth 2008;

18: 8912

60 Hannallah RS, Broadman LM, Belman AB, Abramowitz MD,

Epstein BS. Comparison of caudal and ilioinguinal/iliohypogastric

nerve blocks for control of post-orchiopexy pain in pediatric ambu-

latory surgery.Anesthesiology1987; 66: 8324

61 Jagannathan N, SohnL, Sawardekar A, etal. Unilateral groin surgery

in children: will the addition of an ultrasound-guided ilioinguinal

nerve block enhance the duration of analgesia of a single-shot

caudal block? Paediatr Anaesth 2009; 19: 8928

62 Markham SJ, Tomlinson J, Hain WR. Ilioinguinal nerve block in chil-

dren. A comparison with caudal block for intra and postoperative

analgesia.Anaesthesia1986; 41: 1098103

63 Smith T, Moratin P, Wulf H. Smaller children have greater bupiva-

caine plasma concentrations after ilioinguinal block. Br J Anaesth

1996; 76: 4525

64 Willschke H, Marhofer P, Bosenberg A, et al.Ultrasonography for

ilioinguinal/iliohypogastric nerve blocks in children. Br J Anaesth

2005; 95: 22630

65 FergusonS, ThomasV,Lewis I. Therectussheathblock inpaediatric

anaesthesia: new indications for an old technique? Paediatr

Anaesth1996; 6: 4636

66 Willschke H, Bosenberg A, Marhofer P, et al. Ultrasonography-

guided rectus sheath block in paediatric anaesthesiaa new ap-

proach to an old technique.Br J Anaesth2006; 97: 2449

67 Casati A, Baciarello M, Di Cianni S, et al. Effects of ultrasound

guidance on the minimum effective anaesthetic volume

required to block the femoral nerve. Br J Anaesth 2007; 98:

8237

68 vanGeffenGJ, GielenM. Ultrasound-guidedsubglutealsciaticnerve

blocks with stimulating catheters in children: a descriptive study.

Anesth Analg 2006; 103: 328 33, table of contents

69 van Geffen GJ, Scheuer M, Muller A, Garderniers J, Gielen M.

Ultrasound-guided bilateral continuous sciatic nerve blocks with


i123


11/11

stimulating catheters for postoperative pain relief after bilateral

lower limb amputations.Anaesthesia2006; 61: 1204 7

70 Tsui BC, Ozelsel TJ. Ultrasound-guided anterior sciatic nerve block

using a longitudinal approach: expanding the view.Reg Anesth

Pain Med2008; 33: 2756

71 Schwemmer U, Markus CK, Greim CA, Brederlau J, Trautner H,

Roewer N. Sonographic imaging of the sciatic nerve and its division

in thepopliteal fossa in children. PaediatrAnaesth 2004; 14: 10058

72 Johr M.The rightthing intherightplace:lumbar plexusblock inchil-

dren. Anesthesiology2005; 102: 865; author reply 6

73 Visoiu M, Yang C. Ultrasound-guided bilateral paravertebral con-

tinuous nerve blocks fora mildly coagulopathicpatientundergoing

exploratorylaparotomyforbowelresection. PaediatrAnaesth2011;

21: 45962

74 Bhalla T, Sawardekar A, Dewhirst E, Jagannathan N, Tobias JD.

Ultrasound-guided trunk and core blocks in infants and children.J

Anesth2013; 27: 10923

75 El-Morsy GZ, El-Deeb A, El-Desouky T, Elsharkawy AA, Elgamal MA.

Can thoracic paravertebral block replace thoracic epidural block in

pediatric cardiac surgery? A randomized blinded study. Ann

Cardiac Anaesth2012; 15: 25963

76 Lonnqvist PA. Continuous paravertebral block in children. Initial ex-

perience.Anaesthesia1992; 47: 6079

Handling editor: H. C. Hemmings

BJA Shah and Suresh

i124

Aplication in Regional Anethesia in Pediatric

Documents

Transcript of Aplication in Regional Anethesia in Pediatric