Dating back to ancient Egypt of 2500 bc,
regional anesthesia was emphasized for circumcision. Traditional Chinese
medicine has touted the use of needles and acupuncture for pain management
for centuries. August Bier reported in 1899 the first study on regional
anesthesia in children. This was followed by a report by Bainbridge on the
use of spinal anesthesia in children.1 The use of caudal
analgesia in children was described in the urology literature in the early
1930s.2 In the past two decades, numerous studies have
demonstrated the need for analgesia in newborn children and
infants.3 This has resulted in significant changes and
advances in clinical anesthesia care for infants, children, and adolescents.
In particular, the decrease in stress has resulted in better outcomes in
infants and children. Infants exposed to significant pain in the neonatal
period may experience biobehavioral changes with advancing
age.4 This and other related research have led the medical
community to improve analgesia in infants. Although
research in regional anesthesia in adults continues to be performed and is
written about prolifically in literature, there seems to be a relative lack
of publications in regional anesthesia in children. Most work in regional
anesthesia has been carried out by a few researchers with a firm commitment to
the use of regional techniques in children. Although the usual dictum that
children are just small adults may apply to regional analgesia in the
adolescent population, it is much less applicable to infants and toddlers.
The goal of this chapter is to provide general principles of practice of
regional anesthesia in children.
Anatomic Differences between Children & Adults
Significant anatomic variations exist between infants and older
adolescents and adults. Differences in anatomy between children and adults
are described in greater detail elsewhere in this chapter. CT-guided
mechanisms and the use of other imaging techniques including ultrasound have
led to a better understanding of the anatomy of infants and
children.5 This has facilitated a more accurate placement
of needles in children with less risk of complications. The epidural space
is superficial compared with that in adults, and this requires greater skill
and care while placing a needle.6 Numerous formulas are
available for estimating the distance of the epidural space from the
skin.6 However, this should not alter the judgment of the
skilled anesthesiologist placing a needle in the spinal or epidural space.
Parents typically provide consent for a procedure for their child.
However, if the child has the cognitive ability to discern right from wrong,
it is suggested that the child's consent for performance of a regional
technique be obtained as well.7 There is growing debate as
to when or what this age may be. We routinely obtain consent for children
over the age of 12 years. If a child refuses to have a regional procedure
despite the parents' insistence, ...