NB: Also refer to chapters 119–155.
|Performance under deep sedation/general anesthesia (GA) not contraindicated in children|
|Awake regional anesthesia (RA) remains popular in ex-premature neonates, children susceptible to malignant hyperthermia and/or with muscular diseases|
|Never exceed local anesthetic (LA) maximum dose, especially in small children (mg/kg) and with a repeated bolus or continuous infusion (mg/kg/h) technique|
|Prefer long-acting LAs. Adequate analgesia achieved with concentrations of 0.2–0.25% (bupivacaine/levobupivacaine/ropivacaine) for PNB and 0.1% for central neuraxial blocks (CNB)|
Single dose: minor surgery or short postoperative pain
Continuous infusion: prolonged surgery, expected severe postoperative pain, painful physical therapy, or complex regional pain syndrome
|Nerve localization techniques: peripheral nerve stimulators (PNS) (if GA, do not use NMB), ultrasound guidance, or both|
Children have a better “acoustic window” than adults
Ultrasound-guided (UG) blocks have faster onset time and increased success rate and use lower LA doses
High-frequency (linear) transducers are more suitable (especially small-footprint “hockey stick” probes) for small children
|Epinephrine test dose can help signal IV injection|
|Obtain consent for RA from parents (preferentially in a written form) and child (if mature enough). Explain that the anesthetized region will “feel” different; discuss possible complications (severity and rate) and an alternate plan if block failure|
|Complication rate and severity is lower than in adults|
Anatomy and Physiology of Children Relevant to Regional Anesthesia
|Birth||1 year – 8 years|
|Conus medullaris||L 3||L1||L1||Higher risk of spinal cord injury in small children|
|Tuffier’s/intercrestal line||L5–S1||L5||L4; L4–L5||For spinal, do not place the needle above this line|
|Dural sac||S3||S2||S2||Increased risk of dural puncture in smaller children during performance of caudal block|
|Sacral hiatus||More cephalad position when compared with adults|
- Not ossified
- Flatter and narrower
|Completes ossification||Better “acoustic window” for UG blocks in smaller children; caudal block is more difficult in older children (>8 years)|
|Lumbar lordosis||No||Yes||Allows easy catheter advancement from caudal to higher levels (lumbar and thoracic)|
|CSF||4 mL/kg||2 mL/kg||Shorter duration of intrathecal anesthesia/analgesia in children (60–90 min)|
|Response to sympathetic block||Little or none||Hypotension||High block levels better tolerated hemodynamically|
|Connective tissue||Looser connective tissue around neuraxial structures and peripheral nerves (“sheaths”) when compared with adults||Improved LA spread in children. Easier advancement of catheters|
|Nerves||Small diameter, thin myelin sheath, short internodal distances than in adults||Lower concentrations of LA produce an adequate surgical block in infants and younger children|
Local Anesthetic Pharmacology in Children
|LAs most commonly used are amino amides (lidocaine, bupivacaine, ropivacaine, and levobupivacaine)|
|Ropivacaine and levobupivacaine have a safer cardiovascular profile than bupivacaine|
|Amino esters (chloroprocaine) metabolized by serum esterases and very fast clearance (Cl) ...|
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