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NB: Also refer to chapters 119155.

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Key Points
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
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Anatomy and Physiology of Children Relevant to Regional Anesthesia
Anatomic structureChildrenAdultsComments
Birth1 year – 8 years
Conus medullarisL 3L1L1Higher risk of spinal cord injury in small children
Tuffier’s/intercrestal lineL5–S1L5L4; L4–L5For spinal, do not place the needle above this line
Dural sacS3S2S2Increased risk of dural puncture in smaller children during performance of caudal block
Sacral hiatusMore cephalad position when compared with adults
Sacrum
  • Not ossified
  • Flatter and narrower
Completes ossificationBetter “acoustic window” for UG blocks in smaller children; caudal block is more difficult in older children (>8 years)
Lumbar lordosisNoYesAllows easy catheter advancement from caudal to higher levels (lumbar and thoracic)
CSF4 mL/kg2 mL/kgShorter duration of intrathecal anesthesia/analgesia in children (60–90 min)
Response to sympathetic blockLittle or noneHypotensionHigh block levels better tolerated hemodynamically
Connective tissueLooser connective tissue around neuraxial structures and peripheral nerves (“sheaths”) when compared with adultsImproved LA spread in children. Easier advancement of catheters
NervesSmall diameter, thin myelin sheath, short internodal distances than in adultsLower concentrations of LA produce an adequate surgical block in infants and younger children
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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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