Regional anesthesia is an essential part of modern pediatric anesthetic practice, conveying many significant advantages to the patient and to the hospital (Table 42–1). However, despite a strong body of evidence highlighting the advantages of regional anesthesia, it has been only relatively recently that regional anesthesia has begun to become more common place in anesthetic practice. Large prospective studies by the French-Language Society of Pediatric Anesthesiologists (ADARPEF) have demonstrated no increased risk to children having blocks performed under general anesthesia.1,2 However, complications were four times greater in children aged less than 6 months compared to those older than 6 months.2
Table 42–1.Advantages of regional anesthesia in children. ||Download (.pdf) Table 42–1. Advantages of regional anesthesia in children.
|Patient benefits ||Superior analgesia: Results in calmer patient and parents/caregivers. |
|Reduced MAC: Reduced risk of deeper GA, smoother emergence, earlier return of appetite. |
|Neurotoxicity: This potential problem is GA dose–dependent; therefore, a reduced MAC exposure may be beneficial. |
|Hemodynamic stability: Up to 8 years of age, CNBs rarely cause significant hypotension. |
|Reduced requirement for postoperative ventilator support: Particularly in neonates and infants undergoing upper abdominal and thoracic surgery. |
|Obtunds the hormonal stress response. |
|Reduced intraoperative blood loss: Demonstrated during hypospadias repair, cleft repair, and tonsillectomy. |
|Improved GI function: Peristalsis better maintained; improved splanchnic perfusion in cases of NEC and gastroschisis. |
|Avoids the need for GA: Premature infants who undergo GA are at risk of postoperative apnea. |
|Hospital benefits ||Easier to nurse: Pain-free children are less labor intensive to care for. |
|Reduced MAC: Rapid discharge from first-stage recovery. |
|Reduced requirement for postoperative ventilatory support: This is of particular benefit when there is limited PICU support. |
|Reduced length of stay. |
Historically, it was thought that neonates required little or no analgesia. However, inadequate analgesia in the neonate can cause biobehavioral changes that may modulate future responses to pain in childhood.3 As a consequence, advanced regional anesthesia techniques (eg, epidural analgesia) have become increasingly utilized in children of all ages. Interestingly, the ADARPEF studies identified that there is a now a trend away from the central neuraxial blocks toward peripheral nerve catheter techniques. This change may have been influenced by advances in minimally invasive surgery and the more predictable administration of peripheral catheter techniques in modern regional anesthesia practice.1,2
All regional anesthetic techniques can be safely performed in the pediatric population with the adequate training and modern equipment.
ANATOMICAL DIFFERENCES BETWEEN CHILDREN & ADULTS
With respect to anatomy, physiology, and pharmacology, adolescents may be considered “little adults”; however, neonates and infants need special consideration.4,5 Anatomically, the major difference lies in the spine and its contents; this topic is ...