Peripheral nerve blocks have been gaining significant popularity in the daily practice among pediatric anesthesiologists. Nerve blocks in children have an excellent risk–benefit ratio and are readily acceptable by both parents and children. Although the performance of peripheral nerve blocks in anesthetized adults is often debated, such practice is well accepted in pediatric patients. Successive large prospective studies performed by the French-Language Society of Pediatric Anesthesiologists (ADARPEF) have demonstrated no increased incidence of complications when regional anesthesia techniques were performed under general anesthesia.1,2 The overall incidence of regional anesthesia–related complications was less than 0.9 of 1000 anesthetic procedures performed. Interestingly, a six-fold increase in the complication rate for central versus peripheral techniques was demonstrated, which should further persuade pediatric anesthesiologists to modify their practice toward more peripherally based regional anesthetic strategies. The complication rate was four times higher in children under 6 months of age; as such, these patients should be managed only by suitably trained specialist pediatric anesthesiologists. Because of the concomitant use of general anesthesia in children, the intraoperative efficacy of nerve blocks is often assessed indirectly using hemodynamic parameters and required depth of anesthesia. Most regional techniques used in children are primarily used for the purpose of providing postoperative pain control rather than surgical anesthesia.
Although most peripheral nerve blocks in children are performed in an operating room environment, their application extends to the emergency department as well as the intensive care unit (ICU) setting.3,4 Peripheral nerve blocks are also used in children with chronic pain conditions, such as chronic headache or chronic regional pain syndrome type 1 (CRPS-1). All adult regional anesthetic techniques are possible in children (Table 44–1); when these procedures are performed with skill and knowledge, their success rates and safety should not significantly differ from those in adults. This chapter will concentrate on the commonly performed pediatric blocks. For each technique, a short description of the relevant anatomy will be followed by descriptions of both landmark-based and ultrasound (US)-guided methods where appropriate. It is assumed for all blocks that appropriate monitoring, intravenous (IV) access, trained assistance, resuscitation equipment, and aseptic precautions are taken.
Table 44–1.Pediatric regional anesthetic techniques: common indications and suggested volume of local anesthetic. |Favorite Table|Download (.pdf) Table 44–1. Pediatric regional anesthetic techniques: common indications and suggested volume of local anesthetic.
|Block ||Indication ||Local Anesthetic Volume (mL/kg)a |
|Greater auricular || |
|Infraorbital || |
Cleft lip repair
Endoscopic sinus surgery
|Supraorbital and supratrochlear ||Frontal scalp incisions; eg, simple minor plastic surgery, frontal craniotomy ||1.0–2.0 |
|Superficial cervical plexus || |
|Greater occipital || |
Posterior fossa surgery
Occipital neuralgia, migraine headaches
|Nerve of Arnold ||Myringotomy ||0.5–1.0 |
|Interscalene ||Shoulder surgery ||0.3–0.5 |
|Supraclavicular ||Upper arm surgery ||0.3–0.5 |
|Infraclavicular ||Upper arm surgery ||0.3–0.5 |
|Axillary ||Elbow and forearm surgery ||0.3–0.5 |
|Median, ulna, and radial ||Syndactyly surgery ||0.1–0.3 |