Chapter 41. Regional Anesthesia in Pediatric Patients: General Considerations
The benefits of regional anesthesia to pediatric surgical patients:
A. Cause an increased length of inpatient stay
B. Include improved postoperative gastric function
C. Are outweighed by the need for more intensive postoperative nursing observations
D. Are limited to older children
B is correct. The use of regional techniques in children is associated with preserved peristalsis and improved splanchnic perfusion. This is especially important for intestinal pathology such as necrotizing enterocolitis (NEC) and gastroschisis. Improved gastric function may also result in early return to enteral feeding.
A is incorrect. The use of regional anesthesia in pediatric practice is associated with a reduced length of hospital stay. This is likely due to a combination of improved analgesia, and a faster return to normal feeding and mobility.
C is incorrect. The superior analgesia provided by working regional analgesia makes postoperative management of pediatric patients less challenging. Benefits include reduced need for supplemental analgesia, parental support, and also less exposure to medication that might induce delirium or dependency.
D is incorrect. Whilst neonatal physiology demands close attention to calculations of safe local anesthetic doses, regional anesthesia can be safely and effectively used in children of all ages.
When managing a neonatal epidural, which of the following increases safety?
A. A maximum of 3 days infusion to prevent local anesthetic (LA) accumulation
B. Operator experience is not important.
C. The decreased risk of toxicity with levobupivacaine
D. Siting the epidural while the patient is awake
C is correct. While all LAs require care in administration, levobupivacaine has a less cardiotoxic profile than the other amide LAs. Animal models show reduced myocardial dysfunction and incidence of dysrhythmia with levobupivacaine compared to bupivacaine.
A is incorrect. The maximum recommended duration is 48 hours for a neonatal epidural due to the risk of LA accumulation secondary to neonatal physiology.
B is incorrect. Most complications occur with inexperienced operators; this procedure should be performed only by an anesthetist who is experienced in pediatric regional techniques, supported by departmental guidelines and training.
D is incorrect. While this remains the approach for most adult epidural insertions, this does not apply to pediatric practice. Insertion under general anesthesia or deep sedation facilitates a safer insertion as it guarantees patient cooperation and minimizes movement (recommended by ESRA and ASRA).