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Modern pediatric anesthesia would not be conceivable without the use of
regional anesthetic techniques. For instance, regional anesthesia decreases
the need for mechanical ventilation following major thoracic or abdominal
surgery. In addition, the need for intraoperative and postoperative opioids
decreases accordingly. Perhaps most importantly, the entire perioperative
experience is less stressful for children whose perioperative pain is
adequately managed. Most of the advantages of perioperative regional
anesthesia are demonstrated in central neuraxial blocks, specifically for
caudal continuous lumbar or thoracic epidural blocks.
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In contrast to central blocks, peripheral nerve blocks (PNBs) have not
been studied extensively in children. A Medline search in April
2005 yielded 42 reports for pediatric anesthesia & epidural and only 17 for
pediatric anesthesia & peripheral nerve block. This finding suggests
that peripheral nerve blockade in children is used less frequently in clinical
practice than in adults. This is compounded by the fact that some pediatric
anesthesiologists are still reluctant to use the nerve stimulator, the
accepted standard tool for locating nerves in adults. “Blind” methods, such
as those used for blockade of the ilioinguinal/iliohypogastric nerves,
continue to be the most prevalent approach in pediatric anesthesia. Even
techniques that today are used exclusively in conjunction with nerve
stimulators in adults, are frequently performed “blind” in children
by using anatomic landmarks as the sole reference or by relying on
fascial click techniques. Giaufré and coworkers1
reported in a much-quoted overview article on a study performed under the
auspices of the French Language Society of Pediatric Anesthesiologists
(ADARPEF). In that study, a total of 24,409 regional anesthetic procedures
were performed in children over a 1-year period, 15,013 (>60%)
of them being central blocks. By comparison, only 38% of these were
peripheral blocks. In this large series, no complications were reported,
suggesting that PNBs in children can be used with remarkable safety.
However, it is possible that some complications were minor or went
clinically undetected. For example, complications during blockade of the
ilioinguinal/iliohypogastric nerves were not observed in that study. It is
unlikely that complications were virtually nonexistent, since the
conventional techniques described are well known to carry a risk of
peritoneal puncture.
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Ultrasound-guided nerve blocks are rapidly becoming popular in adults. The
smaller body size of children, allows the use of high-frequency,
high-resolution probes, making ultrasound particularly suitable to
the practice of PNBs in the pediatric patient. The reader should
be advised that at the time of the publication of this book, this area of
regional anesthesia is still in its infancy and scientific data on the true
efficacy and safety of ultrasound-guided nerve blocks in children are
limited. Consequently, some views expressed in this chapter necessarily
reflect our own bias and clinical experience. Finally, because of our group's
specific interest in anesthesia for pediatric trauma, most discussion in
this chapter focuses on blocks in pediatric patients with traumatic injury
of the upper and lower extremities.
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Technical & Practical Details
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