Sections View Full Chapter Figures Tables Videos Annotate Full Chapter Figures Tables Videos Supplementary Content ++ NB: Also refer to chapters 119–155. ++Table Graphic Jump Location|Download (.pdf)|PrintKey PointsPerformance under deep sedation/general anesthesia (GA) not contraindicated in childrenAwake regional anesthesia (RA) remains popular in ex-premature neonates, children susceptible to malignant hyperthermia and/or with muscular diseasesNever exceed local anesthetic (LA) maximum dose, especially in small children (mg/kg) and with a repeated bolus or continuous infusion (mg/kg/h) techniquePrefer 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 painContinuous infusion: prolonged surgery, expected severe postoperative pain, painful physical therapy, or complex regional pain syndromeNerve localization techniques: peripheral nerve stimulators (PNS) (if GA, do not use NMB), ultrasound guidance, or bothChildren have a better “acoustic window” than adultsUltrasound-guided (UG) blocks have faster onset time and increased success rate and use lower LA dosesHigh-frequency (linear) transducers are more suitable (especially small-footprint “hockey stick” probes) for small childrenEpinephrine test dose can help signal IV injectionObtain 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 failureComplication rate and severity is lower than in adults++Table Graphic Jump Location|Download (.pdf)|PrintAnatomy and Physiology of Children Relevant to Regional AnesthesiaAnatomic structureChildrenAdultsCommentsBirth1 year – 8 yearsConus medullarisL 3L1L1Higher risk of spinal cord injury in small childrenTuffier’s/intercrestal lineL5–S1L5L4; L4–L5For spinal, do not place the needle above this lineDural sacS3S2S2Increased risk of dural puncture in smaller children during performance of caudal blockSacral hiatusMore cephalad position when compared with adultsSacrumNot ossifiedFlatter and narrowerCompletes 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 hemodynamicallyConnective tissueLooser connective tissue around neuraxial structures and peripheral nerves (“sheaths”) when compared with adultsImproved LA spread in children. Easier advancement of cathetersNervesSmall diameter, thin myelin sheath, short internodal distances than in adultsLower concentrations of LA produce an adequate surgical block in infants and younger children++Table Graphic Jump Location|Download (.pdf)|PrintLocal Anesthetic Pharmacology in ChildrenLAs most commonly used are amino amides (lidocaine, bupivacaine, ropivacaine, and levobupivacaine)Ropivacaine and levobupivacaine have a safer cardiovascular profile than bupivacaineAmino esters (chloroprocaine) metabolized by serum esterases and very fast clearance (Cl) (even for neonates)Amino amide bound ... Your Access profile is currently affiliated with [InstitutionA] and is in the process of switching affiliations to [InstitutionB]. Please select how you would like to proceed. Keep the current affiliation with [InstitutionA] and continue with the Access profile sign in process Switch affiliation to [InstitutionB] and continue with the Access profile sign in process Get Free Access Through Your Institution Learn how to see if your library subscribes to McGraw Hill Medical products. Subscribe: Institutional or Individual Sign In Error: Incorrect UserName or Password Username Error: Please enter User Name Password Error: Please enter Password Sign in Forgot Password? Forgot Username? Sign in via OpenAthens Sign in via Shibboleth You already have access! Please proceed to your institution's subscription. Create a free profile for additional features.