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FOCUS POINTS
Most peripheral nerve blocks in children are performed under general anesthesia.
Transversus abdominus plane (TAP) blocks may provide analgesia for lower abdominal surgery (T10-L1).
Complications associated with TAP blocks include peritoneal or bowel injury.
Quadratus lumborum (QL) blocks can block a wide range of dermatomes of the anterior abdominal wall, roughly T7-L1. In addition, spread to the paravertebral space can provide analgesia for peritoneal or visceral pain.
Rectus sheath blocks provide analgesia to the anterior abdominal wall and are often used as complements to TAP or QL blocks, especially above the umbilicus.
Paravertebral (PV) blocks are primarily used for thoracic surgeries.
Complications associated with PV blocks are related to the proximity of this deep space to the pleura (pneumothorax). Other complications are inadvertent vascular puncture or intrathecal/epidural injection.
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As the name implies, truncal blocks deliver local anesthetic to nerve trunks, or bundles of nerves, rather than a specific, individual nerve. While trunks may form close to the spinal cord, they are bilateral rather than midline structures, and thus truncal blocks are unilateral. Also, since trunks are distal to the central nervous system, side effects of neuraxial blocks, such as urinary retention, nausea and vomiting, and bilateral motor blockade, can be avoided with truncal blocks.
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Truncal blocks take advantage of tissue planes and allow for local anesthetics to spread within the plane to the intended neurovascular bundle or bundles. As with most regional blocks, the placement of truncal blocks is augmented using ultrasound, which has become the standard of care when performing most peripheral regional anesthetics.
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The pediatric considerations, mechanisms, and metabolism of local anesthetics are covered in Chapter 8 and will not be repeated here. However, it is important to note that because truncal blocks are not targeting a specific nerve, but rather a plane, the spread of local anesthetic is crucial to the success of the block. Therefore, in smaller children and infants, it may be necessary to use a more dilute local anesthetic to increase the total volume of medication that may be delivered safely.1 Dilute local anesthetic is usually effective in young, small children due to ongoing myelination at young ages that renders nerves susceptible to sodium channel blockade with lower concentrations.
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As with many regional blocks, truncal blocks are often single-shot injections, but catheters may also be placed for continuous infusions or intermittent boluses. Equipment for truncal blocks is the same for other regional blocks: ultrasound with linear or curvilinear probe depending on target depth, sterile prep, drape, probe cover, short-beveled or Tuohy needle, catheter and supplies if applicable, sterile gloves, and local anesthetic.
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As with many blocks performed in pediatric patients, truncal blocks in children are often performed with the patient under general anesthesia.2,3 Most commonly, truncal blocks are performed with the needle ...