Safety and Efficacy of Regional Anesthesia in Infants, Children, and Adolescents

Educational Objectives

The goal of this program is to improve management of pediatric patients receiving nerve blocks. After hearing and assimilating this program, the clinicians will be better able to:

1. Use ultrasonography-guided nerve blocks to provide regional anesthesia to pediatric patients.
2. Choose procedures for regional anesthesia to avoid motor block.
3. Select a nerve block for patients undergoing abdominal surgery.

Summary

Pediatric regional anesthesia network (PRAN): PRAN includes ≈2000 blocks/mo recorded from 25 institutions across the United States; Walker et al (2018) investigated the safety and efficacy of regional anesthesia in 100,000 pediatric blocks; as physicians gain experience with regional anesthesia, the incidence of complications has declined; the advent of ultrasonography (US) has improved the administration of regional anesthesia in children; the younger the child, the more beneficial US is

Caudal blocks in children: caudal blocks are the most common block; a study of 20,000 caudal blocks found 4 serious complications; the blocks were performed by physicians who perform a large volume of blocks; the biggest issue with neuraxial catheters was disconnection rate; US should be used for children <2 yr of age; US is helpful in locating the right spot and tracking the spread of the local anesthetic

Head and neck blocks: common procedures in pediatric patients include hernia repair, hypospadias, or cleft lips or palate; opioids are usually avoided because of potential airway issues; regional analgesia can provide pain control with less need for opioids; the speaker uses a bilateral suprazygomatic nerve block; pulsation of the maxillary artery may be visualized near the maxillary nerve; occipital nerve block is helpful for pediatric neurosurgery (bilaterally blocks C2 and C3) and may be done with guided US

Upper extremity blocks: may be performed at the interscalene, supraclavicular, infraclavicular, or axillary level; the most common in the PRAN database is supraclavicular nerve block; US should be used because the target site for a supraclavicular block is close to the pleura; questions have been raised about the use of blocks in sleeping patients; a paper recommended against the use of interscalene blocks in any population unless done in patients who are awake; in the pediatric population, 75% of interscalene blocks were placed under general anesthesia with no neurologic injury or toxicity, according to data from the PRAN database; the outcomes were comparable with adult studies in awake populations

Dosing guidelines for anesthetics: based on a prospectively controlled audit in the PRAN database, the recommended dose is 0.2 to 0.3 mL of bupivacaine equivalents/kg of body weight; supraclavicular blocks are placed in close proximity to the pleura; the “eight ball corner pocket” looks like a bunch of grapes near the subclavian and identifies the optimal position for US guided supraclavicular block; sliding lung signs should be done to assess for pneumothorax

Neural checks in the postanesthesia care unit (PACU): patients undergoing upper extremity blocks should be checked for nerve damage; children may be assessed with a neural check; a thumbs up sign is for radial nerve, making an O is for median nerve, and crossing fingers for ulnar nerve; a patient with a supracondylar fracture with nerve injury should not be blocked; the infraclavicular approach is useful for placing catheters; catheters are also placed in the interscalene area

Lower extremity blocks: the most common is femoral nerve block; some blocks more commonly done in pediatric patients include adductor canal or saphenous nerve block and lateral femoral cutaneous nerve block; lumbar plexus block is commonly done when an epidural cannot be given (eg, instrumentation in the back); more adductor canal catheters are placed than femoral nerve catheters, as femoral nerve catheters leave patients with quadriceps weakness; for pediatric patients, clinicians should try to tunnel the catheters to reduce the likelihood of dislodgement; the rate of disconnection is high in peripheral nerve catheters

Saphenous nerve block: the nerve bundle is underneath the sartorius near the superficial femoral artery; quadriceps weakness is avoided with use of the saphenous nerve block; blocking the nerve higher (in the top third) may result in blocking the nerve to the vastus medialis, which leads to weakness; the block should be placed as low as possible

Lateral femoral cutaneous nerve block: frequently used in pediatrics; applications include lateral fascia lata grafts and hip pinning; the linear probe is placed to override the sartorius, fascia lata, and fascia iliaca to identify the target area; an easily placed block; provides a sensory block

Sciatic nerve block: blocking the common peroneal nerve leads to foot drop; providers should place blocks as low as possible to block the tibial nerve; the common peroneal nerve should be avoided unless lateral coverage is needed

Truncal blocks: truncal blocks with US may be used with pediatric patients; clinicians are able to perform ilioinguinal, rectus sheath, and transversus abdominis plane (TAP) blocks; for umbilical hernia repair or single incision laparoscopic surgery, blocking exclusively at the T10 level is effective; in patients between the ages of 8 and 10 yr, caudal blocks are usually not done, as they lead to some degree of motor block; ilioinguinal and iliohypogastric blocks may be useful instead; US guidance is needed to avoid puncturing the colon; for hernia repair, the genitofemoral nerve needs to be blocked or the scrotum will be missed

TAP block: larger volumes of local anesthetic were once thought to produce better blocks; however, data do not support the use of larger volumes

Quadratus lumborum (QL) block: areas to block include lateral, posterior, or anterior areas; the nerve is blocked in variety of different places; similar to a TAP block; however, providers may block the QL area

Paravertebral blocks: routinely used in the speaker’s group for cardiac patients; the downdraft of the pleura may be seen as local anesthetic is injected

Erector spinae plane blocks (ESPB): newly emerging block; routinely done in older cardiac patients; the erector spinae catheters do not affect the coagulation parameters, so patients may be heparinized; useful for patients with spinal issues undergoing major abdominal surgery

Local anesthetic dosing: work on local anesthetic dosing is ongoing; only retrospective data are currently available; for adjuvants, guidelines in collaboration with European Society of Regional Anesthesia recommend clonidine as an effective adjuvant; corticosteroids have not been found to be effective in the pediatric population

Readings

Adler AC, Belon CA, Guffey DM, Minard CG, Patel NV, Chandrakantan A. Real-time ultrasound improves accuracy of caudal block in children. Anesth Analg. 2020;130(4):1002-1007. doi:10.1213/ANE.0000000000004067; Chiono J, Raux O, Bringuier S, et al. Bilateral suprazygomatic maxillary nerve block for cleft palate repair in children: a prospective, randomized, double-blind study versus placebo. Anesthesiol. 2014; 120:1362-1369; Guay J, Suresh S, Kopp S. The use of ultrasound guidance for perioperative neuraxial and peripheral nerve blocks in children. Cochrane Database Syst Rev. 2019(2); Ilfeld BM, Loland VJ, Sandhu NS, et al. Continuous femoral nerve blocks: the impact of catheter tip location relative to the femoral nerve (anterior versus posterior) on quadriceps weakness and cutaneous sensory block. Anesth Analg. 2012; 115:721-727; Kenney RJ, Hammert WC. Physical examination of the hand. J Hand Surg Am. 2014;39(11):2324-2334. doi:10.1016/j.jhsa.2014.04.026; Long JB, Joselyn AS, Bhalla T, et al. The use of neuraxial catheters for postoperative analgesia in neonates: a multicenter safety analysis from the Pediatric Regional Anesthesia Network. Anesth Analg. 2016; 122:1965-1970; Relland LM, Tobias JD, Martin D, et al. Ultrasound-guided rectus sheath block, caudal analgesia, or surgical site infiltration for pediatric umbilical herniorrhaphy: a prospective, double-blinded, randomized comparison of three regional anesthetic techniques. J Pain Res. 2017;10:2629-2634. Published 2017 Nov 9. doi:10.2147/JPR.S144259; Soares LG, Brull R, Lai J, et al. Eight ball, corner pocket: the optimal needle position for ultrasound-guided supraclavicular block. Reg Anesth Pain Med. 2007;32:94-105; Suresh S, Long J, Birmingham PK, et al. Are caudal blocks for pain control safe in children? An analysis of 18,650 caudal blocks from the Pediatric Regional Anesthesia Network (PRAN) database. Anesth Analg. 2015; 120:151-156; Tsui BC, Suresh S, Warner DS. Ultrasound imaging for regional anesthesia in infants, children, and adolescents: a review of current literature and its application in the practice of extremity and trunk blocks. J Am Soc Anesthesiol. 2010; 112:473-492; Walker BJ, Long JB, Sathyamoorthy M, et al. Complications in pediatric regional anesthesia: an analysis of more than 100,000 blocks from the pediatric regional anesthesia network. Anesthesiol. 2018; 129:721-732.

Disclosures

For this program, members of the faculty and planning committee reported nothing relevant to disclose.

Acknowledgements

Dr. Suresh was recorded at the 49th Annual Mid-Year Seminar of the American Osteopathic College of Anesthesiologists, held March 25-27, 2022, in Chicago, IL, and presented by American Osteopathic College of Anesthesiologists. For more information about upcoming CME activities from this presenter, please visit https://www.aocaonline.org. Audio Digest thanks the speakers and presenters for their cooperation in the production of this program.

CME/CE INFO

Accreditation:

The Audio- Digest Foundation is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

The Audio- Digest Foundation designates this enduring material for a maximum of 1.00 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Audio Digest Foundation is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's (ANCC's) Commission on Accreditation. Audio Digest Foundation designates this activity for 1.00 CE contact hours.

Lecture ID:

AN650802

Expiration:

This CME course qualifies for AMA PRA Category 1 Credits™ for 3 years from the date of publication.

Instructions:

To earn CME/CE credit for this course, you must complete all the following components in the order recommended: (1) Review introductory course content, including Educational Objectives and Faculty/Planner Disclosures; (2) Listen to the audio program and review accompanying learning materials; (3) Complete posttest (only after completing Step 2) and earn a passing score of at least 80%. Taking the course Pretest and completing the Evaluation Survey are strongly recommended (but not mandatory) components of completing this CME/CE course.

Estimated time to complete this CME/CE course:

Approximately 2x the length of the recorded lecture to account for time spent studying accompanying learning materials and completing tests.