Pediatric Regional Anaesthesia (PRA) is today a universally well established method for providing pain control, but there is still a debate about the safety/efficacy  of performing RA in children.

In the last century it was the work ofPaolo Busoni, Claude  Saint-Maurice, Lynn Broadman ,Linda Jo Rice and few others (more recently the book by Bernard Dalens) who started to use PRA in their daily clinical practice to give an official scientific approval

A big problem rose immediately  :the never ending debate about the need of unconscious children for performing RA.  why two types of anesthesia (general and regional) doubling the risks?Only  now the story ended: it has been demonstrated that performing a block during anesthesia is a basic rule for safety (absence of pain, fear, agitation or shaking, that can cause severe anatomic damages, such as dural or vessel puncture, nerve injury, etc.).

There are certainly some other “obstacles” that must be known and overcome; these problems are unique to pediatric population, such as small dimensions, reduced emuntory functions due to immaturity in newborns and infants, the need of unconscious chidren for performing an anesthetic block.

Briefly debating each of these sides of the question, it emerges that, as a matter of fact, they are easily remedied:

1. Small dimensions: this results in increasing failure rate and greater risks of close structures injury. A good knowledge of  pediatric anatomy allows to perform peripheral and central blocks being fully aware of how and where we are acting: a large survey of ADARPEF (French Society of Paediatric Anaesthesia) assessed that PRA is a safe method if performed by experts, with pediatric equipment (needles, catheters, etc. adequate in gauge and size) and the more recent survey repated by the same Society confirms the safety with no sequelae and /or deaths on more tham 33000 blocks

2. Immaturity: with a possible increase in plasmatic levels of circulating drugs, due to a reduced metabolism and clearance, a narrow therapeutic window; all recent scientific studies and researches lead to the synthesis of two new local anesthetics with a greater margin of safety (levobupivacaine and ropivacaine), thanks to their reduced affinity with the cardiocirculatory and the nervous systems in comparison with the racemic drugs like bupivacaine.

 Moreover, the addition of adjuvants like clonidine and ketamine contributes to the reduction of toxicity, decreasing the local anaesthetic concentration, while obtaining an increase in analgesic property (synergism).

Epidural continuous infusion

· benefits have already been assessed from many years, and they concern a better patient outcome and money saving, related to a demonstrated reduction in times of ICU staying and in the total period of hospitalization in patients with epidural analgesia in comparison with those treated with intravenous analgesia.

Referring again to the first French survey, we can see that, after 1155 catheter positioning, the only complication was caused by a mistake in positioning (the catheter was too long, wrong size). · the addiction of adjuvants (like clonidine, and not morphine) to local anesthetics can overcome the opiod side effects (it is true that nausea, emesis, urinary retention, respiratory depression and itching are independent of the route of administration).

In conclusion epidural continuous analgesia must remain as one of  the  main method for pain control in children

The recent availability from the industry of padiatric catheters for continuous peripheral nerve block allows a further application for RA in children, useful for surgical procedures or long duration pain control for upper and lower extremities.

The new century brought also a new tool that can improve both the safety and the efficacy of the blocks: the use of Ultrasound (US)for nerve detection. This technique is extremely useful in children where a plexus or a nerve is generally very superficial and close to imprortant structure. The possibility of seeing the nerves and the needle allows a more accurate and safer block also with a reduction in the drug amount as confirmed by the first papers on its pediatric use.

Thus reduction of local anesthetic needed and an easier avoidance of intaneural or accidental iv injection are the keys of the sure success in the use of US in PRA

The two biggest Society of Regional Anesthesia, ESRA and ASRA, are publishing now the recommendations of the US RA giving suggestions and the basis for its safe execution.

Conclusively, the new century leads not only to affirmation and consolidation of the Regional Anaesthesia methods, but also to an extension of its performances, making it really a basic tool in the pediatric anesthesiologist’s kit.

 

Suggested Readings

-Giaufre E.,Dalens B,Gombert A. Epidemiology and morbidity of regional anesthesia in children. A one year prospective survey of the french language society of  pediatric anesthesiologists. Anesthesia and Analgesia.1996;83:904-912

-Broadman L. Where should advocacy for pediatric patients end and concerns for patient safety begin? Reg Anesth Pain Med editorial 1997;22:205-208

-Krane EJ Spinal epidermoid tumors: will a forgotten complication rise again?
Reg Anesth Pain Med. 1999 Nov-Dec;24(6):553-6

-Ivani G Ropivacaine: is it time for children? Paediatr Anaesth. 2002 Jun;12(5):383-7.

-Ivani G, DeNegri P, Conio A  Comparison of racemic bupivacaine, ropivacaine, and levo-bupivacaine for pediatric caudal anesthesia: Effects on postoperative analgesia and motor block. Reg Anesth Pain Med 2002;27:157-161

-Ivani G,De Negri P,Lonnqvist PA et al  Comparison of three different concentrations of levobupivacaine for caudal block in children. Anesth Analg 2003,in press

-Bergendahl HT, Lonnqvist PA, De Negri P et al  Increased postoperative arterial blood pressure stability with continuous epidural infusion of clonidine in children. Anesth Analg. 2002 Oct;95(4):1121-2.

-Lonnqvist PA, Ivani G, Moriarty T  Use of caudal-epidural opioids in children: still state of the art or the beginning of the end? Paediatr Anaesth. 2002 Nov;12(9):747-749.

-De Negri P, Ivani G, Visconti C, et al. How to prolong postoperative analgesia after caudal anaesthesia with ropivacaine in children: S-ketamine versus clonidine. Paediatr Anaesth 2001 ;11:679-83

-Marhofer P, Krenn CG, Plochl W, et al. S(+)-ketamine for caudal block in paediatric anaesthesia. Br.J.Anaesth.2000

-Krane E The ethics of  Regional Anesthesia in Anesthetized Children. TRAPM 2002 ; 6: 90-94

-McNeely JK,Farber NE,Rusy LM,Hoffman GM. Epidural analgesia improves outcome following pediatric fundoplication.A retrospective analysis. Reg Anesth  1997;22(1):16-23.

-Wilson et al Is epidural analgesia associated with an improved outcome following open Nissen fundoplication?. Paediatr Anaesth 2001;11:65-70

-Sciard D, Matuszczak M, Gebhard Ret al. Continuous posterior lumbar block for acute postoperative pain control in infants. Anesthesiology 2001; 95: 1521-3.

-Ivani G., Mossetti V, Gagliardi F et al. A lond term continuous infusion via a sciatic catheter in a 3-year-old-boy. Case report. Paediatr Anaesth 2003; in press.

-Tan T, Watcha M, Safavi F, et al. Cannulation of the axillary brachial plexus sheath in children. Anesth Analg 1995; 80:640-641.

-Johnson C. Continuous femoral nerve blockade for analgesia in children with femoral fractures. Anaesth Int Care 1994; 22: 281-283.

-Tobias J. Continuous femoral nerve block to provide analgesia following femoral fracture in a pediatric ICU population. Anaesth Int Care 1994; 22: 616-618.

-Grau T. Ultrasonography in the current practice of regional anaesthesia.
Best Pract Res Clin Anaesthesiol. 2005 Jun;19(2):175-200.

-Rapp HJ, Folger A, Grau T.Ultrasound-guided epidural catheter insertion in children.
Anesth Analg. 2005 Aug;101(2):333-9,

-Marhofer P, Willschke H, Kettner S .Imaging techniques for regional nerve blockade and vascular cannulation in children.Curr Opin Anaesthesiol. 2006 Jun;19(3):293-300.

-Marhofer P, Bosenberg A, Sitzwohl C et al.Pilot study of neuraxial imaging by ultrasound in infants and children.Paediatr Anaesth. 2005 Aug;15(8):671-6.

-Willschke H, Marhofer P, Bosenberg A et al Epidural catheter placement in children: comparing a novel approach using ultrasound guidance and a standard loss-of-resistance technique.Br J Anaesth. 2006 May 23

-Willschke H, Marhofer P, Bosenberg A et al.Ultrasonography for ilioinguinal/iliohypogastric nerve blocks in children. Br J Anaesth. 2005 Aug;95(2):226-30

- Sites B, Chan V, Neal J et al The American Society of Regional Anesthesia (ASRA) and the European Society of Regional Anesthesia (ESRA) Joint Committee:Recommendations for Education and Training in Ultrasound Guided Regional Anesthesia .Reg Anesth Pain Med  2009 ;1:40-46-

Ivani G and Ferrante F. MThe American Society of Regional Anesthesia and Pain Medicine (ASRA) and the European Society of Regional Anaesthesia and Pain Therapy (ESRA) Joint Committee Recommendations for Education and Training in Ultrasound Guided Regional Anesthesia:  Why Do We Need These Guidelines? Reg Anesth Paio Med  2009;1:8-9

 

Giorgio Ivani,Valeria Mossetti,Elisa Oldani

Division  Pediatric Anesthesia and Intensive Care

Regina Margherita Children’s Hospital

P.za Polonia 94, 10126 Turin, Italy

Tel. +390113135937, fax +390113135575

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