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PEDIATRIC REGIONAL ANESTHESIA

PEDIATRIC REGIONAL ANESTHESIA. Jodie L. Johnson, M.D. Assistant Professor of Clinical Anesthesia Riley Hospital for Children. Introduction. Regional anesthesia being used more frequently in pediatric setting Most blocks placed at beginning of case “preemptive analgesia” Some placed at end

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PEDIATRIC REGIONAL ANESTHESIA

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  1. PEDIATRIC REGIONAL ANESTHESIA Jodie L. Johnson, M.D. Assistant Professor of Clinical Anesthesia Riley Hospital for Children

  2. Introduction • Regional anesthesia being used more frequently in pediatric setting • Most blocks placed at beginning of case • “preemptive analgesia” • Some placed at end • Rarely used as sole anesthetic

  3. General Principles • Must acquire experience/dexterity with RA in adults before employing techniques in kids • Be aware of anatomical differences between small child and adult • Be aware of pharmacokinetic differences

  4. General Principles • Consider individual drug profiles • Skin infection in area of needle/catheter insertion is contraindication • Coagulation disorders are contraindication (unless corrected) • Chemotherapeutic agents cause vascular fragility and thus central blocks are contraindicated in pts on chemo

  5. General Principles • Have clear strategy • Good organization of equipment, drugs and assistant helps avoid delays • Close monitoring just as important as with GA

  6. General Principles • Significant development in regional anesthesia in peds due to: • Advances in safety information • Advances in pharmacology(Ropivicaine) • Improvements in equipment • Types of blocks limited only by skill and interest of individual anesthesiologist

  7. Benefits • Analgesia provided by block reduces amount of GA • More rapid recovery • Decreased incidence of nausea & vomiting • Faster return of appetite • Earlier discharge • Decreased need for opioids

  8. Benefits • Regional block eliminates undesirable autonomic reflexes • Laryngospasm decreased • Cardiac dysrhythmias decreased • Muscle relaxation can be obtained with suitable local anesthetic • Can avoid use of muscle relaxants, decrease risk of respiratory insufficiency

  9. Benefits • Easier to obtain immobilization of limb after delicate surgery if child is pain-free and there is some residual motor block

  10. Benefits • Hypotension and urinary retention rarely seen in children • Intra- and post-operative bleeding reduced under neural blockade • A technique of choice if history of MH • Can avoid interference with respiratory tract in premies with BPD

  11. Benefits • Diminished stress response • Fewer episodes of hypoxia • Greater cardiovascular stability • Faster return of GI function • Reduced need for postop vent support • Shorter stay in ICU

  12. Safety • Low complication rates • Lack of hypotensive response from sympathectomy produced by LA • Loose perineurovascular sheaths • Wider spead of LA from single injection site

  13. Pharmacology and Physiology • Increased risk of toxicity with local anesthetics • Infants have immature hepatic metabolism • Increased total body water • Larger Volume of Distribution • Longer elimination half-life • Decreased plasma proteins ( more drug in free/active form) • Rapid increase in blood levels due to higher cardiac output/regional blood flow

  14. Pharmacology • Long-acting local anesthetics provide for 6-12 hours of post-operative pain relief • Bupivicaine 0.2% to 0.5% • Ropivicaine 0.2%

  15. Pharmacology • Strictly follow maximal dosing guidelines to prevent side effects

  16. Physiology • Decreased minimum anesthetic concentration required to block impulse conduction • Nerves have thinner myelin sheaths • Nerves have smaller fiber diameter and a shorter internodal distance • Adequate surgical block with smaller concentrations of LA

  17. Equipment • Appropriate equipment decreases risk of injury despite risks of increased toxicity • Use nerve stimulator in anesthetized kids to improve success rate of peripheral nerve blockade • 1- or 2-inch insulated needles used

  18. Caudal Blockade • Most common regional block in children • Simple to perform • Easily adaptable to ambulatory anesthesia practice • Greatly decreases risk of reflex laryngospasm

  19. Caudal - Anatomy • Sacral hiatus easy to identify • Palpable large bony processes on each side of hiatus called cornua • Hiatus covered by sacrococcygeal membrane • Dural sac may extend to S3 or S4 in infants (short distance between hiatus and dural sac)

  20. Caudal- Technique • Lateral decubitus position • Palpate coccyx • Move finger gently from side to side and proceed in cephalad direction • First double bony protuberance encountered are sacral cornua which define the sacral hiatus

  21. Caudal - Technique • Sterile prep/drape • 21 g butterfly needle usually used • Insert at 45-60 degree angle with bevel facing anteriorly • Distinct pop felt as sacrococcygeal membrane pierced • Lower angle of needle and advance 2-3 mm

  22. Caudal Blockade • If outpatient, use just local anesthetic • 0.25% Bupiv or 0.2% Ropiv with epi • Test dose: 0.1 ml/kg with 5mcg/ml of epi (max 3ml) • Look for signs of intravascular injection • Increased heart rate > 10 bpm above baseline • Increased blood pressure • >25% change in T-wave amplitude • Doses: • 0.5cc/kg for LE/perineal surgery • 0.75cc/kg for T-10 level • 1cc/kg for lower thoracic level

  23. Caudal Blockade • For inpatients, can add PF MSO4 for 18 to 24 hours of postop analgesia • 50 mics/kg for perineal surgery • 60 mics/kg for mid abdominal incision • 70 mics/kg for sternotomy (open hearts)

  24. Caudal Blockade • Recent interest in Clonidine • Less respiratory depression • Less nausea/vomiting • Less pruritis • Similar/prolonged analgesia VS. Morphine • ? Dose • 1, 2 or 3 mcgs/ kg… to be determined

  25. Caudal Blockade • ? Use of Clonidine in outpatients • Some staff do not use at all • Some use if > 1 year of age • ? Use of hydromorphone • ? Use of ketamine

  26. Caudal Blockade • Major complications rare • Intravascular injection with systemic toxicity • Dural puncture causing high spinal blockade • Infection (especially after interosseous puncture/penetration)

  27. Continuous Caudal Catheter • Manufactured kits available • Styletted catheter increases passage to thoracic level • Care taken to prevent fecal contamination

  28. Continuous Caudal Catheter • Caudal approach to thoracic epidural anesthesia used in children > 10 years of age • Success related to less densely packed epidural fat • Easy cephalad passage of catheter

  29. Continuous Caudal Catheter • Correct placement confirmed by: • Ease of injection • Negative aspiration • Radiographic imaging • Nerve Stimulation through catheter

  30. Epidural Block • Improved surgical outcomes: • Decreased stress response • Fewer episodes of hypoxia • Decreased cardiac morbidity • Decreased pulmonary infections • Decreased thromboembolic events • Decreased blood loss • Faster return of GI function

  31. Epidural Block • Drugs Used: • Ropivacaine/Bupivacaine • 2 - Chloroprocaine • Morphine • Clonidine

  32. Epidural Block • Line drawn between two iliac crests passes closer to L5 (vs. L3-4 interspace in adults) • Under 1 year of age: • Spinal cord ends at lower level (L3 vs. L1) • Dural sac ends at lower level (S4 vs. S2)

  33. Epidural block • Lateral decub position • Surgical side down • Hips and knees flexed by 90 degrees • Sterile prep/drape • “Loss of Resistance” technique with saline

  34. Epidural Block • Epidural space more superficial in children than adults • Guideline for determining epidural depth: • 1mm/kg of body weight • Depth (cm) = 1 + 0.15 X age (years) • Depth (cm) = 0.8 + 0.05 X weight (kg) • Use shorter needles and extreme care

  35. Epidural Block • Dosing: • Depends on upper level of analgesia required • > 10 years of age: • Volume to block one spinal segment • V (in ml) = 1/10 X (age in years) • < 10 years old: • 0.04ml/kg/segment

  36. Epidural Block • Dosing:

  37. Epidural Block • Complications: • Intrathecal injection • High block • Postdural puncture headache • Intravascular injection/Local anesthetic toxicity • Sympathectomy • Hypotension • Bradycardia

  38. Epidural Block • Complications: • Opioid –induced respiratory depression • Damage to neural structures • Infection • Epidural Hematoma  paraplegia • < 1 in 150,000 • Usually associated with anticoagulation

  39. Epidural Block • Although potential complications, there are multiple benefits • Decreased stress response • Decreased thromboembolic complications • Decreased pulmonary problems • Improved patient/parent satisfaction

  40. Ilioinguinal and Iliohypogastric Nerve Block • Simple Block • Good pain relief for hernia repair, hydrocelectomy and orchiopexy • Can be done at beginning of case for both intraop and postop analgesia • May be done intraop under direct visualization

  41. Ilioinguinal Nerve Block • Anatomy • Nerves run between abdominal muscles • Close to ASIS • Both blocked by infiltration in area medial to ASIS

  42. Ilioinguinal Nerve Block • 25-gauge needle • Puncture skin 1 cm medial and 1 cm inferior to ASIS • Three fan-shaped injections • Sub Q wheal as needle withdrawn • Bupiv 0.25% w/ epi up to 2mg/kg used

  43. Penile Nerve Block • Provides analgesia after superficial surgery of penis • Circumcision • Meatotomy • Blocks both dorsal nerves at base of penis • Anesthesia to distal two-thirds of penis

  44. Penile Nerve Block • Usually performed by surgeon • Avoid epinephrine • May lead to ischemia of tissue • Complications: • Intravascular injection • Hematoma formation

  45. Brachial Plexus Block • Can be done at three levels: • Axillary • Interscalene • Supraclavicular • Excellent analgesia during/after surgery on the upper extremities

  46. Brachial Plexus Block • Axillary approach used most • Major complications rare • Interscalene/ Supraclavicular approaches provide better analgesia of upper arm/shoulder • Higher complication rate : pneumothorax and subarachnoid blockade

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