Reg Anesth 1997 May;22(3):212-217
Department of Anesthesiology, Istanbul University, Cerrahpasa Medical Faculty, Turkey.
BACKGROUND AND OBJECTIVES: Since the first report of epidural opioid administration to pediatric patients, several studies have described the quality of analgesia, doses, pharmacokinetics, and side effects of this procedure. A pediatric series using an easy and cheap single-injection technique of epidural morphine administration for postoperative analgesia is presented. METHODS: Postoperative analgesia was achieved with a single lumbar epidural morphine injection (0.1 mg/kg in 0.2 mL/kg saline), which was given via a 22-gauge intramuscular needle to 153 pediatric patients (aged 4 months-17 years) following 175 lower abdominal or urologic operations. Injections were given by 43 anesthesiology residents under the supervision of pediatric anesthesiologists, after termination of surgery performed under general anesthesia. RESULTS: The success rate of epidural puncture on the first attempt was 92%. Pain control was considered excellent in 76% of patients for 24 hours. The remaining patients had analgesia lasting 10.9 +/- 5.5 hours after epidural morphine administration. No alterations in hemodynamic parameters were observed. Two patients (1.1%) developed respiratory depression during early postoperative care and one, with a history of apneic spells, had an episode of apnea 5 hours after morphine administration. The incidences of minor side effects were: nausea, 33.9%; vomiting, 42.9%; pruritis 9%; and urinary retention 12.5%. CONCLUSIONS: This technique is easy to perform, even for trainees in anesthesiology. With appropriate patient selection and avoidance of the concomitant use of narcotics and sedatives, epidural morphine provides prompt, effective, safe, and prolonged analgesia in children.
Reg Anesth 1997 Jan;22(1):16-23
Department of Anesthesiology, Medical College of Wisconsin, Milwaukee, USA.
BACKGROUND AND OBJECTIVES: Nissen fundoplication is a common procedure in high-risk pediatric patients. This cohort study evaluated the influence of epidural versus intravenous opioid analgesia on the postoperative course of infants and children undergoing fundoplication. METHODS: A retrospective review was made of the perioperative courses of 155 consecutive patients, aged 1 month to 19 years, who underwent elective open fundoplication from January 1993 to October 1994. Of these 155 patients, 72 received perioperative analgesia with epidural opioids, while 83 received parenteral opioids. Outcome variables included major morbidity factors, recovery of bowel and bladder function, and economic impact. RESULTS: Patients in the epidural and parenteral groups did not differ with respect to age, weight, or associated preoperative medical diagnoses. The postoperative complication rate was significantly decreased in the epidural group (5.5% versus 20%) (P < .001). In the epidural group 4 patients required mechanical ventilation for longer than 24 hours, compared with 15 in the parenteral group. Patients in the epidural group were discharged earlier from the hospital and incurred approximately 20% less in hospital charges on average than their cohorts in the intravenous group. CONCLUSIONS: These findings suggest that perioperative epidural analgesia, administered by a dedicated pain service, amy improve outcome in high-risk pediatric patients undergoing fundoplication.
Pediatr Emerg Care 1996 Dec;12(6):404-406
Division of Pediatric Orthopaedics, Arkansas Children's Hospital, Little Rock, USA.
OBJECTIVE: To determine if intravenous regional anesthesia (Bier block) is safe and efficacious for the management of children's extremity fractures in the emergency department (ED). DESIGN: Retrospective review of 470 ED records of children presenting with extremity fractures reduced with intravenous regional anesthesia from 1989 through 1994. SETTING: ED of a 256-bed teriary care children's hospital. PATIENTS: Four hundred seventy children treated in the ED from 1989 through 1994 for extremity fractures reduced with Bier block anesthesia. Three hundred eleven boys and 159 girls with a mean age of 9.4 years (range two-19 years) were included in the review. INTERVENTION: Utilization of intravenous regional anesthesia for fracture reduction of affected extremity. MAIN OUTCOME MEASURES: ED records and orthopaedic consultation notes were reviewed for adequacy of reduction, number of reduction attempts, efficacy of anesthesia, and any associated untoward effects or complications, and review of operative notes of any children who required a subsequent procedure in the operating room (OR) under general anesthesia. RESULTS: Ninety-nine percent (467) had adequate anesthesia for fracture reduction. There were no complications noted. Specifically, there were no incidents of hypotension, tachycardia, seizures, or arrhythmia. Bier block anesthesia was aborted in three patients because venous access could not be obtained in the affected extremity. Less than 2% (8) required a general anesthetic in the OR for further treatment. All of the children taken to the OR underwent internal fixation of the fracture. CONCLUSIONS: Intravenous regional anesthesia (Bier block) is safe and efficacious in the treatment of children's extremity fractures in the ED.
Reg Anesth 1996 Nov;21(6):561-564
Department of Anesthesiology and Rain Management, Parkland Memorial Hospital, Dallas, TX, USA.
BACKGROUND AND OBJECTIVE: EMLA cream is an effective topical anesthetic, which is commonly used for analgesia during venous cannulation in the pediatric population. This study was designed to compare the efficacy of EMLA cream with that of infiltration with lidocaine in relieving the pain associated with administration of spinal anesthesia. METHODS: The patient population consisted of 41 ASA status I and II women scheduled for postpartum tubal ligation. Spinal anesthesia was administered with a 25-gauge spinal needle via a 20-gauge introducer. The patients were randomly allocated to receive either EMLA cream for a minimum of 30 minutes or infiltration with 3 mL of 1% lidocaine prior to spinal needle insertion. Pain during spinal needle insertion was assessed immediately after each procedure by a 10-cm visual analog scale. RESULTS: Pain scores were significantly lower in the EMLA group (mean, 1.5) than in the lidocaine group (mean, 3.52) (P < .001). The number of patients satisfied with the method of analgesia was significantly higher in the EMLA than in the lidocaine group (90% vs 55%, P < .05). CONCLUSION: EMLA cream is an effective alternative to lidocaine infiltration for analgesia during the administration of spinal anesthesia when using a 25-gauge spinal needle via a 20-gauge introducer. Application of EMLA cream for at least 30 minutes prior to spinal needle insertion is adequate to provide good analgesia during needle insertion.
Reg Anesth 1996 Nov;21(6):557-560
Anesthesia and Resuscitation Unit, A. Meyer Pediatric Hospital, Italy.
BACKGROUND AND OBJECTIVES: The study was designed to compare the analgesic efficacy of the local anesthetic EMLA when applied as a patch and as a cream in combination with a Tegaderm dressing to pediatric oncology patients undergoing repeated lumbar punctures. METHODS: The analgesic effect of the two products was assessed by a continuous or discrete visual analog scale in 24 children 3-16 years old, during two lumbar punctures. Distress was rated by use of the Observational Scale of Behavioral Distress. RESULTS: No significant differences were found between the pain and distress scores for the different preparations of EMLA. CONCLUSION: The EMLA patch and the EMLA cream are equally effective in alleviating pain associated with lumbar puncture. The EMLA patch simplifies and speeds up the application of EMLA. It also allows for control of the dose administered per application, thus preventing both over- and underdosing.
Anesth Analg 1996 Nov;83(5):904-912
Service de Chirurgie Pediatrique, Fondation-Hopital Saint-Joseph, Marseille, France.
We report the results of a prospective study on the practice of pediatric regional anesthesia by the French-Language Society of Pediatric Anesthesiologists (ADARPEF) during the period from May 1, 1993 to April 30, 1994. This study was designed to provide data concerning the epidemiology of regional anesthesia and its complications in a totally anonymous way. Data from 85,412 procedures, 61,003 pure general anesthetics and 24,409 anesthetics including a regional block, were prospectively collected. Central blocks (15,013), most of which were caudals, accounted for more than 60% of all regional anesthetics. Peripheral nerve blocks and local anesthesia techniques represented only 38% of regional blocks and Bier block was used only 69 times. Central and peripheral nerve blocks were performed in all pediatric age groups with some intergroup differences. Most blocks were performed under light general anesthesia (89%), confirming the fact that regional anesthetics are used as techniques of analgesia rather than anesthesia. Complications were rate (25 incidents involving 24 patients) and minor, and did not result in any sequelae or medicolegal action. Peripheral nerve blocks and local anesthesia techniques were generally safe. The overall complication rate of regional anesthesia was 0.9 per 1000, but because all complications occurred with central blocks, the complication rate of central blocks is in fact 1.5 per 1000 with significant variations in different age groups. This prospective study, based on a large and representative series of pediatric anesthetics, establishes the safety of regional anesthesia in children of all ages. It provides new insights on the practice of regional blocks and reveals that complications are rare and minor as they occur most often in the operating room and are readily managed by experienced anesthesiologists with resuscitative equipment at hand. The extremely low incidence of complications (zero in this study) after peripheral nerve blocks should encourage pediatric anesthesiologists to use them more often when they are appropriate, in the place of a central block.
Reg Anesth 1996 Sep;21(5):442-445
Anesthesia Department, Hospital Universitari de Badalona Germans Trias i Pujol, Barcelona, Spain.
BACKGROUND AND OBJECTIVES: The optimal rate of injection of local anesthetic in pediatric caudal blocks has not been determined. The purpose of this study was to determine the influence of two rates of injection on the level of analgesia in children. METHODS: The patients, 79 children, American Society of Anesthesiologists class 1, who were scheduled for minor surgery, were allocated to three groups according to age: group 1, 0-12 months; group 2, 13-36 months; and group 3, 37-72 months. Each age group was further divided randomly into two subgroups according to rate of injection: subgroup A received 1 mL/kg of 0.25% bupivacaine with 1:200,000 epinephrine at a rate of 1 mL/s, and subgroup B received the same dose at a slower rate of 1 mL per 10 s. Level of analgesia was assessed by loss of sensation to skin pinching. Age, weight, height, time of surgery, onset, and level of analgesia and complications were recorded. RESULTS: For the faster rate, significant differences in level of analgesia were found between groups 1 and 2; the groups were not significantly different for the slower rate, however. The median level in patients 12 months and under was two dermatomes above that of patients older than 12 months at both rates. The levels for each rate (subgroups A and B) were not significantly different in any age group. The time needed to reach the highest level became progressively longer with age (from group 1 to 3), and differences were significant at both rates. CONCLUSIONS: Level of analgesia is not affected by the rate injection of 0.25% bupivacaine into the epidural caudal space in children. The time needed to reach the highest level increases as the child ages.
Pain 1996 Apr;65(1):63-69
Department of Anesthesia, Children's Hospital, Boston, MA 02115, USA.
The objectives of this study were to identify the characteristics of children who required regional anesthesia for pain associated with terminal malignancy and to identify the safety, tolerability and effectiveness of regional anesthesia as an analgesic modality in terminal pediatric malignancy. A retrospective examination was made of the medical records of children who died of malignancy following treatment at the Dana-Farber Cancer Institute and Children's Hospital, Boston, Massachusetts and who required either epidural or subarachnoid infusions, or neurolytic blockade for pain management (June, 1986--April, 1994) during the terminal phase of their illness. Eleven patients were identified, with a duration of epidural or subarachnoid infusions ranging from 3 days to 7 weeks. Indications for this intervention included limiting side effects of opioids, neuropathic pain unresponsive to either rapid escalation of opioids or massive opioid infusions, analgesia for thoracocenteses for the drainage of malignant pleural effusions and instillation of intrapleural chemotherapy. Pain was localized to one area in ll patients. Analgesia was judged to be satisfactory in all cases after regional anesthesia was instituted and remained satisfactory in all cases throughout the treatment course. Complications associated with regional anesthesia included dural puncture headache and mild respiratory depression. Five patients were nursed at home with either epidural or subarachnoid infusions.
J Pediatr Orthop 1996 Mar;16(2):187-191
Department of Orthopaedic Surgery and Rehabilitation, University of Oklahoma Health Sciences Center, Oklahoma City, USA.
A prospective, randomized study of intravenous (i.v.) regional anesthesia compared with nitrous oxide gas was performed in a group of 28 pediatric patients with forearm fractures requiring manipulation in the emergency department. The groups were compared in terms of pain perceived by the patients, success of manipulation, safety, and duration of procedure. The methods showed no significant difference in amount of pain perceived by the patient for the total pain experience. No medical complication was seen in either group. Because of a technical problem with an i.v. regional block, fracture manipulation was not completed in one patient. Nitrous oxide treatment required significantly less time for completion of the procedure.
Ann Thorac Surg 1995 Oct;60(4):927-930
Department of Surgery, University of Virginia Health Sciences Center, Charlottesville.
BACKGROUND. Since 1981, we have performed 68 thoracoscopic procedures in 62 patients aged 7 months to 21 years. METHODS. We reviewed the anesthetic and ventilation strategy used for each procedure to determine which anesthetic strategies are safe and effective for particular children and conditions. RESULTS. Regional anesthesia with sedation was used for six procedures in 5 patients with a mean age of 16 years (range, 9 to 21 years). One patient required conversion to general anesthesia. General anesthesia with one-lung ventilation was attempted for 18 procedures in 17 patients with a mean age of 12 years (range, 7 months to 18 years). Two patients required conversion to two-lung anesthesia secondary to pulmonary intolerance. One of these patients and 2 others required thoracotomy. General anesthesia with two-lung ventilation was used for 44 procedures in 41 patients with a mean age of 9 years (range, 1 to 17 years). There were no anesthesia-related difficulties. CONCLUSIONS. Regional anesthesia should be limited to the older, more cooperative patient. General anesthesia with one-lung ventilation is useful in adolescents, as they tolerate collapse of one lung well, and it is particularly desirable for procedures requiring exposure of the mediastinum and for talc pleurodesis. General anesthesia with two-lung ventilation can be used in any age group but is generally necessary for infants and small children, as they often will not tolerate the collapse of one lung, and in the larger child or adolescent with severe pulmonary compromise.
J Pain Symptom Manage 1995 Jan;10(1):21-29
Department of Anesthesiology, University of Washington School of Medicine, Seattle, USA.
Phantom sensations and pain occur with an unknown frequency in children. We hypothesized that such experiences are common among children, and occur more often than is recognized by health-care personnel. Children and adolescents, ages 5-19 years, who had undergone limb amputation in the past 10 years, served as subjects for this retrospective study. Subjects were divided into three major groups depending upon the indication for amputation: congenital deformity (CD), trauma/infection (TI), and cancer (Ca). Surveys assessing phantom sensations and phantom pain were mailed to children and their parents/guardians. The incidence of phantom sensations was 100% in each group, and phantom pain occurred in the overwhelming majority. Both types of phantom phenomena began within days of surgery for almost all patients. Seventy-five percent of children and adolescents who had experienced phantom pain also had preoperative limb pain. At the time of the study, phantom pain had resolved in only 35% of the subjects. Phantom pain was documented in the medical records of only 40% of those answering positively to questions regarding phantom pain on the questionnaire. We conclude that phantom pain occurs commonly in children and adolescents. The association of preoperative pain in the diseased extremity and the later occurrence of phantom pain suggests that preoperative regional anesthesia may prevent phantom pain.
Am J Pediatr Hematol Oncol 1994 Nov;16(4):305-308
Edward Mallinckrodt Department of Pediatrics, Washington University School of Medicine.
PURPOSE: After the harvesting of bone marrow for use in transplantation, pain control needs are greatest in the first 12 to 24 hours. This is also the time during which systemic side effects of parenterally administered narcotics are greatest as a result of the recent general anesthetic. We examined the role of regional anesthesia as an adjunct to pain management in pediatric patients undergoing bone marrow harvest. PATIENTS AND METHODS: Ten pediatric bone marrow donors were treated with intraoperative caudal blocks using bupivacaine or a combination of bupivacaine and morphine. RESULTS: Donors who received regional anesthesia had a significant decrease in postoperative parenteral narcotic requirement and fewer systemic complications when compared with a control group of 10 age-matched children who did not receive the caudal block. CONCLUSIONS: Regional anesthesia with caudal block can decrease the morbidity associated with bone marrow harvest in donors.
J Pediatr Orthop 1994 Jul;14(4):534-537
University of Utah Department of Pediatrics, Salt Lake City.
The safety and effectiveness of the "mini-dose" Bier block, a technique of i.v. regional anesthesia using low-dose lidocaine (1.5 mg/kg) without routine premedication, was evaluated in the emergency department treatment of pediatric upper-extremity fractures and dislocations. We prospectively studied 69 patients, aged from 2 to 16 years, treated at a pediatric primary care/referral-based emergency department. Good to excellent anesthesia was achieved during closed reduction in 90% of the cases. All patients achieved an acceptable reduction, as demonstrated by follow-up radiographs. None required further treatment of the injury under general anesthesia. No significant complications were noted. We conclude that the mini-dose Bier block provides safe, reliable, and cost-effective anesthesia for the outpatient reduction of pediatric upper-extremity injuries.
Anesth Analg 1994 Jul;79(1):129-131
Division of Pediatric Surgery, E. Wolfson Medical Center, Holon, Israel.
Dorsal penile nerve block (DPNB) is a useful procedure for analgesia in circumcision. It has minor complications and a reported failure rate of from 4% to 6.7%. To evaluate the intraoperative value of additional anesthesia of the perineal nerves--a branch of the pudendal nerve--during circumcision, we conducted a prospective randomized double-blind study on 250 adults. The postoperative period was not studied. The subpubic space technique of DPNB was used. Patients received DPNB (Group I) or DPNB with an additional ventral injection (Group II) for perineal nerve analgesia. Seventeen patients (13.6%) from Group I suffered pain. Of these, nine (7.2%) had discomfort and mild pain but no supplemental analgesia was needed. In the remaining eight patients, however, it was necessary to add local analgesia. This represents a total failure rate of 6.4%. On the other hand, only six patients (4%) in Group II had a mild diffused discomfort with no need for additional local anesthesia (P < 0.01). The average operating time was 12.4 +/- 2.7 min (range 9-22 min) in Group I and 10.7 +/- 1.6 min (range 8-15 min) in Group II (P < 0.001). We think that perineal nerves play an important part in innervation of the penis and must be anesthetized during the penile block.
J Pediatr Surg 1993 Apr;28(4):560-564
Department of Surgery, College of Medicine, University of Vermont, Burlington 05401.
Postoperative pain control (PPC) in children is a difficult management problem. Systemic narcotics often result in respiratory depression, while nonnarcotic analgesics are associated with inconsistent PPC. This report reviews a 29-month (January 1989 through July 1991) experience with 174 children (aged < 18 years) who received regional PPC through indwelling catheters. There were 105 males and 69 females. Patient age ranged from 1 day to 17 years 10 months (mean age, 97 months). All catheters were placed using introduction needles ranging from 24 to 16 gauge. Agents were delivered as either continuous infusion (151 patients, 87%) or bolus injections (23 patients, 13%). Analgesics were age- and weight-determined dosages of bupivacaine with or without narcotic supplementation. All patients had surgical procedures except two who had catheters placed for pain control after trauma and one who had a catheter for intractable abdominal pain of unknown etiology. Twenty-five (15%) children had thoracic incisions, 76 (43%) abdominal, 16 (9%) flank, and 54 (31%) extremity. Catheter placement included 40 thoracic epidurals (23%), 100 lumbar (57%), 27 caudal (16%), and 7 pleural (4%). Catheters were utilized for a duration of 0.5 to 8 days (mean, 2.1 +/- 1.2 days). One hundred forty-four children required no additional pain medications (83%). Thirty (17%) patients required supplemental medications. Acetaminophen was used in 6 (3%), acetaminophen with codeine in 4(2%), morphine in 18 (10%), and Percocet in 1(1%). Minor complications occurred 21 times in 16 children (9%).
J Pediatr Orthop 1992 Sep;12(5):633-635
National Naval Medical Center Bethesda, Maryland.
Intravenous (i.v.) regional anesthesia with low-dose lidocaine (1 mg/kg) lidocaine 1% diluted to 0.125% vol) provided safe and effective anesthesia for closed reductions of pediatric forearm fractures in outpatients. This procedure was prospectively evaluated in 44 children at The Nemours Children's Clinic, Jacksonville, Florida. Forty-three of 44 patients achieved adequate anesthesia (minimal or no pain on closed reduction). No significant complications were noted. Both patients and physicians were satisfied with the procedure. Patient pain was objectively assessed with visual pain charts in the preanesthesic, immediate postanesthetic, and postreduction time periods. The technique was both safe and effective in providing pain relief for reduction of forearm fractures in children.
Reg Anesth 1992 May;17(3):119-125
Department of Anesthesiology, Cliniques Universitaires Saint Luc, University of Louvain Medical School, Brussels, Belgium.
METHODS. The demographic and technical data of all the pediatric caudal blocks (CBs) performed from August 1986 to September 1989 in our teaching hospital were prospectively collected on a computerized protocol. Except for 22 high-risk ex-premature infants, all CBs were performed under halothane or isoflurane anesthesia, after premedication with atropine. Moreover, they were performed using local anesthetic solutions containing 1:200,000 epinephrine. A total of 1100 CBs were performed in children younger than 7 years; 203 patients weighed 5 kg or less; 260, 5.1-10 kg; 300, 10.1-15 kg; and 337, more than 15.1 kg. The CBs were also analyzed according to the anesthesiologist's experience with CB: 184 were performed by anesthesiologists who had performed fewer than 10 CBs (Group A); 210, 10-20 CBs (Group B), and 704, more than 20 CBs (Group C). RESULTS. We found difficult landmarks in 11.2% of our patients. Moreover, it was significantly more frequent (p = 0.0004) if the patients weighed less than 10 kg, because of poor anatomy or obesity. There were 76 bloody taps (BTs, 6.9%); although there was a statistically insignificant trend toward a lower incidence of BTs in the 5.1-10-kg group, experience seemed to influence the incidence of BTs, as it decreased from 11.4% in Group A to 8.9% and 5.4% in Groups B and C, respectively (p less than 0.05). There were eight systemic reactions (i.e., brisk onset of tachycardia during or shortly after the CB), which were all short-lived and responded quickly to hyperventilation with oxygen. Two occurred despite repositioning the needle after a previous BT, but six occurred with no previous evidence of blood and were thus called "concealed" BTs. Moreover, all occurred in children weighing 10 kg or less. There was only one dural tap. Only nine CBs (0.81%) failed to provide effective intraoperative anesthesia, and 93% of the patients left the recovery room without having required narcotic or non-narcotic analgesics. CONCLUSIONS. Our results confirm that CB is a reliable technique, easy to perform by beginners. It should be stressed, however, that small infants are at increased risk of concealed BTs.
Cah Anesthesiol 1992;40(6):399-402
[Article in French]
Departement d'Anesthesie-Reanimation, Faculte de Medecine, Universite de Naples.
This study compares three techniques of anesthesia on the ground of the course of plethysmography, pulse oximetry and evaluation of postoperative pain in 75 pediatric patients divided into 3 groups. Results show that combined anesthesia, intravenous and regional anesthesia, has a less desaturation incidence, a better development of plethysmography and a positive reply to postoperative pain.
Anesth Analg 1991 Oct;73(4):434-440
Claude Bernard University, Lyon, France.
Regional anesthesia with bupivacaine in pediatric patients is often accompanied by light levels of halothane general anesthesia. To determine the potential cardiotoxicity of these two drugs when used together, we defined the interaction between moderate plasma bupivacaine concentrations (1270-1760 ng/mL) and halothane (end-tidal concentrations, 0.5%-1.0%) on ventricular contractility and conduction in 22 closed-chest dogs anesthetized with chloralose. Bupivacaine alone (1-mg/kg intravenous bolus plus a 0.1-mg.kg-1.min-1 constant rate infusion) resulted in significant increases in ventricular conduction time (VCT) and effective refractory period (VERP) and nonsignificant decreases in dP/dtmax and blood pressure. The addition of halothane resulted in hypotension and in progressively increasing plasma bupivacaine levels secondary to reduced hepatic clearance, which led to further dose-related significant increases in VCT and VERP and to significant decreases in dP/dtmax and blood pressure. In other dogs given halothane but in which bupivacaine levels were held constant (1400 ng/mL), VCT remained constant and VERP lengthened slightly, whereas dP/dtmax decreased. We conclude that the combination of bupivacaine and halothane can cause adverse effects on ventricular contractility and intraventricular conduction.
Reg Anesth 1991 Jan;16(1):20-22
Children's Hospital of Wisconsin, Medical College of Wisconsin, Milwaukee.
Nineteen pediatric patients aged 6 months to 12 years scheduled for elective upper extremity surgery were randomly assigned to receive either a parascalene block or sham injection. Both groups received a potent inhalational agent for operative anesthesia. At completion of surgery, the treatment group received an injection of 0.5 ml/kg 0.25% bupivacaine with 1:200,000 epinephrine into the brachial plexus via the parascalene approach with the aid of a nerve stimulator; the control group received a subcutaneous needle puncture only. Patients in the parascalene group had superior postoperative analgesia, as evidenced by significantly less opioid requirement in the first 12 postoperative hours and by significantly lower scores on an objective pain scale. We found the parascalene approach to the brachial plexus a simple and reliable analgesic technique in anesthetized children.
Reg Anaesth 1989 Jan;12(1):25-29
[Article in German]
Abteilung fur Anaesthesiologie der Stadtischen Kliniken Dortmund.
Local and regional anesthesia, especially peridural anesthesia, is a rarely used method in pediatric anesthesia. That cannot be explained by children's physis, since it shows in general neither a different margin of therapeutic safety nor a different effect/side-effect ratio than in adult. Nevertheless, psychologic alteration of children through operation and anesthesia necessitate simultaneous endotracheal narcosis during peridural anesthesia. The following characteristics of regional anesthesia in children should be regarded: The younger the child the higher is the ratio between extracellular water and body weight. Thus higher doses of local anesthetics in relation to body weight can be applied. The smaller diameters of children's nerves support diffusion of local anesthetics and, therefore, allow the use of lower concentrations. Increased perfusion of tissues and high cardiac output lead to rapid resorption and accelerated increase of anesthetic blood levels. This disadvantage can be avoided by use of lower concentrations of anesthetics. Even an extended sympathetic block during peridural anesthesia hardly causes any negative effect on circulatory parameters. We performed thoracic epidural anesthesia during thoracic and upper abdominal surgery in 40 5-15-year-old children. In many of the patients additional risks had already occurred through atelectasis or lung fibrosis. Before introducing the epidural catheter we always carried out endotracheal anesthesia with relaxation to achieve perfect conditions for the puncture. This puncture was made between Th 6 and 10, mostly between Th 7/8, the patient lying on one side. An extension of analgesia between Th 3 and Th 12 was intended, which, however, could not be controlled because of simultaneous endotracheal anesthesia.