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Regional anaesthesia in children. Presenter: B. Uma Moderator: Dr. Asha Tyagi. University College of Medical Sciences & GTB Hospital, Delhi. www.anaesthesia.co.in. email: anaesthesia.co.in@gmail.com. Regional anaesthesia in children. Differences in anatomy and physiology

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Regional anaesthesia in children
Regional anaesthesia in children

Presenter: B. Uma

Moderator: Dr. Asha Tyagi

University College of Medical Sciences & GTB Hospital, Delhi

www.anaesthesia.co.in

email: anaesthesia.co.in@gmail.com


Regional anaesthesia in children1
Regional anaesthesia in children

  • Differences in anatomy and physiology

  • Selection of techniques, agents and equipments

  • Central neuraxial blockade in children including caudal block


Introduction
Introduction

  • Regional anaesthesia in children first studied by August Bier in 1899

  • In 1900, Bainbridge reported a case of strangulated hernia repair under spinal anaesthesia in an infant of three months

  • Tyrell Gray, a British surgeon published a series of 200 cases of lower abdominal surgeries in infants and children under spinal anaesthesia in 1909-1910


Introduction contd
Introduction(contd.)

  • Advantages over GA:

  • Safe, reliable technique in infants at risk of apnoea, bradycardia and desaturation after GA

  • Good alternative for day care surgeries

  • Minimal risk of postoperative respiratory depression

  • Limited stress response to surgery

  • Cost effective


Perception of pain
Perception of pain

  • Somatic pain has 3 components:

  • Motivational directive:

  • conveyed by unmyelinated C fibres

  • Slow/true pain

  • Fully functional from early fetal life

  • Leads to protective reflexes

  • Sensory discriminatory

  • Cognitive evaluative


Perception of pain contd
Perception of pain(contd.)

  • Immature connections b/w dorsal horn neurons and C fibres till 2wks of life

  • Heightened response to nociceptive stimulation till 2 wks of life in response to large amounts of substance P

  • Immaturity of inhibitory control pathways till 2wks of life





Indications of regional anaesthesia
Indications of regional anaesthesia

  • Infraumbilical extraperitoneal surgeries like inguinal hernia, circumcision, hypospadias, orchidopexy, cystoscopy, colostomy for imperforate anus, rectal biopsy and other perineal surgeries

  • Lower extremity orthopaedic and reconstructive surgeries

  • Preterm and former preterm infants less than 60 weeks post-conceptual age/less than 3 Kg/hematocrit <30% and with other co-morbidities who are prone to post-operative apnoea,bradycardia and desaturation after GA


Indications contd
Indications(contd.)

  • Neonates with respiratory diseases like bronchopulmonary dysplasias, hyaline membrane disease

  • Children with h/o or high risk for malignant hyperthermia

  • Children with acute respiratory conditions, chronic disease of the airways like asthma or cystic fibrosis

  • Meningomyelocele, gastroschisis repair, open heart surgery etc in addition to light GA (rare)


Indications contd1
Indications(contd.)

  • Management of nonsurgical pain

  • Herpes zoster, AIDS, mucocutaneousleisons-regional blocks

  • Vaso-occlusive crisis of sickle cell disease

  • Non analgesic indications

  • Sympathetic blockade for severe trauma

  • Vascular insufficiency in Kawasaki disease

  • Severe frostbite

  • Accidental intra arterial injection of LA


Contraindications to regional anaesthesia
Contraindications to regional anaesthesia

  • Absolute contraindications to neuraxial blocks:

  • Severe coagulation disorders- constitutional or acquired

  • Severe infection such as septicemia or meningitis

  • Hydrocephaly and intracranial tumoralprocess

  • True allergy to local anesthetics

  • Chemotherapies (such as with cisplatin)

  • Uncorrected hypovolemia

  • Cutaneousor subcutaneous lesions at the contemplated site of puncture

  • Parental refusal


Contraindications contd
Contraindications( contd.)

  • Absolute contraindication to PNB procedures:

  • True allergy to the local anaesthetic agent

  • Relative contraindications:

  • Patients at risk of compartment syndrome

  • Sickle cell ds a/w hypoxemia and hemodynamic disorder

  • Extended malformations of vertebrae, spinal fusion, myelomeningoceles, open spina bifida, and major spondylolisthesis

  • Pre-existing neurologic disorder


Complications of regional anaesthesia
Complications of regional anaesthesia

  • Local complications:

  • Inappropriate needle insertion damaging the nerve and surrounding anatomic structures

  • Tissue coring and introduction of epithelial cells into tissues where they do not belong

  • Injection of neurotoxicsolutions

  • Leakage around the puncture site which may cause partial block failure and favor bacterial contamination

  • Systemic complications:

  • Accidental iv injection of LA

  • Excessive dosing


Selection of materials techniques and agents
Selection of materials, techniques and agents

  • Considerations for selection of suitable procedure:

  • Adequate sensory blockade

  • Minimal potential morbidity

  • Postoperative analgesia

  • Various approaches:

  • Single-shot technique with either a short-acting or a long-acting local anaesthetic

  • Single-shot technique with local anaestheticand adjuvants

  • Catheter technique with repeat/continuous injections of local anaesthetic


Selection of equipments contd
Selection of equipments….(contd.)

  • Identification of anatomic space:

  • Surface mapping or percutaneous guidance

  • Ultrasound techniques (Jockey probes)

  • Acoustic devices

  • Electrostimulation

  • Loss of resistance with air or saline

  • Whoosh test is now obsolete


Selection of equipments contd1
Selection of equipments….(contd.)

  • Selection of anaesthetic agent depends on:

  • Site/ extent of surgery

  • Expected duration of intense postoperative pain

  • Hospital stay vs early discharge


Selection of equipments contd2
Selection of equipments….(contd.)

  • Selection of block needles and catheters:


Safety precautions
Safety precautions

  • Acceptable environment for performing regional blocks:

  • Minimal mandatory monitoring

  • Anaesthetic and emergency drugs

  • Resuscitation equipments

  • Trained anaesthesiologist

  • Trained staff

  • iv line in situ



Spinal anaesthesia
Spinal anaesthesia

  • Anatomy and physiology:

  • The spinal cord and dural sac of infants younger than 1 year of age end at a lower level

  • Volume of CSF

  • 10 mL/kg in neonates

  • 4 mL/kg in infants weighing less than 15 kg

  • 3 mL/kg in children

  • 1.5 to 2.0 mL/kg in adolescents and adults

  • 50% CSF volume is located within the spinal subarachnoid space versus 25% in adults

  • Lower CSF hydrostatic pressure

  • Children older than 5yr behave like adults after spinal anaesthesia, whereas younger patients remain hemodynamically stable, without significant hypotension or bradycardia


Spinal anaesthesia contd
Spinal anaesthesia(contd.)

  • Indications:

  • Inguinal hernia repair in former preterm infants <60 weeks of postconceptual age

  • Elective lower abdominal or lower extremity surgery

  • Cardiac surgery or cardiac catheterization (controversial)


Spinal anaesthesia contd1
Spinal anaesthesia(contd.)

  • Technique of spinal anaesthesia:

  • Position:

  • Lateral position with head extended to avoid airway compromise

  • Sitting position

  • Firm grasp of the awake infant by an assistant

  • Neonates and infants: 1.5” 22G spinal needle with stylet at L4-5 level

  • >2yr: longer needle, smaller guage

  • Pop felt as needle enters the ligamentumflavum

  • Free flow of CSF

  • Inject the LA slowly

  • Child to remain supine and legs should not be raised for any reason



Caudal anaesthesia
Caudal anaesthesia

Anatomy of sacral hiatus


Caudal anaesthesia contd
Caudal anaesthesia(contd.)

  • Anatomy of sacral hiatus:

  • V-shaped aperture formed d/t lack of dorsal fusion of the 5th and 6th sacral vertebral arches

  • Limited laterally by sacral cornua

  • Covered by sacrococcygeal membrane

  • Mean distance from skin to anterior sacral wall: 21 mm (2 mo to 7 yr)

  • Less suitable after 6-7yrs as

  • Change in axis of sacrum

  • Difficulty to identify sacral hiatus

  • Densely packed epidural fat


Caudal anaesthesia contd1
Caudal anaesthesia(contd.)

  • Indications of caudal anaesthesia:

  • Surgical procedures below the umbilicus

  • As an adjuvant to GA

  • Sole anaesthetic technique in fully awake ex-premature infants younger than 60 wk of post conceptual age

  • Contraindications to caudal anaesthesia:

  • Major malformations of sacrum (myelomeningocele, open spina bifida)

  • Meningitis

  • Intracranial hypertension



Caudal anaesthesia contd2
Caudal anaesthesia(contd.)

  • Technique of caudal anaesthesia:

  • Positioning the patient

  • Sim’s position

  • Semiprone

  • Prone- esp. in non anaesthetized (frog position)

  • Palpate for sacral cornua along the spinal processes at the level of sacrococcygeal joint

  • The sacral hiatus along with both PSIS forms an equilateral ∆

  • Introduce needle in midline at 45⁰ or less

  • Resistance felt on piercing the sacrococcygeal ligament

  • Inject the LA with frequent aspirations

  • Finger should palpate the skin cephalad t the injection to ensure drug is not s/c


Caudal anaesthesia contd3
Caudal anaesthesia(contd.)

  • Technique using ultrasound:

  • Linear ultrasound transducer set at highest operational frequency to achieve max. resolution of the superficial anatomy

  • Transducer placed in longitudinal plane b/w 2 sacral cornua

  • Sacrococcygeal ligament identified

  • Needle introduced at 20⁰

  • In difficult cases longitudinal paramedian approach


Caudal anaesthesia contd4
Caudal anaesthesia(contd.)

  • The armitage regime:

  • O.5 ml/kg- all sacral dermatomes blocked

  • 1 ml/kg- sacral and lumbar dermatomes blocked

  • 1.25 ml/kg- upto midthoracic levels blocked


Caudal anaesthesia contd5
Caudal anaesthesia(contd.)

  • Complications with caudal blocks:

  • Risks during performance of the block

  • Intravascular placement

  • Needle into subarachnoid space

  • Needle into sacral marrow

  • Risks from injection of LA

  • Side effects of other agents used

  • Block failure (3%- 5%)


Epidural anaesthesia
Epidural anaesthesia

  • Anatomy and physiology of epidural space:

  • The epidural space surrounds the spinal cord and the meninges from the foramen magnum to the sacral hiatus

  • Limited posteriorly by the vertebral laminae and the ligamentaflava

  • Communicates quite freely with the paravertebral spaces

  • Near the spinal ganglia, connected with the subarachnoid space owing to protrusion of arachnoid granulations

  • Contains blood vessels and lymphatics

  • Filled with loose fat in infants and in children up to 6 to 8 years of age


Epidural anaesthesia contd
Epidural anaesthesia(contd.)

  • Indications of epidural anaesthesia:

  • Major abdominal surgeries

  • Retroperitoneal, pelvic and thoracic surgeries

  • Pectusexcavatum repair

  • Scoliosis corrective surgeries

  • Controversial in cardiac surgeries

  • Contraindications to epidural anaesthesia:

  • Severe malformations of spine and spinal cord

  • Intraspinalleisons and tumors

  • Tethered cord syndrome

  • Hydrocephalus, unstable epilepsy

  • Previous spine surgery


Epidural anaesthesia contd1
Epidural anaesthesia(contd.)

  • Technique (for lumbar epidural anaesthesia):

  • Midline approach below L2-L3 interspace, which represents the lower limit of the conusmedullaris

  • Paramedian approach in spinous process anomaly or spine deformity

  • Semiproneposition with the side to be operated lowermost and the spine bent to enlarge the interspinousspaces

  • LOR with air in infants and saline in older children

  • Distance from skin to epidural space 1 mm/kg b/w 6mo- 10yr

  • Disconnect the LOR syringe

  • No reflux of biological fluid at hub

  • Catheter is inserted to not more than 3 cm in order to avoid buckling, knotting, and lateralization of blockade or erratic migration



References
References

  • Bernard DJ. Regional anesthesia in children. In: Miller RD, editor. Miller’s Anaesthesia. 7th ed. Philadelphia: Churchill Livingstone; 2010.

  • Pawar D. Regional anaesthesia in pediatric patients. Indian J. Anaesth.2004;48(5).

  • Davis PJ, Cladis FP et al. Smith’s anaesthesia for infants and children. 8th ed. 2012.


Thank you
Thank you

www.anaesthesia.co.in


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