regional anaesthesia in pediatrics
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Regional Anaesthesia in PediatricsTRANSCRIPT
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REGIONAL ANAESTHESIA IN CHILDREN
Dr Tarun Yadav
Jawarlal Nehru Medical College , Sawangi(M) , Wardha
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Regional anaesthesia in children Differences in anatomy and
physiology
Selection of techniques, agents and equipments
Central neuraxial blockade in children including caudal block
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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
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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
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Difference in Perception of pain from adults
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
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Spinal cord anatomy
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Relevant Differences between Children and AdultsAnatomic factors Anaesthetic implications
Lower termination of spinal cord (L3-4)
•Increased risk of direct trauma to the spinal cord•Avoid epidural approaches above L3
Lower projection of dural sac (S3-4)
•Increased risk of inadvertent penetration of the dura mater
Delayed myelinization of nerve fibers
•Easier intraneural penetration of local anesthetics•Onset time shortened•Diluted local anesthetic as effective as more concentrated anesthetic
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Anatomic factors Anaesthetic complications
Cartilaginous structure of bones and vertebrae
•Danger of direct trauma and bacterial contamination of ossification nuclei•Use short and short beveled needles
Lack of fusion of sacral vertebrae
•Persistence of sacral intervertebral spaces
Delayed development of curvatures of the spine
•Same orientation of epidural needles at all level before 6 months of age
Changing axis of coccyx and absence of growth of sacral hiatus
•Identification of sacral hiatus difficult above 6-8 years •Increased failure rate of caudal anesthesia
Delayed ossification and growth of iliac crests
•Tuffier’s line passes over L5-S1 interspace
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Anatomic factors Anaesthetic implications
Increased fluidity of epidural fat
•Increased diffusion of local anesthetic up to 6-7 years of age with excellent caudal blockade
Loose attachment of sheaths and aponeuroses to underlying structures
•Larger volume of LA for epidural blocks due to leakage along spinal nerve roots•Increased spread along nerve paths with danger of penetrating remote anatomic spaces and blocking distant nerves
Sympathetic immaturity, diminished autonomic adaptability of the heart, smaller vascular bed in lower extremities
•Hemodynamic stability during neuraxial blocks•Fluid preloading and use of vasoactive agents unnecessary
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Pharmacologic factors Anaesthetic implications
Low plasma protein content (HSA and AAG)
•Increased unbound free fraction of all local anesthetic: greater danger of systemic toxicity
Increased cardiac output and heart rate
•Increased regional blood flow resulting in increased systemic absorption of LA: shorter duration of action
Enzymatic immaturity •Slower metabolism of LA with risk of accumulation
Increased extracellular fluids
•Increased distribution volume and mean body residency time of LA with increased risk of accumulation after continous infusion
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Pharmacologic factors
Anaesthetic implications
Red cell storage •In neonates: high hematocrit values and enlargement of erythrocytes result in consistent “entrapment” of LA•In infants: physiologic anemia reduces red cell storage; protective effect against systemic toxicity of LA
Pulmonary extraction
•Children with right-to-left shunts undergo considerable increase in arterial plasma concentration of LA due to pulmonary bypass
Absorption from epidural space
•The time (Tmax) to reach peak plasma concentration (Cmax) remains basically unchanged•Ropivacaine and Levobupivacaine Tmax is prolonged up to 2 hours in infants and Cmax is increased •Reduced continous infusion rates/repeat injections dosage
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Pharmacologic factors Anaesthetic implications
Metabolism •Low plasma cholinesterase activity•Decreased cytochrome P450 activity•Phase 2 reactions immature upto 3yrs of age
Elimination half life •>1yr: same as adults•< 1yr: increased thus favoring accumulation with repeated injections
Systemic toxicity •Thresholds of toxicity of the unbound form of LA:0.3 μg/ml for bupivacaine0.6 μg/ml for ropivacaine
Hepatic extraction and clearance of aminoamides
•High hepatic extraction ratio•GFR 30% of adult values
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Pharmacologic factors
Anaesthetic implications
Opioids : morphine •Elimination half-life of neuraxial opioids increase in neonates and infants•CSF concentrations very high after epidural injection; takes 12 to 24 hours before their decrease below minimal effective concentrations (near 10 ng/mL)
Fentanyl, sufentanil •Acute respiratory depression (sudden apnoea)
Additives: Clonidine •Clearance in neonates is approximately one third that in adults owing to immature elimination pathways;
•Several instances of respiratory depression in neonates and small infants•Should be avoided during the first 6 month of life.
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Additive Recommended doses
Maximum doses
Morphine•Epidural•Intrathecal
30 µg/kg10 µg/kg
50 µg/kg20 µg/kg
Fentanyl (epidural)
1-1.5 µg/kg 2.5 µg/kg
Sufentanil (epidural)
0.25-0.5 µg/kg 0.75 µg/kg
Clonidine (epidural)
1-1.5 µg/kg 2 µg/kg
Ketamine (epidural)
0.5 mg/kg 1 mg/kg
Commonly used additives in pediatric RA
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Psychological factors Anaesthetic implications
Delayed acquisition of body scheme and conceptualization, anxiety
•Inability of patients to locate precise body areas
•Concept of paresthesia not understandable
•Difficult cooperation
•Heavy sedation or general anesthesia is required in most patients
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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
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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
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Indications(contd.)
Management of nonsurgical paina. Herpes zoster, AIDS, mucocutaneous leisons-regional
blocks
b. Vaso-occlusive crisis of sickle cell disease
Non analgesic indicationsa. Sympathetic blockade for severe trauma
b. Vascular insufficiency in Kawasaki disease
c. Severe frostbite
d. Accidental intra arterial injection of LA
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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 tumoral process True allergy to local anesthetics Chemotherapies (such as with cisplatin) Uncorrected hypovolemia Cutaneous or subcutaneous lesions at the
contemplated site of puncture Parental refusal
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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
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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 neurotoxic solutions Leakage around the puncture site which
may cause partial block failure and favor bacterial contamination
Systemic complications: Accidental iv injection of LA Excessive dosing
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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 anaesthetic
and adjuvants Catheter technique with repeat/continuous
injections of local anaesthetic
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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
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Selection of equipments….(contd.) Selection of anaesthetic agent
depends on: Site/ extent of surgery Expected duration of intense postoperative pain Hospital stay vs early dischargeLocal
anaestheticUsual conc.
Max dose of plain soln mg/kg
Max dose with epinephrine mg/kg
Lidocaine 0.25-0.2 5 10
Bupivacaine 0.125-0.5
2 3
Levobupivacaine
0.125-0.5
3 4
Ropivacaine 0.1-10 3 Not recommended
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Selection of equipments….(contd.) Selection of block needles and
catheters:Block procedure
Recommended device
Spinal anaesthesia
Spinal needle (24-25 gauge; 30, 50 or 100 mm long, Quincke bevel, stylet)
Caudal anaesthesia
Short (25-30 mm) and short beveled (45-degree) needle with stylet
Epidural anaesthesia
Tuohy needle (22, 20, and 19/18 gauge); LOR syringe and medium epidural catheter
PNB Insulated 21-23 gauge short beveled needles
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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
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Discharge criteria- Modified Aldrete score
Parameters Scores
Level of consciousness•Fully awake•Arousable on calling•No response
210
Oxygen saturation•>90% on room air•>90% on oxygen•<90% on oxygen
210
Circulation/ BP•SBP within 20mm Hg of pre sedation values•SBP within 20-50 mm Hg of pre sedation values•SBP >50 mm Hg of pre sedation values
210
Movement /activities•Moves all extremities on command•Moves 2 extremities•Does not move
210
Respiration•able to breathe and cough freely•Dyspnea is with shallow breathing•Apneic
210
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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 CSFa. 10 mL/kg in neonatesb. 4 mL/kg in infants weighing less than 15 kgc. 3 mL/kg in childrend. 1.5 to 2.0 mL/kg in adolescents and adults
e. 50% CSF volume is located within the spinal subarachnoid space versus 25% in adults
f. Lower CSF hydrostatic pressure g. Children older than 5yr behave like adults after spinal
anaesthesia, whereas younger patients remain hemodynamically stable, without significant hypotension or bradycardia
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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)
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Spinal anaesthesia(contd.) Technique of spinal anaesthesia: Position:a. Lateral position with head extended to avoid airway
compromiseb. Sitting position Firm grasp of the awake infant by an assistant Neonates and infants: 1.5” 25-27G spinal needle
with stylet at L4-5 level >2yr: longer needle, smaller guage Pop felt as needle enters the ligamentum flavum Free flow of CSF Inject the LA slowly Child to remain supine and legs should not be
raised for any reason
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Spinal anaesthesia(contd.)Local anaesthetic (neonates)
Dose mg/kg Volume ml/kg
0.5% bupivacaine isobaric/hyperbaric
o.5-1 0.1-0.2
0.5% levobupivacaine 1 0.2
0.5% ropivacaine 1.08 0.22
Local anaesthetic (children)
Usual dose
0.5% bupivacaine isobaric/hyperbaric
5 to 15 kg: 0.4 mg/kg (0.08 mL/kg)>15 kg: 0.3 mg/kg (0.06 mL/kg)
0.5% levobupivacaine
5 to 15 kg: 0.4 mg/kg (0.08 mL/kg)15-40 kg: 0.3 mg/kg (0.06 mL/kg)>40 kg: 0.25 mg/kg (0.05 mL/kg)
0.5% ropivacaine 0.5 mg/kg (max 20 mg)
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Caudal anaesthesia
Anatomy of sacral hiatus
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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 asa. Change in axis of sacrum
b. Difficulty to identify sacral hiatus
c. Densely packed epidural fat
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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
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Caudal anaesthesia
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Caudal anaesthesia(contd.) Technique of caudal anaesthesia: Positioning the patienta. Sim’s positionb. Semipronec. 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 Acute the angle of needle by 10-15 degree. Inject the LA with frequent aspirations Finger should palpate the skin cephalad t the injection
to ensure drug is not s/c
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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
Bupivacaine in
Concentration
Dose Possible additives
Single dose caudal
0.175%- 0.5%
0.75- 1.25 ml/kg (max. 3 ml/kg)
Epinephrine 2.5- 5 µg/kgClonidine 1- 2 µg/kgMorphine 30- 70 µg/kg
Continous caudal
0.1%- 0.25%
0.4 ml/kg Fentanyl 2- 5 µg/kg
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Caudal anaesthesia(contd.)
Complications with caudal blocks: Risks during performance of the blocka. Intravascular placement
b. Needle into subarachnoid space
c. Needle into sacral marrow
Risks from injection of LA Side effects of other agents used Block failure (3%- 5%)
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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 ligamenta flava
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
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Epidural anaesthesia(contd.) Indications of epidural anaesthesia: Major abdominal surgeries Retroperitoneal, pelvic and thoracic surgeries Pectus excavatum repair Scoliosis corrective surgeries Controversial in cardiac surgeries
Contraindications to epidural anaesthesia:
Severe malformations of spine and spinal cord Intraspinal leisons and tumors Tethered cord syndrome Hydrocephalus, unstable epilepsy Previous spine surgery
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Epidural anaesthesia(contd.) Technique (for lumbar epidural
anaesthesia): Midline approach below L2-L3 interspace, which
represents the lower limit of the conus medullaris Paramedian approach in spinous process anomaly or
spine deformity Semiprone position with the side to be operated
lowermost and the spine bent to enlarge the interspinous spaces
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
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Epidural anaesthesia(contd.)
Agent Initial dose Continous infusion (max dose)
Bupivacaine, levobupivacaine
Solution: 0.25% with 5 µg/mL (1/200,000) epinephrineDose:<20 kg: 0.75 mL/kg20-40 kg: 8-10 mL>40 kg: same as for adults
<4 mo: 0.15 mL/kg/hr of 0.125% or 0.3 mL/kg/hr of 0.0625% (0.2mg/kg/hr)4-18 mo: 0.2 mL/kg/hr of 0.125% or 0.4 mL/kg/hr of 0.0625% (0.25mg/kg/hr)>18 mo: 0.3 mL/kg/hr of 0.125% or 0.6 mL/kg/hr of 0.0625% (0.3mg/kg/hr)
Ropivacaine Solution: 0.2%Dose: same regimen in mL/kg as for bupivacaine
Same age-related infusion rates in mg/kg/hr as for bupivacaine (0.1%, 0.15%, or 0.2%)Do not infuse for more than 36 hr in infants < 3 mo
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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.
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Thank you