Fundamentals and innovations in regional anaesthesia for infants and children

Abstract

Summary Regional anaesthesia in children has evolved rapidly in the last decade. Although it previously consisted of primarily neuraxial techniques, the practice now incorporates advanced peripheral nerve blocks, which were only recently described in adults. These novel blocks provide new avenues for providing opioid‐sparing analgesia while minimising invasiveness, and perhaps risk, associated with older techniques. At the same time, established methods, such as infant spinal anaesthesia, under‐utilised in the last 20 years, are experiencing a revival. The impetus has been the concern regarding the potential long‐term neurocognitive effects of general anaesthesia in the young child. These techniques have expanded from single shot spinal anaesthesia to combined spinal/epidural techniques, which can now effectively provide surgical anaesthesia for procedures below the umbilicus for a prolonged period of time, thereby avoiding the need for general anaesthesia. Continuous 2‐chloroprocaine infusions, previously only described for intra‐operative regional anaesthesia, have gained popularity as a means of providing prolonged postoperative analgesia in epidural and continuous nerve block techniques. The rapid, liver‐independent metabolism of 2‐chloroprocaine makes it ideal for prolonged local anaesthetic infusions in neonates and small infants, obviating the increased risk of local anaesthetic systemic toxicity that occurs with amide local anaesthetics. Debate continues over certain practices in paediatric regional anaesthesia. While the rarity of complications makes comparative analyses difficult, data from large prospective registries indicate that providing regional anaesthesia to children while under general anaesthesia appears to be at least as safe as in the sedated or awake patient. In addition, the estimated frequency of serious adverse events demonstrates that regional blocks in children under general anaesthesia are no less safe than in awake adults. In infants, the techniques of direct thoracic epidural placement or caudal placement with cephalad threading each have distinct advantages and disadvantages. As the data cannot support the safety of one technique over the other, the site of epidural insertion remains largely a matter of anaesthetist discretion.

Thoracic epidural analgesia and immediate extubation for less than 10 kg infants undergoing living donor liver transplantation: A report of two successful cases

“…Furthermore, the postoperative need for opioids was overall decreased and even absent in the second case we reported. Other potential benefits of TEA include better splanchnic perfusion and reduced dose of inhalational agents 3,31 . Although we used total intravenous anesthesia, this is relevant since most practitioners still rely on inhalational anesthesia, and there is evidence suggesting an association between this anesthetic technique—which seems to be dose dependent—and late neurocognitive impairment in pediatric patients 7,32 …”

“…Additionally, pain assessment in infants is a difficult task and frequently overlooked, 2 which may also render physicians reluctant to IE. Although most practitioners still rely on intravenous opioids for postoperative pain control, regional and neuraxial techniques have been increasingly used for infants undergoing a variety of surgical procedures 3 . TEA, for example, has been successfully employed in the setting of cardiothoracic or major abdominal surgery, providing excellent pain relief with improved outcomes 4–7 .…”

“…procedures. 3 TEA, for example, has been successfully employed in the setting of cardiothoracic or major abdominal surgery, providing excellent pain relief with improved outcomes. [4][5][6][7] Unfortunately, its use for infants undergoing a liver transplant seems to lag behind, probably because of concerns about epidural hematoma.…”

Opioid-free anesthesia with interfascial dexmedetomidine in a high-risk infant

“…It therefore represents a cornerstone of “low-neurotoxicity anesthesia” and OFA, being a technique of choice in high-risk infants. [ 10 11 12 ]…”

Transversus Abdominis Plane Block with Different Bupivacaine Concentrations in Children Undergoing Unilateral Inguinal Hernia Repair: A Double-Blind Randomized Clinical Trial

“…Typically, a distinct neural structure is not seen in this fascial plane. Instead, there is an extension of small nociceptive bers within the intended target to anesthetize (3).…”