The European Society of Regional Anaesthesia and Pain Therapy and the American Society of Regional Anesthesia and Pain Medicine Joint Committee Practice Advisory on Controversial Topics in Pediatric Regional Anesthesia

Abstract

High-level evidence is not yet available for the topics evaluated, and most recommendations are based on Evidence B studies. The ESRA/ASRA recommendations intend to provide guidance for the safe practice of regional anesthesia in children.

The European Society of Regional Anaesthesia and Pain Therapy/American Society of Regional Anesthesia and Pain Medicine Recommendations on Local Anesthetics and Adjuvants Dosage in Pediatric Regional Anesthesia

“…1 Representatives from both ASRA and ESRA composed the joint committee practice advisory on LA dosage and adjuvants in PRA. Committee members met in work groups, and decisions on specific topics to be addressed were made through consensus.…”

“…The scientific evidence was classified according to the quality of research design as presented in Table 1, similar to what has been previously described in other practice advisories. 1 When the literature search revealed a lack of published studies or when the only evidence was generated from studies with insufficient quality due to methodological constraints, it was deemed as "insufficient literature," and expert opinion from the ASRA/ESRA joint committee was considered.…”

“…Fundamental Requirements of Adjuvant Drugs: Fundamental requirements of adjuvant drugs include the following: (1) preferably meta-analysis data should verify the beneficial effect of the adjuvant in order to recommend routine use outside clinical trials; (2) there should be sufficient insight into the mechanism of action of the adjuvant; (3) the side effect profile should be tolerable in comparison with the use of plain LAs; (4) the adjuvant must be available as a preservative-free preparation; and (5) overall safety issues must be acceptable in animal studies. [53][54][55][56][57] Evidence-Based Conclusions and Clinical Advice for Neuraxial Adjuvants…”

Lower extremity regional anesthesia: essentials of our current understanding

“…Similarly, lower extremity nerve blocks should only be performed with extreme caution if the patient has a concomitant neuraxial block. In contrast, both the ASRA and the European Society of Regional Anesthesia and Pain Therapy support the performance of nerve blocks under general anesthesia in pediatric patients,293 as multi-institutional prospective studies have demonstrated the safety of peripheral nerve blocks in children who are asleep 294–297…”

Asleep Versus Awake and Standard of Care

“…Of note, ASRA recommendations on this topic are different for pediatric patients. 8 The ASRA practice advisory and guideline processes are intended to provide learned recommendations, but not to replace common sense or sound clinical judgment. Scientific evidence is absent or conflicting with regard to regional blocks in asleep versus awake patients, and future evidence is not likely to emerge because serious longterm anesthesia-related perioperative nerve injury is so infrequent as to logistically preclude randomized controlled trials.…”