40 - Regional anesthesia

Abstract

Regional anesthesia has become an integral and common component of both intraoperative anesthesia and postoperative analgesia in infants and children. Advantages of regional blockade include the reduction of general anesthetic dose requirements, effective blunting of hemodynamic and autonomic responses, and excellent postoperative analgesia with decreased requirement of systemic analgesics and their concomitant adverse effects. For many orthopedic operations, peripheral nerve blockade permits the anesthesiologist to provide prolonged analgesia limited to the surgical site. Spinal anesthesia in infants is an effective alternative to general anesthesia for subumbilical operations lasting an hour or less. However, the risks of local anesthetic toxicity may be magnified in infants and children because of their size and immaturity, and great care and precision must be used when choosing the volume and concentration of the local anesthetic. Because most regional blocks in children are performed after induction of anesthesia, early signs of toxicity may be obscured. The emergence of lipid emulsion therapy for local anesthetic systemic toxicity improved outcomes after these events and should be administered promptly. Regional anesthetics in children are quite safe and administering regional blocks to children under general anesthesia confers no increased risk of injury. Although one must have specific technical skills and an understanding of the differences in pediatric physiology, anatomy, and pharmacology to use regional blockade in infants and children, the benefits of these techniques are great. In this chapter, ultrasound-guided techniques will be emphasized, while retaining classic landmark-guided descriptions of many common blocks; the former has rapidly become the preferred modality for some blocks due to its safety and its potential to decrease the local anesthetic dose but knowledge of the latter should not be lost in order to accommodate situations in which the technology is unavailable.