Block In Infants Research Articles

A simple method to deliver pharyngeal anesthesia in syndromic infants prior to awake insertion of the intubating laryngeal airway

To the Editor, Infants with a craniofacial abnormality who are potentially difficult to mask ventilate may benefit from awake placement of a supraglottic device to aid in tracheal intubation. Moreover, in some syndromic infants, severe upper airway obstruction may be present at birth, which often requires a mandibular advancement procedure or a tracheostomy. As these procedures require general anesthesia, clinicians may be hesitant to proceed with induction of anesthesia until upper airway obstruction is relieved. Options with the potential to alleviate airway obstruction prior to induction of anesthesia include: a change in position of the patient from supine to lateral or prone, placement of a naso-pharyngeal airway, or awake insertion of a supraglottic airway device. In this clinical scenario, the primary advantage of a supraglottic device is to relieve upper airway obstruction while providing a reliable conduit for tracheal intubation. Awake placement of the laryngeal mask airway (LMA) (LMA North America; San Diego, CA, USA) in the face of upper airway obstructions in syndromic infants is well tolerated without sedation or local anesthesia. However, the use of an air-Q intubating laryngeal airway (ILA) (Cookgas LLC; St. Louis, MO, USA) for this same purpose can be more stimulating and therefore require some degree of pharyngeal anesthesia to minimize the risk of gagging upon placement. In our experience, the following features of the ILA make its insertion more stimulating in the awake infant when compared with the LMA: 1) the mask size of the ILA is wider and deeper than the LMA of equivalent size; 2) the airway tube of the ILA is wider, hyper-curved, and more rigid than the LMA (Figure A); and 3) the silicone-based reusable LMAs have a softer mask than the ILA. For these reasons, we find that infants do not tolerate awake placement of the ILA as well as they tolerate placement of the LMA. The primary advantage of the ILA for tracheal intubation is the capacity to place cuffed tracheal tubes with subsequent easy removal after tracheal intubation; 4 therefore, we prefer use of the ILA over the LMA for purposes of tracheal intubation. The use of glossopharyngeal blocks in infants is effective to minimize the risk of gagging, but this method is invasive, and it can be more stressful and impractical in an awake child. We describe a simple technique that we employ in our practice to provide pharyngeal anesthesia prior to awake ILA placement. Prior to inserting the ILA, we make use of a standard infant pacifier (Figure B) to deliver 2% lidocaine jelly 20 mg mL (AstraZeneca; Wilmington, DE, USA). Lidocaine jelly is injected into the nipple portion of an infant pacifier, and the pacifier is placed in the infant’s mouth approximately 10 to 15 min prior to placement of the ILA. A maximum volume of approximately 5 mL can be accommodated within the nipple portion of an infant pacifier, this volume could be less based on the weight of the child, while adhering to the manufacturer’s recommended maximal dose of 6 mg kg. To achieve this dose, we mix lidocaine jelly with either a glucose solution or a surgical lubricant while remaining within these dosage guidelines. Several small perforations are then made in the nipple with a standard 20G needle to ensure pharyngeal spread upon infant sucking. Pharyngeal spread and systemic absorption of local anesthetic is governed by the N. Jagannathan, MD (&) C. T. Truong, MD Children’s Memorial Hospital, Northwestern University’s Feinberg School of Medicine, Chicago, IL, USA e-mail: simjag2000@yahoo.com A Xylocaine (Lidocaine HCl) 2%. Package insert and instructions for use. AstraZeneca, Wilmington, DE 19850.

Ultrasound-guided sciatic nerve block in infants and toddlers produces successful anesthesia regardless of the motor response

The primary objective of this study was to assess the success rate of ultrasound-guided sciatic needle placement regardless of the motor stimulation in infants and toddlers. Forty-five consecutive patients aged 7 months-2 years, scheduled for foot surgery, were included in this prospective, descriptive and blinded study. After induction of general anesthesia, sciatic nerve block was performed under ultrasound guidance in the subgluteal area using an insulated needle connected to a nerve stimulator, with the power off. At the precise point when it was presumed that the needle was touching the sciatic nerve, the peripheral nerve stimulator was turned on at 0.5 mA and the current was slowly decreased to 0.2 mA. Presence and location of any motor responses were observed and recorded. Statistical analysis was applied to compare the success rate in patients who did and did not exhibit a motor response to electrical stimulation. Postoperatively, block duration and analgesic consumption were recorded. The sciatic nerve could be distinctly visualized in 44 children, and all these blocks were successful. Only 22% patients showed any motor response to electrical stimulation. There was no significant difference in block characteristics between patients who exhibited a motor response with electrical stimulation and those who did not. Success rate of ultrasound-guided sciatic nerve block remains unaltered irrespective of motor response to neurostimulation.

Ultrasound guided transversus abdominis plane block in infants, children and adolescents: a simple procedural guidance for their performance

The transversus abdominis plane block (TAP) has been described recently for pain management following abdominal surgery. Although many techniques have been described using anatomical landmarks, a simple ultrasound (US) guidance technique for the block has not been described in children. An article published by Hebbard and colleagues on the use of US-guidance for TAP blocks described the technique with the probe positioned at the midaxillary line with a needle insertion that is located further medial on the abdominal wall. This technique, although feasible in adults is not possible in children due to the need for obtaining a more thorough spread of the local anesthetic solution. We describe in this article, a user-friendly approach to the placement of a TAP block in infants, children and adolescents. Further pharmacokinetic data has to be obtained for actual dosing for these blocks in infants and children.

Anatomic Study Using Three-Dimensional Computed Tomographic Scan Measurement for Truncal Maxillary Nerve Blocks Via the Suprazygomatic Route in Infants

A maxillary nerve block using external anatomic landmarks is a safe regional anesthesia for adults. However, the classic approach to the nerve may be difficult in infants. To use this block in infants, we describe the anatomical landmarks needed to reach the foramen rotundum area using the suprazygomatic route.Computed tomographic scans of 55 infants (mean age, 8.5 months; range, 1 week to 16 months) without any malformation were retrospectively evaluated using multimodal and multiplanar software. For each side, the distances and angles from the skin to the greater wing of the sphenoid and to the foramen rotundum area (representing the maxillary nerve) were measured in the axial and oblique planes.The distances from the skin at the frontozygomatic angle to the greater wing of the sphenoid in the axial plane and the foramen rotundum area in the oblique plane are 24.1 mm +/- 2.7 and 47.4 mm +/- 4.1, respectively. From the skin landmark, the direction of the trajectory was oriented 19.3 +/- 5.3 and 8.7 +/- 2.9 degrees forward. These distances and angles must be slightly adapted for infants younger than 6 months, although none of these parameters were correlated with age during the period studied.This anatomic study based on computed tomographic scan information may be useful for clinical application of the truncal maxillary nerve block in infants using the suprazygomatic route.

Postoperative pain relief in infants undergoing myringotomy and tube placement: comparison of a novel regional anesthetic block to intranasal fentanyl – a pilot analysis

The aim of this study was to investigate the use of a novel regional anesthetic technique for the management of pain in the postoperative period in infants and children undergoing myringotomy and tube placement. After institutional review board (IRB) approval was obtained, 200 children were randomized in this double blind, prospective, randomized controlled trial to receive either a nerve block of the auricular branch of the Vagus (Nerve of Arnold) with 0.2 ml of 0.25% bupivacaine or receive intranasal fentanyl 2 mcg.kg(-1) after induction of general anesthesia. Patients were monitored in the recovery room for analgesia, need for additional analgesia, incidence of nausea and vomiting, and time to discharge from the hospital. Additional analgesics administered in the PACU, surgical short-stay unit as well as at home were also recorded. There was no difference in the pain scores between groups (P = 0.53); there was no difference in the amount of rescue medications between groups (P = 0.86); there was no difference in the incidence of nausea and vomiting between groups (P = 0.34); there was no difference in the time to discharge between groups (P = 0.5). This pilot study demonstrates the efficacy of a peripheral nerve block for management of postoperative pain in infants and children undergoing myringotomy and tube placement. This may be a viable alternative for postoperative pain control in this population. Future multi-center, randomized controlled trials may be necessary to validate the efficacy of this block in infants and children.

Dose–response study of intrathecal fentanyl added to bupivacaine in infants undergoing lower abdominal and urologic surgery

Intrathecal (IT) adjuncts often are used to enhance the duration of spinal bupivacaine. Fentanyl is a spinal analgesic that could be a useful adjunct, and enhances the duration and quality of sensory block in adult surgical and obstetric population. However, no data exist to assess the dose-response characteristics of IT fentanyl when added to bupivacaine in infants. Fifty-eight infants undergoing lower abdominal and urologic procedures were randomized into four groups to receive plain 0.5% hyperbaric bupivacaine F0 (<5 kg = 0.5 mg.kg(-1); 5-10 kg = 0.4 mg.kg(-1)). Groups F0.25, F0.5, and F1 groups received bupivacaine added with 0.25, 0.5, and 1 mug.kg(-1) of fentanyl, respectively. Duration of spinal anesthesia (SA) as assessed by the recovery of hip flexion in the postoperative period was the primary variable analyzed. In addition, the duration of analgesia in the postoperative period, rescue postoperative analgesic requirements and hemodynamic changes were recorded. Fifty-six infants were studied. The four groups were similar for age, weight, duration of surgery, onset of sensory, motor block, and the highest level of analgesia attained. The addition of 1 mug.kg(-1) fentanyl (F1) significantly increased the duration of SA (74.27 +/- 6.1 min) compared to the control group (51.21 +/- 5.2 min) (P = 0.001). Postoperative pain-free interval was prolonged (P = 0.004) and significantly less rescue analgesics were required after 1 mug.kg(-1) IT fentanyl (P = 0.032). These parameters did not show any significant difference among groups F0, F0.25, and F0.5. The addition of 1 mug.kg(-1) IT fentanyl to spinal bupivacaine prolonged the duration of spinal block in infants undergoing lower abdominal and urologic procedures.

Detecting intravascular injection during caudal anaesthesia in children

Kasper DL, Isselbacher KJ, Hauser SL, Wilson JD, Longo DL,Randolph T, eds. Harrison’s Principles of Internal Medicine,14th edn. New York: McGraw-Hill, 1998: 2183–2194.2. Hobbs WR, Sponseller PD, Weiss APC, Pyeritz RE. Thecervical spine in Marfan syndrome. Spine 1997; 22: 983–989.3. Herzka A, Sponseller PD, Pyeritz RE. Atlantoaxialrotatory subluxation in patients with Marfan syndrome.Spine 2000; 25: 524–525.4. Place HH, Enzenauer RJ. Cervical spine subluxation inMarfan syndrome. A case report. J Bone Jt Surg Am 2006;88: 2479–2282.5. Judge DP, Dietz HC. Marfan’s syndrome. Lancet 2005;366: 1965–1976.6. Rath GP, Bithal PK, Guleria R et al. A comparative studybetween preoperative and postoperative pulmonary func-tions and diaphragmatic movements in congenitalCraniovertebral junction anomalies. J Neurosurg Anesthesiol2006; 18: 256–261.7. Shores J, Berger KR, Murphy EA, Pyeritz RE. Progressionof aortic dilatation and the benefit of long term beta-adrenergic blockade in Marfan’s syndrome. N Engl J Med1994; 330: 1335–1341.

Regional anaesthesia in paediatric practice

Regional anaesthetic techniques are now well established in the practice of paediatric anaesthesia. Caudal blockade remains the most popular and frequently performed block in infants and children undergoing surgical procedures due to its simplicity, high success rate and good safety profile. However, with recent developments in equipment available specifically for paediatric regional anaesthesia and the introduction of newer local anaesthetic agents, the use of techniques that target the site of surgery is increasingly popular.

Hemodynamic Stability after Pediatric Epidurals

We would like to thank Dr. Rebecca Lowery for her interest in our case report. The quote to which Dr. Lowery referred was only half of our original sentence, which read “The absence of epidural spread was assessed by hemodynamic stability after the performance of the blocks and by the presence of an adequate reaction to pin prick of the opposite leg after emergence.” Although we also recognize that the hemodynamic changes associated with neuroaxial blockade may be absent or less pronounced in infants and young children, it is critical to acknowledge also the following. (1) Dohi et al. 1and Oberlander et al. 2reported on a very limited number of infants and young children. Although Dohi et al. 1reported that significant hypotension might be observed in young children around 5 yr of age and older, extrapolating from these articles, the concept that 5 yr represents the absolute lower limit for children to be exposed to such risk following a neuroaxial block may be excessive. (2) More importantly, in infants and young children, any diagnosis is often the result of the convergence of symptoms, and therefore, even if the risk is minimum, it should not be ignored. (3) We would like to believe that Dr. Lowery is not recommending not monitoring blood pressure following the performance of lumbar plexus block in infants and young children. In conclusion, we are happy to have provided an opportunity for Dr. Lowery to remind us about the expected hemodynamic changes associated with neuroaxial blocks in infants and young children. However, we would like to maintain that monitoring blood pressure is essential when performing a lumbar plexus block, even in this patient population.

Caudal blocks

Caudal blocks, when used in conjunction with a light general anesthetic, are most useful when combined with the following surgical procedures: circumcision, orchidopexy, inguinal hernia repair, hydrocelectomy, and rectal dilatation, and in orthopedic procedures involving the lower extremities. This report will instruct the reader in how to safely place caudal blocks in infants and children. It discusses the efficacy and pitfalls associated with test dosing and the use of gentle aspiration to detect inadvertent intravascular injections. It also outlines the proper drug selection and dosage for the placement of pediatric caudal blocks. In short, the authors recommend 1.0 mL/kg of 0.125% bupivacaine without epinephrine for the following T-10 level procedures: orchidopexy, inguinal hernia repair, and hydrocelectomy, whereas only 0.5 mL/kg of the local anesthetic solution is suggested for rectal, vaginal, and penile analgesia, Inadequate postoperative pain control is frequently cited as the number one complaint of adult patients on their postadmission hospital survey forms. By inference the same is probably true for infants and children; pediatric pain control remains a substantial challenge. The duration of single-shot caudal neuroblockade obtained with bupivacaine may be of such short duration that this local anesthetic may only be of value when it is used to provide postoperative analgesia for ambulatory surgical cases. More recently, ketamine, clonidine, and ropivacaine have been employed to potentiate the intensity and duration of axis analgesia in pediatric patients. The authors suggest the use of caudally administered ketamine 0.5 mg/kg, clonidine 1.0 mcg/kg alone or in combination with 0.25% bupivacaine, and ropivacaine 0.2% to obtain the maximum duration of postoperative analgesia, with the fewest possible adverse side effects. The report concludes with a brief discussion of the safety of pediatric caudal blocks. Caudal blocks are safe and easy to perform, particularly in children less than 12 years of age. Complications are more prevalent in infants less than 6 months of age.

The pharmacokinetics of bupivacaine following interpleural nerve block in infants of very low birthweight.

Infants of very low birthweight (VLBW) who underwent thoracotomy were given 2.0 mg.kg-1 of bupivacaine by the intrapleural route, and serial blood levels were taken to determine the pharmacokinetic profile in this group of babies. It was apparent that the half life was longer, clearance lower, and volume of distribution greater than in term infants. Although the drug did not reach toxic levels at this dose, caution should be observed when redosing as the accumulation of the drug may be unpredictable.

Pharmacodynamic and Hemodynamic Effects of Mivacurium in Infants Anesthetized with Halothane and Nitrous Oxide

The newly developed neuromuscular blocking agent, mivacurium, has been evaluated in adults and children, but there are no data on its effects in infants. This study was designed to evaluate the neuromuscular effects of mivacurium by dose-response analysis, and its cardiovascular effects in 90 infants 2-11 months of age anesthetized with 1% halothane and nitrous oxide:oxygen. The neuromuscular response was measured by recording the force of contraction of the adductor pollicis during train-of-four stimulation at 0.1 Hz. The infants were divided according to age into two equal groups of 45; group A infants were 2-6 months of age, and group B infants were 7-11 months of age. Each group was further subdivided into five subgroups of nine. Infants in group A received mivacurium at sequential doses of 40, 50, 55, 75, and 150 micrograms/kg, while those in group B received mivacurium at doses 40, 50, 60, 75, and 150 micrograms/kg. The first four doses in each group were used to determine dose-response relationships. The last two doses of 75 and 150 micrograms/kg were based on the observed preceding dose-response data to approximate the ED95 and 2XED95. Heart rate and blood pressure were determined every minute for a minimum of 3 min after mivacurium. The effective doses for 50% depression of the first twitch response of the train-of-four (ED50) were 44-50 micrograms/kg (confidence limits 29-74 micrograms/kg), without any significant difference between groups A and B. In both groups, a larger dose of mivacurium, 150 micrograms/kg, caused complete ablation of the twitch response in 1.3 +/- 0.2 min (mean +/- SE) with recovery to 5, 25, and 95% of control in 7.6 +/- 0.5, 9.4 +/- 0.6, and 16.2 +/- 0.9 min, respectively. In infants, the 25-75% recovery index was 3.8 +/- 0.4 min, and the 5-95% recovery index was 8.5 +/- 0.8 min. In 28 infants, in whom surgical relaxation was required for more than 20 min, the infusion requirements to maintain 90-99% neuromuscular block in infants 2-6 and 7-11 months of age were 12.1 +/- 1 and 9.9 +/- 1 micrograms.kg-1.min-1, respectively (NS). No significant changes of heart rate of blood pressure occurred in infants, except in the subgroup of infants 7-11 months of age who received 150 micrograms/kg mivacurium. In this group, a 13-mmHg increase in mean systolic blood pressure was seen without any significant change in diastolic pressure or heart rate. In addition, in 7 of 36 patients receiving 75-150 micrograms/kg mivacurium, a greater than 29% change in systolic or diastolic pressure occurred. One infant with cholinesterase deficiency had a prolonged neuromuscular block from mivacurium. The ED50 duration of action and infusion requirements of mivacurium in infants 2-6 months of age are comparable with those of infants 7-11 months of age.

Epidural and spinal anaesthesia in children

Summary This chapter points out the peculiarities of children and their consequences for central blocks. The determining factors in considering the anatomy are the spinal curves, the rate of formation of the CSF, and the relationships between the spinal cord, the dura and the spinal column. The physiological characteristic is the lack of haemodynamic changes, even with high blocks in infants. The need for sedation is the major psychological point. Recent investigations into pharmacology in children emphasize the importance of protein binding as well as drug interaction. Before the description of the technique, the safety rules, practical conditions and equipment are reviewed. The caudal is the most frequently performed central block in children, because of its safety and simplicity. After a description of the puncture at S5 level, a route peculiar to children (the trans-sacral route) is reported. The way to enter the lumbar epidural space (perpendicularly) and the modified Taylor route are described. The thoracic epidural approach via the caudal route is discussed before the description of the spinal block. The recent data for drugs (local anaesthetics and narcotics) and doses, and the evidence of efficiency of concentrations as low as 0.125% for bupivacaine are reported before the discussion of the indications and the contraindications. In order to better explain the interest in central blocks in children the advantages are detailed, and to prompt anaesthesiologists to better investigate these blocks, the complications are listed prior to the conclusion.

The morphologic substrates for pediatric arrhythmias

SummaryRecent studies on the development of the heart6have increased markedly our appreciation of the disposition of the specialized conduction tissues, showing how some rests of tissues in unexpected locations are remnants of a well organized system found throughout avian and mammalian species. These studies also help us to account more logically for the distribution of the conduction tissues in congenitally malformed hearts. On the basis of our overall studies, therefore, combined with these recent advances, we are able to understand the normal and abnormal disposition of the conduction tissues. These understandings then permit us to offer explanations for those arrhythmias which have a “natural” basis, such as the grossly abnormal patterns found in hearts with isomerism of the atrial appendages or univentricular atrioventricular connection, and the accessory pathways found in the setting of ventricular preexcitation. We are also able to understand the changes affecting these tissues as part of acquired disease, such as the fibrosis of the long atrioventricular bundles found in atrioventricular septal defect and corrected transposition and the immunologic damage underscoring congenitally complete heart block in infants of mothers with collagen disease. We are only beginning to explore the possibility that abnormalities of the myocardiutn itself, or the fibrous tissue matrix, can also underscore the existence of abnormal rhythms. With all this knowledge, it is to be hoped that, in the future, we will see far fewer of those arrhythmias which have an “unnatural” basis, such as those related to direct surgical damage to the conduction tissues and their arterial supply, or those produced by abnormal loading conditions which are themselves the consequence of congenital malformations. Although we have learned, and applied, a great deal, there is still much to be done before we unravel all the secrets of the causes of arrhythmias in childhood.

Influence of age on the dose-response relationship of atracurium in paediatric patients.

To assess the influence of age on the dose-response relationship of atracurium in paediatric patients during thiopental-fentanyl-N2O-O2-anaesthesia, we studied 85 patients from neonates to adolescents. Each patient was given two doses of atracurium: following the maximum EMG response to the first dose of 150 micrograms/kg, an individual second dose was given, to produce exactly 95% neuromuscular block. The onset time of atracurium (time from administration to maximum effect) was shortest in neonates (2.6 min) and infants (3.3 min) and longest in adolescents (5.5 min) (P less than 0.01). The dose-response curves were parallel in all patients aged 3 months or older. The ED95 of atracurium was comparable for neonates and infants (226 micrograms/kg). This was 28% less than the ED95 for patients aged 1 year or older (316 micrograms/kg) (P less than 0.01). The results explain the slightly longer-lasting neuromuscular block in infants as compared to children following a constant atracurium dose in micrograms/kg. The great individual variability of the neuromuscular response, however, indicates that neuromuscular monitoring is essential in paediatric patients.

Two:One atrioventricular block in infants with congenital long QT syndrome

Congenital prolongation of the QT interval is a rare but life-threatening disorder of the cardiac conduction system. 1–5 The disorder usually presents as syncope or sudden death due to complex polymorphic ventricular tachycardia (torsade de pointes) or ventricular fibrillation. 6 The major hypothesis explaining the disorder is an imbalance of sympathetic discharge between the right and left stellate ganglia resulting in inhomogeneity of ventricular refractoriness and a substrate for reentrant ventricular arrhythmias. 4–6 Although sinus bradycardia may be associated with the syndrome, abnormalities in atrioventricular (AV) conduction are rare. 4 In this report we present 3 infants with the congenital long QT syndrome and 2:1 AV block and provide support for the role of the long effective refractory period in producing the block.

MECHANISM OF 2:1 ATRIOVENTRICULAR BLOCK IN INFANTS WITH CONGENITAL LONG QT SYNDROME

The mechanism of 2:1 atrioventricular block in infants with the congenital long QT syndrome has been postulated to result from a long ventricular effective refractory period interrupting conduction of successive sinus impulses. Three infants age 1-2 days exhibited bradycardia demonstrated to be 2:1 atrioventricular block by the surface electrocardiogram. Mean sinus cycle length (SCL) was 0.56 sec where as mean QT interval was 0.65 sec (QTc 0.63); this .07 sec difference between the SCL and mean QTc was sufficient to block successful capture of the ventricles by successive sinus impulses. Programmed ventricular extrastimulation in one patient demonstrated a markedly prolonged ventricular effective period (480 sec) at ventricular basic cycle length (BCL) 1000 msec shortening to 280 msec with a ventricular BCL of 400 msec. Permanent ventricular pacing shortened the ventricular effective refractory period in each infant and effectively suppressed polymorphic ventricular arrhythmias in the affected two. We conclude that the mechanism of 2:1 atrioventricular block in infants with the congenital long QT syndrome is a function of the age related SCL relative to the QT interval as well as the markedly prolonged but rate dependent ventricular effective refractory period. Ventricular pacemaker implant is effective in increasing ventricular rate, shortening ventricular effective refractory period, and suppressing complex ventricular arrhythmias.

Management of Postoperative Complete Heart Block in Infants and Children

Surgically induced complete heart block (CHB) occurred in 40 (9 percent) of 425 infants and children who underwent intracardiac repair of congenital heart disease. Thirteen patients died in the immediate postoperative period from causes other than CHB, and there was one late death following a Stokes-Adams attack. Among the 26 survivors, 18 reverted to a sinus rhythm and eight patients required permanent cardiac pacing. The complications of permanent cardiac pacing were numerous; yet all eight patients survived and enjoyed normal activities up to five years after surgery. A new method of managing postoperative CHB in infants and children has been presented.

COMPLETE HEART BLOCK IN INFANTS AND CHILDREN.

THE presence of complete heart block in the pediatric age group has been known for many years.1 A sizable number of publications, consisting mostly of reports of a small number of cases, indicates that third-degree heart block is not too uncommon in children.2 3 4 5 6 7 8 9 10 11 Three principal considerations prompted the present report. In the first place, the almost uniformly benign prognosis of congenital heart block, proposed by Campbell et al.,3 , 4 has recently been challenged by the publication of Molthan et al.12 reporting 3 fatal cases with Adams–Stokes attacks. Secondly, we believed that the concept of congenital heart block as a solitary finding, . . .