Nerve Block In Children Research Articles

Effectiveness of two-stage versus one-stage injection in reducing discomfort during inferior alveolar nerve block in children

Background: Inferior alveolar nerve block (IANB) anesthesia is a painful procedure & many attempts are made to render the injection painless, especially in children. Aim: To assess discomfort expressed during modified two-stage IANB injection versus one-stage injection in 8-10 years old children. Subjects & Methods: Sixty children were randomly & equally allocated to either intervention group (two-stage) or control group (one-stage). For all patients, topical anesthesia gel was applied. Intervention group: A short needle was used for the initial piercing & deposition of the local anesthesia (LA), the needle was inserted for 4mm & 0.4ml of the solution was deposited, then withdrawn. After 5 min, a long needle (gauge 27) was advanced till the point of LA drug deposition & bone touching & the rest of the LA solution was deposited. Control group: A long needle was inserted, dropping 0.4 ml of the solution incrementally till the point of LA drug deposition & bone touching & the rest of the LA solution was deposited. The overall patients’ levels of discomfort were assessed using Face Legs Activity Cry Consolability scale (FLACC) & Facial Image Scale (FIS). Results were tabulated & statistically analyzed. Results: For FLACC scale, the post-anesthetic values recorded a median=1 (range=0-3) in two-stages group, & a median=2 (range=0-4) in one-stage group; with statistically significant difference between them (p=0.00). For FIS, a median=2 (range=1-4) in the two-stage group & a median = 3 (range=1-5) in one-stage group; the difference between groups was statistically significant (p=0.017). Conclusion: The two-stage IANB injection technique is a simple & an effective method of reducing the overall discomfort in children.

Ultrasound-guided dorsal penile nerve block vs neurostimulator-guided pudendal nerve block in children undergoing hypospadias surgery: A prospective, randomized, double-blinded trial.

Hypospadias is a common congenital malformation in pediatric patients. Surgical repair of this malformation is a painful procedure and has long-term effects. Pudendal and penile nerve blocks are commonly preferred techniques for maintaining postoperative analgesia. However, the conventional landmark-based penile block technique involves numerous potential complications and provides a shorter analgesic period compared to the pudendal block. A promising ultrasound-guided dorsal penile nerve block was recently described. We aimed to compare the analgesic effectiveness of ultrasound-guided penile nerve block with that of neurostimulator-guided pudendal nerve block. Thirty-three patients aged 1-7years were included in this prospective, double-blinded, randomized controlled trial. Patients were divided into two groups and received either ultrasound-guided dorsal penile nerve block or neurostimulator-guided pudendal nerve block. All blocks were performed by the same two anesthesiologists, and the same surgeons performed the surgical procedures. The Face, Legs, Activity, Cry, and Consolability (FLACC) scale was used for postoperative pain management. The primary outcome of the study was time to first analgesic requirement. Secondary outcomes were FLACC scores at different time points, and types and cumulative doses of analgesic drugs. Dorsal penile nerve block provided longer analgesia than pudendal nerve block (32.29±5.47hours and 21.13±3.53hours, respectively; differences in mean: 11.16, 95% CI: 7.873-14.465) (P<.001). FLACC scores at the time of first analgesic requirement were significantly lower in dorsal penile nerve block group than pudendal nerve block group (median [IQR]: 2 [2-2.5] and 3 [3-5], respectively; differences in median: -1, 95% CI: -1.851 to -0.149) (P<.001). Ultrasound-guided dorsal penile nerve block provided a longer analgesic period and reduced opioid consumption compared to neurostimulator-guided pudendal nerve block.

Anatomy of the greater occipital nerve block in infants.

Pain relief for posterior fossa craniotomies as well as occipital neuralgia, are indications for the use of the greater occipital nerve block in children. The greater occipital nerve originates from the C2 spinal nerve and is accompanied by the occipital artery as it supplies the posterior scalp. The aim of this study was to develop a unique, yet simple technique for blocking the greater occipital nerve in children through the evaluation of the anatomy of this nerve and the accompanying occipital artery in the occipital region. The greater occipital nerve and occipital artery were dissected and exposed in six formalin-fixed cadavers (five infants [average age of 51.4days] and one 2-year-old) from the Department of Anatomy, University of Pretoria. Measurements between the nerve and selected bony landmarks were obtained. The relationship between the greater occipital nerve and the occipital artery at the trapezius muscle hiatus was also evaluated. The greater occipital nerve is on average 22.6±5.6mm from the external occipital protuberance in infants. The average width of the medial three fingers measured at the proximal interphalangeal joint, for each respective cadaver is 20.4±4.0mm, with a strong correlation coefficient of 0.97 between the aforementioned distances. In 83.3% of the specimens, the occipital artery lies lateral to the greater occipital nerve at the trapezius muscle hiatus. In infants, the greater occipital nerve can be blocked approximately 23mm from the external occipital protuberance, medial to the occipital artery. This distance is equal to the width of the medial three fingers at the proximal interphalangeal joint of the patient.

The Effect of Glossopharyngeal Nerve Block on Post-Tonsillectomy Pain of Children; Randomized Controlled Trial.

BackgroundSensory fibers of the glossopharyngeal nerve supply the tonsillar and peritonsillar areas. Thus, bilateral glossopharyngeal nerve block may alleviate post-tonsillectomy pain and improve postoperative analgesia.ObjectivesThe purpose of this clinical trial was to evaluate the effect of glossopharyngeal nerve block on postoperative analgesia in children undergoing adeno-tonsillectomyMethodsNinety ASA I-II pediatric patients presented for adeno-tonsillectomy were included in this trial. They were equally divided and randomly assigned to one of two groups: A control group, in which children did not receive a nerve block, and a glossopharyngeal nerve block group, in which children received bilateral glossopharyngeal nerve block after surgery. The postoperative pain score (FLACC score) during rest and swallowing, the time for the first request for rescue analgesia, the total dose consumption of pethidine rescue analgesia, and the incidence of postoperative complications were all assessed. Moreover, response to gag reflex, degree of difficulty in swallowing, and parents’ satisfaction were recorded.ResultsBilateral glossopharyngeal nerve block in children presented for adeno-tonsillectomy significantly prolonged the time for the first request of rescue analgesia, compared to the control group, reaching 5.833 ± 2.667 hours (P < 0.0001). It also decreased postoperative pethidine consumption to 0.878 ± 0.387 mg/kg (P = 0.0009). Moreover, it significantly decreased the postoperative FLACC score assessed two, four, six, and twelve hours after surgery, during rest and swallowing (P < 0.05). The response to gag reflex and difficulty in swallowing were also significantly decreased (P ≤ 0.0001 and 0.006, respectively). In addition, glossopharyngeal nerve block significantly increased parents’ satisfaction (P = 0.0002), with no significant increase in the incidence of postoperative complications (P > 0.05).ConclusionsBilateral glossopharyngeal nerve block in children undergoing adeno-tonsillectomy improved the duration and the quality of postoperative analgesia, decreased swallowing difficulties, and improved parents’ satisfaction.

Does Neurostimulation Improve Efficacy for Ultrasound-Guided Transperineal Pudendal Nerve Block In Children

Does Neurostimulation Improve Efficacy for Ultrasound-Guided Transperineal Pudendal Nerve Block In Children

Ketamine as an adjunct to bupivacaine in infra-orbital nerve block analgesia after cleft lip repair

We conducted this study to investigate the safety and analgesic efficacy of the addition of Ketamine to Bupivacaine in bilateral extra-oral infra-orbital nerve block in children undergoing cleft lip surgeries. Sixty patients were randomly allocated into two groups (n=30), Group B received infra-orbital nerve block with 2mL of 0.25% Bupivacaine and Group BK received 0.5mg.kg-1 Ketamine for each side added to 1mL of 0.5% Bupivacaine solution diluted up to 2mL solution to 0.25% Bupivacaine concentration. Assessment parameters included; hemodynamics, recovery time, time to first oral intake, postoperative Faces Legs Activity Cry Consolability (FLACC) scores, Four-point Agitation scores, analgesic consumption and adverse effects. Patients in Group BK showed lower postoperative FLACC scores during all recorded time points (p<0.0001). Two patients in Group BK versus 12 in Group B requested for postoperative rescue analgesia (p<0.001). There were no differences between groups in time, minutes (min), to first request for rescue analgesia. Patients in Group BK reported lower analgesic consumption (366.67±45.67 vs. 240.0±0.0mg, p<0.04). The time to first oral intake was significantly reduced in Group BK (87.67±15.41 vs. 27.33±8.68min, p<0.001). Lower postoperative Agitation scores were recorded in Group BK patients that reached a statistical significance at 45min (0.86±0.11 vs. 0.46±0.16, p<0.04) and in the first hour (h) postoperatively (1.40±0.17 vs. 0.67±0.14, p<0.003). Higher parent satisfaction scores were recorded in Group BK (p<0.04) without significant adverse effects. The addition of Ketamine to Bupivacaine has accentuated the analgesic efficacy of infra-orbital nerve block in children undergoing cleft lip repair surgeries.

Dexamethasone as an Adjuvant to Femoral Nerve Block in Children and Adolescents Undergoing Knee Arthroscopy: A Prospective, Randomized, Double-Blind, Placebo-Controlled Trial.

Perineural dexamethasone has been demonstrated to extend postsurgical analgesia after peripheral nerve blockade in adults. The mechanism of action of dexamethasone as a regional anesthetic adjuvant is unclear as intravenous dexamethasone has been shown to have similar analgesic efficacy as perineural dexamethasone. The efficacy of perineural dexamethasone has not been previously explored in the pediatric population. After obtaining informed consent, children (aged 10-18 years) presenting for arthroscopic knee surgery with a femoral nerve block were randomized to 1 of 3 groups: ropivacaine 0.5% and intramuscular saline (group R), ropivacaine 0.5% plus perineural dexamethasone 0.1 mg/kg (maximum 4 mg) and intramuscular saline (group D), and ropivacaine 0.5% and intramuscular dexamethasone 0.1 mg/kg (maximum 4 mg) (group M). The primary outcome was the number of doses of analgesic agents in the first 48 hours after hospital discharge. The number of doses was compared across study groups using Wilcoxon rank sum tests. Seventy-seven patients were enrolled in the study, of whom 4 were withdrawn because of additional surgical repair being performed, emergence delirium requiring unblinding, or loss to follow-up. The remaining 36 boys and 37 girls (aged 15 ± 2 years) included 23 patients randomized to group D, 23 patients randomized to group M, and 27 patients randomized to group R. The median number of pain medication doses within 48 hours of discharge was 2, 3, and 2 in groups D, M, and R, respectively. There were no significant differences in this outcome between groups D and M (difference in medians, 1; 95% confidence interval [CI] of difference in medians, -1 to 2; P = 0.475), groups D and R (difference in medians, 0; 95% CI of difference, -2 to 1; P = 0.821), or groups M and R (difference in medians, -1; 95% CI of difference, -2 to 1; P = 0.594). Other secondary outcomes, including time to first analgesic consumption after discharge, visual analog scale pain score, and subjective intensity of motor block, did not evince statistically significant differences among the study groups. In the pediatric population, perineural or intramuscular dexamethasone did not improve analgesia after femoral nerve blockade for knee arthroscopy. Whether the observed lack of benefit reflects a true adult-pediatric difference or a limitation of the study could not be determined. Future pediatric studies are needed to evaluate dexamethasone for other block types and other types of surgery. This study was registered at ClinicalTrials.gov, identifier NCT01971645.

Ketamine as an adjunct to bupivacaine in infra-orbital nerve block analgesia after cleft lip repair

ObjectivesWe conducted this study to investigate the safety and analgesic efficacy of the addition of Ketamine to Bupivacaine in bilateral extra-oral infra-orbital nerve block in children undergoing cleft lip surgeries. MethodsSixty patients were randomly allocated into two groups (n=30), Group B received infra-orbital nerve block with 2mL of 0.25% Bupivacaine and Group BK received 0.5mg.kg−1 Ketamine for each side added to 1mL of 0.5% Bupivacaine solution diluted up to 2mL solution to 0.25% Bupivacaine concentration. Assessment parameters included; hemodynamics, recovery time, time to first oral intake, postoperative Faces Legs Activity Cry Consolability (FLACC) scores, Four-point Agitation scores, analgesic consumption and adverse effects. ResultsPatients in Group BK showed lower postoperative FLACC scores during all recorded time points (p<0.0001). Two patients in Group BK versus 12 in Group B requested for postoperative rescue analgesia (p<0.001). There were no differences between groups in time, minutes (min), to first request for rescue analgesia. Patients in Group BK reported lower analgesic consumption (366.67±45.67 vs. 240.0±0.0mg, p<0.04). The time to first oral intake was significantly reduced in Group BK (87.67±15.41 vs. 27.33±8.68min, p<0.001). Lower postoperative Agitation scores were recorded in Group BK patients that reached a statistical significance at 45min (0.86±0.11 vs. 0.46±0.16, p<0.04) and in the first hour (h) postoperatively (1.40±0.17 vs. 0.67±0.14, p<0.003). Higher parent satisfaction scores were recorded in Group BK (p<0.04) without significant adverse effects. ConclusionsThe addition of Ketamine to Bupivacaine has accentuated the analgesic efficacy of infra-orbital nerve block in children undergoing cleft lip repair surgeries.

Analysis of the analgesic effect and safety of dexmedetomidine combined with dorsal penile nerve block in children with circumcision

Objective To investigate the effect and safety of dexmedetomidine combined with dorsal penile nerve block for circumcision in children. Methods 130 children with circumcision were divided into the observation group and the control group according to the digital table, 65 cases in each group. The control group received total inhalation of seven halothane anesthesia, and the observation group received dexmedetomidine combined with dorsal penile nerve block anesthesia. The efficacy and safety of the two groups were compared. Results In the observation group after induction, the mean arterial pressure[(69.89±5.24)mmHg], awake and mean arterial pressure[(70.14±5.30)mmHg], rhythm of the heart after induction[(100.36±10.67)times/min], the rhythm of the heart when they woke up[(102.64±10.58)times/min], blood oxygen saturation after induction[(98.25±0.63)%], awake and blood oxygen saturation[(98.64±0.66)%]and other signs of vital signs had no statistically significant differences compared with the control group(F=0.130, 0.215, 0.548, 0.613, 0.106, 0.257, all P>0.05). In the observation group, the eyelash reflex disappearing time, operation time, awakening time were(23.16±2.13)s, (9.70±1.24)min, (10.03±1.27)min, respectively, which in the control group were(27.98±3.87)s, (11.88±2.87)min, (11.89±3.87)min, respectively, there were statistically significant differences between the two groups(t=8.797, 5.621, 6.633, all P<0.05). In the observation group, the postoperative agitation score, sedation score, pain score were(2.75±1.25)points, (1.11±0.13)points, (5.26±1.44)points, respectively, which in the control group were(6.78±2.89)points, (1.11±0.13)points, (8.97±3.64)points, respectively, there were statistically significant differences between the two groups(t=10.318, 17.236, 10.318, all P<0.05). Conclusion Application of dexmedetomidine combined with penile dorsal nerve block anesthesia in pediatric circumcision takes effect quickly, children with stable vital signs, less postoperative agitation, it is worthy of popularization and application in clinic. Key words: Circumcision, male; Penis; Nerve block; Dexmedetomidine; Child

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.

Dosage of local anesthetics (LAs) used for regional anesthesia in children is not well determined. In order to evaluate and come to a consensus regarding some of these controversial topics, The European Society of Regional Anaesthesia and Pain Therapy (ESRA) and the American Society of Regional Anesthesia and Pain Medicine (ASRA) developed a Joint Committee Practice Advisory on Local Anesthetics and Adjuvants Dosage in Pediatric Regional Anesthesia. Representatives from both ASRA and ESRA composed the joint committee practice advisory. Evidence-based recommendations were based on a systematic search of the literature. In cases where no literature was available, expert opinion was elicited. Spinal anesthesia with bupivacaine can be performed with a dose of 1 mg/kg for newborn and/or infant and a dose of 0.5 mg/kg in older children (>1 year of age). Tetracaine 0.5% is recommended for spinal anesthesia (dose, 0.07-0.13 mL/kg). Ultrasound-guided upper-extremity peripheral nerve blocks (eg, axillary, infraclavicular, interscalene, supraclavicular) in children can be performed successfully and safely using a recommended LA dose of bupivacaine or ropivacaine of 0.5 to 1.5 mg/kg. Dexmedetomidine can be used as an adjunct to prolong the duration of peripheral nerve blocks in children. High-level evidence is not yet available to guide dosage of LA used in regional blocks in children. The ASRA/ESRA recommendations intend to provide guidance in order to reduce the large variability of LA dosage currently observed in clinical practice.

Correlation of Mandibular Foramen to Occlusal Plane as a Clinical Guide for Inferior Alveolar Nerve Block in Children: A Digital Panoramic Radiographic Study.

Aim:The study aimed to correlate the position of mandibular foramen with occlusal plane as a clinical guide for inferior alveolar nerve block (IANB) injection in children from 3 to 13 years of age.Materials and Methods:The study was carried out on 180 children visiting our department and required orthopantomogram as a routine diagnostic aid. Mandibular casts were obtained and radiographs were digitally analyzed to obtain linear and angular measurements.Statistical Analysis:The measurements were correlated with the position of mandibular foramen with Karl Pearson's correlation test.Results:The results of the study suggest that the needle for IANB should be placed below the occlusal plane in 3–4-year-old children (1.26 mm approximately), almost at the level of occlusal plane in 5–7 years (0.33 mm), above the occlusal plane in 7–9 years (1.54 mm), 9–12 years (1.64 mm), 11–12 years (1.98 mm), and 12–13 years (2.9 mm), respectively. The distance of the mandibular foramen from anterior border of mandible was greater than that from posterior border. The gonial angle values decrease with increasing age.Conclusion:The bony landmarks within the jaws keep changing their relative positions along with the skeletal growth. It is therefore necessary to modify the placement of needle during local anesthesia techniques with advancing age.

Ultrasound-guided pudendal nerve block in children: A new technique of ultrasound-guided transperineal approach.

Transperineal pudendal nerve block guided by nerve stimulator is used in pediatric anesthesia as an alternative to caudal analgesia in perineal surgery. The risk of rectal puncture or intravascular injection is inherent to this blinded technique. We described a new technique of transperineal pudendal nerve block, with ultrasound guidance, to improve safety of the technique. The first goal of this study was to describe this new technique and to test its feasibility. The second objective was to evaluate intra operative effectiveness and postoperative pain control. After parental and children consent, this prospective descriptive study included children aged 1-15 years, ASA status I-III, scheduled for general anesthesia associated with bilateral pudendal nerve block for an elective perineal surgery. After standardized general anesthesia, the anesthesiologist performed pudendal nerve block under ultrasound guidance with "out of plane" approach and evaluated the visualization of anatomical structures (ischial tuberosity, rectum, and pudendal artery), of the needle and of the local anesthetic spread. Pudendal nerve block failure was defined as an increase in mean arterial blood pressure or heart rate more than 20% compared to baseline values after surgical incision. In the postoperative period, the need for rescue analgesia was noted. During the study period, 120 blocks were performed in 60 patients, including 59 boys. Quality of the ultrasonographic image was good in 81% of blocks, with easy visualization of ischium and rectum in more than 95% of cases. Localization of the tip of the needle was possible for all pudendal nerve blocks, directly or indirectly. The spread of local anesthetic was seen in 79% of cases. The block was effective in 88% of cases. The new technique of ultrasound-guided pudendal nerve block, described in this study, seems to be easy to perform with a good success rate, and probably improves safety of the puncture and of the injection by real-time visualization of anatomical structures and local anesthetic spread.

Effects of different doses of dexmedetomidine combined with ropivacaine for brachial plexus nerve block in children undergoing polydactyly surgery

To observe the anesthetic effect and safety of different doses of dexmedetomidine combined with ropivacaine for brachial plexus nerve block in children undergoing polydactyly surgery. Eighty children undergoing polydactyly surgery were randomized into 4 groups to receive brachial plexus nerve block with dexmedetomidine at 0.25, 0.50 or 0.75 µg/kg combined with 0.25% ropivacaine (0.20 mL/kg) (D1, D2, and D3 groups, respectively) or with 0.25% ropivacaine (0.20 mL/kg) only (control group). The onset time, duration of brachial plexus nerve block, awakening time, success rate, and incidence of complications were compared among the groups. Results In D2 and D3 groups, the onset time and awakening time were shorter and anesthesia lasted longer than those in the control group. The onset time and awakening time were shorter and anesthesia maintenance time was longer in D3 group than in D1 group. The success rates of brachial plexus nerve block were significantly higher in D1-3 groups than in the control group (P<0.05). Hematoma was found in one of the patients. In each of the 4 groups, laryngeal nerve block occurred in 1 child and respiratory depression in another; 2 or 3 patients had Horner syndrome, and 1 patient in D3 group experienced an episode of lowered heart beat to below 70 min-1. All the complications were managed properly and the patients all recovered uneventfully. Brachial plexus nerve block with 0.5 µg/kg dexmedetomidine combined with 0.25% ropivacaine (0.20 mL/kg) is safe for effective anesthesia in children undergoing surgery for polydactyly.

Lateral Supratrochanteric Approach to Sciatic and Femoral Nerve Blocks in Children: A Feasibility Study.

Background Sciatic and femoral nerve blocks (SNB and FNB) result in effective lower limb analgesia. Classical SNB and FNB require patient repositioning which can cause pain and discomfort. Alternative approaches to sciatic and femoral nerve blocks in supine patients can be useful. Materials and Methods Neurostimulator-guided SNB and FNB from the lateral supratrochanteric approach were performed. Local anesthetic spread in SNB and FNB after radiographic opacification was analyzed. Time and number of attempts to perform blocks, needle depth, and clinical efficacy were assessed. Results Mean needle passes number and procedure time for SNB were 2.5 ± 0.3 and 2.4 ± 0.2 min, respectively. Mean needle passes number and procedure time for FNB were 2.7 ± 0.27 and 2.59 ± 0.23 min, respectively. Mean skin to nerve distance was 9.1 ± 0.45 cm for SNB and 8.8 ± 0.5 cm for FNB. Radiographic opacification of SNB showed local anesthetic spread close to the sacrum and involvement of sacral plexus nerve roots. Spread of local anesthetic in FNB was typical. Intraoperative fentanyl administration was required in 2 patients (9.5%) with mean dose 1.8 ± 0.2 mcg/kg. Mean postoperative pain score was 0.34 ± 0.08 of 10. Conclusion The lateral supratrochanteric approach to SNB and FNB in children can be an effective lower limb analgesic technique in supine patients. The trial is registered with ISRCTN70969666.

Comparison of a New Auto-controlled Injection System with Traditional Syringe for Mandibular Infiltrations in Children: A Randomized Clinical Trial.

Background:Pain in the dental operatory can have a profound effect on the behavior of children.Aim:The aim of this study is to evaluate the pain perception while administering local infiltration, in children undergoing dental extractions, using a new auto-controlled injection system.Materials and Methods:Children in the age range of 6–10 years with teeth indicated for extraction were recruited and allocated to either Group I, computer-controlled injection system (auto system with special cartridge and compatible disposable 30-gauge, 10 mm needles), or Group II, traditional system (30-gauge, 10 mm needle and disposable traditional syringe). Local infiltration was administered and extraction performed after 3 min. The time of administration (TOA) of infiltrate was noted whereas anxiety and pain in both groups were assessed using the Modified Child Dental Anxiety Faces Scale simplified (MCDAS(f)), pulse rate, Faces Pain Scale-Revised (FPS-R), and Face, Legs, Activity, Cry, Consolability (FLACC) Scale.Results:The TOA was high in computer group, compared to the traditional system (P < 0.001***); however, anxiety and pain were significantly less in computer group as reported in MCDAS(f), pulse rate, FPS-R, and FLACC (P < 0.001***).Conclusions:Computer system created a positive and comfortable experience for the child, as well as the practitioner. The possibility of using buccal infiltration instead of inferior alveolar nerve block in children below 10 years was also demonstrated.

Self-Inflicted Trauma Secondary to Local Anaesthesia in Children

Long acting local anaesthetics and inferior alveolar nerve block in children can cause loss of sensation and proprioception in a large area supplied by that particular nerve. Similar to the maxilla in mandible also, adequate level of anaesthesia can be achieved in the desired site of treatment by using a short acting local anaesthetic. Early return of normal sensory feedback after using short acting anaesthetics can be helpful in preventing self-harm.

Abstract PR249

Background & Objectives: To investigate the efficacy of ultrasound-guided modified dorsal penile nerve block in children undergoing circumcision. Materials & Methods: Eighty ASA I children scheduled for circumcision, aged 5-12 yr, weighting 15-52 kg, were randomly divided into 2 groups (n=40 each): Modified untrasound-guided dorsal penile nerve block (Group A) and traditional dorsal penile nerve block(Group B). Target controlled infusion of propofol (Marsh mode) was used to maintain the anesthesia and the initial target effect site concentration was 2μg/ml. The children in group A was placed in the dorsal lithotomy position.the ultrasound probe was placed in a coronal parallel plan just beneath the skin of the scrotum. By using ultrasound scanning technique, the penile neurovascular bundles and adjacent structures were directly identified. The needle was inserted 0.5 cm from the lateral aspect of the probe, and directed to approach the penile neurovascular sheath. Once the needle tip was placed into the penile neurovascular sheath, 1% lidocaine +0.375% ropivacaine 0.1 ml/kg was injected after negative aspiration. Group B underwent traditional dorsal penile nerve block with 1% lidocaine +0.375% ropivacaine 0.2 ml/kg. Heart rate (HR), SpO2, body movement, the total dosage of propofol and postoperative recovery time were recorded during surgery. Face legs activity cry consolability (FLACC) score at 2, 4, and 8 h postoperation were evaluated. Perioperative adverse events were also recorded. Puncturing time and success rate was recorded. Results: Bradycardia, nausea, vomiting, restlessness, urinary retention, or pruritus was not occurred during the perioperative period. Compared with group B, the total dosage of propofol, the postoperative recovery time, the incidence of body movement during surgery, the use rate of paracetamol suppositories and the nerve block puncturing time(3.9±1.6 vs 5.5±2.7min) was decreased in group A (P<0.05). Success rate of puncture was 100% in two groups, there was no significant difference in the incidence of respiratory depression between two groups. Conclusion: Ultrasound-guided modified dorsal penile nerve block was safe and effect for children undergoing circumcision which clinically superior to traditional block. It could not only reduce the amount of anesthetics and improve the anesthesia quality, but also reduce the perioperative adverse event and improve the postoperative pediatric analgesia. Disclosure of Interest: None declared

The Use of Ultrasound Guidance for Perioperative Neuraxial and Peripheral Nerve Blocks in Children: A Cochrane Review.

Objectives were to determine whether the use of ultrasound guidance offers any clinical advantage in the performance of neuraxial or peripheral nerve blocks in children in terms of increasing the success rate or decreasing the rate of complications. We searched the following databases to March 2015: Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE (OvidSP), EMBASE (OvidSP), and Scopus (to January 2015). We included all parallel randomized controlled trials that evaluated the effect of ultrasound guidance to perform a regional blockade technique in children. We assessed the selected studies for risk of bias with the Cochrane collaboration tool. We graded the level of evidence for each outcome according to the Grading of Recommendations Assessment, Development and Evaluation (GRADE) working group scale. We included 20 studies (1241 participants). Ultrasound guidance increases the success rate by decreasing the occurrence of a failed block: risk difference -0.11 (95% confidence interval [CI], -0.17 to -0.05); I 64%; number needed for additional beneficial outcome for peripheral nerve blocks 6 (95% CI, 5-8). The younger the child, the greater the benefit. From 8 studies (414 participants), pain scores at 1 hour in the postanesthesia care unit were reduced when ultrasound guidance was used; however, the clinical relevance of the difference was unclear (equivalent to -0.2 on a scale from 0 to 10). From 8 studies (358 participants), block duration was longer when ultrasound guidance was used: standardized mean difference (SMD) 1.21 (95% CI, 0.76-1.65: I 73%; equivalent to 62 minutes). Here again, younger children benefited the most from ultrasound guidance. Time to perform the procedure was reduced when ultrasound guidance was used for prescanning before a neuraxial block (SMD -1.97; 95% CI, -2.41 to -1.54; I 0%; equivalent to 2.4 minutes) or as an out-of-plane technique (SMD -0.68; 95% CI, -0.96 to -0.40; I 0%; equivalent to 94 seconds). From 2 studies (122 participants), ultrasound guidance reduced the number of needle passes required to perform the block: SMD -0.90 (95% CI, -1.27 to -0.52; I 0%; equivalent to 0.6 needle pass per participant). From 2 studies (204 participants), we could not demonstrate a difference in the incidence of bloody puncture when ultrasound guidance was used for neuraxial blockade, but we found that the number of participants was well below the optimal information size (risk difference -0.07, 95% CI, -0.19 to 0.04). No major complications were reported for any of the 1241 participants. We rated the quality of evidence as high for success, pain scores at 1 hour, block duration, time to perform the block, and number of needle passes. We rated the quality of evidence as low for bloody punctures. Ultrasound guidance seems advantageous, particularly in young children, for whom it improves the success rate and increases block duration. Additional data are required before conclusions can be drawn on the effect of ultrasound guidance in reducing the rate of bloody puncture.

Anaesthetic efficacy of 4% articaine mandibular buccal infiltration compared to 2% lignocaine inferior alveolar nerve block in children with irreversible pulpitis.

Lidocaine is the gold standard anaesthetic solution that has been used since its inception into dentistry till date. Around 80% of failures have been reported when lignocaine has been used for inferior alveolar nerve block in children and adults with irreversible pulpitis. There is a need to use newer drugs which are available which have been reported to be effective like lignocaine, such as articaine. Although articaine has been used in adults, literature supporting its use in children is sparse. The purpose of this study is to compare the anaesthetic efficacy of 4% articaine buccal infiltration and 2% lignocaine inferior alveolar nerve block in children with irreversible pulpitis. It also aims to assess the need for supplemental intrapulpal injections. This study was designed as a randomized double-blind cross over trial comparing the anaesthetic effectiveness of 4% articaine with 1:100,000 epinephrine in buccal infiltration and 2% lignocaine IAN block anaesthesia. The study subject and the pediatric dentist performing the pulpectomy procedures were blinded to the study. A sample size of 40 subjects in the age group of 5-8 y was included in the study. The onset of anaesthesia with 4% articaine was faster as compared to 2% lignocaine. The duration of anaesthesia with articaine infiltration was shorter. The need for supplemental injection in the articaine group was less. Four percent articaine infiltration can be used in children with irreversible pulpitis. It can be used to replace the IAN block in children thereby reducing the post anaesthetic complications like lip biting.

Comment on Ultrasound‐guided parasacral approach to the sciatic nerve block in children

Comment on Ultrasound‐guided parasacral approach to the sciatic nerve block in children