Detection of intravascular injection of regional anaesthetics in children

Local Anesthetic Systemic Toxicity in an Infant Following a Caudal Block: A Case Report and Review of Literature

Local anesthetic systemic toxicity (LAST) is a rare but serious complication of regional anesthesia, particularly in neonates and infants due to their immature hepatic metabolism, reduced protein-binding capacity, and increased vascular absorption. We report the case of a two-month-old ex-premature infant who developed ventricular fibrillation following a caudal block with bupivacaine during hernia repair and circumcision. Despite negative aspiration tests, systemic absorption of bupivacaine led to toxic plasma concentrations, resulting in sudden cardiovascular collapse without preceding neurological symptoms, a presentation typical in pediatric LAST. Immediate resuscitation, including cardiopulmonary resuscitation, epinephrine, and lipid emulsion therapy, successfully restored normal cardiac rhythm. This case underscores the importance of vigilance, strict adherence to weight-based dosing, and the availability of lipid emulsion therapy in pediatric anesthesia while emphasizing prevention through careful technique, monitoring, and the use of ultrasound guidance to minimize the risk of this life-threatening complication.

Local anesthetic systemic toxicity in children: a review of recent case reports and current literature

BACKGROUND

Local anesthetic systemic toxicity (LAST) in children occurs at an estimated rate of 8 per 100 000 blocks (95% CI 0.3 to 1.6). Due to the potential lethality of this iatrogenic complication, a better clarity of risk factors, clinical presentation, and prognosis may be clinically useful for contemporary treatment and prevention.

METHODS

An extensive literature search and detailed analysis of reported cases of LAST in patients less than 18 years of age published between April 2014 and August 2019 was performed. Clinical patterns were summarized.

RESULTS

Thirty-two cases of LAST were described in 17 published articles and 2 additional cases reported to lipidrescue.org, for a total of 34 cases. Three patients did not meet the inclusion criteria. Thirty-one cases were included in the analysis.

DISCUSSION

Infants represented a disproportionately large number of reports of LAST. The majority of local anesthetic doses were within currently published guidelines. Among the reported cases, penile and caudal blocks were the most commonly associated with LAST. Needle aspiration and test dosing with epinephrine failed to predict LAST with certainty. When LAST presented with severe cardiac compromise, intravenous lipid emulsion was given within 10 min in 43% of cases (13 of 30 reported cases). The vast majority of children were under general anesthesia when local anesthetic medications were administered. In children under general anesthesia, LAST presented with cardiac manifestations in 90% of cases (19 of 21 cases). There were no deaths or long-term morbidity reported.

Unintentional Infiltration of High Dose Epinephrine in an Infant: A Case Report

Verbal orders in the operating room between the surgeon and circulating nurse are prevalent at many institutions. We present a case in which a communication breakdown involving a verbal order resulted in the patient receiving an excessively high dose of epinephrine via subcuticular infiltration. The overdose was quickly identified by an increase in T-wave amplitude on electrocardiogram (ECG). The hemodynamic changes were treated, and the patient suffered no long-term sequelae. This report emphasizes the need to have strategies in place to prevent medication errors.

Changes of epidural blood flow after epidural administration of epinephrine in young rats

PURPOSE

For caudal epidural analgesia, the needle is inserted at a site where vessels are abundant. To avoid complications related to intravascular administration of the local anesthetic, epinephrine is usually added, but there is no evidence about the safety of epidural administration of epinephrine in pediatric patients. The objective of this study was to assess the changes in epidural blood flow after epidural injection of epinephrine in young rats.

METHODS

With approval of the local ethics committee, four young Sprague-Dawley rats weighing 110-120 g were investigated. The rats were anesthetized with isoflurane via a mask. After there was no escape reaction to pain, an arterial catheter, epidural blood flow monitor (Laser Doppler blood flow ALF 21; ADVANCE Corp.), and caudal epidural catheter were inserted while the rats remained under general anesthesia. Exactly, 10 μl of 1 : 1000 epinephrine was then infused, followed by measurement of the blood pressure and epidural blood flow. After the recovery of the blood pressure and epidural blood flow to baseline, 10 μl of saline was infused through the epidural catheter. The blood pressure and epidural blood flow were then measured again.

RESULTS

One rat was excluded because epinephrine was inadvertently injected into the epidural vessels. Therefore, three rats were investigated in this experiment. Blood flow in the epidural space showed no change after the injection of saline. When epinephrine was administered into the epidural space, epidural blood flow decreased immediately and low flow persisted for 6-15 min. The reduction of blood flow was not very great, being only 8-14%, so there was no risk of spinal ischemia which would require 60-80% reduction.

CONCLUSION

Administration of epinephrine into the epidural space was safe in young rats. While reduction of epidural blood flow was observed, there was no spinal ischemia.

Phenylephrine as a simulated intravascular epidural test dose in pediatrics: a pilot study

BACKGROUND

A test dose is used to detect intravascular injection during neuraxial block in pediatrics. Accidental intravascular epidural local anesthetic injection might be unrecognized in anesthetized children leading to potential life-threatening complications. In children, sevoflurane anesthesia blunts the hemodynamic response when intravascular cathecolamines are administered. No studies have explored the hemodynamics and the criteria for a positive test dose result following phenylephrine in sevoflurane anesthetized children.

METHODS

Healthy children undergoing minor procedures were randomly assigned to receive intravenous placebo, or 5 μg∙kg(-1) phenylephrine (n = 11/group) during sevoflurane anesthesia. Hemodynamic response was assessed using electrocardiography, pulse oxymetry and non-invasive blood pressure monitoring for 5 min following drug administration in anesthetized patients.

RESULTS

All patients receiving phenylephrine showed a decreased heart rate (HR) but not all of them met the positive criterion for test dose response. Overall, at 1 min, patients receiving phenylephrine showed a 25% decrease in HR from the baseline while an increase in blood pressure was noticed in 54% of patients receiving phenylephrine.

DISCUSSION

Phenylephrine might be a future indicator of positive intravascular test dose. Further investigation is needed to find out the phenylephrine dose that elicits a reliable hemodynamic response and whether phenylephrine needs to be dose age-adjusted in order to appreciate relevant hemodynamic changes in children receiving neuraxial blocks undergoing general anesthesia.

Electrocardiographic and blood pressure alterations caused by intravenous injection of ropivacaine - a study in piglets

OBJECTIVES

Objective signs to detect inadvertent intravascular injection of local anesthetics are essential in the anesthetized pediatric patient. For early detection of intravenous bupivacaine administration, it was shown that an epinephrine containing test dose reliably provoked T-wave alterations, changes in heart rate (HR) and blood pressure, whereas intravenous injection of plain bupivacaine could not be detected until high doses were applied. This study investigates electrocardiographic and hemodynamic alterations caused by intravenous ropivacaine.

METHODS

Twenty-four piglets, anesthetized with sevoflurane, were randomized into two groups: Group R received as test dose plain ropivacaine 0.2% and group RE, ropivacaine 0.2% + epinephrine 5 μg·ml(-1) . Under stable conditions, 0.2 ml kg(-1) of the test solution was intravenously injected. Twenty minutes later, 0.4 ml kg(-1) was applied. A positive effect was defined as HR increase ≥ 10 bpm, increase in mean arterial pressure (MAP) ≥ 15 mmHg, T-wave increase ≥ 25% baseline. In another setting ropivacaine was intravenously infused until cardiac arrest.

RESULTS

After injection of 0.2 or 0.4 ml kg(-1) test solution, a positive increase in HR and MAP was found in 0% of group R and in 100% of group RE. An increase in T-wave ≥ 25% was found in 42% of group R and in 100% of group RE. During intoxication, T-elevation was seen in 83%.

CONCLUSIONS

An epinephrine containing test dose ropivacaine reliably provoked T-wave elevations and increases in HR and MAP. A small dose plain ropivacaine caused T-elevations in a remarkable percentage, whereas higher, quite toxic doses provoked T-elevations in most of the pigs.

[Pediatric caudal anesthesia : importance and aspects of safety concerns]

Caudal block is a safe procedure commonly used for pediatric perioperative analgesia. Complications are extremely rare but nevertheless local and systemic contraindications must be excluded. Optimal safety and quality result when strict attention is paid to technical details. These are discussed in detail in this review. A local anesthetic (LA) containing epinephrine allows early detection of inadvertent intravascular LA administration; therefore an epinephrine/LA mixture is recommended at least for the test dose. In terms of safety the choice of LA itself is probably of secondary importance. Clonidine as an adjuvant has an excellent risk/benefit profile with minimal side effects. Inadvertent systemic LA intoxication is a rare but potentially fatal complication of regional anesthesia and measures for prevention and early detection are essential. Should circulatory arrest occur, immediate resuscitation following standard guidelines is to be initiated including the use of epinephrine as the first line drug. Intravenous administration of lipid solutions may be beneficial as a secondary adjunct to stabilize hemodynamics but is not an alternative to epinephrine.

[Pediatric caudal anesthesia: importance and aspects of safety concerns]

Caudal block is a safe procedure commonly used for pediatric perioperative analgesia. Complications are extremely rare but nevertheless local and systemic contraindications must be excluded. Optimal safety and quality result when strict attention is paid to technical details. A local anesthetic (LA) containing epinephrine allows early detection of inadvertent intravascular LA administration; therefore an epinephrine/LA mixture is recommended at least for the test dose. In terms of safety the choice of LA itself is probably of secondary importance. Clonidine as an adjuvant has an excellent risk/benefit profile with minimal side effects. Inadvertent systemic LA intoxication is a rare but potentially fatal complication of regional anesthesia and measures for prevention and early detection are essential. Should circulatory arrest occur, immediate resuscitation following standard guidelines is to be initiated including the use of epinephrine as the first line drug. Intravenous administration of lipid solutions may be beneficial as a secondary adjunct to stabilize hemodynamics but is not an alternative to epinephrine.

Controversial issues in pediatric regional anesthesia

Regional anesthesia in children has reached in the last decades a widespread approval and today is a valid and effective technique used in the daily activity in many pediatric centres. Data from surveys and studies show the very low rate of complications and suggest that the use of regional techniques in children is at least as safe as general anesthesia alone. Despite these evidences there are aspects still creating discussions on the best approach to avoid or prevent risks and on the way to make this techniques more and more reliable and safe. Compartment syndrome, test dose, loss-of-resistance technique and blocks performed under general anesthesia are examples of, sometimes, never-ending stories; this review without the presumption to solve every problem shows the more recent data to offer, if possible, the best updated-answer on these topics.

Pediatric regional anesthesia: what is the current safety record?

The use of regional anesthetics, whether as adjuncts, primary anesthetics or postoperative analgesia, is increasingly common in pediatric practice. Data on safety remain limited because of the paucity of very large-scale prospective studies that are necessary to detect low incidence events, although several studies either have been published or have reported preliminary results. This paper will review the data on complications and risk in pediatric regional anesthesia. Information currently available suggests that regional blockade, when performed properly, carries a very low risk of morbidity and mortality in appropriately selected infants and children.

Impact of propofol on electrocardiographic alterations during intravascular application of bupivacaine--a study in piglets

BACKGROUND

Intravascular application of a small dose of local anesthetics (LA) with epinephrine as well as larger doses of LA under sevoflurane anesthesia results in increase in T-wave amplitude in the electrocardiogram (ECG). The aim of this study was to elucidate whether propofol anesthesia affects these ECG alterations or not.

METHODS

Thirty neonatal pigs were randomized into two groups. Group 1 was anesthetized with sevoflurane, group 2 with sevoflurane plus continuous propofol infusion (10 mg·kg(-1)·h(-1)). A test dose of 0.2 ml·kg(-1) bupivacaine 0.125% + epinephrine 1 : 200,000 was injected intravenously. Arterial pressure was monitored. ECG was analyzed for changes in T-wave amplitude (positive if ≥25% baseline) and heart rate. In another setting, bupivacaine 0.125% was intravenous infused at a rate of 4 mg·kg(-1)·min(-1). ECG was analyzed for alteration in T-wave amplitude and heart rate at 1.25, 2.5, and 5 mg·kg(-1) bupivacaine infused.

RESULTS

T-wave elevation after the administration of an epinephrine containing LA test dose was similar between the two groups. Increase in heart rate caused by the test dose were significantly higher in group 2 (P = 0.008). During continuous bupivacaine administration, T-wave elevation occurred in 40% and 71% (group 1 and 2) at 1.25 mg·kg(-1), in 80% and 100% at 2.5 mg·kg(-1), and in 93% and 86% at 5 mg·kg(-1) bupivacaine infused.

CONCLUSION

Continuous propofol infusion does not suppress the ECG signs of a systemically administered epinephrine containing LA test dose nor does it suppress the ECG signs caused by high doses of intravenous applied bupivacaine.

Successful resuscitation of bupivacaine-induced cardiotoxicity in a neonate

We report a case of bupivacaine-induced cardiotoxicity in a neonate following caudal epidural block under general anesthesia for urologic surgery. Prompt recognition of the complication allowed early intervention with both standard resuscitative measures and administration of 20% Intralipid(®) , resulting in a good outcome.

Epinephrine test dose in children: is it interpretable on ECG monitor?

BACKGROUND

Epidural and other regional blocks are performed in children under general anesthesia; the response to a 'test dose' may be altered during administration of general anesthetics. Limited data is available describing changes in electrocardiogram, blood pressure and heart rate (HR) following unintentional intravascular injection of a lidocaine-epinephrine-containing test dose, under sevoflurane anesthesia in children.

METHODS

Sixty-eight children undergoing elective surgeries under sevoflurane anesthesia were administered 0.1 ml x kg(-1) of 1% lidocaine with epinephrine 0.5 microg x kg(-1) or normal saline intravenously, to simulate an accidental intravascular test dose. T-wave changes in lead II on the anesthesia monitor and on a printed ECG were noted over the initial 1 min as well as changes in HR and systolic blood pressure (SBP) over an initial 3 min period.

RESULTS

Following injection of lidocaine-epinephrine, a significant increase in T-wave amplitude in lead II was noted in 91% of children on the ECG monitor and in 94% of children on the ECG printout of the same lead. In 64% of children, an increase in HR of > or =10 b x min(-1) and in 76% of children an increase in SBP of > or =15 mmHg was noted.

CONCLUSION

An increase in T-wave amplitude can easily be detected by carefully observing the ECG monitor or an ECG printout within a minute following the accidental i.v. administration of 0.1 ml x kg(-1) of 1% lidocaine-epinephrine (0.5 microg x kg(-1)) regional anesthetic test dose in children under sevoflurane anesthesia.

Plethysmographic pulse wave amplitude is an effective indicator for intravascular injection of epinephrine-containing epidural test dose in sevoflurane-anesthetized pediatric patients

BACKGROUND

Plethysmographic pulse wave amplitude (PPWA) was effective in detecting intravascular injection of epidural test dose with 100% sensitivity and specificity in adults. We evaluated the efficacy of PPWA in detecting intravascular injection of a simulated epidural test dose during sevoflurane anesthesia in pediatric patients.

METHODS

Eighty infants and children were randomized to receive either 0.5 minimal alveolar concentration (MAC) or 1 MAC sevoflurane and nitrous oxide in oxygen. Patients in each anesthesia group were further randomized to receive either 0.1 mL/kg of 1% lidocaine with 1:200,000 epinephrine (0.5 mug/kg of epinephrine) IV to simulate the intravascular injection of epidural test dose or saline. Heart rate (HR), systolic blood pressure (SBP), and PPWA were monitored for 5 min after injection. A positive test response was defined as HR increase > or =10 bpm, SBP increase > or =15 mm Hg, and PPWA decrease > or =10%.

RESULTS

Injecting the test dose resulted in an average maximum PPWA decrease by 69% +/- 18% and 58% +/- 14% at 79 +/- 22 and 80 +/- 19 s in the 0.5 MAC and 1 MAC sevoflurane groups, respectively. The sensitivity, specificity, positive predictive, and negative predictive values for PPWA were 100% in both sevoflurane groups, whereas by using HR and SBP criteria, the sensitivity was 90% and 95% respectively during 0.5 MAC sevoflurane anesthesia and 85% for both during 1 MAC sevoflurane anesthesia.

CONCLUSION

PPWA is effective for detection of an intravascular injection of a simulated epidural epinephrine-containing test dose in pediatric patients.

Perioperative anesthetic and analgesic management of newborn bladder exstrophy repair

OBJECTIVE

Reconstruction of bladder exstrophy in newborn infants requires immobilization, sedation and pain management to prevent distracting forces from compromising the repair. We present a 6-year review of our experience.

SUBJECTS AND METHODS

We reviewed the perioperative management of newborn infants undergoing reconstruction between November 1999 and October 2006. Data are presented as means+/-SD.

RESULTS

Twenty-three newborn infants underwent surgery under a combined epidural and general anesthetic technique. Tunneled caudal epidural catheters were inserted in all patients and intermittently injected with 0.25% bupivacaine with 1:200,000 epinephrine. Postoperatively, a continuous infusion of 0.1% lidocaine, 0.8-1mg/kg/h was administered for 15+/-8 (range 4-30) days. Children were sedated with diazepam for 20+/-13 (range 2-40) days. Central venous catheters were maintained for 20+/-9 (range 1-34) days for fluids, drug administration and blood sampling. No patient experienced bladder prolapse or wound dehiscence.

CONCLUSION

Perioperative management with tunneled epidural and central venous catheters in newborn infants with bladder exstrophy facilitates immobilization, analgesia and sedation, resulting in an excellent cosmetic repair with no case of bladder prolapse or wound dehiscence.

New insights into regional anesthesia in children: new techniques and new indications

The applications and indications for pediatric regional anesthesia continue to increase. Several recent advances have occurred in the understanding of this technology in children, including improved techniques, alternative drug combinations, as well as prospective investigations to understand the nature and incidence of adverse effects associated with these techniques when used in pediatric patients. The following article will review recent information from the literature concerning various regional anesthetic techniques in children, including caudal epidural block, lumbar and thoracic epidural anesthesia, and peripheral nerve blockade.

Is a fall in baseline heart rate a reliable predictor of a successful single shot caudal epidural in children?

BACKGROUND

This study was designed to investigate whether a fall in heart rate (HR) with injection of local anesthetic into the caudal space can be used as a predictor of correct needle placement.

METHODS

Two hundred and twenty pediatric patients undergoing infraumbilical surgery were recruited to the study. After induction of general anesthesia, baseline HR was recorded and caudal block was performed using 0.75-1 ml x kg(-1) 0.25% bupivacaine, which was injected at a rate of 1 ml x 3 s(-1). The change in HR while injecting an initial 0.2 ml x kg(-1) of drug and during total drug injection was recorded. HR reduction of > or = 3 b x min(-1) was considered a positive test for correct needle placement. The success of block was judged by HR response to skin incision, endtidal halothane concentration required for maintenance of anesthesia and postoperative pain scores.

RESULTS

Caudal block was successful in 209/220 (95%) patients. Mean HR following the initial drug injection (111 +/- 17.7, P < 0.01) and entire drug injection (108.8 +/- 17.2, P < 0.01) was significantly lower than baseline (116.2 +/- 17.5). HR reduction of > or = 3 b x min(-1) was present in 190/209 and 199/209 successful block following initial drug injection and total drug injection respectively. The analysis of study data showed that a fall in HR is a predictor of successful caudal block, with a sensitivity of 90.9%, specificity of 100% and a positive predictive value of 100% after initial injection of local anesthetic.

CONCLUSIONS

We conclude that decrease in HR with drug injection is a simple, objective and reliable test to predict success of caudal block.

Clinically unrecognized intravascular placement of epidural catheter in a child--an argument for the use of radio-opaque contrast?

An epidural catheter was inserted after induction of anesthesia in a 28.2 kg 9-year-old boy scheduled to undergo bilateral femoral varus derotational osteotomies. There was no gravity free flow of blood down the catheter and there was no blood aspirated with a 2 ml syringe. After a negative test dose of a 4 ml solution of 0.25% levobupivacaine with epinephrine 1 : 200 000, a further 8 ml was administered via the epidural catheter. No significant increase in heart rate was noted. On surgical skin incision the heart rate increased from 94 to 116 b.min(-1) and blood pressure increased from 104/44 to 116/46 mmHg. A further 3 ml 0.25% levobupivacaine with epinephrine and clonidine 2 mug.kg(-1) were administered via the epidural catheter. The operation continued uneventfully although it was noted that the heart rate increased intermittently during the procedure. In view of the unexplained tachycardia and a history of cerebral palsy with the potential for postoperative muscle spasms, it was felt important to have a reliable epidural. To confirm placement, 2 ml of Isovue 300 (Iopamidol) was administered via the epidural catheter. X-ray screening demonstrated intravascular placement and the rapid disappearance of contrast. The catheter was removed and reinserted. Contrast demonstrated good spread in the epidural space. The merits of screening with contrast for epidural catheter placement in children are discussed.

The Epidural Test Dose: A Review

This review systematically examines the literature on the ability of the classical epidural test dose and other strategies to detect intravascular, intrathecal, or subdural epidural needle/catheter misplacement. For detection of simulated intravascular misplacements, a sensitivity (S) and a positive predictive value (PPV) > or =80 demonstrated by at least two randomized controlled trials coming from two different centers were determined for the following tests and patient populations: Nonpregnant adult patients = increase in systolic blood pressure (SBP) > or =15 mm Hg (S = 80-100 and 93-100; PPV = 80-100 and 83-100) or either an increase in SBP > or =15 mm Hg or an increase in heart rate > or =10 bpm after the injection of 10 (S = 100; PPV = 83-100) or 15 microg of epinephrine (S = 100; PPV = 83-100); pregnant patients = sedation, drowsiness, or dizziness within 5 min after the injection of 100 microg of fentanyl (S = 92-100; PPV = 91-95); and children = increase in SBP > or =15 mm Hg after the injection of 0.5 microg/kg of epinephrine (S = 81-100; PPV = 100). Conversely, more studies are required to determine the best strategies to detect intrathecal and subdural epidural needle/catheter misplacements in these three patient populations.

S-wave in lead III is helpful for the early detection of bupivacaine-induced cardiac depression in dogs

PURPOSE

Unintentional intravascular bupivacaine injection is known to be associated with treatment-resistant cardiovascular collapse. Therefore, it is important for safe anesthetic management to establish an early sign of bupivacaine-induced cardiac depression with available monitoring. We hypothesized that bupivacaine induced-cardiac depression in dogs could be detected early by analyzing the electrocardiogram (ECG). We performed this study to investigate changes of ECG and ultimately find a variable reflecting cardiac output (CO) changes in dogs with bupivacaine-induced cardiac depression.

METHODS

Bupivacaine was infused into pentobarbital-anesthetized dogs (n = 9) at a rate of 0.5 mg x kg(-1) x min(-1) for 30 min. R-wave, S-wave and T-wave amplitudes in leads I, II and III were measured every five minutes after the start of bupivacaine infusion, and electrical axes of the heart were calculated at each time. The PR interval, QRS complex duration and corrected QT interval were also measured. CO, mean arterial blood pressure and heart rate were recorded at five-minute intervals. The relationships between CO and ECG wave parameters and of CO vs the hemodynamic variables were compared by correlation coefficients and regression analysis.

RESULTS

The electrical mean axis of the heart was deviated to the left by the bupivacaine infusion. S-wave in lead III increased approximately twice within the first five minutes and showed the closest correlation with CO (r = 0.751, P < 0.001) during 30 min bupivacaine infusion.

CONCLUSION

Close monitoring of an ECG, and especially the S-wave amplitude in lead III can be helpful for the early detection of bupivacaine-induced cardiac depression in dogs.

Pharmacokinetics and efficacy of ropivacaine for continuous epidural infusion in neonates and infants

INTRODUCTION

The primary objective of this noncomparative study was to evaluate the pharmacokinetics of ropivacaine during a 48-72-h continuous epidural infusion of ropivacaine in children under 1 year. The secondary objectives were to assess efficacy and safety.

METHODS

Neonates and infants (ASA I-III, gestational age > or =37 weeks, > or =2.5 kg, scheduled for major abdominal or thoracic surgery) were included and separated into age groups: 0-30 (neonate), 31-90, 91-180, and 181-365 days. Ethics committee approval and informed parental consent were obtained before inclusion. An epidural catheter was introduced under general anesthesia at the appropriate dermatomal level. An initial bolus dose (0.9-2.0 mg.kg(-1) of ropivacaine 0.2%) was followed by an epidural infusion (0.2 mg.kg(-1).h(-1) for infants <180 days or 0.4 mg.kg(-1).h(-1) for infants >180 days). Plasma samples were collected every 12 h from 24 h, and on termination of the epidural infusion. Postoperative pain was evaluated using both the Objective Pain Scale and a four-graded descriptive scale.

RESULTS

Forty-five infants, median age 116 (0-362) days, were included. Forty-three and 19 patients received an infusion for at least 48 and 72 h, respectively. Satisfactory analgesia was provided in the majority, only 20 patients were given supplementary medication during the infusion. In all age groups, plasma concentrations of unbound ropivacaine leveled at 24 h, without any further increase at 48 and 72 h. Because of lower clearance of unbound ropivacaine in neonates (mean 33 ml.min(-1).kg(-1)) than in infants above the age of 30 days (80, 124, and 163 ml.min(-1).kg(-1), respectively, in the age groups 31-90, 91-180, and 180-365 days), unbound ropivacaine concentrations at the end of infusion were higher in neonates [median 0.10 mg.l(-1) (0.04-0.21 mg.l(-1))] than in infants >30 days [median 0.03 mg.l(-1) (0.003-0.10 mg.l(-1))].

CONCLUSION

Epidural infusions (0.2-0.4 mg.kg(-1).h(-1) ropivacaine) provided satisfactory pain relief in neonates and infants under 1 year. As plasma concentrations of unbound ropivacaine were not influenced by the duration of the infusion, ropivacaine can be safely used for postoperative epidural infusion for 48-72 h. Levels of unbound ropivacaine were higher in the neonates than in the infants, but were below threshold concentrations for CNS toxicity in adults (> or =0.35 mg.l(-1)). This should not preclude the use of ropivacaine infusions in neonates but suggests a need for caution during the first weeks of life.

Choice of electrocardiography lead does not affect the usefulness of the T-wave criterion for detecting intravascular injection of an epinephrine test dose in anesthetized children

Accidental intravascular injection of an epinephrine-containing test dose increases T-wave amplitude of lead II electrocardiogram (EKG) in anesthetized children. We designed this study to test whether the choice of EKG lead would affect the usefulness of simulated intravascular test dose. We studied 32 ASA physical status I infants and children (aged 6-49 mo) undergoing elective surgeries during 1.0 minimum alveolar anesthetic concentration sevoflurane and 67% nitrous oxide in oxygen. When hemodynamic stability was obtained, all subjects received IV saline 0.1 mL/kg, followed 4 min later by an IV test dose (0.1 mL/kg) consisting of 1% lidocaine with 1:200,000 epinephrine (epinephrine 0.5 microg/kg) via a peripheral vein to simulate the intravascular injection of the test dose. Heart rate and systolic blood pressure were recorded every 20 and 60 s, respectively, and leads II (n = 32), V(5) (n = 32) and either lead I (n = 15) or III (n = 17), choosing the one with greater preinjection T-wave amplitude, were continuously recorded for 4 min after the saline and the test dose injections. An IV test dose produced significant increases in heart rate, systolic blood pressure, and T-wave amplitude of all EKG leads studied in all subjects, whereas IV saline elicited no changes in these variables. Maximal increases in T-wave amplitude of leads II, I, III, and V(5) were 158% +/- 69%, 175% +/- 78%, 147% +/- 89%, and 170% +/- 72%, respectively (mean +/- SD, P > 0.05). There was no significant difference in temporal changes in T-wave amplitude among the 4 leads, and sensitivity and specificity were 100% on the basis of the T-wave criterion irrespective of the lead examined. Our results indicate that leads II, I, III, and V(5) of EKG are equally effective for detecting intravascular injection of the epinephrine-containing test dose in sevoflurane-anesthetized children.

IMPLICATIONS

To determine whether an epidurally administered local anesthetic has been accidentally injected into a blood vessel, a small dose of epinephrine is often added to a local anesthetic. We found that increases in T-wave amplitude in leads I, II, III, and V(5) of the electrocardiogram are equally sensitive and specific for detecting intravascular injection of the epinephrine-containing test dose in sevoflurane-anesthetized infants and children.

Simulated epidural test doses using adrenaline and adrenaline/clonidine in sevoflurane-anaesthetized children

A pilot study was conducted using a simulated epidural test dose to ascertain the effects adrenaline, adrenaline/clonidine mixture, and clonidine alone on the accepted criteria for determining the occurrence of an epidural intravascular injection. Seventy-five ASA 1 or 2 children aged from six months to twelve years were sequentially allocated to one of three groups: group A: adrenaline 0.5 microgram/kg, group AC: adrenaline 0.5 microgram/kg and clonidine 0.3 microgram/kg, and group C: clonidine 0.3 microgram/kg. Effects on heart rate, T-wave amplitude and systolic blood pressure were determined after induction of anaesthesia and stabilization using sevoflurane in nitrous oxide and oxygen. Heart rate varied from baseline in a biphasic manner. The maximal increase in mean heart rate for all groups was < 10 beats per minute (bpm). A heart rate rise of > 10 bpm was not seen at any time in 54% of groups A and AC and 92% of group C (Chi-square 11.4, P = 0.003). T-wave changes were also biphasic. 50% of groups A and AC had no increase in T-wave size of > 25% at any sample point, compared with 96% in group C (Chi square = 49.4, P < 0.0001). 34% of groups A and AC did not have a change in systolic blood pressure of > 15 mmHg during the study compared with 100% of group C (Chi-square = 30.2, P < 0.0001). There were no significant differences between groups A and AC for any parameter. Negative predictive value estimates for the current criteria for intravascular injection were low. Clonidine 0.3 microgram/kg produced no effects on the study variables.

Unusual presentation of long QT syndrome

We describe the case of a 9-yr-old child with undiagnosed long QT syndrome who experienced an intraoperative cardiac arrest after accidental intravascular injection of bupivacaine with epinephrine via a misplaced epidural catheter.

Benefit and risks of local anesthetics in infants and children

Regional anesthesia has become a routine part of the practice of anesthesiology in infants and children. Local anesthetic toxicity is extremely rare in infants and children; however, seizures, dysrhythmias, cardiovascular collapse, and transient neuropathic symptoms have been reported. Infants and children may be at increased risk from local anesthetics compared with adults. Larger volumes of local anesthetics are used for epidural anesthesia in infants and children than in adults. Metabolism and elimination of local anesthetics can be delayed in neonates, who also have decreased plasma concentrations of alpha(1)-acid glycoprotein, leading to increased concentrations of unbound bupivacaine. Most regional anesthetic procedures in infants and children are performed with the patient heavily sedated or anesthetized; because of this, and because a test dose is not a particularly sensitive marker of intravenous injection in the anesthetized patient, detection of intravascular local anesthetic injection is extremely difficult. The same local anesthetics used in adult anesthetic practice are also used in infants and children. Because of its extremely short duration of action, chloroprocaine has been used primarily for continuous epidural techniques in infants and children. The use of tetracaine has generally been limited to spinal and topical anesthesia. Lidocaine (lignocaine) has been used extensively in infants and children for topical, regional, plexus, epidural and spinal anesthesia. The association between prilocaine and methemoglobinemia has generally restricted prilocaine use in infants and children to the eutectic mixture of local anesthetics (EMLA). Because of its greater degree of motor block compared with other long-acting local anesthetics, etidocaine has generally been limited to plexus blocks in infants and children. Mepivacaine has been used for both plexus and epidural anesthesia in infants and children. Because postoperative analgesia is often the primary justification for regional anesthesia in infants and children, bupivacaine, a long-acting local anesthetic, is the most commonly reported local anesthetic for pediatric regional anesthesia. Given the lower toxic threshold of bupivacaine compared with other local anesthetics, the risk-benefit ratio of bupivacaine may be greater than that of other local anesthetics. Two new enantiomerically pure local anesthetics, ropivacaine and levobupivacaine, offer clinical profiles comparable to that of bupivacaine but without its lower toxic threshold. The extreme rarity of major toxicity from local anesthetics suggests that widespread replacement of bupivacaine with ropivacaine or levobupivacaine is probably not necessary. However, there are clinical situations, including prolonged local anesthetic infusions, use in neonates, impaired hepatic metabolic function, and anesthetic techniques requiring a large mass of local anesthetic, where replacement of bupivacaine with ropivacaine, levobupivacaine or (for continuous techniques) chloroprocaine appears prudent.

The caudal catheter in neonates: where are the restrictions?

PURPOSE OF REVIEW

In neonates, epidural catheters inserted at the sacral hiatus can easily be advanced to a lumbar or thoracic level. These 'caudal catheters' are popular because they allow the neonate to benefit from epidural analgesia without the concerns of spinal cord injury potentially associated with primary thoracic placement in an asleep neonate. This review looks at use and benefits, and risks and complications of caudal epidural catheters in neonates.

RECENT FINDINGS

Restrictions of neonatal caudal catheters are related to risks associated with placement and advancement of the catheters, infectious risks of caudal catheters, and toxicity risks related to the higher free fraction and lower clearance of bupivacaine in neonates. Caudal catheters in neonates are popular, but evidence that they improve outcome is lacking.

SUMMARY

Epidural anesthesia and analgesia for neonates should be performed and managed by pediatric anesthesiologists. Potential risks and complications must be appreciated and all steps to maximize safety of the technique must be taken. In particular, close postoperative observation and pain service management are indispensable. Future research should investigate the risks of caudal and segmentally placed catheters in neonates, study the role of epidural analgesia in outcome improvement for neonates, and guide us to safer use of local anesthetics suitable for neonates with their pharmacologic immaturity.

Caudal clonidine prolongs analgesia from caudal S(+)-ketamine in children

We performed a prospective randomized double-blinded study to test preservative-free S(+)-ketamine alone or in combination with clonidine for intra- and postoperative caudal blockade in pediatric surgery over a 24-h period. Fifty-three children (1-72 mo) scheduled for inguinal hernia repair were caudally injected with either S(+)-ketamine 1 mg/kg alone (Group K) or with additional clonidine (Group C1 = 1 microg/kg; Group C2 = 2 microg/kg) during sevoflurane anesthesia via a laryngeal mask. Intraoperative monitoring included heart rate, blood pressure, and pulse oximetry; postoperative monitoring included a pain discomfort scale and a sedation score. No additional analgesic drugs were required during surgery. The mean duration of postoperative analgesia was 13.3 +/- 9.2 h in Group K, 22.7 +/- 3.5 h in Group C1, and 21.8 +/- 5.2 h in Group C2 (P < 0.0001, Group K versus other groups). Groups C1 and C2 received significantly fewer analgesics in the postoperative period than Group K (15% and 18% vs 63%; P < 0.01). The three groups had similar postoperative sedation scores. We conclude that the combination of S(+)-ketamine 1 mg/kg with clonidine 1 or 2 microg/kg for caudal blockade in children provides excellent analgesia without side effects over a 24-h period.

IMPLICATIONS

Caudally administered preservative-free S(+)-ketamine combined with 1 or 2 microg/kg clonidine provides excellent perioperative analgesia in children and has minimal side effects.

Practical pediatric regional anesthesia

In children, regional anesthetic techniques are safe and effective adjuncts to general anesthesia and for postoperative pain relief. Application of the techniques described in this article will contribute to improved care for pediatric patients undergoing surgical procedures. The judicious choice of local anesthetics, along with the blockades of targeted nerves, decrease the need for supplemental analgesics in the recovery phase.