Applications of regional anaesthesia in paediatrics

Infraorbital nerve block for pain management in pediatric cleft lip surgery in resource-limited areas of Indonesia: A case series

INTRODUCTION AND IMPORTANCE

Cleft lip and palate (CLP) are congenital anomalies of the craniofacial region, commonly found in low- and middle-income countries, including Indonesia. Surgical correction of clefts typically begins at around three months of age to support infant growth. An infraorbital nerve block is an option for regional anesthesia in CLP surgery. This case series aims to determine the effectiveness of infraorbital nerve block in pain management for pediatric CLP surgery.

CASE PRESENTATION

This case series includes five patients who fulfilled the Millard criteria for CLP surgery. All patients received general anesthesia followed by an infraorbital nerve block with 0.2 % ropivacaine in the infraorbital foramen area using the intraoral approach. Data were collected preoperatively, intraoperatively, and postoperatively.

DISCUSSION

The combination of general anesthesia and infraorbital nerve block resulted in stable hemodynamics, low delirium scores, low pain intensity, and adequate oral intake postoperatively.

CONCLUSION

Infraorbital nerve block with ropivacaine provides intraoperative hemodynamic stability, decreased delirium, and effective postoperative pain management in pediatric patients undergoing CLP surgery.

The effect of local injection of bupivacaine with and without fentanyl at the operative site in mandibular open reduction on acute pain intensity and opioid requirement: a randomized clinical trial

PURPOSE

The aim of this study is to investigate the effects of bupivacaine local injection with and without fentanyl at the operative site in mandibular open reduction surgeries on the severity of acute pain and the need for opioids.

METHODS

This randomized clinical trial, age-sex-matched double-blind study included 44 patients with isolated mandibular fractures who would be candidates for open reduction. They were divided into two groups (intervention using fentanyl and control not using fentanyl). In both groups, the amount of opioid used, hemodynamic indices, oxygen saturation, and pain intensity were collected based on the Visual Analogue Scale (VAS) every 4 h for 24 h.

RESULTS

As for basic and demographic variables such as gender, age, ASA class, and duration of surgery (P > 0.05), there was neither a significant difference between the two groups nor was there any difference in nausea and vomiting and subsequent anti-nausea medication (P > 0.05). The need for a post-operative opioid in the bupivacaine + fentanyl group (13.6%) was significantly less than in those who received only bupivacaine (45.5%) (P < 0.05). Changes in pain scores over time were significantly different in the two groups, and bupivacaine + fentanyl reduced pain more than bupivacaine (P < 0.05). However, over time, there was no significant difference between the two groups in terms of changes in oxygen saturation, heart rate, systolic blood pressure, and diastolic blood pressure (P > 0.05).

CONCLUSION

The addition of fentanyl to bupivacaine for supraperiosteal injection in the open reduction surgery site reduces post-operative pain in the first 24 h and reduces the need for opioids without causing complications such as nausea and vomiting.

Reconsidering injection volume for caudal epidural block in young pediatric patients: a dynamic flow tracking experimental study

INTRODUCTION

Caudal epidural block is a commonly used analgesic technique in pediatric patients. Ultrasound could be used to increase the accuracy of the block by visual confirmation of the drug-spreading. Therefore, we aimed to estimate the cephalad spread of injection volume by caudal route using dynamic ultrasound imaging in young pediatric patients.

METHODS

Forty patients, aged 6-24 months, undergoing foot surgery were included. After inducing general anesthesia, an angiocatheter was inserted into the sacral canal under ultrasound guidance. Thereafter, the probe was placed in the paramedian sagittal oblique position, and prepared 0.15% ropivacaine was injected, 1 mL at a time, up to 1.0 mL.kg-1. The ultrasound probe was moved cranially following the bulk flow of local anesthetics. Our primary outcome was the required volume of local anesthetics to reach each level of interlaminar space.

RESULTS

The dynamic flow tracking was available in 39 patients, and the required volume of the injectate to reach L5-S1, L4-L5, L3-L4, L2-L3, L1-L2, T12-L1, and T11-T12 was 0.125, 0.223, 0.381, 0.591, 0.797, 0.960, and 1.050 mL.kg-1, respectively. The required volume to reach the immediate upper spinal level was inconsistent across various spinal levels.

CONCLUSIONS

Local anesthetics of 0.223, 0.591, and 0.797 mL.kg-1 could provide sufficient analgesia for localized foot, knee, and hip surgeries, respectively. However, since the required volume of the local anesthetics could not be calculated linearly, the real-time dynamic flow tracking technique for the caudal epidural block is recommended in young pediatric patients.

TRIAL REGISTRATIONS

ClinicalTrials.gov (NCT04039295).

Local anesthetic dosing and toxicity of pediatric truncal catheters: a narrative review of published practice

BACKGROUND/IMPORTANCE

Despite over 30 years of use by pediatric anesthesiologists, standardized dosing rates, dosing characteristics, and cases of toxicity of truncal nerve catheters are poorly described.

OBJECTIVE

We reviewed the literature to characterize dosing and toxicity of paravertebral and transversus abdominis plane catheters in children (less than 18 years).

EVIDENCE REVIEW

We searched for reports of ropivacaine or bupivacaine infusions in the paravertebral and transversus abdominis space intended for 24 hours or more of use in pediatric patients. We evaluated bolus dosing, infusion dosing, and cumulative 24-hour dosing in patients over and under 6 months. We also identified cases of local anesthetic systemic toxicity and toxic blood levels.

FINDINGS

Following screening, we extracted data from 46 papers with 945 patients.Bolus dosing was 2.5 mg/kg (median, range 0.6-5.0; n=466) and 1.25 mg/kg (median, range 0.5-2.5; n=294) for ropivacaine and bupivacaine, respectively. Infusion dosing was 0.5 mg/kg/hour (median, range 0.2-0.68; n=521) and 0.33 mg/kg/hour (median, range 0.1-1.0; n=423) for ropivacaine and bupivacaine, respectively, consistent with a dose equivalence of 1.5:1.0. A single case of toxicity was reported, and pharmacokinetic studies reported at least five cases with serum levels above the toxic threshold.

CONCLUSIONS

Bolus doses of bupivacaine and ropivacaine frequently comport with expert recommendations. Infusions in patients under 6 months used doses associated with toxicity and toxicity occurred at a rate consistent with single-shot blocks. Pediatric patients would benefit from specific recommendations about ropivacaine and bupivacaine dosing, including age-based dosing, breakthrough dosing, and intermittent bolus dosing.

A Systematic Review and Meta-Analysis Comparing the Effectiveness of Transversus Abdominis Plane Block and Caudal Block for Relief of Postoperative Pain in Children Who Underwent Lower Abdominal Surgeries

Background and Objectives: Postoperative pain after lower abdominal surgery is typically severe. Traditionally, in pediatric anesthesia, a caudal block (CB) has been used for pain management in these cases. Nowadays, a transversus abdominis plane block (TAPB) seems to be an effective alternative. However, which technique for perioperative analgesia is better and more effective remains unclear in children who undergo abdominal surgeries. The aim of this study was to compare the efficacy and safety of a TAPB and CB for pain management in children after abdominal surgery by conducting a meta-analysis of published papers in this area. Methods: We conducted a thorough search of PubMed, EMBASE, the Cochrane Library, and the Web of Science for randomized controlled trials (RCTs) that compared a TAPB and CB for pain management in children who had abdominal surgery. Two researchers screened and assessed all the information with RevMan5.3 used for this meta-analysis. Pain scores, the total dose of rescue analgesic given, the mean duration of analgesia, the intraoperative and postoperative hemodynamic conditions 24 h after surgery, and adverse events were compared. Results: 15 RCTs that involved a total of 970 pediatric patients were included in this study. The results of this meta-analysis showed that there were no significant differences between the 2 groups in terms of postoperative pain scores at 1 h (SMD = 0.35; 95% CI = -0.54 to 1.24; p = 0.44, I2 = 94%), 6 h (SMD = -0.10; 95% CI = -0.44 to -0.23; p = 0.55, I2 = 69%), 12 h (SMD = -0.02; 95% CI = -0.45 to -0.40; p = 0.93, I2 = 80%), and 24 h (SMD = -0.66; 95% CI = -1.57 to -0.25; p = 0.15, I2 = 94%); additional analgesic requirement (OR 0.25; 95% CI 0.09 to 0.63; p = 0.004, I2 = 72%); total dose of rescue analgesic given in 24 h (SMD = -0.37; 95% CI = -1.33 to -0.58; p = 0.44; I2 = 97%); mean duration of analgesia (SMD = 1.29; 95% CI = 0.01 to 2.57; p = 0.05, I2 = 98%); parents' satisfaction (SMD = 0.44; 95% CI = -0.12 to 1.0; p = 0.12; I2 = 80%); and intraoperative and postoperative hemodynamic conditions 24 h after the surgery and adverse events (SMD = 0.78; 95% CI = 0.22 to 2.82; p = 0.70; I2 = 62%). Compared to a CB, a TAPB resulted in a small but significant reduction in additional analgesic requirement after surgery (OR 0.25; 95% CI 0.09 to 0.63; p = 0.004). Conclusions: TAPBs and CBs result in similar efficient early analgesia and safety profiles in children undergoing abdominal surgeries. Moreover, no disparities were observed for adverse effects between TAPBs and CBs.

Effect of paediatric caudal injection volume on optic nerve sheath diameter and regional cerebral oximetry: A randomised trial

BACKGROUND

Caudal injections commonly used for neuraxial anaesthesia in children can displace cerebrospinal fluid cranially causing safety concerns in terms of raised intracranial pressure. Optic nerve sheath diameter (ONSD) is a noninvasive surrogate for the measurement of intracranial pressure. Regional cerebral oximetry (CrSO 2 ) can monitor brain oxygenation, which may decrease by a reduction in cerebral flow due to increased intracranial pressure.

OBJECTIVES

Comparing how caudal injection volumes of 0.8 and 1.25 ml kg -1 influence ONSD and CrSO 2 within the first 30 min after injection.

DESIGN

Prospective, randomised and parallel group trial.

SETTING

Operating room.

PATIENTS

Fifty-eight elective paediatric surgical patients between ages 1 and 7 years old, ASA class I or II, without previous intracranial or ocular pathology and surgery appropriate for single - shot caudal anaesthesia.

INTERVENTION

Single-shot caudal anaesthesia with 0.8 ml kg -1 (group L, n  = 29) and 1.25 ml kg -1 (group H, n  = 29) of 2 mg kg -1 bupivacaine solution.

MAIN OUTCOME MEASURES

Optic nerve sheath diameter measured with ultrasonography and regional cerebral oximetry measured by near - infrared spectroscopy before (NIRS), immediately after, 10, 20 and 30 min after the block.

RESULTS

Mean ONSD values increased from a baseline of 4.4 ± 0.2 mm to a maximum of 4.5 ± 0.2 mm 20 min after injection in group L and from a baseline of 4.5 ± 0.3 mm to a maximum of 4.8 ± 0.3 mm 10 min after injection in group H. Eight of 29 patients in group H and none in group L had an ONSD increase by more than 10%. Both groups had a reduction of less than 2.5% in CrSO 2 .

CONCLUSION

Caudal injection with 1.25 ml kg -1 increased ONSD, an indirect measurement of ICP, more than 0.8 ml kg -1 and neither volume caused a clinically important reduction in CrSO 2 .

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT04491032.

Infraclavicular block in children: Is blocking lateral or posterior cord equally successful?

Background and Aims

The most effective approach for infraclavicular brachial plexus block in adults is to target the posterior cord, usually situated posterior to axillary artery. However, we do not know if this can be extrapolated in children. Our primary objective was to compare the clinical success rate of ultrasound guided infraclavicular brachial plexus block in children with local anesthetic injection aimed at two targets. These were posterior to axillary artery (posterior cord) and lateral to axillary artery (lateral cord). The secondary objectives involved need for intraoperative rescue analgesia, evaluation of duration of analgesia, incidence of complications such as pneumothorax and arterial puncture, comparison of postoperative pain scores and fluoroscopic dye spread pattern was also observed.

Material and Methods

It was a randomized, prospective pilot study. Forty children undergoing forearm and hand surgeries were randomized to two groups, in accordance with the target site of the block. Target sites of Group P (20 patients) and Group L (20 patients) were posterior and lateral to the axillary artery, i.e., posterior and lateral cord respectively. Aforesaid objectives were assessed. SPSS (Version 15.0) statistical package was used. Comparison between Group L and P was by using student's unpaired t test for age and weight. Fisher's exact probability test was applied to compare percentages between groups.

Results

Blocks of both groups were equally successful. No patient required intraoperative rescue analgesia. Duration of analgesia was comparable. Both groups had no major complications and similar postoperative pain scores.

Conclusions

The success rate of infraclavicular brachial plexus block by aiming at the lateral and posterior cord was similar.

Comparison Between Ultrasound-guided Caudal Analgesia versus Peripheral Nerve Blocks for Lower Limb Surgeries in Pediatrics: A Randomized Controlled Prospective Study

Background and Aim

Ultrasound (US) guided regional analgesia is a safe and effective method in providing perioperative analgesia in pediatrics with a high success rate rapid onset and fewer side effects. The aim of this study was to compare the efficacy of US-guided caudal block versus US-guided peripheral nerve blocks (femoral and sciatic nerve blocks) in providing perioperative analgesia in pediatrics undergoing unilateral lower limb surgery.

Methods

Children aged 1–12 years scheduled for unilateral lower limb surgery during the period from January 2020 to December 2021 were randomly allocated into two groups. Group C where pediatrics received US-guided caudal block, while in group P, pediatrics received US-guided femoral and sciatic nerve blocks after the induction of general anesthesia (GA). The primary aim was to compare the postoperative pain (evaluated by the COMFORT pain score) between the two groups. Secondary aims were to compare perioperative opioids used parents’ satisfaction and occurrence of side effects.

Results

Pediatrics who underwent unilateral lower limb surgeries were allocated into two groups (group C and group P). There was no significant difference between patients’ baseline characteristics and the postoperative pain score at 2, 4, 16, and 20 h.’ However there was a statistical significance at 6, 8, 12, and 24 h postoperatively, frequency of analgesia as well as the total postoperative dose of opiates (nalbuphine). Time to first analgesic (nalbuphine) requirement was significantly less in group C with a mean of (9.6±2.9 h) than in group P with a mean of (15.1±3.5 h). Parents of children in group P were more satisfied than those in group C with no recorded complications for both techniques.

Conclusion

US-guided lower limb peripheral nerve block is a simple and safe method to provide adequate and more prolonged analgesia compared to US-guided caudal block for lower limb surgeries in pediatrics.

Elimination of postoperative narcotics in infant robotic pyeloplasty using caudal anesthesia and a non-narcotic pain pathway

INTRODUCTION

Research suggests that narcotic pain medications are dramatically overprescribed. We hypothesize that narcotics are unnecessary for post-operative pain control in most infants undergoing robotic pyeloplasty. In this series, we report our experience combining caudal blocks with a non-narcotic postoperative pathway as a means of eliminating postoperative narcotics following infant robotic pyeloplasty.

METHODS

We reviewed 24 consecutive patients who underwent robotic pyeloplasty by a single surgeon treated with an end-procedure caudal block followed by a non-narcotic postoperative pain pathway treated between May 2017 and May 2021. The standardized postoperative pathway consisted of an end-procedure caudal block followed by alternating intravenous acetaminophen and ketorolac. We reviewed demographics, outcomes and unscheduled healthcare encounters within 30 postoperative days.

RESULTS

63% (15/24) patients were male and average age was 12.1 months (range 4-34 months). 58% (9/15) underwent surgery on the left. 16.7% (4/24) of patients received a single postoperative dose of narcotics in the PACU. No patient required narcotic prescriptions at discharge or anytime thereafter. The average length of stay was 1.13 days. There was no pain-related, unscheduled visits or phone calls after discharge.

CONCLUSIONS

This series shows that a non-narcotic standardized pain management strategy is a viable option for infants undergoing robotic pyeloplasty. Post procedure caudal block is a good addition to a non-narcotic pathway. In the future, we intend to expand these findings to other pediatric urologic procedures in the hope of eliminating unnecessary narcotic use.

Ultrasound-guided transverse abdominis plane block, ilioinguinal/iliohypogastric nerve block, and quadratus lumborum block for elective open inguinal hernia repair in children: a randomized controlled trial

BACKGROUND AND OBJECTIVES

Ultrasound-guided ilioinguinal/iliohypogastric (II/IH) nerve blocks and transverse abdominis plane (TAP) blocks are widely used for postoperative analgesia in children undergoing inguinal hernia repair (IHR). Quadratus lumborum block (QLB) provides analgesia for both upper and lower abdominal surgery. Very few randomized controlled trials in children have assessed the efficacy of QLB in IHR. Thus, this study was designed to find the comparative effectiveness of QLB versus TAP and II/IH blocks in children undergoing open IHR.

MATERIALS AND METHODS

Sixty children scheduled for open IHR were randomly allocated in groups of 20 to receive either ultrasound-guided TAP block with 0.4 mL/kg of 0.25% ropivacaine, II/IH nerve block with 0.2 mL/kg of 0.25% ropivacaine, or QLB with 0.4 mL/kg of 0.25% ropivacaine. Anesthesia was standardized for all patients, and an experienced anesthesiologist performed the blocks after anesthesia induction.

PRIMARY OUTCOME

Time to first analgesia.

SECONDARY OUTCOMES

Postoperative pain scores, intraoperative and postoperative opioid consumption, cumulative paracetamol usage, block performance time, and block-related complications.

RESULTS

The median time to first analgesia was 360 (120), 480 (240), and 720 (240) min in the TAP block, II/IH block, and QLB groups, respectively; and was significantly longer in the QLB versus TAP (p<0.001) and II/IH (p<0.001) groups. The time to first analgesia was not significantly different between the TAP and II/IH groups (p=0.596). The mean postoperative tramadol consumption was 11 (12.7), 4 (7.16), and 3 (8) mg in the TAP, II/IH, and QLB groups, respectively (p=0.023); and it was lowest in the QLB group. No significant differences were found between the groups for other secondary outcomes.

CONCLUSIONS

QLB provides a prolonged period of analgesia and leads to decreased opioid consumption compared with TAP blocks and II/IH nerve blocks in children undergoing open IHR.

TRIAL REGISTRATION NUMBER

CTRI/2019/09/021377.

Ambulatory Pain Management in the Pediatric Patient Population

PURPOSE OF REVIEW

Outpatient surgery in the pediatric population has become increasingly common. However, many patients still experience moderate to severe postoperative pain. A poor understanding of the extent of pain after pediatric ambulatory surgery and the lack of randomized control studies of pain management of the outpatient necessitate this review of scientific evidence and multimodal analgesia.

RECENT FINDINGS

A multimodal approach to pain management should be applied to the ambulatory setting to decrease postoperative pain. These include non-pharmacological techniques, multimodal pharmacologics, and neuraxial and peripheral nerve blocks. Postoperative pain management in pediatric ambulatory surgical patients remains suboptimal at most centers due to limited evidence-based approach to postoperative pain control. Pediatric ambulatory pain management requires a multipronged approach to address this inadequacy.

Comparison of the postoperative analgesic effects of US-guided caudal block and US-guided pudendal nerve block in circumcision

AIM

To compare the postoperative analgesic efficacy and postoperative complications of the pudendal nerve block (PNB) and caudal block (CB) with ultrasound (US).

STUDY DESIGN

A prospective observational study.

METHODS

This study was included male patients aged between 4 and 12 years in the ASA I-II group and scheduled for circumcision. A low-dose CB or US-guided PNB was administered under general anaesthesia before the operation. Postoperative pain was evaluated using the Children's Hospital Eastern Ontario Pain Scale (CHEOPS) and Faces Pain Scale-Revised. Postoperative analgesic need was also noted.

RESULTS

The study was completed with a total of 100 patients consisting of 50 patients who received a CB and 50 who received a PNB. Intraoperative block failure was not seen in any patient. The mean CHEOPS score (P < .001) and the 6th (P = .003) and 12th hours (P < .001) CHEOPS scores were found to be statistically significantly higher in the CB group. There were no postoperative side effects in the PNB group with a statistically significant difference compared with the CB group (P = .027).

CONCLUSION

This first prospective study in the literature shows that US-guided PNB provided a more pronounced and longer analgesic effect and resulted in less requirement for postoperative analgesics than US-guided CB.

Evaluation of the Efficacy of Regional Anesthesia and Intramuscular Diclofenac in the Management of Postoperative Pain: A Comparative Study

Aim:

Managing postoperative pain following maxillofacial surgery is an important task. Our study aims to compare this with regional anesthesia or IM diclofenac.

Materials and Methods:

This study included 30 patients who underwent bi-jaw orthognathic surgery between April 2016 and January 2020. Two groups were formed. Group A was administered inferior alveolar nerve block at the surgical site bilaterally using 0.5% ropivacaine and Group B were administered 75 mg intramuscular diclofenac just before extubation. Tramadol HCl 2 mg/kg body wt is used as a rescue analgesic. The pain was evaluated periodically at 2^nd, 4^th, 6^th, and 12 h postoperatively.

Results:

The mean Visual Analog Scale score was 2 in Group A and 5 in Group B. The mean duration of analgesia was 6 h 42 min, whereas in Group B, it was 8 h and 5 min. In 2 patients (13.3%) belonging to Group A and 3 patients (20%) belonging to Group B. There were no local complications in any group.

Conclusion:

It was observed that regional anesthesia in the form of intraoral nerve blocks was efficient than diclofenac (75 mg) administered intramuscularly for the management of immediate postoperative pain.

The Role of Interfascial Plane Blocks in Paediatric Regional Anaesthesia: A Narrative Review of Current Perspectives and Updates

Regional anaesthesia has been increasingly used for analgesia in the perioperative period in paediatric anaesthesia for better pain control and improved patient outcomes. Interfascial plane blocks are considered as a subgroup of peripheral nerve blocks. The advent of ultrasound in modern regional anaesthesia practice has led to the evolution of various interfascial plane blocks. The ease of their performance and the low complication rates, compared with neuraxial anaesthesia, have led to their increased use in the perioperative period. Interfascial plane blocks are often incorporated in the multimodal analgesia regimen in the early recovery and ambulation after surgery protocols for various chest wall and abdominal surgeries. This achieves better pain control and decreases the requirements of opioids in the perioperative period, thereby facilitating early mobilization and discharge. This narrative review focuses on the relevant anatomic considerations, technique for the performance of each block along with its current applications and limitations, and includes a review of the current literature on various interfascial plane blocks in paediatric regional anaesthesia.

Identification of perineural cysts during ultrasound-guided caudal anaesthesia

An 8-year-old boy was scheduled for urethral fistula correction under general anaesthesia with an ultrasound-guided caudal block. During scanning of the caudal area, we noticed two cystic structures in the caudal space in the region of the intended needle endpoint so we decided against performing the caudal block. Surgery was conducted uneventfully and a penile block was administered as an alternative for analgesia postoperatively. Radiological evaluation of the child 3 weeks later revealed the presence of perineural cysts in the sacral region. Routine use of ultrasound for caudal anaesthesia procedures may reveal unexpected anomalies in the sacral area, which could have implications for optimal patient management.

[Effects of caudal block in pediatric surgical patients: a randomized clinical trial]

BACKGROUND

Surgery generates a neuroendocrine stress response, resulting in undesirable hemodynamic instability, alterations in metabolic response and malfunctioning of the immune system.

OBJECTIVES

The aim of this research was to determine the effectiveness of caudal blocks in intra- and postoperative pain management and in reducing the stress response in children during the same periods.

METHODS

This prospective, randomized clinical trial included 60 patients scheduled for elective herniorrhaphy. One group (n = 30) received general anesthesia and the other (n = 30) received general anesthesia with a caudal block. Hemodynamic parameters, drug consumption and pain intensity were measured. Blood samples for serum glucose and cortisol level were taken before anesthesia induction and after awakening the patient.

RESULTS

Children who received a caudal block had significantly lower serum glucose (p < 0.01), cortisol concentrations (p < 0.01) and pain scores 3 hours (p = 0.002) and 6 hours (p = 0.003) after the operation, greater hemodynamic stability and lower drug consumption. Also, there were no side effects or complications identified in that group.

CONCLUSIONS

The combination of caudal block with general anesthesia is a safe method that leads to less stress, greater hemodynamic stability, lower pain scores and lower consumption of medication.

Effects of caudal block in pediatric surgical patients: a randomized clinical trial

Background

Surgery generates a neuroendocrine stress response, resulting in undesirable hemodynamic instability, alterations in metabolic response and malfunctioning of the immune system.

Objectives

The aim of this research was to determine the effectiveness of caudal blocks in intra- and postoperative pain management and in reducing the stress response in children during the same periods.

Methods

This prospective, randomized clinical trial included 60 patients scheduled for elective herniorrhaphy. One group (n = 30) received general anesthesia and the other (n = 30) received general anesthesia with a caudal block. Hemodynamic parameters, drug consumption and pain intensity were measured. Blood samples for serum glucose and cortisol level were taken before anesthesia induction and after awakening the patient.

Results

Children who received a caudal block had significantly lower serum glucose (p <  0.01), cortisol concentrations (p <  0.01) and pain scores 3 h (p =  0.002) and 6 h (p =  0.003) after the operation, greater hemodynamic stability and lower drug consumption. Also, there were no side effects or complications identified in that group.

Conclusions

The combination of caudal block with general anesthesia is a safe method that leads to less stress, greater hemodynamic stability, lower pain scores and lower consumption of medication.

Evolving pediatric epidural practice: An institution's clinical experience over 20 years-A retrospective observational cohort study

BACKGROUND AND OBJECTIVES

Epidural analgesia is an effective, established perioperative intervention in all age-groups. In children, however, epidural-related data are limited compared to the adult population. The aim of this study was to examine the use of pediatric epidural analgesia in our institution and, thereby, add to the existing data pool.

METHODOLOGY

Patients who received epidural analgesia as part of their perioperative management between 1996 and 2016 at Great Ormond Street Hospital, London, UK, were studied to determine how epidural practice has changed over time, associated incidence of serious adverse events, complications, and patient/parent satisfaction. Epidural use and monitoring were in accordance with standard hospital protocols. Data were prospectively collected and entered into a secure database by trained personnel. These data were subsequently extracted for retrospective analysis.

RESULTS

A total of 3876 patients were included. The median age was 4.4 years (range 1 day to 20 years), and the median weight was 20.3 kg. Across all age-groups, the lumbar region was the most common site of epidural insertion while urology (42.2%) and general surgery (37.3%) were the specialities for which it was most utilized. Over the study period, the number of epidurals performed declined while the number of surgical procedures performed simultaneously increased. The infusate most commonly used was local anesthetic with preservative-free morphine (71.9%). In 923 (23.2%) patients, systemic opioids were additionally used for analgesic management by means of patient-controlled analgesia or nurse-controlled analgesia. There was one serious adverse event in the form of permanent nerve injury, giving an overall incidence of approximately 1:3800. Other complications included postoperative nausea and vomiting (35.9%), urinary retention (4.4%), and pruritus (31%). Overall global satisfaction with the service was generally high, with 95% providing a rating of "very good" or "good."

CONCLUSION

This study evaluated two decades of epidural practice in our institution. Epidural analgesia remains a safe, effective option for postoperative analgesia, but its use has declined over time, and this trend is likely to continue. Rates of serious adverse events and complications were low and comparable to those published in other similar studies. Global satisfaction among patients/parents remains high.

A Population Pharmacokinetic Model of Intravenous Dexmedetomidine for Mechanically Ventilated Children after Neurosurgery

Dexmedetomidine is a selective alpha-2 adrenergic agonist with concurrent sedative and analgesic effects, and it is being increasingly used in pediatric anesthesia and intensive care. This study aimed to investigate the pharmacokinetics of intravenous dexmedetomidine in mechanically ventilated children in the intensive care unit (ICU) after neurosurgery. Pediatric patients aged 2–12 years, who were mechanically ventilated in ICU after neurosurgery, were allocated into a low-dose (n = 15) or high-dose (n = 14) group. The low-dose group received dexmedetomidine at a loading dose of 0.25 µg/kg for 10 min, followed by a maintenance dose of 0.25 µg/kg/h for 50 min, whereas the high-dose group received dexmedetomidine at a loading dose of 0.5 µg/kg for 10 min, followed by a maintenance dose of 0.5 µg/kg/h for 50 min. Serial blood samples were collected for a pharmacokinetic analysis up to 480 min after the end of the infusion. The sedative effect of dexmedetomidine was assessed using the Bispectral Index and University of Michigan Sedation Scale. Adverse reactions, electrocardiography findings, and vital signs were monitored for a safety assessment. A population pharmacokinetic analysis was performed using non-linear mixed effects modeling. Dexmedetomidine induced a moderate-to-deep degree of sedation during infusion in both groups. The pharmacokinetics of dexmedetomidine were best described by a two-compartment disposition model with first-order elimination kinetics. The parameters were standardized for a body weight of 70 kg using an allometric power model. The population estimates (95% confidence interval) per 70 kg body weight were as follows: clearance of 81.0 (72.9–90.9) L/h, central volume of distribution of 64.2 (50.6–81.0) L, intercompartment clearance of 116.4 (90.6–156.0) L/h, and peripheral volume of distribution of 167 (132–217) L. No serious adverse reactions or hemodynamic changes requiring the discontinuation of dexmedetomidine were observed. Dexmedetomidine had increased clearance and volume of distribution in mechanically ventilated children in ICU after neurosurgery, thereby indicating the need to adjust the dosage to obtain a target plasma concentration.

Newer nerve blocks in pediatric surgery

PURPOSE OF THE REVIEW

The purpose of this manuscript is to provide a brief discussion of the current direction in pediatric regional anesthesia, highlighting both newer nerve blocks and techniques and traditional nerve blocks.

RECENT FINDINGS

The number of nerve blocks performed in pediatric patients continues to increase. This growth is likely related in part to the recent focus on perioperative multimodal analgesia, in addition to growing data demonstrating safety and efficacy in this patient population. Multiple studies by the Pediatric Regional Anesthesia Network (PRAN) and the French-Language Society of Pediatric Anesthesiologists (ADARPEF) have demonstrated lack of major complications and general overall safety with pediatric nerve blocks. The growing prevalence of ultrasound-guided regional anesthesia has not only improved the safety profile, but also increased the efficacy of both peripheral nerve blocks and perineural catheters.

SUMMARY

As the push for multimodal analgesia increases and the breadth of pediatric regional anesthesia continues to expand, further large prospective studies will be needed to demonstrate continued efficacy and overall safety.

Retrobulbar dexmedetomidine in pediatric vitreoretinal surgery eliminates the need for intraoperative fentanyl and postoperative analgesia: A randomized controlled study

Purpose

This study evaluated the efficacy of retrobulbar ropivacaine plus dexmedetomidine compared with systemic fentanyl in pediatric vitreoretinal (VR) surgery.

Methods

This prospective double-blind, randomized controlled study was performed in 60 children undergoing VR surgery, age from 2 to 7 years. After general anesthesia, the following procedure was administrated: (1) retrobulbar block with 0.5% ropivacaine plus dexmedetomidine 1 μg/kg (group RD, n = 20), (2) retrobulbar block with 0.5% ropivacaine (group RB, n = 20), and (3) control group with general anesthesia only (group F, n = 20). Hemodynamics, postoperative pain scores, anesthetics consumption (remifentanil, propofol, fentanyl), and emergence agitation were recorded.

Results

Respiratory depression was observed in 7 of the 20 patients in group F after the laryngeal mask airway was removed in the operating room, compared with none in groups RD and RB. All patients in group F required intraoperative rescue fentanyl (average intraoperative fentanyl consumption, 26.6 ± 12.6 μg per patient). Some rescue fentanyl was required in group RB (three patients required one dose of rescue fentanyl). Patients in group RD required none. Groups RD and RB reported lower pain scores than group F at 4 h postoperatively (RD group: P < 0.001; RB group: P =0.002); pain scores in group RD were lower than that in group F at 6 h postoperatively (P < 0.001).

Conclusion

Retrobulbar dexmedetomidine as an adjuvant to ropivacaine is a safe and effective alternative to systemic fentanyl. This regimen provides better pain management, hemodynamic stability, and stress response suppression in pediatric VR surgery.

Ultrasound-guided Lumbar Erector Spinae Plane Block For Postoperative Analgesia in Femur Fracture: A Pediatric Case Report

The erector spinae plane (ESP) block is a recently defined regional anesthesia technique which is considered as an effective method in postoperative multimodal analgesia. ESP block is usually performed at the thoracic region in pediatric patients, but it is also possible to perform ESP block at the lumbar region. Femur fracture is one of the most common procedures especially in pediatric orthopedic surgery where postoperative pain management is essential. We aim to present a case of effective postoperative analgesia provided by ultrasound-guided lumbar ESP block in a 6-year-old patient after femur fixation surgery.

Getting to know a familiar face: Current and emerging focused ultrasound applications for the perioperative setting

Ultrasound technology is available in many pediatric perioperative settings. There is an increasing number of ultrasound applications for anesthesiologists which may enhance clinical performance, procedural safety, and patient outcomes. This review highlights the literature and experience supporting focused ultrasound applications in the pediatric perioperative setting across varied disciplines including anesthesiology. The review also suggests strategies for building educational and infrastructural systems to translate this technology into clinical practice.

Caudal epidural blocks in paediatric patients: a review and practical considerations

Caudal epidural blockade in children is one of the most widely administered techniques of regional anaesthesia. Recent clinical studies have answered major pharmacodynamic and pharmacokinetic questions, thus providing the scientific background for safe and effective blocks in daily clinical practice and demonstrating that patient selection can be expanded to range from extreme preterm births up to 50 kg of body weight. This narrative review discusses the main findings in the current literature with regard to patient selection (sub-umbilical vs mid-abdominal indications, contraindications, low-risk patients with spinal anomalies); anatomical considerations (access problems, age and body positioning, palpation for needle insertion); technical considerations (verification of needle position by ultrasound vs landmarks vs 'whoosh' or 'swoosh' testing); training and equipment requirements (learning curve, needle types, risk of tissue spreading); complications and safety (paediatric regional anaesthesia, caudal blocks); local anaesthetics (bupivacaine vs ropivacaine, risk of toxicity in children, management of toxic events); adjuvant drugs (clonidine, dexmedetomidine, opioids, ketamine); volume dosing (dermatomal reach, cranial rebound); caudally accessed lumbar or thoracic anaesthesia (contamination risk, verifying catheter placement); and postoperative pain. Caudal blocks are an efficient way to offer perioperative analgesia for painful sub-umbilical interventions. Performed on sedated children, they enable not only early ambulation, but also periprocedural haemodynamic stability and spontaneous breathing in patient groups at maximum risk of a difficult airway. These are important advantages over general anaesthesia, notably in preterm babies and in children with cardiopulmonary co-morbidities. Compared with other techniques of regional anaesthesia, a case for caudal blocks can still be made.

Recent trends in paediatric regional anaesthesia

Paediatric regional anaesthesia today is one of the fastest growing and exciting aspects of paediatric anaesthesia, which requires an ongoing fervour to learn. Application of paediatric regional anaesthesia in neonates, infants, toddlers and children is undertaken to treat perioperative pain without disturbing the physiological milieu with additional advantages elaborated in the review. The available choices, traditional methods and the most recently described methods are discussed with emphasis on their advantages and disadvantages. Clear pointers for selection of the blocks are also discussed. To present a holistic overview of this rapidly growing subject, a comprehensive literature search was performed in May 2019 in MEDLINE, PubMed and Google Scholar to retrieve articles pertaining to all the above topics. The keywords used in various combinations included 'Central neuraxial, blocks, Paediatric(s)', 'Peripheral Nerve blocks', 'Safety, controversies, regional, anaesthesia'.

Regional anesthesia to ameliorate postoperative analgesia outcomes in pediatric surgical patients: an updated systematic review of randomized controlled trials

Regional anesthesia is becoming increasingly popular among anesthesiologists in the management of postoperative analgesia following pediatric surgery. The main objective of this review was to systematically evaluate the last 5 years of randomized controlled trials on the role of regional anesthesia techniques in alleviating postoperative pain associated with various pediatric surgical procedures. Forty studies on 2,408 pediatric patients were evaluated. The majority of the articles published from 2013 to 2017 reported that the use of regional anesthesia minimized postoperative pain and reduced opioid consumption. Only a few surgical procedures (cholecystectomy, inguinal hernia repair, and non-laparoscopic major abdominal surgery) reported no significant difference in the postoperative pain relief compared with the standard anesthetic management. The growing number of randomized controlled trials in the pediatric literature is very promising; however, additional confirmation is needed to reinforce the use of specific regional anesthesia techniques to provide optimal postoperative pain relief for a few surgical procedures (reconstructive ear surgery, chest wall deformity, hypospadias, umbilical hernia, cleft palate repair) in pediatric patients. More randomized controlled trials are needed to establish regional anesthesia as an essential component of postoperative analgesia management in children.

Retrobulbar Block in Pediatric Vitreoretinal Surgery Eliminates the Need for Intraoperative Fentanyl and Postoperative Analgesia: A Randomized Controlled Study

BACKGROUND AND OBJECTIVES

Pediatric ophthalmologic surgery is traditionally accomplished by general anesthesia with opioids, but respiratory depression remains a major concern. Our study compared the efficacy of retrobulbar block with systemic fentanyl on pain, hemodynamic, and stress response in pediatric vitreoretinal surgery.

METHODS

A prospective double-blind, randomized controlled study was performed comparing retrobulbar block with intravenously administered fentanyl in 28 children aged 1 to 6 years undergoing vitreoretinal surgery. After general anesthesia was induced, retrobulbar block with 0.5% ropivacaine was accomplished in group RB (general anesthesia plus retrobulbar block) (n = 13), and normal saline was injected into retrobulbar space in group F (general anesthesia alone) (n = 15). Fentanyl 0.5 μg/kg was administered when signs of inadequate anesthesia were observed.

RESULTS

Respiratory depression (defined as a persistent respiratory rate <10 breaths/min or persistent oxygen desaturation <92%) was observed in 5 of 15 patients in group F after laryngeal mask airway was removed in the operating room, compared with none in group RB. All children in group F consumed intraoperative fentanyl rescue (average intraoperative fentanyl consumption, 1.3 ± 0.3 μg/kg) compared with none in group RB. Pain scores assessed with Faces, Legs, Activity, Cry and Consolability were significantly lower in group RB than in group F (1 [0, 3.5] vs 5 [3, 7], P = 0.003) immediately after laryngeal mask airway removal. Heart rate in group RB was significantly lower than that in group F before anesthesia induction, at the beginning and end of surgery, respectively. Mean blood pressure in group RB was significantly lower than that in group F at the beginning of surgery. Postoperative tumor necrosis factor α concentration in group RB was significantly lower than that in group F.

CONCLUSIONS

Retrobulbar block is safe and effective as an alternative to systemic fentanyl and could provide better pain management, hemodynamic suppression, and stress response suppression in pediatric vitreoretinal surgery.

Regional anesthetics: traditions and innovations

The wide implementation of different regional anesthesia techniques is also actual in pediatric anesthesiology. Using modern methods of regional anesthesia (RA) and modern local anesthetics is a new level in development of pediatric anesthesiology. This article is about advantages of regional pediatric anesthesia in intra- and post-surgery pain management and analgesia. We analyse the techniques of spinal and epidural anesthesia, as well as their varieties such as unipolar spinal block and caudal anesthesia, compare their advantages and disadvantages. Some more techniques such as paravertebral block, TAP-block are considered as an alternative to epidural anesthesia. Methods and possibilities of ilioinguinal, iliohypogastric and TAP-blocks are also mentioned here. The use of the above-mentioned methods allows to reduce the use of narcotic analgesics and hypnotics and, as a consequence, reduces their systemic effects on the child’s body. These methods are safer for use, since they allow you to plan a safe anesthetic for each child and minimize complications.

Persistent pain following common outpatient surgeries in children: A multicenter study in Italy

INTRODUCTION

The prevalence of persistent postsurgical pain in children is over 20% after major surgeries; however, data are scarce on the prevalence, character, and risk factors among children undergoing common ambulatory surgeries. The primary aim of this study was to evaluate the prevalence of persistent pain following pediatric ambulatory surgery at 1, 3, and 6 months. Secondary aims were to identify risk factors and characterize the pain and consequences of persistent postsurgical pain.

METHODS

ASA I-II, ages 1 month to 16 years old, undergoing elective hypospadias repair, herniorraphy, orchiopexy, and orthopedic surgery were enrolled in a prospective, longitudinal, observational study at 3 pediatric centers in Italy. All patients received general plus regional anesthesia. Postoperative pain was evaluated using age appropriate pain scales at 1 and 3 hours. At 1, 3, and 6 months, pain scores were obtained and Parent's Postoperative Pain Measures (<8 yo) and Child Activity Limitations Interview (>8 yo) surveys were administered.

RESULTS

About 350 patients completed the study. The prevalence of pain at 1, 3, and 6 months was 24% (84/350), 6.0% (21/350), and 4.0% (14/350), respectively. Inguinal herniorraphy patients experienced significantly higher pain at all 3-time points; 35.6%, 14.9%, and 9.2%. There was no significant association between mean pain scores >4 in PACU and persistent pain. Pain persisting at 6 months had neuropathic characteristics and frequently interfered with daily activities and sleep.

CONCLUSION

Our data support the presence of persistent pain in pediatric patients after common surgeries. Most patients who developed persistent pain at 6 months had pain at 1 month. We recommend questioning at follow-up visit about persistent pain and functional impairment with follow-up until resolution.

Comparison of Intraoperative and Early Postoperative Outcomes of Caudal vs Dorsal Penile Nerve Blocks for Outpatient Penile Surgeries

OBJECTIVE

To compare intraoperative and 1-hour postoperative outcomes in caudal vs dorsal penile nerve block (DPNB) patients undergoing penile surgeries.

MATERIALS AND METHODS

We performed a retrospective cohort study of boys <10 years old undergoing penile procedures (2013-2015) using the Pediatric Regional Anesthesia Network, Pediatric Health Information System databases, and our medical records. The primary outcome was a maximum Faces Limbs Activity Crying Consolability pain score of >3. Secondary outcomes were intraoperative-postanesthesia care unit (PACU) narcotics, preincision anesthesia time, adjusted operating room charges, and complications. We performed bivariate and multivariable analyses controlling for demographic and procedural characteristics and clustering by surgeon.

RESULTS

Of 738 patients (mean age 2.1 years), 74.1% had a caudal block. DPNB patients were more likely to have a maximum pain score of >3 (19.5% vs 8.1%, P <.0001), receive intraoperative (33.0% vs 2.9%, P <.0001) and PACU (15.7% vs 7.5%, P = .0009) narcotics, and had shorter preincision anesthesia times (19.5 vs 27.9 minutes, P <.0001) and lower adjusted operating room charges ($9,402 vs $12,760, P <.0001). In a bivariate logistic regression, DPNB patients had 2.7 times the odds of a maximum pain score of >3 (95% confidence interval 1.7-4.4, P <.0001) and 5.2 times the odds of intraoperative and PACU narcotic administration (95% confidence interval 3.3-8.1, P <.0001). In multivariable analyses, caudal patients had longer preincision anesthesia times (27.9 ± 7.4 vs 19.5 ± 6.6 minutes, P <.0001) and higher adjusted operating room charges ($12,760 ± 4077 vs $9,402 ± 3741, P = .01).

CONCLUSION

Caudal blocks may offer a small advantage in the immediate postoperative period, although cost-effectiveness is unproven.

Two Cases of Duchenne Muscular Dystrophy That Showed Different Reactions to Nerve Stimulation During Peripheral Nerve Block: A Case Report

In recent years, the technique of combined ultrasound and electrical stimulation-guided nerve block has been recommended. We present 2 patients with Duchenne muscular dystrophy who exhibited different muscle responses to nerve stimulation during the performance of peripheral nerve blocks for surgeries. Whereas a 2-year-old boy without severe disability showed the expected muscle contraction to electrical nerve stimulation, a 14-year-old boy with severe disability showed no muscle response. Our experience suggests that muscle responses to electrical nerve stimulation will vary with the stage of Duchenne muscular dystrophy.

Awake caudal anaesthesia in neonates/young infants for improved patient safety

Caudal epidural block in a conscious infant is a recognised technique that allows the avoidance of general anaesthesia and risks associated with it. It is also technically easier to perform reliably compared with an awake subarachnoid block in skilled hands.1 While local anaesthetic systemic toxicity is a rare complication of caudal anaesthesia, this case illustrates the potential for caudal anaesthesia done awake in enhancing patient safety through early recognition of local anaesthetic systemic toxicity.

Topical versus caudal ketamine/bupivacaine combination for postoperative analgesia in children undergoing inguinal herniotomy

Background:

Multiple studies claim that caudal administration of ketamine causes effective postoperative analgesia. The aim of this study was to assess the clinical effectiveness of ketamine after caudal or topical administration in pediatric patients undergoing inguinal herniotomy.

Patients and Methods:

This randomized, comparative, double-blind study included eighty children (aged 6 months to 6 years) received either 1 ml/kg of 0.25% bupivacaine/ketamine 0.5 mg/kg for caudal analgesia (caudal group) or 0.3 ml/kg of 0.25% bupivacaine/ketamine 0.5 mg/kg sprayed by the surgeon around the spermatic cord and upon the ilioinguinal nerve before wound closure for topical analgesia (topical group). The duration of postoperative analgesia, pain scores, rescue analgesic consumption, sedation score, hemodynamic monitoring, and side-effects were evaluated 48 h postoperative.

Results:

Kaplan–Meier survival analysis of analgesia free time demonstrated a significant advantage of topical ketamine (TK) group over caudal ketamine (CK) group. The duration of postoperative analgesia was longer in TK group than in CK group (28.74 ± 2.88 vs. 21.43 ± 5.01 h, P = 0.000). Fewer children asked for oral analgesics in the topical group (24 of 36, 66.7%) than in the caudal one (28 of 32, 87.5%; P < 0.01). Postoperative pain scores at the 6^th till 48^th h were lower in topical group with comparable analgesic consumption between two groups. In the caudal group, four subjects suffered from retention of urine: Two presented with a residual motor block and two had photophobia.

Conclusion:

Wound instillation of bupivacaine/ketamine is a simple, noninvasive, and effective technique that could be a safe alternative to CK for postoperative analgesia in children undergoing inguinal hernia repair.

Role of Anesthesiologist in the Management of a Child with Cerebral Palsy

Cerebral palsy (CP) refers to a spectrum of nonprogressive neurological disorders with disturbances in posture and movement, resulting from perinatal intrauterine insult to developing infant brain. Many conditions associated with CP require surgery. Such cases pose important gastrointestinal, respiratory, and other perioperative considerations. Anesthetic management in these cases is delicate. Intraoperative complications including hypovolemia, hypothermia, muscle spasms, seizures, and delayed recovery might complicate the anesthetic management. A thorough preanesthetic evaluation allows for a better intra- and post-operative care. Postoperative analgesia is important, particularly in orthopedic surgeries one for pain relief. This review highlights the clinical manifestations in CP and anesthetic considerations in such child presenting for various surgeries.

The role of ultrasound guidance in pediatric caudal block

Objectives:

To compare the time interval of the procedure, possible complications, post-operative pain levels, additional analgesics, and nurse satisfaction in ultrasonography-guided and standard caudal block applications.

Methods:

This retrospective study was conducted in Celal Bayar University Hospital, Manisa, Turkey, between January and December 2014, included 78 pediatric patients. Caudal block was applied to 2 different groups; one with ultrasound guide, and the other using the standard method.

Results:

The time interval of the procedure was significantly shorter in the standard application group compared with ultrasound-guided group (p=0.020). Wong-Baker FACES Pain Rating Scale values obtained at the 90th minute was statistically lower in the standard application group compared with ultrasound-guided group (p=0.035). No statistically significant difference was found on the other parameters between the 2 groups. The shorter time interval of the procedure at standard application group should not be considered as a distinctive mark by the pediatric anesthesiologists, because this time difference was as short as seconds.

Conclusion:

Ultrasound guidance for caudal block applications would neither increase nor decrease the success of the treatment. However, ultrasound guidance should be needed in cases where the detection of sacral anatomy is difficult, especially by palpations.

Dose effect of local anesthetics on analgesic outcomes for the transversus abdominis plane (TAP) block in children: a randomized, double-blinded, clinical trial

BACKGROUND

Current knowledge on local anesthetic dosage for the TAP block in pediatric patients is very limited.

OBJECTIVE

To evaluate the effect of two escalating local anesthetic doses on postsurgical analgesic outcomes in children receiving a TAP block.

METHODS

The study was a prospective, randomized, double-blinded, clinical trial. Children (<8 years) were randomized to one of the two intervention groups: TAP block with bupivacaine at a dose of 2.5 mg · kg(-1) or 1.25 mg · kg(-1). Analgesic outcomes included pain scores in the postanesthesia care unit (PACU), time to analgesic requirement and total number of analgesic requirements.

RESULTS

Thirty-six patients were recruited in the study. Pain scores in PACU were not different between study groups. The total number of analgesic dosage required in 24 h after surgery was higher in the lower dose group, median (IQR) of 4 (3 to 5) compared to 2.5 (1.5 to 3) in the greater dose group, P = 0.03. There was a clinically but not statistically significant difference in the time to first analgesic requirement in the 2.5 mg · kg(-1) group, median (IQR) of 248 (130 to 367) minutes compared to 146 (95 to 261) minutes in the 1.25 mg · kg(-1) dose group, P = 0.15.

CONCLUSIONS

The use of higher local anesthetic doses for the TAP block in children does not provide benefits on early pain scores but seems to improve analgesic duration and decrease the need for additional analgesics over 24 h after surgery. The use of higher, but yet safe, local anesthetic dosages for TAP blocks is a viable strategy to improve analgesia in children.

Spinal anaesthesia for orthopaedic surgery in children with cerebral palsy: Analysis of 36 patients

BACKGROUND AND OBJECTIVE

Cerebral palsy is one of the most common childhood neuromuscular diseases in the world. Spinal anaesthesia in children is an evolving technique with many advantages in perioperative management. The aim of this retrospective study was to provide first-hand reports of children with cerebral palsy who underwent orthopaedic surgery under spinal anaesthesia.

METHODS

Records of the children with cerebral palsy who underwent orthopaedic surgery under spinal anaesthesia between May 2012 and June 2013 at Selcuk University Hospital were investigated. In all patients, lumbar puncture was performed in lateral decubitus position with mask sevoflurane-nitrous oxide anaesthesia. In patients who were calm prior the spinal block, inhalation anaesthesia was terminated. In patients who were restless before the spinal block, anaesthesia was combined with light sevoflurane anaesthesia and a laryngeal mask. From anaesthesia records, the number of attempts required to complete the lumbar puncture, and the success rates of spinal anaesthesia and perioperative complications were noted. Data were expressed as numbers and percentages.

RESULTS

The study included 36 patients (20 girls and 16 boys). The mean age was 71 months. The rate of reaching subarachnoid space on first attempt was 86%. In all patients, spinal anaesthesia was considered successful. In 26 patients, laryngeal mask and light sevoflurane anaesthesia were required to maintain ideal surgical conditions. No major perioperative complications were observed.

CONCLUSION

Spinal anaesthesia alone or combined with light sevoflurane anaesthesia is a reliable technique with high success rates in children with cerebral palsy undergoing orthopaedic surgery.

A systematic review and meta-analysis of caudal block as compared to noncaudal regional techniques for inguinal surgeries in children

This systematic review and meta-analysis were designed to compare the analgesic effectiveness and adverse effects with the use of caudal analgesia as compared to noncaudal regional analgesia techniques in children undergoing inguinal surgeries. MEDLINE, EMBASE, and CENTRAL (Cochrane) databases were searched for randomized control trials published in English language from 1946 up to 2013. Use of rescue analgesia and adverse effects were considered as primary and secondary outcomes, respectively. Outcomes were pooled using random effects model and reported as risk ratio (RR) with 95% CI. Out of 3240 hits and 24 reports for final selection, 17 were included in this review. Caudal analgesia was found to be better in both early (RR = 0.81 [0.66, 0.99], P = 0.04) and late (RR = 0.81 [0.69, 0.96], P = 0.01) periods, but with a significant risk of motor block and urinary retention. According to GRADE, the quality of evidence was moderate. Although potentially superior, caudal analgesia increases the chance of motor block and urinary retention. There are limited studies to demonstrate that the technical superiority using ultrasound translates into better clinical success with the inguinal nerve blocks.