Practice advisory on the prevention and management of complications of pediatric regional anesthesia.

STUDY OBJECTIVES: To develop evidence-based recommendations for prevention and management of infections, bleeding, and local anesthetic toxicity in children undergoing regional anesthesia. DESIGN: A joint committee of the European Society of Regional Anesthesia and Pain Therapy (ESRA) and the American Society of Regional Anesthesia and Pain Medicine (ASRA) studied electronic literature databases of pediatric regional anesthesia to construct evidence-based recommendations. MAIN RESULTS: For epidural anesthesia lumbar or thoracic placement is preferred. Skin preparation prior to block placement with chlorhexidine is preferred to povidone iodine. A tunneled catheter technique is suggested when using the caudal route or if the epidural catheter placement is kept in situ for more than 3 days. Inspection of the epidural catheter insertion site should be performed at least once a day as part of the postoperative management. When medical and physical examination is normal, coagulation tests are usually unnecessary but if coagulation tests are abnormal, neuraxial and deep peripheral nerve blocks are contraindicated. For patients receiving Low Molecular Weight Heparin thromboprophylaxis, a safety interval of two half-lives plus the time required for heparin to reach maximal levels is considered an adequate compromise between bleeding risk and thrombosis risk when removing epidural catheters. Ultrasound-guided peripheral nerve blocks reduce the risk of vascular puncture and thus the risk of local anesthetic toxicity is reduced. CONCLUSIONS: In children undergoing regional anesthesia the incidence of infection, hematoma, and local anesthetic toxicity is low. The ASRA/ESRA joint committee proposes a practice advisory to prevent and treat these complications.

The value of Tuffier's line for neonatal neuraxial procedures.

The spine of L4 usually lies on a line drawn between the highest points of the iliac crests (Tuffier's line) in adults. Although its accuracy has been questioned, it is still commonly used to identify the spinous process of the 4th lumbar vertebra before performing lumbar neuraxial procedures. In children, this line is said to cross the midline at the level of L5. A literature search revealed that the description this surface anatomical line is vague in neonates. The aims of this study were to determine the vertebral level of Tuffier's line, as well as its distance from the apex of the sacrococcygeal membrane (ASM), in 39 neonatal cadavers in both a prone and flexed position. It was found that when flexed, Tuffier's line shifted from the level of L4/L5 (prone position) to the upper third of L5. The mean distance from the ASM to Tuffier's line was 23.64mm when prone and 25.47 mm when flexed, constituting a statistically significant increase in the distance (P=0.0061). Therefore, in the absence of advanced imaging modalities, Tuffier's line provides practitioners with a simple method of determining a level caudal to the termination of the spinal cord, at approximately the L4/L5 in a prone neonate and the upper margins of L5 when flexed.

Regional anaesthesia for cleft lip surgery in a developing world setting.

BACKGROUND: The role of regional anaesthesia in cleft lip surgery in the developing world is not well documented. METHOD: A retrospective chart review of 100 patients aged >14 years who had cleft lip surgery during an Operation Smile South Africa (OSSA) volunteer surgical programme in Madagascar during 2007 and 2008. The nerve blocks used included a bilateral infraorbital nerve block, a dorsalnasal nerve block and a septal block supplemented with peri-incisional local in_ltration. Appropriateness of the regional anaesthesia alone for cleft lip surgery was determined by absence of any intraoperative complications, postoperative complications or conversions to general anaesthesia. RESULTS: Seventy-four patients commenced their operation under regional anaesthesia. There were no intraoperative or postoperative complications documented, and no patient required conversion to general anaesthesia. Two patients required additional analgesia in the immediate postoperative period. CONCLUSION: Regional anaesthesia for cleft lip surgery in patients >14 years of age was well tolerated and associated with few complications. It is a safe and effective option when used as the sole anaesthetic modality for cheiloplasty in the developing world.

Improving surgical safety globally: pulse oximetry and the WHO Guidelines for Safe Surgery.

Access to safe surgery should be considered as part of the basic human right for health, but unfortunately, this ideal is far from being reached in many low-income countries. Pulse oximetry is recommended as a minimum standard of monitoring by all anesthesia organizations that have set standards, yet around 78,000 operating theaters worldwide lack this essential monitor. The WHO Safe Surgery Saves Lives Program has identified evidence-based guidelines for safe surgery that are applicable in any setting, and the Global Pulse Oximetry Program will help improve access to pulse oximetry in countries where it is not available. However, these initiatives are just a start; capacity, infrastructure, trained healthcare providers and access to essential drugs, and equipment for anesthesia and surgery need to become a public health priority in many low-income countries.

Paediatric anaesthesia in developing countries.

Each year millions of children undergo surgery in the developing world with inadequate facilities, equipment and drugs. In many hospitals, anaesthesia is largely dependent on the availability of ketamine. Application of well-established clinical techniques, particularly for postoperative pain control, would relieve unnecessary suffering in children. Improvements in peri-operative care are required by investment in health systems and training.

Meningococcal septicaemia complications involving skin and underlying deeper tissues--management considerations and outcome.

OBJECTIVE: To describe surgical experience with purpura fulminans related to meningococcaemia in a single institution, and to suggest a management protocol. METHODS: A retrospective review was done of patients admitted to the intensive care unit at Red Cross War Memorial Children's Hospital in Cape Town with the clinical diagnosis of purpura fulminans. RESULTS: During a 28-year period (1977-2005) 112 children (average age 3.4 years) were treated for meningococcaemia with purpura fulminans. Overall mortality was 10.7%. Local treatment consisted of measures to improve circulation, infection control and healing of necrotic tissue. Demarcation of necrotic areas was evident at 5.5 days and the average area of skin necrosis was 14% total body surface area (range 2-85%). The lower limbs were predominantly affected. Purpura fulminans resolved in 35 children (31.2%) without skin necrosis. Skin grafting was required in 77 children (68.8%). Factors associated with a poor outcome for peripheral extremity salvage were progressive irreversible skin changes, early disappearance of distal pulses, tense cold swollen extremities and intense pain on passive movement of the affected extremity. Amputations were performed proximal to the area of necrosis, on average 27 days after injury. CONCLUSIONS: Meningococcaemia is a disease with potentially devastating consequences. Early surgical consultation is essential. Skin- and soft-tissue-releasing incisions should be considered early to reduce the incidence of extremity necrosis. Small necrotic areas usually separate spontaneously with secondary healing or can be excised and sutured. Larger necrotic areas should be excised only after demarcation has been established, and can be covered with delayed skin grafting. Amputation should be conservative but may require revision.

Ultrasonographic guidance for sciatic and femoral nerve blocks in children.

BACKGROUND: Recent studies have shown that ultrasound guidance for paediatric regional anaesthesia can improve the quality of upper extremity and neuraxial blocks. We therefore investigated whether ultrasound guidance for sciatic and femoral nerve blocks prolongs sensory blockade in comparison with nerve stimulator guidance in children. METHODS: Forty-six children scheduled for surgery of one lower extremity were randomized to receive a sciatic and femoral nerve block under either ultrasound or nerve stimulator guidance. After induction of general anaesthesia, the blocks were performed using an ultrasound-guided multiple injection technique until the nerves were surrounded by levobupivacaine, or by nerve stimulator guidance using a predefined dose of 0.3 ml kg(-1) of levobupivacaine. An increase in heart rate of more than 15% of baseline during surgery defined a failed block. The duration of the block was determined from the injection of local anaesthetic to the time when the patient received the first postoperative analgesic. RESULTS: Two blocks in the nerve stimulator group failed. There were no failures in the ultrasound group. The duration of analgesia was longer in the ultrasound group mean (sd) 508 (178) vs 335 (169) min (P < 0.05). The volume of local anaesthetic in sciatic and femoral nerve blocks was reduced with ultrasound compared with nerve stimulator guidance [0.2 (0.06) vs 0.3 ml kg(-1) (P < 0.001) and 0.15 (0.04) vs 0.3 ml kg(-1) (P < 0.001), respectively]. CONCLUSIONS: Ultrasound guidance for sciatic and femoral nerve blocks in children increased the duration of sensory blockade in comparison with nerve stimulator guidance. Prolonged sensory blockade was achieved with smaller volumes of local anaesthetic when using ultrasound guidance.

Ultrasonography-guided rectus sheath block in paediatric anaesthesia--a new approach to an old technique.

BACKGROUND: The purpose of this study was an anatomical and clinical evaluation of ultrasonography-guided rectus sheath blocks in children. METHOD: A total of 30 children were included in the sono-anatomical part of the study. The depth of the anterior and posterior rectus sheath was evaluated with a portable SonSite 180 plus ultrasound machine and a 5-10 MHz linear probe. In total, 20 consecutive children undergoing umbilical hernia repair were included in the clinical part of this study. After induction of general anaesthesia children received a rectus sheath block under real-time ultrasonographic guidance by placing 0.1 ml kg(-1) bilaterally in the space between the posterior aspect of the sheath and the rectus abdominis muscle. RESULTS: Ultrasonographic visualization of the posterior rectus sheath was possible in all children. The correlation between the depth of the posterior rectus sheath and weight (adjusted r(2)=0.175), height (adjusted r(2)=0.314) and body surface area (adjusted r(2)=0.241) was poor. The ultrasound-guided rectus sheath blockade provided sufficient analgesia in all children with no need for additional analgesia in the perioperative period. CONCLUSION: The bilateral placement of levobupivacaine 0.25% 0.1 ml kg(-1) in the space between the posterior aspect of the rectus sheath and the rectus abdominis muscle under real-time ultrasonographic guidance provides sufficient analgesia for umbilical hernia repair. The unpredictable depth of the posterior rectus sheath in children is a good argument for the use of ultrasonography in this regional anaesthetic technique in children.

Ultrasonographic-guided ilioinguinal/iliohypogastric nerve block in pediatric anesthesia: what is the optimal volume?

Recently, our study group demonstrated the usefulness of ultrasonographic guidance in ilioinguinal/iliohypogastric nerve blocks in children. As a consequence, we designed a follow-up study to evaluate the optimal volume of local anesthetic for this regional anesthetic technique. Using a modified step-up-step-down approach, with 10 children in each study group, a starting dose of 0.2 mL/kg of 0.25% levobupivacaine was administered to perform an ilioinguinal/iliohypogastric nerve block under ultrasonographic guidance. After each group of 10 patients, the results were analyzed, and if all blocks were successful, the volume of local anesthetic was decreased by 50%, and a further 10 patients were enrolled into the study. Failure to achieve a 100% success rate within a group subjected patients to an automatic increase of half the previous volume reduction to be used in the subsequent group. Using 0.2 and 0.1 mL/kg of 0.25% levobupivacaine, the success rate was 100%. With a volume of 0.05 mL/kg of 0.25% levobupivacaine, 4 of 10 children received additional analgesia because of an inadequate block. Therefore, according to the protocol, the amount was increased to 0.075 mL/kg of 0.25% levobupivacaine, where the success rate was again 100%. We conclude that ultrasonographic guidance for ilioinguinal/iliohypogastric nerve blocks in children allowed a reduction of the volume of local anesthetic to 0.075 mL/kg.

Epidural catheter placement in children: comparing a novel approach using ultrasound guidance and a standard loss-of-resistance technique.

BACKGROUND: We report a prospective, randomized study to evaluate ultrasound guidance for epidural catheter placement in children 0-6 yr of age. METHODS: Epidural catheters were placed at lumbar or thoracic cord levels in 64 children undergoing major surgery, using either ultrasonography or loss-of-resistance (LOR) for guidance. Using a 5-10 MHz linear ultrasound probe, the neuraxial structures were identified, the skin-epidural depth and epidural space was measured, the advancing epidural catheter visualized, and the spread of local anaesthetic verifying catheter position was confirmed. Epidural placement procedures were analysed for bone contacts and speed of execution. Children under 6 months were analysed separately. RESULTS: Epidural placement involved bone contacts in 17% of children in the ultrasound group and 71% of children in the LOR group (P<0.0001). Epidurals were executed more swiftly in the ultrasound group [162 (75) s vs 234 (138) s; P<0.01]. Children under 6 months revealed a 0.9 correlation between skin-epidural depth and body weight. CONCLUSIONS: Ultrasonography is a useful aid to verify epidural placement of local anaesthetic agents and epidural catheters in children. Advantages include a reduction in bone contacts, faster epidural placement, direct visualization of neuraxial structures and the spread of local anaesthetic inside the epidural space. Ultrasound guidance requires additional training and good manual skills, and should only be used once experience in ultrasound-guided techniques of regional anaesthesia has been acquired.

Ultrasonography for ilioinguinal/iliohypogastric nerve blocks in children.

BACKGROUND: The ilioinguinal/iliohypogastric nerve block is a popular regional anaesthetic technique for children undergoing inguinal surgery. The success rate is only 70-80% and complications may occur. A prospective randomized double-blinded study was designed to compare the use of ultrasonography with the conventional ilioinguinal/iliohypogastric nerve block technique. METHODS: One hundred children (age range, 1 month-8 years) scheduled for inguinal hernia repair, orchidopexy or hydrocele repair were included in the study. Following induction of general anaesthesia, the children received an ilioinguinal/iliohypogastric block performed either under ultrasound guidance using levobupivacaine 0.25% until both nerves were surrounded by the local anaesthetic or by the conventional 'fascial click' method using levobupivacaine 0.25% (0.3 ml kg(-1)). Additional intra- and postoperative analgesic requirements were recorded. RESULTS: Ultrasonographic visualization of the ilioinguinal/iliohypogastric nerves was possible in all cases. The amount of local anaesthetic used in the ultrasound group was significantly lower than in the 'fascial click' group (0.19 (SD 0.05) ml kg(-1) vs 0.3 ml kg(-1), P<0.0001). During the intraoperative period 4% of the children in the ultrasound group received additional analgesics compared with 26% in the fascial click group (P=0.004). Only three children (6%) in the ultrasound-guided group needed postoperative rectal acetaminophen compared with 20 children (40%) in the fascial click group (P<0.0001). CONCLUSIONS: Ultrasound-guided ilioinguinal/iliohypogastric nerve blocks can be achieved with significantly smaller volumes of local anaesthetics. The intra- and postoperative requirements for additional analgesia are significantly lower than with the conventional method.

Anatomical considerations of the pediatric ilioinguinal/iliohypogastric nerve block.

BACKGROUND: The ilioinguinal/iliohypogastric nerve block is safe, effective and easy to perform in order to provide analgesia for a variety of inguinal surgical procedures in pediatric patients. A relatively high failure rate of 10-25% has been reported, even in experienced hands. The aim of this study was to determine the exact anatomical position of the ilioinguinal and iliohypogastric nerves in relation to an easily identifiable constant bony landmark, the anterior superior iliac spine (ASIS) in neonates and infants. The current ilioinguinal/iliohypogastric nerve block techniques were also evaluated from an anatomical perspective. METHOD: Dissections were performed on a sample of 25 infant and neonatal cadavers (mean weight = 2.2 kg; mean height = 45.6 cm). The distance from the ASIS to both the ilioinguinal and iliohypogastric nerves, on a line connecting the ASIS to the umbilicus was carefully measured using a digital caliper. Three techniques, commonly used in clinical practice, were simulated on the anatomical specimens. RESULT: The left and right ilioinguinal nerves were closer to the ASIS than previously described, i.e. 1.9 +/- 0.9 mm (mean +/- sd) and 2.0 +/- 0.7 mm, respectively. The mean distance from the left and right iliohypogastric nerves to the ASIS are 3.3 +/- 0.8 mm and 3.9 +/- 1.0 mm, respectively. CONCLUSIONS: We suggest that the high failure rate of the ilioinguinal/iliohypogastric nerve block in this age group could be due to lack of specific spatial knowledge of the anatomy of these nerves in infants and neonates. This cadaver-based study suggests an insertion point closer to the ASIS, approximately 2.5 mm (range: 1.0-4.9) from the ASIS on a line drawn between the ipsilateral ASIS and the umbilicus.

Validation of a six-graded faces scale for evaluation of postoperative pain in children.

BACKGROUND: The faces pain scales are often used for self-report assessment of paediatric pain. The aim of this study was to evaluate the validity of a six-graded faces pain scale after surgery by comparing the level of agreement between the children's report of faces pain scores and experienced nurses' assessment of pain by observation of behaviour. The faces pain scores before, at and after administration of analgesics were analysed. The study was performed in two South African hospitals, one with a mainly rural population and the other with an urban population. METHODS: A total of 110 children aged 4-12 years, scheduled for inguinal surgery in the two South African hospitals, were included in the study. The anaesthetic technique was standardized. All patients received a caudal block preoperatively. Postoperative pain assessments were made every hour for 8 h after the caudal block was performed. A designated nurse assessed pain by using a four-graded descriptive scale (no, mild, moderate or severe pain) and thereafter the child reported pain by using the six-graded faces pain scale. RESULTS: A high correlation was found between the two methods of assessment (tau = 0.76, P < 0.0001). The correlation between methods was high in both hospital populations and in all age groups. The weakest correlation was found in children aged 8-12 years (tau = 0.56, P < 0.01). Significantly lower faces pain scores were found after administration of analgesics compared with pain rating before analgesics (P < 0.0001). The proportion of patients with pain scores above 2 decreased from 86% to 31% (P < 0.001). CONCLUSIONS: The findings support this six-graded faces pain scale as a useful and valid instrument for measuring pain in the postoperative period in children aged 4-12 years.

Surface mapping of peripheral nerves in children with a nerve stimulator.

Defining anatomical landmarks may be difficult in the growing child. With the aid of a peripheral nerve stimulator, the path of many superficial peripheral nerves can be 'mapped' prior to skin penetration by stimulating the motor component of the peripheral nerve percutaneously with a 2-3.5 mA output. The required current will vary and is dependent upon the depth of the nerve and the moistness of the overlying skin. This 'nerve mapping technique' has proved particularly useful for brachial plexus, axillary, ulna and median nerve blocks in the upper limb and femoral and popliteal nerve blocks in the lower limb. It is a useful teaching tool and improves the success rate of peripheral nerve blocks in children of all ages.

The efficacy of caudal ropivacaine 1, 2 and 3 mg x l(-1) for postoperative analgesia in children.

BACKGROUND: The aim of this double blind, randomized, comparative study was to assess the analgesic efficacy and incidence of motor block after caudal block using three different concentrations of ropivacaine, 1, 2 and 3 mg x l(-1), in children 4-12-year-old. METHODS: One hundred and ten children ASA I-II, scheduled for inguinal surgery, were included in the study. After induction of a standardized general anaesthetic technique, all patients received 1 ml x kg(-1) of the ropivacaine solution for a caudal block and were assessed for 8 h after the injection. RESULTS: The ropivacaine was well tolerated in all patients. Median time to treatment with analgesics was 3.3, 4.5 and 4.2 h in the 1, 2 and 3 mg x ml(-1) groups, respectively. During the first 4 h, the pain scores for both a 6-graded faces scale and a 4-graded observer scale were higher in the 1 mg x ml(-1) group than the 3 mg x ml(-1) group. The median sensory block reached T12 in all groups 1 h after the caudal block. Thereafter, the speed of regression was correlated with the ropivacaine concentration. In the patients with a sensory block from T12 and above, the median time to treatment with analgesics was longer than in the children with a sensory block below T12. The incidence of motor block was 28% in the 3 mg x ml(-1) group in comparison with 0 and 13% in the 1 and 2 mg x ml(-1) groups. CONCLUSIONS: It was concluded that 1 ml x kg(-1) of ropivacaine 2 mg x ml(-1) for caudal block provided satisfactory postoperative pain relief after inguinal surgery in 4-12-year-old children. Ropivacaine 1 mg x ml(-1) showed less efficacy while the use of ropivacaine 3 mg x ml(-1) was associated with a higher incidence of motor block with minimal improvement in postoperative pain relief.

Plasma concentrations of ropivacaine following a single-shot caudal block of 1, 2 or 3 mg/kg in children.

BACKGROUND: For documenting the properties of ropivacaine used for regional anaesthesia in children, the relationship between dose and resulting systemic exposure is essential. The aim of this pharmacokinetic part of a randomised, multicentre, double-blind study was to determine the free and total plasma levels of ropivacaine in children aged between 4 and 12 years following a single-shot caudal dose of 1, 2 or 3 mg/kg of ropivacaine for postoperative pain management. METHOD: Following induction of a standardised general anaesthetic (halothane; nitrous oxide: oxygen 60:40), a caudal block using 1 ml/kg ropivacaine in concentrations of 1, 2 or 3 mg/ml was performed in 43 ASA I children (body weight 12-25 kg) scheduled for elective inguinal surgery. Blood samples were collected prior to and 15, 30, 45, 60 and 240 min after placement of the caudal block for determination of total and free ropivacaine plasma concentrations. RESULTS: The peak plasma concentration of total ropivacaine, reached within 15-241 min after the block, increased in proportion to dose, with mean values at 0.27, 0.64 and 0.90 mg/l following 1, 2 and 3 mg/kg respectively. The peak plasma level of free ropivacaine also increased in a dose-proportional manner, with mean levels at 0.014, 0.030 and 0.042 mg/l. The highest individual peak plasma level of free ropivacaine was 0.070 mg/l, well below the threshold levels of CNS toxicity described in adults. No clinical signs of systemic toxicity were observed. CONCLUSION: Following single-shot caudal doses of 1-3 mg/kg in children up to 25 kg and aged between 4 and 12 years, plasma levels of free ropivacaine increase in proportion to dose and all were shown to be within safe limits.

Congenital diaphragmatic hernia repair--impact of delayed surgery and epidural analgesia.

This study was undertaken to assess the impact on mortality and the need for postoperative ventilation of intra- and postoperative epidural analgesia and delayed surgery in neonates with congenital diaphragmatic hernia. The study was a retrospective chart review of 35 neonates with congenital diaphragmatic hernia treated in Durban between 1988 and 1993. The mortality rate was 30%, with too few patients having delayed surgery to demonstrate a benefit from this policy. Mortality and the requirement for postoperative ventilation were reduced in the epidural group. However, the patients with the worst prognosis all received general anaesthesia. The benefit of delaying surgery for congenital diaphragmatic hernia repair could not be demonstrated because of small numbers. Epidural analgesia appears to be a useful technique to reduce the need for postoperative ventilation following repair in lower-risk patients.