Pediatric Regional Anesthesia: A Practical Guideline for Daily Clinical Practice

Abstract

The past two decades have seen remarkable progress in pediatric regional anesthesia. Significant efforts have been made to develop central and peripheral techniques that are both practicable and reliable, with increasing success and very low complication rates driving a growing appreciation for this subspecialty. Regional anesthesia can be used to optimize perioperative pain control, to avoid mechanical ventilation, and to take advantage of favorable immunomodulatory and gastrointestinal side effects in children. Implementing a broad spectrum of these techniques will require specialized knowledge of anatomic structures, experience to select appropriate techniques for specific surgical procedures, and considerable hand skills to execute these techniques. This review has been written to summarize state-of-the-art information about all relevant aspects of pediatric regional anesthesia and to provide a practical approach to how regional anesthesia in children can be implemented in daily clinical practice.

Fig. 1.

Longitudinal ultrasound image of the relevant anatomy for caudal blockade. The local anesthetic, which is administered during caudal blockade, is mainly visible by downward movement of the dosal part of the dura mater (DM). The right side is the caudal direction. (See also supplemental video 1, https://links.lww.com/ALN/E5.) CE, caudal equina.

Fig. 2.

Longitudinal ultrasound image of the relevant anatomy for epidural blockade.The spread of local anesthetic (LA) appears from a caudal (right side of the image) to a cranial direction as hypoechoic and the epidural space distends between the flavum ligament (FL) and the dura mater (DM). The gray double-headed arrow indicates the spinal cord. SP, spinous process.

Fig. 3.

Cross-sectional ultrasound image of the paravertebral space, which is visible between the transverse process (TP), the pleura, and the internal intercostal membrane (IIM). The right side is the medial direction.

Fig. 4.

Cross-sectional ultrasound image of the infraclavicular portion of the brachial plexus (encircled by the dotted line) below the pectoralis major muscle (PMM) and lateral to the subclavian vein (SCV) and artery (SCA).The right side is the lateral direction. P, pleura.

Fig. 5.

Cross-sectional ultrasound image of the sciatic nerve (SN) below the long head of the biceps (LHBM) and the semitendinosus (STM) muscles. The puncture is recommended via an in-plane needle guidance technique from lateral between the LHBM and the lateral vastus (LVM) muscles. This image also serves as example for the ultrasound appearance of peripheral nerve structures. The right side is the medial direction.

Fig. 6.

Ultrasound image of the rectus sheath block (one side), where the local anesthetic is administered below the rectus abdominis muscle (RAM) in the posterior sheath of the muscle (PS_RAM). Care should be taken to avoid puncture of the visceral peritoneum (VP), where intestinal loops (IL) can be adjacent. The right side is the lateral direction. SC, shaft of the cannula.