1) Regional anesthesia in pediatrics requires special considerations due to anatomical and physiological differences compared to adults. Key differences include lower spinal cord termination, delayed myelination, and decreased plasma protein content. 2) Common regional anesthesia techniques in children include caudal epidural blocks, peripheral nerve blocks, and spinals. Caudal blocks are often used for infraumbilical surgery while peripheral nerve blocks are used for procedures on the extremities. 3) Proper technique and monitoring are important to avoid potential complications such as local toxicity, dural puncture, and hemodynamic issues. Ultrasound guidance can improve success and safety.

1. PEDIATRIC REGIONAL
ANAESTHESIA

2. ANATOMICAL DIFFERENCES BETWEEN
CHILD AND ADULT
• Change in body size resulting from growth process
• At birth dura matter ends at s3 or s4 and cord (conus
medullaris )at l3 or l4
• At end of 1 year l1 for conus medullaris and s2 for
dural sac

3. PEDIATRIC FACTORS RESULTING DANGER IMPLICATIONS OF
REGIONAL ANESTHESIA
LOWER TERMINATION OF
SPINAL CORD
DIRECT TRAUMA AVOID EPIDURAL ABOVE L3
LOWER PROJECTION OF
DURAL SAC
PENETRATION OF DURA CHECK FOR CSF REFLUX
INCLUDING DURING
CAUDAL APPROACHES
DELAYED MYELINATION EASIER INTRANEURAL
PENETRATION OF LOCAL
ANESTHETICS
SHORTENED
ONSET,DILUTED DRUG AS
EFFECTIVE AS
CONCENTRATED
CARTLAGINOUS BONES AND
VERTEBRAE
REDUCED RESISTANCE TO
PENETRATION BY SHARP
NEEDLES
USE SHORT BEVELED
NEEDLES
LACK OF FUSION OF SACRAL
VERTEBRAE
PERSISTENCE OF SACRAL
SPACES
INTERVERTEBRAL EPIDURAL
APPROACHES CAN BE
PERFORMED
THROUGHOUT CHILDHOOD
DELAYED DEVELOPMENT OF
CURVATURE
CERVICAL LORDOSIS (3-6
MONTHS)LUMBAR LORDOSIS
(8-9 MONTHS)
ORIENTATION OF NEEDLE IS
SAME WHATEVER SPINAL
LEVEL TILL 6 MONTHS OF
AGE

4. PEDIATRIC FACTORS RESULTING DANGER IMPLICATIONS FOR
REGIONAL ANAESTHESIA
CHANGING AXIS OF COCCYX
AND ABSENCE OF GROWTH
OF SACRAL HIATUS
SACRAL HIATUS
COMPARATIVELY SMALLER
WITH INCREASING AGE
DIFFICULT IDENTIFICATION
AFTER 6-8 YRS-INCREASE
FAILURE OF CAUDAL
ANAESTHESIA
DELAYED OSSIFICATION AND
GROWTH OF ILIAC CRESTS
TUFFIERS LINE CROSSES
SPINE AT L5 IN INFANTS
LINE PASSES OVER L5-S1
INSTEAD OF L4-L5
INTERSPACE
INCREASED FLUIDITY OF
EPIDURAL FAT
INCREASED DIFFUSION OF
LOCAL ANAESTHETIC
UPTO 6- 7 YRS OF AGE
EXCELLENT BLOCKADE
AFTER CAUDAL ANALGESIA
UPTO 6-7 YRS OF AGE
LOOSE ATTACHMENT OF
SHEATHS AND APONEUROSIS
INCREASED SPREAD
ALONG NERVE PATHS
WITH DANGER OF
PENETRATING REMOTE
ANATOMICAL SPACES AND
BLOCKING DISTANT
NERVERS
LARGER VOLUME REQUIRED
FOR EPIDURAL BLOCKS
BECAUSE OF LEAKAGE
ALONG SPINAL NERVE
ROOTS
ENZYMATIC IMMATURITY SLOWER METABOLISM OF
LOCAL ANAESTHETICS
INCREASED MEAN BODY
RESIDENCY TIME AND HALF
LIFE

5. PEDIATRIC FACTORS RESULTING DANGER IMPLICATIONS FOR
REGIONAL ANAESTHESIA
INCREASED
EXTRACELLULAR FLUIDS
INCREASED DISTRIBUTION
OF VOLUME AND MEAN
BODY RESIDENCY TIME OF
LOCAL ANAESTHETICS
DECREASED Cmax AFTER
SINGLE INJECTION
,ACCUMULATION AFTER
REPEAT ADMINISTRATION
LOW PLASMA PROTEIN
CONTENT
INCREASE PLASMA
CONCENTRATION OF FREE
FRACTION
INCREASED SYSTEMIC
TOXICITY
INCREASED CARDIAC
OUTPUT AND HR
INCREASED REGIONAL
BLOOD FLOW,INCREASING
SYSTEMIC ABSORPTION
(DECREASED Tmax AND
SHORTER DURATION OF
BLOCKADE)
INCREASED EFFICACY OF
EPINEPHRINE-
VASOCONSTRICTION LEAD
TO REDUCE ABSORPTION
AND PROLONG DURATION
SYMPATHETIC IMMATURITY
,DIMINISHED AUTONOMIC
ADAPTABILITY OF
HEART,SMALLER VASCULAR
BED IN LOWER EXTREMITY
HEMODYNAMIC STABILITY
DURING NEURAXIAL BLOCK
FLUID PRELOADING AND
USE OF VASOACTIVE
AGENTS UNNECESSARY

6. PHYSIOLOGICAL DIFFERENCES
Incomplete myelination-takes nearly 12 years to complete
Myelinization begins in fetal period in cervical neuromeres and extends
cephalad and caudad
Pharmacological consequence:
1) Local anesthetics penetrate and block nerve more easily-onset time is
shortenened
2) Duration of blockade is reduced: trapping of local anesthetics within
myelin with subsequent progressive-release is reduced and local
circulation and thus vascular absorption are greater in infants

7. INDICATIONS FOR REGIONAL
ANAESTHESIA
I. Mature child willing to undergo Sx under regional anaesthesia
II. Child at risk of severe complications during general anesthesia:
1.Severe acute/chronic respiratory distress
2.Emergency conditions with severe metabolic/endocrine disorders
3.Neuromuscular disorders, myasthenia gravis or porphyria
4.Congenital syndromes or skeletal deformities-cervical instabilty making
tracheal intubation risk for tetraplegia seen in chiari
malformation,achondroplasia and downs syndrome,facial
deformities,microtomia.

8. 5.Testicular torsion/incarcenated hernia at immediate risk for
rupture in children who have nothing by mouth guildeline
violation
III. Trauma pts with extremity lesions –allevate pain without
impending monitoring and evaluation of head
trauma/hemodynamic disorders and temporary stabilization of
fractures provided precautions are taken to avoid masking of
developing compartment syndrome
IV. Intraoperative and postoperative analgesia and procedural
pain

9. V. Management of non surgical pain-
1.Herpes zoster
2.Aids
3.Mucosal and cutaneous lesions
4.Cancer
5.Child with sickle cell disease-benifits from epidural analgesia during
vasoocclusive crisis/thoracic syndromes with intractable pain
VI. Non analgesic indication-continous epidural blockade(sympathetic
blockade) in vascular insufficiency resulting from kawasaki
disease,accidental intraarterial injection ,penile block with local anesthetic
containing epinehrine and severe frostbite

10. CONTRAINDICATIONS AND
LIMITATIONS:
• ABSOLUTE CONTRAINDICATION TO NEURAXIAL BLOCKS:
MEDICAL:
1.Severe coagulation disorders-constitutional (hemophilia),acquired(dic)or
therapeutic
2.Severe infection such as septicemia or meningitis
3.Intracranial tumor with increase icp
4.Allergy to local anesthetics
5.Chemotherapy with cisplatin prone to induce subclinical neurologic lesions
that can be acutely aggravated by block
6.Uncorrected hypovolemia
7.Cutaneous /subcutaneous lesions at the site of puncture
• NON MEDICAL:PARENTAL REFUSAL

11. ABSOLUTE C/I TO PERIPHERAL NERVE BLOCKS: True allergy to local anesthetics
RELATIVE C/I TO NEURAAXIAL BLOCKADE:
1)extended malformations of vertebrae,
2)spinal fusion,
3) myelomeningoceles,
4) open spina bifida,
5) major spondylolisthesis
6)tethered cord syndrome

12. COMPLICATIONS OF RA
LOCAL:
1. Inappropriate needle insertion
2. Tissue coring and introduction of epithelial cells into tissues where
they do not belong-develop as compressive tumors (especially in
the spinal canal)
3. Injection of neurotoxic solutions (syringe mismatch, epinephrine
close to a terminal artery)
4. Leakage around the puncture site when introducing catheter-
partial block failure and favor bacterial contamination (very rare)

13. SYSTEMIC COMPLICATIONS:
Accidental intravenous injection of local anesthetics or, less frequently,
excessive dosing.
Two types-
1.Neurologic :Early signs of neurologic toxicity (tinnitus, malaise,
metallic taste in the mouth) are unfortunately masked by general
anesthesia.
2.Cardiac:block sodium and potassium channels.
heart conduction disorders,
cardiac arrhythmias (bradycardia or tachycardia), and
atrioventricular block
QRS widening, bradycardia, and torsade de pointes are followed by
ventricular fibrillation, asystole, or both

14. • During continuous injections; the dosage of local anesthetic should be
systematically reduced in very young children or after prolonged
administration (>48 hours).
• Impaired ventricular conduction is the primary manifestation of local
anesthetic toxicity.
• Treatment -oxygenation, cardiac massage, and epinephrine, which is given
in small incremental boluses beginning with 1 to 2 μg/kg.
• If ventricular fibrillation persists, defibrillation (2-4 J/kg) is performed.
Although resuscitation measures must be initiated immediately, the specific
treatment of local anesthetic toxicity is rapid administration of
Intralipid.The recommended dose of 20% Intralipid for pediatric patients is
2 to 5 mL/kg by intravenous bolus. If cardiac function does not return, this
dose (up to 10 mL/kg)

15. LA DOSAGES AND ADDITIVES
0.2% ropivacaine,
0.25% bupivacaine and
2% lignocaine with adrenaline are commonly
used
Clonidine in a dose of 1 μg/kg is routinely
used as an adjuvant to prolong the duration of
analgesia.

18. ULTRASOUND
• Ultrasound improves the success rate, prolongs block duration,
reduces time of block performance and the number of needle
passes.
• high-frequency linear probe is required for superficial blocks-
especially in infants and small children
• and for deeper blocks a low-frequency curvilinear probe is
necessary
• Facet tip needle for peripheral nerve blocks facilitates precise
placement of needle with minimal pain for the child

20. SPECIFIC REGIONAL BLOCKS
1) Single-shot caudal epidural neuraxial block
• indicated for circumcision, orchidopexy, herniotomy, hypospadias repair,
infraumbilical surgery and lower limb surgery
• This block involves placing the child in the lateral position with flexion of
the spine and hip which creates a cephalad dural sac shifts adding safety.
• The needle is inserted through the sacral hiatus to deliver the LA into the
caudal–lumbar–lower thoracic (in neonates) epidural space. The two
posterior superior iliac spines and sacral hiatus make an equiangular
triangle.
• The use of equiangular triangle concept to identify the sacral hiatus is
common, but may be inappropriate because the actual triangle formed by
the sacral hiatus and the posterior superior iliac spine is not equiangular.

21. • distance between the depth of the caudal epidural space to prevent dural sac
puncture during the caudal block in children matters the most in neonates
as the distance between the dural sac and the sacral hiatus is very small.
• Rare but known complications are
1. total spinal leading to apnoea,
2. osteomyelitis of the sacrum,
3. damage to the rectum and
4. LAST.

23. 2) Continuous caudal epidurals
• The sacral hiatus is also a portal for continuous catheters which can be
passed into the lumbar or thoracic vertebral level for continuous infusion in
the postoperative period.
3) Lumbar and thoracic continuous epidurals
• These are indicated for major orthopaedic, abdominal and thoracic
surgeries and have their own firm place in PRA. LOR technique is
commonly used to detect the epidural space.
• Alternative methods described to locate the tip of the catheter are use of
electrocardiograph signals or nerve stimulation guidance.
• Reported complications include spinal cord injury, paraplegia, total spinal
and LAST.

24. 4) Spinal anaesthesia
This is mostly indicated in the sick neonate or preterm babies and may be used in
an awake child.
Spinal anaesthesia in infants and young children is devoid of cardiorespiratory
disturbances and has a fast onset of action.
Hyperbaric or isobaric bupivacaine in the dose of 0.5 mg/kg is the most common
choice.
Spinal blockade in infants has a shorter duration of analgesia and less dense
blockade compared with adults. It also has a measurable failure rate and can lead to
high spinal block requiring resuscitation.

25. PERIPHERAL REGIONAL ANESTHESIA
1) upper extremity brachial plexus blocks in children
• Various approaches to brachial plexus are available. These
blocks can be guided by peripheral nerve stimulation (PNS)
and USG. The choice of the block is made depending on the
indications.
a. The interscalene block is indicated for surgeries of shoulder
or proximal humerus, which are very uncommon in
children. The common complications associated are the
phrenic nerve palsy, intraarterial injection and epidural
injection.

26. b. The supraclavicular approach covers all the surgeries of humerus
complications such as arterial and pleural puncture are known.
c. Infraclavicular block –Most commonly used. It is indicated in distal
humerus, elbow, forearm and hand surgeries as it combines the advantages
of supraclavicular and axillary block.The nerves spared in axillary
(musculocutaneous and axillary) approach are covered with this block.
Anatomically, it renders itself very well for catheter placements.
Complications such as vascular punctures and pneumothorax are possible.
d. Axillary approach to brachial plexus block is indicated mainly for wrist and
finger surgeries. Arterial damage is a common complication with this
approach.

30. 2)Lower extremity blocks
• A combination of femoral and sciatic nerve blocks or fascia iliaca
compartment block (FICB)
• FICB can be given under ultrasound guidance and LOR technique.
• Femoral block provides analgesia to the anterior aspect of the thigh and the
femur itself.
• The FICB is well-suited for the anterolateral surgeries of the thigh.
• The subgluteal, intragluteal and popliteal sciatic nerve blocks are the most
common approach. These are indicated in surgeries below the knee.

32. 3)Trunk blocks:
1.Posterior rectus sheath blocks provide anaesthesia extending from the central aspect
of the anterior abdominal wall to the iliac crest.
Indication : surgeries around the umbilicus
Complication: Peritoneal puncture and injury to the bowel
2.The ilioinguinal and iliohypogastric nerves block render analgesia for surgeries in
the inguinal region, for example, inguinal hernia.
3.TAP block gives analgesia to the ipsilateral anterolateral abdominal wall.
.

33. 4.The QL block (QL 1, 2, 3 and 4) somatic and visceral analgesia to the ipsilateral
side
Indication: ileostomy, unilateral laparoscopic surgeries, pyeloplasty,
herniorrhaphy and unilateral limb surgeries.
Complications: Injury to the kidney, peritoneum, lingering motor blockage of
the ipsilateral limb.
5. Erector spinae block
Visceral analgesia in unilateral abdominal and thoracic sx
6. Paravertebral block
Ipsilateral somatosensory analgesia for unilateral surgeries on thorax and trunk
Complications : hypotension, vascular puncture, pleural puncture and
pneumothorax.

36. • Penile block
Indication: for circumcision, meatoplasty, hypospadias repair
The dorsal penile nerve is blocked.
Alternative to caudal epidural for the above surgeries.
Complications:
Arterial puncture and ischaemia.

38. POST OPERATIVE CARE
1. Postoperative advice pertaining to protecting the anaesthetised area
should be given to the family.
2. The family and child should be made aware of occurrence of muscle
weakness and diminished sensation
3. Every institution must have guidelines for monitoring of regional
anaesthetic techniques and staff must receive regular education on
managing regional blocks postoperatively and care of the anaesthetised
extremity.
4. For continuous blocks, the infusions should be set up by the anaesthesia
team. The infusion pumps or elastomeric pumps should be labelled with the
name and concentration of LA, infusion rate and additive, if any

39. REFERENCES
• 1.Miller’s anesthesia-8th edition
• 2.Miller’s anesthesia-9th edition
• 3.INDIAN JOURNAL OF ANESTHESIA
SEPTEMBER 2019-VOLUME 63-ISSUE 9-p46-
753