Chapter 45
- Regional Anesthesia in Children
- Bernard J. Dalens
Regional anesthesia is an essential and growing part of pediatric
anesthesia. It finds application in virtually all aspects of surgical and procedural
pain, including outpatient surgery, whether the techniques are used alone or in combination
with general anesthesia. The aura of suspicion that initially prevented many anesthesiologists
from using these techniques in pediatric patients has been almost completely eliminated
by hundreds of scientific studies published during the past 30 years. Pharmacokinetic
and pharmacodynamic characteristics of available local anesthetics have been fully
evaluated, even in neonates, and the fear of nerve damage and neurologic sequelae
has proved unfounded.[1]
Location techniques for
mixed nerves and anatomic spaces allow safe needle insertion and catheter placement
in noncooperative or anesthetized patients when the safety rules are scrupulously
followed. Devices specifically designed for use in pediatric patients are commonly
available.
Neuraxial blocks are particularly well tolerated by infants and
young children, which make these approaches mandatory in many operations involving
the infra-umbilical part of the abdomen, the pelvic girdle, and the lower limbs.
Although plexus and peripheral conduction nerve blocks are still underused, they
have elicited increasing interest because they provide localized analgesia with small
amounts of local anesthetic. Two major scientific discoveries have reinforced this
interest. First, peripheral nervous system sensitization plays a considerable role
in sustaining postoperative pain and can be prevented only by conduction nerve blockade,
whereas opioid analgesia is effective exclusively on central sensitization. Second,
opioids have pronociceptive effects that are clinically relevant when their administration
is discontinued. These pronociceptive effects are proportional to the given doses
and duration of treatment. These data strongly incite practitioners to consider
using peripheral nerve blocks instead of opioid analgesia. Although former limitations
for peripheral nerve blockade included a limited duration of analgesia, this drawback
is now easily overcome by the availability of devices allowing safe placement of
perineural catheters, pumps, and inflatable bags, allowing precise delivery of local
anesthetic continuously or on demand over long periods. The safety of these continuous
techniques, which are still being evaluated, will probably make them suitable for
outpatient surgery in children, as they are in adult practice in some institutions,
at least in educated families, contributing to a decrease in the psychological stress
of surgery and overall costs of hospitalization.
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