Book Text

INDICATIONS AND CONTRAINDICATIONS

Indications

Regional anesthetic techniques can be used for anesthetic, analgesic, or nonanalgesic purposes.^[97] ^[98] Anesthetic indications are mainly for emergency procedures and to improve the comfort of the patient, allowing pain-free clinical and radiologic examinations, wound dressings, and reduction of limb fractures without compromising vital functions or affecting the evaluation of the status of the central nervous system. When a decision is made to operate on a patient with a full stomach, a regional block procedure can avoid general anesthesia, improving the safety of the management of the patient.

Analgesic indications are usually for regional anesthetic techniques in children, especially in elective surgery, because they can provide intraoperative and postoperative pain relief. Many procedures on the abdomen, pelvis, and extremities, including outpatient surgery^[99] ^[100] ( Table 45-4 ), are well managed under regional anesthesia, including those performed on preterm neonates^[101] ^[102] or critically ill pediatric patients.^[103] ^[104] Continuous techniques of regional anesthesia have become popular for use in adults as in children. Catheter placement within the epidural^[105] and even the subarachnoid^[106] space allows long-lasting pain relief, and patient-controlled analgesia can be used even in rather young children (≥5 years). Such continuous and on-demand techniques have been adapted to plexus and peripheral nerve blocks^[107] ^[108] ; even though they are

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**TABLE 45-4** -- Recommended indications of regional techniques for outpatient surgery
Type of Surgery	Typical Indications	Suitable Block Procedures
Orthopedics	Usual fractures of the limbs, removal of wires and most implants, joint testing and mobilization, clubfoot	Peripheral nerve blocks
	Tenotomy, aponeurotomy, arthrography	Peripheral nerve blocks, infiltrations of local anesthetics
	Distal surgery (fingers, toes)	Transthecal digital blocks, infiltrations of local anesthetics
Plastic surgery	Correction of prominent ears, removal of superficial lesions and sutures, revision of scars, dressing changes, ingrowing toenails	Infiltrations of local anesthetics, topical anesthesia, specific nerve block
Odontology and stomatology	Dental: conservation, extraction, orthodontics, drainage of sinuses	Infiltrations of local anesthetics, topical anesthesia
General surgery	Inguinal and crural hernia repair, anal dilatation, rectoscopy, epigastric or umbilical hernia repair	Ilioinguinal and iliohypogastric nerve block, caudal anesthesia (no opioids), umbilical or rectus sheath block
Urology	Excision of hydrocele, orchidopexy, circumcision, penoscrotal web, testicular torsion, glansplasty, meatotomy	Ilioinguinal and iliohypogastric nerve block, pudendal nerve block, penile block, caudal anesthesia
	Submucosal Teflon injection	Caudal or lumbar epidural anesthesia
	Cystoscopy, change of urethral catheter, urethral dilatation	Topical anesthesia, penile block
Ear, Nose, and Throat	Myringotomy or grommets, adenoidectomy, amygdalectomy, nasal or aural foreign body removal, short-lasting endoscopic examination, antral lavage, nasal cautery	Infiltrations of local anesthetics, topical anesthesia
Ophthalmology	Simple skin lesions of eyelids, probing of tear ducts	Infiltrations of local anesthetics, topical anesthesia
Miscellaneous	Bone marrow sampling, skin or node biopsy, lumbar puncture, intrathecal injection, venesection, arteriovenous fistula, blood tests, muscle biopsy, metabolic or endocrine tests	Infiltrations of local anesthetics, topical anesthesia, peripheral nerve (axillary) block

still being evaluated, these techniques are very promising and may be applicable to outpatient surgery, at least in educated families, as they are in some institutions for adult patients.^[109] ^[110] ^[111]

Other indications of regional block procedures include relief of nonsurgical pain, physiotherapy of talipes equinus deformity in children recovering from severe brain damage, and some nonanalgesic applications such as vasodilatation in ischemic disorders or maintenance of motor block throughout the recovery period in a patient with an unstable fracture or nerve or tendon repair.