Anesth Pain Med.  2024 Oct;19(Suppl 1):S73-S86. 10.17085/apm.23164.

Expert's tips on regional blocks in neonates and infants

• KMID: 2563588
• DOI: http://doi.org/10.17085/apm.23164

Abstract

Pediatric regional anesthesia (RA) has emerged as a rapidly advancing dimension within pediatric anesthesia, demanding a continual commitment to knowledge acquisition. This review underscores the contemporary significance of this specialty, focusing on its application in neonates and infants. The primary objective of RA is to address perioperative pain effectively while preserving the delicate physiological balance, thereby enhancing overall patient care. This review explores the advantages offered by RA in this age group. Furthermore, conventional, and recently introduced techniques of RA are examined by exploring the advantages and disadvantages of these methods. The aim is to provide clinicians with a nuanced understanding of their applicability in different clinical scenarios. Additionally, the review elucidates the unique considerations associated with pediatric RA, acknowledging pediatric patients’ distinctive anatomical and physiological characteristics. The exceptional cases of congenital anomalies and their implications for the choice of RA are considered. An aspect of the review is its focus on dosages of local anesthetics and the volumes required for various blocks in neonates and infants. The dosages for continuous infusion and practical issues with infusions are considered. Complications due to RA are described with their prevention and treatment. The review offers pragmatic insights into the selection criteria for various regional blocks, aiding anesthesiologists in making informed decisions tailored to individual patient needs.

Figure

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  Fig. 1. (A) Position of the baby during caudal block. (B) Important landmarks to be noted during performing caudal block. PSIS: posterior superior iliac spine.

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  Fig. 2. (A) Probe position in transverse orientation. (B) US image showing ‘Frogs eyes’ represented by the cornua of the sacrum. PSIS: posterior superior iliac spine, SC: sacral cornua.

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  Fig. 3. (A) Longitudinal scan showing the Sacrococcygeal ligament and caudal space. (B) shows needle entry piercing the ligament and needle tip in the caudal space. (C) shows the LA deposition in the caudal space and the anterior displacement of the posterior dura. LA: local anesthetic.

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  Fig. 4. (A) The transverse scan of the central neuraxis at the level of thoracic level. (B) The various central neuraxial structure labelled at thoracic level. PVS: paravertebral space.

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  Fig. 5. (A) Probe position during lateral infraclavicular block. (B) Ultrasonic image of lateral infraclavicular block showing the various cords of branchial plexus around the axillary artery. AA: axillary artery, AV: axillary vein, LC: lateral cord, MC: medial cord, PC: posterior cord.

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  Fig. 6. (A) Sonoanatomy of femoral nerve block. (B) Sonoanatomy of popliteal sciatic nerve block. FN: femoral nerve, FA: femoral artery, TN: tibial nerve, CPN: common peroneal nerve.

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  Fig. 7. The management of the LAST. LAST: local anesthesia systemic toxicity, LA: local anesthetic, ACLS: advanced cardiac life support, CVS: cardiovascular system. *The dosage of epinephrine is restricted to 1 mcg/kg. Vasopressin should not be given. †Class 1 antiarrhythmics, beta blockers, calcium channel blockers are to be avoided. ‡The cumulative dose of intralipid infusion should not exceed 12 ml/kg.

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