https://rapm.bmj.com/content/rapm/40/5/401.full.pdf

The Second ASRA Practice Advisory on Neurologic Complications Associated With Regional Anesthesia and Pain Medicine: Executive Summary 2015

Editor’s PerspectiveWhat We Already Know about This TopicRegional anesthesia is associated with a low but poorly quantified incidence of complications.What This Article Tells Us That Is NewIn a prospective multicenter cohort of more than 100,000 blocks in children, there were no cases of permanent n

Complications in Pediatric Regional Anesthesia: An Analysis of More than 100,000 Blocks from the Pediatric Regional Anesthesia Network.

Summary Caudal epidural blockade in children is one of the most widely administered techniques of regional anaesthesia. Recent clinical studies have answered major pharmacodynamic and pharmacokinetic questions, thus providing the scientific background for safe and effective blocks in daily clinical practice and demonstrating that patient selection can be expanded to range from extreme preterm births up to 50 kg of body weight. This narrative review discusses the main findings in the current literature with regard to patient selection (sub-umbilical vs mid-abdominal indications, contraindications, low-risk patients with spinal anomalies); anatomical considerations (access problems, age and body positioning, palpation for needle insertion); technical considerations (verification of needle position by ultrasound vs landmarks vs ‘whoosh' or ‘swoosh' testing); training and equipment requirements (learning curve, needle types, risk of tissue spreading); complications and safety (paediatric regional anaesthesia, caudal blocks); local anaesthetics (bupivacaine vs ropivacaine, risk of toxicity in children, management of toxic events); adjuvant drugs (clonidine, dexmedetomidine, opioids, ketamine); volume dosing (dermatomal reach, cranial rebound); caudally accessed lumbar or thoracic anaesthesia (contamination risk, verifying catheter placement); and postoperative pain. Caudal blocks are an efficient way to offer perioperative analgesia for painful sub-umbilical interventions. Performed on sedated children, they enable not only early ambulation, but also periprocedural haemodynamic stability and spontaneous breathing in patient groups at maximum risk of a difficult airway. These are important advantages over general anaesthesia, notably in preterm babies and in children with cardiopulmonary co-morbidities. Compared with other techniques of regional anaesthesia, a case for caudal blocks can still be made.

Caudal epidural blocks in paediatric patients: a review and practical considerations

PURPOSE OF REVIEW: This article summarizes recent data related to the safety and efficacy of postoperative analgesia in children that influence clinical practice recommendations.
RECENT FINDINGS: Postoperative pain continues to be experienced by hospitalized children and following discharge after short stay or ambulatory surgery. Updated recommendations for post-tonsillectomy analgesia exclude codeine and suggest regular administration of paracetamol and NSAID, but evidence for the most appropriate dose and type of opioid for rescue analgesia is limited. The incidence of opioid-related respiratory depression/oversedation in hospitalized children ranges from 0.11 to 0.41%, with recent large series identifying high-risk groups and contributory factors that can be targeted to minimize the risk of serious or permanent harm. Data demonstrating feasibility and safety of regional analgesic techniques is increasing, but additional and procedure-specific evidence would improve technique selection and inform discussions of efficacy and safety with patients and families/carers. Persistent postsurgical pain is increasingly recognized following major surgery in adolescents. Evaluation of potential predictive factors in clinical studies and investigation of underlying mechanisms in laboratory studies can identify targets for both pharmacological and nonpharmacological interventions.
SUMMARY: Recommendations for postoperative pain in children continue to evolve, with data incorporated from randomized controlled trials, case series and large audits. Management of pain following surgery in children needs to not only encompass efficacy and safety in the immediate perioperative period, but also consider pain following discharge after ambulatory surgery and the potential risk of persistent postsurgical pain following major surgery.

Pain after surgery in children: clinical recommendations.

Prophylactic analgesia with local anaesthesia is widely used in children and has a good safety record. Performing regional blocks in anaesthetised children is a safe and generally accepted practice. When compared with adults, lower concentrations of local anaesthetics are sufficient in children; the

Regional anaesthesia in neonates, infants and children: an educational review.

https://rapm.bmj.com/content/rapm/39/6/502.full.pdf

Interscalene brachial plexus blocks under general anesthesia in children: is this safe practice?: A report from the Pediatric Regional Anesthesia Network (PRAN).

Asleep Versus Awake: Does It Matter?

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Interscalene brachial plexus blocks under general anesthesia in children: is this safe practice?: A report from the Pediatric Regional Anesthesia Network (PRAN).

Asleep Versus Awake: Does It Matter?