A.T. Bosenberg

Benefits of regional anesthesia in children

Faculty Health Sciences, Department Anesthesiology and Pain Management, Seattle Children’s Hospital, University Washington, Seattle,WA, USAKeywordsregional anesthesia; benefits; reviewsCorrespondenceAdrian Bosenberg,Faculty Health Sciences, DepartmentAnesthesiology and Pain Management,Seattle Children’s Hospital, UniversityWashington, 4800 Sandpoint Way NE,Seattle, WA 98105, USAEmail:adrian.bosenberg@seattlechildrens.orgSection Editor: Per-Arne LonnqvistAccepted 5 August 2011doi:10.1111/j.1460-9592.2011.03691.x

Pro con debate: the use of regional vs systemic analgesia for neonatal surgery

In recent years the inclusion of regional techniques to pediatric anesthesia has transformed practice. Simple procedures such as caudal anesthesia with local anaesthetics can reduce the amounts of general anesthesia required and provide complete analgesia in the postoperative period while avoiding large amounts of opioid analgesia with potential side effects that can impair recovery. However, the application of central blocks (epidural and spinal local anesthesia) via catheters in the younger infant, neonate and even preterm neonate remains more controversial. The potential for such invasive maneuvers themselves to augment risk, can be argued to outweigh the benefits, others would argue that epidural analgesia can reduce the need for postoperative ventilation and that this not only facilitates surgery when intensive care facilities are limited, but also reduces cost in terms of PICU stay and recovery profile. Currently, opinions are divided and strongly held with some major units adopting this approach widely and others maintaining a more conservative stance to anesthesia for major neonatal surgery. In this pro‐con debate the evidence base is examined, supplemented with expert opinion to try to provide a balanced overall view.

Improving surgical safety globally: pulse oximetry and the WHO Guidelines for Safe Surgery

Access to safe surgery should be considered as part of the basic human right for health, but unfortunately, this ideal is far from being reached in many low‐income countries. Pulse oximetry is recommended as a minimum standard of monitoring by all anesthesia organizations that have set standards, yet around 78 000 operating theaters worldwide lack this essential monitor. The WHO Safe Surgery Saves Lives Program has identified evidence‐based guidelines for safe surgery that are applicable in any setting, and the Global Pulse Oximetry Program will help improve access to pulse oximetry in countries where it is not available. However, these initiatives are just a start; capacity, infrastructure, trained healthcare providers and access to essential drugs, and equipment for anesthesia and surgery need to become a public health priority in many low‐income countries.

Regional Anesthesia in Neonates and Infants

Optimal pain management can significantly impact the surgical outcome and length of stay in the neonatal intensive care unit (NICU). Regional anesthesia is an effective alternative that can be used in both term and preterm neonates. A variety of neuraxial and peripheral nerve blocks have been used for specific surgical and NICU procedures. Ultrasound guidance has increased the feasibility of using these techniques in neonates. Education and training staff in the use of continuous epidural infusions are important prerequisites for successful implementation of regional anesthesia in NICU management protocols.

Descriptive study of the differences in the level of the conus medullaris in four different age groups

In performing neuraxial procedures, knowledge of the location of the conus medullaris in patients of all ages is important. The aim of this study was to determine the location of conus medullaris in a sample of newborn/infant cadavers and sagittal MRIs of children, adolescents, and young adults. The subjects of both the samples were subdivided into four developmental stages. No statistical difference was seen between the three older age groups (P > 0.05). A significant difference was evident when the newborn/infant stage was compared with the other, older stages (P < 0.001 for all comparisons). In the newborn/infant group the spinal cord terminated most frequently at the level of L2/L3 (16%). In the childhood stage, the spinal cord terminated at the levels of T12/L1 and the lower third of L1 (21%). In the adolescent population, it was most often found at the level of the middle third of L1 and L1/L2 (19%). Finally, in the young adult group, the spinal cord terminated at the level of L1/L2 (25%). This study confirmed the different level of spinal cord termination between newborns/infants less than one‐year‐old and subjects older than one year. In this sample the conus medullaris was not found caudal to the L3 vertebral body, which is more cranial than the prescribed level of needle insertion recommended for lumbar neuraxial procedures. It is recommended that the exact level of spinal cord termination should be determined prior to attempting lumbar neuraxial procedures in newborns or infants. Clin. Anat. 28:638–644, 2015.

The value of Tuffier's line for neonatal neuraxial procedures

The spine of L4 usually lies on a line drawn between the highest points of the iliac crests (Tuffiers line) in adults. Although its accuracy has been questioned, it is still commonly used to identify the spinous process of the 4th lumbar vertebra before performing lumbar neuraxial procedures. In children, this line is said to cross the midline at the level of L5. A literature search revealed that the description this surface anatomical line is vague in neonates. The aims of this study were to determine the vertebral level of Tuffiers line, as well as its distance from the apex of the sacrococcygeal membrane (ASM), in 39 neonatal cadavers in both a prone and flexed position. It was found that when flexed, Tuffiers line shifted from the level of L4/L5 (prone position) to the upper third of L5. The mean distance from the ASM to Tuffiers line was 23.64mm when prone and 25.47 mm when flexed, constituting a statistically significant increase in the distance (P=0.0061). Therefore, in the absence of advanced imaging modalities, Tuffiers line provides practitioners with a simple method of determining a level caudal to the termination of the spinal cord, at approximately the L4/L5 in a prone neonate and the upper margins of L5 when flexed. Clin. Anat. 27:370–375, 2014.

The potential future or just a way of trespassing the safety limits of pediatric regional anesthesia

Risk analysis is part of everyday life. The mortality associated with various extreme sport activities is far riskier than undergoing anesthesia (1) Mountaineering in the Himalayas carries the highest risk of mortality (1/100), while piloting a microlight aircraft or flying a helicopter carries a similar risk as ASA 3–5 patients undergoing cardiac surgery (1/1000) (1). However, in these extreme activities, the individual has the choice of whether the risk should be taken or not. Their fate is in their own hands. No one else is at risk except perhaps the mountain rescuers who also have a choice. Modern anesthesia is safer than road travel, some occupations (fishing, chemical industry), and overall medical risk (1). But when it comes to providing anesthesia, the patient undergoing surgery is at the mercy of the anesthesiologist who has a number of options or techniques at their disposal to provide safe anesthesia. Primum non nocere. Risk-benefit analysis should therefore be an important aspect of anesthetic practice. Regional anesthesia in children is popular because a successful block provides effective analgesia with improved outcome. If pain relief and improved outcome are the primary benefits of regional anesthesia, it should be balanced against the consequences of any risks associated with the procedure. Ever since the introduction of regional anesthesia, it has been used in pediatric patients. August Bier in fact performed a number of spinal anesthetics on teenage children initially. Gray, only a few years later, published an extensive case series of 200 children treated with this new technique (1909) (2). The reason for the popularity of spinal anesthesia in that day and age was that it was found to be infinitely safer than general anesthesia based on the very low morbidity and mortality found in the Gray case series. Coincidentally, Bier performed a ‘self-experiment’ to investigate the problems he had encountered in his patients who had had spinal anesthetics. After being on the receiving end of an aborted spinal anesthetic provided by Hildebrand, Bier considered that the spinal headache and the incapacitation it caused were not worth the risk. He did not feel it was justified to do further investigations in humans (3). The safety of general anesthesia improved and the use of regional anesthesia decreased till the resurgence in pediatric regional anesthesia in the mid-1980s, again stimulated by the use of spinal anesthesia in high-risk ex-premature infants who were at risk of respiratory complications including postoperative apnea after general anesthesia. This soon leads to a rapid increase in its use and the development of new techniques. Subsequently, a number of case reports were published, highlighting the potential risks of regional anesthesia in infants and children (4–6), with a retrospective report of four cases of spinal cord damage following epidural anesthesia being the most disturbing example (7). Against this background, the French Language Society of Paediatric Anesthesia (ADARPEF) in 1996 published a prospective 1-year collection of 24 409 cases of pediatric regional anesthesia where the focus was on the incidence of complications (8). The results of this study were very reassuring, showing an overall incidence of self-limiting complications of 1/1000, with no long-term sequelae or any medicolegal action reported. The complications were more frequent with neuraxial blockade than with peripheral nerve blocks, and 50% of the complications were judged to be caused by the use of inappropriate sized (adult) regional anesthesia equipment. Despite the development of equipment more appropriate for use in small infants and children, the risk of complications remains in the order of 1 in 1000. Three large-scale audits focussing on the safety of pediatric regional anesthesia have been published recently. The UK pediatric epidural audit (9) reported on 10 633 neuraxial blocks collected prospectively over a 5-year period. This audit included 729 epidurals in neonates (caudal, lumbar and thoracic). The overall incidence of short-term complications were similar to that reported in the initial prospective ADARPEF study, but they also describe an incidence of long-term problems of only 1 in 10 000 (one patient with persistent paraesthesia at 12 months). The ADARPEF has recently reported on a further 31 132 regional anesthetics in children in a prospective 1-year follow-up study (10). The low incidence of complications was confirmed (approximately 1/1000) despite a trend toward an increased use of peripheral nerve blocks, including continuous peripheral catheter techniques. This trend the authors suggested was because of the better safety profile of peripheral nerve blockade and an increase in laparoscopic surgery. Further data attesting to the safety of regional anesthesia in children are soon to be submitted for publication by the Paediatric Regional Anesthesia Network (PRAN) (Polaner D, Martin L, Suresh S and the PRAN, submitted). The PRAN records problems related to regional anesthesia from participating institutions in

Revisiting the anatomy of the ilio-inguinal/iliohypogastric nerve block

The ilio‐inguinal/iliohypogastric nerve block (INB) is one of the most common peripheral nerve block techniques in pediatric anesthesia, which is largely due to the introduction of ultrasound (US) guidance. Despite the benefits of US guidance, the absence of an US machine should not deter the provider from performing INB, considering that many institutions, especially in developing countries, cannot afford to provide ultrasound machines in their anesthesiology departments. The aim of this study was to revisit the anatomical position of the ilio‐inguinal and iliohypogastric nerves in relation to the anterior superior iliac spine (ASIS), in a large sample of neonatal cadavers, and compare the results with a similar group in a previously published US‐guided study.

Determining the extent of the dural sac for the performance of caudal epidural blocks in newborns

Information regarding the position and relationship of vital structures within the caudal canal is important for anesthesiologists who perform a caudal block. This information can be acquired by anatomical dissection, with ultrasound technology, or radiological studies.

Regional anaesthesia for cleft lip surgery in a developing world setting : plastic surgery

BACKGROUND The role of regional anaesthesia in cleft lip surgery in the developing world is not well documented. METHOD A retrospective chart review of 100 patients aged >14 years who had cleft lip surgery during an Operation Smile South Africa (OSSA) volunteer surgical programme in Madagascar during 2007 and 2008. The nerve blocks used included a bilateral infraorbital nerve block, a dorsalnasal nerve block and a septal block supplemented with peri-incisional local in_ltration. Appropriateness of the regional anaesthesia alone for cleft lip surgery was determined by absence of any intraoperative complications, postoperative complications or conversions to general anaesthesia. RESULTS Seventy-four patients commenced their operation under regional anaesthesia. There were no intraoperative or postoperative complications documented, and no patient required conversion to general anaesthesia. Two patients required additional analgesia in the immediate postoperative period. CONCLUSION Regional anaesthesia for cleft lip surgery in patients >14 years of age was well tolerated and associated with few complications. It is a safe and effective option when used as the sole anaesthetic modality for cheiloplasty in the developing world.