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Technical details
Caudal anaesthesia is easy to learn (9), much easier than Fig. 2: Specially designed sets for paediatric caudal anaesthesia give
lumbar epidural or even spinal anaesthesia in adults. Os- optimal working conditions.
seous landmarks can be reliably identified even in
neonates and infants; this contributes to safe perfor-
mance of the technique in all age groups. cornua; at that point the sacrococcygeal membrane is
thickest and a clear "pop” or "give” can be felt. Further-
After induction of general anaesthesia and placement of more, at that point the sacral canal is larger, making too
the usual monitors, a left lateral position is obtained with deep needle insertion with intraosseous injection less
the patient’s upper hip flexed at 90°, the lower one only likely (10). The index finger of the palpating left hand lies
45° (Fig. 1). on spinous process S4 while the right hand advances the
needle inclined 45°–60° to the skin (Fig. 3). After feeling
the give of passing the sacrococcygeal membrane, the
needle should only be minimally advanced, no more than
1 to 3 mm, to avoid vascular puncture or intrathecal in-
jection (10). The use of extension tubing for an immobile
needle technique is recommended. The injection of air to
identify correct needle placement is no longer recom-
mended, and may be associated with severe complica-
tions (11).
Fig. 1: A left lateral position is obtained with the patient’s upper hip
flexed at 90°, the lower one only 45°.
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fant and neonatal pain: anaesthetists' perceptions and prescribing vacaine 0.2% in children. A study of infants aged less than 1 year
patterns. BMJ 1996; 313: 787- and toddlers aged 1-5 years undergoing inguinal hernia repair.
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MC: French survey of anesthesia in 1996. Anesthesiology 1999; 91: 23. Hansen TG, Ilett KF, Reid C, Lim SI, Hackett LP, Bergesio R: Cau-
1509-20 dal ropivacaine in infants: population pharmacokinetics and plasma
concentrations. Anesthesiology 2001; 94: 579-84
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gional anesthesia in children: a one-year prospective survey of the 24. Bouchut JC, Dubois R, Foussat C, Moussa M, Diot N, Delafosse C,
french-language society of pediatric anesthesiologists. Anesth Analg Claris O, Godard J: Evaluation of caudal anaesthesia performed in
1996; 83: 904-12 conscious ex-premature infants for inguinal herniotomies. Paedia-
tr.Anaesth. 2001; 11: 55-8
5. Gunter, J. Caudal anesthesia in children: a survey. Anesthesiology 75,
A936. 1991. Ref Type: Abstract 25. Breschan C, Hellstrand E, Likar R, Lonnquist PA: Early signs of tox-
icity and "subtoxic" conditions in infant monitoring. Bupivacaine
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26. Jöhr M, Seiler SJ, Berger TM: Caudal anesthesia with ropivacaine in
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pediatric caudal blocks in a teaching hospital. Reg Anesth. 1992; 17:
119-25 27. Tanaka M, Nishikawa T: Evaluating T-wave amplitude as a guide for
detecting intravascular injection of a test dose in anesthetized chil-
8. Broadman L: Complications of pediatric regional anesthesia, Com- dren. Anesth Analg 1999; 88: 754-8
plications of regional anesthesia. Edited by Finucane BT. New York,
Churchill Livingstone, 1999, pp 245-56 28. Cook B, Grubb DJ, Aldridge LA, Doyle E: Comparison of the ef-
fects of adrenaline, clonidine and ketamine on the duration of cau-
9. Schuepfer G, Konrad C, Schmeck J, Poortmans G, Staffelbach B, Johr dal analgesia produced by bupivacaine in children. Br J Anaesth.
M: Generating a learning curve for pediatric caudal epidural blocks: 1995; 75: 698-701
an empirical evaluation of technical skills in novice and experienced
anesthetists. Reg Anesth Pain Med. 2000; 25: 385-8 29. Lee JJ, Rubin AP: Comparison of a bupivacaine-clonidine mixture
with plain bupivacaine for caudal analgesia in children. Br J
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caudal canal in children: a study using magnetic resonance imaging.
Paediatr.Anaesth. 2000; 10: 137-41 30. Breschan C, Krumpholz R, Likar R, Kraschl R, Schalk HV: Can a
dose of 2microg.kg(-1) caudal clonidine cause respiratory depression
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perts (Congrès Sfar 1997). Ann Fr Anesth Reanim. 1997; 16: 985-
1029 31. Bouchut JC, Dubois R, Godard J: Clonidine in preterm-infant cau-
dal anesthesia may be responsible for postoperative apnea. Reg
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sia in children. Br J Anaesth 1999; 83: 65-77
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sia. Anesth Analg 1992; 75: 164-6 caudal bupivacaine and intravenous morphine. Anesth Analg 1987;
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14. Mazoit JX, Denson DD, Samii K: Pharmacokinetics of bupivacaine
following caudal anesthesia in infants. Anesthesiology 1988; 68: 387- 33. Karl HW, Tyler DC, Krane EJ: Respiratory depression after low-
91 dose caudal morphine. Can J Anaesth 1996; 43: 1065-7
15. Morton NS: Ropivacaine in children [editorial]. Br J Anaesth. 2000; 34. Lee HM, Sanders GM: Caudal ropivacaine and ketamine for postop-
85: 344-6 erative analgesia in children. Anaesthesia 2000; 55: 806-10
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macokinetics and clinical efficacy of long-term epidural ropivacaine W, Nikolic A, Turnheim K, Semsroth M: Analgesic effects of caudal
infusion in children. Br J Anaesth. 2000; 85: 347-53 and intramuscular S(+)-ketamine in children. Anesthesiology 2000;
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17. Ivani G, Lampugnani E, Torre M, Calevo MG, DeNegri P, Borrometi
F, Messeri A, Calamandrei M, Lonnqvist PA, Morton NS: Compari- 36. Marhofer P, Krenn CG, Plochl W, Wallner T, Glaser C, Koinig H,
son of ropivacaine with bupivacaine for paediatric caudal block. Br J Fleischmann E, Hochtl A, Semsroth M: S(+)-ketamine for caudal
Anaesth 1998; 81: 247-8 block in paediatric anaesthesia. Br J Anaesth. 2000; 84: 341-5
18. Koinig H, Krenn CG, Glaser C, Marhofer P, Wildling E, Brunner M, 37. Krane EJ, Dalens BJ, Murat I, Murrell D: The safety of epidurals
Wallner T, Grabner C, Klimscha W, Semsroth M: The dose-response placed during general anesthesia. Reg Anesth Pain Med 1998; 23:
of caudal ropivacaine in children. Anesthesiology 1999; 90: 1339-44 433-8
19. Da Conceicao MJ, Coelho L: Caudal anaesthesia with 0.375% ropi- 38. Lenox WC, Kost-Byerly S, Shipley R, Yaster M: Pediatric caudal
vacaine or 0.375% bupivacaine in paediatric patients. Br J Anaesth. epidural catheter sequestration: an unusual complication. Anesthesi-
1998; 80: 507-8 ology 1995; 83: 1112-4
20. Dony P, Dewinde V, Vanderick B, Cuignet O, Gautier P, Legrand E, 39. Emmanuel ER: Post-sacral extradural catheter abscess in a child. Br
Lavand'homme P, De Kock M: The comparative toxicity of ropiva- J Anaesth 1994; 73: 548-9
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2000; 91: 1489-92
Peripheral blocks in children:
Which techniques to begin with?
Bernard Dalens
Pavillon Gosselin
Hôtel-Dieu BP 69
F-63003 Clermont-Ferrand Cedex 1
France
During the last 20 years, the use of regional anaesthetic Anatomic Considerations: The umbilicus and umbilical
techniques in children has expanded considerably. Sur- area are supplied by the terminal branch of the 10th in-
prisingly, the first block procedures that were extensively tercostal nerve of each side, after their emergence from
used in paediatric patients were central blocks, namely the intercostal space, near the linea alba. At this level, the
caudal and epidural then spinal anaesthesia, i.e., the most terminal branch crosses the deep aponeurosis of the rec-
dangerous techniques of regional anaesthesia. Only re- tus abdominis muscle, then traverses antero-posteriorly
cently, peripheral nerve and compartment blocks have the substance of the muscle (supplying motor and senso-
gained general acceptance due to their established safety ry twigs) and, finally, crosses the superficial aponeurosis
and efficacy (1). However, few institutions are currently of the rectus muscle before it divides in several terminal
able to provide adequate teaching in these techniques subcutaneous branches supplying the skin surrounding
and many anaesthesiologists of today who are willing to the umbilicus.
perform these techniques in their practice, are wondering The aponeurosis of the rectus muscle delineates a closed
which techniques they can use safely with limited training space where the nerve runs. Injecting a small amount of
and experience, and which techniques they will be able to local anaesthetics within this space results in complete
use with increasing experience in paediatric regional blockade of the ipsilateral terminal branch of the tenth
anaesthesia. intercostal nerve, thus providing anaesthesia to the um-
bilical area.
Anatomical considerations: The ilioinguinal and iliohy- The block procedure is performed with the child placed
pogastric nerves are terminal branches of the lumbar in the dorsal recumbent position. The puncture site is lo-
plexus, both deriving from L1 roots, which supply sensory cated at the union of the lateral with the medial three
innervation to the inguinal region, the spermatic cord and quarters of the line uniting the umbilicus to the anterior
upper part of the scrotum and penis (Figure 2A). The two superior iliac spine (located by palpation). A short-bev-
nerves emerge at the lateral border of the psoas muscle elled needle is inserted at a 45 to 60° angle to the skin
and run within the lateral (Figure 2B) then anterior wall pointing towards the midpoint of the inguinal ligament
of the abdomen. The iliohypogastric nerve crosses the until the external aponeurosis of the external oblique
transversus abdominis muscle and runs obliquely along muscle is pierced, usually with some difficulty and a
the posterior aspect of the internal oblique muscle; at the clearly identifiable give (Figure 2D). Then, a single injec-
level of the iliac crest it divides into a lateral branch sup- tion of 0.3 to 0.4 ml/kg of 0.25-0.5% bupivacaine (up to
plying the buttock and a medial branch supplying the ab- 10 ml) is made in a fan shape manner. The overall success
dominal wall, above the pubis (Figure 2C). rate of the technique is higher than 95% and the distribu-
tion of anaesthesia allows pain free surgery of the in-
The ilioinguinal nerve runs parallel to the iliohypogastric guinal area.
nerve but more caudally and in a distinct fascial plane; it
crosses obliquely the quadratus lumborum and the iliacus
muscle, then pierces the transversus abdominis (at the
level of the iliac crest), enters the oblique muscles and fi-
nally reaches the lower border of the spermatic cord (or
the round ligament of the uterus) within the inguinal
canal (Figure 2C). It supplies sensory innervation to the
upper part of the thigh, the spermatic cord, scrotum and
penis in males or round ligament, labia major and mons
pubis in females.
Pubic bone
▲ Figure 4: Penile block via the subpubic space
Scarpa's Fascia C: Unilateral spread of the solution
▲
Subpubic space ▲
Figure 5: Anatomy of the lumbar (and sacral) plexus (Figure 3 from Tu- Figure 7: Fascia iliaca compartment block
torial from the Ulm rehabilitation hospital, page 10) B: Technique
(which also covers the iliacus muscle), i.e., the fascia ilia- Anatomical considerations: The ventral aspect of each
ca: any sufficient volume of local anaesthetic will spread digit is centred by one flexor tendon wrapped in a syn-
along the inner surface of this fascia and anaesthetise all ovial sheath the role of which is to allow movements of
the contacted lumbar plexus nerves. the tendon without friction. Outside the synovial sheaths
there is a membranous sheath derived from the palmar
Technique: The child is placed in the dorsal recumbent aponeurosis extending from the head of each metacarpal
position, preferably (if acceptable) with the thigh slightly bone to the distal phalanx delineating a closed longitudi-
abducted and laterally rotated (but any position is suit- nal canal surrounding each flexor tendon and called the
able). The main landmark is the inguinal ligament ex- flexor tendon sheath (22,23). The four digital nerves
tending from the anterior superior iliac spine to the pubic which supply each digit run within this canal and outside
spine located by palpation. The site of puncture is identi- the digital synovial sheath of the flexor tendons. A single
fied 0.5-1 cm caudal to the union of the lateral with the injection of local anaesthetic within this flexor tendon
medial two thirds of the skin projection of the inguinal sheath will reach the core of the digit and all four digital
ligament (Figure 7A), i.e., at significant distance from the nerves by circumferential spreading.
femoral artery (and the femoral nerve). A short-bevel
non-insulated needle, connected via an extension line to
the syringe filled with the local anaesthetic, is then insert-
ed vertically (Figure 7B) until it pierces the two underly-
ing fascial planes with a clearly identifiable loss of resis-
tance (often with an audible "click" noise): the first loss
of resistance corresponds to the crossing of the fascia lata
and the second one to that of the fascia iliaca.
Depending on the mandatory duration of analgesia, lig- Figure 8: Metacarpal (Transthecal) Block
nocaine, mepivacaine, bupivacaine or ropivacaine can be Landmarks, Technique
administered at different concentrations (depending on
the need for motor blockade). Due to the rather large
surface along which the solution spreads, increased vas- Technique: The technique is performed with the hand
cular absorption might occur; however, acceptable peak supinated. The main landmark is the head of the relevant
plasma concentrations were measured, following injec- metacarpal bone located by palpation. Right in the centre
tion of 2 mg/kg of bupivacaine, either plain or with adren- of the skin projection of this metacarpal head, an intra-
aline (21), even though the higher concentrations were dermalic needle is inserted perpendicularly to the palmar
observed following administration of plain solutions. aspect of the hand (Figure 8) until bone contact is made.
The needle is then slightly withdrawn to avoid sub-pe-
riosteal injection. At this time, any flexion of the distal
phalanx of the relevant digit is transmitted to the needle.
However, this confirmation is not necessary and the sy-
ringe filled with 2-3 ml of a plain solution of local anaes-
Metacarpal (Transthecal) Block thetic (lignocaine or bupivacaine) can be connected
directly to the needle (to avoid any inadvertent displace-
Indications, contraindications and complications: The ment of the needle). A volume of 1 to 3 ml of the local
technique aims at infiltrating the flexor tendon sheath anaesthetic (depending on the patient's size) is slowly in-
which surrounds the synovial sheath of the flexor tendon jected: the injection must be stopped when resistance is
of each digit and within which run the four digital nerve felt. Within 2 minutes all four digital nerves (2 ventral
supplying the relevant finger. The metacarpal/transthecal and 2 dorsal) are fully anaesthetised in more than 95% of
block procedure is recommended for any surgery on the patients (24, 25).
relevant digit (either traumatic or elective). This tech-
nique is an alternative to digital nerve blocks with many
advantages: it is a safer (no terminal artery in close prox-
imity), simpler (a single injection is made) and less
Plexus and conduction nerve block
painful procedure (even though injection is not pain- Plexus and conduction nerve blocks require a good
free) in conscious patients. Caution should be taken in knowledge of anatomy, especially anatomical relation-
case of infection; if there is a possibility of bacterial cont- ships to be achieved both successfully and safely. Most
amination of the synovial sheath, the technique should be such nerves are mixed nerves which are localised precise-
considered contra-indicated. This block is very simple ly with the help of a nerve stimulator. Selection of block
and is virtually free of complication. Its only real draw- needles is critical: they must be short-bevelled, insulated,
back is that puncturing the flexor tendon sheath is un- of appropriate length to reach the nerve path but not too
pleasant, even painful. long to avoid damage to deeper structures.
Brachial Plexus Nerve Blocks
Indications, contraindications and complications: The aim
of the technique is to inject a local anaesthetic within the
fascial envelope surrounding the plexus, either the inter-
scalene (above the clavicle) or the axillary sheath (in the
axilla). The brachial plexus and its terminal branches can
be approached in many ways. Basically, there are two
Dorsal scapular nerve
Suprascapular nerve
Subclavian nerve
Pectoral nerves
Musculocutaneous nerve
Axillary nerve
Figure 11: Opacification of the interscalene space during a parascalene
C5 block procedure. Note the lack of spread of contrast material below the
scapula.
C6
C7
A
B T1
C
T2
D
E
F
mains types of approaches: plexus approaches, above the Figure 12: Opacification of the axillary sheath: note the lack of spread
clavicle, and plexus nerve approaches below the clavicle, of contrast material above the scapula. Even in presence of an inflated
the morbidity of which differs significantly. tourniquet the contrast material does not spread to the interscalene
space.
Axillary blocks should be preferred whenever they are
suitable, especially for elective and emergency surgery on
the forearm and the hand. These blocks have few con-
traindications, mainly represented by lymphadenopathy
(infectious or malignant) and their morbidity is very low.
1 Axillary nerve
2 Musculocutaneous nerve
3 Radial nerve
4 Medial cutaneous nerve
of the arm
5 Medial cutaneous nerve
of the forearm
6 Median nerve
7 Ulnar nerve
Figure 13: Parasagittal cross-section of the body at the midpoint of the
Figure 10: Sensory supply of the upper limb (Figure 2 from Tutorial clavicle in a neonate. Note that the apex of the lung is located above the
from the Ulm rehabilitation hospital, page 9) first rib and clavicle.
Supraclavicular approaches are considered when the op-
erative field involves the arm and/or shoulder, or when
the limb cannot be positioned for performing an axillary
block either due to the pain or the lesion (in emergency
conditions). Classical contraindications to supraclavicular
bocks procedures include bilateral blockade and marked ▲
respiratory insufficiency (acute or chronic) due to the po-
tential danger of pneumothorax and (bilateral) phrenic
▲
nerve palsy. The parascalene approach (26,27,28), howev-
er, does not have the same limitations as the technique
does not threaten any vital organs, especially the apical
pleura.
Anatomic considerations: The brachial plexus is formed
by the union of the ventral rami of the 5th cervical to the
1st thoracic spinal nerves (Figure 9). It supplies sensory,
motor and sympathetic innervation to the upper extremi- Pectoralis major Coracobrachialis muscle
ty (Figure 10). It lies in the interscalene space, a fascial
Figure 15: Trans-coracobrachialis axillary approach to the brachial
compartment derived from the deep cervical fascia and plexus.
limited by the anterior and middle scalene muscles. The
interscalene space ends caudally at the level of the cora- muscle and penetrates the coracobrachialis muscle (Fig-
coid process of the scapula and does not communicate ure 14). The level at which the musculocutaneous nerve
with the axillary region (Figure 11): no local anaesthetic leaves the axillary sheath is variable: in half the patients,
injected in the interscalene space can spread to the axilla it emerges above the skin projection of the coracoid
and no solution introduced in the axillary sheath can process of the scapula and then will not be contacted by a
reach the interscalene even if a tourniquet is used (Figure local anaesthetic injected via the axilla: the lateral aspect
12). Supraclavicular and axillary blocks are not equiva- of the forearm will not be anaesthetised.
lent. Axillary approaches to the brachial plexus: The same
The interscalene space is very close to the great vessels of techniques as used in adult are suitable for children ex-
the neck and the spine medially. Caudally, it is close to cept for the transaxillary artery approach. Their main lim-
the subclavian vessels and the apical pleura. In infants, itation is the inconstant blockade of the musculocuta-
the upper part of the lung lies above the superior fora- neous nerve. As this nerve runs within the
men of the thorax, i.e. in the neck (Figure 13): the subcla- coracobrachialis muscle, which is easily identifiable by
vian vessels do not project above but below the apical palpation, a trans-coracobrachialis approach will almost
part of the lung. Thus, any subclavian approach to the constantly provide complete blockade of the median, ul-
brachial plexus directly threaten the underlying lung and nar, radial and musculocutaneous nerves. The relevant
will sooner or later results in pneumothorax. No needle arm is abducted by 90° as in classical approaches. The
should be introduced below the horizontal plane lying 1 landmarks are the lower border of the pectoralis major
cm above the clavicle. muscle and the lateral border of the coracobrachialis
Below the clavicle, the plexus consists of three trunks muscle. The site of puncture lies slightly medial to the
(lateral, medial and posterior) which redistribute their fi- crossing of these two border (in order to insert the block
bres in three cords surrounding the axillary artery. From needle through the substance of the coracobrachialis
muscle) (Figure 15). The needle is inserted vertically,
pointing to the lower border of the humerus, just above
the axillary artery which is firmly held by finger compres-
sion, until a "click" is felt and twitches are elicited. What-
ever the technique used and unlike adults, location of
several nerves and administration of fractionated doses
of local anaesthetic in children bring no benefit to the
quality of sensory and motor block (29). However, selec-
tive block of the musculocutaneous nerve (which is sys-
tematically achieved with trans-coracobrachialis ap-
proach) is recommended when a surgical procedure takes
place in this territory. Commonly used local anaesthetics
are displayed in Table 1 and recommended volumes of in-
jection in Table 2.
The development of catheter placement techniques is rev-
olutionising postoperative pain management. Even
though it is still under evaluation, this technique allows
safe and long-lasting pain management of patients (30).
The technique allows both intermittent bolus administra-
Figure 14: Dissection of the axillary region in a neonate. tion, continuous infusion and self administered bolus in-
jection of diluted solutions of local anaesthetics. Common-
these cords emerge the terminal nerves of the plexus: the ly administered bolus doses of local anaesthetics range
ulnar nerve medially, the median nerve above or slightly from 0.2 to 0.4 ml/kg (up to 10 ml) of 0.5-1% lignocaine or
lateral to the artery, and the radial nerve posterior to the mepivacaine every 6 (or, at the very maximum, 4) hours.
artery. The musculocutaneous nerve emerges from the Continuous infusion of 0.1-0.125% plain bupivacaine (or
lateral cord at the upper border of the pectoralis minor 0.2% ropivacaine) at a rate of 0.5 ml per hour and per
1 and recommended volumes of injection in Table 2.
The overall success rate of the technique is high
(26,32,33,34). The upper branches of the brachial plexus
are anaesthetised earlier whereas blockade of the distal
branches (median, radial and ulnar nerves) are often de-
layed and, sometimes (rarely), incomplete. Morbidity of
the parascalene technique is extremely low and even
Horner’s syndrome is unlikely (less than 5% of proce-
dures); only a very faulty technique ("… as suggested by
the marked resistance to injection, by the agonizing pain
experienced by the patient…" ) can result in adverse ef-
fects (54).
A catheter can be introduced within the interscalene
space to provide long-lasting pain relief, either by inter-
mittent, continuous and/or patient-controlled delivery of
bolus doses of local anaesthetic (35,36). Patient-con-
trolled delivery of local anaesthetic provides better pain
relief, less adverse effects (nausea and vomiting especial-
ly) and better patient satisfaction than patient-controlled
intravenous analgesia with opioids (37). Catheter fixation
is easier at neck level than in the axilla and the danger of
accidental removal is minimised.
Sciatic block in the popliteal fossa: The sciatic nerve can Conclusion
be approached in the popliteal fossa with smaller doses of
local anaesthetics than following a proximal approach. In Peripheral blocks are being increasingly considered for
this fossa, the sciatic nerve and its branches lie below the use in children due to their many advantages. They pro-
popliteal membrane which has important clinical implica- vide limited distribution of anaesthesia, require smaller
tions in regard to the spread of the local anaesthetic (43). amounts of local anaesthetics than most central block
A simplified single-shot technique was recently reported procedures and are very safe with virtually no general or
for use in children placed in the lateral decubitus position systemic effects. This interest is still enhanced by the con-
with the affected extremity lying uppermost (44). The siderable improvements in the design of devices made by
landmarks are the limits of the popliteal fossa: 1) the ten- the manufacturers which make the performance of such
don of the biceps femoris muscle laterally; 2) the tendon blocks not only possible but safe whatever the age of the
of the semi-tendinosus muscle medially; and 3) the hori- patient, including the neonatal period. New perspectives,
zontal skin crease of the knee joint. The landmarks are still under evaluation, are offered by the development of
made more visible with the legs flexed at 30°. The site of catheter techniques which allow long-lasting and well
puncture lies slightly lateral to bisecting line of the upper adapted analgesia either by repeat bolus injection just
angle formed by the convergence of the two tendons, at prior to short-lasting but repeated painful procedures
the level of the union of the lower third with the upper (joint mobilisation), or continuous infusion (long-lasting
two thirds (Figure 20A). An insulated needle is inserted pain) or both continuous infusion and self-administered
cephalad at a 45° angle to the skin in direction to the fe- additional bolus doses (allowing fine tuning of the level
mur until twitches are elicited in the sciatic territory. of analgesia under the control of the patient). Since there
are no more theoretical reasons not to use peripheral
blockades there seem to be practical limits because these
techniques are basically not taught and anaesthesiologists
are therefor not aware of it. Continuous education pro-
grams have to compensate for this incomplete training
and the best way to achieve this goal is by establishing a
progressive plan beginning with the easiest and most use-
ful techniques, then progressively moving towards more
complicated procedures. In this regard, infiltration tech-
niques and compartment blocks are the simplest tech-
niques, not requiring particular skills or sophisticated de-
vices, the indications of which are numerous in daily
paediatric anaesthesic practice. Once significant experi-
ence, and confidence, have been acquired with these pro-
cedures, the time has come to move forward to peripheral
conduction nerve blocks. Whether these techniques look
more complicated as they require the use of insulated
Figure 20: Sciatic nerve block in the popliteal fossa needles of appropriate length connected to a nerve stim-
A: Landmarks and insertion route ulator correctly adjusted, they do not need particular
skills (less than those necessary for performing a tracheal
intubation) but just some precise knowledge of local
anatomy: the important point is the correct location of
the puncture site. If this is achieved, the nerve stimulator
will allow the anaesthetist to locate the nerve without
error; if the needle is not put in the right place, whatever
the skills of the practitioner, it will not be possible to find
a nerve where it does not run.
2. Ferguson S, Thomas V, Lewis I. The rectus sheath block in paediatric 25. Low CK, Wong HP, Low YP. Comparison between single injection
anesthesia: new indications for an old technique ? Paediatr Anesth transthecal and subcutaneous digital blocks. J Hand Surg [Br] 1997;
1996; 6: 463-61996. 22: 582-4.
a: Maximum doses are controversial; the doses mentioned above are safe when given as single injections.
Table 2: Commonly recommended volume of injection of local anaesthetic solutions (according to patient's weight).
Lumbar Level
The spinal cord ends at birth at L3 level and the inter-
cristal line crosses L5. Usually the lumbar block is per-
formed at L5-S1 or L4-L5 level with a midline approach
(Taylor modified) with a Tuohy needle, almost perpendic-
ularly to the skin with the bevel facing cephalad, crossing
Fig 2: Detecting the epidural space
the superficial planes and the yellow ligament (Fig 1).
The indications for the lumbar block are operations in-
volving dermatomes between T5 and S5, single shot for
surgery lasting less than 90 min and with no need for long
post-operative analgesia
Thoracic Level
The anatomy of the thoracic approach increases the diffi-
culty in the block performance because the spinous
processes are more oblique than at lumbar level, the
epidural space is reduced and the dura mater is much clos-
er to the yellow ligament and the spinal canal is narrower.
We have to balance the risk/benefit ratio and only well-
trained, experienced anaesthetists must approach this
block
The landmarks are the prominent spine of the 7th cervical
vertebra and the line joining the angles of the shoulder
blades that crosses the 7th thoracic vertebra. The Tuohy
Fig 1: Approaching the lumbar level in a newborn (a big sacral teratoma needle must be inserted with a more oblique inclination;
can be seen) the median approach is preferable and, as usual, a seda-
tion/light anaesthesia is mandatory before the block per-
formance.
The Loss of Resistance Technique (LOR) can be per-
Indications: T2-T4 level for the thoracic surgery, T6-T8
formed with air or with saline solution or CO2 (1). In
level for upper abdominal surgery and T10-T12 for lower
Italy we are used to work with air. Moreover air may be
abdominal surgery.
useful in newborns or infants to detect if dura mater was
accidentally punctured (saline solution may mask CSF
reflux that at this age has not the usual adult pressure)
Continuous infusion or single shot?
and saline can dilute the small amount of drug used.We The decision if a single shot or a continuous infusion
use 1-1.5 ml of air just to detect the change of resistance must be performed depends on the length of surgery and
and not to inject into the epidural space. (Fig 2) on the intensity of postoperative pain. A procedure can
be very short but very painful too, even in the postopera- we can perform a block and a catheter positioning even
tive period or may be very longlasting so that a single in very low weight newborns so that also in the paediatric
shot cannot provide adequate analgesia along the opera- field the accelerated program and the outcome improve-
tion itself. ment can be applied.
Generally speaking for the so called “minor surgery”
such as inguinal hernia,hydrocele, phymosis the analgesic Of course what is needed for a continuous infusion is
requirement is reduced and a single shot is the best solu- mandatory for a single shot too, both at lumbar or tho-
tion while for a long term surgery a catheter positioning racic level and even the caudal approach requires the ap-
is advisable. propriate size and needle,short bevelled and with a stylet
inside (20).
Continuous epidural catheter placement
In conclusion pain control is one of the main targets in
When a catheter positioning is required, even if there are children and it is a big challenge for the new century.
reports about the placement of an epidural catheter at Today we, paediatric anaesthesiologists, have many op-
lumbar or thoracic level from the caudal space, Tuohy portunities to work in a safe and effective way for an ade-
needle should be inserted in the correct site ,close to the quate pain control and with drugs such as ropivacaine
surgical target area, with the indwelling catheter just 2-3 and levobupivacaine, adjuvants such as clonidine and ket-
cm in the epidural space in order to avoid postoperative amine and paediatric tools such as small Tuohy and cau-
infusion of excessive drug doses or kinking or malposi- dal needles and catheters, regional anaesthesia can be
tioning. Moreover, as case reports describe infections or considered one of the best solution playing a great role
colonizations after catheterisation "if catheter is sup- in the perioperative pain management. (21-22)
posed to be mantained after the end of surgery for the
postoperative pain control, the lumbar approach seems
to have less risks than the caudal one (2-7)".
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93:976-980.
5. Meunier JF, Noorwood P, Dartayet B et al. Skin abscess with lumbar
catheterization in infants: is it dangerous? Report of two cases. 17. Lee HM, Sanders GM. Caudal ropivacaine and ketamine for postop-
Anesth Analg 1997; 84:1248-1249 erative analgesia in children. Anaesthesia 2000; 55:806-810.
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1995; 80:234-238 tamine vs clonidine. Paediatr Anaesth 2001; in press
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