Pediatric Anesthesia ISSN 1155-5645

REVIEW ARTICLE

Benefits of regional anesthesia in children

Adrian Bosenberg
Faculty Health Sciences, Department Anesthesiology and Pain Management, Seattle Children’s Hospital, University Washington, Seattle,
WA, USA

Keywords
regional anesthesia; benefits; reviews
Correspondence
Adrian Bosenberg,
Faculty Health Sciences, Department
Anesthesiology and Pain Management,
Seattle Children’s Hospital, University
Washington, 4800 Sandpoint Way NE,
Seattle, WA 98105, USA
Email:
adrian.bosenberg@seattlechildrens.org
Section Editor: Per-Arne Lonnqvist
Introduction
Regional anesthesia has wide-ranging benefits but requires technical exper-
tise. Its use in neonates, infants, and children continues to escalate, both as
a sole anesthetic or in combination with general anesthesia, to provide both
intraoperative and initial postoperative analgesia (1–7). Untreated pain has
several deleterious effects, whereas effective pain relief may play a signifi-
cant role in surgical outcome because ‘untreated’ surgical stress produces a
spectrum of autonomic, hormonal, metabolic, immunologic/inflammatory,
and neurobehavioral consequences. Regional anesthesia is almost univer-
sally employed to provide analgesia, but it may also be used for its auto-
nomic and motor effects in special circumstances.

Accepted 5 August 2011

doi:10.1111/j.1460-9592.2011.03691.x

In choosing regional anesthesia, the risks and bene-
fits of the technique must be weighed against the risks
and benefits of other forms of analgesia. Many factors
influence the choice of technique (4–7). These include
informed consent, the age and general condition of the
patient, and the presence of co-morbidities (respira-
tory, cardiac), the severity and site of the pain, the skill
of the anesthesia provider, and whether any contrain-
dication to regional anesthesia is present. In making
the choice, the anesthesiologist should also take into
account the equipment, facilities, and the level of mon-
itoring and nursing care available. In general terms, a
peripheral nerve block is considered safer than a
neuraxial block (2,3).
It is difficult to show clear ‘evidence-based’ benefits
of regional anesthesia over other forms of analgesia
(3,7). With respect to the pyramid of evidence, apart
from many single institution case series, retrospective
reviews, and anecdotal reports, there are few prospec-
tive randomized controlled studies comparing regional
anesthesia with general anesthesia or systemic analge-
sics in children (6,7). Those that have been performed
are often underpowered, have different and varying
endpoints, and are usually from single institutions. In
addition, more surgery is being performed laparoscopi-
cally or thoracoscopically, negating the need for neur-
axial blockade where a peripheral nerve block or
different analgesic method will suffice (2).
Taking this into consideration, this review, unless
stated, confines itself to studies pertaining to children.
In some instances, regional anesthesia is combined
with adjuvants (opiates, clonidine, ketamine) that may
contribute to the risk. The areas covered include the
safety of regional blocks in children, analgesia, and
consequently other beneficial physiological effects both
within and outside the operating room and in the
postoperative period.
Safety
Regional anesthesia in children is safe, provided
appropriate care and attention to detail are taken.
Infants and neonates carry a slightly greater risk of
complication, and these age groups should therefore

10 Pediatric Anesthesia 22 (2012) 10–18 ª 2011 Blackwell Publishing Ltd

A. Bosenberg
remain the domain of experienced practitioners (1,4,6–
12). Because most regional blocks are performed on
anesthetised children, techniques described in adults
are not always appropriate for use in children. For
example, insufficient negative pressure is generated
during inspiration to allow the ‘hanging drop’ tech-
nique or other negative pressure detectors to be used
safely (13). Intuitively, provided it is used correctly,
the advent of ultrasound should reduce complications
because most peripheral nerves are relatively superficial
in children (14,15). This is supported by a recent meta-
analysis of nine studies involving only 649 children
from a few centers (16). Large multicentre studies are
needed to provide more evidence.
While serious complications have been reported
anecdotally (14), the morbidity related to regional
anesthesia in children, based on large retrospective (8–
10) and prospective studies (1,7,11,12,16–19), is low –
approximately 1 : 1000 overall. The majority of
complications (e.g., intravascular injection, convul-
sions, dural puncture) occur at the ‘end of the needle’
when the anesthesiologist is still present and should be
successfully managed without long-term sequelae. With
the advancement of technology and custom designed
equipment for children, further improvement in the
safety of regional anesthesia can be expected.
Pain relief
Regional anesthesia provides profound analgesia with
minimal physiological pertubations or side effects (20–
23). Single-shot blocks are limited by the duration of
the local anesthetic agent used. However, with the
recent development and application of continuous
peripheral nerve catheters, more prolonged analgesia is
possible (24,25). Regional anesthesia is an effective
alternative to systemic analgesics (26,27). This is par-
ticularly relevant when systemic opiates are contraindi-
cated in children at risk of opiate-induced respiratory
depression (acute) or have become tolerant to their
analgesic effects (chronic pain). Regional anesthesia is
considered more effective against visceral pain, e.g.,
bladder spasms following genito-urinary surgery
(28,29) than systemic opiates.
The profound analgesia provided by regional anes-
thesia provides ideal psychological conditions for the
recovering child and indeed their family (30,31). Car-
ing for an alert, calm, and cooperative child reduces
the workload for nurses in the recovery room because
children who are pain free are less inclined to be unco-
operative and are less likely to interfere with the oper-
ation site, remove dressings, drainage tubes or urinary
catheters (32).
Pediatric Anesthesia 22 (2012) 10–18 ª 2011 Blackwell Publishing Ltd
Benefits of regional anesthesia
An additional benefit of regional anesthesia is that it
can be used when general anesthesia is contraindicated,
considered technically difficult or associated with
increased morbidity and mortality (32). Children or
infants in this category include ex-prematures for her-
nia repair (33–35) or other minor procedures (36,37);
those with neuromuscular, (38) metabolic, cardiac, or
chronic lung disease; children at risk of malignant
hyperthermia or in emergency situations when patients
are at risk of aspiration (39). Regional anesthesia can
be used to reduce simply fractures in the emergency
room (40,41), thereby facilitating earlier discharge and
avoiding a long wait for a break in operating room
schedule.
A rare but very real benefit of regional anesthesia is
that it provides those children with a morbid fear of
‘going to sleep’; those who dislike the ‘loss of control’
during induction; or those who fear ‘never waking up’,
an alternative to general anesthesia. In my experience,
these children are invariably in their early teens and
are well aware of their illness that is usually chronic or
life threatening.
Despite the profound analgesia provided by regional
anesthesia, consideration should always be given to the
psychological aspects of pain. ‘Just because its numb
doesn’t mean it doesn’t hurt’ (42) is a quote that drives
home this point. Some children particularly those over
about 6 years may become very distressed by the
absence of sensation over large areas of their body
(43). Conversely, in the absence of pain, infants and
young children may focus their attention on the ‘pain’
from the intravenous cannula or plaster cast, or be dis-
turbed by awakening in a foreign environment sur-
rounded by strangers. Both situations need to be
handled with sensitivity, care, and understanding.
Reduction in general anesthetic requirement
(MAC)
Regional anesthesia is generally performed in combina-
tion with general anesthesia in children (1,44–47).
There are a number of advantages to this practice
because anesthetic depth can be reduced by regional
anesthesia, thereby potentially reducing the complica-
tions of both forms of anesthesia. Immature organ sys-
tems (cardiovascular, central nervous and respiratory)
are sensitive to the depressant effects of anesthetic
drugs. All inhaled anesthetic agents produce dose and
agent-related decrease in cardio-respiratory mechanics
and central ventilatory control, particularly in
neonates, infants, and young children.
The reduction in anesthetic depth (MAC) offers sev-
eral advantages including (i) avoidance of airway
11
Benefits of regional anesthesia
instrumentation and by implication respiratory assis-
tance is not usually required, (ii) reduced need for
muscle relaxants, (iii) smoother more comfortable
emergence (iv) faster wake-up times, (vi) rapid dis-
charge from recovery (vii) earlier return of appetite,
and importantly (viii) reduction in the risks associated
with deeper planes of general anesthesia (1,4,26,27,
32,46).
Regional anesthesia has been used as a sole agent for
ex-prematures undergoing inguinal hernia repair to
avoid the complications associated with general anesthe-
sia. Inguinal hernia repair under spinal anesthesia (47)
or caudal (48,49) is reported to have fewer episodes of
apnea, hypoxemia, and bradycardia than those who
receive general anesthesia (50,51). The jury is out,
though, because recent publications using newer inhala-
tional agents (desflurane, sevoflurane) suggest little dif-
ference (52–54). However, the ex-premature today is
very different from those described in the earlier studies.
Ventilation strategies have changed, and surfactant is
now available resulting in less barotrauma and less
severe broncho-pulmonary dysplasia. Comparison with
the studies carried out prior to the sevoflurane and
desflurane era is therefore questionable.
Neurotoxicity of general anesthetic agents
The impact that general anesthetic agents have on the
developing brain is stimulating great interest and is
worth considering. Recent studies in rat and primate
models have suggested that anesthetics (NMDA recep-
tor agonists, GABA receptor antagonists) may induce
neuronal cell death (apoptosis) in the immature devel-
oping brain (55–60). The neurodegenerative effect
seems to be both time- and dose-sensitive (58,60) and
is thought to coincide with the peak period for
synaptogenesis (60). Intuitively, if exposure to general
anesthetic agents can be reduced, then the detrimental
effects of inhalational anesthesia could be reduced
when used in combination with regional anesthesia.
Furthermore, a recent editorial suggests that local
anesthetics may be neuroprotective in adults. Follow-
ing cardiac surgery, a continuous infusion of lidocaine
reduced cognitive dysfunction following cardiopulmo-
nary bypass (61). The study would be difficult to
repeat in children but the potential benefits are worthy
of further investigation.
Physiological benefits
Hemodynamic stability
Central neuraxial blockade in young children is char-
acterized by remarkable hemodynamic stability (21,62–
12
A. Bosenberg
66), and clinically significant decreases in blood pres-
sure are seldom seen in children younger than 8 years
of age (66). This obviates the need for volume preload-
ing or vasoconstrictors. The reason for this hemody-
namic stability has not been clearly defined but is
probably related to the small lower limb capacity in
younger children or the ability of those vessels in the
unblocked segments to compensate (65).
Some argue that the neurodegenerative changes seen
in the rat model are secondary to cardiovascular
depression leading to low tissue perfusion and hypoxia
(60). These insults could also induce neurodegeneration
in immature brains. If this were true, it could be
argued that regional anesthesia, by maintaining hemo-
dynamic and respiratory stability in both premature
and mature newborns, could reduce the severity of
these insults.
Reduced need for postoperative ventilatory support
Several investigators report that epidural analgesia is
more beneficial than conventional opiate therapy in
children, particularly infants, undergoing thoracic and
upper abdominal procedures (67–71). The reasons sug-
gested include excellent analgesia without the risk of
opiate-induced respiratory depression, an improved
ventilatory efficiency, (72) improved ventilatory
response to hypercapnia (73,74) with bupivacaine (but
not lignocaine) (73), and possibly a direct stimulatory
effect of bupivacaine on the respiratory center (72,73).
In contrast to intravenous opiates, the need for post-
operative ventilatory support (67,70,71) is reduced by
regional anesthesia and, if required, ventilation is of a
shorter duration (66), with fewer complications (hyp-
oxemia, pneumonia) (70) and as a consequence shorter
intensive care stays (70) This was particularly evident
in high-risk children under 2 years of age with neuro-
logical and respiratory disorders undergoing Nissan
fundoplication (70).
Neonates and infants in particular are sensitive to
the respiratory depressant effects of opiate analgesia.
In this age group, epidural analgesia may be indi-
cated when the goal is early extubation [e.g., after
tracheoesophageal fistula (6,67) or gastroschisis repair
(6,46,75)] or spontaneous ventilation to avoid baro-
trauma (e.g., following congenital diaphragmatic her-
nia repair). These goals are particularly relevant in
developing countries where facilities are limited or
stretched (46,67). In addition to analgesia, epidural
blockade affords some degree of muscle relaxation
(motor blockade). Neonates who have undergone
closure of a gastroschisis or omphalocoele benefit
from both continuous analgesia and abdominal mus-
Pediatric Anesthesia 22 (2012) 10–18 ª 2011 Blackwell Publishing Ltd
A. Bosenberg
cle relaxation, whether they are ventilated or not
(46,75).
Analgesia following thoracotomy
Post thoracotomy pain is considered the most intense
pain imaginable (39). Although intravenous opioid
infusions are widely used, some authors consider that
adequate analgesia cannot be achieved in doses that
permit safe spontaneous ventilation (32). Epidural anal-
gesia (67,76,77), paravertebral block (78), intrapleural
infusion(79), and intercostal nerve blocks (80,81) have
all been shown to be effective for thoracotomy pain.
Inadequate analgesia following thoracotomy leads to
respiratory dysfunction (39,76,77), while adequate
analgesia preserves pulmonary function and may hasten
recovery (67,68).
Anecdotal reports of a neonate following tracheo-
esophageal repair (76) and a toddler following a thora-
cotomy (76) lend support to the benefits of regional
anesthesia. Both children in these reports showed
improved respiratory function after restarting epidural
analgesia when alternative methods had failed.
Somewhat controversially, proponents of regional
anesthesia suggest that spinal or epidural anesthesia is
beneficial for both closed- and open-heart surgery (82–
84). Neuraxial blocks were placed at least one hour
before anticoagulation for cardiopulmonary bypass.
Thoracic epidural was considered the most effective
(83). The perceived benefits for cardiac surgery include
earlier extubation – 89% in the operating theater (83)
– and a shorter hospital stay. This may be particularly
advantageous following Fontan repair or other single
ventricle pathology where spontaneous ventilation is
believed to improve pulmonary blood flow and oxy-
genation (85).
Hormonal stress response
Surgical trauma induces a stress response that may
have detrimental autonomic, hormonal, metabolic,
immunologic/inflammatory, and neurobehavioral con-
sequences This could seriously effect the outcome of
surgery (86), particularly in malnourished or immuno-
compromised individuals (87). The severity of the
stress response varies in direct proportion to the degree
of surgical stress (88,89). There is some evidence to
suggest that severe stress may be pathological and con-
tributes to postoperative morbidity and mortality;
extreme catecholamine responses are associated with
the worst outcome (88,89). Numerous publications
attest to the efficacy of epidural, spinal, and peripheral
nerve blocks in obtunding the neuroendocrine stress
Pediatric Anesthesia 22 (2012) 10–18 ª 2011 Blackwell Publishing Ltd
Benefits of regional anesthesia
response (6,84,87,90–92). The lack of definable end-
points, however, makes it difficult to assess whether
one anesthetic technique is superior.
In terms of hormonal levels, studies have shown
that stress hormones (epinephrine, norepinephrine,
adrenocorticotropic hormone, cortisol, prolactin) and
blood glucose levels are lower following regional anes-
thesia than after general anesthesia, with (84,90,91) or
without (87,92) opiate analgesia, or when the regional
block is placed at the end of surgery (92). These lower
levels may persist for longer than 24 h after lower
abdominal surgery (87). However, in terms of pain
scores and other clinical endpoints, no difference
could be detected despite these lower hormonal levels.
Further studies in larger groups with more appropri-
ate clinical endpoints are required.
Reduction in intraoperative blood loss
Clinical experience suggests that general anesthesia
supplemented with regional anesthesia produces better
operating conditions and a reduction in surgical blood
loss in children. Three studies involving infants under-
going cleft lip repair (infraorbital nerve block) (93) or
children undergoing tonsillectomy (94) or hypospadias
repair (caudal anesthesia) (23) support this hypothesis.
In the hypospadias study, the authors found that the
blood loss under general anesthesia alone was almost
double that of children who had received a caudal
block (31 ± 17 ml vs 16 ± 10 ml) (28). In view of the
relatively small volumes involved, it is not surprising
that the intraoperative blood loss did not correlate
with an increase in heart rate or fall in blood pressure.
All children were allowed to breathe spontaneously
throughout and mild hypercarbia developed in those
who received general anesthesia alone but this was not
considered significant enough to have contributed to
the increased blood loss. The authors suggest that the
reduced blood loss may have contributed to the
shorter operating time (92 ± 13 vs 103 ± 14 min)
(28).
Gastrointestinal function
Earlier return of gut function is a further benefit of
regional anesthesia (46,75,95,96). Peristalsis is better
maintained with epidural infusions, whereas opiates
increase intestinal muscle tone and slow peristalsis
(95). The vasodilatory effects of autonomic blockade
may improve splanchnic perfusion in necrotizing
enterocolitis (46,75,96) and gastroschisis (46,75),
whereas opiates increase intestinal muscle tone increas-
ing the risk of anastomotic leaks (96).
13
Benefits of regional anesthesia
Host-defense mechanisms
There is a popularly held belief, particularly among
surgeons, that wound infiltration may increase the risk
of infection. While the evidence for this is inconclusive,
there is increasing evidence both in vitro and in vivo of
the beneficial effects of local anesthetics on the inflam-
matory response (97). Local anesthetics may have an
influence on other cellular systems at levels much lower
than required for sodium channel blockade. An area
of particular clinical interest and relevance is their
effect on inflammatory cells [mainly polymorphonu-
clear leukocytes (PMNL) but also macrophages and
monocytes] (97,98).
Overactive inflammatory responses that destroy
rather than protect are critical in the development of a
number of perioperative disease states. These include
postoperative pain syndromes, respiratory distress syn-
drome, systemic inflammatory response syndrome, and
multi-organ failure. Perioperative modulation of these
responses is relevant to anesthesiologists and is the
subject of an excellent review (97). Local anesthetics
may influence inflammatory lung injury, micro-vascu-
lar permeability, and ischemia-reperfusion injury in
addition to a host of other effects under investigation
(97).
In the only comparative study performed in chil-
dren, halothane was associated with more prolonged
depression (>24 h) of PMNL chemiluminescence than
after caudal block for lower abdominal surgery (98).
Chemiluminescence is used to evaluate oxygen-depen-
dant microbiocidal activity in PMNL. The clinical rele-
vance of this study is unknown but is part of a series
of ongoing studies in this field.
Finally, local anesthetics, and not opioids, stimulate
the activity of natural killer cells that play an
important part in nonspecific cellular-mediated and
antitumoral immunity (99,100). To date, there have
been no studies in children that show a reduction in
neoplastic recurrence following regional blocks.
Outside the operating room
The benefits of regional anesthesia have also been
applied outside the operating room.
Caudal blocks have been used to reduce incarcerated
inguinal herniae prior to surgery, thereby obviating the
need for intravenous sedation in premature infants sus-
ceptible to apnoeic spells (101).
Purpura fulminans (102) and tetanus (103) are two
particularly painful conditions. The ischemic pain of
purpura fulminans or painful tetanic muscle spasms
can be effectively managed using continuous epidural
14
A. Bosenberg
infusions or appropriate peripheral nerve blocks
(102,103). The autonomic instability associated with
such diverse conditions such as tetanus (103) snakebite
and pheochromocytoma (104,105) can be successfully
managed with epidural blockade.
Other situations where autonomic blockade may be
beneficial include vasodilation of ischemic or compro-
mised limbs (106–111) after arterial line (110,111) or
umbilical arterial catheter misadventure (112) or penile
ischemia (113). Painless placement of percutaneously
inserted central catheters (PICC lines) can also be
facilitated with an axillary block or femoral nerve
block that will both dilate the veins and immobilize
the limb (36,37).
Regional anesthesia has a role in unusual causes of
intractable pain, postherpetic itch (114), or chronic
pain management, particularly those with an auto-
nomic component (115–117). Epidural and peripheral
nerve catheters have been used to provide analgesia in
terminal patients, thereby moderating opioid require-
ments and allowing end-of-life care at their preferred
location (118).
Economics
In the current climate of cost awareness and economics
in medicine, the impact of regional anesthesia will
come under close scrutiny. While the anesthetic
charges for epidural anesthesia are greater than for
intravenous opiates, in terms of overall charges (oper-
ating room time, hospital costs, acute pain service),
epidural analgesia has been shown to be significantly
cheaper in view of the reduced ventilatory support,
reduced stay in the ICU, and shorter hospital stays
(46,67,70,71,82,83).
With regard to day-stay surgery, earlier discharge is
dependant on discharge criteria at a particular institu-
tion. While regional anesthesia allows children to be
more alert postoperatively and to eat sooner with less
nausea and vomiting, controversy exists as to whether
these children can be discharged while the residual
effects of the block remain. Children have been
allowed home earlier with peripheral nerve catheters in
situ without significant complications but considerable
cost saving (25). The cost savings would therefore be
determined by the policy adopted by each institution.
Conclusion
Regional anesthesia is a safe and effective method of
analgesia (119), especially as a supplement to general
anesthesia. The benefits have been difficult to demon-
strate in adults (120), for many of the reasons that
Pediatric Anesthesia 22 (2012) 10–18 ª 2011 Blackwell Publishing Ltd
A. Bosenberg Benefits of regional anesthesia

apply to children. In modern anesthesia using an end-
point of morbidity and mortality, it is very difficult to
show a difference without very large numbers. Clearly
defined endpoints need to be drawn to demonstrate a
quantifiable improvement in outcome.
The benefits in children as outlined in this manu-
script are significant. Enthusiasts would claim that fur-
ther study is unnecessary and that children deserve the
benefit of regional anesthesia in view of the low risks
involved. Purists on the other hand would insist on
prospective studies to claim any benefit. Some less
experienced anesthesiologists are reluctant to offer the
benefit of some of the more difficult blocks because
they consider the risk too great, particularly in the face
of adverse medico-legal climate and lack of evidence.
Most of the popular regional anesthetic techniques
are easy to perform, but simply because a block can be
performed does not mean that it is necessarily the best
choice for a particular patient. Each block requires
careful consideration. With the advent of ultrasound-
guided nerve blocks, together with ongoing improve-
ment in equipment for use in children, meticulous
attention to detail, careful monitoring, and regular
audit, the safety of regional anesthesia in infants and
children will continue to improve and more children
should benefit.
Acknowledgements
This research was carried out without funding.
Conflict of interest
No conflicts of interest declared.

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