MINERVA MEDICA COPYRIGHT®

REVIEWS

Pediatric regional anesthesia

G. IVANI, V. MOSSETTI
Division of Pediatric Anesthesiology and Intensive Care Unit, Regina Margherita Children’s Hospital, Turin, Italy

ABSTRACT
Pediatric regional anesthesia has attained wide use internationally because of its efficacy and safety; its use is support-
ed by the existence of extensive data from the international literature underlining the safety and efficacy of this tech-
nique. Safer drugs and dedicated pediatric tools are the keys to this success. Indeed, if we compare the drugs available
to pediatric anesthesiologists for use in performing a block years ago with those in use today, it can be seen that progress
in this area has been tremendous. The long journey began many years ago; at that time, pediatric regional anesthesia
was seen as an extravagant and useless technique, used by only a few and opposed by many detractors. Despite its
well-known benefits, clinical failures can occur during the application of regional anesthetic techniques. Neurovascular
anatomy is highly variable, and presently available nerve localization techniques provide little or no information regard-
ing the anatomical spread of local anesthesia; furthermore, traditional nerve localization techniques (nerve stimulation)
rely on anatomical assumptions that may be incorrect. Modern imaging techniques, such as computed tomography
scanning and ultrasound, are now available for improving these procedures. The ultrasound technique is now widely
applied in children and many reports confirm the efficacy and advantages of this method. In children, ultrasound
guidance has been shown to improve block characteristics, resulting in shorter block performance time, higher success
rates, shorter onset, longer block duration, reduction in volume of local anesthetic agents required, and better visibil-
ity of neuraxial structures. Clinical studies in children suggest that ultrasound guidance has some advantages for region-
al block over more traditional nerve stimulation-based techniques. However, with the exception of ilio-inguinal blocks,
the advantage of ultrasound guidance over traditional with respect to safety has not been adequately demonstrated in
children, since there are only a limited number of randomized control trials in children comparing ultrasound-guid-
ed peripheral nerve block with other techniques. Real-time ultrasound guidance for peripheral regional anesthesia is
not a foolproof technique. New data have emerged suggesting that the novice ultrasonographer may often commit repeat-
ed errors, the two most common being failure to visualize the needle during advancement and unintentional probe move-
ment. For this reason, the American Society of Regional Anesthesia and the European Society of Regional Anesthesia
created a Joint Committee, and a document was produced “to recommend to members and institutions the scope of
practice, the teaching curriculum, and the options for implementing the medical practice of ultrasound-guided region-
al anesthesia services”. (Minerva Anestesiol 2009;75:577-83)
Key words: Ultrasonography, interventional, instrumentation - Anesthesia, conduction - Child.

P ediatric regional anesthesia (PRA) has today
reached widespread use, supported by reassur-
ing data from the international literature show-
ing the safety and efficacy of this technique. The
long journey to its present-day success began many
years ago, at a time when PRA was seen as an
extravagant and useless technique suited for only
a few and opposed by many detractors.
The founders
During the last century, the work of Armando
Fortuna, Ted Armitage, Paolo Busoni, Claude
Saint-Maurice, Lynn Broadman and a few others
(including more recently an exhaustive book on
pediatric regional anesthesia by Bernard Dalens) 1
began to provide PRA with official scientific

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IVANI
approval. The results reported by these workers
had a major effect in the pediatric world; the papers
and books they published showed the world of
anesthesia that regional anesthesia (RA) was a tech-
nique that was available and appropriate for use
in children.
The spread of their work was slow but progres-
sive and other “pioneers” followed their example.
Problems
As the number of publications increased and
the first pediatric regionalists were invited to speak
at a meeting of anesthesiologists, a problem became
evident.
An important first question arose: as very often
there is need for sedation/anesthesia before per-
forming a block in a child, it is important to choose
the right type of anesthesia, i.e., general or region-
al. The contrast was based on the idea that risks
could double in combining general and regional
anesthesia. Many "adult" anesthesiologists who
reviewed the papers on PRA use in children viewed
the problem in this manner and therefore, in many
cases, these papers were rejected irrespective of the
quality of the paper itself because of the use of
“inappropriate methods”.
The dark age
For a long time, nearly all pediatric anesthesiol-
ogists who presented their work at meetings or in
print received negative feedback; they were often
criticized because they "voluntarily" increased the
risk for their young patients. Their work never-
theless continued; however, after another strong
attack by Benumof and Bromage in 1998, it was
decided that something must be done lest the pio-
neering efforts in this field become hopeless.2
Describing a case report of serious damage after
a block in a sedated adult patient, these two authors
stated “Had the patient been able to report pares-
thesis, this complication would have been prevent-
ed”, thus condemning de facto the performance of
epidurals under general anesthesia and effectively
depriving children of an effective technique for
perioperative analgesia.
It was time to reply.
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PEDIATRIC REGIONAL ANESTHESIA
The milestone
In 1998, Elliot Krane, Bernard Dalens, Isabelle
Murat and more than 50 pediatric anesthesiologists
from all over the world signed and published in
Regional Anesthesia a paper that was then repub-
lished also in many other journals, both interna-
tional and national.3
This document represented the end of any cred-
ible attack on our work. The authors demonstrat-
ed that the performance of a block in an anes-
thetized child is safe, reliable and ethical and that
the use of this technique in a sedated child is much
safer than its use in an awake, often crying and
excited baby.
During the same period, Adrian Bosenberg and
Giorgio Ivani (also part of the fifty) wrote an edi-
torial “Regional anesthesia: Children are differ-
ent” underlining the necessity of not considering
children as small adults and supplying the provi-
so that, when applying the technique to children,
distinct parameters must be considered.4
At that time, in 1996, a paper published by the
French Speaking Society of Pediatric Anesthesia
received widespread attention.5 In it, were report-
ed the results of the largest survey to date on RA
in children, a prospective evaluation of one year
experience with more than 24000 pediatric blocks,;
they provided irrefutable evidence that PRA is a
reliable technique.
Though 89% of the blocks were performed
under sedation/anesthesia, only 0.9/1000 com-
plications occurred, with no deaths and no seque-
lae, comparing favorably with similar surveys in
adults, showing that PRA is at least as safe as RA
in awake adult patients.
Indeed, this problem was now put to sleep.
Moreover, the study demonstrated that periph-
eral blocks are safer than central ones (more than
9 000 blocks without any complication) and that,
as 50% of the complications were ascribed to the
use of inappropriate tools, the use of adequate
devices, suited for children, is strongly recom-
mended.
The Renaissance
Following the publication of these papers, the
work became easier; hundreds of papers appeared
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describing new techniques, new local anesthetics
and adjuvants to improve regional anesthesia in
children.6-9
In the meantime, the industry advanced our
work, introducing more and more dedicated tools.
New drugs that increased safety entered the mar-
ket; many more papers on the subject were pub-
lished and many congresses or books dedicated to
RA included pediatric contributions.
Ropivacaine and levobupivacaine, new levo-
isomers, were introduced; these compounds pos-
sessed better safety profiles. As adjuvants, cloni-
dine and ketamine became more popular, increas-
ing the efficacy of blocks while at the same time
reducing the number of case reports of complica-
tions ascribed to local anesthetics.10-13
Today
The new century began with a new energy; if a
detractor still exists, he or she is usually only a
provocative part of a pro-con session on PRA and
no longer a danger.
At present, PRA undoubtedly offers a major
advantage for pain control and plays an impor-
tant role in daily clinical practice. As in adults,
PRA is now shifting to peripheral blocks when-
ever possible; continuous peripheral infusions
have been put into use in different pediatric cen-
ters14-19. These data emerge clearly from the second
epidemiologic study carried out by the French
Speaking Society of Pediatric Anesthesia from
November 2005 to October 2006.20 The same
study confirms the safety of PRA for all ages. The
overall complication rate reported in this study
was higher than in previous studies (5 per 1 000)
but, again, the events included no deaths and/or
sequelae, and peripheral nerve blocks techniques,
from 38% in 1996, reached 66%.
Another important recent survey was performed
over a 5-year period by the UK and Ireland
Paediatric Pain Services, in order to establish a
national audit of epidural infusion analgesia prac-
tice in these centers and to obtain sufficient data
on the number of pediatric epidurals performed
and the incidence of unwanted events.21 These
data were collected over the 5-year period (2001-
2005) and the results are extremely interesting.
There were no reported deaths associated with
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IVANI
epidural infusion in this audit; there were 5 severe
incidents in 10,633 epidurals; of these, only one
patient had persistent problems at one year. The
occurrence of all relatively minor-grade incidents,
predominantly local infection, was approximate-
ly 1:253 epidurals.
Moreover, a new tool, i.e., nerve mapping with-
out needle, has become increasingly popular. It
represents a technique which assists the anesthesi-
ologist in finding the exact place to enter the nee-
dle for a peripheral block in any pediatric age, very
useful for teaching and for adding safety to the
performance.22 Since the plexuses in children are
quite superficial, before introducing the needle it
is possible to detect the position of the plexus with
the transcutaneous technique, called mapping of
the nerves. This requires the use of the unblunted
tip of the negative electrode of the neurostimula-
tor or a pen-like stimulator. Increasing the amper-
age to 3 mA or more, we can touch the skin close
to the nerve plexus, stimulating until twitches are
elicited and then reduce the voltage, detecting the
best point to perform the block. With this tech-
nique, the success rate of a block in children can
be increased, keeping in mind that often one has
to deal with malformations for which it is hard to
find the placement of the needle (i.e., arthrogripo-
sis).
Which techniques in children?
CENTRAL BLOCKS
The anatomy of children differs from adults’ in
terms of size and position of the spinal cord and its
enveloping structures: at birth the cord ends at L3
and the dura at S3, therefore an injury to the spinal
cord can occur when a lumbar epidural block is
performed even at low levels. As the child grows,
the cord and the dural sac rise to reach their adult
level, L1 and S2 respectively, by the end of the first
year of life. The epidural technique in children is
quite similar to the technique used in adults;
among epidural blocks, the caudal approach to
the epidural space is the most commonly used
technique for intra- and postoperative analgesia
in pediatric surgery, easy and safe; the position of
the spinal cord and the dural sac in the spinal canal
varies with age. Therefore, even if a caudal
approach is used, cord injuries may occur, espe-
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cially in small children. In newborns and infants,
the sacral bone is composed mostly of cartilage
and soft bony tissue: it is not surprising that cas-
es of bone and even rectal punctures have been
reported performing this kind of block.7 The dis-
tance between dural sac and hiatus varies, but it is
less than 10 mm in newborns; thus the risk of dur-
al puncture during caudal anesthesia. For this rea-
son, the so called “no turn” technique, described
by Ivani, might be preferable; in this technique,
the needle is inserted at a 60° angle to the sacral
plane in the midline at the apex of the sacral hia-
tus so that, after crossing the sacrococcygeal liga-
ment, the needle is already within the epidural
space with no need for further movements.9
An epidural catheter introduced through the
caudal space can be easily advanced in the epidur-
al space at very high levels, especially in younger
children, as the fatty tissue contained in the epidur-
al space at that age is very thin and loose. However,
because of the proximity of the anus, the risk of
infection is higher and a lumbar approach is pre-
ferred. Moreover, it is advisable to advance the
catheter only 2-3 cm because the risk of kinking
increases for further indwelling.
The lumbar epidural block is usually performed
at L4-L5 or at L5-S1 level, the so called Taylor’s
modified level, using a midline approach. The
landmark is the intercristal line that crosses the
midline at L5-S1 space in the newborn and that
crosses L5 in older children. The landmark for the
thoracic approach is a line joining the inferior
angles of the scapulae that crosses T7.
The loss-of-resistance technique can be per-
formed with air or with saline solution; different
opinions support one or the other technique.23
Air may be useful in newborns and infants to ver-
ify eventual accidental puncture of the dura mater,
in fact, use of saline solution may mask reflux of
cerebrospinal fluid, which at this age does not have
the normal pressure as in adults. In addition, saline
solution may dilute the small amount of drug used.
PERIPHERAL NERVE BLOCKS
The entire variety of peripheral nerve blocks
used in adults can be used in pediatric patients.
In this paper, we highlight only typical pediatric
blocks not commonly used in adults that we nor-
mally perform and recommend. The parascalene
580 MINERVA ANESTESIOLOGICA
PEDIATRIC REGIONAL ANESTHESIA
block is the easiest and safest approach to the supr-
aclavicular part of the brachial plexus in children,
aiming at penetrating the interscalene space at a dis-
tance from the apical pleura, the great vessels and
nerves of the neck, the stellate ganglion and the
spinal canal. The landmarks are the clavicle, the
lateral border of the sternocleidomastoid muscle,
and the transverse process of C6 (Chassaignac
tubercle). An imaginary line is drawn between the
Chassaignac tubercle and the midpoint of the clav-
icle. The insulated beveled needle, connected to
the nerve stimulator is introduced perpendicular-
ly at the junction of the upper 2/3rd and lower
1/3rd of this imaginary line and directed in the
antero-posterior plane until twitches (contraction
of biceps and/or brachial muscle) are obtained.
The fascia iliaca compartment block is a multi-
block technique using a single injection made just
below the fascia iliaca, which covers the psnoas
muscle, from which emerge all the terminal nerves
of the lumbar plexus. The femoral nerve (100%),
the lateral femoral cutaneous and the obturator
nerves (70-90%) are blocked with this technique.
The landmark is the inguinal ligament. The line
uniting the pubic spine to the anterior superior
iliac spine is divided into three equal parts. A short
bevelled needle, i.e., a caudal needle, is then intro-
duced vertically 0.5-1 cm below the union of the
lateral one-third to the medial two-thirds, until
two losses of resistance, respectively correspon-
ding to the fascia lata and the fascia iliaca, are felt.
The lateral approach to the sciatic nerve is an
easy block to perform in children under general
anesthesia, since it can be performed in the later-
al position with no need to mobilize the child.
Since children are often sedated during the per-
formance of the block, the child is under sponta-
neous ventilation with this approach and can
breathe properly. The landmark is the greater
trochanter of the femur. The needle (21-gauge,
55-mm-or, in larger children a 20-gauge, 120-
mm--insulated beveled) is introduced horizontal-
ly 1 to 3 cm below the lateral skin projection of
the greater trochanter of the femur and advanced,
passing below the femur, until the motor response
of the foot and toes is elicited.
In addition, the lateral approach to popliteal
block is particularly advantageous. The leg to be
blocked is elevated on a pillow at the knee level.
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The landmarks are the patellar crest, the vastus
lateralis muscle and the tendon of the long head of
the biceps femoris muscle. The biceps femoris ten-
don is identified and the needle (21-gauge, 55-
mm, insulated and beveled) is placed between the
vastus lateralis and the biceps femoris tendon at
an angle of about 30 degrees, about 5 to 6 cm
above the popliteal crease.
For most hernia surgery in children, a caudal
block is the block of choice. However, if there is a
relative contraindication to a caudal block due to
the presence of a sacral dimple or if the child is
obese and the caudal space is not easily identified,
an ilioinguinal nerve block is utilized.
The ilioinguinal and iliohypogastric nerves orig-
inate from the T12 (subcostal nerve) and L1 (ilioin-
guinal, iliohypogastric) nerve roots of the lumbar
plexus. These nerves pierce the internal oblique
aponeurosis 2 to 3 cm medial to the anterior supe-
rior iliac spine and travel between the internal
oblique and the external oblique aponeurosis. To
perform this block, a line is drawn between the
umbilicus and anterior superior iliac spine that
divides it into thirds. The point where the lateral
third meets with the medial 2/3rds is where the nee-
dle is inserted. The needle (short and beveled, i.e.,
a caudal needle) is advanced towards the inguinal
canal and passed in until a “pop” is felt, correspon-
ding to the piercing of the superficial layer of the
external oblique muscle. Two major complications
have been described with this block: undesired
femoral nerve block due to the spread of the local
anesthetic to the inguinal ligament and perfora-
tion of the bowel wall.
The use of ultrasound technique has deeply
changed this approach and the landmarks (see
below).
The penile block is indicated to provide anal-
gesia during and after surface operations on the
penis, such as circumcision and phymosis; it is
also suitable for pain management following
hypospadia repair, while it is not sufficient for
the surgery itself, for which caudal anesthesia is
preferable. The landmark is the pubic symph-
ysis. The penis is pulled downward and two sym-
metrical sites for needle insertion are marked,
each 0.5-1 cm below the pubic symphysis, later-
al to the midline. The short beveled needle, i.e.,
a caudal needle, is then inserted vertically point-
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IVANI
ing slightly caudally until there is a loss of resist-
ance due to the piercing of Scarpa’s fascia. The
two-injection technique is recommended because
the pubic space is frequently divided into two
separate compartments by a medial division.
Another very useful technique is the subcuta-
neous ring approach: it is a very simple and suc-
cessful technique using a subcutaneous ring of
local anesthetic placed around the base of the
penis. In this case, no attempt is made to inject
local anesthetic within Buck’s fascia; this avoids
the risk of compression of the vascular structures
when an excessive volume of local anesthetic is
injected within Buck’s fascia. The points of injec-
tion are 2-3 cm from the base, at 10 and 2 o’clock
levels in the subcutaneous space, pointing to the
base with the needle raised superficially and
injecting half of the dose each side, making a ring
of local anesthetic; to complete the ring, 1 ml of
local anesthetic should be injected at the base of
the penis, in the ventral part.
Ultrasound technique
Despite its well-known benefits, clinical fail-
ures can occur during the application of regional
anesthetic techniques. Neurovascular anatomy is
highly variable and current nerve localization tech-
niques provide little or no information regarding
the anatomical spread of local anesthesia. Modern
imaging techniques, computed tomography (CT)
scan and ultrasound, are now available for improv-
ing these procedures.
The ultrasound technique is now widely applied
in children and several papers have confirmed the
efficacy and the advantages of this method.24-31
Traditional nerve localization techniques (nerve
stimulation) rely on anatomical assumptions that
may be incorrect. In a 2005 editorial, Denny not-
ed that “regional anesthesia always works provided
you put the right dose of the right drug in the right
place. When it does not work, it is usually because
the local anesthetic has not been put in the right
place”.32 With respect to the interscalene brachial
plexus, cadaver studies suggest that the “typical” sit-
uation of the brachial plexus, lying between the
anterior and middle scalene muscles, exists in only
60% of situations. The most common variation
(34%) is direct penetration of the anterior scalene
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muscle by the C5 and/or C6 ventral nerve roots.
It has been proposed that such anatomical varia-
tions explain failures of surface landmark-based
approaches to the interscalene block in which the
anterior scalene muscle serves as a barrier to the
distribution of local anesthesia.33
Axillary blocks have been associated with nerve
injury, vascular puncture, and intra-vascular injec-
tions. These limitations are compounded by com-
mon anatomic variations of the ulnar and medi-
an nerves, excessive vascularity, and the need for
multiple injections (musculocutaneous nerve). In
a randomized controlled trial comparing trans-
arterial to ultrasound-guided axillary blockade,
Sites et al. demonstrated that ultrasound guidance
improved both the performance time (3.2 min
faster) and success rate for surgical anesthesia (71%
for trans-arterial vs. 100% for the ultrasound
group).34
In 2005, the ultrasound technique was com-
pared with the “fascial click” method for perform-
ing ilioinguinal and iliohypogastric nerve blocks in
children receiving inguinal hernia repairs.35 Results
demonstrated a reduction in failure rates (defined
by postoperative fentanyl consumption) from 26%
(fascial click group) to 4% (ultrasound group) and
documented the short distance from skin to nerve
and from nerve to peritoneum and the different
landmark positions (close to the anterior superior
iliac spine).
The main advantages conferred by ultrasono-
graphically-guided techniques in children are the
imaging of all anatomical structures and the pos-
sibility of directly ascertaining the position of the
tip of the cannula relative to the nerve.
Consequently, inadvertent trauma of surround-
ing structures (e.g., cervical pleura during peri-
clavicular brachial plexus blocks, peritoneum dur-
ing abdominal wall blocks) or puncture of nerves
or neuraxial structures with subsequent damage
can reliably be avoided. Another advantage is the
direct control of the distribution of local anesthet-
ic. This may sound simplistic, but the tip of a nee-
dle does not block nerves, the local anesthetic
blocks them. Therefore, a prediction of the suc-
cess of a block is possible, and in cases of misdis-
tribution of the local anesthetic, correction of the
needle position is possible. Additional advantages
lie with the faster onset of sensory and motor
582 MINERVA ANESTESIOLOGICA
PEDIATRIC REGIONAL ANESTHESIA
blocks, longer duration of blocks,25 increased block
quality and reduced volumes of local anesthet-
ics.36, 37
Real-time ultrasound guidance for peripher-
al regional anesthesia is not error-free. New data
have emerged suggesting that the novice ultra-
sonographer makes repeated errors, the two most
common being failure to visualize the needle
during advancement and unintentional move-
ment of the probe. For this reason, the American
Society of Regional Anesthesia (ASRA) and the
European Society of Regional Anesthesia (ESRA)
created a Joint Committee; the result was a doc-
ument “to recommend to members and institu-
tions the scope of practice, the teaching curriculum,
and the options for implementing the medical prac-
tice of ultrasound guided regional anesthesia
(UGRA) services”.38, 39
The future, the “new frontier”
In this field, challenges are, of course, still ongo-
ing as even more safety, efficacy and longer dura-
tions of analgesia are sought. In addition, the goals
are now changing: as in adults, the patient’s well-
being requires that children be cared for not only
in the perioperative period but also at home.
New studies demonstrate the importance of
sending patients home with a peripheral continu-
ous infusion, giving optimal results for rehabili-
tation or chronic diseases.40
Our efforts to maintain updated techniques and
drugs must be continued in order to give our lit-
tle and special patients every possible opportuni-
ty for a better quality of life.
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Received on February 03, 2009 - Accepted for publication on April 07, 2009.
Corresponding author: G. Ivani, Chairman, Division Pediatric Anesthesiology and Intensive Care Unit, Regina Margherita Children’s
Hospital, Piazza Polonia 94, 10126 Turin, Italy. E-mail: gioivani@libero.it
Vol. 75 - No. 10 MINERVA ANESTESIOLOGICA
IVANI
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