Curr Anesthesiol Rep
DOI 10.1007/s40140-017-0217-6
PEDIATRIC ANESTHESIA (J LERMAN, SECTION EDITOR)
Pediatric Regional Anesthesia: an Update
Madhankumar Sathyamoorthy 1
# Springer Science + Business Media New York 2017
Abstract
The Purpose of Review The purpose of this study was to re-
view the recent literature describing techniques, outcomes,
and complications in pediatric regional anesthesia primarily
among neonates and infants.
Recent Findings Regional anesthetic techniques can be safely
performed in anesthetized children, and is so widespread, that
it has become accepted as standard of practice. Spinal anes-
thesia in the neonate requires a larger dose of local anesthetic
than in adults, yet has a shorter duration of action. Neuraxial
technique combined with sedation or light general anesthesia
is commonly used for hernia repairs. In preterm and ex-
preterm infants, awake regional techniques are reasonable al-
ternatives. Neuraxial catheters can deliver local anesthetics
and opioids both intraoperatively and postoperatively for ef-
fective pain control in all age groups including neonates.
Ultrasound guidance has rapidly become the norm to ensure
successful peripheral nerve blocks and abdominal wall blocks
with the least amounts of local anesthetics. The dose of local
anesthetic should be adjusted for each patient based on the
recommended range.
Summary Regional anesthesia has shown to be safe and is
being increasingly practiced. But safety should be the priority
and adequate precautions should be taken to reduce potential
complications.
This article is part of the Topical Collection on Pediatric Anesthesia
* Madhankumar Sathyamoorthy
msathyamoorthy@umc.edu
1
Department of Anesthesiology, University of Mississippi Medical
Center, Jackson, MS 39216, USA
Keywords Regional anesthesia . Epidural . Caudal . Spinal .
Nerve blocks . Neonates . Infants
Introduction
Interest in regional anesthesia in neonates, infants, and chil-
dren is growing among pediatric anesthesiologists, surgeons,
and parents. Data analyzed from more than 50,000 blocks in
the Pediatric Regional Anesthesia Network (PRAN) database
show that both central and peripheral nerve blocks in anesthe-
tized infants and children are considered safe and effective
[1••]. However, significant challenges remain before regional
anesthesia in children becomes commonplace. Assessment of
pain for the efficacy of regional blocks in neonates and infants
is extremely challenging and often inaccurate. In addition,
there are too few clinicians trained and skilled in pediatric
regional anesthesia to perform all the regional blocks in any
facility. As compared with systemic opioids, the effectiveness
of regional anesthesia to improve pain outcomes in children
after surgical procedures has not been clearly established in
any large randomized controlled trial. In a review by Suresh
et al., there was substantial evidence for regional blocks im-
proving pain outcome only for a few surgical procedures such
as hernia repair, cleft lip repair, and circumcision [2•].
This article reviews the recent literature in pediatric region-
al anesthesia.
Caudal Epidural Blocks
Single shot caudal blocks are the most commonly performed
neuraxial blocks in children [3]. It is usually performed in left
lateral decubitus position with hips flexed and sacral hiatus
identified by palpation. Abundant subcutaneous fat and
 Curr Anesthesiol Rep

normal variations in anatomy can obscure the landmark dur- availability and institutional practices. Shorter needles such as
ing the palpation technique. In a fetal study, a single sacral butterfly needles used for a blood draw are convenient and
cornua was palpable in 27%, and no sacral cornua was palpa- reduce the risk of vascular or dural puncture. Plastic intravenous
ble in another 15%. [4]. Loose epidural fat helps with the cannulas reduce the risk of skin coring due to the stylet, and
better cranial spread of local anesthetics in neonates and easy threading of the catheter helps to confirm proper place-
young infants compared with older children [5, 6], but a great- ment of the needle within the epidural space. Most practitioners
er speed of injection did not [7]. Larger volumes of local use a landmark-based technique as it is simple and easy to
anesthetics increased the cranial spread, but the effect was perform. Some routinely use ultrasound in addition to
minimal when 0.7 mL/kg was compared with 1.3 mL/kg. landmark-based technique to confirm spread of local anesthetic
The majority of blocks did not reach the thoracolumbar junc- in the epidural space. Ultrasound adds a layer of complexity to
tion [8]. The anatomic spread visualized by fluoroscopy is less the technique and usually requires an extra person as a “third
than the clinical sensory block. A minimum volume of 1 mL/ hand” to hold the ultrasound probe [13]. This approach can be
kg local anesthetic is needed to achieve a block to L2 derma- useful if there is difficulty palpating the anatomical landmarks
tome level in 90% of children older than 1 year [9]. The and for teaching purposes.
discrepancy observed between the level of spread by cutane-
ous testing and the anatomical spread assessed by ultrasound
or fluoroscopy can be attributed to the secondary spread of
Epidural Anesthesia
local anesthetics, to both intrasegmental as well as cranial
spread [10]. In general, most practitioners use 0.75–1 ml/kg
The use of epidural catheters in children and their potential
of local anesthetic for urologic, perineal, and lower extremity
advantages has been well described. They have been used
procedures and slightly greater volumes, 1.25 to 1.5 ml/kg, for
safely, even in neonates. An analysis of combined data pub-
abdominal incisions. This dosage was recommended by
lished from the UK, France, and the USA pointed to an inci-
Armitage back in 1979 and still holds true.
dence of transient neurologic symptoms of 2 per 10,000 [14].
In neonates, there was a 13.3% complication rate in 307
Awake vs. Sedated/Combined General?
neuraxial catheters from PRAN, mostly catheter malfunction,
contamination, and vascular puncture. Severe complications
The feasibility and advantages of completely awake regional
with long-term sequelae were not reported [15•]. Severe is-
techniques have been explored in ex-premature infants under-
chemic injuries to the spinal cord of unknown etiology have
going hernia surgery. Pure regional techniques are often un-
been reported in older infants and children after epidural an-
able to prevent the infant from moving their upper body or
esthesia [16, 14]. A case of spinal hematoma after thoracic
from straining with increased intra-abdominal pressure during
epidural catheter has been reported in a sickle cell child.1
the procedure; these represent very challenging issues to re-
The number of cases remains small, precluding a reliable es-
solve. Continuous caudal anesthesia using a bolus of 3% 2-
timate of the incidence of rare complications [17].
chlorprocaine at a dose up to 2 ml/kg, titrated 0.5 ml/kg every
Complications occur more often at the time of procedure or
3–5 min, followed by a continuous infusion at 1.5 ml/kg/h has
immediately thereafter in the operating room. Examples of
been used successfully in hernia repair as the sole anesthetic in
such complications include dural puncture, vascular puncture,
awake neonates. In that study, the time until induction of an-
and local anesthetic toxicity and drug errors. Epidurals in ne-
esthesia was complete required almost 48 min. The authors
onates should be performed only by those who have excellent
argued that continuous caudal is a reliable technique without
technical expertise in regional anesthesia [18]. Some suggest
the need for supplemental sedation as compared with a single-
that the future of epidural analgesia in infants and children
shot spinal for hernia surgery in the same patient population
may be limited in the future, replaced by peripheral nerve
[11].The awake caudal technique also demonstrates a greater
blocks and other blocks (TAP) [19].
success rate and technically easier to perform than the awake
Inserting the caudal catheter through the sacral hiatus and
spinal technique [12].Good training, hand skills, infrastruc-
advancing to the lumbar or thoracic level is technically easy
ture, appropriate selection of indicated procedure, and “buy
and safe in infants and children. However, a styletted or large-
in” from the surgeons and entire OR team are essential for
bore catheter may be needed to avoid catheter coiling or mal-
successful awake techniques [13].
position. Fluoroscopic guidance with contrast epidurography
For sedated techniques, propofol infusions up to a max dose
can be used to ensure the catheter reaches the desired spinal
of 4 mg/kg are titrated to achieve adequate sedation while main-
level. Tunneling the catheter under the skin using a Tuohy
taining spontaneous respirations. A second anesthesia provider
needle or an angiocath and sealing the puncture site with skin
should be available to monitor the patient and support respira-
tion if needed while the anesthesiologist proceeds with the cau- 1
Abstract #1697 at the 16th World Congress of Anaesthesiologists, 2016,
dal block. An assortment of needles is used depending on local Hong Kong.
Curr Anesthesiol Rep
adhesive helps to secure the catheter and reduce contamina-
tion of the catheter. [20–22].
A lumbar catheter for infra-umbilical abdominal incisions
and a thoracic catheter for upper abdominal/thoracic incisions
provide more effective analgesia when the catheter tip is cited
closer to the incision site. Usually, the catheter is placed after
induction of general anesthesia [1, 23]. Loss of resistance to
0.9% saline technique is commonly used, and most avoid
injection of air in the epidural space [24]. Bupivacaine and
ropivacaine infusions at a loading dose of 1.5–2 mg/kg
followed by infusion dose of 0.2 mg/kg/h are safe for up to
48 h [25, 26]. But ropivacaine is commonly preferred for
infusions because of its safer cardiac profile and plasma con-
centration of unbound ropivacaine does not increase with an
infusion with a dose of 0.2–0.4 mg/kg/h for 48–72 h [27, 28].
Special attention must be paid to limit the dose of local anes-
thetic in neonates to avoid potentially toxic doses, a practice
that seems to be on the rise recently [15•]. Rapid metabolism
of chloroprocaine by plasma cholinesterases reduces the risk
of local anesthetic toxicity, particularly in neonates. 1.5% 2-
chlorprocaine has been used at infusion rates ranging from
0.25 to 1.5 ml/kg/h in major abdominal and thoracic proce-
dures in young neonates and infants [29–31]. The toxic thresh-
old for chlorprocaine is thought to be 12 mg/kg/h.
Opioids are commonly used as adjuvants to local anes-
thetics in epidural anesthesia. Shorter acting lipophilic opioids
have a more spinal effect and help in wider dermatomal cov-
erage by local anesthetics. Fentanyl at a concentration of 1–
2 μg/ml is one such lipophilic opioid. Long-acting opioids
such as morphine have a more central respiratory depressant
effect but are infrequently used [19]. In neonates, most opioid
adjuvants are avoided. In older children, clonidine can be a
useful adjuvant especially in thoracic procedures such as Nuss
procedures. [32].
In addition to providing postoperative analgesia, epidural
anesthesia may be used to supplement general anesthesia,
resulting in several potential advantages such as reducing in-
traoperative concentrations of inhalational anesthetic, earlier
tracheal extubation, and faster intestinal motility recovery
[33–35].
Spinal Anesthesia
Awake spinal anesthesia in preterm infants was originally in-
troduced by Dr. C. Abajian, VT, USA, as an alternative to
general anesthesia to reduce the risk of postoperative apnea
[36]. Spinal anesthesia is more commonly performed in neo-
nates and infants than in older children. This represents 1.3%
of central neuraxial blocks reported from PRAN data [3]. The
increased concern that general anesthesia may cause poor
neurodevelopmental outcomes in young infants has increased
the interest in spinal anesthesia recently. [37] Awake spinal
anesthesia is performed in a small percentage of high-risk
preterm infants in a select few centers. This number may in-
crease in the coming years as more anesthesiologists become
comfortable with this technique. Many prefer not to perform
this technique because of a lack of expertise, the relatively
brief duration of the block, challenges of preventing move-
ment during the procedure, and the fact that many surgeons
elect to complete the procedure using a laparoscopic tech-
nique. In preclinical animal studies, spinal bupivacaine caused
neither apoptosis nor spinal toxicity [38, 39]. Indeed, there
was no relationship found between exposure to spinal anes-
thesia and poor performance in elementary school achieve-
ment testing [40••].
Most practitioners prefer to perform a spinal anesthetic
with sedation or light general anesthesia. Mask induction with
sevoflurane helps to secure the intravenous access, or the latter
can be obtained in the foot after the spinal in the awake tech-
nique. Light general anesthesia can be maintained with titrated
doses of propofol maintaining spontaneous respiration [13].
Alternatively, sevoflurane with a supraglottic airway can be
used to ensure adequate ventilation [41]. In neonates and
young infants, spinal anesthesia itself produces sedation by
de-afferentiation and may not require any supplemental seda-
tion other than sucrose-dipped pacifiers [42].
Positioning the child in a sitting position with maximal hip
flexion provides the optimal position with largest interspinous
space as compared with the lateral decubitus position [43]. In
sedated children, lateral decubitus position with the hip and
neck flexed is also effective. Sitting or head tilted up in a lateral
position can increase the success rate by increasing the cerebro-
spinal fluid (CSF) pressure [44]. The conus medullaris ends at
the lowest level in the neonates at the level of L2 or L3. The line
connecting the highest point of iliac crests (Tuffier’s line) pro-
vides a safe landmark for spinal anesthesia in the neonate. From
a cadaver study, it was confirmed that Tuffier’s line crosses L4–
L5 in a neutral position and upper L5 in flexed position in the
neonate [45]. Local subcutaneous lidocaine injection can cause
burning pain in an awake infant. Pre-operative application of
lidocaine-prilocaine cream at least 30 min before the procedure
or needle-free jet injection of lidocaine with faster onset within
1–3 min can mitigate the pain of spinal needle [46].
Isobaric bupivacaine 0.5% at a dose of 1 mg/kg for infants
<5 kg provides adequate anesthesia for procedures 45 min to
an hour in duration [12, 47]. Alternatively, 0.5% ropivacaine
can be used, but the duration of the motor block may be less as
compared with bupivacaine [48]. Baricity of local anesthetic is
not important. In fact, hyperbaric bupivacaine may have a
greater failure rate compared with isobaric bupivacaine
[49•]. Addition of epinephrine can prolong the duration of
the block by up to 90 min [50]. Other additives such as fenta-
nyl or clonidine are usually avoided out of fear of increasing
the risk of postoperative apnea. After the local anesthetic is
injected, the stylet can be reinserted in the spinal needle to

reduce the leakage of local anesthetic through the dural punc-
ture. Also, raising the lower limbs to apply the electrocautery
pad to the back of the infant should be avoided; rather, the
infant should be log-rolled to avoid unintentional high spinal
block which can compromise respiration [51]. The failure rate
for spinal anesthesia is up to 20% due to failure to get CSF,
blood tap, or need to convert to complete general anesthesia
[12]. Bloody tap on first attempt seemed to be significantly
associated with block failure [49•].
Ultrasound-Guided Regional Techniques
Most of the peripheral block techniques described in adults
can be done in infants and young children using ultrasound.
The number of indications may be limited. Most of the lower
limb procedures can be covered by caudal block. For brachial
plexus blocks, the infraclavicular approach is more practical
using ultrasound [52]. Continuous catheter techniques can be
challenging due to extremely superficial location of nerve
structures. Leakage of local anesthetic along the catheters
can be reduced by using skin adhesives to seal the needle
puncture site around the catheter. Abdominal wall techniques
can be done under ultrasound as an alternative to neuraxial
blocks when these are not possible due to spinal anomalies or
coagulation abnormalities. Rectus sheath block is performed
by injecting a local anesthetic between the rectus muscle and
posterior rectus sheath. It may provide better analgesia com-
pared with wound infiltration for umbilical hernia surgery
[53]. Transverse abdominis plane (TAP) block is performed
by injecting a local anesthetic into the plane between the in-
ternal oblique and transverse abdominis muscles. This may
block abdominal wall covering dermatomes T10-L1 [54,
55]. More cephalad dermatomes can be covered by a sub-
costal TAP block. Bilateral injections are needed to cover both
sides of the body. There is concern about toxic levels of local
anesthetics in bilateral blocks. Limiting the dose to 0.3 to
0.5 ml/kg on each side and the total dose of 20 ml decreases
this risk. Very small complication rates with the upper limit of
0.3% have been reported from a large series of TAP blocks in
the PRAN study [56]. Alternatively, ilio-inguinal nerve block
can be used for inguinal hernia repair with better results
[57].With the use of ultrasound, though technically more dif-
ficult than TAP block, these blocks can reduce many of the
potential complications of the landmark technique. Typically,
a smaller volume of local anesthetic, 0.1 to 0.3 ml/kg, is used
for this block.
Conclusion
Caudal blocks remain the single most commonly practiced
pediatric regional technique. There is renewed interest in
Curr Anesthesiol Rep
spinal anesthesia for high-risk ex-preterm babies to reduce
exposure to general anesthesia. Definitive evidence for im-
proved outcome with pediatric regional anesthesia is still
lacking.
Compliance with Ethical Standards
Conflict of Interest Madhankumar Sathyamoorthy declares that he has
no conflict of interest.
Human and Animal Rights and Informed Consent This article does
not contain any studies with human or animal subjects performed by any
of the authors.
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