Pediatric regional anesthesia
Myron Yaster MD and Lynne G. Maxwell MD
When I finished my training more than 45 years ago, the routine use of regional anesthesia was rare…as rare as finding a full sized spare tire in a new car today! Why use a regional anesthetic technique when you had to induce general anesthesia to place the central or peripheral block in the first place? Was it even safe let alone necessary? When we realized that neural blockade could be used as an adjunct to general anesthesia much like when we add an opioid or muscle relaxant to a vapor general anesthetic (does ANYONE practice pure vapor anesthesia anymore?) we came to understand that we could use regional AND general anesthesia rather than regional OR general anesthesia. And based on the PRAN data base data, the safety of regional blocks is now well established. Thus over the past 2 decades, our use of neural blockade has expanded exponentially and continues to grow because of the almost ubiquitous use of ultrasound guidance when placing blocks in our practice…How times have changed!
In today’s PAAD, Lynne and I will review 2 related articles that were recently published on this topic. The first is a review article by Kathryn Handlogten1 and the second is a literature review of standardized dosing rates, dosing characteristics, and cases of toxicity of truncal catheters (paravertebral and transversus abdominis plane) in children less than 18 years of age by Fettiplace et al.2
And of course Happy Valentine’s day! Myron Yaster MD
Original article
Handlogten K. Pediatric regional anesthesiology: a narrative review and update on outcome-based advances. Int Anesthesiol Clin. 2024 Jan 1;62(1):69-78. doi: 10.1097/AIA.0000000000000421. Epub 2023 Dec 8. PMID: 38063039.
Original article
Fettiplace M, Joudeh L, Bungart B, Boretsky K. Local anesthetic dosing and toxicity of pediatric truncal catheters: a narrative review of published practice. Reg Anesth Pain Med. 2024 Jan 11;49(1):59-66. doi: 10.1136/rapm-2023-104666. PMID: 37429620.
Handlogten provides a concise, almost text book like review article of pediatric regional anesthesia and is an excellent resource for practitioners who are new to this form of anesthesia. She provides an excellent review of the pharmaco-kinetics and -dynamics of local anesthetics in children and how and why these differ from adults. She also points out that “local anesthetic selection and dosing vary considerably among institutions and providers” making it a perfect segue to the other PAAD by Fettiplace et al. which we will discuss below.
Handlogten also provides an excellent discussion of 2 relatively new and very controversial techniques that may be new to you and which you may find helpful in your practices, namely cryoablation3-5 and the use of liposomal bupivacaine.6 Indeed, the latter has raised a firestorm of controversy that we’ve discussed previously in the PAAD (Mary Ellen McCann is a HERO, Feb 18, 2022 https://ronlitman.substack.com/p/mary-ellen-mccann-is-a-hero). Handlogten presents a valuable and balanced review of the question “is liposomal bupivacaine superior to plain bupivacaine, does it have an acceptable safety profile for young pediatric patients, are some applications more beneficial than others (ie, infiltration vs. perineural placement)?”1
Both of today’s PAADs discuss the diagnosis and management of local anesthetic toxicity (LAST). “The initial treatment in pediatric patients includes assessment and stabilization of the airway, breathing, and circulation. In the pediatric anesthesia patient, regional anesthesia and potential for LAST commonly occur when the patient is already under GA masking early diagnosis. If LAST is suspected, rapid administration of 1.5 mg/kg of 20% intralipid should occur, followed by an infusion of 0.25 mL/kg/min. However, in a crisis who can actually remember and calculate this dosing? We think it far better to open the Society for Pediatric Anesthesia’s Pedi Crisis app (v 2) as one of your initial first steps rather than relying on your memory. Indeed, if you haven’t already downloaded this app do it now! Just go to the iOS or Android app stores or SPA’s website.
The ”swiss army knife” of pediatric regional anesthesia has traditionally been the caudal block. Increasingly, this simple block has been replaced with more specific nerve blocks. Indeed, on my recent experience in Israel, I (MY) was surprised that many of the surgical procedures that I would have routinely used a caudal block like orchiopexy, hypospadias and inguinal hernia repairs were performed under more specific truncal blocks like the Transversus Abdominis Plane (TAP) block or penile/pudendal nerve blocks.
But how should one dose a single or continuous infusion TAP or paravertebral nerve blocks? In an extensive literature review, Fettiplace et al.2 provide some guidance. “Many patients tolerated doses of ropivacaine up to 0.5 mg/kg/hour for an average of 72 hours and doses of bupivacaine of up to 0.35–0.4 mg/kg/hour up to 48 hours with a low rate of toxicity. The only case occurred due to a 29 mg/kg breakthrough bolus of chloroprocaine, reinforcing package insert dosing recommendations. The median hourly infusion dose of 0.33 mg/kg/hour for bupivacaine and 0.5 mg/kg/hour for ropivacaine reflects the potency equivalence of bupivacaine:ropivacaine of 1.0:1.5.”2
Because of differences in drug metabolism and plasma protein concentrations, lower doses are used in neonates and infants less than 6 months of age. Their final recommendations which are consistent with dosing recommendations for epidurals as well:
Ropivacaine bolus : 2.0–2.5 mg/kg using 0.2 or 0.5% with maximum of 2.5–3.0 mg/kg.
Ropivacaine infusion: 0.3–0.5 mg/kg/hour using 0.1–0.2% with maximum of 0.5 mg/kg/hour.
Reduced in 0–4 months to max of 0.2 mg/kg/hour and 5–12 months to 0.3 mg/kg/hour based on prior safety studies.7 17
Bupivacaine bolus: 1.2–1.4 mg/kg using 0.25% with max of 2.2–2.5 mg/kg.
Bupivacaine infusion: 0.25–0.35 mg/kg/hour using 0.1% with max of 0.5 mg/kg/hour.
Reduced in 0–4 months to max of 0.2 mg/kg/hour and 5–12 months to 0.3 mg/kg/hour based on prior safety studies.
Duration: 48–72 hours, maximum 120 hours.
Send your thoughts and comments to Myron who will post in a Friday reader response.
References
1. Handlogten K. Pediatric regional anesthesiology: a narrative review and update on outcome-based advances. International anesthesiology clinics 2024;62(1):69-78. (In eng). DOI: 10.1097/aia.0000000000000421.
2. Fettiplace M, Joudeh L, Bungart B, Boretsky K. Local anesthetic dosing and toxicity of pediatric truncal catheters: a narrative review of published practice. Regional anesthesia and pain medicine 2024;49(1):59-66. (In eng). DOI: 10.1136/rapm-2023-104666.
3. Fraser JA, Briggs KB, Svetanoff WJ, et al. Short and long term outcomes of using cryoablation for postoperative pain control in patients after pectus excavatum repair. J Pediatr Surg 2022;57(6):1050-1055. (In eng). DOI: 10.1016/j.jpedsurg.2022.01.051.
4. Clark RA, Jacobson JC, Singhal A, Alder AC, Chung DH, Pandya SR. Impact of Cryoablation on Pectus Excavatum Repair in Pediatric Patients. J Am Coll Surg 2022;234(4):484-492. (In eng). DOI: 10.1097/xcs.0000000000000103.
5. Rettig RL, Rudikoff AG, Lo HYA, et al. Cryoablation is associated with shorter length of stay and reduced opioid use in pectus excavatum repair. Pediatr Surg Int 2021;37(1):67-75. (In eng). DOI: 10.1007/s00383-020-04778-x.
6. Tirotta CF, de Armendi AJ, Horn ND, et al. A multicenter study to evaluate the pharmacokinetics and safety of liposomal bupivacaine for postsurgical analgesia in pediatric patients aged 6 to less than 17 years (PLAY). Journal of clinical anesthesia 2021;75:110503. (In eng). DOI: 10.1016/j.jclinane.2021.110503.