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Pediatric Neuraxial Blockade University of Massachusetts Medical School eScholarship@UMMS Anesthesiology and Perioperative Medicine Publications Anesthesiology and Perioperative Medicine 1993-7 Pediatric neuraxial blockade John Pullerits University of Massachusetts Medical School Et al. Let us know how access to this document benefits ou.y Follow this and additional works at: https://escholarship.umassmed.edu/anesthesiology_pubs Part of the Anesthesiology Commons Repository Citation Pullerits J, Holzman RS. (1993). Pediatric neuraxial blockade. Anesthesiology and Perioperative Medicine Publications. https://doi.org/10.1016/0952-8180(93)90131-W. Retrieved from https://escholarship.umassmed.edu/anesthesiology_pubs/82 This material is brought to you by eScholarship@UMMS. It has been accepted for inclusion in Anesthesiology and Perioperative Medicine Publications by an authorized administrator of eScholarship@UMMS. For more information, please contact [email protected]. Pediatric Neuraxial Blockade John Pullerits, MD, FRCPC,* Robert S. Holzman, MD? Department of Anesthesiology, University of Massachusetts Medical Center, Worcester, MA, and Department of Anesthesia, Children’s Hospital, Boston, MA. Regional anesthetic techniques for children have recently enjoyed Historical Perspective a justified resurgence in popularity. Intraoperative blockade of August Bier’s investigation of spinal anesthesia in Ger- the neuraxis, whether by the spinal or epidural route, provides many’ and Siccard’s* and Cathelin’$ studies of caudal excellent analgesia with minimal physiologic alteration and, epidural anesthesia in France introduced to the late 19th- with an indwelling catheter, can provide continuous pain relief century medical world the novel concept of anesthesia for many days postoperatively. As a supplement to general anes- for selected regions of the human body. Ten years after thesia, local anesthetic blockade of the neuraxis decreases the Bier’s 1899 paper on the subarachnoid injection of co- total amount of general anesthetic required for surgery, hastens caine,’ regional anesthesia was described in children. emergence, and allows for a better postoperative experience by Tyrrell-Gray4 published his experience with spinal an- providing a pain-free emergence from general anesthesia. Al- esthesia in 300 infants and children in Lancet in 1909 though some practitioners contend that a regional block on an and followed this initial report with an extension of his already anesthetized child adds to the risk of the general anesthet- series a year later.5 Pediatric spinal anesthesia continued ic itself, in experienced hands the risks are negligible and the to be popular well into the 1940s. Indeed, Leigh and benefits dramatic. Belton, in their 1948 Textbook of Pediatric Anesthesia, noted In this review of caudal and lumbar epidural and subarach- that 10% of all anesthetics performed in children at Van- noid blockade in infants and children, anatomy, physiologic couver General Hospital were spinal anesthetics.‘j alterations, and pharmacology pertinent to the three types of However, with the introduction of neuromuscular neuraxial blockade are described, with the aim of providing blocking drugs in the 1940s and modern volatile anes- the Facticing anesthesiologist with the foundation needed to thetics in the late 1950s and 196Os, regional anesthesia perform these blocks with relative confidence. for children was almost forgotten. In the early 197Os, papers on regional anesthetic techniques in children Keywords: Anesthesia-neurosurgical, pediatric, again began to appear in the literature,‘s8 and interest in regional; neuraxis-blockade. pediatric regional techniques has grown steadily since. Safer local anesthetic drugs are now available, and their pharmacologic and physiologic effects are well docu- mented. Technical difficulties have been overcome with the introduction of regional equipment specifically de- signed for infants and children. Widespread acceptance *Assistant Professor of Anesthesiology, University of Massachusetts of the concept that general and regional anesthesias in Medical Center, Worcester, MA children are complementary, along with an appreciation that regional techniques have minimal hemodynamic ef- TAssistant Professor of Anaesthesia, Harvard Medical School, Bos- ton, MA fects, also have helped spur a resurgence of interest in this field. Address correspondence to Dr. Pullerits at the Department of Anes- thesiology, University of Massachusetts Medical Center, 55 Lake Avenue North, Worcester, MA 01605, USA. Anatomic Considerations Received for publication December 22, 1992; revised manuscript In the fetus, the notocord develops along the entire accepted for publication March 8, 1993. length of the spinal canal. At about the midpoint of fetal 0 1993 Butterworth-Heinemann life, the growth of the canal begins to outstrip the growth of the developing cord so that the tip of the spinal cord J. Clin. Anesth. 5:34%354,1993 at birth lies at the level of Ls. By about 1 year of age, 34.2 J. Clin. Anesth., vol. 5, July/August 1993 Pediatric neuraxial blockade: Puller-its and Ho&an for this is poorly understood but has been attributed to the lower systemic vascular resistance (SVR) found in the young.‘0 Caudal and lumbar epidural blockade in healthy infants and children cause clinically insignifi- cant hemodynamic alterations.* Epidural blockade to the T, dermatome results in only a modest drop in heart rate (HR) and systolic blood pressure, and left ventricular function, as measured by echocardiography, is unaffected.11 Similarly, there have been no reports of clinically significant hypotension with spinal anesthe- sia in children less than 5 years of age.‘2 As a conse- quence, fluid loading is usually unnecessary in these pediatric patientsi Although there is a dearth of information on the effect of neuraxial blockade on respiratory function in children, it seems that it has no adverse effect on respiratory function in children as long as the level of the motor block, usually a few segments below the sensory level, remains low enough to spare most of the intercostal muscles. Yu14 found that if a spontaneously breathing child received a caudal block high enough to achieve a T2 sensory level (and, therefore, a mid- thoracic motor level), atelectasis with hypoxemia could occur. In the case of spinal anesthesia, Pascucci et aLI found that a sensory level at Tp-T, decreased the normal outward movement of the rib cage during inspiration and often induced a paradoxical inward Figure 1. Sacral Surface Anatomy. Reproduced with per- movement during inspiration. Notably, they did not mission from: Ecoffey C, McIlvaine WB: Techniques of find any deterioration in oxygen saturation in their regional anesthesia in children. In: Raj PP (ed): Clinical infants as a result of this change in respiratory dynam- Practice of Regional Anesthesia. New York: Churchill Living- ics. stone, 1991: 369. Regional anesthetic techniques can ablate the meta- bolic and stress responses of children to surgery and prevent the increase in catecholamine and blood glucose the tip of the spinal cord reaches its permanent position concentrations that is commonly seen with general anes- at L1. The lower end of the dural sac is generally at thesia. Some authors even suggest that children who have the Sl-Sp intervertebral foramen. Whereas the epidural had a caudal or lumbar epidural block should have a space in an adult is characterized by densely packed fat glucose-containing solution running during surgery.t6 lobules and fibrous strands, the epidural fat of neonates Our preference is to monitor blood glucose levels in and young children is spongy in nature, with discrete the operating room (OR) and give glucose-containing spaces between the individual fat lobules.g solutions only as indicated. A clinician wishing to perform a caudal epidural block in a young child will find that the sacral hiatus is easily identified. Drawing an equilateral triangle on the skin Pharmacologic Considerations with the base connecting the two posterior superior iliac spines usually locates the sacral hiatus at the apex. Palpa- The volume of distribution of local anesthetics is larger tion of the sacral hiatus at the apex of this inverted trian- in children due to age-related differences in fluid gle should identify the puncture site bounded by the two compartments. Rates of elimination of local anesthetics, sacral cornua (Figure 1). however, may be lower due to a reduction in the The clinician wishing to do a lumbar epidural block efficiency of clearance pathways (amide local anesthetic needs to be aware that the distance from the skin to the drugs) or a reduction in plasma cholinesterase activity lumbar epidural space in small children is much shorter (ester local anesthetics) in infants younger than 6 than in adults, with an increased risk of an inadvertent months of age. Decreased concentrations of albumin spinal tap. In the neonate, the distance from the skin to and a-l acid glycoprotein may result in decreased epidural space is only about 1 cm. protein binding of amide local anesthetics, thereby resulting in an increase in the free fraction of the drug. Acidosis, both metabolic and respiratory, can Physiologic Effects increase the free fraction of lidocaine and bupivacaine The cardiovascular effects of neuraxial blocks are much and may be a consideration when sedation or general less pronounced in children than in adults. The reason anesthesia with spontaneous ventilation is contem- J. Clin. Anesth., vol. 5,
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