SPINAL,EPIDURAL/SPINAL,EPIDURAL/CAUDAL,PENILE NERVE BLOCK IN CAUDAL,PENILE NERVE BLOCK IN

PEDIATRIC PATIENTSPEDIATRIC PATIENTS

MODERATOR:Dr. JYOTI PATHANIAMODERATOR:Dr. JYOTI PATHANIA

PRESENTED BY: Dr. SUCHIT PRESENTED BY: Dr. SUCHIT KHANDUJAKHANDUJA

INDICATIONS OF REGIONAL BLOCKADEINDICATIONS OF REGIONAL BLOCKADE

Analgesia:Both intraop and postopAnalgesia:Both intraop and postop Testicular torsion or incarcerated hernia at immediate risk of rupture Testicular torsion or incarcerated hernia at immediate risk of rupture

in nonfasted childrenin nonfasted children Inguinal hernia repair in former preterm infants younger then 60 Inguinal hernia repair in former preterm infants younger then 60

weeks of postconceptual age weeks of postconceptual age Severe acute or chronic respiratory insufficiencySevere acute or chronic respiratory insufficiency Emergency conditions in children with severe metabolic or Emergency conditions in children with severe metabolic or

endocrine disordersendocrine disorders Neuromuscular disorders, myasthenia gravis, or some types of Neuromuscular disorders, myasthenia gravis, or some types of

porphyriaporphyria Some types of polymalformative syndromes and skeletal deformitiesSome types of polymalformative syndromes and skeletal deformities

Absolute Contraindications to Neuraxial Absolute Contraindications to Neuraxial BlocksBlocks

Parental refusal Parental refusal Severe coagulation disorders, which may be either Severe coagulation disorders, which may be either

constitutional (hemophilia), acquired constitutional (hemophilia), acquired (disseminated intravascular coagulation)(disseminated intravascular coagulation)

Severe infection such as septicemia or meningitisSevere infection such as septicemia or meningitis Hydrocephaly and intracranial tumoral processHydrocephaly and intracranial tumoral process True allergy to local anestheticsTrue allergy to local anesthetics Certain chemotherapies (such as with cisplatin) Certain chemotherapies (such as with cisplatin)

prone to induce subclinical neurologic lesionsprone to induce subclinical neurologic lesions Uncorrected hypovolemia Uncorrected hypovolemia Cutaneous or subcutaneous lesionsCutaneous or subcutaneous lesions

Absolute Contraindications to Absolute Contraindications to Peripheral Nerve Block ProceduresPeripheral Nerve Block Procedures

True allergy to local anesthetics is the only True allergy to local anesthetics is the only absolute medical contraindication to peripheral absolute medical contraindication to peripheral nerve blocks. nerve blocks.

Coagulation disorders.Coagulation disorders. Septicemia does not necessarily contraindicate Septicemia does not necessarily contraindicate

peripheral nerve blockade if expected benefits peripheral nerve blockade if expected benefits are significant. are significant.

Hypovolemia should preferably be corrected Hypovolemia should preferably be corrected

OTHERS..OTHERS.. Patients at risk of compartment Patients at risk of compartment

syndromesyndrome HaemoglobinopathiesHaemoglobinopathies Bone and joint anomaliesBone and joint anomalies

Local ComplicationsLocal Complications

Inappropriate needle insertion damaging the Inappropriate needle insertion damaging the nerve and surrounding anatomic structuresnerve and surrounding anatomic structures

    Tissue coring and introduction of epithelial cells Tissue coring and introduction of epithelial cells into tissues where they do not belonginto tissues where they do not belong

      Injection of neurotoxic solutions (syringe Injection of neurotoxic solutions (syringe mismatch, epinephrine close to a terminal artery)  mismatch, epinephrine close to a terminal artery)  

      Leakage around the puncture site, especially Leakage around the puncture site, especially when a catheter has been introduced, which may when a catheter has been introduced, which may cause partial block failure and favor bacterial cause partial block failure and favor bacterial contamination contamination

Systemic ComplicationsSystemic Complications

Usually concomitant with accidental IV Usually concomitant with accidental IV or arterial injectionor arterial injection

Caudal AnaesthesiaCaudal Anaesthesia

Indications:Indications: Most surgical procedures of the infraumblical part Most surgical procedures of the infraumblical part

including inguinal hernia repairincluding inguinal hernia repair Urinary and digestive tract surgeryUrinary and digestive tract surgery Orthopedic procedures on the pelvic girdle and lower Orthopedic procedures on the pelvic girdle and lower

extremities. extremities. Contraindications:Contraindications:Specific contraindications include major malformations of Specific contraindications include major malformations of

the sacrum (myelomeningocele, open spina bifida), the sacrum (myelomeningocele, open spina bifida), meningitis, and intracranial hypertension.meningitis, and intracranial hypertension.

EQUIPMENTSEQUIPMENTS

50 mm, 35 mm, and 50 mm, 35 mm, and 30 mm with 5 mm 30 mm with 5 mm depth markingsdepth markings

0.9 mm / 20 G, 0.7 0.9 mm / 20 G, 0.7 mm / 22 G, 0.5 mm / mm / 22 G, 0.5 mm / 25 G25 G

Appropriate sizes for Appropriate sizes for new-borns, infants new-borns, infants and school childrenand school children

Caudal Anesthesia – Caudal Anesthesia – TechniqueTechnique

TechniquesTechniques Performed with the patient in the semiprone or, especially in Performed with the patient in the semiprone or, especially in

nonanesthetized premature infants, in the prone position either with nonanesthetized premature infants, in the prone position either with a rolled towel slipped under the pelvis or with the legs flexed in the a rolled towel slipped under the pelvis or with the legs flexed in the frog position. frog position.

The two sacral cornua limiting the V-shaped sacral hiatus are The two sacral cornua limiting the V-shaped sacral hiatus are located by palpation along the spinal process line at the level of the located by palpation along the spinal process line at the level of the sacrococcygeal joint sacrococcygeal joint

23 G needle is directed at 60 deg to skin till sacrococcygeal 23 G needle is directed at 60 deg to skin till sacrococcygeal membranes are pierced and then cephalaud For about 2 mm.membranes are pierced and then cephalaud For about 2 mm.

Whoosh/swoosh test may be performed to confirm needle Whoosh/swoosh test may be performed to confirm needle placementplacement

LA is then administeredLA is then administered Epidural catheter can also be placedEpidural catheter can also be placed

Armitage regimeArmitage regimeDosage:With 0.5 mL/kg, all sacral dermatomes Dosage:With 0.5 mL/kg, all sacral dermatomes

are blocked.    are blocked.   

•    •    With 1.0 mL/kg, all sacral and lumbar With 1.0 mL/kg, all sacral and lumbar dermatomes are blocked.    dermatomes are blocked.   

•    •    With 1.25 mL/kg, the upper limit of With 1.25 mL/kg, the upper limit of anesthesia is at least midthoracicanesthesia is at least midthoracic

Anesthesiology 101:A1470, 2004

Specific Complications Specific Complications Delayed postoperative voiding Delayed postoperative voiding Block failureBlock failure Venous air embolismVenous air embolism

EPIDURAL ANAESTHESIAEPIDURAL ANAESTHESIA

INDICATIONS:INDICATIONS: Major abdominal, retroperitoneal, pelvic, and thoracic surgeries.Major abdominal, retroperitoneal, pelvic, and thoracic surgeries. Cardiac surgery in a few institutions:Considered controversialCardiac surgery in a few institutions:Considered controversialCONTRAINDICATIONS:CONTRAINDICATIONS: Severe malformations of the spine and the spinal cordSevere malformations of the spine and the spinal cord Intraspinal lesions or tumors Intraspinal lesions or tumors History of hydrocephalusHistory of hydrocephalus Elevated intracranial pressureElevated intracranial pressure Unstable epilepsyUnstable epilepsy Reduced intracranial complianceReduced intracranial compliance

EQUIPMENTEQUIPMENT

Three different Three different needle sizesneedle sizes

(1.3 mm/18 G, 0.9 (1.3 mm/18 G, 0.9 mm/20 G,mm/20 G,0.7 0.7 mm/22 G)mm/22 G)

Special length of Special length of 50 mm with 5 mm 50 mm with 5 mm depth markingsdepth markings

Combinations….Combinations….

0.7 x 50 mm (20 G) needle/0.7 x 50 mm (20 G) needle/

0.6 x 750 mm (24 G) catheter0.6 x 750 mm (24 G) catheter 1.3 x 50 mm (18 G) needle/0.85 x 1.3 x 50 mm (18 G) needle/0.85 x

960 mm (20 G) catheter960 mm (20 G) catheter

TechniquesTechniquesLUMBAR EPIDURALLUMBAR EPIDURAL Space is usually approached in anesthetized patients via Space is usually approached in anesthetized patients via

a midline route below the L2-L3 interspace.a midline route below the L2-L3 interspace. A paramedian approach can be used instead in cases of A paramedian approach can be used instead in cases of

spinous process anomaly or spine deformity. spinous process anomaly or spine deformity. The child is positioned in the semiprone position with The child is positioned in the semiprone position with

the side to be operated lowermost and the spine bent to the side to be operated lowermost and the spine bent to enlarge the interspinous spaces). enlarge the interspinous spaces).

The sitting position can be used in conscious patientsThe sitting position can be used in conscious patients For most paediatric patients LOR is by air and after 8 For most paediatric patients LOR is by air and after 8

yrs it is by salineyrs it is by saline

1 mm/kg is a useful approximation between 6 1 mm/kg is a useful approximation between 6 months and 10 years of agemonths and 10 years of age

Catheter is inserted not more than 3 cmCatheter is inserted not more than 3 cm Around 0.1 mL per year of age is necessary to Around 0.1 mL per year of age is necessary to

block 1 neuromereblock 1 neuromere Usual volumes of injectate range from 0.5 to Usual volumes of injectate range from 0.5 to

1 mL/kg (up to 20 mL.)1 mL/kg (up to 20 mL.) Adjuncts not to be used below<6yrsAdjuncts not to be used below<6yrs

Local anesthetic dosage:Local anesthetic dosage:

Loading dosage:Bupivacaine, Loading dosage:Bupivacaine, levobupivacaine:Solution: 0.25% levobupivacaine:Solution: 0.25% Dose:Dose:<20 kg: 0.75 mL/kg<20 kg: 0.75 mL/kg20-40 kg: 8-10 mL (or 0.1 mL/year/number of 20-40 kg: 8-10 mL (or 0.1 mL/year/number of metameres)metameres)>40 kg: same as for adults>40 kg: same as for adults

Maintainance dosage:.1ml/kg every 6-12 hrly of Maintainance dosage:.1ml/kg every 6-12 hrly of half conchalf conc

For continuous infusion:For continuous infusion:<4 mo: 0.2 mg/kg/hr (0.15 mL/kg/hr of a 0.125% <4 mo: 0.2 mg/kg/hr (0.15 mL/kg/hr of a 0.125%

solution or 0.3 mL/kg/hr of a 0.0625% solution)solution or 0.3 mL/kg/hr of a 0.0625% solution)

4-18 mo: 0.25 mg/kg/hr (0.2 mL/kg/hr of a 4-18 mo: 0.25 mg/kg/hr (0.2 mL/kg/hr of a 0.125% solution or 0.4 mL/kg/hr of a 0.0625% 0.125% solution or 0.4 mL/kg/hr of a 0.0625% solution)solution)

>18 mo: 0.3-0.375 mg/kg/hr (0.3 mL/kg/hr of a >18 mo: 0.3-0.375 mg/kg/hr (0.3 mL/kg/hr of a 0.125% solution or 0.6 mL/kg/hr of a 0.0625% 0.125% solution or 0.6 mL/kg/hr of a 0.0625% solutionsolution

ROPIVACAINE(.2%): Loading and maintainance ROPIVACAINE(.2%): Loading and maintainance dosage same as bupivacainedosage same as bupivacaine

Thoracic Epidural Thoracic Epidural AnaesthesiaAnaesthesia

Indicated for major operations requiring long-Indicated for major operations requiring long-lasting pain relief. lasting pain relief.

Not commonly used techniques in children.Not commonly used techniques in children. In children younger than 1 year of age, the In children younger than 1 year of age, the

procedure is similar to that for a lumbar procedure is similar to that for a lumbar approach, with a needle insertion.approach, with a needle insertion.

Perpendicular to the spinous process line.Perpendicular to the spinous process line. With age needle goes in more cephalic With age needle goes in more cephalic

Spinal AnaesthesiaSpinal Anaesthesia

INDICATIONS:INDICATIONS: Inguinal hernia repair in former preterm Inguinal hernia repair in former preterm

infants younger than 60 weeks of infants younger than 60 weeks of postconceptual agepostconceptual age

Elective lower abdominal or lower extremity Elective lower abdominal or lower extremity surgerysurgery

Cardiac surgery, cardiac Cardiac surgery, cardiac catheterization:controversialcatheterization:controversial..

EquipmentsEquipments

Spinal needle (24-25 gauge; 30, 50 or 100 mm Spinal needle (24-25 gauge; 30, 50 or 100 mm long, Quincke bevel can be usedlong, Quincke bevel can be used

Neonatal lumbar puncture needle (22 gauge, Neonatal lumbar puncture needle (22 gauge, 30-50 mm long)30-50 mm long)

Whitacre spinal needle used for adults is also Whitacre spinal needle used for adults is also an alternativean alternative

Techniques Techniques Same as that of adultSame as that of adult

hyperbaric bupivacaine are the most hyperbaric bupivacaine are the most commonly used local anesthetics.commonly used local anesthetics.

Approximate Distance: Approximate Distance: Skin to Subarachnoid SpaceSkin to Subarachnoid Space

0

10

20

30

40

50

1 yr 3 yr 5 yr 10 yr 18 yr

MILLIMETERS

PremieNewborn5 months

Cote´, A Practice of Anesthesia for Infants and Children

Doses of LA for Spinal Anesthesia in Neonates and Doses of LA for Spinal Anesthesia in Neonates and Former Preterm Neonates Younger than 60 Former Preterm Neonates Younger than 60 Weeks of Preconceptual Age (up to a Weight of Weeks of Preconceptual Age (up to a Weight of 5 kg)5 kg)Local Anesthetic

Dose (mg/kg

Volume (mL/kg)

Duration (min

Bupivacaine 0.5% isobaric or hyperbaric

0.5-1.0 0.1-0.2 65-75

Ropivacaine 0.5%

1.08 0.22 51-68

Usual Doses of Local Anesthetics Usual Doses of Local Anesthetics for Spinal Anesthesia in Children for Spinal Anesthesia in Children and Adolescentsand Adolescents

Local Anesthetic Usual Dose(s)

0.5% Isobaric or hyperbaric bupivacaine

5 to 15 kg: 0.4 mg/kg (0.08 mL/kg)>15 kg: 0.3 mg/kg (0.06 mL/kg)

0.5% Isobaric or hyperbaric tetracaine

5 to 15 kg: 0.4 mg/kg (0.08 mL/kg)>15 kg: 0.3 mg/kg (0.06 mL/kg)

0.5% Isobaric ropivacaine 0.5 mg/kg (max 20 mg)

ComplicationsComplications

Higher rate of failure..Higher rate of failure..

PENILE N BLOCKPENILE N BLOCK

INDICATIONS:INDICATIONS: Release of paraphimosis Dorsal slit of the foreskin CircumcisionCircumcision Repair of penile lacerations. Repair of penile lacerations.

TechniqueTechnique

Anatomical considerations:Anatomical considerations: Innervation of penis by pudendal nerveInnervation of penis by pudendal nerve Enters the penis deep to bucks fasciaEnters the penis deep to bucks fascia Genitofemoral and ilioinguinal may Genitofemoral and ilioinguinal may

additionally supply penis.additionally supply penis.

TechniqueTechnique A fan shaped is created on A fan shaped is created on

base of penisbase of penis Bupivacaine .5% (2mg/kg) Bupivacaine .5% (2mg/kg)

more commonly usedmore commonly used If more profound block needed If more profound block needed

deep dorsal nerve blocked deep dorsal nerve blocked with a 25g needle piercing with a 25g needle piercing Bucks fascia10 30 and 1-30 Bucks fascia10 30 and 1-30 positions lateral to base of positions lateral to base of penispenis

Epinephrine is avoidedEpinephrine is avoided

THANK YOU!!!THANK YOU!!!