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SPINAL,EPIDURAL/CAUDAL,PENILE NERVE BLOCK IN PEDIATRIC PATIENTS MODERATOR:Dr. JYOTI PATHANIA PRESENTED BY: Dr. SUCHIT KHANDUJA.

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Presentation on theme: "SPINAL,EPIDURAL/CAUDAL,PENILE NERVE BLOCK IN PEDIATRIC PATIENTS MODERATOR:Dr. JYOTI PATHANIA PRESENTED BY: Dr. SUCHIT KHANDUJA."— Presentation transcript:

1 SPINAL,EPIDURAL/CAUDAL,PENILE NERVE BLOCK IN PEDIATRIC PATIENTS MODERATOR:Dr. JYOTI PATHANIA PRESENTED BY: Dr. SUCHIT KHANDUJA

2 INDICATIONS OF REGIONAL BLOCKADE Analgesia:Both intraop and postop Analgesia:Both intraop and postop Testicular torsion or incarcerated hernia at immediate risk of rupture in nonfasted children Testicular torsion or incarcerated hernia at immediate risk of rupture in nonfasted children Inguinal hernia repair in former preterm infants younger then 60 weeks of postconceptual age Inguinal hernia repair in former preterm infants younger then 60 weeks of postconceptual age Severe acute or chronic respiratory insufficiency Severe acute or chronic respiratory insufficiency Emergency conditions in children with severe metabolic or endocrine disorders Emergency conditions in children with severe metabolic or endocrine disorders Neuromuscular disorders, myasthenia gravis, or some types of porphyria Neuromuscular disorders, myasthenia gravis, or some types of porphyria Some types of polymalformative syndromes and skeletal deformities Some types of polymalformative syndromes and skeletal deformities

3 Absolute Contraindications to Neuraxial Blocks Parental refusal Parental refusal Severe coagulation disorders, which may be either constitutional (hemophilia), acquired (disseminated intravascular coagulation) Severe coagulation disorders, which may be either constitutional (hemophilia), acquired (disseminated intravascular coagulation) Severe infection such as septicemia or meningitis Severe infection such as septicemia or meningitis Hydrocephaly and intracranial tumoral process Hydrocephaly and intracranial tumoral process True allergy to local anesthetics True allergy to local anesthetics Certain chemotherapies (such as with cisplatin) prone to induce subclinical neurologic lesions Certain chemotherapies (such as with cisplatin) prone to induce subclinical neurologic lesions Uncorrected hypovolemia Uncorrected hypovolemia Cutaneous or subcutaneous lesions Cutaneous or subcutaneous lesions

4 Absolute Contraindications to Peripheral Nerve Block Procedures True allergy to local anesthetics is the only absolute medical contraindication to peripheral nerve blocks. True allergy to local anesthetics is the only absolute medical contraindication to peripheral nerve blocks. Coagulation disorders. Coagulation disorders. Septicemia does not necessarily contraindicate peripheral nerve blockade if expected benefits are significant. Septicemia does not necessarily contraindicate peripheral nerve blockade if expected benefits are significant. Hypovolemia should preferably be corrected Hypovolemia should preferably be corrected

5 OTHERS.. Patients at risk of compartment syndrome Patients at risk of compartment syndrome Haemoglobinopathies Haemoglobinopathies Bone and joint anomalies Bone and joint anomalies

6 Local Complications Inappropriate needle insertion damaging the nerve and surrounding anatomic structures Inappropriate needle insertion damaging the nerve and surrounding anatomic structures Tissue coring and introduction of epithelial cells into tissues where they do not belong Tissue coring and introduction of epithelial cells into tissues where they do not belong Injection of neurotoxic solutions (syringe mismatch, epinephrine close to a terminal artery) Injection of neurotoxic solutions (syringe mismatch, epinephrine close to a terminal artery) Leakage around the puncture site, especially when a catheter has been introduced, which may cause partial block failure and favor bacterial contamination Leakage around the puncture site, especially when a catheter has been introduced, which may cause partial block failure and favor bacterial contamination

7 Systemic Complications Usually concomitant with accidental IV or arterial injection

8 Caudal Anaesthesia Indications: Most surgical procedures of the infraumblical part including inguinal hernia repair Most surgical procedures of the infraumblical part including inguinal hernia repair Urinary and digestive tract surgery Urinary and digestive tract surgery Orthopedic procedures on the pelvic girdle and lower extremities. Orthopedic procedures on the pelvic girdle and lower extremities.Contraindications: Specific contraindications include major malformations of the sacrum (myelomeningocele, open spina bifida), meningitis, and intracranial hypertension.

9 EQUIPMENTS 50 mm, 35 mm, and 30 mm with 5 mm depth markings 50 mm, 35 mm, and 30 mm with 5 mm depth markings 0.9 mm / 20 G, 0.7 mm / 22 G, 0.5 mm / 25 G 0.9 mm / 20 G, 0.7 mm / 22 G, 0.5 mm / 25 G Appropriate sizes for new-borns, infants and school children Appropriate sizes for new-borns, infants and school children

10 Caudal Anesthesia – Technique

11 Techniques Performed with the patient in the semiprone or, especially in nonanesthetized premature infants, in the prone position either with a rolled towel slipped under the pelvis or with the legs flexed in the frog position. Performed with the patient in the semiprone or, especially in nonanesthetized premature infants, in the prone position either with a rolled towel slipped under the pelvis or with the legs flexed in the frog position. The two sacral cornua limiting the V-shaped sacral hiatus are located by palpation along the spinal process line at the level of the sacrococcygeal joint The two sacral cornua limiting the V-shaped sacral hiatus are located by palpation along the spinal process line at the level of the sacrococcygeal joint 23 G needle is directed at 60 deg to skin till sacrococcygeal membranes are pierced and then cephalaud For about 2 mm. 23 G needle is directed at 60 deg to skin till sacrococcygeal membranes are pierced and then cephalaud For about 2 mm. Whoosh/swoosh test may be performed to confirm needle placement Whoosh/swoosh test may be performed to confirm needle placement LA is then administered LA is then administered Epidural catheter can also be placed Epidural catheter can also be placed

12 Armitage regime Armitage regime Dosage:With 0.5 mL/kg, all sacral dermatomes are blocked. Dosage:With 0.5 mL/kg, all sacral dermatomes are blocked. With 1.0 mL/kg, all sacral and lumbar dermatomes are blocked. With 1.0 mL/kg, all sacral and lumbar dermatomes are blocked. With 1.25 mL/kg, the upper limit of anesthesia is at least midthoracic With 1.25 mL/kg, the upper limit of anesthesia is at least midthoracic

13 Anesthesiology 101:A1470, 2004

14 Specific Complications Specific Complications Delayed postoperative voiding Delayed postoperative voiding Block failure Block failure Venous air embolism Venous air embolism

15 EPIDURAL ANAESTHESIA INDICATIONS: Major abdominal, retroperitoneal, pelvic, and thoracic surgeries. Major abdominal, retroperitoneal, pelvic, and thoracic surgeries. Cardiac surgery in a few institutions:Considered controversial Cardiac surgery in a few institutions:Considered controversialCONTRAINDICATIONS: Severe malformations of the spine and the spinal cord Severe malformations of the spine and the spinal cord Intraspinal lesions or tumors Intraspinal lesions or tumors History of hydrocephalus History of hydrocephalus Elevated intracranial pressure Elevated intracranial pressure Unstable epilepsy Unstable epilepsy Reduced intracranial compliance Reduced intracranial compliance

16 EQUIPMENT Three different needle sizes Three different needle sizes (1.3 mm/18 G, 0.9 mm/20 G,0.7 mm/22 G) (1.3 mm/18 G, 0.9 mm/20 G,0.7 mm/22 G) Special length of 50 mm with 5 mm depth markings Special length of 50 mm with 5 mm depth markings

17 Combinations…. 0.7 x 50 mm (20 G) needle/ 0.7 x 50 mm (20 G) needle/ 0.6 x 750 mm (24 G) catheter 0.6 x 750 mm (24 G) catheter 1.3 x 50 mm (18 G) needle/0.85 x 960 mm (20 G) catheter 1.3 x 50 mm (18 G) needle/0.85 x 960 mm (20 G) catheter

18 Techniques LUMBAR EPIDURAL Space is usually approached in anesthetized patients via a midline route below the L2-L3 interspace. Space is usually approached in anesthetized patients via a midline route below the L2-L3 interspace. A paramedian approach can be used instead in cases of spinous process anomaly or spine deformity. A paramedian approach can be used instead in cases of spinous process anomaly or spine deformity. The child is positioned in the semiprone position with the side to be operated lowermost and the spine bent to enlarge the interspinous spaces). The child is positioned in the semiprone position with the side to be operated lowermost and the spine bent to enlarge the interspinous spaces). The sitting position can be used in conscious patients The sitting position can be used in conscious patients For most paediatric patients LOR is by air and after 8 yrs it is by saline For most paediatric patients LOR is by air and after 8 yrs it is by saline

19 1 mm/kg is a useful approximation between 6 months and 10 years of age 1 mm/kg is a useful approximation between 6 months and 10 years of age Catheter is inserted not more than 3 cm Catheter is inserted not more than 3 cm Around 0.1 mL per year of age is necessary to block 1 neuromere Around 0.1 mL per year of age is necessary to block 1 neuromere Usual volumes of injectate range from 0.5 to 1 mL/kg (up to 20 mL.) Usual volumes of injectate range from 0.5 to 1 mL/kg (up to 20 mL.) Adjuncts not to be used below<6yrs Adjuncts not to be used below<6yrs

20 Local anesthetic dosage: Loading dosage:Bupivacaine, levobupivacaine:Solution: 0.25% Dose: 40 kg: same as for adults Loading dosage:Bupivacaine, levobupivacaine:Solution: 0.25% Dose: 40 kg: same as for adults Maintainance dosage:.1ml/kg every 6-12 hrly of half conc

21 For continuous infusion: <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 % solution) 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 % solution) >18 mo: mg/kg/hr (0.3 mL/kg/hr of a 0.125% solution or 0.6 mL/kg/hr of a % solution ROPIVACAINE(.2%): Loading and maintainance dosage same as bupivacaine

22 Thoracic Epidural Anaesthesia Indicated for major operations requiring long- lasting pain relief. Indicated for major operations requiring long- lasting pain relief. Not commonly used techniques in children. Not commonly used techniques in children. In children younger than 1 year of age, the procedure is similar to that for a lumbar approach, with a needle insertion. In children younger than 1 year of age, the procedure is similar to that for a lumbar 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

23 Spinal Anaesthesia INDICATIONS: Inguinal hernia repair in former preterm infants younger than 60 weeks of postconceptual age Inguinal hernia repair in former preterm infants younger than 60 weeks of postconceptual age Elective lower abdominal or lower extremity surgery Elective lower abdominal or lower extremity surgery Cardiac surgery, cardiac catheterization:controversial. Cardiac surgery, cardiac catheterization:controversial.

24 Equipments Spinal needle (24-25 gauge; 30, 50 or 100 mm long, Quincke bevel can be used Spinal needle (24-25 gauge; 30, 50 or 100 mm long, Quincke bevel can be used Neonatal lumbar puncture needle (22 gauge, mm long) Neonatal lumbar puncture needle (22 gauge, mm long) Whitacre spinal needle used for adults is also an alternative Whitacre spinal needle used for adults is also an alternative

25 Techniques Same as that of adult hyperbaric bupivacaine are the most commonly used local anesthetics.

26 Approximate Distance: Skin to Subarachnoid Space MILLIMETERS PremieNewborn5 months Cote´, A Practice of Anesthesia for Infants and Children

27 Doses of LA for Spinal Anesthesia in Neonates and Former Preterm Neonates Younger than 60 Weeks of Preconceptual Age (up to a Weight of 5 kg) Local Anesthetic Dose (mg/kg Volume (mL/kg) Duration (min Bupivacain e 0.5% isobaric or hyperbaric Ropivacain e 0.5%

28 Usual Doses of Local Anesthetics for Spinal Anesthesia in Children and Adolescents Local AnestheticUsual 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)

29 Complications Higher rate of failure..

30 PENILE N BLOCK INDICATIONS: Release of paraphimosis Release of paraphimosis Release of paraphimosis Release of paraphimosis Dorsal slit of the foreskin Dorsal slit of the foreskin Dorsal slit of the foreskin Dorsal slit of the foreskin Circumcision Circumcision Repair of penile lacerations. Repair of penile lacerations.

31 Technique Anatomical considerations: Innervation of penis by pudendal nerve Innervation of penis by pudendal nerve Enters the penis deep to bucks fascia Enters the penis deep to bucks fascia Genitofemoral and ilioinguinal may additionally supply penis. Genitofemoral and ilioinguinal may additionally supply penis.

32 Technique A fan shaped is created on base of penis A fan shaped is created on base of penis Bupivacaine.5% (2mg/kg) more commonly used Bupivacaine.5% (2mg/kg) more commonly used If more profound block needed deep dorsal nerve blocked with a 25g needle piercing Bucks fascia10 30 and 1-30 positions lateral to base of penis If more profound block needed deep dorsal nerve blocked with a 25g needle piercing Bucks fascia10 30 and 1-30 positions lateral to base of penis Epinephrine is avoided Epinephrine is avoided

33 THANK YOU!!!


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