Presentation on theme: "SPINAL,EPIDURAL/CAUDAL,PENILE NERVE BLOCK IN PEDIATRIC PATIENTS"— Presentation transcript:
1SPINAL,EPIDURAL/CAUDAL,PENILE NERVE BLOCK IN PEDIATRIC PATIENTS MODERATOR:Dr. JYOTI PATHANIAPRESENTED BY: Dr. SUCHIT KHANDUJA
2INDICATIONS OF REGIONAL BLOCKADE Analgesia:Both intraop and postopTesticular torsion or incarcerated hernia at immediate risk of rupture in nonfasted childrenInguinal hernia repair in former preterm infants younger then 60 weeks of postconceptual ageSevere acute or chronic respiratory insufficiencyEmergency conditions in children with severe metabolic or endocrine disordersNeuromuscular disorders, myasthenia gravis, or some types of porphyriaSome types of polymalformative syndromes and skeletal deformities
3Absolute Contraindications to Neuraxial Blocks Parental refusalSevere coagulation disorders, which may be either constitutional (hemophilia), acquired (disseminated intravascular coagulation)Severe infection such as septicemia or meningitisHydrocephaly and intracranial tumoral processTrue allergy to local anestheticsCertain chemotherapies (such as with cisplatin) prone to induce subclinical neurologic lesionsUncorrected hypovolemiaCutaneous or subcutaneous lesions
4Absolute Contraindications to Peripheral Nerve Block Procedures True allergy to local anesthetics is the only absolute medical contraindication to peripheral nerve blocks.Coagulation disorders.Septicemia does not necessarily contraindicate peripheral nerve blockade if expected benefits are significant.Hypovolemia should preferably be corrected
5OTHERS..Patients at risk of compartment syndromeHaemoglobinopathiesBone and joint anomalies
6Local ComplicationsInappropriate needle insertion damaging the nerve and surrounding anatomic structures 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) Leakage around the puncture site, especially when a catheter has been introduced, which may cause partial block failure and favor bacterial contamination
7Systemic Complications Usually concomitant with accidental IV or arterial injection
8Caudal Anaesthesia Indications: Most surgical procedures of the infraumblical part including inguinal hernia repairUrinary and digestive tract surgeryOrthopedic 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.
9EQUIPMENTS 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 GAppropriate sizes for new-borns, infants and school children
11TechniquesPerformed 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 joint23 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 placementLA is then administeredEpidural catheter can also be placed
12Armitage regime Dosage:With 0 Armitage regime Dosage:With 0.5 mL/kg, all sacral dermatomes are blocked. • With 1.0 mL/kg, all sacral and lumbar dermatomes are blocked. • With 1.25 mL/kg, the upper limit of anesthesia is at least midthoracic
14Specific Complications Delayed postoperative voidingBlock failureVenous air embolism
15EPIDURAL ANAESTHESIA INDICATIONS: Major abdominal, retroperitoneal, pelvic, and thoracic surgeries.Cardiac surgery in a few institutions:Considered controversialCONTRAINDICATIONS:Severe malformations of the spine and the spinal cordIntraspinal lesions or tumorsHistory of hydrocephalusElevated intracranial pressureUnstable epilepsyReduced intracranial compliance
16EQUIPMENT Three different needle sizes (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
17Combinations…. 0.7 x 50 mm (20 G) needle/ 0.6 x 750 mm (24 G) catheter
18Techniques LUMBAR EPIDURAL 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.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 patientsFor most paediatric patients LOR is by air and after 8 yrs it is by saline
191 mm/kg is a useful approximation between 6 months and 10 years of age Catheter is inserted not more than 3 cmAround 0.1 mL per year of age is necessary to block 1 neuromereUsual volumes of injectate range from 0.5 to 1 mL/kg (up to 20 mL.)Adjuncts not to be used below<6yrs
20Local anesthetic dosage: Loading dosage:Bupivacaine, levobupivacaine:Solution: 0.25% Dose: <20 kg: 0.75 mL/kg kg: 8-10 mL (or 0.1 mL/year/number of metameres) >40 kg: same as for adults Maintainance dosage:.1ml/kg every 6-12 hrly of half conc
21For 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
22Thoracic Epidural Anaesthesia Indicated for major operations requiring long-lasting pain relief.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.Perpendicular to the spinous process line.With age needle goes in more cephalic
23Spinal Anaesthesia INDICATIONS: Inguinal hernia repair in former preterm infants younger than 60 weeks of postconceptual ageElective lower abdominal or lower extremity surgeryCardiac surgery, cardiac catheterization:controversial.
24EquipmentsSpinal needle (24-25 gauge; 30, 50 or 100 mm long, Quincke bevel can be usedNeonatal lumbar puncture needle (22 gauge, 30-50 mm long)Whitacre spinal needle used for adults is also an alternative
25TechniquesSame as that of adult hyperbaric bupivacaine are the most commonly used local anesthetics.
26Approximate Distance: Skin to Subarachnoid Space MILLIMETERSPremieNewborn5 monthsCote´, A Practice of Anesthesia for Infants and Children
27Doses 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 AnestheticDose (mg/kgVolume (mL/kg)Duration (minBupivacaine 0.5% isobaric or hyperbaric65-75Ropivacaine 0.5%1.080.2251-68
28Usual Doses of Local Anesthetics for Spinal Anesthesia in Children and Adolescents 0.5% Isobaric or hyperbaric bupivacaine5 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 tetracaine0.5% Isobaric ropivacaine0.5 mg/kg (max 20 mg)
30PENILE N BLOCK INDICATIONS: Release of paraphimosis Dorsal slit of the foreskinCircumcisionRepair of penile lacerations.
31Technique Anatomical considerations: Innervation of penis by pudendal nerveEnters the penis deep to bucks fasciaGenitofemoral and ilioinguinal may additionally supply penis.
32Technique A fan shaped is created on base of penis Bupivacaine .5% (2mg/kg) more commonly usedIf more profound block needed deep dorsal nerve blocked with a 25g needle piercing Bucks fascia10 30 and 1-30 positions lateral to base of penisEpinephrine is avoided