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
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
Severe acute or chronic respiratory insufficiency
Emergency conditions in children with severe metabolic or endocrine disorders
Neuromuscular disorders, myasthenia gravis, or some types of porphyria
Some types of polymalformative syndromes and skeletal deformities

3. Absolute Contraindications to Neuraxial Blocks
Parental refusal
Severe coagulation disorders, which may be either constitutional (hemophilia), acquired (disseminated intravascular coagulation)
Severe infection such as septicemia or meningitis
Hydrocephaly and intracranial tumoral process
True allergy to local anesthetics
Certain chemotherapies (such as with cisplatin) prone to induce subclinical neurologic lesions
Uncorrected hypovolemia
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.
Coagulation disorders.
Septicemia does not necessarily contraindicate peripheral nerve blockade if expected benefits are significant.
Hypovolemia should preferably be corrected

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

6. Local Complications
Inappropriate 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

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
Urinary and digestive tract surgery
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
0.9 mm / 20 G, 0.7 mm / 22 G, 0.5 mm / 25 G
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.
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.
Whoosh/swoosh test may be performed to confirm needle placement
LA is then administered
Epidural catheter can also be placed

12. Armitage 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

13. Anesthesiology 101:A1470, 2004

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

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

16. EQUIPMENT 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

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

18. Techniques 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 patients
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
Catheter is inserted not more than 3 cm
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.)
Adjuncts not to be used below<6yrs

20. Local 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

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.
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

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

24. Equipments
Spinal needle (24-25 gauge; 30, 50 or 100 mm long, Quincke bevel can be used
Neonatal lumbar puncture needle (22 gauge, 30-50 mm long)
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
Premie
Newborn
5 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
Bupivacaine 0.5% isobaric or hyperbaric
65-75
Ropivacaine 0.5%
1.08
0.22
51-68

28. Usual Doses of Local Anesthetics for Spinal Anesthesia in Children and Adolescents
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
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
Dorsal slit of the foreskin
Circumcision
Repair of penile lacerations.

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

32. Technique A fan shaped is created on base of penis
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
Epinephrine is avoided

33. THANK YOU!!!