1. Maria Matuszczak MD Professor of Anesthesiology Division Chief Pediatric Anesthesia 6 th Anesthesia And Critical Care Conference Kuwait 20-22 Nov 2014

2. Nothing to disclose

3. Know the commonly use regional blocks in children Know the treatment of local anesthetic toxicity Know how to set up a pediatric regional service Objectives

4. 1. Regional anesthesia for neonates/infants. 2. Update on intralipid protocol for pediatrics 3. System setup for regional anesthesia program

5. Regional anesthesia for neonates/infants.

6. contrarily to adults, blocks should not be performed on awake children

7. Asleep vs. Awake - Does it matter? Pediatric regional block complications by patient state. A report from the Pediatric Regional Anesthesia Network (PRAN). Andreas H. Taenzer, et al. Reg Anesth Pain Med 2014 39(4): 279-83 53,564 pediatric regional anesthesia blocks from an observational prospective database (PRAN) were analyzed in regard of the rate of adverse events in relation to the patient being awake or anesthetized at the time of block placement Primary outcomes: 1. (PONS) postoperative neurologic symptoms 1. (PONS) postoperative neurologic symptoms 2. (LAST) local anesthetic systemic toxicity 2. (LAST) local anesthetic systemic toxicity ( ) ( either in the form of cardiovascular symptoms or seizures ) Secondary outcome: 1. extended hospital stay due to a block complication.

8. Landmarks little modifications small children have less well defined landmarks

9. Distance skin-nerve bony growth is not the same for long, short or flat bones variations of body fluids have influence on skin thickness

10. Pharmacokinetic of Local Anesthetics little information concerning diffusion, protein binding and LA metabolism, lower level of alpha-1-glycoprotein means higher fraction of free local anesthetic, considerable individual variations local spread is easier in children, fat is less dense,

11. Single Shot maximum dosage for Local Anesthetics Bupivacaine 2.5mg/kg Ropivacaine 2-3mg/kg Lidocaine 7mg/kg Prilocaine 7-10mg/kg

12. Maximum hourly doses Bupivacaine/Ropivacaine 0.4-0.5 mg/kg/hr in children 0.20-0.25 mg/kg/hr in newborns the continuous infusion rate should not exceed:

13. Use of Adjuvant Clonidine can be used at 1-2 mcg/kg to prolong a peripheral/central single shot nerve block or 1-2mcg/ml for continuous infusion

14. But: hematoma, infection, transient arterial vasospasm And local anesthesia toxicity !!! Complications ? closed claim analysis: no data concerning nerve injury from peripheral nerve blocks in children

15. Epidemiology and morbidity of regional anesthesia in children: A one-year prospective survey of the French- language society of pediatric anesthesiologists. E. Giaufre et al. Anesthesia & Analgesia 1996; 83:904-912 prospective 1-year survey of regional anesthesia in French- language Society of Pediatric Anesthesiologists, 24409 blocks, 60% central blocks ( mostly caudals) 4090 peripheral blocks, 997 upper extremity 103/997 in children younger than 3 years no complications related to peripheral nerve blocks 1.5% complications all related to caudal epidural blocks

16. Epidemiology and morbidity of regional anesthesia in children: a follow-up one-year prospective survey of the french-Language Society of Pediatric Anaesthesiologists C Ecoffey et al, Pediatr Anesth 2010, 20:1061-1069 Anonymous survey, 104,612 pure GA; 29,870 GA with blocks; 1,262 pure blocks 34% of all RA = central blocks 66% PNB, 29% extremities, 71% trunk blocks and face blocks 3 years: 4x more PNB 41 complications in 40 patients, overall 0.12% complications complications 6 x higher for central than for PNB

17. Pediatric Regional Anesthesia Network (PRAN) A Multi-institutional Study of the Use nd Incidence of Complications of Pediatric Regional Anesthesia D. Polaner, A Taenzer, B.Walker Anesth Analg 2012, 10:1-12 Prospective data collection, April 2007 March 2010 14,917 rgional blocks on 13,725 children No deaths or complication > 3 months 95% blocks placed under GA 40 % caudals, 35% peripheral nerve blocks complications are higher for central than for PNB 33% of complications due to catheter dislocations

18. Paravertebral /Intercostal Block Rectus Sheath Block Transabdominal Plan Block Ilioinguinal/Hypogastric Nerve Block Dorsal Penile Block

19. TRUNKAL BLOCKS

20. 3 Abdominal wall blocks: ilioinguinal/hypogastric block rectus sheath block TAP block

21. TRUNKAL BLOCKS Ilioinguinal/hypogastric block

22. TRUNKAL BLOCKS Rectus sheath block

23. TRUNKAL BLOCKS TAP block

24. TRUNKAL BLOCKS Intercostal Block Grau: Ultraschall in der Anaesthesie und Intensivmedizin

25. Central Block Caudal Block

26. Update on intralipid protocol for pediatrics

27. Successful Use of a 20% Lipid Emulsion to Resuscitate a Patient after a Presumed Bupivacaine-related Cardiac Arrest MA. Rosenblatt, M Abel, GW Fischer, CJ Itzkovich, JB Eisenkraft Anesthesiology 2006; 105:217–8 First published case 58Y, 82kg, intra-scalene block, 20ml Bupi 0.5% + 20ml Mepi 1.5% 20 minutes CPR 100ml of 20% intralipid, within seconds return to sinus rythm

28. Treatment of Local Anesthetic Systemic Toxicity (LAST) Guy L. Weinberg, MD Reg Anesth Pain Med 2010;35: 188Y193 Review article Airway management Seizure suppression ( Benzo first choice, Propofol??) Circulatory support ( bypass, no permanent cardiac injury) Lipid infusion ( Cyclodextrins capture local anesthetics) Generalization of lipid infusion ( used for other medication overdosage) Vasopressor therapy ( vasopressin no advantage over epinephrine)

29. Timing and safety ? Treatment regimen ? Use in children ? Alternative formulation ? Treatment of CNS symptoms of toxicity ? Dosing ? Unanswered questions about:

30. Safety of High Volume Lipid Emulsion Infusion A First Approximation of LD50 in Rats DB Hiller, G Di Gregorio, K Kelly, R Ripper, L Edelman, R Boumendjel, K Drasner, GL Weinberg Reg Anesth Pain Med 2010;35: 140-144 Study safety and systemic adverse effects of high volume lipid emulsion administration Dixon‘s up-and-down Method of estimating LD50 Rats weighting between 385 and 413 g anesthetised, LD50 = 67.7ml +/-10.7 equivalent human LD50 dose 10.5-16.4ml hemorrhagic pulmonary vascular congestion @ 80 ml

31. Safety of High Volume Lipid Emulsion Infusion Infusing lipid emulsion is not without risk Neonates: possible pulmonary embolus “fat overloading syndrome” with pulmonary fat emboli causing death in 4 infants large lipid globules can lodge in the lung, engorge pulmonary capillaries, and exacerbate ventilation-perfusion mismatches in the preterm lung. Autopsy found evidence of pulmonary fat microemboli.

32. Successful resuscitation in infants/neonates Successful resuscitation following ropivacaine-induced systemic toxicity in a neonate M. Huebler, et al, Anaesthesia, 2010, 65, pages 1137–1140 Use of Intralipid in an infant with impending cardiovascular collapse due to local anesthetic toxicity S Shah et al, J Anesth (2009) 23:439–441 Successful resuscitation of bupivacaine-imduced cardiotoxicity in a neonate EP Lin et al, Pediatr Anesth 2010, 20:955-957 36 weeker, 41 week old 4 kg, recieves 10mg/kg of ropi unintentionally via caudal CPR with 30ml gelatine, normal SR before lipid infusion ready 1 month 4.9kg baby 4 ml bupi with epi via caudal CPR started lipid infusion 10ml stabilization over 2 minutes 2 day old 3.2 kg baby bupi 0.25 1ml /kg via caudal with US CPR started lipid 1 ml/kg Ecg normalized over 3 min

33. Recommendation for treatment of Local Anesthetic Systemic Toxicity (LAST)

34. www.lipidrescue.org www.lipidrescue.org www.aagbi.org/publications/guidelines/doc s/latoxicity07.pdf

37. System setup for regional anesthesia program

38. Dedicated block team? MD, resident, nurse, CRNA, AA ? Separate regional block room ? Which block to perform in the OR? Block performed pre-or postop ? Blocks in PACU? Blocks on the floor?

39. The Efficacy of Pre-versus Post Surgical Axillary Block on Postoperative Pain in Paediatric Patients Fatis Altintas et al. PaediatrAnaesth 2000, 10:23-28 double blind randomized study, 55 children, 1-11 years, ASA I-II, axillary block after induction, before surgery or after surgery, use of nerve stimulation no use of opioids, faces pain scales recorded for 24 hours, no difference in cumulative pain scores, significant difference @ 10 hours after surgery, additional analgesic consumption was similar in both groups, lower isoflurane concentration in pre-surgical block group, faster emergence, faster recovery could not demonstrate preemptive analgesia

40. Regional anesthesia, block room and efficiency: putting things in perspective P Drolet, M Girard Can J Anesth 2004, 51: 1 pp 1–5 Factors impacting on-time transfer to the operating room in patients undergoing peripheral nerve blocks in the preoperative area JE Chelly, JL Horne, ME Hudson, JP Williams J Clin Anesth 2010, 22: 115–121

41. maria.matuszczak@uth.tmc.edu Questions ?