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

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

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

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

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

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

Systemic Complications Usually concomitant with accidental IV or arterial injection

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.

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

Caudal Anesthesia – Technique

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

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

Anesthesiology 101:A1470, 2004

Specific Complications Delayed postoperative voiding Block failure Venous air embolism

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

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

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

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

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

Local anesthetic dosage: Loading dosage:Bupivacaine, levobupivacaine:Solution: 0.25% Dose: <20 kg: 0.75 mL/kg 20-40 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

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 0.0625% 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 0.0625% solution) >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% solution ROPIVACAINE(.2%): Loading and maintainance dosage same as bupivacaine

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

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.

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

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

Approximate Distance: Skin to Subarachnoid Space MILLIMETERS Premie Newborn 5 months Cote´, A Practice of Anesthesia for Infants and Children

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 0.5-1.0 0.1-0.2 65-75 Ropivacaine 0.5% 1.08 0.22 51-68

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)

Complications Higher rate of failure..

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

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

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

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