SPINAL,EPIDURAL/ CAUDAL,PENILE NERVE BLOCK IN PEDIATRIC PATIENTS MODERATOR:Dr. JYOTI PATHANIA PRESENTED BY: Dr. SUCHIT KHANDUJA
Mar 22, 2016
SPINAL,EPIDURAL/CAUDAL,PENILE NERVE BLOCK IN PEDIATRIC PATIENTS
MODERATOR:Dr. JYOTI PATHANIAPRESENTED BY: Dr. SUCHIT KHANDUJA
INDICATIONS 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 age Severe 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
Absolute Contraindications to Neuraxial Blocks
• 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• Parental refusal .
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 and where they can develop as compressive tumors (especially in the spinal canal)
• 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 Anesthesia
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.
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
• 25 G needle is directed at 90 deg to skin till sacrococcygeal membranes are pierced and then cephalaud
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.Epidural catheter can also be placed
Caudal Anesthesia – Technique
Anesthesiology 101:A1470, 2004
Specific Complications • Delayed postoperative voiding • Block failure
EPIDURAL ANAESTHESIAINDICATIONS:• Major abdominal, retroperitoneal, pelvic, and thoracic surgeries.• Cardiac surgery in a few institutions:Considered controversialCONTRAINDICATIONS:• Severe malformations of the spine and the spinal cord• Intraspinal lesions or tumors • History of hydrocephalus• Elevated intracranial pressure• Unstable epilepsy• Reduced intracranial compliance
TechniquesLUMBAR 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
• 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% with 5 µg/mL (1/200,000) epinephrineDose:<20 kg: 0.75 mL/kg20-40 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.
Techniques Same as that of adulthyperbaric tetracaine and bupivacaine are the
most commonly used local anesthetics.
Approximate Distance: Skin to Subarachnoid Space
0
10
20
30
40
50
1 yr 3 yr 5 yr 10 yr 18 yr
MILLIMETERS
PremieNewborn5 months
Cote´, A Practice of Anesthesia for Infants and Children
Doses of Local Anesthetics 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
Tetracaine 1% 0.4-1.0 0.04-0.1 60-75Tetracaine 1% with epinephrine
0.4-1.0 0.04-0.1 90-120
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
Local Anesthetic Usual 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)
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 (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