Pediatric regional anesthesia: A review of the relevance of surface anatomy and landmarks used for peripheral nerve blockades in infants and children

Updates on the clinical integration of point-of-care ultrasound in pediatric emergency medicine

PURPOSE OF REVIEW

There is expanding evidence for point-of-care ultrasound (POCUS) use in pediatric emergency medicine - this review highlights the benefits and challenges in the clinical integration of high-yield POCUS applications. Specifically, it will delve into POCUS applications during resuscitations, controversies of Focused Assessment with Sonography for Trauma (FAST) in pediatric trauma, POCUS-guided procedures, and examples of clinical pathways where POCUS can expedite definitive care.

RECENT FINDINGS

POCUS can enhance diagnostic accuracy and aid in management of pediatric patients in shock and help identify reversible causes during cardiac arrest. The use of the FAST in pediatric blunt abdominal trauma remains nuanced - its proper use requires an integration with clinical findings and an appreciation of its limitations. POCUS has been shown to enhance safety and efficacy of procedures such as nerve blocks, incision & drainage, and intravenous access. Integrating POCUS into pathways for conditions such as intussusception and testicular torsion expedites downstream care.

SUMMARY

POCUS enhances diagnostic efficiency and management in pediatric patients arriving at the ED with undifferentiated shock, cardiac arrest, or trauma. Additionally, POCUS improves procedural success and safety, and is integral to clinical pathways for expediting definitive care for various pediatric emergencies. Future research should continue to focus on the impact of POCUS on patient outcomes, ensuring user competency, and the expansion of POCUS into diverse settings.

Continuous Epidural Analgesia Versus Continuous Peripheral Nerve Block in Unilateral Lower Extremity Pediatric Orthopedic Surgery: A Matched Case Comparison Study

Introduction Continuous epidural analgesia (CEA) provides effective postoperative pain relief but includes a substantial side effect profile. Continuous peripheral nerve blocks (CPNBs) have fewer side effects and may quicken ambulation. The purpose of this study was to compare the morphine milligram equivalents (MMEs), need for analgesic rescue, visual analog scale (VAS) pain scores, time to ambulation, postoperative blood pressures, length of stay (LOS), and adverse event rates. Methods This was a matched case comparison study of pediatric patients (ages 8-17) undergoing unilateral lower limb surgery (41 CEA and 36 CPNB). Patients with a history of chronic pain, previous lower extremity surgery, and developmental delay were excluded. The Chi-square test and Student's t-test were used, and p-values < 0.05 were considered significant. Results There were no statistically significant differences in demographics or the American Society of Anesthesiologists (ASA) grade. There were no significant differences in postoperative MMEs, the need for analgesic rescue, or VAS scores on any postoperative day. The CEA group had a longer time to ambulation (2.56 ± 0.93 days versus 1.89 ± 0.69 days, p = 0.004). The CEA group demonstrated a higher number of days of systolic hypotension (0.61 ± 0.97 mmHg versus 0.06 ± 0.23 mmHg, p = 0.0009) and diastolic hypotension (1.90 ± 1.24 mmHg versus 1.00 ± 0.93 mmHg, p = 0.0006). There were no significant differences in the length of stay between the CEA and CPNB groups (5.08 versus 4.24, p = 0.28). There was no statistically significant difference between the rates of pruritus, light-headedness, and altered mental status. The CEA group demonstrated higher rates of nausea (51.2% versus 13.9%, p = 0.001), constipation (36.6% versus 8.3%, p = 0.004), urinary retention (9.8% versus 0%, p = 0.006), and average number of minor adverse events per patient (1.02 versus 0.25, p = 0.002). Conclusions CPNBs and CEAs demonstrate equivalent postoperative opioid use after unilateral lower extremity surgery in the pediatric population. In our population, a low complication rate and a decreased time to ambulation were seen in the CPNB group. There may be certain select scenarios priorly managed with a CEA that can be appropriately managed with a CPNB. A prospective multicenter study incorporating patient satisfaction data could further facilitate the incorporation of CPNB in pediatric pain management protocols after orthopedic surgery.

Peripheral Nerve Block Complications in Children

Regional anesthesia, and in particular peripheral nerve block (PNB) techniques, complement existing anesthetic and pain management strategies and facilitate a comprehensively safer experience for the pediatric patient. Ultimately, the use of regional anesthesia cultivates a more satisfactory experience for all involved. Complication rates are very low, making PNBs a very safe option as proliferative incorporation of ultrasound technology has led to further enhancement of regional anesthesia safety and efficacy in the pediatric population.

Procedural Applications of Point-of-Care Ultrasound in Pediatric Emergency Medicine

Point-of-care ultrasound can improve efficacy and safety of pediatric procedures performed in the emergency department. This article reviews ultrasound guidance for the following pediatric emergency medicine procedures: soft tissue (abscess incision and drainage, foreign body identification and removal, and peritonsillar abscess drainage), musculoskeletal and neurologic (hip arthrocentesis, peripheral nerve blocks, and lumbar puncture), vascular access (peripheral intravenous access and central line placement), and critical care (endotracheal tube placement, pericardiocentesis, thoracentesis, and paracentesis). By incorporating ultrasound, emergency physicians caring for pediatric patients have the potential to enhance their procedural scope, confidence, safety, and success.

Educational Perspectives: Anesthesia 101: What the Neonatologist Needs to Know About Anesthesiology

As the complexity of medicine increases, so too do the challenges with multidisciplinary communication and coordinated patient care. Anesthesiology represents a field for which there is no required study for medical students, pediatric residents, or neonatal-perinatal medicine fellows in the United States, so a neonatologist may have never received any formal training in anesthesiology (and vice versa for pediatric anesthesiologists in neonatology). In this review, we address frequently asked questions of neonatologists to anesthesiologists to better frame common issues. These topics include thermal regulation, fluid management, airway management, and the field of regional anesthesiology. Finally, collaborative efforts between the surgical and medical fields, such as the American College of Surgeons Children's Surgery Verification Quality Improvement Program, and the American Academy of Pediatrics NICU Verification Program, are ongoing and robust; these programs represent important opportunities to significantly improve the perioperative care of infants. Our hope is that this summary can serve as a primer and reference for those caring for neonatal patients during any perioperative period, including seasoned neonatologists and those early in their training. It is our further desire that this review will lead to improved communication and collegiality between the specialties.