[Regional anesthesia in pediatrics]

Everyday regional anesthesia in children

Regional anesthesia in children is an evolving technique with many advantages in perioperative management. Although most regional anesthesia techniques are sufficiently described in the literature, the implementation of these techniques into daily clinical practice is still lacking. The main problems associated with pediatric regional anesthesia (PRA) include the appropriate selection of blockade, the management around the block, and how to teach these techniques in an optimal manner. This review article provides an overview of these 'hot' topics in PRA.

Recent advances in pediatric anesthesia

Writing about advances in a field of medicine normally includes some pride about progress which one was witness to or even a participant in. The younger one is, the more enthusiastically every advance is lauded and welcomed. This is human nature and nothing to be complained about. However, when anesthesiologists, having worked and struggled in the field of pediatric anesthesia for about 40 years, look back to past advances, a more realistic, even painful picture comes to mind. There was a price which a considerable number of patients had to pay for progress, ruined health or even death. This experience of decades of practice is rarely presented in the literature but should not be forgotten when we proudly remember advances in pediatric anesthesia.

Regional anesthesia is a good alternative to general anesthesia in pediatric surgery: Experience in 1,554 children

BACKGROUND/PURPOSE

Although caudal and spinal blocks are modern and safe techniques, in many centers children still are operated on under general anesthesia (GA), or the blocks are used for postoperative analgesia after GA in infraumbilical operations. The authors aimed to document the results and the complications of 1,554 regional anesthesia cases, thereby assessing their validity.

METHODS

The analysis of 1,459 caudal and 95 spinal blocks cases collected until January 2001 in children from newborn to 12 years of age are documented retrospectively. The types of anesthesia analyzed in the study were caudal block (CB) only, CB plus GA, GA plus CB, GA plus spinal block, and spinal block only.

RESULTS

There were 1,338 caudal and 95 spinal block cases that clinically were satisfactory. Because the duration of CB was not sufficient in 39 cases, GA was used. Failure to produce a CB occurred in 82 cases (5.57%). There were 257 of 1,338 patients operated on under GA and supported by caudal block for postoperative analgesia.

CONCLUSIONS

Caudal anesthesia seems to be an inexpensive, simple, and effective technique not only as a supplement for postoperative analgesia, but also as a single method of anesthesia. and the authors recommend its use in a wider setting of clinical entities in infraumbilical surgical procedures of children.

Prevention and management of pain and stress in the neonate

This statement is intended for health care professionals caring for neonates (preterm to one month of age). The objectives of this statement are to: increase awareness that neonates experience pain; provide a physiological basis for neonatal pain and stress assessment and management by health care professionals; make recommendations for reduced exposure of the neonate to noxious stimuli and to minimize associated adverse outcomes; and recommend effective and safe interventions that relieve pain and stress.

[Surgery for epidermolysis bullosa in children: value of the association of inhalation anesthesia and locoregional anesthesia]

Due to the cutaneous and mucosal fragility associated with epidermolysis bullosa, this disease is a source of various practical problems for the anaesthesiologist concerning the surgical posture, the monitoring of vital functions, the airways control and the vascular access, as all these procedures may worsen, sometimes dramatically, the lesions in these young patients, still in a precarious health state. Basing on published studies and their own experience, the authors have used in these patients a combined locoregional and general anaesthesia. The latter was obtained with isoflurane, administered in the non intubated and spontaneously breathing patient through a closed surgical isolation container (Vi-Drape), including the patient's head and ventilated with a ventilator generating a PEEP for long procedures. The results obtained during 9 procedures in 3 children are reported and discussed. For several shorter procedures (for example wound dressing), intramuscular ketamine was used.

[Acute pain in children and its treatment]

Pain in paediatrics has long been underestimated. The numerous scientific studies carried out during the last decade show that its existence can no longer be doubted: in fact, pain already exists during the neonatal period, and probably throughout the last trimester of gestation as well. Pain pathways mature during the embryonic period and peripheral receptors develop between the 7th and 20th week. A-delta and C fibers, as well as spinal roots and nerves, are completely differentiated before the end of the second month. The development of specific neurotransmitters and thalamic and cortical dendritic branching occurs later on; it is well enough developed to allow perception of painful stimuli (slow or protopathic component) from the beginning of the foetal period onwards. The discriminative rapid component develops in parallel to myelinisation, and the psycho-affective component, which requires a long and complex learning process, will not be fully operative until the end of puberty. Assessing pain, already a difficult task in the adult, is all the more so in children because of lesser verbal communicative capabilities, difficulty in handling abstract concepts, lack of experience of painful stimuli to make comparisons, and ignorance of their body image. In the very young child, diagnosing pain relies on suggestive circumstances, and an altered behaviour, knowing that no one symptom in pathognomonic. As the child grows up, methods for self-assessment of pain become usable, such as coloured scales and simplified verbal scales. However, behavioural tests remain the mainstay until the prepubertal period. The treatment of acute pain requires a reasoned approach which takes into account the state of the child, that of the aetiological investigations, the likely course of the lesions, as well as the patient's analgesic requirements. Therapeutic means do not differ from those for adult patients; however, the differences of distribution of body water, the small possibilities of linking with plasma proteins, and limited conjugation with glucuronate must be taken into account, especially during the first months of life. Local and regional anaesthetic block techniques are of great interest in elective and emergency surgery, as well as in trauma: they can provide complete pain relief, mostly without having any effect on the patient's physiological state (haemodynamics and consciousness). Peripherally acting analgesic agents, which are well supported on the whole, as well as co-analgesics, have a great part to play, although there are less drugs available than for adults. The most useful ones are paracetamol, followed by the salicylates, propionic acid derivatives and non steroid anti-inflammatory drugs.(ABSTRACT TRUNCATED AT 400 WORDS)