Plasma bupivacaine concentrations following lumbar epidural anaesthesia in children

Regional Anesthesia in Children

The future of regional anesthesia in children is to continue to use current techniques, but also to search for ways to make them easier to employ. The potential development of safe local anesthetic agents with much longer durations, will serve to facilitate improvements in the techniques and styles of practice. The advances in minimally invasive surgical techniques do not mean that regional techniques will not be necessary, but will result in an adaptation of techniques. Peripheral nerve blockade and local wound infiltration can still be used and in some instances, may be very appropriate.

Paediatric regional anaesthesia--what makes a difference?

Regional anaesthetic techniques are useful for providing post-operative pain control for ambulatory surgery in children. This chapter focuses on unique features of paediatric anatomy and physiology that allow successful performance of these techniques. An overview of the effective use of long-acting local anaesthetics in children is presented. Combinations of local anaesthetics and adjunct medications that prolong caudal blockade, the most commonly performed paediatric block, are reviewed, with a goal of providing prolonged analgesia with minimal side-effects. An overview of the use of peripheral nerve blockade and specific recommendations for the use of these blocks in children is also presented.

Regional Anesthesia for Pain Relief in Children

Managing pain in children is a complex area that requires an understanding of the unique challenges offered by this young population. Regional anesthesia is emerging as an adjunct to pain management in children, particularly in the perioperative arena.The following article will assist the practitioner with the management of pain in children through regional techniques. Prior to the presentation of the regional techniques, an overview is presented to address the neurodevelopment of the child, the pharmacologic concerns in the younger patients, and the assessment of pain in the different age groups. Several of the commonly performed regional blocks with appropriate dosing guidelines are reviewed, with an emphasis on blocks that are more unique to the pediatric population.

Epidural analgesia for major neonatal surgery

Safe effective analgesia for neonates undergoing major surgery remains a challenge particularly in institutions where resources are limited. The experience in the use of epidural analgesia in 240 neonates weighing between 0.9-5.8 kg body weight (lumbar n = 211, thoracic n = 29) is reviewed. Dural puncture (n = 1), convulsion (n = 1) and intravascular migration of catheter (n = 1) were the only complications. In all cases effective analgesia was established intraoperatively. Postoperatively analgesia was maintained by intermittent 'top-ups' (n = 170) and continuous infusion (n = 10). Skin epidural distance ranged between 3 and 12 mm (mean 6.0 +/- 1.7 mm) and did not correlate with the patients' weight. Patients remained haemodynamically stable except occasional bradycardia below 100 (n = 15) which was successfully managed with anticholinergics. The potential risks and benefits of epidural analgesia in this age group are discussed and arguments for intermittent 'top-up' doses rather than continuous infusions presented.

Accidents following extradural analgesia in children. The results of a retrospective study

A retrospective multicentre study of the complications observed after regional anaesthesia in children was undertaken in 1991 at the request of the association of Anesthésistes-Réanimateurs Pédiatriques d'Expression Française (ADARPEF). The incidence of accidents seen in the study was comparable to that found in the literature. Five cases which were exceptional due to the severity of the sequelae have been analysed separately. Different pathophysiological mechanisms are proposed.

Column liquid chromatographic determination of bupivacaine in human serum using solid-phase extraction

A convenient and economical procedure for the extraction of bupivacaine and its major metabolites, desbutylbupivacaine and 4'-hydroxybupivacaine, from serum is described. A 0.25-ml aliquot of 4 micrograms/ml solution of N-pentyl-2,6-pipecoloxylidide used as the internal standard and an equal volume of the serum sample are applied to a 1-ml BondElut C18 silica extraction column which has been conditioned by subsequent washing once with 1 M HCl, twice with methanol and once with water. After passing the sample at a slow rate, the column is washed twice with water and once with acetonitrile. The desired compounds are then eluted with a 0.25-ml aliquot of a mixture of 35% perchloric acid-methanol (1:40, v/v). A 5-microliters aliquot of the eluate is injected onto a 150 x 4.6 mm I.D. column packed with 5-microns C8 silica particles, which is eluted at ambient temperature with a mobile phase of acetonitrile-10 mM KH2PO4 (25:80, v/v) at a flow-rate of 1.5 ml/min. The peaks are detected at 205 nm. The extraction recovery of all the compounds is in the range of 90%. The chromatogram is clean and the desired peaks are well separated from each other and from the extraneous peaks.

Plasma bupivacaine concentrations during caudal analgesia and ilioinguinal-iliohypogastric nerve block in children

Plasma bupivacaine concentrations were measured in 27 children aged 3-7 years who received one of two analgesic regimens for herniotomy or orchidopexy. Analgesia was provided either by caudal epidural bupivacaine 0.2% 2 mg/kg (n = 14) or by ilioinguinal-iliohypogastric nerve block with bupivacaine 0.5% 1.25 mg/kg (n = 13). Mean (SD) peak venous bupivacaine concentrations were 0.57 (0.17) microgram/ml and 0.79 (0.38) microgram/ml respectively. Time to peak plasma concentrations were 29.6 (7.9) and 22.3 (10.9) minutes respectively. These concentrations are well below the potentially toxic level of 4.0 micrograms/ml, but suggest that uptake of bupivacaine is more rapid after ilioinguinal-iliohypogastric nerve block than during caudal analgesia.