Ultrasonographic-Guided Ilioinguinal/Iliohypogastric Nerve Block in Pediatric Anesthesia: What is the Optimal Volume?

Regional anesthesia for pain control in children with solid tumors-a review of case reports

Introduction

Around seventy percent of all childhood cancer patients suffer from severe pain. This pain can arise from various sources, including tumors themselves, pain caused by metastasizing tumor cells or as the outcome of therapy meant to deal with tumors. If managed inadequately, such pain can lead to many hazardous sequelae. However, there are extreme cases when pain does not respond to standard treatment. For such cases, regional anesthesia or nerve blocks are utilized as the utmost pain control measure. Blocks are used to treat pain in patients who no longer respond to conventional opioid-based treatment or whose worsened condition makes it impossible to receive any other therapy. The data regarding the use of regional anesthesia for such cases in the children population is limited.

Methods

For this review we searched for case reports in Scopus and PubMed from inception to 2023. The descriptive search items included terms related to childhood cancer and the description of each block. The inclusion criteria for review include children (0-18 years old) receiving oncology-related surgical procedures or palliative care. The data collection was limited to solid tumor-related cases only. We analyzed a total of 38 studies that included case reports and one retrospective study.

Results and discussion

It was concluded that nerve blocks, although rarely performed, are a safe and efficient way of pain control in children with solid tumors. The major settings for block performance are postoperative pain control and palliative care. We observed that block indication and its outcomes depend on unique health circumstances in which they should be performed. Patients with similar diagnoses had differing outcomes while receiving the same block treatment.

Rectus sheath block versus local anesthetic infiltration in pediatric laparoscopic inguinal hernia repair: a randomized controlled trial

BACKGROUND

Rectus sheath block (RSB) and local anesthetic infiltration (LAI) are used for postoperative analgesia in pediatric laparoscopic inguinal hernia repair. However, whether the analgesic effect of RSB is superior to LAI remains unclear. The authors hypothesized that RSB would reduce opioid consumption in patients.

METHODS

Patients aged 3-14 years scheduled for laparoscopic inguinal hernia repair were randomly allocated to the RSB, local anesthetic infiltration high concentration (LAIHC), local anesthetic infiltration low concentration (LAILC), or control groups. Preoperatively, they received 0.4 ml/kg of 0.25% ropivacaine (RSB), 0.4 ml/kg of 0.25% ropivacaine (LAILC), or 0.2 ml/kg of 0.5% ropivacaine(LAIHC), and 0.2 ml/kg of normal saline (control). The primary outcome was equivalent morphine consumption.

RESULTS

The authors analyzed 136 patients (RSB, 33; LAIHC, 34; LAILC, 35; control, 34). Intraoperative morphine equivalent consumption was lower in the RSB group [0.115 (0.107-0.123)] than in the LAIHC [0.144 (0.137-0.151)], LAILC [0.141 (0.134-0.149)], and control [0.160 (0.151-0.170)] groups ( P <0.001). In the post-anesthesia care unit, morphine equivalent consumption differed between the RSB [0.018 (0.010-0.027)], LAIHC [0.038 (0.028-0.049)], LAILC [0.056 (0.044-0.067)], and control [0.074 (0.063-0.084)] groups ( P <0.001). The rescue morphine equivalent consumption did not differ significantly between the RSB [0.015 (0.007-0.023)] and LAIHC [0.019 (0.010-0.029)] groups, which were lower than that in the control group [0.037 (0.029-0.045)] ( P =0.001).

CONCLUSIONS

RSB can provide effective analgesia for pediatric laparoscopic inguinal hernia repair, with better effectiveness than that of LAI at the same dose.

Analgesic efficacy of ultrasound guided quadratus lumborum block versus ilioinguinal/iliohypogastric nerve block following pediatric open inguinal hernia repair: A prospective randomized controlled trial

Background and Aims

Inguinal hernia repair is a common surgical procedure. We compared the analgesic efficacy of ultrasound-guided anterior quadratus lumborum (QL) block versus ilioinguinal/iliohypogastric (II/IH) nerve block in pediatric patients undergoing open inguinal hernia repair.

Material and Methods

It was a prospective randomized study in which 90 patients of 1-8 years of age were randomly assigned into control (general anesthesia only), QL block, and II/IH nerve block groups. Children's Hospital Eastern Ontario Pain Scale (CHEOPS), perioperative analgesic consumptions, and time to first analgesic request were recorded. The normally distributed quantitative parameters were analyzed by one-way ANOVA with post-hoc Tukey's HSD test while parameters that did not follow a normal distribution and the CHEOPS score were analyzed using the Kruskal-Wallis test followed by the Mann-Whitney U test with Bonferonni correction for post-hoc analysis.

Results

In the 1st 6h postoperative, the median (IQR) CHEOPS score was higher in the control group than II/IH group (P = 0.000) and QL group (P = 0.000) while comparable between the latter two groups. CHEOPS scores were significantly lower in the QL block group than the control group and II/IH nerve block group at 12 and 18h. The intraoperative fentanyl and postoperative paracetamol consumptions in the control group were higher than II/IH and QL groups while lower in QL than II/IH group.

Conclusion

Ultrasound-guided QL and II/IH nerve blocks provided effective postoperative analgesia in pediatric patients undergoing inguinal hernia repair with lower pain scores and less perioperative analgesic consumptions in the QL block group compared to II/IH group.

Comparison of Ultrasoundguided Ilioinguinal Iliohypogastric Nerve Block with Wound Infiltration during Pediatric Herniotomy Surgeries

Background and Aims:

The purpose of this study was to compare the analgesic efficacy of the ilioinguinal-iliohypogastric nerve block (II/IH) with local wound infiltration in children undergoing herniotomy surgeries.

Methods:

After ethics committee approval and informed consent, 100 children aged 6 months–7 years posted for herniotomy surgeries were randomly divided into Group B and Group W. Local wound infiltration was performed in Group W by the surgeon at the time of port placement and the end of the surgery with 0.2 mL.kg⁻¹ of 0.25% bupivacaine. Ipsilateral II/IH was performed in Group B at the end of the surgery, under ultrasonographic guidance with a Sonosite portable ultrasound unit and a linear 5–10 MHz probe with a 22G hypodermic needle, and 0.2 mL.kg⁻¹ of 0.25% bupivacaine was used on each side. The parameters recorded were postoperative hemodynamics, paracetamol and opioid requirements, postoperative pain scores, postoperative nausea vomiting, and the need for rescue analgesia in the first 6 h postoperatively.

Results:

The median pain scores were significantly lower in the II/IH group than the local wound infiltration group at 10 min (2 [0–2.5] compared to 2 [3–4]; P = 0.011), 30 min (1.5 [0–3] compared to 3 [2–5]; P < 0.001), 1 h (1.5 [0–2] compared to 2 [2–3]; P < 0.001) and 2 h (2 [0–2] compared to 2 [1.5–2.5]; P = 0.010) postoperatively. The need for postoperative opioids and rescue analgesia was also significantly lower in the II/IH group (P < 0.001).

Conclusion:

II/IH is superior to local wound infiltration for postoperative analgesia in pediatric herniotomy surgeries.

Ultrasound Imaging of Injections in Masseter Muscle without Contrast Agent Using Strain Elastography and a Novel B-Mode Spatiotemporal Filter

Botulinum toxin type A (BTX-A) injections in masseter muscle can alleviate muscle tightness and aching pain caused by idiopathic masticatory myalgia, a subform of the myofascial pain syndrome. Yet the injection procedure (number, amount) is currently empirical. In this ex vivo study, we determined the feasibility of using contrast-free ultrasound imaging to visualize the short-term injectate propagation. Ultrasound annotations of BTX-A injectate spread in N = 12 porcine masseter muscles were compared with the histopathology of the excised masseter. BTX-A presence was automatically detected in the ultrasound cine by: compensating tissue motion and deformation during injection with a novel spatiotemporal filtering (SF) algorithm, and by imaging tissue swelling strains with strain elastography (SE). BTX-A injectate introduced 6.5% (standard deviation = 5.0%) echogenicity contrast and 13.9% (standard deviation = 3.7%) tissue swelling strain. Muscle fasciae were a border for BTX-A distribution. The SF algorithm achieved significantly higher noise rejection (contrast-to-noise ratio = 4.63) than SE (2.56, p = 0.01), and state-of-the-art 2-D digital image correlation (1.81, p < 0.001) and direct image subtraction (1.29, p < 0.001) methods. Histopathology agreed well with ultrasound (Dice coefficient = 0.48), with deviations mainly explained by the three-dimensional inhomogeneous distribution of BTX-A. Preliminary in vivo patient results indicated that SF and SE discard artifactual BTX-A detection outside the injection region. The proposed methods contribute to objectivize ultrasound-guided injections, with additional applications, for instance, to monitor injectate spread of local anesthetics.

Interfascial plane blocks

Many novel interfascial plane blocks have been developed in the last 10 years in the effort to improve perioperative pain management that are safe, efficacious, efficient, and inexpensive. These blocks have been widely adopted into clinical practice despite relatively few high-quality clinical investigations of the techniques and how they affect perioperative outcomes. This article defines interfascial plane blocks, discusses the potential benefits, reviews the most common techniques and evidence supporting their indication, and guides clinicians in selecting an appropriate interfascial plane block for different types of surgical procedures.

Effects of Ultrasound-Guided Thoracic Paravertebral Block on Postoperative Pain in Children Undergoing Percutaneous Nephrolithotomy

Objective

To compare the effects of ultrasound-guided thoracic paravertebral block (PVB) and intravenous paracetamol on postoperative pain control in paediatric patients undergoing percutaneous nephrolithotomy (PNL).

Methods

Forty patients aged 1-5 years, with an American Society of Anesthesiologists physical status I-II, scheduled for PNL were enrolled into this prospective randomised controlled trial. After arrival in the operating room, all patients were administered standardised general anaesthesia. Patients in Group PVB received ultrasound-guided PVB using bupivacaine 0.5% at a total volume of 0.5 mL kg^-1 at the vertebral levels T11, T12 and L1. Patients in Group P were administered paracetamol intravenously (15 mg kg^-1) before the beginning of surgery. Patients in both groups were given tramadol (1 mg kg^-1) for supplemental analgesia. Patient demographics, haemodynamic parameters, peripheral oxygen saturation and sevoflurane concentration were recorded. The Face, Legs, Activity, Cry and Consolability pain scores; satisfaction of parents; the number of patients requiring supplemental analgesia; and complications were evaluated during the postoperative period.

Results

Pain scores were significantly lower in Group PVB compared with Group P (p=0.001). There were no analgesic requirements in Group PVB; however, all patients needed a supplemental analgesic in Group P. Parental satisfaction was higher in Group PVB than in Group P.

Conclusion

This study demonstrated that ultrasound-guided PVB provides more effective postoperative analgesia with no side effects compared to intravenous paracetamol in children undergoing PNL.

Postoperative pain management in children: Guidance from the pain committee of the European Society for Paediatric Anaesthesiology (ESPA Pain Management Ladder Initiative)

The main remit of the European Society for Paediatric Anaesthesiology (ESPA) Pain Committee is to improve the quality of pain management in children. The ESPA Pain Management Ladder is a clinical practice advisory based upon expert consensus to help to ensure a basic standard of perioperative pain management for all children. Further steps are suggested to improve pain management once a basic standard has been achieved. The guidance is grouped by the type of surgical procedure and layered to suggest basic, intermediate, and advanced pain management methods. The committee members are aware that there are marked differences in financial and personal resources in different institutions and countries and also considerable variations in the availability of analgesic drugs across Europe. We recommend that the guidance should be used as a framework to guide best practice.

Comparison of Ultrasonography-guided Bilateral Intercostal Nerve Blocks and Conventional Patient-controlled Intravenous Analgesia for Pain Control After the Nuss Procedure in Children: A Prospective Randomized Study

Objectives:

Patients experience severe pain after pectus excavatum (PE) surgery. The aim of this prospective, randomized study was to compare analgesic effects of ultrasonography-guided bilateral intercostal nerve blocks (UG-ICNBs) with those of conventional patient-controlled intravenous analgesia (PCIA) on acute pain after the Nuss procedure for PE repair in children.

Methods:

A prospective randomized study was performed in children with PE who were scheduled for the Nuss procedure. Participants were randomly assigned to receive either UG-ICNBs or PCIA for postoperative analgesia. Faces Pain Scale-Revised scores, opioid consumption, analgesia-associated side effects (respiratory depression, pruritus, nausea, vomiting) during the first 24 hours, and lengths of stay in the postanesthesia care unit (PACU) and hospital were recorded after the surgery.

Results:

Sixty-two children undergoing the Nuss procedure were enrolled in the trial. Faces Pain Scale-Revised scores were significantly decreased in the UG-ICNBs group compared with the PCIA group for up to 6 hours after surgery. The opioid doses required in the PACU and during the first 24 hours after surgery were significantly greater in the PCIA group compared with the UG-ICNBs group. Accordingly, patients in the UG-ICNBs group showed a lower incidence of analgesia-associated side effects and faster PACU discharge compared with the PCIA group.

Conclusions:

Our study suggests that UG-ICNBs might be more effective than PCIA for postoperative analgesia in children who undergo the Nuss procedure for PE.

A comparative study to evaluate ultrasound-guided transversus abdominis plane block versus ilioinguinal iliohypogastric nerve block for post-operative analgesia in adult patients undergoing inguinal hernia repair

Background and Aims:

Both transversus abdominis plane (TAP) block and combined ilioinguinal-iliohypogastric (IIN/IHN) blocks are used routinely under ultrasound (USG) guidance for postoperative pain relief in patients undergoing inguinal hernia surgery. This study compares USG guided TAP Vs IIN/IHN block for post-operative analgesic efficacy in adults undergoing inguinal hernia surgery.

Methods:

Sixty adults aged 18 to 60 with American Society of Anesthesiologsts' grade I or II were included. After general anaesthesia, patients in Group I received USG guided unilateral TAP block using 0.75% ropivacaine 3 mg/kg (maximum 25 mL) and those in Group II received IIN/IHN block using 10 mL 0.75% ropivacaine. Postoperative rescue analgesia was with tramadol (intravenous) IV ± diclofenac IV in the first 4 h followed by oral diclofenac subsequently. Total analgesic consumption in the first 24 h was the primary objective, intraoperative haemodynamics, number of attempts and time required for performing the block as well as the postoperative pain scores were also evaluated.

Results:

Time to first analgesic request was 319.8 ± 115.2 min in Group I and 408 ± 116.4 min in Group II (P = 0.005). Seven patients (23.33%) in Group I and two (6.67%) in Group II required tramadol in first four hours. No patient in either groups received diclofenac IV. The average dose of tablet diclofenac was 200 ± 35.96 mg in Group I and 172.5 ± 34.96 mg in Group II (P = 0. 004).

Conclusion:

USG guided IIN/IHN block reduces the postoperative analgesic requirement compared to USG guided TAP block.

[Effects of different doses of dexmedetomidine combined with ropivacaine for brachial plexus nerve block in children undergoing polydactyly surgery]

OBJECTIVE

To observe the anesthetic effect and safety of different doses of dexmedetomidine combined with ropivacaine for brachial plexus nerve block in children undergoing polydactyly surgery.

METHODS

Eighty children undergoing polydactyly surgery were randomized into 4 groups to receive brachial plexus nerve block with dexmedetomidine at 0.25, 0.50 or 0.75 µg/kg combined with 0.25% ropivacaine (0.20 mL/kg) (D1, D2, and D3 groups, respectively) or with 0.25% ropivacaine (0.20 mL/kg) only (control group). The onset time, duration of brachial plexus nerve block, awakening time, success rate, and incidence of complications were compared among the groups. Results In D2 and D3 groups, the onset time and awakening time were shorter and anesthesia lasted longer than those in the control group. The onset time and awakening time were shorter and anesthesia maintenance time was longer in D3 group than in D1 group. The success rates of brachial plexus nerve block were significantly higher in D1-3 groups than in the control group (P<0.05). Hematoma was found in one of the patients. In each of the 4 groups, laryngeal nerve block occurred in 1 child and respiratory depression in another; 2 or 3 patients had Horner syndrome, and 1 patient in D3 group experienced an episode of lowered heart beat to below 70 min^-1. All the complications were managed properly and the patients all recovered uneventfully.

CONCLUSION

Brachial plexus nerve block with 0.5 µg/kg dexmedetomidine combined with 0.25% ropivacaine (0.20 mL/kg) is safe for effective anesthesia in children undergoing surgery for polydactyly.

Utility of ultrasound-guided transversus abdominis plane block for day-case inguinal hernia repair

BACKGROUND

The transversus abdominis plane (TAP) block is a regional anesthesia technique that effectively reduces the pain intensity and use of analgesia in abdominal surgery. The aim of this study was to determine the utility of the ultrasound-guided TAP block in improving the efficacy of the ultrasound-guided ilioinguinal/iliohypogastric nerve (IIN/IHN) block for intraoperative anesthesia and postoperative pain control in day-case inguinal hernia repair (IHR).

METHODS

We conducted a descriptive study of patients undergoing elective primary unilateral open IHR. Fifty-nine patients were divided into two groups according to the anesthetic technique used: ultrasound-guided TAP block plus ultrasound-guided IIN/IHN block (TAP group) vs. ultrasound-guided IIN/IHN block alone (IIN/IHN group). The outcome measures were the adequacy of anesthesia during surgery and postoperative analgesia.

RESULTS

Four patients (12.5%) in the TAP group and 10 patients (37.0%) in the IIN/IHN group experienced inadequate anesthesia and needed systemic sedation (P < 0.05). No significant differences in additional local anesthetic volume were found between the two groups. Patients in the TAP group reported lower pain scores at the end of surgery (0.4 ± 0.8 vs. 2.1 ± 2.5, P < 0.01), at 2 hours after surgery (0.8 ± 1.3 vs. 3.0 ± 2.2, P < 0.01), at discharge (1.4 ± 1.2 vs. 4.3 ± 2.2, P < 0.01), and at 24 hours (1.5 ± 1.1 vs. 4.5 ± 2.3, P < 0.01).

CONCLUSIONS

The combination of the TAP and IIN/IHN blocks is associated with better intraoperative anesthesia and lower postoperative pain scores compared with the IIN/IHN block alone.

The Effect of Pre-Incision Field Block versus Post-Incision Inguinal Wound Infiltration on Postoperative Pain after Paediatric Herniotomy

BACKGROUND:

The Ilioinguinal/iliohypogastric nerve block has been shown to significantly decrease opioid analgesic requirements and side effects after inguinal herniotomy. We compared the effect of pre-incisional field block with 0.25% bupivacaine and post-incisional wound infiltration with 0.25% bupivacaine for postoperative pain control after inguinal herniotomy.

PATIENTS & METHODS:

This was a randomized controlled double blind study in 62 ASA I and II children aged 1-7 years scheduled for inguinal herniotomy. They were assigned to receive either pre-incision field block (group I) or post-incision wound infiltration at the time of wound closure (group II). The pain score was assessed in the recovery room using mCHEOPS score and VAS or FLACC score at home by the parents for 24 hours.

RESULTS:

The mean pain scores during the 2 hour stay in the recovery room, at 12 and 18 hours at home were similar in both groups, p > 0.05. However, the mean pain scores were significantly lower at 6 hours at home in group I (1.22 ± 0.57) than in group II (1.58 ±0.90), p <0.001, but significantly higher at 24 hours at home in group I (3.29 ± 0.46) than in group II (2.32 ± 0.24), p = 0.040. There was no difference in mean paracetamol requirement, and in the number of patients who required paracetamol for pain relief at home in both groups, p > 0.05.

CONCLUSION:

We have demonstrated that both pre-incisional ilioinguinal/iliohypogastric field block and post incisional wound infiltration provided adequate postoperative analgesia for 24 hours after inguinal herniotomy.

Minimum effective concentration of bupivacaine for axillary brachial plexus block guided by ultrasound

INTRODUCTION

The use of ultrasound in regional anesthesia allows reducing the dose of local anesthetic used for peripheral nerve block. The present study was performed to determine the minimum effective concentration (MEC90) of bupivacaine for axillary brachial plexus block.

METHODS

Patients undergoing hand surgery were recruited. To estimate the MEC90, a sequential up-down biased coin method of allocation was used. The bupivacaine dose was 5 mL for each nerve (radial, ulnar, median, and musculocutaneous). The initial concentration was 0.35%. This concentration was changed by 0.05% depending on the previous block; a blockade failure resulted in increased concentration for the next patient; in case of success, the next patient could receive or reduction (0.1 probability) or the same concentration (0.9 probability). Surgical anesthesia was defined as driving force ≤ 2 according to the modified Bromage scale, lack of thermal sensitivity and response to pinprick. Postoperative analgesia was assessed in the recovery room with numeric pain scale and the amount of drugs used within 4h after the blockade.

RESULTS

MEC90 was 0.241% [R(2): 0.978, confidence interval: 0.20-0.34%]. No patient, with successful block, reported pain after 4h.

CONCLUSION

This study demonstrated that ultrasound guided axillary brachial plexus block can be performed with the use of low concentration of local anesthetics, increasing the safety of the procedure. Further studies should be conducted to assess blockade duration at low concentrations.

The use of ultrasound-guided regional anaesthetic techniques in neonates and young infants

Optimal pain therapy during the perioperative period or at the neonatal intensive care unit and subsequent reduced use of opioids and various sedative drugs is an important factor for patients care. The use of various regional anaesthetic techniques in experienced hands provides excellent pain relief and has the potency to reduce the requirement for perioperative mechanical ventilation. Most of regional anaesthesia techniques are applicable also in neonates and young infants and can be used in an effective and safe manner. Ultrasound guidance should be used for all regional anaesthetic techniques to increase efficacy and safety. The spectrum of indications for ultrasound-guided regional anaesthesia in babies and infants are surgery, selective pain therapy and sympathicolysis. This review reflects an expert-based description of the most recent developments in ultrasound-guided regional anaesthetic techniques in babies and infants.

Ultrasound-guided rectus sheath block or wound infiltration in children: a randomized blinded study of analgesia and bupivacaine absorption

BACKGROUND

Rectus sheath block can provide analgesia following umbilical hernia repair. However, conflicting reports on its analgesic effectiveness exist. No study has investigated plasma local anesthetic concentration following ultrasound-guided rectus sheath block (USGRSB) in children.

OBJECTIVES

Compare the effectiveness and bupivacaine absorption following USGRSB or wound infiltration (WI) for umbilical hernia repair in children.

METHODS

A randomized blinded study comparing WI with USGRSB in 40 children undergoing umbilical hernia repair was performed. Group WI (n = 20) received wound infiltration 1 mg·kg(-1) 0.25% bupivacaine. Group RS (n = 20) received USGRSB 0.5 mg·kg(-1) 0.25% bupivacaine per side in the posterior rectus sheath compartment. Pain scores and rescue analgesia were recorded. Blood samples were drawn at 0, 10, 20, 30, 45, and 60 min.

RESULTS

Patients in the WI group had a twofold increased risk of requiring morphine (hazard ratio 2.06, 95% CI 1.01, 4.20, P = 0.05). When required, median time to first morphine dose was longer in the USGRSB group (65.5 min vs. 47.5 min, P = 0.049). Peak plasma bupivacaine concentration was higher following USGRSB than WI (median: 631.9 ng·ml(-1) IQR: 553.9-784.1 vs. 389.7 ng·ml(-1) IQR: 250.5-502.7, P = 0.002). Tmax was longer in the USGRSB group (median 45 min IQR: 30-60 vs. 20 min IQR: 20-45, P = 0.006).

CONCLUSIONS

USGRSB provides more effective analgesia than WI for umbilical hernia repair. USGRSB with 1 mg·kg(-1) 0.25% bupivacaine is associated with safe plasma bupivacaine concentration that peaks higher and later than WI. Caution against using larger volumes of higher concentration local anesthetic for USGRSB is advised.

Applications of regional anaesthesia in paediatrics

Advances in the field of paediatric regional anaesthesia have specific applications to both acute and chronic pain management. This review summarizes data regarding the safety of paediatric regional anaesthetic techniques. Current guidelines are provided for performing paediatric regional techniques, with a focus on applications for postoperative pain management. Brief descriptions of relevant anatomy followed by indications for commonly performed blocks are highlighted along with the potential of adverse side-effects.

Ultrasound-guided parasacral approach to the sciatic nerve block in children

BACKGROUND

The parasacral (PS) approach to sciatic nerve blockade has the potential for safe and effective use in children, but has never been studied in this population. Its potential advantages include increased posterior cutaneous nerve block reliability, potential for hip joint analgesia, and decreased nerve depth, making ultrasound guidance easier.

OBJECTIVE

To assess the efficacy of an ultrasound-guided PS sciatic nerve block in children.

METHODS

Nineteen patients, 1-16 years old, scheduled for lower limb surgery with peripheral nerve blockade (PNB) were prospectively enrolled. A PS sciatic block was performed using both ultrasound guidance and nerve stimulation, and 0.5 ml·kg(-1) ropivacaine 0.2% (maximum 20 ml) was administered. Patient demographics, the time to perform the block, the lowest intensity of nerve stimulation, evoked response, identification of gluteal arteries, and amount of narcotic given were recorded. Postoperatively, pain scores, block success or failure, block duration, and complications were recorded.

RESULTS

The block was performed using the PS approach in 95% of the cases. The success rate was 100% in the PS sciatic blocks performed. The pain scores for all patients in the first postsurgical hour were zero, except one patient that had a pain score of 3 of 10 at 30 min; his pain improved to 0 of 10 after administration of one dose of fentanyl and distraction techniques. The blocks lasted 17.3 ± 5.4 h. No complications were identified.

CONCLUSION

The PS approach is an effective option for sciatic nerve blockade to provide postoperative pain relief in children having lower extremity surgery.

Regional anesthesia in neonates and infants

Optimal pain management can significantly impact the surgical outcome and length of stay in the neonatal intensive care unit (NICU). Regional anesthesia is an effective alternative that can be used in both term and preterm neonates. A variety of neuraxial and peripheral nerve blocks have been used for specific surgical and NICU procedures. Ultrasound guidance has increased the feasibility of using these techniques in neonates. Education and training staff in the use of continuous epidural infusions are important prerequisites for successful implementation of regional anesthesia in NICU management protocols.

Ultrasound-guided ilioinguinal/iliohypogastric nerve blocks versus caudal block for postoperative analgesia in children undergoing unilateral groin surgery

CONTEXT

Ultrasound (US) guidance is strongly recommended when performing peripheral nerve blocks in infants and children.

AIMS

To assess whether US-guided ilioinguinal/iliohypogastric (II/IH) nerve blocks with local anesthetic (LA) would provide comparable postoperative analgesia to blind technique caudal block with LA following pediatric unilateral groin surgery. Secondary endpoints included analgesic consumption, parental satisfaction, and postoperative complications.

SETTINGS AND DESIGN

Prospective, crossover randomized controlled trial performed on children undergoing unilateral groin surgery.

METHODS

Fifty children aged 1-6 years scheduled for unilateral groin surgery were included in the study. After induction of general anesthesia and prior to surgical incision, patients were prospectively randomized into one of two groups: Group B received US-guided II/IH nerve blocks with 0.1 ml.kg(-1) of 0.25% bupivacaine and Group C received a caudal blockade with 0.7 ml.kg(-1) of 0.25% bupivacaine. Patients were assessed in the recovery room, the day-stay unit and for 24 h at home for pain score, analgesic consumption, and parental satisfaction.

STATISTICAL ANALYSIS

Arithmetic mean and standard deviation values were calculated and statistical analyses were performed for each group. Independent sample t-test was used to compare continuous variables exhibiting normal distribution, and Chi-squared test or Fisher exact test for non-continuous variables. P<0.05 was considered significant.

RESULTS

The average pain scores during hospital stay were 1.82±1.71and 1.52±1.41 for group C and group B respectively (P>0.05). The average time to first rescue analgesia was longer in group B 253±102.6 min as compared to 219.6±48.4 min in group C. In recovery room, four patients in group C required pain rescue medication compared to five patients in group B (P>0.05). Similarly eight patients in the group C and six patients in group B required pain rescue medication at day-stay unit or at home (P>0.05). Group C received 0.74 pain rescue medication doses (range 0-8), while group B received 0.65 pain rescue medication doses (range 0-6) at hospital and at home (P>0.05).

CONCLUSIONS

US-guided II/IH nerve blocks is an ideal postoperative analgesic for unilateral groin surgery in children, particularly hernia repairs and is as effective as caudal block, with a lower volume of local anesthetics.

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.

Ultrasound guidance characteristics and efficiency of suprazygomatic maxillary nerve blocks in infants: a descriptive prospective study

BACKGROUND

Bilateral suprazygomatic maxillary nerve blocks approach improves pain relief after palate surgery. We report the feasibility and efficiency of ultrasound-guided suprazygomatic maxillary nerve blocks in cleft palate repair in children.

METHODS

Twenty-five children scheduled to undergo surgical cleft palate repair were included. Ultrasound-guided suprazygomatic maxillary blocks were performed according to landmarks previously defined. The ultrasound probe was located optimally over the maxilla and under the zygomatic bone to visualize the pterygopalatine fossa. 0.15·ml·kg(-1) of 0.2% ropivacaine was injected bilaterally. Feasibility of block, spread of local anesthetic, pain scores and side effects were noted.

RESULTS

Fifty ultrasound-guided suprazygomatic maxillary nerve blocks were performed in 25 children. The needle movement was seen in all cases using an out-of-plane approach. The spread of LA was clearly observed in 94% (47/50) of cases. A poor ultrasound imaging was found in 4% (2/50), and the spread of LA was not identified in 2% of case (1/50). The median time to perform the block was 56 s (35-120 s). The median pain scores and consumption of nalbuphine were low during the study period. 80% of patients did not require continuous opioid infusion. No complication related to maxillary blocks was reported.

CONCLUSION

With a very low technical failure rate and a good clinical success rate, ultrasound appears to be a useful and simple tool to aid suprazygomatic maxillary nerve block in children.

Regional anesthesia in children: the future

Pediatric regional anesthesia continues to evolve. Education and attention to anatomical detail remain key elements to successful outcomes. New techniques, some adapted from adult practice, provide analgesia for pediatric surgical procedures such cleft palate or congenital hip dysplasia. Despite technological advances a number of controversial issues remain unresolved.

Pediatric regional anesthesia: abdominal wall blocks

Abdominal wall blocks are an effective regional anesthetic technique to provide sufficient analgesia in abdominal surgery. This article reviews the use of abdominal wall blocks in pediatric regional anesthesia.

Safety in pediatric regional anesthesia

The use of regional anesthesia is increasingly common in pediatric practice. This review reports the complications and risks in pediatric regional anesthesia. Few large studies reported incidence of complications. However, the different studies have shown that regional anesthesia, when performed properly, carried a very low risk of morbidity in appropriately selected infants and children. In addition, the use of ultrasound-guided peripheral nerve blockade has shown some promise toward increasing the safety profile of these already safe techniques.

[Application of ultrasound in paediatric abdominal trunk blocks]

Although relatively few studies have compared US guidance with established "blind" techniques, the available evidence suggests that the use of US guidance is a safe and effective way to facilitate correct needle placement and adequate spread of LA for abdominal wall nerve blocks. It improves block effectiveness and safety by reducing LA doses and by detecting anatomic variants or unsuspected pathologies. Different techniques are described and discussed: the transverse abdominal nerve blocks, the paraombilical block, the inguinal field block and the fascia transversalis block. Matched with improving technology, the use of US has significant benefits over conventional techniques to perform classic and new abdominal wall nerve blocks in children. However, more studies are required to evaluate the potential of US to support this finding.

The Loss of Resistance Nerve Blocks

Presently ultrasound guided nerve blocks are very fashionable but vast majority of people around the world cannot practice these techniques mostly due to lack of resources but even in the developed countries there is lack of training which precludes people from using it. Lack of resources does not mean that patient cannot be provided with appropriate pain relief using nerve blocks. There are some nerve blocks that can be done using the loss of resistance (LOR) techniques. These blocks like, tranversus abdominis plane (TAP), rectus sheath, ilio-inguinal and fascia iliaca blocks can be effectively utilized to provide pain relief in the peri-operative period. For these blocks to be effectively delivered it is essential to understand the anatomical basis. It is also important to understand the reasons for failure, which is mostly due to delivery of the local anaesthetic in the wrong plane. The technique for LOR is not only simple and effective but also it can be delivered with minimal resources. This article deals with the techniques used for LOR blocks, the relevant anatomy and the methods used to administer the blocks. The article also describes the various indications where these blocks can be utilized, especially in the post-operative period where the pain management is sub-optimal.

Percutaneous ilioinguinal-iliohypogastric nerve block or step-by-step local infiltration anesthesia for inguinal hernia repair: what cadaveric dissection says?

Purpose

The repair of groin hernias with local anesthesia has gained popularity. Two main methods have been described for local anesthesia. This study was aimed at comparing percutaneous truncular ilioinguinal-iliohypogastric block and step-by-step infiltration technique by using cadaver dissections.

Methods

The study was performed on an adult male cadaver by using blue dye injection. A percutaneous nerve block simulation was done on right side and the dye was given in between the internal oblique and transversus muscles. On the left side, a skin incision was deepened and the dye was injected under the external oblique aponeurosis. Following the injections, stained areas were investigated superficially and within the deeper tissues with dissection.

Results

There was a complete superficial staining covering the iliohypogastric and ilioinguinal nerves in the inguinal floor at both sides. On the right side, intraabdominal observation showed a wide and intense peritoneal staining, while almost no staining was seen on the left side. Preperitoneal dissection displayed a massive staining including testicular vascular pedicule and vas deferens on the right side. The dye solution also infiltrated the area of the femoral nerve prominently. On the contrary, a very limited staining was seen on the left.

Conclusion

It may not always be easy to keep the percutaneous block within optimum anatomical limits without causing adverse events. A step-by-step infiltration technique under direct surgical vision seems to be safer than percutaneous inguinal block for patients undergoing inguinal hernia repair.

Retrospective review of ilioinguinal-iliohypogastric nerve block with general anesthesia for herniotomy in ex-premature neonates

OBJECTIVES AND AIMS

We examine the efficacy and complications of general anesthesia with ilioinguinal-iliohypogastric nerve block performed on ex-premature neonates undergoing inguinal herniotomy.

BACKGROUND

  The ex-premature neonate has many co-morbidities and is at risk of postoperative apnea and bradycardia. Anesthesia techniques aimed to provide good surgical conditions include general anesthesia and central neuroaxial techniques. There are still significant complications after these techniques and none is superior.

METHODS/MATERIALS

A retrospective search of our department's computer database was conducted on ex-premature neonates, post-menstrual age of 48 weeks and under, who received general anesthesia and ilioinguinal-iliohypogastric nerve block for bilateral inguinal herniotomy from 1997 to 2009.

RESULTS

Eighty-two neonates were selected. All medical notes were traced and information including the demographics, co-morbidities and perioperative data were obtained. The mean gestational age was 30.3 weeks (sd ± 3.2) and the mean post-conception age was 40.0 weeks (sd ± 3.1). Mean birth weight was 1284 g (sd ± 518) and mean weight at the time of surgery was 2795 g (sd ± 958). Thirty-two (39.0%) neonates had apnea of prematurity, which required caffeine treatment. Thirty-five (42.7%) neonates required intubation for ventilatory support preoperatively. There was a good success rate of the ilioinguinal-iliohypogastric nerve block in 73 (89.0%) patients. They were deemed successful clinically by the attending anesthesiologist. No perioperative rescue opioid was required. Four neonates had postoperative apnea requiring intervention.

CONCLUSION

Ilioinguinal-iliohypogastric nerve block has a success rate similar to other techniques and when combined with general anesthesia, provides a viable alternative technique of anesthesia in these high-risk patients.

Single Level Paravertebral versus Caudal Block in Paediatric Inguinal Surgery

Paravertebral block (PVB) has been used for postoperative analgesia in children since 1992. There are no prospective randomised studies comparing the use of PVB versus caudal block (CB) for outpatient inguinal hernia repair surgery. The hypothesis of this study is that a single level, single injection PVB can provide a longer duration of analgesia and less requirement for supplemental analgesia than single shot CB for children undergoing inguinal surgery.

Seventy children, aged three to seven, American Society of Anesthesiologists score I to II, having unilateral inguinal surgery were enrolled in the study. The patients were divided into two randomised groups. In group PVB, a single shot of 0.2 ml/kg levobupivacaine was administered via the lumbar paravertebral route and in group CB, patients were given 1 ml/kg levobupivacaine caudally. Sevoflurane concentration was evaluated after induction and recorded during incision, sac traction and closure. Face, legs, activity, cry and consolability (FLACC) scores, heart rate, blood pressure and SpO2 were evaluated postoperatively.

Only four (11.4 %) patients in the PVB group needed rescue analgesic drugs compared to 12 (34.3%) patients in the CB group (P=0.044). Patients were given tramadol as rescue analgesia in the first four postoperative hours. No other supplemental analgesic drug was given apart from tramadol. FLACC scores were the same in the both groups. Parental satisfaction was significantly higher in the PVB group compared to the CB group (74.3 vs 40%, P=0.01).

This study has demonstrated that a single level single injection paravertebral block provides superior intraoperative and postoperative analgesia when compared to a caudal block for unilateral inguinal hernia repair.

Prospective randomized observer-blinded study comparing the analgesic efficacy of ultrasound-guided rectus sheath block and local anaesthetic infiltration for umbilical hernia repair

BACKGROUND

Umbilical hernia repair, a common day-surgery procedure in children, is associated with considerable postoperative discomfort. Possible modes of postoperative analgesia for umbilical hernia repair are rectus sheath block (RSB) and local anaesthetic infiltration of the surgical site (LAI).

METHODS

We undertook an observer-blinded, randomized, prospective, observational study to compare the efficacy of ultrasound-guided RSB and LAI in providing postoperative analgesia for umbilical hernia repair. Our primary objective was to compare the use of opioid medication between patients who receive RSB and those who receive LAI. Our secondary objectives were to compare the duration of analgesia based on time to first rescue analgesic, to compare the quality of analgesia based on revised FACES scale, and to determine the incidence of side-effects.

RESULTS

Fifty-two patients (26 in each group) completed the study. There was a statistically significant difference in the perioperative opioid medication consumption between the LAI group [mean: 0.13 mg kg(-1), confidence interval (0.09-0.17 mg kg⁻¹)] and the RSB group [mean: 0.07 mg kg⁻¹, confidence interval (0.05-0.09 mg kg⁻¹)] (P=0.008). When we compared the postoperative opioid consumption between the LAI group [mean: 0.1 mg kg⁻¹, 95% confidence interval (0.07-0.13 mg kg⁻¹)] and the RSB group [mean: 0.07 mg kg(-1), 95% confidence interval (0.05-0.09 mg kg⁻¹)] (P=0.09), there was a trend towards statistical significance between the two groups. The difference in time to rescue analgesic administration between the RSB group [49.7 (36.9) min] and the LAI group [32.4 (29.4) min] was not statistically significant (P=0.11).

CONCLUSIONS

This study demonstrates that ultrasound-guided RSB provides superior analgesia in the perioperative period compared with infiltration of the surgical site after umbilical hernia repair. In comparing only the postoperative period, analgesia provided by an ultrasound-guided RSB showed a trend towards statistically significant improvement compared with infiltration of the surgical site.

Pediatric regional anesthesia: what is the current safety record?

The use of regional anesthetics, whether as adjuncts, primary anesthetics or postoperative analgesia, is increasingly common in pediatric practice. Data on safety remain limited because of the paucity of very large-scale prospective studies that are necessary to detect low incidence events, although several studies either have been published or have reported preliminary results. This paper will review the data on complications and risk in pediatric regional anesthesia. Information currently available suggests that regional blockade, when performed properly, carries a very low risk of morbidity and mortality in appropriately selected infants and children.

Axillary brachial plexus block

The axillary approach to brachial plexus blockade provides satisfactory anaesthesia for elbow, forearm, and hand surgery and also provides reliable cutaneous anaesthesia of the inner upper arm including the medial cutaneous nerve of arm and intercostobrachial nerve, areas often missed with other approaches. In addition, the axillary approach remains the safest of the four main options, as it does not risk blockade of the phrenic nerve, nor does it have the potential to cause pneumothorax, making it an ideal option for day case surgery. Historically, single-injection techniques have not provided reliable blockade in the musculocutaneous and radial nerve territories, but success rates have greatly improved with multiple-injection techniques whether using nerve stimulation or ultrasound guidance. Complete, reliable, rapid, and safe blockade of the arm is now achievable, and the paper summarizes the current position with particular reference to ultrasound guidance.