Regional anesthesia techniques commonly used in pediatrics dictated sl

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Regional anesthesia techniques commonly used in pediatrics Pain management in children:

Regional anesthesia techniques commonly used in pediatrics Pain management in children Professor: Maribeth Massie, CRNA,MS University of New England Master of Science Program in Nurse Anesthesia

Caudal anesthesia :

Caudal anesthesia In young children, epidural space easily reached by caudal approach Less risk of dural puncture Single-shot or continuous catheter technique Useful for thoracic, abdominal, pelvic and orthopedic procedures

Anatomy :

Anatomy Sacral hiatus bound posteriorly by sacrococcygeal ligament, superiorly by sacral cornu and fused arch of sacrum Needle can be misplaced into bone marrow, subperiostium, sacral ligaments

Caudal position:

Caudal position

Caudal position and anatomy marking:

Caudal position and anatomy marking

Caudal Technique:

Caudal Technique Position patient in either prone, lateral, or knee-chest position Prep and drape sacral area sterilely Posterosuperior iliac spines located and palpate the sacral cornu and sacral hiatus Wipe with alcohol No-touch technique Insert pediatric Touhy/Crawford needle or 20/22G needle/angiocath through sacral hiatus midline at 45* angle After needle “pops” through sacrococcygeal ligament, reduce angle of needle to ~30* to skin and advance 2-3mm into caudal canal

Caudal technique:

Caudal technique

Caudal Technique:

Caudal Technique Aspirate then give test dose of 0.1 ml/kg of Bupivacaine 0.25% with epinephrine 1:200,000 Make sure to keep palpating finger over sacrum during injection so that SQ injection can be immediately recognized with bleb raised under finger Initial dose: Bupivacaine 0.25% with epi solution 1 ml/kg If continuous indwelling catheter to be inserted, same technique Correct insertion depth is measured preinsertion to midlevel of surgical incision Usually readily passes in children < 5 years of age

Penile block:

Penile block Utilized for circumsion (best) and hypospadias repair Provides postoperative analgesia for 3-6 hours Roots from S2-S4 form paired penile nerves, located under symphysis pubis and run next to dorsal arteries and vein of penis deep to Buck’s fascia Supply dorsal aspect of penis and foreskin

Penile block technique:

Penile block technique 25 G needle inserted to left and right of dorsal penile vein at the 10:30 and 1:30 positions to a depth of 3-5 mm until Buck’s fascia pierced Aspirate and Bupivacaine 0.25% WITHOUT EPINEPHRINE up to 2 mg/kg Max dose: 1 ml in infant/small child 6 ml in larger child Can also perform Ring block: Circumferentially inject base of penis superficial to Buck’s fascia Avoids risk of distal ischemia

Penile block technique:

Penile block technique

Penile block technique:

Penile block technique

Ilioinguinal /iliohypogastric block:

Ilioinguinal /iliohypogastric block Provides analgesia over inguinal region Useful for postoperative analgesia after inguinal herniorrhaphy for several hours Inadequate analgesia for manipulation of spermatic cord or testicle but will block incisional pain after these procedures Performed immediately after induction or after wound closure Nerve runs beneath internal oblique muscle medial to the anterosuperior iliac spine Blocked by a fan-shaped infiltration of the abdominal wall in region

Anatomy of ilioinguinal/iliohypogastric nerves:

Anatomy of ilioinguinal/iliohypogastric nerves Ilioinguinal nerve Iliohypogastric nerve

Ilioinguinal/iliohypogastric technique:

Ilioinguinal/iliohypogastric technique 22/25G needle inserted 1-1.5 cm cephalad and 1-1.5 cm medial to anterior superior iliac spine 2 distinct pops felt through the external oblique fascia and aponeurosis Needle directed to ilium and half volume injuected as needle withdrawn Needle then redirected toward inguinal ligament and all but 0.5-1 ml injected Remaining LA injected SQ to block iliohypogastric nerve

Ilioinguinal/iliohypogastric block:

Ilioinguinal/iliohypogastric block Bupivacaine 0.25% or 0.50% up to 2 mg/kg Large volumes of LA at higher concentrations have been known to cause prolonged motor blockade of femoral nerve

Pediatric Pain Management:

Pediatric Pain Management

History of pain:

History of pain Ancient civilizations recorded accounts of pain Pain related to evil demons

History of pain:

History of pain Greeks and Romans Brain and CNS have a role in pain perception Middle Ages (1400-1500) Central organ for sensation and spinal cord  brain  transmits pain Rene Descartes (1664) Described pain pathway

History of pain:

History of pain Swafford study (1968) 2 out of 60 post-op children received analgesics Adolescents and school age children complained more of pain than younger children and infants Elland study (1977) Chart review of adults vs. children for post-op analgesic use Robinson and Gregory (1981) Preterm neonate received O2 and fentanyl Late 80’s (1985) Hormonal stress response study in AJPS

Pediatric pain management:

Pediatric pain management Multiple studies 29% of parents reported child experienced unbearable or severe pain during 24 hrs after surgery Literature shows ~ 87% of children report post-op pain Numerous studies report over- and under-medication of children compared to recommended protocols


Background Historically children and infants received less post-operative analgesia than adults Well documented that children are often undertreated for pain Specifically in neonates: Recent studies show that neonates can experience pain by 26 weeks of gestation Mature afferent pain transmission Untreated pain in neonates lead to increased distress and altered pain response in the future


Myths Children are just small adults! Nocioception and pain are not experienced by neonates because CNS immature Risks of opioids or regional far outweigh the benefits There are no valid and reliable pain assessment tools for infants and children Neonatal pain causes no adverse effects

Classification of Pain:

Classification of Pain Nocioceptive Somatic Bone, joint, muscle, skin, or connective tissue Well localized Aching & throbbing Visceral Visceral organs such as GI tract Poorly localized Cramping Neuropathic Central Injury to peripheral or central nervous system causing phantom pain Dysregulation of the autonomic nervous system (e.g. Complex regional pain syndrome) Peripheral Peripheral neuropathy due to nerve injury Pain along nerve fibers

Pain Pathways:

Pain Pathways

5 General Principles of Pain Management:

5 General Principles of Pain Management Anticipate & prevent pain Adequately assess pain Use multi-modal approach Involve parents Use non-noxious routes Pediatrics in Review 2003; 24 (10)

1: Anticipate & Prevent Pain:

1: Anticipate & Prevent Pain Prepare patient and parent on what to expect Guide them on ways to minimize pain and anxiety Utilize quiet environment Treat pain prophylactically when anticipated E.g. Following surgery or local anesthetic for lumbar puncture Takes more medication to treat pain than to prevent its occurrence

2: Pain Assessment:

2: Pain Assessment Obtain a detailed assessment of pain HPI, description of pain, experience with pain medications, use of non-pharmacologic techniques, parent experience with pain Quality, location, duration, intensity, radiation, relieving & exacerbating factors, & associated symptoms Use age appropriate tool Scales for neonate, infant, children ages 3-8, >8 years, and children with cognitive impairments Directly ask child when possible Pain can be multi-dimensional and therefore, tools can be limited

Assessment in Neonates & Infants:

Assessment in Neonates & Infants Challenging Combines physiologic and behavioral parameters Many scales available NIPS (Neonatal Infant Pain Scale) FLACC scale (Face, Legs, Activity, Cry Consolability)

Neonatal Infant Pain Scale (NIPS):

Neonatal Infant Pain Scale (NIPS)

FLACC scale:

FLACC scale



Manchester Pain Scale:

Manchester Pain Scale

Children between 3-8 years :

Children between 3-8 years Usually have a word for pain Can articulate more detail about the presence and location of pain; less able to comment on quality or intensity Examples: Color scales Faces scales

Children older than 8 years:

Children older than 8 years Use the standard visual analog scale Same used in adults

Children with Cognitive Impairment:

Children with Cognitive Impairment Often unable to describe pain Altered nervous system and experience pain differently Use behavioral observation scales e.g. FLACC Can apply to intubated patients

3: Multi-modal Approach:

3: Multi-modal Approach Cognitive-behavioral Education Relaxation, imagery Psychotherapy, counseling Hypnosis Biofeedback Music, literature, art, play Prayer, meditation Physical Approach Massage Acupuncture Acupressure Heat or Cold TENS Therapeutic exercise

Sucrose for Infants:

Sucrose for Infants Sucrose 24% oral solution Can be used for procedures such as heel stick, venipuncture, catheterization, etc. Effective analgesic in preterm and term infants Not effective beyond 3 months old Dip pacifier in sucrose solution or give 0.2 mL to buccal area May repeat but be cautious with many doses to younger infants

4: Patient & Parental Involvement:

4: Patient & Parental Involvement Parent Excellent sources of information on child Learn techniques to help coach through pain Reduces anxiety Patient Age & developmentally appropriate Gives them control in their pain experience Learn techniques to help with pain control Reduces anxiety

5: Non-noxious Routes:

5: Non-noxious Routes Administer analgesia through most painless route Avoid IM injections Oral and Intravenous routes are preferred Oral route for mild to moderate pain Intravenous route for immediate pain relief and severe pain

Principles of Pharmacology:

Principles of Pharmacology Consider patient’s age, associated medical problems, type of pain, & previous experience with pain Choose type of analgesia Choose route to control pain as rapidly and effectively as possible Titrate further doses based on initial response Anticipate side effects Recognize synergistic effects

PowerPoint Presentation:

NEJM 2002; 347 (14).

Agents to treat mild pain:

Agents to treat mild pain Acetaminophen Ibuprofen Choline Magnesium Salicylate Naproxen

Agents to treat moderate pain:

Agents to treat moderate pain Codeine, hydrocodone, oxycodone +/-acetaminophen Ketorolac

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