Pnr pediatric regional


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Pnr pediatric regional

  3. 3. HISTORY<br />
  4. 4. First introduced at the end of last century at almost the same time as GA<br />In 1898 BIER in his original paper on spinal anaesthesia on eleven year old boy described clinical effects<br />JUNKIN, 1933 and ROBSON, 1936 described spinal anaesthesia for thoracic surgery<br />Epidural anaesthesia in children was described by SIEVERS in 1936<br />1959 RUSTON introduced continuous epidural catheter technique. <br />
  5. 5. Local anaesthesia was invented by LADD by infiltration for abdominal procedures in neonates in 1930<br />Sedation guidelines are released by ASA in 1996 and by AAP in 1992 and in 1997 by emergency physicians. <br />In 1986 Dr. ANAND published his remarkable paper on pain in children and opened the eyes of many physicians’.<br />RA in children is currently undergoing a renaissance in anaesthesia practice. <br />RA with GA fulfills the characters of an ideal anaesthetic. <br />RA is also becoming the main stay of post operative pain relief in children. <br />
  6. 6. INTRODUCTION<br />
  7. 7. Rarely done procedure<br />French study – RA in paediatrics-12%, infants-1%, neonates and prematures-very rare<br />
  8. 8. ADVANTAGES<br />
  9. 9. Modification of stress response and improved out come.<br />IVRA in emergency department for surgeries on extremities with full stomach<br />Epidural with catheter is very useful in ortho surgeries and post operative pain relief<br />Caudal block as anaesthetic, analgesic for post operative and also after bone marrow harvesting.<br />Effective for controlling pain in ICUs where Narcotics are dangerous or inadequate leading to undesirable effects.<br />Decreases the GA drugs<br />Optimal post operative analgesia<br />
  10. 10. RISK – BENEFIT RATIO<br />
  11. 11. Warning signals are missing such as pain in case of intra neural or CNS Symptoms in case of intra vascular injection. <br />It is an accepted procedure provided the clinician performs the technique care fully and skillfully<br />DALENS 1999 quoted that “It would be considered malpractice to perform RA in children who are not fully anaesthetized”. <br />De Negri 2002 said “Any performance of a block in a agitated moving child is not only unethical but could be dangerous when needle approaches the delicate nerve structures”.<br />
  13. 13. Skill in performing RA in adults for long time.<br />Supportive surgical nursing facilities.<br />Assistance in OR <br />Proper equipment<br />PACU and DSU<br />Policies and procedures<br />
  15. 15. Psychological and parents psychology<br />Physiological<br />Pharmacological<br />Anatomical<br />
  16. 16. PSYCHOLOGICAL: <br />More apprehensive<br />Separation phobia<br />Universal needle phobia<br />Pain and disfigurement in older children<br />
  17. 17. PSYCHOLOGICAL: <br />Parents and grand parents:<br />Loss of control over the situation<br />Dependency behavior<br />Financial constraints<br />Concern about the child’s problem and outcome<br />
  18. 18. PHYSIOLOGICAL<br />Post OP APNOEA is common in premature infants.<br />Immature CNS <br />Immature BBB<br />Immature Sympathetic system<br />Nerve fibreare thin, less myelinated, less nodes of Ranvier<br />
  19. 19. PHARMACOLOGICAL:<br />Volume distribution is more<br />CSF volume high<br />Total body water high<br />Protein binding less<br />Metabolism of drugs-<br />Less than six months metabolism is less<br />More than six months metabolism is active.<br />
  20. 20. Rate of absorption of local Anaesthetic<br />AIRWAY > INTERCOSTEL > CAUDAL > EPIDURAL >BRACHIAL > DISTALPERIPHERAL> SUBCUTAENIOUS <br />DOSAGE OF Drugs:<br />0.25 % BUPIVICAINE 0.5 to 1ml per kg caudal <br />
  21. 21. CSF Volume<br />
  22. 22. Duration of action of LA<br />
  23. 23. Total body water<br />
  24. 24. Protein binding<br />It is low at birth<br />Albumin and alpha acid glycol protein less<br />Comes to adult level at one year<br />Clearance –<br /> Liver: phase 1 and phase 2 reactions decreased <br /> Kidney: GFR 30 % of adults<br /> Adult level by 3-5 years of age.<br />
  25. 25. Morphine t 1/2 life is twice of adults <br />IV < 6/12 Apnoea, Cei < 12/12 no fentanyl<br />Be careful with repeated dosing and infusions <br />Neurological symptoms > cardiac symptoms first symptom may be grand mal epilepsy<br />
  26. 26. Anatomical:<br />
  27. 27. Anatomical:<br />Spinal cord is at lower level ( L3-L4)<br />Laminae are not well developed<br />CSF volume is high, turnover is high, shorter duration of LAs action<br />No hypotension up to 6-8 yrs as sympathetic system is not well developed<br />Epidural fat is like gel<br />Ligaments are not well developed<br />
  29. 29. <ul><li>REGIONAL ONLY
  30. 30. COMBINED REGIONAL AND GENERAL</li></li></ul><li>RA only : <br />Reduces the risk of post operative apnoea in pre mature children. <br />Over night monitoring must be there<br />Caudal 0.25 % , 1 ml/ kg + clonidine mcg/ kg<br />Spinal bupivicaine 0.5 % heavy depending on the age of the patient ( 0.3 to 0.6 mg/kg)<br />In older age group RA can not be done alone.<br />
  31. 31. COMBINED RA + GA :<br />Usually RA for anaesthesia and also for post operative pain relief<br />Single caudal <br />Continuous epidural / caudal<br />Peripheral nerve blocks <br />Field blocks<br />Local infiltration.<br />
  32. 32. Indications: All blocks which are possible in adults can be done. PNS can be used; ultra sounding also can be done.<br />MH<br />Avoiding need of OPIOIDS <br />Better analgesia <br />Epidural infusions <br />Pulmonary diseases, fracture ribs<br />Bladder surgery<br />Abdominal and thoracic surgeries<br />
  33. 33. Contra-indications: <br />Parent refusal <br />Sensory nervous system diseases<br />Serious sepsis<br />Bleeding disorders<br />Vertebral malformations<br />Previous surgery on spines<br />Allergy<br />
  34. 34. Caudal anaesthesia and analgesia <br />Single Dose<br />Continuous Infusions<br />Adjuvants<br />Spinal anesthesia<br />
  35. 35. Caudal Anesthesia – Technique<br />
  36. 36.
  37. 37.
  38. 38.
  39. 39.  <br />Where can a caudal go? <br /><ul><li>Periosteum
  40. 40. Sacral ligaments
  41. 41. Dural sheath
  42. 42. Sacral marrow
  43. 43. Intra vascular
  44. 44. Sacral foraminae</li></li></ul><li>Commonly used drugs<br />
  45. 45. LA volumes:<br />Traditional <br />0.05ml/seg/kg <br />0.5 ml/kg upto T-10 segments 0.25% Bupi<br />1 ml/kg upto T-6 segments<br />For longer duration<br />Lower concentrations with higher dosage – 1.5ml/kg upto T-2 segments<br />
  46. 46. Concentration of local anaesthetics:<br />Balance analgesia with risk of motor block, 0.25% Bupivacaine, maximum dose of 1mg/kg gives excellent analgesia, less motor blockade and shorter duration of action. <br />0.175% Bupivacaine, 1.5mg/kg causes less motor blocked, good analgesia with higher level and longer duration of action (10ml = 7 ml of 0.25 + 3 ml of NS) <br />
  47. 47. Caudal morphine: <br />30-40 mcg provides analgesia for 12 to 24 hours no respiratory depression. <br />Nausea present <br />less labor intensive. <br />Does not require special pain clinics.<br /> Side effects: <br />Nausea, itching<br />Clonidine:<br />Increases the effects of Bupi. Risk of sedation if given more than 1 mcg/kg. <br /> <br />
  48. 48.
  49. 49. Continous infusions:<br />Caudal 16 G angio-cath with 19 G epidural catheter can be threaded up to thoracic level and covered with sterile drape.<br />Volume of drug:<br />Less than 1 yr.: 0.1-0.2 ml/kg/hr<br />More than 1 yr. 0.1-0.4 ml/kg/hr + Fentanyl: < 0.5 mcg/kg/hr<br />Concentration of drug:<br />Less than 1 yr.: 0.1% Bupivacaine<br />More than 1 yr.: 0.1% Bupivacaine + Fentanyl<br />
  50. 50.
  51. 51. Epidural anaesthesia: Technically similar to adults except for <br />Depth of epidural space is less<br />Ligaments are thinner and difficult to feel the resistance<br />Midline approach is preferred as laminae are not well developed<br />Epidural fat is like gel and catheters can be passed very easily<br />
  52. 52.
  53. 53. Spinal anaesthesia: Technically similar to adults. Not very commonly done procedure, must have IV access, 1.5 inch 25 G beveled needle.<br />Dose: 0.3-0.6 mg/kg of 0.5 % Bupivacaine heavy. Higher the age, lower the dose and vice versa<br />
  54. 54. Distance from skin to Subarachnoid space<br />
  55. 55. Spinal cord is at lower level ( L3-L4)<br />Laminae are not well developed<br />CSF volume is high, turnover is high, shorter duration of LAs action<br />No hypotension up to 6-8 yrs as sympathetic system is not well developed<br />Do not flex the head<br />25-30 G needle<br />Lateral or sitting position<br />
  56. 56. Combined spinal epidural (CSE): <br />This overcomes shorter duration of action. <br />Major procedures can done and <br />post-operative analgesia well maintained.<br />
  57. 57. PERIPHERAL BLOCKS<br />
  58. 58. Penile block (Dalen’s sub pubic block): <br />
  59. 59. Simple subcutaneous ring block at the root of the penis is sufficient but duration is only for 2-4 hrs. <br />
  60. 60. Abdominal wall blocks: <br />Ilio-inguinal and ilio-hypogastric block: Popularized by Shandling and Steward. <br />Indications are:<br />Herniotomy<br />Orchidoplexy and <br />Post-operative pain <br /> relief<br />
  61. 61.
  62. 62. Rectus sheath block<br />First described in 1899, better done with ultra sound guidance<br />This block is used for umbilical hernia repair or umbilical incision for lap procedures. <br />Blocking nerves in the posterior part of the sheath deep to rectus muscle. <br />Anterior an posterior blocks are available.<br />A need is inserted lateral to umbilicus and advanced through the fascia which can be detected by loss of resistance. <br />LA is injected bilaterally, 0.2 to 0.3 ml/kg, 0.25 % Bupivacaine. At least 6 minutes needed to get anaesthesia. <br />
  63. 63. Transverse abdominal plane block (TAP)<br />Blind injection at the triangle of DE PETIT. Now ultrasound guided injections are done between transverse and internal oblique muscles. This gives good post operative analgesia after appendectomy.<br />
  64. 64.
  65. 65. UPPER LIMB BLOCKS<br />
  66. 66. Brachial plexus block:<br />It can be sole anaesthetic or as an adjuvant to GA or for post OP analgesia or for sympathetic blocks. It should not be used for trivial reasons. Age is not a contra-indication for this block. Must be associated with GA. PNS or USG can be used to locate the nerves. <br />
  67. 67. Inter scalene block:<br />
  68. 68. Supra clavicular block:<br />
  69. 69. Axillary block:<br />
  70. 70. Para Scalene approach (DALENES):<br />Patient supine with a role under the shoulder, arm by the side and head turned to opposite side. <br />The injection site is the junction of upper ⅔ with lower ⅓ of the line joining the mid point of the clavicle and transverse process of sixth vertebra. <br />Less complication. <br />
  71. 71. LOWER LIMB BLOCKS<br />
  72. 72. Femoral nerve block:<br />
  74. 74. Sciatic nerve block (L4 – S2):<br />
  75. 75. COMPLICATIONS <br />
  76. 76. Complications due to the needle:<br />Wrong needle<br />Imprudently inserted<br />Symptoms can be delayed by several hours<br />Spinal haematoma<br />
  77. 77. Complications related to technique:<br />Location of nerve and space – electrical burns<br />LOR syringe <br />Saline<br />Air<br />Accidental PDPH<br />
  78. 78. Complications due to catheters:<br />Misplacement<br />Kinking<br />Knotting<br />Migration<br />Delayed lumbar stenosis<br />Shearing<br />Bacterial contamination<br />
  79. 79. Complications due to LA solutions:<br />Local toxicity :<br />Injection of wrong solutions<br />Continuous infusions<br />Preservatives and additives<br />High concentrations <br />
  80. 80. Systemic toxicity<br />CNS toxicity<br />Cardiac<br />Methhaemoglobinemias<br /> Most LAs are anticonvulsants (1-5 mcg)<br />High concentartionsconvulsant and respiratory arrest<br />Drug interactions – digoxin , bilirubin, cimetidine and propronolol.<br />
  81. 81. Methaemoglobinemia :<br />Can occur after several hours<br />With prilocaine and benzocaine and rarely lidocaine.<br />Predisposing factors<br />G6p deficiency<br />Aniline dyes<br />Oxidants<br />Treatement – injmethyline blue 1-5 mg/kg<br />
  82. 82. Complications due to adjuvants:<br />Preservatives like metabisulfate, antioxidants can produce severe toxicity<br />Narcotics can produce respiratory depression , pruritis , bladder distension.<br />
  83. 83. Complications resulting from inadequate management:<br />Bacterial contamination<br />Unsafe technique of injection – high pressure epidural injection<br />Injection in the wrong space<br />
  84. 84. Complications wrongly attributed to regional blocks:<br />Hypotension , blood loss, position, surgical manipulation<br />Sickle cell disease <br />Sudden infant death syndrome<br />
  85. 85. CONCLUSIONS<br />All blocks can be given like adults<br />Differences from adult in various body systems must be known<br />PNS or ultrasound guidance is advisable<br />Blocks are given under GA, be careful about injuring the nerves and intravascular injections<br />Continuous catheters with infusion can be used<br />Correct dose and correct drug must be selected<br />Be careful with narcotics in pre-mature children<br />Be careful with adjuvants<br />
  86. 86. Conclusions……….<br />Emergency equitment for CPR, if required should be available<br />Necessary monitoring systems should be present<br />IV access<br />Starvation guideline <br />Proper equipment and needles<br />Adequate exposure to regional anaesthesia in adults<br />PACU and DSU facilities<br />Recovery room facilities <br />Discharge guidelines<br />
  87. 87. THANK YOU<br />