This document discusses the use of ultrasonography for pediatric regional anesthesia. It provides an overview of the benefits of regional anesthesia for children, including reduced opioid use, stress response, surgical blood loss and rapid recovery. It then examines the safety of pediatric regional blocks based on data from large studies showing very low rates of transient neurological deficits and no permanent injuries. The document emphasizes the importance of ultrasound guidance for pediatric regional blocks to ensure safety and effectiveness, and provides examples of ultrasound-guided regional techniques for the upper and lower extremities.

1. Ultrasonography for Pediatric Regional Block
Boohwi Hong
koho0127@gmail.com
2021. 6.

3. 1.Safety of pediatric regional anesthesia
2.Pediatric regional anesthesia for upper extremity
3.Pediatric regional anesthesia for lower extremity
Contents

4. Benefit of Regional Anesthesia
Pediatric Anesthesia 22 (2012) 10–1
PAIN Control with
Regional Analgesia
Opioids
Nausea, Vomiting, Respiratory depression, GI motility
Surgical
Stress
response
Stress
hormones
release
Surgical
blood loss
BJA 113 (3): 375–90 (2014
MAC
Avoid
GA
Support
Care
Pain
Behavior
Rapid
Recovery
Double the anesthetic, Double the risk?

5. PRAN
Pediatric Regional Anesthesia Network
20 children hospitals
Dr. Santhanam Suresh
Department of Anesthesiology and director of the Pain Management Team
at Ann & Robert H. Lurie Children’s Hospital of Chicago

6. • From 2007 to 2015
• No permanent neurologic deficits
• Transient neurologic deficit
• 2.4:10,000
• Not different between peripheral and neuraxial blocks.
• Local anesthetic systemic toxicity
• 0.76:10,000
• Majority of cases occurred in infants.
Safety
Anesthesiology 2018; 129:721-32

7. Anesthesiology 2018; 129:721-32
Transient neurologic deficit

8. LAST
11 additional cases of mild local anesthetic systemic toxicity
metallic taste in mouth, tinnitus or the small electrocardiographic changes.

9. Anesthesiology 2018; 129:721-3

10. Anesthesiology 2018; 129:721-32

11. • Complications 2.2:10,000 vs 15.2:10,000
• OR 2.93
High complication risk in Awake/Sedated

12. Reg Anesth Pain Med 2008;33:449-460

13. • April 2007 through May 2013
• 518 ISB
• No LAST, PONSs
• 1 reported vascular puncture (? US)
• US use in 88%
Reg Anesth Pain Med 2014;39: 502–505

14. Not to routinely perform regional anesthetic or interventional pain medicine
procedures in anesthetized or deeply sedated adult patients
Peripheral and neuraxial nerve blocks in anesthetized children
seems not to increase injury

15. • 47 institution
• 31,132 regional blocks (1262 pure RA)
• Peripheral 66%, 29% upper and lower
• Overall rate of complication: 0.12 %
• 6 times higher in central vs peripheral blocks
• 4 times higher in < 6 months vs > 6 months
• Neurological symptoms of 0.17% in 29,870 blocks performed under GA.
• LAST occurred in only one awake patient
Safety
Paediatr Anaesth . 2010 Dec;20(12):1061-9.

16. • Zero mortality
• No permanent sequelae
RA under GA is
standard of care with good safety

17. • 565 cases (2014~2018)
• Mild sedation with propofol
• Overall 95% success rate
• No complications
• Failure rate 1.2% (0~3yr) ~12.5% (15~18yr)
BJA, 125 (1): 104 -109 (2020)
Avoid GA

18. Avoid GA

19. • 10 yr, Female
• Distal Tibia Fx.
• Anaphylactic shock Hx.
• Propofol & Rocuronium
• Skin provocation test
• NMBA (+) Rocuronium (+)
• Refuse GA
• Popliteal sciatic nerve block and Saphenous nerve block
Avoid GA

20. Reg Anesth Pain Med 2016;41: 229–241
• Performance time: LM > US > NS
• Onset of block: reduced
• Block success: US (≈ LM) > NS
• Block quality:
• Analgesia consumption: Improved, (≈ NS)
• Duration: Improved
• Pain: Improved (≈ NS)
• LA spreading
• LA dose: ?
• Visualization of anatomical structures, needle/catheter

21. US vs No-US
• 33 trials
• 2293 participants
• 0.9 to 12 yr
• Reduces the failed block
• Pain reduction 1.3 points
• Block duration increase 42 min
• Procedure time
• Number of Needle pass
• No difference major complications
Cochrane Database of Systematic Reviews 2019, Issu

22. Anesthesiology 2018; 129:721-3
Ultrasound

23. Complications occur at the ‘end of needle’
Curr Opin Anesthesiol 2018, 31:649–655

24. British Journal of Anaesthesia, 120 (2): 317-322 (201
• 40,121 block
• LA dose varied up to 10-fold for the same neve blocks
• Femoral 0.98 (0.36-2.19)
• Popliteal S 1.06 (0.42-1.94)
• SupraBPB 1.0(0.35-2.22)
• LAST 2 case
• No long term sequelae
• We Need Guideline !!!!!
LA Dose

25. Reg Anesth Pain Med 2018;43: 211–2
LA Dose

26. Dose in Adult: 3 mg/kg Ropivacaine
Reg Anesth Pain Med 2004; 29:564-575.

27. BJA Education, 19(10): 342-348 (2019)
Differences btw Adults and Children

28. Cushion effect
Nerve injury by Overshooting

29. Needle

30. Supraclavicular BPB
1cm
19 month

31. Sequential ultrasound imaging technique
Songthamwat B, et al. Reg Anesth Pain Med 2021
7 yr, F
SUIT: identify the individual
elements of the brachial plexus
above the clavicle

32. Corner pocket image

33. 4 yr
Supraclavicular BPB
1cm

34. KJA Epub
Siddiqui U, et al. Reg Anesth Pain Med May 2020
Intertruncal approach of SupraBPB
10, M
132cm 35 kg

35. DSA
Dorsal Scapular Artery

36. Paracoracoid
approach
Infraproximal
approach
Infraclavicular approach
Pediatric Anesthesia 2008, 18, 838–84

37. Costoclavicular approach
6, F
117 27

38. HDP
• D2 - D1 > 20 mm
• HDP: 2.5 % vs 40 %
Korean J Pain 2020;33(2):144-1
Hemidiaphragmatic palsy
CCB vs SCB

39. • Supraclavicular BPB
• 110 cm 22 kg 6,F
• 10 mm change
• HDP ?
Anesth Pain Med 2019;14:280-28
HDP in Child

40. • Clavicle fx.
• ISB + superficial cervical plexus
Clavicle surgery

41. Femoral nerve block

42. Bjørn S, et al. Reg Anesth Pain Med 2020;45:107–116
Anterior femoral cutaneous nerves
Intermediate femoral cutaneous nerve (IFCN)
Medial femoral cutaneous nerve (MFCN))
10 yr / M
Limb length discrepancy
Distal femur fixation screw
Femoral nerve block
POD 1, Anterior area Numbness,
Intact motor function

43. Femoral nerve block

44. Fascia iliaca compartment block
Anaesthesia, 2011, 66, pages 300–305
15,F

45. Bendtsen TF, et al. Reg Anesth Pain Med 2021
Fascia iliaca compartment block
Kantakam P, et al. Reg Anesth Pain Med 2021
MEV90 for ultrasound-guided SIFIB was
estimated to be 62.5 mL (95% CI 60 to 65). Artificial passageways

46. Medicina 2020
Analgesic effect of Obturator nerve block

47. Popliteal sciatic nerve block

48. Reg Anesth Pain Med 2013;38: 447–451

49. 감사합니다
Boohwi Hong
koho0127@gmail.com