Pediatric Caudal Anesthesia Technique, Dosage and Indications

ANESTESIA CAUDAL EN CIRUGIA
PEDIATRICA
TECNICA, DOSIS E INDICACIONES

ANESTESIA CAUDAL EN CIRUGIA
PEDIATRICA
TECNICA, DOSIS E INDICACIONES

DR. LUIS VERA LINARES
MEDICO ANESTESIOLOGO

ANESTESIA CAUDAL EN CIRUGIA PEDIATRICA


• HISTORIA


• HISTORIA

• INDICACIONES


• HISTORIA

• INDICACIONES

• TECNICA EMPLEADA


• HISTORIA

• INDICACIONES

• TECNICA EMPLEADA

• DOSIS EMPLEADA


DATA DESDE LOS PRIMEROS DIAS DE LA ANESTESIA REGIONAL.

BRAINBRIDGE EN 1901 Y GREY EN 1909 USARON ANESTESIA
ESPINAL EN LACTANTES Y NIÑOS.

CAMPBELL EN 1933: PRIMERA SERIE REPORTADA DE CASOS.

POSTERIORMENTE...

SIEVERS EN 1936, RUSTON EN 1957, SPIEGEL EN 1962, FORTUNA
EN 1967...

1. Cousins MJ. Bloqueos Nerviosos. Edición Española. Barcelona España. Ediciones Doyma S.A.; 1991.p 690.

ACTUALMENTE ES LA TECNICA REGIONAL
MAS UTILIZADA EN PACIENTES PEDIATRICOS
Y NEONATALES.

Dalens B,Hasnaoui A.Caudal Anestesia in Pediatric Surgery: Success Rate and Adverse effects in 750 consecutive patients. Anesth Analg 1989;68:83-9.

Giaufré E, Dalens B, Gombert, Epidemiology and Morbidity of Regional Anesthesia in Children: A one- year prospective survey of the French-Language Society of
Pediatric Anesthesiologists. Anesth Analg 1996;83:904-12.

BLOQUEO CAUDAL EN PEDIATRIA
VENTAJAS
MINIMAS ALTERACIONES FISIOLOGICAS.

ASOCIADA A ANESTESIA GENERAL DISMINUYE LAS NECESIDADES
DE ANESTESICOS Y ACELERA EL DESPERTAR.

OFRECE UN PERIODO POSTOPERATORIO INMEDIATO LIBRE DE
DOLOR.

Brown L. D. Regional Anesthesia and analgesia. Philadelphia, Pensylvania: W.B. Saunders Company; 1996. p 562.

CONTACTO PRECOZ CON SUS
PADRES DISMINUYE TRAUMA
PSICOLOGICO.

POSIBILIDAD DE COLOCAR UN
CATETER EPIDURAL PARA
PROLONGAR EL EFECTO
ANALGESICO.

INDICACIONES

1. Niños con historia de hipertermia maligna.

2. Pacientes que presenten enfermedades neuromusculares que tengan
reducción de la reserva respiratoria o reflejos faríngeos disminuidos.

3. Pacientes prematuros con historia de apnea que sean sometidos a
procedimientos quirúrgicos de abdomen, genitourinarios o de extremidades
inferiores.
4. Pacientes con enfermedad crónica de vías aéreas incluyendo asma y
fibrosis cística.


CONTRAINDICACIONES

Se consideran como contraindicaciones absolutas:

1. Falta de consentimiento paterno.

2. Infección en el sitio de la inyección.

3. Coagulopatía.


Contraindicaciones Relativas
1. En sentido legal estricto se permite la realización de técnicas de anestesia regional, en contra de la
voluntad de menores cuando se considera preferible y existe el consentimiento paterno; sin embargo,
cuando el paciente es lo suficientemente grande como para lograr el diálogo (arbitrariamente de cinco
años en adelante) debería ser realizado previa discusión y aceptación del niño.

2. Estados convulsivos mal controlados.

3. Vía aérea difícil.

4. Anomalías anatómicas en el sitio de inyección, como espina bífida.

5. Hipovolemia.

6. Enfermedad neurológica.

Gregory G. Pediatric Anesthesia. 2nd. ed. Churchill Livigston; 1989. p. 647


CONSIDERACIONES ANATOMICAS

NO OLVIDAR QUE:

MEDULA ESPINAL TERMINA A NIVEL DE L3.

SACO DURAL TERMINA A NIVEL DE S4.

Anestesia Locorregional en Niños y Adolescentes. Barcelona: Masson-Williams & Wilkins España S.A.;1998. p. 180-182.

TIPOS DE BLOQUEO CAUDAL

BLOQUEO CAUDAL DE INYECCION UNICA

BLOQUEO CAUDAL CONTINUO

BLOQUEO CAUDAL DE INYECCION
UNICA

AMPLIAMENTE USADO PARA PROPORCIONAR
ANALGESIA PERIOPERATORIA EN LA PRACTICA
PEDIATRICA.

OFRECE UN BLOQUEO CONFIABLE Y EFECTIVO.
EN CIRUGIA GENERAL, UROLOGICA,
TRAUMATOLOGICA QUE INVOLUCRE EL ABDOMEN
BAJO Y EN MIEMBROS INFERIORES.


¿ES NECESARIO USAR MEDICACION PRE
ANESTESICA?


¿ES NECESARIO USAR MEDICACION PRE
ANESTESICA?

SI


SE RECOMIENDA USAR SEDACION
ENDOVENOSA O INHALADA.


ADEMAS DE USAR UN
DISPOSITIVO DE CONTROL DE VIA
AEREA PREVIA INSTALACION DEL
BLOQUEO.

¿COMO SE REALIZA EL BLOQUEO
CAUDAL DE INYECCION UNICA?

• POSICION: DECUBITO LATERAL O
EN DECUBITO PRONO

ELECCION ES
PERSONAL

VOLUMEN DE INYECCION

DETERMINA LA ALTURA METAMERICA
ALCANZADA.

SE HAN PROPUESTO VARIOS MODELOS
MATEMATICOS PARA DETERMINAR EL VOLUMEN A
ADMINISTRAR Y LA ALTURA FINAL DEL BLOQUEO
SENSITIVO SEGUN LA EDAD Y LE PESO DEL
PACIENTE

Takasaki M, Dohi S, Kawabata Y, Takayashi T. Dosage of Lidocaine for Caudal Anestesia in Infants and Children. Anesthesiology 1977;47:527-9.
Hain WR. Anaesthetic Doses for Extradural Anaesthesia in Children. Br J Anaesth 1978:50;303.

VOLUMEN Y DOSIS DE ANESTESICO LOCAL
EMPLEADO

BROMAGE Y SCHULTE-STEINBERG
VOLUMEN: EDAD X 0.1ML/DERMATOMA X N DE DERMATOMAS
ANESTESIADOS.

TAKASAKI
VOLUMEN: PESO X 0.056 ML/ SEGMENTO ANESTESIADO.

EYRES Y COL.
DOSIS MAXIMA DE BUPIVCAINA 0.5% CAUDAL: 0.6 ML/KG

ACTUALMENTE: BUPIVACAINA 0.25% VOL: 1ML/ KG

Pediatric Anesthesia ISSN 1155-5645 Pediatric Anesthesia ISSN 1155-5645 Pediatric Anesthesia ISSN 1155-5645

ORIGINAL ARTICLE ORIGINAL ARTICLE ORIGINAL ARTICLE

Management of hypertrophic pylorus stenosis with Effect of epidural clonidine on minimum local anesthetic S e g m e n t a l d i s t r i b u t i o n o f h i g h-v o l u m e c a u d a l a n e s t h e s i a
ultrasound guided single shot epidural anaesthesia – a concentration (ED50) of levobupivacaine for caudal block i n n e o n a t e s, i n f a n t s, a n d t o d d l e r s a s a s s e s s e d b y
retrospective analysis of 20 cases in children ultrasonography
Harald Willschke1, Anette-Marie Machata1, Winfried Rebhandl2, Thomas Benkoe2, Nicola Disma1, Geoff Frawley2,3, Leila Mameli1, Angela Pistorio4, Ornella D. Casa Alberighi5, Marit Lundblad1, Per-Arne Lonnqvist2, Staffan Eksborg3 & Peter Marhofer4
¨ ¨
Stephan C. Kettner1, Lydia Brenner1 & Peter Marhofer1 Giovanni Montobbio1 & Pietro Tuo1
1 Department of Paediatric Anaesthesia & Intensive Care, Karolinska University Hospital, Stockholm
1 Department of Anaesthesia, Intensive Care Medicine and Pain Therapy, Medical University of Vienna, Vienna, Austria 1 Department of Anaesthesia, IRCCS Gaslini Children’s Hospital, Genoa, Italy 2 Department of Physiology and Pharmacology, Section of Anaesthesiology & Intensive Care, Karolinska Institutet, Stockholm
2 Department of Surgery, Division of Paediatric Surgery, Medical University of Vienna, Vienna, Austria 2 Department of Paediatric Anaesthesia and Pain Management, Royal Children’s Hospital, Anaesthesia Research Unit, Murdoch Children’s 3 Department of Women’s and Children’s Health, Karolinska Institutet, Stockholm, Sweden
Research Institute, Melbourne, Australia 4 Department of Anaesthesia and Intensive Care Medicine, Medical University of Vienna, Vienna, Austria
3 Department of Pharmacology, Melbourne University, Melbourne, Australia
4 Clinical Epidemiology and Biostatistics Unit, IRCCS Gaslini Hospital, Genoa, Italy
5 Clinical Pharmacology Unit, IRCCS Gaslini Hospital, Genoa, Italy

Keywords Summary
hypertrophic pylorus stenosis; thoracic
epidural anaesthesia; ultrasound Aim: To retrospectively describe the performance of ultrasound guided tho- Keywords Abstract
racic epidural anaesthesia under sedation for anaesthesia management of caudal; anesthesia; ultrasound; children
Correspondence open pyloromyotomy. Keywords Summary Background: The aim of this prospective, age-stratified, observational study
Peter Marhofer, Background: Anaesthesia management for hypertrophic pylorus stenosis anesthetic techniques; regional; caudal; Correspondence was to determine the cranial extent of spread of a large volume (1.5 mlÆ
Professor of Anaesthesia and Intensive Care anesthetics local; stereoisomers; Background: Clonidine has the potential to significantly prolong the dura- Marit Lundblad,
¨ kg)1, ropivacaine 0.2%), single-shot caudal epidural injection using real-
(HPS) is usually performed under general anaesthesia with tracheal intuba-
Medicine, Medical University of Vienna, pharmacology; clonidine; potency; tion of caudal epidural anesthesia. We investigated the effect of the addi- Department of Pediatric Anesthesia & time ultrasonography.
tion. Only a few publications describe avoidance of tracheal intubation in
Department of Anaesthesia, Intensive Care anesthetic; ED {50} tion of clonidine to the MLAC of levobupivacaine in a randomized Intensive Care, ALB, Karolinska University
Methods: Fifty ASA I-III children were included in the study, stratified in
Medicine and Pain Therapy, Waehringer infants by using spinal or caudal anaesthesia. The present retrospective Hospital, S 17176 Stockholm Sweden
controlled dose–response trial. three age groups; neonates, infants (1–12 months), and toddlers (1–4 years).
Guertel 18-20, A-1090 Vienna, Austria analysis describes the performance of ultrasound guided thoracic epidural Correspondence Email: marit.lundblad@karolinska.se
Methods: A group of 120 children aged <6 years of age received caudal The caudal blocks were performed during ultrasonographic observation of
Email: peter.marhofer@meduniwien.ac.at anaesthesia under sedation for anaesthetic management of open pyloromy- Geoff Frawley,
anesthesia with levobupivacaine and 1, 2, or 3 lgÆkg)1 of clonidine. The the spread of local anesthetic (LA) in the epidural space.
otomy. Department of Paediatric Anaesthesia and Section Editor: Adrian Bosenberg
Section Editor: Per-Arne Lonnqvist Pain Management. Royal Children’s MLAC was determined according to a Dixon-Massey protocol. The pri- Results: A significant inverse relationship was found between age, weight,
Methods: Twenty consecutive infants scheduled for pyloromyotomy accord-
Hospital, Melbourne Australia mary outcome was effective surgical anesthesia. Secondary outcomes were Accepted 9 November 2010 and height, and the maximal cranial level reached by 1.5 mlÆkg)1 of LA. In
ing to the Weber–Ramstedt technique were retrospectively analysed. After
Accepted 14 October 2010 Email: geoff.frawley@rch.org.au the duration of postoperative analgesia, postoperative pain scores, cloni- neonates, 93% of the blocks reached a cranial level of ‡Th12 vs 73% and
sedation with nalbuphine and propofol, an ultrasound guided single shot
dine side effects, and time to hospital discharge. doi:10.1111/j.1460-9592.2010.03485.x
doi:10.1111/j.1460-9592.2010.03452.x thoracic epidural anaesthesia was performed with 0.75 mlÆkg)1 ropivacaine Section Editor: Per-Arne Lonnqvist
25% in infants and toddlers, respectively. Based on our data, a predictive
Results: The MLAC of caudal levobupivacaine was 0.106%, 0.077%, and equation of segmental spread was generated: Dose (ml/spinal seg-
0.475%. Insufficient blockade was defined as increase of HR > 15% from
0.035% with 1, 2, and 3 lgÆkg)1 of clonidine, respectively. There were sig- ment) = 0.1539Æ(BW in kg)–0.0937.
initial value and/or any movements at skin incision. In those cases we were Accepted 6 November 2010
nificant dose-dependent increases in median duration of analgesia. The inci- Conclusions: This study found an inverse relationship between age, weight,
prepared for rapid sequence intubation according to the departmental stan-
doi:10.1111/j.1460-9592.2010.03478.x dence of delayed discharge, somnolence, and PONV was significantly and height and the number of segments covered by a caudal injection of
dard.
increased in the 3 lgÆkg)1 of clonidine group. 1.5 mlÆkg)1 of ropivacaine 0.2% in children 0–4 years of age. However, the
Results: All pyloromyotomies could be performed under single shot tho-
Conclusions: Clonidine produces a local anesthetic sparing effect with a cranial spread of local anesthetics within the spinal canal as assessed by
racic epidural anaesthesia and sedation. One case of moderate oxygen
dose-dependent decrease in levobupivacaine MLAC for caudal anesthesia. immediate ultrasound visualization was found to be in poor agreement
desaturation was treated with intermittent ventilation via face mask.
Conclusions: Thoracic epidural anaesthesia under sedation for pyloromyot- In addition, there is a dose-dependent prolongation of postoperative anal- with previously published predictive equations that are based on actual
omy has been a useful technique in this retrospective series of infants suf- gesia following lower abdominal surgery in children. A dose of 2 lgÆkg)1 cutaneous dermatomal testing.
fering from HPS. In 1/20 infants short term assisted ventilation via face of clonidine provides the optimum balance between improved analgesia
mask was required. Undisturbed surgery was possible in all cases. and minimal side effects.

extension of a caudal block (e.g. Schulte-Steinberg,
Caudal block is a popular regional anesthetic tech- ous firing rate of the Locus Coeruleus in the brain- Introduction
Takasaki, Busoni) (1–3). The methodology to deter-
nique, which reliably provides effective intra- and post- stem, leading to central nervous system depression. As Caudal block is the most widely used regional anesthe- mine the cranial extension of the block has also varied
weight of infants with HPS is 5 weeks and 4 kg, operative analgesia in infants and children (1). To a result, use of clonidine can be limited by the inci-
Introduction sia method in neonates and small children. Despite considerably between publications: reaction to surgical
respectively (5). prolong postoperative analgesia and avoid or minimize dence of significant sedation. being the most common pediatric regional anesthetic stimulation, pin-prick or pinching, injection of radio-
Hypertrophic pyloric stenosis (HPS) is a frequent dis- Anaesthesia management for HPS is usually per- postoperative motor block, adjuvants such as opioids, The optimal dose of caudal clonidine and levobupi- block, there are still certain issues that remain unclear. opaque dye with subsequent X-ray visualization or
ease in infants with an incidence of 0.9–5.1 per 1000 formed under general anaesthesia with tracheal intuba- clonidine, and ketamine have been suggested (2). Clo- vacaine associated with the greatest improvement in One such issue is the relationship between the injected cadaver studies (1–5). However, none of these methods
cases (1–4). The main symptoms of HPS are progres- tion. Tracheal intubation puts these infants at risk of nidine is an a2 adrenergic agonist, which binds to a2 analgesia without unwanted side effects such as volume of local anesthetics and the resultant spread of allow real-time visualization of the spread within the
sively worsening ‘projectile’ vomiting, poor feeding regurgitation, with the potential of aspiration of gastric adrenoreceptors in the dorsal horn of the spinal cord sedation, hypotension, or bradycardia is unknown. the local anesthetic solution within the spinal canal. spinal canal.
and dehydration caused by a gastric outlet obstruction contents, and rapid sequence intubation is indicated. within several brainstem nuclei (3). Activation of A randomized, double-blind sequential allocation Various patient-related factors have been used to Because of the incomplete ossification of the sacrum
due to a hypertrophic pylorus. The average age and Beside the special character of anaesthesia induction in a2-adrenoceptors by clonidine suppresses the spontane- study was performed to test the hypothesis (i) that determine predictive equations regarding the cranial and the vertebrae in young children, it has been shown

110 Pediatric Anesthesia 21 (2011) 110–115 ª 2010 Blackwell Publishing Ltd
128 Pediatric Anesthesia 21 (2011) 128–135 ª 2010 Blackwell Publishing Ltd Pediatric Anesthesia 21 (2011) 121–127 ª 2010 Blackwell Publishing Ltd 121

Pediatric Anesthesia 2010 20: 1017–1021 doi:10.1111/j.1460-9592.2010.03422.x Pediatric Anesthesia 2010 20: 866–872 doi:10.1111/j.1460-9592.2010.03374.x Pediatric Anesthesia 2010 20: 620–624 doi:10.1111/j.1460-9592.2010.03316.x

The effect of volume of local anesthetic on the Efficacy of bupivacaine-neostigmine and
anatomic spread of caudal block in children aged Comparison of awake spinal with awake caudal
bupivacaine-tramadol in caudal block in pediatric anesthesia in preterm and ex-preterm infants for
1–7 years
inguinal herniorrhaphy herniotomy1
M . L . T H O M A S * , D . R O E B U C K †, C . Y U L E* A N D
R .F . H O W A R D * R E Z A T A H E R I M D * , S HA H N A Z S H A YE GH I M D †, S EY E D S.
Departments of *Anaesthesia and †Radiology, Great Ormond Street Hospital, London, UK R A Z A V I M D †, A F S A N E H SA D E G H I M D †, K A M Y A R M A R T I N H O E L Z L E M D , M A R K U S WE IS S M D , C L A U D I A
Section Editor: Adrian Bosenberg G H A B I LI M D ‡, M O R T E Z A G H O J A Z A D E H M D § A ND DILLIER MD AND ANDREAS GERBER MD
MOHSEN ROUZROKH MD† Department of Anaesthesia, University Children’s Hospital Zurich, Switzerland
*Department of Anesthesiology, Children’s Hospital, Tabriz University of Medical Sciences,
Tabriz, †Mofid Hospital, Shaheed Beheshti, University of Medical Sciences, Tehran, Section Editor: Prof Per-Arne Lonnqvist
Summary ‡Tuberculosis and Lung Disease Research Center, Tabriz University of Medical Sciences,
Objectives: To examine the anatomic spread of caudal local anesthetic Tabriz and §Faculty of Medicine, Tabriz University of Medical Sciences, Tabriz, Iran
solution in children aged 1–7 years. Section Editor: Per-Arne Lonnqvist
Aim: To determine whether incremental increases in the volume of Summary
caudal injections of 0.5, 0.75, and 1.0 mlÆkg)1 result in reliable (>90%) Background: Spinal anesthesia (SA) is widely used for awake
and potentially clinically significant increases in the number of
regional anesthesia in ex-preterm infants scheduled for herniotomy.
vertebral segments reached.
Summary Awake caudal anesthesia (CA) is suggested as an alternative
Background: Caudal block is one of the most frequently performed
Background: Limited duration of analgesia is among the limitations of approach for these patients and type of surgery. The aim of this
pediatric regional analgesic techniques. Traditional formulae suggest
that changes in the volume of caudal injectate in the range 0.5– single caudal injection with local anesthetics. Therefore, the purpose of study was to compare efficacy and complications of the two
1.0 mlÆkg)1 would have clinically useful effects. this study was to evaluate the effectiveness and safety of bupivacaine different techniques.
Methods: In a single blind design, 45 children aged 1–7 years under- in combination with either neostigmine or tramadol for caudal block Methods: Two historical populations of 575 ex-preterm infants
going caudal block received one of the three predetermined volumes in children undergoing inguinal herniorrhaphy. undergoing herniotomy under awake SA (n = 339; 1998–2001) and
(0.5, 0.75, and 1 mlÆkg)1) of local anesthetic solution containing radio- Methods: In a double-blinded randomized trial, sixty children under- under awake CA (n = 236; 2001–2009) were investigated. Data are
opaque contrast under controlled conditions. Following X-ray exam- going inguinal herniorrhaphy were enrolled to receive a caudal block
compared using t-test and chi-square tests (P < 0.05).
ination, the anatomic spread of the block was reported by a radiologist with either 0.25% bupivacaine (1 mlÆkg)1) with neostigmine
Results: The SA group consisted of 339 patients, they were born
blinded to the volume of solution received. (2 lgÆkg)1) (group BN) or tramadol (1 mgÆkg)1) (group BT). Hemo-
Results: There were 15 children in each group, and they were similar after 32.0 (3.3) weeks of gestation on average with a mean birth
dynamic variables, pain and sedation scores, additional analgesic
in terms of age, height, and weight. Spread was observed between the weight of 1691 g (725). The CA group consisted of 236 patients born
requirements, and side effects were compared between two groups.
5th lumbar (L5) and 12th thoracic (T12) vertebral levels. A volume of after 32.1 weeks (3.7) with a mean birth weight of 1617 g (726). At
1 mlÆkg)1 results in a small but significantly greater spread of solution
Results: Duration of analgesia was longer in group BT (17.30 ± 8.24 h)
compared with group BN (13.98 ± 10.03 h) (P = 0.03). Total con- the time of operation, the total age was 41.37 (3.6) and 41.28 (4.0),
than 0.5 mlÆkg)1 (P < 0.05), but there was no difference between 0.5
sumption of rescue analgesic was significantly lower in group BT respectively, for SA and CA patients, and the corresponding
and 0.75 ml or between 0.75 and 1.0 ml. No volume reliably reached a
level higher than the second lumbar vertebra (L2). compared with group BN (P = 0.04). There were no significant weights were 3326 (1083) g and 3267 (931) g for SA and CA
Conclusions: Incrementally increasing the volume of injectate between differences in heart rate, mean arterial pressure, and oxygen satura- patients, respectively. For SA, significantly more puncture attempts
0.5 and 1.0 results in a modest increase in the spread of the caudal tion between groups. Adverse effects excluding the vomiting were not were needed (1.83 vs 1.44, P < 0.001). Surgery was performed under
solution. It is unlikely that volumes of <1 ml will reliably reach a observed in any patients. pure regional anesthesia in 85% (SA) and 90.1% (CA) (ns). A
vertebral level that is higher than L2. Conclusion: In conclusion, tramadol (1 mgÆkg)1) compared with change to general anesthesia was necessary in 7.7% (SA) and 3.9%
neostigmine (2 lgÆkg)1) might provide both prolonged duration of (CA) (ns). Overall, intra- and postoperative complications were not
Keywords: anesthetic techniques; regional; caudal; pediatric; anatomy
analgesia and extended time to first analgesic in caudal block. statistically different.
Conclusions: Caudal anesthesia was shown to be technically less
Keywords: bupivacaine; neostigmine; tramadol; caudal block; difficult than SA and to have a higher success rate. Its application as
pediatric; herniorrhaphy awake regional anesthesia technique in these patients seems more
Correspondence to: M.L. Thomas, Department of Anaesthesia, Great Ormond Street Hospital, London WC1N 3JH, UK (email: appropriate than SA.
thomam@gosh.nhs.uk). Introduction
The technique of caudal block provides analgesia Keywords: anesthesia; spinal; caudal; awake; preterm; herniotomy
Ó 2010 Blackwell Publishing Ltd 1017 during surgery and postoperative period in lower
Correspondence to: Kamyar Ghabili, MD, Tuberculosis and Lung
Disease Research Center, Tabriz University of Medical Sciences, abdominal, urologic, and lower limb surgeries (1,2).
Tabriz, Iran (e-mail: kghabili@gmail.com). Meanwhile, limited duration of analgesia is among Correspondence to: KD Dr. Andreas Gerber, MD, Department of Anaesthesia, University Children’s Hospital, Steinwiesstrasse 75, 8032
Zurich, Switzerland (email: andreas.gerber@kispi.uzh.ch).
1
Prior Publication: A preliminary abstract was presented during the APA-SGKA Joint Meeting in Zurich, Switzerland, 2004 (Pediatric

are transformed, transmitted, modified, and perceived as pain by an individual are
collectively referred to as nociception. Many of these processes lend themselves to

Pharmacolo gic
pharmacologic interventions that can attenuate or block the transmission of pain.
Pain treatment plans that target a single step in the nociceptive process with a single
medication may be less effective than plans that target multiple steps by using

Ma nagement of Acute
a combination of analgesics.5–9 Although opiates continue to be mainstays in the
treatment of moderate to severe acute pain, by combining them with drugs and tech-

Pe diatric Pain
niques that target other components of nociceptive pathways it may be possible to
reduce the opiate consumption, provide equivalent or superior analgesia, and reduce
the incidence and severity of opiate-related adverse drug events such as nausea,
vomiting, constipation, pruritus, respiratory and central nervous system depression,
and urinary retention.7,10 In recent years regional analgesic techniques supplemented
with systemic opiate or nonsteroidal anti-inflammatory drug (NSAID) therapy have

F. Wickham Kraemer, MD *, John B. Rose, MD
emerged as invaluable methodsa,b, controlling severe acute a,c
for postoperative pain in

a
University of Pennsylvania, School of Medicine, Department of Anesthesiology and Critical
Care, 3400 Spruce Street, Philadelphia, PA 19104, USA
KEYWORDS
b
Department of Anesthesiology and Critical Care Medicine, Children’s Hospital of Philadelphia,
34th and Civic Center Boulevard, Philadelphia, PA 19104, USA
c
Pain Management Service, Department of Anesthesiology and Critical Care Medicine, Children’s
Pediatric pain management
Hospital of Philadelphia, 34th and Civic Center Boulevard, Philadelphia, PA 19104, USA
Acute Pediatric pain pharmacology
* Corresponding author. University of Pennsylvania, School of Medicine, Philadelphia, PA
19104.
E-mail address: KRAEMER@email.chop.edu (F. W. Kraemer).

Anesthesiology Clin 27 (2009) 241–268
doi:10.1016/j.anclin.2009.07.002 anesthesiology.theclinics.com
The accurate assessment and effective treatment of acute pain in children in the
1932-2275/09/$ – see front matter ª 2009 Elsevier Inc. All rights reserved.

hospital setting is a high priority. Evidence is growing that pediatric patients of all
Pharmacologic Management of Acute Pediatric Pain 251
ages, even the most extremely premature neonates, are capable of experiencing
pain as a result of tissue injuries due to medical illnesses, therapeutic and diagnostic
procedures, trauma, and surgery.1,2 If pain is not recognized and adequately treated,
the resulting physiologic and behavioral responses can be potentially harmful, result-
ingTable 1
in long-lasting negative effects on the developing nociceptive system.3,4
The complex processes bydoses (mg/kg) thermal, chemical, or mechanical stimuli
Local anesthetic maximal which noxious
are transformed, transmitted, modified, and perceived as pain by an individual are
Drug Spinal Epidural Infusion (h) Peripheral Infiltrate
collectively referred to as nociception. Many of these processes lend themselves to
pharmacologic interventions NR can attenuate or block the transmission of8–10
2-Chloroprocaine that 10–30 30 pain. 8–10
Pain treatment plans that target a single step in the nociceptive process with a 5–7
Lidocaine 1–2.5 5–7 2–3 single 5–7
medication may be less effective than plans that target multiple steps by using
a combination of analgesics.5–9 Although opiates continue to be mainstays 2–3
Bupivacaine 0.3–0.5 2–3 0.4 in the 2–3
treatment of moderate to severe acute pain, 2.5–4
Ropivacaine NR by combining them with drugs and2.5–4
0.4–0.5 tech- 2.5–4
niques that target other components of nociceptive pathways it may be possible to
Levobupivacaine NR 2.5–4 0.4 2.5–4 2.5–4
reduce the opiate consumption, provide equivalent or superior analgesia, and reduce
the incidence and severity of opiate-related adverse drug events such as nausea,
Abbreviation: NR, not recommended.
vomiting, constipation, pruritus, respiratory and central nervous system depression,
and urinary retention.7,10 In recent years regional analgesic techniques supplemented

SIN EMBARGO...

EN LA PRACTICA CLINICA ES MAS UTIL
SEGUIR LAS SIGUIENTES
RECOMENDACIONES:

1. NIVEL LUMBOSACRO: 0.5 ML/KG
2. NIVEL TORACOLUMBAR: 1 ML/KG
3. NIVEL MEDIO TORACICO: 1.25 A 1.6 ML/KG


EN RESUMEN:

EN LA POBLACION PEDIATRICA, EL PESO
CORPORAL ES MEJOR INDICADOR QUE LA
EDAD EN CORRELACIONAR LA DIFUSION DEL
ANESTESICO LOCAL LUEGO DE UN BLOQUEO
CAUDAL.


PARA USO CAUDAL LA CONCENTRACION
OPTIMA DE BUPIVACAINA ES DE 0.125% A
0.175%.

LA DOSIS MAXIMA A EMPLEAR ES DE 2.5 A 4
MG/KG.

EN INFUSION CONTINUA:
0.2 MG/KG/H EN NEONATOS
0.4 MG/KG/H EN NIÑOS MAYORES


SI USA ROPIVACAINA:

EN BLOQUEO CAUDAL DE INYECCION UNICA USAR
UN BOLO DE 1 ML/KG DE ROPIVACAINA 0.2%

CONTINUAR CON INFUSION A RITMO DE:

0.2 MG/KG/H DE ROPIVACAINA 0.1% EN INFANTES
0.4 MG/KG/H EN NIÑOS MAYORES.

HASTA POR 48 HORAS...

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