This document discusses caudal anesthesia in pediatric surgery. It covers the history of caudal anesthesia, indications, contraindications, techniques, dosages, and considerations for caudal anesthesia in children. Specifically, it provides details on single-shot caudal anesthesia, including appropriate sedation, positioning, asepsis, volumes and dosages used, and definitions for insufficient blockade. The document aims to guide anesthesiologists on the safe and effective use of caudal anesthesia for pediatric surgical procedures.
Regional anesthesia can be safely used in pediatric cases. While initially there was concern over its use in children, several large studies proved its efficacy and safety. Proper technique must account for anatomical differences in children, such as higher spinal levels and more flexible vertebrae. With the correct dose and placement of local anesthetic, regional anesthesia provides effective pain relief for pediatric surgeries and procedures.
This document discusses the management of inguinal hernias. It notes that hernias can be managed conservatively or surgically, with surgical management being the gold standard. The main surgical repair procedures discussed are herniotomy, herniorraphy, and hernioplasty. Laparoscopic surgery techniques like TEP and TAPP are also summarized. Potential intraoperative, early, and late complications of hernia repair are listed.
This document discusses regional nerve blocks for pediatric surgery, including their benefits over general anesthesia alone and differences compared to adults. It provides details on caudal analgesia, ilioinguinal nerve blocks, and penile blocks including indications, anatomy, techniques, dosages, and potential complications. Regional blocks can reduce pain, nausea, vomiting and airway issues compared to general anesthesia with opioids alone. Techniques must account for anatomical differences in children such as thinner tissues and lower nerve locations.
Spinal anesthesia can be used as a primary anesthetic technique in children, especially for former preterm infants to reduce postoperative apnea risk compared to general anesthesia. Key differences in pediatric spinal anatomy and physiology require lower needle insertion points and higher local anesthetic doses in children. Spinal anesthesia provides effective pain control and fewer cardiovascular and respiratory complications than general anesthesia for many pediatric surgeries under 90 minutes. Complications are generally minor when performed carefully according to age-specific anatomical considerations and monitoring.
Drs. Milam and Thomas's CMC X-Ray Mastery Project: February CasesSean M. Fox
Drs. Claire Milam and Alyssa Thomas are Emergency Medicine Residents and interested in medical education. With the guidance of Dr. Michael Gibbs, a notable Professor of Emergency Medicine, they aim to help augment our understanding of emergent imaging. Follow along with the EMGuideWire.com team as they post these monthly educational, self-guided radiology slides on:
• Mycoplasma pneumonia
• Thoracic aortic aneurysm
• Hydropneumothorax
• Sternal fracture
• Foreign body
• Iatrogenic pneumothorax
• Pulmonary contusion
• Type A aortic dissection
• Cardiomegaly
• PCP pneumonia
• Pneumothorax
Update in Central Neuraxial Blockade in Pediatricscairo1957
This document discusses central neuraxial blockade techniques in pediatrics. It begins by noting key anatomical and physiological differences between children and adults that impact neuroaxial techniques. It then covers indications, contraindications, preoperative management, safety measures, technical procedures, advantages, disadvantages and complications of central neuraxial blockade in pediatrics. The document emphasizes the need to understand pediatric spinal anatomy and physiology to safely perform these techniques.
This document describes the case of a 21-month-old boy who presented to the emergency room with a Glasgow Coma Score of 3 after reportedly falling from a standing position on a kitchen chair. Imaging showed subdural hemorrhage, subarachnoid hemorrhage, hypoxic-ischemic encephalopathy, and retinal hemorrhages. The autopsy later revealed an impact site on the skull and fatal injury to the cervicomedullary junction, as well as traumatic spinal cord injury without radiographic abnormality from T5 to T12. Biomechanical analysis could not rule out nonaccidental injury but found the injuries were also consistent with an accidental fall as described.
This document summarizes spinal anaesthesia techniques for children. It notes that spinal anaesthesia provides a good alternative to general anaesthesia for newborns undergoing lower abdominal or lower extremity surgery in the first 6 months of life, as it reduces the risk of postoperative apnea. The technique requires experienced providers due to the technical challenges of performing lumbar puncture in newborns. Spinal anaesthesia is most effective for short surgeries lasting less than 90 minutes. Complications are rare when performed correctly by trained staff, but may include traumatic puncture, respiratory issues, or post-dural puncture headache in older children.
Regional anesthesia can be safely used in pediatric cases. While initially there was concern over its use in children, several large studies proved its efficacy and safety. Proper technique must account for anatomical differences in children, such as higher spinal levels and more flexible vertebrae. With the correct dose and placement of local anesthetic, regional anesthesia provides effective pain relief for pediatric surgeries and procedures.
This document discusses the management of inguinal hernias. It notes that hernias can be managed conservatively or surgically, with surgical management being the gold standard. The main surgical repair procedures discussed are herniotomy, herniorraphy, and hernioplasty. Laparoscopic surgery techniques like TEP and TAPP are also summarized. Potential intraoperative, early, and late complications of hernia repair are listed.
This document discusses regional nerve blocks for pediatric surgery, including their benefits over general anesthesia alone and differences compared to adults. It provides details on caudal analgesia, ilioinguinal nerve blocks, and penile blocks including indications, anatomy, techniques, dosages, and potential complications. Regional blocks can reduce pain, nausea, vomiting and airway issues compared to general anesthesia with opioids alone. Techniques must account for anatomical differences in children such as thinner tissues and lower nerve locations.
Spinal anesthesia can be used as a primary anesthetic technique in children, especially for former preterm infants to reduce postoperative apnea risk compared to general anesthesia. Key differences in pediatric spinal anatomy and physiology require lower needle insertion points and higher local anesthetic doses in children. Spinal anesthesia provides effective pain control and fewer cardiovascular and respiratory complications than general anesthesia for many pediatric surgeries under 90 minutes. Complications are generally minor when performed carefully according to age-specific anatomical considerations and monitoring.
Drs. Milam and Thomas's CMC X-Ray Mastery Project: February CasesSean M. Fox
Drs. Claire Milam and Alyssa Thomas are Emergency Medicine Residents and interested in medical education. With the guidance of Dr. Michael Gibbs, a notable Professor of Emergency Medicine, they aim to help augment our understanding of emergent imaging. Follow along with the EMGuideWire.com team as they post these monthly educational, self-guided radiology slides on:
• Mycoplasma pneumonia
• Thoracic aortic aneurysm
• Hydropneumothorax
• Sternal fracture
• Foreign body
• Iatrogenic pneumothorax
• Pulmonary contusion
• Type A aortic dissection
• Cardiomegaly
• PCP pneumonia
• Pneumothorax
Update in Central Neuraxial Blockade in Pediatricscairo1957
This document discusses central neuraxial blockade techniques in pediatrics. It begins by noting key anatomical and physiological differences between children and adults that impact neuroaxial techniques. It then covers indications, contraindications, preoperative management, safety measures, technical procedures, advantages, disadvantages and complications of central neuraxial blockade in pediatrics. The document emphasizes the need to understand pediatric spinal anatomy and physiology to safely perform these techniques.
This document describes the case of a 21-month-old boy who presented to the emergency room with a Glasgow Coma Score of 3 after reportedly falling from a standing position on a kitchen chair. Imaging showed subdural hemorrhage, subarachnoid hemorrhage, hypoxic-ischemic encephalopathy, and retinal hemorrhages. The autopsy later revealed an impact site on the skull and fatal injury to the cervicomedullary junction, as well as traumatic spinal cord injury without radiographic abnormality from T5 to T12. Biomechanical analysis could not rule out nonaccidental injury but found the injuries were also consistent with an accidental fall as described.
This document summarizes spinal anaesthesia techniques for children. It notes that spinal anaesthesia provides a good alternative to general anaesthesia for newborns undergoing lower abdominal or lower extremity surgery in the first 6 months of life, as it reduces the risk of postoperative apnea. The technique requires experienced providers due to the technical challenges of performing lumbar puncture in newborns. Spinal anaesthesia is most effective for short surgeries lasting less than 90 minutes. Complications are rare when performed correctly by trained staff, but may include traumatic puncture, respiratory issues, or post-dural puncture headache in older children.
EMGuideWire's Radiology Reading Room on Pediatric Adult Aortic CoarctationSean M. Fox
The Department of Emergency Medicine at Carolinas Medical Center is passionate about education! Dr. Michael Gibbs is a world-renowned clinician and educator and has helped guide numerous young clinicians on the long path of Mastery of Emergency Medical Care. With his oversight, the EMGuideWire team aim to help augment our understanding of emergent imaging. You can follow along with the EMGuideWire.com team as they post these monthly educational, self-guided radiology slides or you can also use this section to learn more in-depth about specific conditions and diseases. This Radiology Reading Room pertains to Pediatric and Adult Aortic Coarctation and is brought to you by Jennifer Potter, MD and Elizabeth Olson, MD.
- An 81-year-old man was admitted due to a 6-month history of dysphagia, regurgitation, and vomiting during meals. Upper endoscopy and radiographs revealed an abnormal corkscrew appearance of the esophagus. Manometry confirmed an alternative form of abnormal peristalsis.
- A 17-year-old boy sustained an avulsion injury to his right pinky finger after his ring caught on a fence he was jumping over. The finger was amputated through the distal joint and the flexor digitorum profundus tendon was completely pulled out.
- The document describes several medical cases illustrated by images from clinical journals, including abnormalities found during examinations, patient
The document discusses sepsis and septic shock. It defines sepsis as a complex syndrome that develops due to an amplified and dysregulated host response to infection. Septic shock is presented as a form of shock that is a combination of distributive, cardiogenic and hypovolemic shock. Early diagnosis of septic shock requires a high index of suspicion and can be recognized through signs of altered perfusion before hypotension occurs. The document outlines treatments for septic shock including rapid fluid resuscitation and vasopressor support.
Spine surgeries present diverse challenges to anaesthetists. The document outlines considerations for anaesthesia including preoperative evaluation and optimization, induction and intubation while maintaining spine stability, positioning prone or sitting, intraoperative monitoring, maintenance with stable anaesthetic depth and blood pressure, transfusion management for blood loss, emergence and extubation when fully awake, postoperative analgesia, and complications prevention and management. Skillful anaesthetic management is key to optimal patient outcomes for various spine procedures.
Tratamiento de lesiones preinvasoras DE CERVIXIMSS
This document discusses the management of preinvasive cervical lesions. It notes that treatment selection will depend on many factors, principally the patient and treating physician. While no treatment is 100% effective, the goal is to remove the entire transformed area based on a balance of risk and benefit, with patient information central. Expectant management may be appropriate for NIC1 lesions confirmed by biopsy, with HPV testing and cytology follow up.
Drs. Rossi and Shreve’s CMC Abdominal Imaging Mastery Project: February CasesSean M. Fox
Dr. Brian Shreve is an Emergency Medicine Resident and Dr. Isolina Rossi is a Surgery Resident at Carolinas Medical Center in Charlotte, NC. They are interested in medical education. With the guidance of Drs. Kyle Cunningham and Michael Gibbs, they aim to help augment our understanding of emergent abdominal imaging. Follow along with the EMGuideWire.com team as they post these monthly educational, self-guided radiology slides on:
• Intrauterine Pregnancy and Trauma
• Ruptured hemorrhagic cyst
• Ovarian teratoma
• Pelvic Inflammatory Disease
The document discusses various reasons for failed spinal anesthesia, including:
- Equipment failures during early experiments with spinal anesthesia that led to leakage of the cocaine solution.
- The wide variation in how cocaine solutions dispersed among patients, referred to as "capriciousness", contributed to inconsistent results.
- Factors like an inexperienced operator, patient characteristics like obesity, and acute medical conditions can increase risks of failure.
- Repeated puncture attempts, lack of adjuvant medication, and patient age over 70 were found to be independent risk factors for failure in one study.
This document discusses the innervation of the clavicle and implications for regional anesthesia. It begins by outlining the concept of periosteum innervation and then details the specific nerves that innervate the clavicle, including the supraclavicular nerves, subclavicular nerve, lateral pectoral nerve, suprascapular nerve, trapezius branch of the cervical plexus, and spinal accessory nerve. It concludes by discussing selective nerve block techniques that are best for anesthesia of different parts of the clavicle based on the innervation patterns.
This document presents a case report of an elderly female patient who presented with acute right iliac fossa pain due to an incarcerated Spigelian hernia. Ultrasound confirmed the diagnosis of a Spigelian hernia containing fluid and intestine in the sac. The patient underwent emergency open surgery which found a 3cm defect lateral to the rectus muscle containing necrotic omentum and adherent small bowel loops. The necrotic tissue was excised and the defect was closed with sutures. Spigelian hernias are rare abdominal wall hernias that can be diagnosed preoperatively using ultrasound or CT scan to help prevent complications from incarceration.
This document discusses caudal anesthesia in pediatric surgery. It covers the history of caudal anesthesia, indications, contraindications, techniques, and dosing. Specifically, it describes:
- The history of caudal anesthesia dates back to the early 1900s, and it is now widely used in pediatric patients.
- Indications for caudal anesthesia include patients at risk for malignant hyperthermia or respiratory complications, as well as surgery involving the lower abdomen, genitourinary system, or lower extremities.
- Techniques discussed include single-shot caudal injection and continuous caudal infusion. Proper patient positioning, aseptic technique, and sedation are emphasized.
- Dosing depends on
The study tested the hypothesis that fever is suppressed by intravenous opioids but not by epidural analgesia. Researchers induced fever in volunteers using interleukin-2 and studied the effects of intravenous fentanyl, epidural ropivacaine alone or with fentanyl. They found that intravenous fentanyl significantly reduced fever, decreasing core temperature and the frequency of temperatures over 38°C, while epidural analgesia did not inhibit fever. This supports the idea that fever appears normal with epidural analgesia because opioids do not suppress it, unlike in control patients where opioids are used for pain relief.
1) The document discusses the development of the fetal pain pathway and whether the fetus can feel pain from invasive procedures.
2) It notes that the necessary neuroanatomical structures for pain perception, like intact thalamocortical connections, do not develop until 26 weeks of gestation.
3) While the fetus reacts to stimuli through stress responses, there is no evidence these reactions involve conscious awareness or feeling of pain. However, providing fetal analgesia can reduce the stress response caused by invasive procedures.
Incidence of self limiting back pain in childrenRicardo Guerra
1. The study prospectively examined the incidence of back pain in 135 pediatric patients following caudal blockade.
2. The incidence of back pain or related symptoms was 4.7% on postoperative day 2 and 1.1% on postoperative day 15.
3. The back pain reported was generally mild and self-limiting, providing evidence that transient back pain can occur after caudal blockade in children.
Incidence of self limiting back pain in childrenRicardo Guerra
1. The study examined the incidence of back pain in children following caudal blockade for postoperative analgesia.
2. The incidence of back pain or pain/discomfort at the injection site was 4.7% on postoperative day 2 and 1.1% on postoperative day 15.
3. The results provide evidence that transient self-limiting back pain can occur after caudal blockade in pediatric patients.
Bettina Smallman is an Associate Professor of Anesthesiology at SUNY Upstate Medical University. She received her medical degree from Albert Ludwig Universität in Germany and completed her residency and fellowship in pediatric anesthesia in Canada. Her curriculum vitae details her extensive experience teaching residents and students, publishing research, and securing grants for pediatric patients.
This randomized, double-blind study compared remifentanil and diazepam for fetal immobilization and maternal sedation during fetoscopic surgery. The study found that remifentanil produced better fetal immobilization with mild maternal respiratory depression, allowing for shorter surgeries, while diazepam resulted in greater maternal sedation but less fetal immobilization and longer surgeries. Remifentanil may thus be superior to diazepam for fetal immobilization during fetoscopic procedures.
The document discusses noninvasive ventilation (NIV) in pediatrics. It notes that while NIV use has increased, pediatric data is limited compared to adults and neonates. There are significant challenges to pediatric NIV including a wide range of patient sizes, limited technology designed for small children, and interface issues. However, NIV may help avoid intubation and mechanical ventilation in situations like respiratory failure, airway obstruction, and neuromuscular weakness. Further research and improved pediatric-specific technology are still needed.
This document summarizes the pharmacologic management protocol for status asthmaticus in children developed at Children's Orthopedic Hospital and Medical Center in Seattle. The protocol involves initial evaluation, initial therapy including intravenous fluids, electrolytes, buffers, aminophylline, corticosteroids and antibiotics if indicated, followed by ongoing evaluation and treatment including adjusting medications and considering assisted ventilation for severe cases. The protocol has been used to successfully treat over 500 children with no fatalities.
Anesthesia for tracheoesophageal fistulaHazem Sharaf
Anesthesia is required for repair of tracheo-esophageal fistula (TEF) in a newborn infant. The infant requires careful preoperative evaluation and stabilization. During surgery, maintaining adequate ventilation and oxygenation while minimizing airway pressures is crucial due to the risk of gastric insufflation and aspiration. Postoperative ventilation may be needed for several days due to lung issues and the repaired tracheal wall. Careful anesthetic management is needed for a successful outcome in this high-risk surgery.
EMGuideWire's Radiology Reading Room on Pediatric Adult Aortic CoarctationSean M. Fox
The Department of Emergency Medicine at Carolinas Medical Center is passionate about education! Dr. Michael Gibbs is a world-renowned clinician and educator and has helped guide numerous young clinicians on the long path of Mastery of Emergency Medical Care. With his oversight, the EMGuideWire team aim to help augment our understanding of emergent imaging. You can follow along with the EMGuideWire.com team as they post these monthly educational, self-guided radiology slides or you can also use this section to learn more in-depth about specific conditions and diseases. This Radiology Reading Room pertains to Pediatric and Adult Aortic Coarctation and is brought to you by Jennifer Potter, MD and Elizabeth Olson, MD.
- An 81-year-old man was admitted due to a 6-month history of dysphagia, regurgitation, and vomiting during meals. Upper endoscopy and radiographs revealed an abnormal corkscrew appearance of the esophagus. Manometry confirmed an alternative form of abnormal peristalsis.
- A 17-year-old boy sustained an avulsion injury to his right pinky finger after his ring caught on a fence he was jumping over. The finger was amputated through the distal joint and the flexor digitorum profundus tendon was completely pulled out.
- The document describes several medical cases illustrated by images from clinical journals, including abnormalities found during examinations, patient
The document discusses sepsis and septic shock. It defines sepsis as a complex syndrome that develops due to an amplified and dysregulated host response to infection. Septic shock is presented as a form of shock that is a combination of distributive, cardiogenic and hypovolemic shock. Early diagnosis of septic shock requires a high index of suspicion and can be recognized through signs of altered perfusion before hypotension occurs. The document outlines treatments for septic shock including rapid fluid resuscitation and vasopressor support.
Spine surgeries present diverse challenges to anaesthetists. The document outlines considerations for anaesthesia including preoperative evaluation and optimization, induction and intubation while maintaining spine stability, positioning prone or sitting, intraoperative monitoring, maintenance with stable anaesthetic depth and blood pressure, transfusion management for blood loss, emergence and extubation when fully awake, postoperative analgesia, and complications prevention and management. Skillful anaesthetic management is key to optimal patient outcomes for various spine procedures.
Tratamiento de lesiones preinvasoras DE CERVIXIMSS
This document discusses the management of preinvasive cervical lesions. It notes that treatment selection will depend on many factors, principally the patient and treating physician. While no treatment is 100% effective, the goal is to remove the entire transformed area based on a balance of risk and benefit, with patient information central. Expectant management may be appropriate for NIC1 lesions confirmed by biopsy, with HPV testing and cytology follow up.
Drs. Rossi and Shreve’s CMC Abdominal Imaging Mastery Project: February CasesSean M. Fox
Dr. Brian Shreve is an Emergency Medicine Resident and Dr. Isolina Rossi is a Surgery Resident at Carolinas Medical Center in Charlotte, NC. They are interested in medical education. With the guidance of Drs. Kyle Cunningham and Michael Gibbs, they aim to help augment our understanding of emergent abdominal imaging. Follow along with the EMGuideWire.com team as they post these monthly educational, self-guided radiology slides on:
• Intrauterine Pregnancy and Trauma
• Ruptured hemorrhagic cyst
• Ovarian teratoma
• Pelvic Inflammatory Disease
The document discusses various reasons for failed spinal anesthesia, including:
- Equipment failures during early experiments with spinal anesthesia that led to leakage of the cocaine solution.
- The wide variation in how cocaine solutions dispersed among patients, referred to as "capriciousness", contributed to inconsistent results.
- Factors like an inexperienced operator, patient characteristics like obesity, and acute medical conditions can increase risks of failure.
- Repeated puncture attempts, lack of adjuvant medication, and patient age over 70 were found to be independent risk factors for failure in one study.
This document discusses the innervation of the clavicle and implications for regional anesthesia. It begins by outlining the concept of periosteum innervation and then details the specific nerves that innervate the clavicle, including the supraclavicular nerves, subclavicular nerve, lateral pectoral nerve, suprascapular nerve, trapezius branch of the cervical plexus, and spinal accessory nerve. It concludes by discussing selective nerve block techniques that are best for anesthesia of different parts of the clavicle based on the innervation patterns.
This document presents a case report of an elderly female patient who presented with acute right iliac fossa pain due to an incarcerated Spigelian hernia. Ultrasound confirmed the diagnosis of a Spigelian hernia containing fluid and intestine in the sac. The patient underwent emergency open surgery which found a 3cm defect lateral to the rectus muscle containing necrotic omentum and adherent small bowel loops. The necrotic tissue was excised and the defect was closed with sutures. Spigelian hernias are rare abdominal wall hernias that can be diagnosed preoperatively using ultrasound or CT scan to help prevent complications from incarceration.
This document discusses caudal anesthesia in pediatric surgery. It covers the history of caudal anesthesia, indications, contraindications, techniques, and dosing. Specifically, it describes:
- The history of caudal anesthesia dates back to the early 1900s, and it is now widely used in pediatric patients.
- Indications for caudal anesthesia include patients at risk for malignant hyperthermia or respiratory complications, as well as surgery involving the lower abdomen, genitourinary system, or lower extremities.
- Techniques discussed include single-shot caudal injection and continuous caudal infusion. Proper patient positioning, aseptic technique, and sedation are emphasized.
- Dosing depends on
The study tested the hypothesis that fever is suppressed by intravenous opioids but not by epidural analgesia. Researchers induced fever in volunteers using interleukin-2 and studied the effects of intravenous fentanyl, epidural ropivacaine alone or with fentanyl. They found that intravenous fentanyl significantly reduced fever, decreasing core temperature and the frequency of temperatures over 38°C, while epidural analgesia did not inhibit fever. This supports the idea that fever appears normal with epidural analgesia because opioids do not suppress it, unlike in control patients where opioids are used for pain relief.
1) The document discusses the development of the fetal pain pathway and whether the fetus can feel pain from invasive procedures.
2) It notes that the necessary neuroanatomical structures for pain perception, like intact thalamocortical connections, do not develop until 26 weeks of gestation.
3) While the fetus reacts to stimuli through stress responses, there is no evidence these reactions involve conscious awareness or feeling of pain. However, providing fetal analgesia can reduce the stress response caused by invasive procedures.
Incidence of self limiting back pain in childrenRicardo Guerra
1. The study prospectively examined the incidence of back pain in 135 pediatric patients following caudal blockade.
2. The incidence of back pain or related symptoms was 4.7% on postoperative day 2 and 1.1% on postoperative day 15.
3. The back pain reported was generally mild and self-limiting, providing evidence that transient back pain can occur after caudal blockade in children.
Incidence of self limiting back pain in childrenRicardo Guerra
1. The study examined the incidence of back pain in children following caudal blockade for postoperative analgesia.
2. The incidence of back pain or pain/discomfort at the injection site was 4.7% on postoperative day 2 and 1.1% on postoperative day 15.
3. The results provide evidence that transient self-limiting back pain can occur after caudal blockade in pediatric patients.
Bettina Smallman is an Associate Professor of Anesthesiology at SUNY Upstate Medical University. She received her medical degree from Albert Ludwig Universität in Germany and completed her residency and fellowship in pediatric anesthesia in Canada. Her curriculum vitae details her extensive experience teaching residents and students, publishing research, and securing grants for pediatric patients.
This randomized, double-blind study compared remifentanil and diazepam for fetal immobilization and maternal sedation during fetoscopic surgery. The study found that remifentanil produced better fetal immobilization with mild maternal respiratory depression, allowing for shorter surgeries, while diazepam resulted in greater maternal sedation but less fetal immobilization and longer surgeries. Remifentanil may thus be superior to diazepam for fetal immobilization during fetoscopic procedures.
The document discusses noninvasive ventilation (NIV) in pediatrics. It notes that while NIV use has increased, pediatric data is limited compared to adults and neonates. There are significant challenges to pediatric NIV including a wide range of patient sizes, limited technology designed for small children, and interface issues. However, NIV may help avoid intubation and mechanical ventilation in situations like respiratory failure, airway obstruction, and neuromuscular weakness. Further research and improved pediatric-specific technology are still needed.
This document summarizes the pharmacologic management protocol for status asthmaticus in children developed at Children's Orthopedic Hospital and Medical Center in Seattle. The protocol involves initial evaluation, initial therapy including intravenous fluids, electrolytes, buffers, aminophylline, corticosteroids and antibiotics if indicated, followed by ongoing evaluation and treatment including adjusting medications and considering assisted ventilation for severe cases. The protocol has been used to successfully treat over 500 children with no fatalities.
Anesthesia for tracheoesophageal fistulaHazem Sharaf
Anesthesia is required for repair of tracheo-esophageal fistula (TEF) in a newborn infant. The infant requires careful preoperative evaluation and stabilization. During surgery, maintaining adequate ventilation and oxygenation while minimizing airway pressures is crucial due to the risk of gastric insufflation and aspiration. Postoperative ventilation may be needed for several days due to lung issues and the repaired tracheal wall. Careful anesthetic management is needed for a successful outcome in this high-risk surgery.
This document discusses 3 common myths about fetal pain and the use of fetal analgesia during procedures:
1) That fetuses do not feel pain or remember pain. However, research shows fetuses may feel pain as early as 20 weeks and have stress responses to invasive procedures.
2) That fetal analgesia is not possible or safe and there is no data to support it. Some studies have shown fetal analgesia is possible and safe in short term use and reduces stress responses.
3) That maternal analgesia is sufficient to cover fetal pain needs. However, not all maternal analgesia crosses the placenta and individual variation exists, so direct fetal analgesia should be considered.
The document argues
This document discusses fetal pain and the development of the human brain prior to birth. It summarizes that the human brain is more developed than once thought by around 2 months before birth, comparable to a newborn macaque. Neurons in the subplate zone of the fetal brain form functional networks and influence cortical development. While cortical neurons were once thought necessary for conscious pain perception, immaturity alone does not preclude fetal pain, as subcortical structures are also involved in consciousness.
A neonate presented with moaning cry and bluish skin at birth. Prenatally, fetal echocardiography showed bradycardia but no structural heart abnormalities. Postnatally, the neonate was found to have a heart rate of 48 bpm, low oxygen saturation, and cyanosis. Electrocardiography confirmed complete atrioventricular block. A permanent pacemaker was implanted in the first week with good results shown on pacing system analyzer. The rare condition of congenital complete heart block was diagnosed and treated with pacing, though regular follow ups were still needed due to risk of future left ventricular dysfunction.
Efectos fetales de la anestesia espinal maternaAnestesia Dolor
1. Spinal anesthesia is commonly used for cesarean sections due to advantages for the mother such as remaining awake for the birth and facilitating post-op pain relief. However, hypotension is a common side effect that can pose risks to both mother and baby if severe or prolonged.
2. The review found that no single method completely prevents hypotension during spinal anesthesia for c-section but the risk can be reduced through IV fluids, vasopressors like ephedrine or phenylephrine, and leg compression. Even minor hypotension may cause issues for the baby like transient carbon dioxide retention.
3. Fetal oxygenation is dependent on several factors like placental function, uterine and umbilical blood
This document provides an introduction to obstetric anesthesia. It discusses how the anesthetist is responsible for maintaining the physiology of both the mother and fetus during childbirth. The anesthetist must understand and account for alterations in the mother's physiology, anatomy, and pharmacology that occur during pregnancy and delivery. This includes changes to organ function, muscle tone, circulation, respiration and more. Providing anesthesia for childbirth also carries certain risks that the anesthetist must be prepared for, such as potential complications related to the dual physiology of mother and fetus. Effective communication with obstetricians is important to achieve the best outcomes.
This document discusses the approach of a pediatrician to a newborn with anorectal malformation (ARM). It describes the pediatrician's role in diagnosis, initial stabilization, and referral to a pediatric surgeon. It provides details on clinical examination findings for ARM in males and females. It also discusses associated malformations, initial management including antibiotics and fluids, and investigations like invertogram to classify the ARM.
A Comparative Study between Caudal Bupivacaine (0.25%) And Caudal Bupivacaine...iosrjce
IOSR Journal of Dental and Medical Sciences is one of the speciality Journal in Dental Science and Medical Science published by International Organization of Scientific Research (IOSR). The Journal publishes papers of the highest scientific merit and widest possible scope work in all areas related to medical and dental science. The Journal welcome review articles, leading medical and clinical research articles, technical notes, case reports and others.
7. ANESTESIA CAUDAL EN CIRUGIA PEDIATRICA
• HISTORIA
• INDICACIONES
• TECNICA EMPLEADA
8. ANESTESIA CAUDAL EN CIRUGIA PEDIATRICA
• HISTORIA
• INDICACIONES
• TECNICA EMPLEADA
• DOSIS EMPLEADA
9. ANESTESIA CAUDAL EN CIRUGIA PEDIATRICA
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.
10.
11.
12. 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.
13. 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.
14. CONTACTO PRECOZ CON SUS
PADRES DISMINUYE TRAUMA
PSICOLOGICO.
POSIBILIDAD DE COLOCAR UN
CATETER EPIDURAL PARA
PROLONGAR EL EFECTO
ANALGESICO.
15. BLOQUEO CAUDAL EN PEDIATRIA
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.
16. BLOQUEO CAUDAL EN PEDIATRIA
CONTRAINDICACIONES
Se consideran como contraindicaciones absolutas:
1. Falta de consentimiento paterno.
2. Infección en el sitio de la inyección.
3. Coagulopatía.
17. BLOQUEO CAUDAL EN PEDIATRIA
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
18. BLOQUEO CAUDAL EN PEDIATRIA
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.
19. TIPOS DE BLOQUEO CAUDAL
BLOQUEO CAUDAL DE INYECCION UNICA
BLOQUEO CAUDAL CONTINUO
20. 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.
31. BLOQUEO CAUDAL EN PEDIATRIA
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.
32. 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
33. 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 Segmental distribution of high-volume caudal anesthesia
ultrasound guided single shot epidural anaesthesia – a concentration (ED50) of levobupivacaine for caudal block in neonates, infants, and toddlers as assessed by
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
34. 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
35. BLOQUEO CAUDAL EN PEDIATRIA
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
36. BLOQUEO CAUDAL EN PEDIATRIA
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.
37. BLOQUEO CAUDAL EN PEDIATRIA
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
38. BLOQUEO CAUDAL EN PEDIATRIA
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...