This document summarizes a workshop on epidural management techniques in pediatric patients. It discusses the use of caudal epidural blockade, which involves accessing the epidural space through the sacrococcygeal ligament. Caudal blockade is commonly used and provides analgesia to mid-thoracic levels with volumes of 1.3-1.5 mL/kg. Controversy around needle type is discussed. Local anesthetics like bupivacaine provide 60-120 minutes of surgical anesthesia when used in 0.2-0.25% concentrations. Awake caudal blockade is sometimes used in high-risk infants to avoid general anesthesia. Chloroprocaine continuous infusion can provide anesthesia for 2-3
This document provides information on cervical epidural anesthesia. It discusses the history and uses of cervical epidural, including for bilateral upper limb surgery, mastectomy, thyroid surgery, and chronic pain management. Risks like spinal cord injury and neurological complications are addressed. Techniques to increase safety are covered, such as using fluoroscopy, avoiding levels above C6-7, and low injection volumes. Drugs commonly used include ropivacaine, lidocaine, and bupivacaine. Overall, the document outlines the applications and techniques of cervical epidural anesthesia while also discussing risks and safety considerations.
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 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.
A review of pediatric regional anesthesia practiceAlvarez Gilmer
1) The use of regional anesthesia (RA) in pediatric patients at a single institution increased dramatically from 1989 to 2005, rising from 9.3% to 24.9% of all anesthetics.
2) There was a significant shift from neuraxial blocks (spinals, caudals, epidurals) to peripheral nerve blocks, with peripheral blocks now accounting for over 75% of RA in older pediatric patients (5 years and older).
3) The placement of perineural catheters to provide continuous postoperative analgesia increased in the last 5 years, being used in 12.9% of peripheral nerve blocks by 2005.
DR deepak chahar polpiteal cyst arthroscopyDeepak Chahar
This document summarizes a study on the arthroscopic management of popliteal cysts. The study retrospectively analyzed 12 patients who underwent arthroscopic decompression of popliteal cysts along with treatment of associated intra-articular knee pathologies. At 24 months post-surgery, 6 patients had complete resolution of symptoms while 5 had minor limitations; 1 patient did not improve. The study concludes that an arthroscopic approach allows for effective decompression of popliteal cysts while simultaneously addressing underlying knee issues like meniscal tears or cartilage damage. This leads to good clinical outcomes with minimal complications.
This document discusses failed spinal anesthesia. It defines failure as the surgery not being able to be performed under spinal anesthesia alone and needing general anesthesia. Failure rates are reported between 3-17% and up to 30% for trainees. Causes of failure include improper patient positioning, difficult lumbar puncture, issues with needle or drug placement, and anatomical abnormalities. Management depends on the extent of failure and includes repeating the spinal, using a lower dose, or switching to general anesthesia. Repeating spinal anesthesia carries risks and general anesthesia is preferable in some situations like emergency surgery. Proper technique is important to prevent failure.
The document discusses cricoid pressure, which was first described in 1774 and popularized in 1961 as a way to prevent regurgitation during anesthesia induction. It examines the controversies around cricoid pressure, including whether it truly occludes the esophagus, causes airway problems, and reduces regurgitation. While early studies on cadavers seemed to validate it, more recent reviews find little evidence that it is effective or that not using it increases risk. Proper application is also inconsistent. The risks and benefits must be weighed for each patient, and strategies may need to change during difficult intubations to prioritize ventilation and gas exchange over cricoid pressure.
This document provides information on cervical epidural anesthesia. It discusses the history and uses of cervical epidural, including for bilateral upper limb surgery, mastectomy, thyroid surgery, and chronic pain management. Risks like spinal cord injury and neurological complications are addressed. Techniques to increase safety are covered, such as using fluoroscopy, avoiding levels above C6-7, and low injection volumes. Drugs commonly used include ropivacaine, lidocaine, and bupivacaine. Overall, the document outlines the applications and techniques of cervical epidural anesthesia while also discussing risks and safety considerations.
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 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.
A review of pediatric regional anesthesia practiceAlvarez Gilmer
1) The use of regional anesthesia (RA) in pediatric patients at a single institution increased dramatically from 1989 to 2005, rising from 9.3% to 24.9% of all anesthetics.
2) There was a significant shift from neuraxial blocks (spinals, caudals, epidurals) to peripheral nerve blocks, with peripheral blocks now accounting for over 75% of RA in older pediatric patients (5 years and older).
3) The placement of perineural catheters to provide continuous postoperative analgesia increased in the last 5 years, being used in 12.9% of peripheral nerve blocks by 2005.
DR deepak chahar polpiteal cyst arthroscopyDeepak Chahar
This document summarizes a study on the arthroscopic management of popliteal cysts. The study retrospectively analyzed 12 patients who underwent arthroscopic decompression of popliteal cysts along with treatment of associated intra-articular knee pathologies. At 24 months post-surgery, 6 patients had complete resolution of symptoms while 5 had minor limitations; 1 patient did not improve. The study concludes that an arthroscopic approach allows for effective decompression of popliteal cysts while simultaneously addressing underlying knee issues like meniscal tears or cartilage damage. This leads to good clinical outcomes with minimal complications.
This document discusses failed spinal anesthesia. It defines failure as the surgery not being able to be performed under spinal anesthesia alone and needing general anesthesia. Failure rates are reported between 3-17% and up to 30% for trainees. Causes of failure include improper patient positioning, difficult lumbar puncture, issues with needle or drug placement, and anatomical abnormalities. Management depends on the extent of failure and includes repeating the spinal, using a lower dose, or switching to general anesthesia. Repeating spinal anesthesia carries risks and general anesthesia is preferable in some situations like emergency surgery. Proper technique is important to prevent failure.
The document discusses cricoid pressure, which was first described in 1774 and popularized in 1961 as a way to prevent regurgitation during anesthesia induction. It examines the controversies around cricoid pressure, including whether it truly occludes the esophagus, causes airway problems, and reduces regurgitation. While early studies on cadavers seemed to validate it, more recent reviews find little evidence that it is effective or that not using it increases risk. Proper application is also inconsistent. The risks and benefits must be weighed for each patient, and strategies may need to change during difficult intubations to prioritize ventilation and gas exchange over cricoid pressure.
Maxillofacial trauma requires aggressive airway management and preliminary care. The document outlines the steps for preliminary care which include:
1) Initial assessment of the patient using ABCDE to evaluate airway, breathing, circulation, disability and exposure.
2) Securing the airway through basic maneuvers like jaw thrust or advanced techniques like endotracheal intubation if needed.
3) Assessing breathing and managing thoracic injuries.
4) Controlling hemorrhage through circulation management and fluid resuscitation to restore perfusion.
5) Conducting a full secondary survey to identify all injuries.
A Prospective comparative study of Local anaesthesia & Spinal anaesthesia for...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.
Decompressive craniectomy is a surgical procedure where part of the skull is removed to relieve pressure on the brain from swelling after severe traumatic brain injury. There are various techniques for decompressive craniectomy including size and location of bone flap removed and methods for opening and repairing the dura mater. Key goals are to provide space for brain swelling, improve blood flow, and reduce pressure while preventing complications like brain herniation. The author discusses their experience with standard large frontotemporoparietal decompressive craniectomy and considerations for optimal decompression balancing risks.
The document summarizes a study that investigated whether adding hyaluronidase to ropivacaine reduces the time to achieve complete sensory block after axillary brachial plexus block. Patients were randomly assigned to receive ropivacaine with or without hyaluronidase. The study found that the group receiving ropivacaine with hyaluronidase had a significantly shorter mean time to achieve complete sensory block, sensory block onset time, and time to reach surgical anesthesia compared to the control group receiving ropivacaine alone. Addition of hyaluronidase to ropivacaine resulted in faster blockade times for axillary brachial plexus blocks.
Spinal epidural injections are a common minimally invasive procedure used to treat low back and leg pain. The document discusses the various techniques, drugs, and considerations for epidural injections. It finds that transforaminal injections may be more effective than interlaminar or caudal injections at delivering drugs closer to the site of pathology. Complications are usually minor but can include headache, hypotension, or nerve injury. Epidural injections provide short-term pain relief, especially for herniated discs, with varying effectiveness depending on the underlying cause and number of injections.
This document provides guidance for a practical class on anesthesia for trauma patients. It begins with an overview of the importance of trauma anesthesia and discusses the initial assessment of trauma patients through a primary survey examining airway, breathing, circulation, disability and exposure. It provides details on establishing the airway for trauma patients while protecting the cervical spine, and assessing breathing and circulation. The document outlines the contents to be covered in the practical class, including anesthesia considerations for different types of trauma injuries.
This study compared outcomes of fasciocutaneous flaps versus biplanar (muscle and fasciocutaneous) flaps for reconstructing pressure ulcers in 90 immobile patients with spinal cord injuries. The biplanar flap group had a significantly lower wound recurrence rate of 25% compared to 53% for the fasciocutaneous flap group. Both groups had similar follow-up times and times to recurrence. While postoperative complications like infection were similar, the addition of muscle flaps in biplanar reconstruction significantly reduced recurrence of pressure ulcers in this high-risk patient population.
More harm than benefit of perioperative dexamethasone on recovery following ...Dibya Falgoon Sarkar
1. A prospective double-blind randomized trial found that perioperative dexamethasone provided minor pain relief but significantly increased insulin requirements and risk of infections in patients undergoing reconstructive head and neck cancer surgery.
2. Dexamethasone did not accelerate recovery or shorten hospital stay and its use in head and neck cancer reconstruction provided no clear clinical benefits while increasing complications.
3. A randomized controlled trial of corticosteroids after transoral robotic surgery found extended perioperative dexamethasone was safe and may allow for earlier improvement in diet consistency and decreased hospital stay, though it minimally affected postoperative pain.
1) A bomb attack in Brussels in 2016 killed 32 people and injured 300 through the use of acetone/peroxide explosive devices in the airport and a train station.
2) Blast injuries are classified as primary (caused directly by the blast wave), secondary (caused by flying debris and shrapnel), tertiary (caused by victim being thrown by the blast), or quaternary (all other injuries).
3) While myths exist about blast injuries overwhelming hospitals and causing many amputations, in reality penetrating injuries from flying debris are most common in survivors and usually do not require extensive surgery. Management follows conventional trauma principles.
Le degré de relâchement musculaire en chirurgie coelioscopique de la vésicule biliaire fait partie du quotidien des discussions entre anesthésistes et chirurgiens au bloc opératoire. Au fond tous sont convaincus de l'efficacité du curare : le chirurgien qui le demande et l'anesthésiste qui pense lui à sa décurarisation.
Cette étude teste curarisation profonde versus curarisation de routine dans la chirurgie coelioscopique de la vésicule biliaire. Avec comme première question "est-ce qu'une curarisation profonde permet de travaillert avec une pression abdominable moindre?", pression dont on sait qu'elle est pourvoyeuse de douleur post-opératoire.
La réponse est que le degré de curarisation participe de façon marginale au confort du chirurgien... et ne permet pas plus fréquemment de travailler à pression abdominale basse.
Post-Thyroidectomy Laryngeal Diplegia in Mali: What Therapeutic Challenge? by Kone Fatogoma Issa in Experiments in Rhinology & Otolaryngology
Post-thyroidectomy laryngeal diplegia is the most common and most feared complication [1]. It occurs following a recurrent nerve lesion in 26 to 59% of cases [1,2]. Tracheotomy was considered until 1922 as the only reference treatment [3,4]. Therapeutic approaches have evolved over time, ranging from convention altranslaryngeal or extralaryngeal therapy to endoscopic laser approaches [5]. These endoscopic methods emphasized endoscopicary tenoidectomy and posterior transverse cordotomy [4,6]. Laser transverse posterior cordotomy has proved its efficacy, illustrated by the work of Denis and Kashima and Laccoureye & Merite Drancy [4,7].
This document summarizes the experience with hypospadias repair at a single medical center in Pakistan between 2007-2011. It found that two-stage Bracka repair was the most common procedure (76.2% of cases) due to a relative lack of expertise in single-stage repairs. Post-operative complications included fistula formation (26.6%), edema (28.3%), and infection (4.2%). Fistula rates were higher for residents compared to specialists (33.1% vs 23.3%) and for two-stage versus single-stage repairs (66.9% vs 44.1%). The document recommends increasing expertise in single-stage repairs, revising guidelines to narrow the criteria for
The document provides an overview of the history and types of surgery. It discusses surgery from ancient times, where procedures like trephining date back thousands of years. Modern surgery advanced with discoveries like anesthesia in the 1800s and antisepsis in the late 1800s, allowing for more complex surgeries. Surgery is classified based on urgency (elective, urgent, emergency), risk level (minor vs major), and purpose (diagnostic, ablative, reconstructive, etc.). The prerequisites for surgery include assessing indication, operability, and surgical risk.
Laparoscopically assisted high ligation of patent processus vaginalis in children was evaluated in this study. The procedure was found to be a safe and effective day procedure for repairing inguinal hernias in children. It allowed for detection of contralateral hernias in 28% of cases without increasing operative time. Outcomes included a low recurrence rate of 2.5% and mean hospital stay of 4 hours. The technique of piecemeal ligation of the patent processus vaginalis externally was found to be simple with no need for additional ports or special instruments.
This study evaluated the efficacy of laparoscopically assisted high ligation of patent processus vaginalis in 40 children aged 6 months to 7 years. The laparoscopic procedure detected unsuspected contralateral hernias in 28.1% of cases, without increasing operative time. All procedures were completed without complications. The mean operative time was 25 minutes for unilateral hernias and 35 minutes for bilateral cases. The mean post-operative hospital stay was 4 hours. One recurrence occurred among 57 hernias repaired over an average 18-month follow-up. Laparoscopic repair was found to be a safe and effective procedure for detecting and repairing hernias in children.
This case report describes the successful use of a continuous interscalene brachial plexus block as the primary anesthetic for open reduction and internal fixation of a left supracondylar humerus fracture in a 16-year old female patient. A total of 40 ml of local anesthetic was administered to establish the block, which provided surgical anesthesia for the 120 minute procedure and was continued post-operatively with intermittent doses of bupivacaine for extended pain control. The case demonstrates that a continuous interscalene block can effectively extend the duration of anesthesia and analgesia for upper extremity surgery.
Surgical approaches for condylar fractures related to facial nerve injury: de...Dibya Falgoon Sarkar
This study compared different percutaneous surgical approaches for treating condylar fractures to determine their relationship to facial nerve injury (FNI). The study found that approaches involving deep dissection beneath the marginal mandibular nerve branch (submandibular and retroparotid approaches) and the presence of a dislocated fracture were significantly associated with higher risks of FNI. In contrast, approaches involving more superficial dissection above the marginal mandibular nerve branch (transparotid, transmasseteric anteroparotid, high cervical transmasseteric anteroparotid approaches) had lower risks of FNI. The study concluded that superficial group approaches should be recommended to minimize the risk of F
In older patients, glenohumeral osteoarthritis can be treated with total shoulder arthroplasty with excellent results. In younger active patients with glenohumeral osteoarthritis, total shoulder arthroplasty yields inferior long-term results and high rates of early glenoid component failure as well as concerns about bone stock for future revision procedures. Multiple potential etiologies can lead to this condition in the young patient, and diagnosis may be challenging. When nonsurgical treatment fails, surgical management of glenohumeral osteoarthritis in this younger patient population emphasizes non-arthroplasty options and can be divided into palliative, reparative, restorative, and reconstructive techniques. Management depends on multiple factors including presence or absence of bipolar disease or diffuse chondrolysis, patient age and activity, and concomitant shoulder pathology. This exhibit will review the diagnosis and management of glenohumeral osteoarthritis in young patients to provide a framework for clinical decision-making in these challenging cases.
Who 2009-dengue-guidelines-for-diagnosis-treatment-prevention-controlMunir Mughal
This document provides guidelines for the diagnosis, treatment, prevention and control of dengue. It begins with an introduction and sections on methodology, acknowledgements and abbreviations. The contents section outlines that the document contains 6 chapters which cover: 1) epidemiology, burden of disease and transmission; 2) clinical management and delivery of clinical services; 3) vector management and delivery of vector control services; 4) laboratory diagnosis and diagnostic tests; 5) surveillance, emergency preparedness and response; and 6) new avenues including dengue vaccines and antiviral drugs. The preface notes that this new edition aims to make information widely available to health practitioners and others involved in dengue prevention and control, and provides concise and up-to
Maxillofacial trauma requires aggressive airway management and preliminary care. The document outlines the steps for preliminary care which include:
1) Initial assessment of the patient using ABCDE to evaluate airway, breathing, circulation, disability and exposure.
2) Securing the airway through basic maneuvers like jaw thrust or advanced techniques like endotracheal intubation if needed.
3) Assessing breathing and managing thoracic injuries.
4) Controlling hemorrhage through circulation management and fluid resuscitation to restore perfusion.
5) Conducting a full secondary survey to identify all injuries.
A Prospective comparative study of Local anaesthesia & Spinal anaesthesia for...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.
Decompressive craniectomy is a surgical procedure where part of the skull is removed to relieve pressure on the brain from swelling after severe traumatic brain injury. There are various techniques for decompressive craniectomy including size and location of bone flap removed and methods for opening and repairing the dura mater. Key goals are to provide space for brain swelling, improve blood flow, and reduce pressure while preventing complications like brain herniation. The author discusses their experience with standard large frontotemporoparietal decompressive craniectomy and considerations for optimal decompression balancing risks.
The document summarizes a study that investigated whether adding hyaluronidase to ropivacaine reduces the time to achieve complete sensory block after axillary brachial plexus block. Patients were randomly assigned to receive ropivacaine with or without hyaluronidase. The study found that the group receiving ropivacaine with hyaluronidase had a significantly shorter mean time to achieve complete sensory block, sensory block onset time, and time to reach surgical anesthesia compared to the control group receiving ropivacaine alone. Addition of hyaluronidase to ropivacaine resulted in faster blockade times for axillary brachial plexus blocks.
Spinal epidural injections are a common minimally invasive procedure used to treat low back and leg pain. The document discusses the various techniques, drugs, and considerations for epidural injections. It finds that transforaminal injections may be more effective than interlaminar or caudal injections at delivering drugs closer to the site of pathology. Complications are usually minor but can include headache, hypotension, or nerve injury. Epidural injections provide short-term pain relief, especially for herniated discs, with varying effectiveness depending on the underlying cause and number of injections.
This document provides guidance for a practical class on anesthesia for trauma patients. It begins with an overview of the importance of trauma anesthesia and discusses the initial assessment of trauma patients through a primary survey examining airway, breathing, circulation, disability and exposure. It provides details on establishing the airway for trauma patients while protecting the cervical spine, and assessing breathing and circulation. The document outlines the contents to be covered in the practical class, including anesthesia considerations for different types of trauma injuries.
This study compared outcomes of fasciocutaneous flaps versus biplanar (muscle and fasciocutaneous) flaps for reconstructing pressure ulcers in 90 immobile patients with spinal cord injuries. The biplanar flap group had a significantly lower wound recurrence rate of 25% compared to 53% for the fasciocutaneous flap group. Both groups had similar follow-up times and times to recurrence. While postoperative complications like infection were similar, the addition of muscle flaps in biplanar reconstruction significantly reduced recurrence of pressure ulcers in this high-risk patient population.
More harm than benefit of perioperative dexamethasone on recovery following ...Dibya Falgoon Sarkar
1. A prospective double-blind randomized trial found that perioperative dexamethasone provided minor pain relief but significantly increased insulin requirements and risk of infections in patients undergoing reconstructive head and neck cancer surgery.
2. Dexamethasone did not accelerate recovery or shorten hospital stay and its use in head and neck cancer reconstruction provided no clear clinical benefits while increasing complications.
3. A randomized controlled trial of corticosteroids after transoral robotic surgery found extended perioperative dexamethasone was safe and may allow for earlier improvement in diet consistency and decreased hospital stay, though it minimally affected postoperative pain.
1) A bomb attack in Brussels in 2016 killed 32 people and injured 300 through the use of acetone/peroxide explosive devices in the airport and a train station.
2) Blast injuries are classified as primary (caused directly by the blast wave), secondary (caused by flying debris and shrapnel), tertiary (caused by victim being thrown by the blast), or quaternary (all other injuries).
3) While myths exist about blast injuries overwhelming hospitals and causing many amputations, in reality penetrating injuries from flying debris are most common in survivors and usually do not require extensive surgery. Management follows conventional trauma principles.
Le degré de relâchement musculaire en chirurgie coelioscopique de la vésicule biliaire fait partie du quotidien des discussions entre anesthésistes et chirurgiens au bloc opératoire. Au fond tous sont convaincus de l'efficacité du curare : le chirurgien qui le demande et l'anesthésiste qui pense lui à sa décurarisation.
Cette étude teste curarisation profonde versus curarisation de routine dans la chirurgie coelioscopique de la vésicule biliaire. Avec comme première question "est-ce qu'une curarisation profonde permet de travaillert avec une pression abdominable moindre?", pression dont on sait qu'elle est pourvoyeuse de douleur post-opératoire.
La réponse est que le degré de curarisation participe de façon marginale au confort du chirurgien... et ne permet pas plus fréquemment de travailler à pression abdominale basse.
Post-Thyroidectomy Laryngeal Diplegia in Mali: What Therapeutic Challenge? by Kone Fatogoma Issa in Experiments in Rhinology & Otolaryngology
Post-thyroidectomy laryngeal diplegia is the most common and most feared complication [1]. It occurs following a recurrent nerve lesion in 26 to 59% of cases [1,2]. Tracheotomy was considered until 1922 as the only reference treatment [3,4]. Therapeutic approaches have evolved over time, ranging from convention altranslaryngeal or extralaryngeal therapy to endoscopic laser approaches [5]. These endoscopic methods emphasized endoscopicary tenoidectomy and posterior transverse cordotomy [4,6]. Laser transverse posterior cordotomy has proved its efficacy, illustrated by the work of Denis and Kashima and Laccoureye & Merite Drancy [4,7].
This document summarizes the experience with hypospadias repair at a single medical center in Pakistan between 2007-2011. It found that two-stage Bracka repair was the most common procedure (76.2% of cases) due to a relative lack of expertise in single-stage repairs. Post-operative complications included fistula formation (26.6%), edema (28.3%), and infection (4.2%). Fistula rates were higher for residents compared to specialists (33.1% vs 23.3%) and for two-stage versus single-stage repairs (66.9% vs 44.1%). The document recommends increasing expertise in single-stage repairs, revising guidelines to narrow the criteria for
The document provides an overview of the history and types of surgery. It discusses surgery from ancient times, where procedures like trephining date back thousands of years. Modern surgery advanced with discoveries like anesthesia in the 1800s and antisepsis in the late 1800s, allowing for more complex surgeries. Surgery is classified based on urgency (elective, urgent, emergency), risk level (minor vs major), and purpose (diagnostic, ablative, reconstructive, etc.). The prerequisites for surgery include assessing indication, operability, and surgical risk.
Laparoscopically assisted high ligation of patent processus vaginalis in children was evaluated in this study. The procedure was found to be a safe and effective day procedure for repairing inguinal hernias in children. It allowed for detection of contralateral hernias in 28% of cases without increasing operative time. Outcomes included a low recurrence rate of 2.5% and mean hospital stay of 4 hours. The technique of piecemeal ligation of the patent processus vaginalis externally was found to be simple with no need for additional ports or special instruments.
This study evaluated the efficacy of laparoscopically assisted high ligation of patent processus vaginalis in 40 children aged 6 months to 7 years. The laparoscopic procedure detected unsuspected contralateral hernias in 28.1% of cases, without increasing operative time. All procedures were completed without complications. The mean operative time was 25 minutes for unilateral hernias and 35 minutes for bilateral cases. The mean post-operative hospital stay was 4 hours. One recurrence occurred among 57 hernias repaired over an average 18-month follow-up. Laparoscopic repair was found to be a safe and effective procedure for detecting and repairing hernias in children.
This case report describes the successful use of a continuous interscalene brachial plexus block as the primary anesthetic for open reduction and internal fixation of a left supracondylar humerus fracture in a 16-year old female patient. A total of 40 ml of local anesthetic was administered to establish the block, which provided surgical anesthesia for the 120 minute procedure and was continued post-operatively with intermittent doses of bupivacaine for extended pain control. The case demonstrates that a continuous interscalene block can effectively extend the duration of anesthesia and analgesia for upper extremity surgery.
Surgical approaches for condylar fractures related to facial nerve injury: de...Dibya Falgoon Sarkar
This study compared different percutaneous surgical approaches for treating condylar fractures to determine their relationship to facial nerve injury (FNI). The study found that approaches involving deep dissection beneath the marginal mandibular nerve branch (submandibular and retroparotid approaches) and the presence of a dislocated fracture were significantly associated with higher risks of FNI. In contrast, approaches involving more superficial dissection above the marginal mandibular nerve branch (transparotid, transmasseteric anteroparotid, high cervical transmasseteric anteroparotid approaches) had lower risks of FNI. The study concluded that superficial group approaches should be recommended to minimize the risk of F
In older patients, glenohumeral osteoarthritis can be treated with total shoulder arthroplasty with excellent results. In younger active patients with glenohumeral osteoarthritis, total shoulder arthroplasty yields inferior long-term results and high rates of early glenoid component failure as well as concerns about bone stock for future revision procedures. Multiple potential etiologies can lead to this condition in the young patient, and diagnosis may be challenging. When nonsurgical treatment fails, surgical management of glenohumeral osteoarthritis in this younger patient population emphasizes non-arthroplasty options and can be divided into palliative, reparative, restorative, and reconstructive techniques. Management depends on multiple factors including presence or absence of bipolar disease or diffuse chondrolysis, patient age and activity, and concomitant shoulder pathology. This exhibit will review the diagnosis and management of glenohumeral osteoarthritis in young patients to provide a framework for clinical decision-making in these challenging cases.
Who 2009-dengue-guidelines-for-diagnosis-treatment-prevention-controlMunir Mughal
This document provides guidelines for the diagnosis, treatment, prevention and control of dengue. It begins with an introduction and sections on methodology, acknowledgements and abbreviations. The contents section outlines that the document contains 6 chapters which cover: 1) epidemiology, burden of disease and transmission; 2) clinical management and delivery of clinical services; 3) vector management and delivery of vector control services; 4) laboratory diagnosis and diagnostic tests; 5) surveillance, emergency preparedness and response; and 6) new avenues including dengue vaccines and antiviral drugs. The preface notes that this new edition aims to make information widely available to health practitioners and others involved in dengue prevention and control, and provides concise and up-to
This document provides an overview of a case presentation on a 73-year-old male patient admitted to the hospital for bronchial asthma in acute exacerbation. It includes the patient's profile, health history, history of present illness, developmental data based on Erikson, Freud, Havighurst, and Piaget's theories of development, and the scope and limitations of the study. The objective is for nursing students to apply the nursing process and critical thinking skills to provide quality care for the patient.
An immersive workshop at General Assembly, SF. I typically teach this workshop at General Assembly, San Francisco. To see a list of my upcoming classes, visit https://generalassemb.ly/instructors/seth-familian/4813
I also teach this workshop as a private lunch-and-learn or half-day immersive session for corporate clients. To learn more about pricing and availability, please contact me at http://familian1.com
3 Things Every Sales Team Needs to Be Thinking About in 2017Drift
Thinking about your sales team's goals for 2017? Drift's VP of Sales shares 3 things you can do to improve conversion rates and drive more revenue.
Read the full story on the Drift blog here: http://blog.drift.com/sales-team-tips
How to Become a Thought Leader in Your NicheLeslie Samuel
Are bloggers thought leaders? Here are some tips on how you can become one. Provide great value, put awesome content out there on a regular basis, and help others.
Spinal anaesthesia is a viable alternative to general anaesthesia in children. Compared to adults, children require a larger dose of long-acting local anaesthetic like bupivacaine due to higher CSF volume, but the duration of block is shorter, around 1 hour for infants. Adjuvants can prolong the block duration but must be preservative-free. Younger children generally do not experience hypotension from spinal anaesthesia unlike adults. It has been used successfully for procedures like hernia repair and myelomeningocele repair in neonates. The needle design does not significantly impact complications like in adults.
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.
Chylous fistula is a complication of neck surgery where the thoracic duct is damaged, causing a leak of milky white fluid known as chyle. It occurs in 1-3% of major neck surgeries and presents with drainage from the surgical site. Prolonged chyle leaks can cause electrolyte imbalances, malnutrition, and increased risk of infection if not properly managed. Treatment involves initially conservative measures like drainage and a low-fat diet to reduce chyle flow and allow the fistula to close. Surgery to repair the leak may be needed if conservative treatments fail or complications arise. Surgical options include direct repair, thoracic duct ligation or embolization, with the goal of preserving duct
The document discusses the lumbar puncture procedure, which involves inserting a needle into the lumbar subarachnoid space to obtain cerebrospinal fluid samples. It describes the anatomy of the lumbar spine, indications for lumbar puncture including diagnostic testing for conditions like meningitis, contraindications, potential complications, the equipment needed, and steps for performing and monitoring the procedure. Normal cerebrospinal fluid components and values are also outlined.
Anathesia in patients with preeclampsiaphoenix11090
This document discusses anesthesia considerations for cesarean delivery in patients with preeclampsia. It recommends neuraxial anesthesia over general anesthesia to avoid hypertension during induction and emergence. Neuraxial techniques like spinal or epidural are preferred but should be administered cautiously to prevent hypotension. Fluid administration should be conservative and vasopressors like phenylephrine given incrementally. While general anesthesia can be used, steps must minimize the hypertensive response to intubation. Magnesium sulfate therapy should continue during surgery.
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.
This document discusses anesthesia for fetal surgeries and intrauterine procedures. It begins with an introduction to fetal surgeries and guidelines for performing them. It then categorizes fetal surgical interventions and discusses specific fetal conditions treated and interventions used. Some risks and benefits of fetal surgery are outlined. The document then focuses on anesthetic management for various procedures, including effects of anesthesia on the fetus and fetal monitoring. It provides details on anesthesia for minimally invasive procedures, open fetal surgery, and fetal response and analgesia. In summary, it is a comprehensive overview of fetal surgeries, conditions treated, and considerations for anesthetic management.
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 provides information on anaesthesia techniques for Caesarean section, including spinal, epidural and general anaesthesia. It discusses the advantages and disadvantages of each technique as well as complications. Spinal anaesthesia is typically the preferred method due to its quick onset and reliable block. However, epidural top-ups or general anaesthesia may be required in some situations. Proper patient assessment, equipment, staff and planning are essential to reduce risks associated with anaesthesia for Caesarean delivery.
Rapid sequence spinal anesthesia (RSS) is a technique used for urgent cesarean sections that requires effective coordination between medical staff. Segmental spinal anesthesia involves puncturing the spinal cord at higher thoracic levels using lower doses of local anesthetic, allowing selective blockade of dermatomes needed for surgery. This technique provides hemodynamic stability, less motor blockade, and faster recovery compared to conventional spinal anesthesia. Careful performance of segmental spinal anesthesia can establish it as a routine procedure for day surgery.
Suprachoroidal drug delivery system is a novel drug delivery used in opthalmology.. It is a novel approach by which ocular side effects can be minimized.
Dr. Charulatha discusses the conduct of regional anesthesia including spinal and epidural anesthesia. She covers topics such as spinal cord anatomy, blood supply, sterile technique for spinal anesthesia, factors influencing spinal block level, advantages of spinal anesthesia, complications, drugs used, and contraindications. Dr. Charulatha also provides an overview of epidural anesthesia including indications, advantages, disadvantages, mechanisms of action, factors affecting block level, local anesthetics used, and additives.
This document discusses fetal endoscopic surgery, including the indications and anesthetic management. It describes several fetal conditions that may benefit from fetoscopic intervention, including twin-twin transfusion syndrome (TTTS), twin reversed arterial perfusion sequence (TRAP), and bladder outlet obstruction from conditions like posterior urethral valves. For TTTS and TRAP sequence, fetoscopic techniques like selective fetoscopic laser photocoagulation of placental vessels and umbilical cord ligation are discussed as alternatives to open fetal surgery or other treatments. The document also reviews maternal and fetal considerations for anesthesia during these procedures.
There are numerous types of brain surgery. The type used is based on the area of the brain and the condition being treated.
Brain surgery is a critical and complicated process. The type of brain surgery done depends highly on the condition being treated.
Intracranial surgery refers to various medical procedures that involve repairing structural problems in the brain.
Craniotomy
A craniotomy involves making an incision in the scalp and creating a hole known as a bone flap in the skull. The hole and incision are made near the area of the brain being treated.
During open brain surgery, it is done to remove tumors, clip off an aneurysm, drain blood or fluid from an infection & remove abnormal brain tissue
Decompressive craniectomy
It is a neurosurgical procedure in which part of the skull is removed to allow a swelling brain room to expand without being squeezed. It is performed on victims of traumatic brain injury, stroke and other conditions associated with raised intracranial pressure.
Regional anesthesia such as spinal or epidural anesthesia is preferred over general anesthesia for cesarean sections due to lower risks for both mother and baby. Spinal anesthesia provides rapid onset but a finite duration, while epidural anesthesia allows for gradual onset and better control of sensory levels via a catheter. Both techniques require careful management of hypotension through fluid administration and vasopressors. Neuraxial opioids can enhance analgesia without negatively impacting the neonate. The goals are to provide adequate anesthesia and analgesia for surgery and postoperatively while maximizing safety for mother and baby.
The document summarizes information about the postpartum period known as the puerperium. It defines the puerperium as the time period following childbirth from delivery of the placenta through the first few weeks as the body's anatomy and physiology revert back to the pre-pregnant state. Common anatomical changes and potential postpartum complications like postpartum hemorrhage are described. Postpartum hemorrhage is defined and its causes like uterine atony and genital tract lacerations are explained. Diagnosis and management of postpartum hemorrhage including conservative treatments and interventions like uterine packing or arterial ligation are outlined.
The document discusses care bundles, which are groups of evidence-based interventions that are more effective at improving patient outcomes when implemented together rather than individually. It provides examples of common care bundles, such as ventilator bundles and central line bundles. The ventilator bundle includes elements like keeping the head of the bed elevated, daily sedation vacations, stress ulcer prophylaxis, deep vein thrombosis prophylaxis, and oral decontamination with chlorhexidine. The central line bundle outlines best practices for insertion, maintenance, and care of central lines to reduce central line-associated bloodstream infections.
This randomized controlled trial compared the effects of a high-rate (15 U/h) versus low-rate (2.5 U/h) oxytocin infusion for maintaining uterine contractility during elective cesarean delivery. The study found no significant differences between the groups in estimated blood loss, adequacy of uterine tone, use of additional uterotonics, or incidence of oxytocin-related side effects such as hypotension. While efficacy was obtained with the low-rate oxytocin infusion, further dose-finding studies are needed to determine the optimal infusion rate that maximizes drug efficacy while minimizing side effects.
This study investigated the effects of different oxytocin infusion rates for maintaining uterine contractility during elective cesarean delivery (CD). In a double-blind randomized clinical trial, 51 women undergoing elective CD were randomly assigned to receive either a low-rate (2.5 U/h) or high-rate (15 U/h) oxytocin maintenance infusion after receiving an initial 1 U oxytocin bolus. The primary outcome was total estimated blood loss (EBL), and secondary outcomes included adequacy of uterine tone, use of additional uterotonics, and oxytocin-related side effects. The study found no significant differences between the low-rate and high-rate groups in EBL, adequ
Pictorial and detailed description of patellar instability with sign and symptoms and how to diagnose , what investigations you should go with and how to approach with treatment options . I have presented this slide in my 2nd year junior residency in orthopedics at LLRM medical college Meerut and got good reviews for it
After getting it read you will definitely understand the topic.
Summer is a time for fun in the sun, but the heat and humidity can also wreak havoc on your skin. From itchy rashes to unwanted pigmentation, several skin conditions become more prevalent during these warmer months.
“Psychiatry and the Humanities”: An Innovative Course at the University of Mo...Université de Montréal
“Psychiatry and the Humanities”: An Innovative Course at the University of Montreal Expanding the medical model to embrace the humanities. Link: https://www.psychiatrictimes.com/view/-psychiatry-and-the-humanities-an-innovative-course-at-the-university-of-montreal
Travel vaccination in Manchester offers comprehensive immunization services for individuals planning international trips. Expert healthcare providers administer vaccines tailored to your destination, ensuring you stay protected against various diseases. Conveniently located clinics and flexible appointment options make it easy to get the necessary shots before your journey. Stay healthy and travel with confidence by getting vaccinated in Manchester. Visit us: www.nxhealthcare.co.uk
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The biomechanics of running involves the study of the mechanical principles underlying running movements. It includes the analysis of the running gait cycle, which consists of the stance phase (foot contact to push-off) and the swing phase (foot lift-off to next contact). Key aspects include kinematics (joint angles and movements, stride length and frequency) and kinetics (forces involved in running, including ground reaction and muscle forces). Understanding these factors helps in improving running performance, optimizing technique, and preventing injuries.
5-hydroxytryptamine or 5-HT or Serotonin is a neurotransmitter that serves a range of roles in the human body. It is sometimes referred to as the happy chemical since it promotes overall well-being and happiness.
It is mostly found in the brain, intestines, and blood platelets.
5-HT is utilised to transport messages between nerve cells, is known to be involved in smooth muscle contraction, and adds to overall well-being and pleasure, among other benefits. 5-HT regulates the body's sleep-wake cycles and internal clock by acting as a precursor to melatonin.
It is hypothesised to regulate hunger, emotions, motor, cognitive, and autonomic processes.
Discover the benefits of homeopathic medicine for irregular periods with our guide on 5 common remedies. Learn how these natural treatments can help regulate menstrual cycles and improve overall menstrual health.
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Giloy in Ayurveda - Classical Categorization and SynonymsPlanet Ayurveda
Giloy, also known as Guduchi or Amrita in classical Ayurvedic texts, is a revered herb renowned for its myriad health benefits. It is categorized as a Rasayana, meaning it has rejuvenating properties that enhance vitality and longevity. Giloy is celebrated for its ability to boost the immune system, detoxify the body, and promote overall wellness. Its anti-inflammatory, antipyretic, and antioxidant properties make it a staple in managing conditions like fever, diabetes, and stress. The versatility and efficacy of Giloy in supporting health naturally highlight its importance in Ayurveda. At Planet Ayurveda, we provide a comprehensive range of health services and 100% herbal supplements that harness the power of natural ingredients like Giloy. Our products are globally available and affordable, ensuring that everyone can benefit from the ancient wisdom of Ayurveda. If you or your loved ones are dealing with health issues, contact Planet Ayurveda at 01725214040 to book an online video consultation with our professional doctors. Let us help you achieve optimal health and wellness naturally.
Histololgy of Female Reproductive System.pptxAyeshaZaid1
Dive into an in-depth exploration of the histological structure of female reproductive system with this comprehensive lecture. Presented by Dr. Ayesha Irfan, Assistant Professor of Anatomy, this presentation covers the Gross anatomy and functional histology of the female reproductive organs. Ideal for students, educators, and anyone interested in medical science, this lecture provides clear explanations, detailed diagrams, and valuable insights into female reproductive system. Enhance your knowledge and understanding of this essential aspect of human biology.
Medical Quiz ( Online Quiz for API Meet 2024 ).pdf
Workshop of epidural management
1. Workshop: Epidural management
Joseph D. Tobias, MD Stephen Hays, MD
University of Missouri Vanderbilt University
Charles Schrock, MD Christine Greco, MD
St. Louis Children’s Hospital Boston Children’s Hospital
Introduction
Epidural blockade in children continues to grow in popularity with increasing applications in the
operating room and beyond. In infants and children, epidural anesthesia is most commonly performed in
conjunction with general anesthesia as a means of providing postoperative analgesia or as a combined
general-regional anesthetic technique to limit the requirements for general anesthetic agents. However,
epidural blockade may also be the sole surgical anesthetic in various clinical scenarios such as the former
premature infant at high risk for post-anesthetic apnea, in patients with concurrent medical conditions that
increase the potential risks of general anesthesia, or in cooperative older pediatric patients who chose a
regional anesthetic technique over general anesthesia. When performed preemptively prior to surgical
incision, epidural blockade may ablate the surgical stress response, decrease postoperative analgesia
requirements, and improve the postoperative course. Epidural anesthesia has also found increasing roles in
the management of acute and chronic pain outside of the perioperative period. Additionally, the sympathetic
blockade that can be induced by epidural anesthesia is occasionally used as a therapeutic tool to improve
regional blood flow in various clinical scenarios with associated vascular insufficiency. This workshop will
review local anesthetic agents, opioids, and adjuvant agents commonly used for pediatric epidural
anesthesia/analgesia and discuss the practical aspects of these techniques. Additionally, specific issues as
they pertain to the use of these techniques in neonates will be reviewed.
Caudal epidural blockade
The most commonly performed pediatric epidural technique is the caudal epidural block. First
described for pediatric use in 193335, caudal epidural analgesia involves accessing the epidural space through
the sacrococcygeal ligament via the sacral hiatus at the base of the sacrum. The technique is relatively easy
to perform and combines a high success rate with a low risk of complications. It is particularly popular in
pediatric practice because of the ability to obtain analgesia extending to the mid-thoracic dermatomes when
volumes of 1.3-1.5 mL/kg are used in infants and young children while approaching the epidural space
below the level of the spinal cord. It may be considered for any procedure or process below the umbilicus.
Caudal block in children is most commonly performed in combination with a general anesthetic, but may be
the sole technique in former premature infants at high risk for post-anesthetic apnea. Caudal block is
performed with the patient in lateral or prone position.
The sacral hiatus is identified above the coccyx, at or near the superior aspect of the gluteal crease,
by palpation of the two sacral cornua. The sacral cornu represent the posterior bony elements of the S5
vertebral body. Using appropriate sterile technique, a needle is inserted midway between and slightly
inferior to the two sacral cornua at a 45o angle to the skin. The needle angle may be decreased immediately
after passing through the skin or after encountering bone, representing the posterior wall of the ventral sacral
elements. The needle is advanced, readjusting the angle as needed, until a characteristic "pop" indicating
passage through the sacrococcygeal membrane is appreciated . Potential sites of improper needle placement
include intraosseous, subdural, in an epidural vein, and under the sacral ligament.
2. Controversy has been raised regarding the type of needle to used: standard or styletted. Advocates
of a styletted needle voice concern regarding coring or the removal of a tissue plug which theoretically could
be carried into the epidural space and develop into an epidermoid tumor. Goldscheider and Brandom
demonstrated residual material in 54% of cases when a non-styletted needle was used. In 33% of the cases,
the core included epidermal tissue. This issue remains to be resolved as many institutions continue to use
standard, short bevel, non-stylleted needles while others use styletted needles such as a standard spinal
needle.
The sacrococcygeal membrane represents the most inferior aspect of the ligamentum flavum
surrounding the spinal epidural space. After negative aspiration for blood or CSF, the same process as
outlined above for dosing an epidural block at the lumbar or thoracic level is followed including the use of a
test dose and fractionating the entire dose of local anesthetic solution. The volume administered depends
upon the desired area level of analgesia. Bupivacaine (0.125-0.25%), levobupivacaine (0.125-0.25%), and
ropivacaine (0.2%) are the local anesthetics most commonly used for bolus caudal epidural administration.
Bupivacaine, levobupivacaine, and ropivacaine when used in concentrations of 0.2-0.25% will provide
surgical anesthesia for 60-120 minutes with persistent analgesia for up to 6-12 hours thereafter. Analgesia at
more distant sites or for longer periods may be achieved by addition of opioid and/or adjuvant agents.
Although caudal block is most commonly performed as a "single shot" bolus technique,
postoperative analgesia can be provided by a continuous caudal infusion following placement of a caudal
epidural catheter as is performed for lumbar or thoracic epidural analgesia. Several commercially prepared
kits are available for caudal anesthesia or standard epidural kits may be used with a Crawford or other end-
hole needle. Alternatively, a standard 20-gauge epidural catheter may be threaded through an 18-gauge
intravenous catheter that has been placed into the caudal epidural space. In neonates and small infants, it
may be feasible to pass a catheter from the caudal area to the thoracic dermatomes to provide analgesia for
thoracic and upper abdominal procedures.
Regional anesthesia, either spinal or caudal block, with the patient awake is occasionally performed
for surgical procedures below the umbilicus in children at high risk for post-anesthetic apnea, particularly
former premature infants. Avoidance of general anesthesia may decrease the likelihood of postoperative
respiratory complications including apnea. Awake regional anesthesia generally uses only local anesthetic
agents as the addition of neuraxial opioid and/or adjuvant agent may confer the same risk for post-anesthetic
apnea as does general anesthesia. Either caudal epidural or spinal anesthesia may be used. Topical
anesthesia is provided by skin infiltration or local anesthetic cream before block placement. Numerous
regimens have been suggested for awake caudal anesthesia with volumes ranging from 1 to 1.5 mL/kg of
bupivacaine in concentrations varying from 0.2%-0.375%. For these techniques, a higher volume is needed
to provide high thoracic block while a higher concentration (0.2-0.375% bupivacaine) of local anesthetic is
needed to improve surgical anesthesia. Limitations of these techniques include incomplete motor block with
resultant unfavorable surgical conditions and duration of anesthesia less than 90 minutes. Additionally, the
combination of a high volume and a higher concentration of local anesthetic agent approaches or in some
suggested regimens exceeds the recommended doses of bupivacaine. These concerns and the need to
prolong anesthesia beyond 90 minutes in some cases has resulted in the use of 3% chloroprocaine by
continuous infusion. Successful anesthesia can be provided for 2-3 hours in the awake neonate using a
regimen of 1.5-2 mL/kg of 3% chloroprocaine as the initial bolus followed by an infusion of 1.5-2.0
mL/kg/hr. Despite the high volume and high concentration of local anesthetic agent, serum concentrations
have been shown to be insignificant even in the neonatal population. This technique has also been shown to
be effective as a combined technique with general anesthesia for abdominal surgical procedures in neonates
thereby allowing for immediate tracheal extubation by avoiding high concentrations of an inhalational
anesthetic agent and eliminating the need for parenteral opioids.
3. Since neuraxial blockade in children is most commonly performed under general anesthesia,
neurologic toxicity may not manifest itself leaving cardiotoxicity as the first sign of systemic toxicity.
Although local anesthetic toxicity may occur during continuous infusion techniques, particularly if the dose
is not appropriately adjusted for patient age, most adverse reactions occur with bolus administration, given
the greater likelihood of rapidly reaching toxic serum levels. Local anesthetic toxicity may also result from
unrecognized intravascular or intraosseous injection. Before the epidural administration of local anesthetic,
aspiration for blood should be performed. Negative aspiration reduces, but does not eliminate the risk of
inadvertent intravascular injection as inadvertent intraosseous injection may occur (generally during caudal
epidural blockade) given the cartilaginous nature of the lumbar and sacral vertebral bodies in neonates and
infants. Following negative aspiration, a test dose of epinephrine-containing local anesthetic is injected (0.5-
1 µg/kg of epinephrine, or 0.1-0.2 mL/kg of a solution containing epinephrine 1:200,000 or 5 µg/mL) with
30-60 seconds of observation for hemodynamic changes suggestive of intravascular injection (ST segment
or T wave changes, increased heart rate or hypertension) before injection is continued. Even if no
hemodynamic changes are noted, many practitioners administer the remainder of the dose slowly and in
fractionated fashion, with repeated aspiration and observation after each subsequent dose. The reader is
referred to the reference list for a review article concerning the history and current status of test dosing.
Pediatric epidural anesthesia: equipment, technique, and complications
Pediatric epidural anesthesia represents a potentially valuable technique in perioperative care of
children. A review of the historical background of pediatric epidural anesthesia provides greater
understanding of its development, underscores possible applications, and reinforces potential
complications and contraindications. Successful pediatric epidural anesthesia requires careful planning
and skillful execution, with the goal of providing optimal analgesia. The analgesia provided is at least
equivalent, and at times may be superior, to that afforded by other modalities. Particularly when
performed pre-emptively, regional anesthesia has been shown to attenuate the surgical stress response,
although the significance of this in pediatric patients is unclear. Regional anesthetic techniques should
provide analgesia while minimizing respiratory depression and other side effects of systemic opioid
therapy, although this has been difficult to demonstrate in clinical practice. Regional anesthetic
techniques permit lighter planes of intraoperative general anesthesia, facilitating emergence and
expediting recovery, and in some cases may allow avoidance of general anesthesia. There are also roles
for epidural anesthesia in pediatric pain management, in the perioperative setting and outside the
operating room.
Pediatric epidural anesthesia does require time and effort on the part of the anesthesia provider,
as well as patience on the part of surgical and nursing colleagues; depending on technique, specialized
equipment may be required. Any regional anesthetic may fail, or be only partially effective.
Intravascular injection is possible, as are vascular injury and bleeding including epidural hematoma.
Infection including epidural abscess is uncommon with single injection techniques, but may be
encountered with indwelling catheters. Concern persists over the potential for regional anesthetic
techniques to mask potentially serious surgical conditions, in particular compartment syndrome of the
distal lower extremity. Intraneural injection and nerve injury are theoretically possible and have been
described, but fortunately are quite rare in children. Coagulopathy, infectious process, patient or parent
refusal, and anatomic deformity are all relative contraindications, although risks and benefits much be
weighed in each patient and for each procedure.
Successful pediatric epidural anesthesia requires careful planning and skillful execution.
Administration of anesthetic at or near the midpoint of the dermatomal area over which analgesia is
desired is probably the single most important determinant of analgesia. Anesthetic may be injected or a
catheter placed directly at the desired vertebral level; in infants and young children, catheters may be
placed caudally and threaded distally. Anesthetic injection or catheter placement may be undertaken by
paramedian or midline approaches. Early pediatric practice entailed paramedian approach, primarily
4. because of historical precedent in adults, but for most pediatric patients midline approach will be
successful. Anesthetic may be administered as a single injection, or by repeated injection or continuous
infusion through an indwelling catheter. Catheters may be placed conventionally for use over several
days, or tunneled for use over weeks to months. Pediatric epidural anesthesia is most commonly
performed with the patient under general anesthesia, although awake placement may be attempted in
particularly cooperative older children. The primary role for awake regional anesthesia in the pediatric
patient is in the former premature infant at risk for apnea following general anesthesia. Clinical studies
in humans have demonstrated little or no difference in timing of pediatric regional anesthesia before or
after a variety of surgical procedures.
Pediatric epidural anesthesia has great historical precedent, and represents a potentially valuable
technique in perioperative care of children. Serious complications and absolute contraindications are
rare; analgesia is at least equivalent, and at times may be superior, to that afforded by other modalities.
Careful planning and skilled execution increase likelihood of optimal analgesia.
Pediatric epidural anesthesia: Medications and pharmacology
Local anesthetics form the backbone of regional anesthesia and analgesia practice. As used in
children they have a narrow therapeutic window for serious complication yet are used with a high
degree of safety. Their efficacy of analgesia is accompanied by an acceptable rate of side effects. The
epidural route of local anesthetics and adjuvant drugs is typically utilized for postoperative analgesia as
part of a balanced general anesthetic technique. Only rarely will epidural anesthesia be the sole
anesthetic for infants and children. Local anesthetics share a structural-activity relationship. A tertiary
amine is linked by an intermediate chain to an unsaturated aromatic. This produces a molecule with
both water solubility and lipophilicity. The local anesthetic must bind the sodium channel in the interior
of the cell to block gate opening, preventing the formation or transmission of an action potential. Local
anesthetics do not alter the resting membrane potential or alter the metabolic activity of the cell
otherwise. Successful blockade of a single nerve’s transmission requires a sufficient concentration
(Cm) of the local anesthetic to be present over a sufficiently long section of nerve. Cm is a function of
drug and nerve type. The practical clinical required concentration is typically 10 fold greater than the in
vitro Cm. The unmyelinated C fibers and smaller myelinated A-delta fibers carry nociceptive
information have a lower Cm than the more heavily myelinated motor fibers.
Peak local anesthetic blood levels are largely a function of total dose administered. The rate of
absorption and time to the peak blood level differs for the location of injection. Increasing absorption
rate follows this general pattern: subcutaneous, distal blocks, brachial plexus, caudal, epidural,
intercostal, intratracheal, intravenous. Vasoconstrictors may slightly decrease the peak levels obtained.
Peak levels and lower effective therapeutic indices result from the dose scaling in children. Comparable
size nerves require similar total doses of local anesthetic to effect blockade, yet the volume of
distribution for the disposition of the local anesthetic varies more proportionately with the weight of the
patient. Producing a similar nerve block in an infant therefore requires a substantially greater dose for
body weight than for adults.
Bupivacaine is the most commonly administered local anesthetic for routine intraoperative and
postoperative analgesia in children. At concentrations appropriate for postoperative analgesia it
produces differential blockade that permits good muscle strength with the possibility for assisted
ambulation with lumbar epidural and especially with thoracic level epidural. Metabolism for amide
local anesthetics is decreased in neonates and care must be taken to avoid excessive infusions. Larsson
followed blood levels in neonates with epidural infusions at 0.2 mg/kg/hour, finding a wide range in
blood levels, with some exceeding 3 µg/ml without showing evidence for plateau at 48 hours. This
would suggest that dosing beyond this or for longer periods in neonates could be of concern.
Levobupivacaine is a single enantiomer of the racemic bupivacaine. Levobupivacaine may have an
improved therapeutic index with respect to the racemic mixture suggested by in vitro studies. In clinical
5. use it appears similar in potency and differential blockade to bupivacaine. There is insufficient clinical
evidence for reduced toxicity yet to suggest higher permissible doses of Levobupivacaine as compared
to racemic bupivacaine. Ropivacaine has in vitro cardiac effects similar to levobupivacaine.
Comparative trials suggest that it is slightly less potent than bupivacaine. Because it appears to have a
greater differential blockade, it might be useful in situations where minimal motor block is desired.
Chloroprocaine is the most rapidly metabolized local anesthetic, degraded by plasma esterases with a
half-life of 45 seconds in neonates and 25 seconds in adults. Systemic reactions have still been
reported, especially as rapid boluses can saturate the limited esterase capacity of infants. This drug is
most useful for testing the functionality of an epidural catheter for which the proper positioning might
be in question. It has also been utilized as a continuous infusion for surgical anesthesia in neonates.
Utility of mixtures of local anesthetics may present hypothetical benefits. It may be possible to
produce faster onset with longer block by mixing, for example, lidocaine with bupivacaine. The
specific advantages of these admixtures have had only limited assessment. One difficulty for
comparison is determining exactly what would be a comparable dose of a single agent. Two percent
lidocaine mixed at equal volumes with 0.25 % bupivacaine will result in 1% lidocaine and 0.125%
bupivacaine concentrations. A rational concentration and dose of a single agent for comparison is not
intuitively obvious. For purposes of avoiding toxicity, the fraction of maximal dose of each should be
summed (e.g. half the permissible lidocaine dose with half the permissible bupivacaine dose is the limit
to be administered). There has been no suggestion of benefit for admixing local anesthetics for use with
continuous postoperative administration.
Toxicities in infants can occur at lower doses compared with children and adults because of
decreased protein binding of the local anesthetic agent. Metabolism of the amide local anesthetics is
significantly slower through age12 to 18 months and consideration of this must be made for repeated
doses or continuous infusions of local anesthetic. Toxicity typically produces CNS symptoms before
cardiovascular effects occur. Agitation, restlessness, and myoclonic movements indicative of CNS
excitement could be confused for unrelieved pain. CNS symptoms generally precede cardiovascular
complications except with bupivacaine. Bupivacaine has a narrower therapeutic index and cardiac
symptoms may coincide or precede CNS symptoms. The dysrhythmias described may produce difficult
to resuscitate conditions. All local anesthetics directly depress cardiac contractility. By altering sodium
channel conduction the propagation of contraction occurs more slowly creating the situation where
reentrant dysrhythmias may occur. Bupivacaine differs from the other amide anesthetics having
increased lipid solubility and a more avid binding to the sodium channel. Cardiac dysrhythmias
precipitated by bupivacaine under the conditions of hypoxia and hypercarbia are probably best managed
with amiodarone in addition to support of ventilation and circulation. Isoproterenol has been
demonstrated to reverse the electrocardiac effects of bupivacaine toxicity and might be useful also in
resuscitation. In summary: For bupivacaine, maximum infusion rate for neonates is 0.2 mg/kg/hour.
Over age 6 months through adult, 0.4 mg/kg/hour.
General considerations for the use of adjuvant drugs for epidural anesthesia and analgesia
include: (1) children often tolerate opiates quite well and can often achieve adequate analgesia utilizing
opiates and NSAIDS. Therefore, epidural safety must at least meet the already high safety profile if IV
opiates. (2) Dose ranging in children is often incomplete or absent. (3) Most experience is from single
dose (typically caudal epidural) use. (4) Drug additives and preservatives may be present in adjuvant
drugs, and have less often been safety tested for epidural and spinal use. (4) Because of the probability
for unintended intrathecal administration, drugs considered for epidural use should be established as
safe for intrathecal use.
6. Clonidine is FDA approved for epidural use in adults with chronic pain. It is available in a
preservative free preparation at 100 µg/ml and 500 µg/ml. Clonidine acts as a presynaptic α2-adrenergic
agonist at the interneurons of the dorsal horn mimicking the activation of descending noradrenergic
pathways and inhibiting neurotransmitter release. Typical side effects of clonidine include sedation,
bradycardia, orthostatic hypotension and dry mouth. Alterations in intraoperative or postoperative
blood pressure are minimal in children. Respiratory depression is minimal, with resting carbon dioxide
levels normal, but ventilatory response to CO2 challenge somewhat blunted. Numerous studies have
evaluated the efficacy of single dose clonidine via the caudal route as an adjuvant with local anesthetics
for procedures below the umbilicus, most finding benefit with doses from 1-2 µg/kg. A dose response
study evaluated three concentrations of clonidine finding improved pain scores without change in
sedation scores in children with continuously infusion epidural catheters. The authors concluded that
clonidine 0.08 to 0.12 µg/kg/hr added to ropivacaine was superior to ropivacaine plain or with 0.04
µg/kg/hr. In children undergoing major abdominal surgery clonidine alone at 0.2 µg/kg/hr as epidural
infusion may be sufficient for a majority of patients. A reasonable role for clonidine in postoperative
management would be to supplant the use of an opiate, thus reducing the complications from PONV and
pruritus and respiratory depression. The spinal administration of clonidine has been shown to produce
antihyperalgesia persisting months after surgery and anesthesia, suggesting that clonidine might have
some preemptive analgesic benefit (that has been elusive in clinical trials for opiates.)
Ketamine is available as a preservative free drug, but is not labeled for epidural or spinal use.
Ketamine acts through the blockade of NMDA receptors in the substantial gelatinosa, and also binds mu
opioid receptors. These receptors are located throughout the CNS and play an important role in central
pain and neural plasticity in the spinal cord. Numerous studies in children mostly for hernia and
genitourinary surgery has demonstrated efficacy for prolonging analgesia for bupivacaine caudals.
Dose ranging for single dose administration suggests that 0.25-0.5 mg/kg is optimal; larger dosing was
associated with urinary retention and behavioral effects.
Neostigmine is available only with preservative (methylparaben, propylparaben, or even phenol
outside the U.S.) and is not labeled for epidural or spinal administration. The paraben preservatives
utilized in the U.S appears safe in animal studies. Muscarinic receptors are present in lamina 2 and 3 of
the spinal cord and are responsible for the analgesics effects. Epidural and intrathecal neostigmine is
associated with significantly increased rates of PONV. Hemodynamics are stable, and blood pressure is
supported more near normal as compared to controls without neostigmine administration. Dose ranging
studies in children have shown dose independence over a range 2-4 µg/kg neostigmine with bupivacaine
versus bupivacaine only controls, yet a similar study exploring the range 10-50 µg/kg using neostigmine
as the sole analgesic found that analgesia was dose dependent throughout this range, but PONV was
increased with doses over 30 µg/kg. Evidently, neostigmine requires substantially larger doses without
the presence of a local anesthetic. It usefully prolongs the duration of conventional caudal block with
local anesthetic but has poor efficacy as a sole analgesic. PONV and sedation are problematic at higher
doses. Continuous infusion has not been explored for continuous epidural infusion.
Midazolam is available as a preservative free drug, but is not labeled for epidural or spinal use.
Action is through GABA-A receptors in the spinal cord in lamina II of the dorsal horn. Dose ranging is
extrapolated from adult upper abdominal surgery, finding 50 µg/kg optimally providing analgesia, with
higher doses associated with excessive sedation. Kumar recently compared effects of midazolam,
ketamine, and neostigmine coadministered with bupivacaine. Time to first analgesic was longest for the
midazolam and neostigmine groups, with the ketamine group having 2 of 20 patients experience
hallucinations. Midazolam has had relatively little study to determine the optimal dose range in children,
or evaluate for unanticipated side effects. Further study is warranted before widespread routine use is
instituted.
Morphine is labeled for epidural and spinal use. It is known to produce a dose and concentration
dependent local tissue inflammation inducing tissue granuloma at the site of intrathecal infusion. This is
7. not an issue with the concentration or duration associated with acute perioperative analgesia use. Side
effects include PONV, urinary retention, pruritus, and hypoventilation and apnea. The principle
concern with the use of neuraxial opiates is for respiratory depression. This CNS effect can occur as a
result of direct action upon the brainstem through CSF circulation or through systemic absorption with
effect similar to IV administration. Morphine has a peak effect for respiratory depression at 4 hours
following administration but cases have occurred up to 12 hours later. This time can often coincide with
circadian sleep, change of staff, and waning staff vigilance to produce critical respiratory depression if
not monitored for and treated. The more lipophilic drugs fentanyl and sufentanil are more rapidly
absorbed from the CSF, making rostral spread less likely; concerns for delayed respiratory depressions
from single doses seems to be less likely than for morphine. Such safety cannot be assumed if these
drugs are utilized as continuous infusions, and all opiate infusions should receive equivalent
postoperative monitoring.
Children often require local anesthetic doses near the maximum acceptable. The first step in
planning an epidural infusion is to determine the maximal amount of acceptable local anesthetic that
may be infused per hour. Written orders for the epidural infusion should include a stated maximum so
that nurses can check subsequent prescribed changes for the infusion. It may be necessary to reduce the
planned concentration of the local anesthetic in order to keep the total dose to an acceptable amount.
Because of variations in surgical procedure, pain perception, patient variables of anatomy and drug
disposition, no fixed regimen can be sufficient for all patients. Starting doses must be adjusted based
upon patient responses. Assessments in children can be quite complicated as language and
understanding of pain and sensation may not convey the experience as clearly as in adults. Children
often express many sensations including the tingling or pins and needles feelings of numb extremities as
pain. Indeed, for many preschool age children the pulse oxymeter, ECG pads and any number of non-
nociceptive stimuli ‘hurt’ if asked. Testing cold sensation as in adults with an alcohol pad will often
lead to ambiguous responses; an ice cube beginning in certainly numb areas sliding toward unblocked
dermatomes may be more obvious.
Smaller patients require a nerve to experience a similar exposure to local anesthetic as adults to
produce block. Children have a smaller volume of distribution and lower clearance for drugs. Because
their drug doses are greater on a weight basis, smaller children will have lower therapeutic indices. The
caudal space will tend to require larger volumes for the same dermatome spread compared to the lumbar
or thoracic region. Body weight in clinical practice is a surrogate for volume of distribution. In the case
of dosing epidurals it is utilized both for estimating the Vd and clearance rate for drugs administered, as
well as for assessing the size of the epidural space. Overweight body compositions may not have larger
volumes of distribution, faster clearance or larger epidural spaces than their body weight alone would
suggest. For purposes of dosing an epidural and estimating maximum doses one should conservatively
utilize the ideal body weight.
A SUGGESTED APPROACH TO EPIDURAL MANAGEMENT:
1) Calculate maximum permissible local anesthetic infusion.
2) Determine desired infusion rates.
Loading volume: 0.05 mL/kg/dermatome spread from catheter/needle tip. At the caudal region
count from the coccyx including all sacral, lumbar and thoracic roots to be anesthetized. For
lumbar catheter count segments in one direction (usually cephalad) from catheter tip.
Infusion rate: 0.2-0.4 mL/kg/hour, not to exceed typical adult infusion rates of up to 15 ml/hour.
For thoracic catheters, use half the loading dose and half the infusion rate.
3) Ensure that chosen rate times concentration is an acceptable dose of local anesthetic.
8. 4) Determine the rate for the adjuvant.
Fentanyl 1 µg/kg/hour
Hydromorphone 1 µg/kg/hour
Morphine 2.5µg/kg/hour
Clonidine 0.2 µg/kg/hour
5) Calculate the required concentration of adjuvant in the epidural solution.
A standardized order page tailored to each institution's typical practices and patients will greatly
facilitate this practice and enhance safety by preventing accidental incorrect or atypical dosing.
THE OVERNIGHT CAUDAL EPIDURAL:
Shorter postoperative hospitalizations often seem to preclude the use of epidural analgesia. In
this situation, where benefit is to be gained from the use of a continuous epidural technique, the
technique must adapt. Clubfoot surgery causes considerable discomfort and casting promotes tendon
stretch and muscle spasm exacerbating pain. This population can be well served by the use of a
continuous caudally placed epidural catheter infusing until the morning of the first postoperative day.
This results in excellent patient and parent satisfaction compared with the single dose blocks with
effects that, despite adjuvant drug use, still wear off in the middle of the night. Our typical regimen uses
bupivacaine 0.1% with fentanyl 5 µg/ml to infuse at 0.2 mL/kg/hr. Bupivacaine dosing is acceptable for
infants. Apnea monitoring and pulse oxymetry are used overnight.
PATIENT-CONTROLLED EPIDURAL ANESTHESIA (PCEA):
PCEA principles:
Demand dose administered by patient is at least minimally effective.
Demand dose administered is unlikely to produce harm.
Dosing interval is governed by the rate of onset of effect. The patient will have the opportunity
to notice the effect before the lockout permits repeat dosing.
Total local anesthetic dose must be considered for both basal and PCEA dosing. Patients may
be relied upon to self-limit systemic opiates as they achieve comfort and somnolence, but
patients using local anesthetic may fail to slow usage in a similar manner.
Tachyphylaxis for local anesthetics is promoted by allowing local anesthetic effects to wane.
Repetitive small fiber stimulus produces a wind up effect within the spinal cord, sensitizing the patient
to pain; effectively this is the clinical opposite of preemptive analgesia. Allowing local anesthetic effect
to wane as would be expected to occur with PCEA without basal infusion might lead to this problem.
Further, reestablishing the analgesia will be difficult for patients unless especially liberal pump lockouts
are utilized. Thus, it is rational to utilize a basal infusion when local anesthetics are included in the
analgesic regimen. Reasonable PCEA demand dose is 20% of the basal with 2 doses per hour limit, or
40% of the basal rate with one dose per hour limit. It must be assumed that the patient will receive all
possible programmed doses and this must be within the acceptable limits for local anesthetic usage.
Epidural analgesia provides excellent pain control, can hasten recovery of GI function, reduce
PONV, and may preemptively reduce the total pain burden by reducing spinal cord ‘wind-up’ effect.
Successful transition from epidural may be considered once the patient is capable of consuming oral
analgesics. Since the pain burden of the procedure is likely significant, having required epidural
analgesia, the oral analgesia regimen should adequately address this. The oral analgesic regimen we use
often consists of a basal or scheduled opiate along with a PRN dose. NSAID adjuvants will also be
utilized if not relatively contraindicated by the surgical procedure. Typical dosing includes Oxycontin
0.5-0.75 mg/kg Q8-12 hours scheduled plus oxycodone 0.15-0.2 mg/kg Q2 PRN. For children who
cannot swallow the oxycontin tablets, a scheduled dose of oxycodone at 4-hour intervals could be
9. substituted. The PRN dosing is quite short, but within 2 hours the full effect, and side effect, can
sufficiently be assessed to warrant repeat dosing if discomfort persists. Intravenous opiates or
reactivation of the catheter can be considered for unrelieved pain. It is uncommon to transition epidural
analgesia to IV PCA; this is sometimes required for bowel procedures requiring prolonged postpone
fasting.
Neonatal epidural anesthesia
There is increasing evidence that infants not only have the neuroanatomic, neurochemical, and
functional ability to respond vigorously to painful stimuli, but equally as important, that early pain
experiences may alter responses to pain later in life. Preterm and term neonates in the neonatal intensive
care unit (NICU) are exposed to numerous sources of pain and stress following major surgical procedures.
Because of the immaturity of inhibitory pathways in the central nervous system in both preterm and full term
infants, tissue-damaging procedures may be particularly painful in these young infants. Untreated pain can
lead to a number of adverse physiologic consequences including increased physiologic energy expenditure,
increased secretion of adrenal stress hormones, altered cerebral blood flow, and disturbed sleep/wake cycles.
Strategies for treating and preventing pain in the NICU and newborn nursery have recently been developed
and preliminary studies have suggested that early aggressive pain control and stress reduction strategies may
minimize long term effects on pain thresholds and behavior. Key in the treatment of acute postoperative
pain is the use of regional anesthetic techniques including epidural anesthesia.
Epidural analgesia can provide excellent postoperative analgesia for neonates undergoing
thoracic, abdominal, and lower extremity surgery. It can be particularly useful for surgeries where early
resumption of spontaneous ventilation is desired to avoid barotrauma (e.g. diaphragmatic hernia repair).
The use of epidural analgesia in neonates has been facilitated by the discovery that a catheter can be
reliably threaded to the thoracic region from the simpler caudal approach in neonates. This technique
tends to be quite reliable in infants less than 5 kg. Since proper alignment of the tip of the epidural
catheter can be crucial to the success of this technique, placement should be verified by the injection of
0.5 mL of radio-opaque dye (Omnipaque 180 or Isovue 200) through the catheter followed by
radiography. Radio-opaque catheters (Theracath , Arrow International, Redding, Pennsylvania) are
also available that allow determination of the level of the catheter tip with a plain radiograph. The
advantage of these catheters is that placement can be easily verified throughout the duration of the
infusion.
Continuous infusions of bupivacaine, levobupivacaine, or ropivacaine can provide excellent
pain relief, but clearance of these local anesthetics can be variable in newborn infants. Bupivacaine is
an amide local anesthetic requiring conjugation to inactive metabolites in the liver and excretion in the
kidneys. Clearance can therefore be delayed in newborns, especially after abdominal surgery. Early
pharmacokinetic studies demonstrated that, in contrast to the steady state levels seen in older infants,
infants less than 4 months of age, receiving infusions of 0.1% bupivacaine can have steadily rising
bupivacaine plasma levels. Subsequent studies focusing specifically on infants less than 1 month of
age, demonstrated that at 48 hours of an infusion at 0.2 mg/kg/hour, rising bupivacaine levels are seen
in 60% of infants. For this reason, it is recommended that infusion rates in infants less than 2 months of
age should not exceed 0.2 mg/kg/hr for the initial infusion and should be lowered as tolerated during the first
several days of infusion. In order to provide adequate spread of the local anesthetic and still maintain
bupivacaine levels below this range, an infusion of 0.05% bupivacaine mixed with 1 µg/mL of fentanyl
has been used at rates of 0.2 – 0.4 mL/kg/hour (0.1 –0.2 mg/kg/hour of bupivacaine) with good success.
When the tip of the epidural catheter is properly placed, infusion rates can often be further reduced to
0.1 mg/kg/hour (0.2 mL/kg/hour) on the second or third postoperative day without significantly
affecting pain relief. Lidocaine has also been used for continuous epidural infusions in newborns with the
possible advantage of allowing plasma blood levels to be easily obtained during the infusion. Concerns
regarding the rapid development of tolerance to this local anesthetic in laboratory animals have limited its
10. widespread use.
To avoid these concerns regarding bupivacaine clearance, 2-chloroprocaine has been used for
epidural infusions in neonates. Since 2-chloroprocaine is an ester local anesthetic, it is metabolized by
plasma cholinesterases and rapidly cleared from the circulation. Theoretically, higher infusion rates can be
administered with less likelihood of accumulation. Henderson and colleagues demonstrated a rapid
clearance of chloroprocaine in neonates even at high infusion rates (1.0 mL/kg/hour of 3% chloroprocaine).
In their cohort of patients, a continuous caudal epidural infusion was used to provide intraoperative surgical
anesthesia during prolonged surgical procedures in former preterm infants as a means of avoiding the need
for general anesthesia. Alternatively, the caudal epidural infusion of chloroprocaine has also been combined
with general anesthesia during major intra-abdominal procedures to allow for tracheal extubation at the
completion of the procedure. Further studies are needed to assess the efficacy and safety of long-term
infusions of 2-chloroprocaine in newborns, since there are limited data currently available in the adult
population and the studies performed to date in the pediatric population, have included intraoperative
infusions with a maximum duration of 3-4 hours. With long term postoperative use, the rapid development
of tachyphylaxis may limit its utility.
Summary
Interest in pediatric epidural blockade continues to grow, with increasing applications of epidural
anesthesia during the perioperative period. Epidural medications generrally include some combination of
local anesthetic agent, opioid, and/or a variety of adjuvant agents such as ketamine or clonidine. Although
the epidural space may be accessed at any vertebral level, caudal block is most common in pediatric practice.
Unless a hydrophilic opioid such as morphine is used, epidural analgesia optimally requires an approach at
the vertebral level corresponding to the dermatome at which maximal analgesia is desired. Epidural
analgesia may entail a single bolus administration or a continuous infusion via an epidural catheter. When
considering the options for prolonged analgesia (up to 24 hours), 3 basic options are available: 1) caudal
epidural injection of a hydrophilic opioid such as morphine, with butorphanol to limit the adverse effect
profile for morphine; 2) lumbar intrathecal morphine which has been shown to be effective for thoracic and
craniofacial procedures; or 3) an indwelling epidural catheter with a continuous infusion of a combination of
the agents outlined in this chapter.
Monitoring is essential for safety. The nursing staff must be trained to understand the
physiologic effects of epidural analgesia. A systematic means of assessment, focusing on the expected
complications from the drug regimen chosen must be instituted for each patient. Physiologic monitors
can be of benefit, but are plagued by false alarms. The SpO2 is sensitive for hypoventilation in children
breathing room air. However the use of supplemental oxygen can result in normal SpO2 readings well
into an evolving respiratory arrest. Standard epidural management orders should not generally allow
supplemental oxygen administration without an additional ongoing assessment of the respiratory status
such as respiratory rate or a non-invasive monitor of PaCO2. Adverse effects from epidural morphine
primarily, and other opiates also to a lesser degree, can cause significant patient distress. PONV,
pruritus, respiratory depression, and urinary retention occur at lower rates for patients who receive local
anesthesia alone, or in conjunction with clonidine or ketamine. Keeping epidural drug management
simple, using the fewest number of drugs to achieve pain control remains the goal.
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