SPINAL,EPIDURAL/CAUDAL,PENILE NERVE BLOCK IN PEDIATRIC PATIENTS

1. SPINAL,EPIDURAL/CAUDAL,PENILE NERVE BLOCK IN PEDIATRIC PATIENTS MODERATOR:Dr. JYOTI PATHANIA PRESENTED BY: Dr. SUCHIT KHANDUJA

2. INDICATIONS OF REGIONAL BLOCKADE • Analgesia:Bothintraop and postop • Testicular torsion or incarcerated hernia at immediate risk of rupture in nonfastedchildren • Inguinal hernia repair in former preterm infants younger then 60 weeks of postconceptual age • Severe acute or chronic respiratory insufficiency • Emergency conditions in children with severe metabolic or endocrine disorders • Neuromuscular disorders, myasthenia gravis, or some types of porphyria • Some types of polymalformative syndromes and skeletal deformities

3. Absolute Contraindications to Neuraxial Blocks • Parental refusal • Severe coagulation disorders, which may be either constitutional (hemophilia), acquired (disseminated intravascular coagulation) • Severe infection such as septicemia or meningitis • Hydrocephaly and intracranial tumoralprocess • True allergy to local anesthetics • Certain chemotherapies (such as with cisplatin) prone to induce subclinical neurologic lesions • Uncorrected hypovolemia • Cutaneousor subcutaneous lesions

4. Absolute Contraindications to Peripheral Nerve Block Procedures • True allergy to local anesthetics is the only absolute medical contraindication to peripheral nerve blocks. • Coagulation disorders. • Septicemia does not necessarily contraindicate peripheral nerve blockade if expected benefits are significant. • Hypovolemiashould preferably be corrected

5. OTHERS.. • Patients at risk of compartment syndrome • Haemoglobinopathies • Bone and joint anomalies

6. Local Complications • Inappropriate needle insertion damaging the nerve and surrounding anatomic structures •   Tissue coring and introduction of epithelial cells into tissues where they do not belong •    Injection of neurotoxic solutions (syringe mismatch, epinephrine close to a terminal artery)   •    Leakage around the puncture site, especially when a catheter has been introduced, which may cause partial block failure and favor bacterial contamination

7. Systemic Complications Usually concomitant with accidental IV or arterial injection

8. Caudal Anaesthesia Indications: • Most surgical procedures of the infraumblical part including inguinal hernia repair • Urinary and digestive tract surgery • Orthopedic procedures on the pelvic girdle and lower extremities. Contraindications: Specific contraindications include major malformations of the sacrum (myelomeningocele, open spina bifida), meningitis, and intracranial hypertension.

9. EQUIPMENTS • 50 mm, 35 mm, and 30 mm with 5 mm depth markings • 0.9 mm / 20 G, 0.7 mm / 22 G, 0.5 mm / 25 G • Appropriate sizes for new-borns, infants and school children

10. Caudal Anesthesia – Technique

11. Techniques • Performed with the patient in the semiprone or, especially in nonanesthetized premature infants, in the prone position either with a rolled towel slipped under the pelvis or with the legs flexed in the frog position. • The two sacral cornua limiting the V-shaped sacral hiatus are located by palpation along the spinal process line at the level of the sacrococcygeal joint • 23 G needle is directed at 60 deg to skin till sacrococcygeal membranes are pierced and then cephalaud For about 2 mm. • Whoosh/swoosh test may be performed to confirm needle placement • LA is then administered • Epidural catheter can also be placed

12. Armitage regime Dosage:With 0.5 mL/kg, all sacral dermatomes are blocked.    •    With 1.0 mL/kg, all sacral and lumbar dermatomes are blocked.    •    With 1.25 mL/kg, the upper limit of anesthesia is at least midthoracic

13. Anesthesiology 101:A1470, 2004

14. Specific Complications • Delayed postoperative voiding • Block failure • Venous air embolism

15. EPIDURAL ANAESTHESIA INDICATIONS: • Major abdominal, retroperitoneal, pelvic, and thoracic surgeries. • Cardiac surgery in a few institutions:Considered controversial CONTRAINDICATIONS: • Severe malformations of the spine and the spinal cord • Intraspinal lesions or tumors • History of hydrocephalus • Elevated intracranial pressure • Unstable epilepsy • Reduced intracranial compliance

16. EQUIPMENT • Three different needle sizes • (1.3 mm/18 G, 0.9 mm/20 G,0.7 mm/22 G) • Special length of 50 mm with 5 mm depth markings

17. Combinations…. • 0.7 x 50 mm (20 G) needle/ 0.6 x 750 mm (24 G) catheter • 1.3 x 50 mm (18 G) needle/0.85 x 960 mm (20 G) catheter

18. Techniques LUMBAR EPIDURAL • Space is usually approached in anesthetized patients via a midline route below the L2-L3 interspace. • A paramedian approach can be used instead in cases of spinous process anomaly or spine deformity. • The child is positioned in the semiprone position with the side to be operated lowermost and the spine bent to enlarge the interspinous spaces). • The sitting position can be used in conscious patients • For most paediatric patients LOR is by air and after 8 yrs it is by saline

19. 1 mm/kg is a useful approximation between 6 months and 10 years of age • Catheter is inserted not more than 3 cm • Around 0.1 mL per year of age is necessary to block 1 neuromere • Usual volumes of injectate range from 0.5 to 1 mL/kg (up to 20 mL.) • Adjuncts not to be used below<6yrs

20. Local anesthetic dosage: Loading dosage:Bupivacaine, levobupivacaine:Solution: 0.25% Dose:<20 kg: 0.75 mL/kg20-40 kg: 8-10 mL (or 0.1 mL/year/number of metameres)>40 kg: same as for adults Maintainance dosage:.1ml/kg every 6-12 hrly of half conc

21. For continuous infusion: <4 mo: 0.2 mg/kg/hr (0.15 mL/kg/hr of a 0.125% solution or 0.3 mL/kg/hr of a 0.0625% solution) 4-18 mo: 0.25 mg/kg/hr (0.2 mL/kg/hr of a 0.125% solution or 0.4 mL/kg/hr of a 0.0625% solution) >18 mo: 0.3-0.375 mg/kg/hr (0.3 mL/kg/hr of a 0.125% solution or 0.6 mL/kg/hr of a 0.0625% solution ROPIVACAINE(.2%): Loading and maintainance dosage same as bupivacaine

22. Thoracic Epidural Anaesthesia • Indicated for major operations requiring long-lasting pain relief. • Not commonly used techniques in children. • In children younger than 1 year of age, the procedure is similar to that for a lumbar approach, with a needle insertion. • Perpendicular to the spinous process line. • With age needle goes in more cephalic

23. Spinal Anaesthesia INDICATIONS: • Inguinal hernia repair in former preterm infants younger than 60 weeks of postconceptual age • Elective lower abdominal or lower extremity surgery • Cardiac surgery, cardiac catheterization:controversial.

24. Equipments • Spinal needle (24-25 gauge; 30, 50 or 100 mm long, Quincke bevel can be used • Neonatal lumbar puncture needle (22 gauge, 30-50 mm long) • Whitacre spinal needle used for adults is also an alternative

25. Techniques Same as that of adult hyperbaric bupivacaine are the most commonly used local anesthetics.

26. Approximate Distance: Skin to Subarachnoid Space MILLIMETERS Premie Newborn 5 months Cote´, A Practice of Anesthesia for Infants and Children

27. Doses of LA for Spinal Anesthesia in Neonates and Former Preterm Neonates Younger than 60 Weeks of Preconceptual Age (up to a Weight of 5 kg)

28. Usual Doses of Local Anesthetics for Spinal Anesthesia in Children and Adolescents

29. Complications Higher rate of failure..

30. PENILE N BLOCK INDICATIONS: • Release of paraphimosis • Dorsal slit of the foreskin • Circumcision • Repair of penile lacerations.

31. Technique Anatomical considerations: • Innervation of penis by pudendal nerve • Enters the penis deep to bucks fascia • Genitofemoral and ilioinguinal may additionally supply penis.

32. Technique • A fan shaped is created on base of penis • Bupivacaine .5% (2mg/kg) more commonly used • If more profound block needed deep dorsal nerve blocked with a 25g needle piercing Bucks fascia10 30 and 1-30 positions lateral to base of penis • Epinephrine is avoided

33. THANK YOU!!!