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A Journal on Anesthesiology, Resuscitation, Analgesia and Intensive Care
Minerva Anestesiologica 2009 October;75(10):577-83
Pediatric regional anesthesia
Ivani G., Mosseti V.
Division of Pediatric Anesthesiology and Intensive Care Unit, Regina Margherita Children’s Hospital, Turin, Italy
Pediatric regional anesthesia has attained wide use internationally because of its efficacy and safety; its use is supported by the existence of extensive data from the international literature underlining the safety and efficacy of this technique. Safer drugs and dedicated pediatric tools are the keys to this success. Indeed, if we compare the drugs available to pediatric anesthesiologists for use in performing a block years ago with those in use today, it can be seen that progress in this area has been tremendous. The long journey began many years ago; at that time, pediatric regional anesthesia was seen as an extravagant and useless technique, used by only a few and opposed by many detractors. Despite its well-known benefits, clinical failures can occur during the application of regional anesthetic techniques. Neurovascular anatomy is highly variable, and presently available nerve localization techniques provide little or no information regarding the anatomical spread of local anesthesia; furthermore, traditional nerve localization techniques (nerve stimulation) rely on anatomical assumptions that may be incorrect. Modern imaging techniques, such as computed tomography scanning and ultrasound, are now available for improving these procedures. The ultrasound technique is now widely applied in children and many reports confirm the efficacy and advantages of this method. In children, ultrasound guidance has been shown to improve block characteristics, resulting in shorter block performance time, higher success rates, shorter onset, longer block duration, reduction in volume of local anesthetic agents required, and better visibility of neuraxial structures. Clinical studies in children suggest that ultrasound guidance has some advantages for regional block over more traditional nerve stimulation-based techniques. However, with the exception of ilio-inguinal blocks, the advantage of ultrasound guidance over traditional with respect to safety has not been adequately demonstrated in children, since there are only a limited number of randomized control trials in children comparing ultrasound-guided peripheral nerve block with other techniques. Real-time ultrasound guidance for peripheral regional anesthesia is not a foolproof technique. New data have emerged suggesting that the novice ultrasonographer may often commit repeated errors, the two most common being failure to visualize the needle during advancement and unintentional probe movement. For this reason, the American Society of Regional Anesthesia and the European Society of Regional Anesthesia created a Joint Committee, and a document was produced “to recommend to members and institutions the scope of practice, the teaching curriculum, and the options for implementing the medical practice of ultrasound-guided regional anesthesia services”