Paediatric anaesthesia
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Abdominal wall blocks are an effective regional anesthetic technique to provide sufficient analgesia in abdominal surgery. This article reviews the use of abdominal wall blocks in pediatric regional anesthesia.
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Paediatric anaesthesia · Jan 2012
ReviewEffects of regional analgesia on stress responses to pediatric surgery.
Invasive surgery induces a combination of local response to tissue injury and generalized activation of systemic metabolic and hormonal pathways via afferent nerve pathways and the central nervous system. The local inflammatory responses and the parallel neurohumoral responses are not isolated but linked through complex signaling networks, some of which remain poorly understood. The magnitude of the response is broadly related to the site of injury (greater in regions with visceral pain afferents such as abdomen and thorax) and the extent of the trauma. ⋯ It is important at the outset to understand that not all components of the stress response are suppressed together and that this is important when discussing different analgesic modalities (i.e. opioids vs regional anesthesia). For example, in terms of the use of fentanyl in the infant, the dose required to provide analgesia (1-5 mcg·kg(-1)) is less than that required for hemodynamic stability in response to stimuli (5-10 mcg·kg(-1)) (1) and that this in turn is less than that required to suppress most aspects of the stress response (25-50 mcg·kg(-1)) (2). In contrast to this considerable dose dependency, central local anesthetic blocks allow blockade of the afferent and efferent sympathetic pathways at relatively low doses resulting in profound suppression of hemodynamic and stress responses to surgery.
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Regional anesthesia in children has reached in the last decades a widespread approval and today is a valid and effective technique used in the daily activity in many pediatric centres. Data from surveys and studies show the very low rate of complications and suggest that the use of regional techniques in children is at least as safe as general anesthesia alone. Despite these evidences there are aspects still creating discussions on the best approach to avoid or prevent risks and on the way to make this techniques more and more reliable and safe. Compartment syndrome, test dose, loss-of-resistance technique and blocks performed under general anesthesia are examples of, sometimes, never-ending stories; this review without the presumption to solve every problem shows the more recent data to offer, if possible, the best updated-answer on these topics.
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The pediatric epidural is an accepted method of advanced analgesia in children. Newer techniques have now superseded pediatric epidural analgesia (PEA), being as effective and safer, especially with the advances in ultrasonography. PEA is, however, still an important technique to master and employ, and it may be that the indications for this mode of analgesia have now become more defined.
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The use of regional anesthesia is increasingly common in pediatric practice. This review reports the complications and risks in pediatric regional anesthesia. ⋯ However, the different studies have shown that regional anesthesia, when performed properly, carried a very low risk of morbidity in appropriately selected infants and children. In addition, the use of ultrasound-guided peripheral nerve blockade has shown some promise toward increasing the safety profile of these already safe techniques.