Pediatric Anesthesia ISSN 1155-5645

RISKS: REVIEW ARTICLE

Pediatric regional anesthesia: what is the current safety

record?
David M. Polaner & Jessica Drescher
Department of Pediatric Anesthesiology, The Children’s Hospital Denver, University of Colorado School of Medicine, Aurora, CO, USA

Keywords
regional anesthesia; pediatrics; infants and
children; risks; safety; complications
Correspondence
David M. Polaner,
Department of Pediatric Anesthesiology,
The Children’s Hospital Denver, University
of Colorado School of Medicine, 13123 East
16th Avenue, B090, Aurora, CO 80045, USA
Email: polaner.david@tchden.org
Section Editor: Charles Cote
Summary
The use of regional anesthetics, whether as adjuncts, primary anesthetics or
postoperative analgesia, is increasingly common in pediatric practice. Data
on safety remain limited because of the paucity of very large-scale prospec-
tive studies that are necessary to detect low incidence events, although sev-
eral studies either have been published or have reported preliminary
results. This paper will review the data on complications and risk in pediat-
ric regional anesthesia. Information currently available suggests that regio-
nal blockade, when performed properly, carries a very low risk of
morbidity and mortality in appropriately selected infants and children.

Accepted 29 November 2010

doi:10.1111/j.1460-9592.2010.03499.x

epidural catheters placed under general anesthesia

Introduction
Regional anesthesia continues to increase in use and
popularity, both as a primary anesthetic and as a
means of providing postoperative analgesia. As more
large series appear in the literature and multicenter col-
laborative studies are published, better information
continues to appear about risk and safety, although
much remains unknown because large-scale prospective
data are limited.
Awake vs asleep
Pediatric regional blocks are usually administered to
children who are anesthetized, although Marhofer (1)
reported placing blocks in sedated or awake children.
There are no conclusive data regarding the relative
safety of regional block placement in awake vs anes-
thetized children. Although case reports have cited
patient complaints of pain during needle or catheter
placement as a hallmark for developing persistent
paresthesia or neuropathic pain, Horlocker et al.
reported 4298 consecutive adult patients who had
without a single case of nerve injury, and an editorial
signed by over 50 international experts in pediatric
regional anesthesia advocated the practice (2,3). Infer-
ences from the UK Epidural Audit, the French Lan-
guage Study of Regional anesthetics, and from the
Pediatric Regional Anesthetic Network (PRAN) all
support this contention (4–6)1. Placement of regional
blocks of all types under general anesthesia is consid-
ered the standard of care in pediatrics. A common log-
ical argument is that there is less risk of injury when
placing a needle in an immobile child than in one who
is struggling and might move unpredictably.
Injuries related to consequences of analgesia or
motor blockade
Motor block of the trunk or extremities produces
immobility, which may result in pressure sores or
compression injury to peripheral nerves. The UK
1
Note that an update to the French Language Study was pub-
lished after the acceptance of this review. See (50).

Pediatric Anesthesia 21 (2011) 737–742 ª 2010 Blackwell Publishing Ltd 737

Regional anesthesia safety
Epidural Audit reported 33 cases of this nature; how-
ever, all were detected early and resolved without sig-
nificant intervention; similar reports exist in adults
(4,7). The author is aware of several cases in which
either dermal injury or peripheral neuropathy was
caused by pressure on an immobile limb, including
one which resulted in chronic regional pain syndrome
following pressure on the peroneal nerve. It is critical
that patients with motor blockade be carefully
positioned, padded, and mobilized to prevent these
injuries.
Controversy exists as to whether regional blockade
can mask the symptoms of compartment syndrome.
Little data exist to support this notion, and one report
suggests the development of inadequate analgesia in a
previously functioning block may enhance early detec-
tion of this surgical complication (8). In the UK Epi-
dural Audit, four cases of compartment syndrome
were reported, heralded by pain that ‘broke through’
the epidural blockade despite adequate postsurgical
analgesia (4).
Intravascular injection and local anesthetic
toxicity
The accidental intravascular (IV) or intramedullary
injection of local anesthetics is a hazard when large
volumes of local anesthetic are injected in proximity to
blood vessels. The risk can be mitigated by careful
attention to technique. An epinephrine-containing test
dose can detect many, but not all, IV injections. Heart
rate changes alone during general inhalation anesthesia
will miss about 25% of IV injections; ST segment
changes will detect more than 97%, although during
total intravenous anesthesia with propofol and remif-
entanil T-wave morphology is insensitive, and one
must look for blood pressure changes (9–11). Fisher
et al. (12) reported a 5.6% incidence of IV injection in
742 caudal and epidural blocks. Of these 42 incidents,
six were detected by blood aspiration, 30 by heart rate
changes (five had decreases due to the baroreceptor
response), and the remainder by ECG morphology
changes. In the PRAN database, positive test doses
were detected in 0.6% of single injection and 0.7% of
catheter blocks (6). As no method of test dosing is
infallible, incremental injection is a critical safety tech-
nique whenever large volumes of local anesthetics are
injected (13). Direct visualization of the location of the
needle tip and the injectate with ultrasound may pro-
vide additional or alternative confirmation of lack of
IV injection (14). Epidurography has been reported to
detect unsuspected IV epidural catheter placement even
when test doses were negative (15).
738
D.M. Polaner and J. Drescher
Continuous catheter techniques increase the risk of
local anesthetic toxicity because of potential drug accu-
mulation over time. This appears to be a greater risk
in infants under 6 months of age who have low levels
of a-1-acid glycoprotein, resulting in a higher unbound
fraction of local anesthetic in blood (16). Care should
be taken not to exceed recommended limits of local
anesthetic administration (0.3 and 0.5 mgÆkg)1Æh)1 in
older children), especially after 24 h of infusion.
Treatment of local anesthetic toxicity consists of
immediate administration of 3 mlÆkg)1 of lipid emul-
sion. Epinephrine is probably unnecessary and detri-
mental (17–19).
Nerve injury
The risk of nerve injury appears to be very low in all
regional blocks in children. Flandin-Bléty’s retrospec-
tive analysis of epidural complications described five
severe permanent neurological complications (three
fatal) that were associated with the use of loss of resis-
tance to air to locate the epidural space. With the pre-
dominant use of loss of resistance to saline, no such
cases have been described in subsequent large-scale
studies. Peripheral nerve injury has been reported in 6
of 10 000 epidurals, all of which resolved in <1 year
and 2 of 1000 peripheral nerve or plexus blocks in
adults (4,20). Although transient paresthesia has been
reported, the incidence of permanent neurologic injury
in children following peripheral nerve blocks is extre-
mely low, and although good pediatric prospective
data are still forthcoming, few case reports of perma-
nent injury can be found. The PRAN database did not
report any permanent nerve injuries from blocks of
any type, and one only case of dysesthesia following a
sciatic nerve block which resolved within 6 months (6).
Infection
The greatest risk of infection occurs with indwelling
catheters (infections following single injection blocks
appear to be vanishingly rare) but the incidence of both
can be minimized with strict aseptic technique. Most
infections are presumed to arise from the insertion site
and migration of bacteria along the catheter tract.
Infections can be categorized as superficial or deep, the
latter obviously having more serious implications.
Superficial infections can generally be managed by with-
drawal of the catheter, local skin care, and a course of
antibiotics. Strafford et al. (21) reported the first large
retrospective analysis of infections of epidural catheters
in a series of 1620 children. The 90% of patients who
had short-term (mean, 2.4 days) postoperative catheters
Pediatric Anesthesia 21 (2011) 737–742 ª 2010 Blackwell Publishing Ltd
D.M. Polaner and J. Drescher
did not have any infections. Of the 10% with long-term
catheters (>5 days), four had suspected infections.
Only one was proven to have a deep infection, an
immunocompromised cancer patient who developed a
candidal epidural abscess and required laminectomy for
incision and drainage. The remaining patients had fever
but no evidence of infection in the epidural space,
although the catheter tip grew staphylococcus epiderm-
itis in one. More recently, the UK prospective audit
reported 28 infections, all of but three of which were
superficial, many caused by staphylococcus aureus (4).
The three deep infections included two epidural
abscesses and one child with meningismus (no lumbar
puncture was performed to confirm the diagnosis). Of
particular note was that several infections in this series,
including one of the epidural abscesses, were detected
more than a day after the catheter had been withdrawn.
Other investigators have reported this too (6). This
highlights the importance of follow-up with a high
index of suspicion should untoward events develop even
after a catheter has been removed.
Ganesh (22) reported one case of cellulitis in 227
children with peripheral nerve catheters; it resolved
with antibiotics. Because these children may be dis-
charged with the catheter in place, meticulous follow-
up and careful instructions to parents are critical.
Central neuraxis anesthesia
Spinal anesthesia (subarachnoid block)
Subarachnoid block (SAB) is the only pediatric regio-
nal technique that is used exclusively for intraoperative
anesthesia. Its popularity began with data suggesting
less risk of postoperative apnea in ex-premature infants
compared to general anesthesia. Concerns have
recently arisen regarding adverse effects of general
anesthetics on the developing brain, prompting even
greater interest in SAB for younger infants.
In 1984, Abajian reported his initial small series of
81 SAB’s, 36 of which were performed in ex-prema-
tures or infants with neonatal respiratory distress syn-
drome, with no complications other than eight block
failures (23). Several larger series have since been pub-
lished. The Vermont Infant Spinal Registry, which
includes data on all infants at the University of Ver-
mont under a year of age in whom spinal anesthesia is
attempted, reported 1554 consecutive SAB’s, and the
Schneider Children’s Hospital (Petach Tikva, Israel)
group reported 505 consecutive cases, all without sig-
nificant complications (24,25).
Failed block. Reports from centers with extensive
experience administering infant SAB’s suggest a failure
Pediatric Anesthesia 21 (2011) 737–742 ª 2010 Blackwell Publishing Ltd
Regional anesthesia safety
rate of <5%. A number of successful blocks may need
supplementation because of the stimulation of perito-
neal traction or prolonged duration of surgery.
Postanesthetic apnea. In Welborn et al.’s (26) prospec-
tive study, where infants <51 weeks postconceptual
age were randomized to spinal or general anesthesia
and followed postoperatively with pneumograms,
there were no episodes of apnea in the spinal group
except in those who received supplementation with
ketamine, compared with a 31% incidence in the gen-
eral anesthesia group. Krane et al. (27) performed a
randomized controlled study of 18 ex-premature
infants who received both preoperative and postoper-
ative pneumograms before randomization to general
or spinal anesthesia, permitting the investigators to
compare the preoperative (baseline) and postoperative
incidence of central apnea, bradycardia, and desatura-
tion. They found no change in central apnea before
and after either anesthetic, but the general anesthesia
group had higher incidences of bradycardia and hyp-
oxemia that were associated with irregular respiratory
patterns. There are several case reports of postanes-
thetic apnea in ex-premature infants following SAB
supported by a retrospective analysis of 133 infants
undergoing general or spinal anesthesia for hernior-
rhaphy (28,29). Early apnea after SAB appears to be
quite rare. Late apnea, occurring more than 8 h after
the resolution of blockade, may be more common
than generally assumed, especially if the SAB was
inadequate and conversion to GA was necessary. Pre-
operative pneumograms were not obtained in these
reports, so it remains unknown if the apneic events
are related to the anesthetic, postoperative opioid
analgesics, or pre-existing problems of respiratory
control.
Hypotension. Hemodynamic stability during SAB is
the rule in infants, unlike in the adult, even with very
high thoracic levels of blockade (30). Analysis of heart
rate variability suggests that decreased parasympa-
thetic modulation of cardiac function preserves blood
pressure and heart rate (31). The risk of hypotension,
even in the fasted infant, appears to be very low. Bon-
net et al., (32) however, measured a moderate fall in
blood pressure in former prematures receiving SAB,
which resulted in a fall in middle cerebral artery dia-
stolic blood flow velocity. Although blood pressure
fell, no infants became hypotensive. The clinical impli-
cations of their findings remain unclear, and this has
not been reported in other studies. The age at which
hemodynamic stability is lost is uncertain, but proba-
bly begins in young childhood.
739
Regional anesthesia safety
Total spinal. Care must be taken not to lift the legs of
the infant or to inject the local anesthetic with barbo-
tage when performing SAB (33,34). Either can drive
the block higher than intended. The incidence of high
blockade resulting in respiratory compromise was
0.6% in the Vermont registry.
Postdural puncture headache. The incidence of postdur-
al puncture headache after SAB in young infants is
unknown, although a 5% incidence in children older
than 1 year has been reported regardless of whether a
pencil point or Quinke point needle was used (35).
These headaches, however, were milder and of shorter
duration than those commonly described in adults. Five
percent of the 200 children in this study also reported
transient radicular irritation or transient low back pain.
Respiratory function. High levels of motor blockade
result from SAB, producing a loss of intercostal mus-
cle activity and diminished outward rib cage motion
(36). Tidal volume and minute ventilation are pre-
served because of increased diaphragmatic excursion.
Some infants develop rib cage paradox, which may
contribute to respiratory insufficiency, although this
also commonly occurs in infants during natural rapid
eye movement sleep (37).
Epidural and caudal blocks
These remain the most commonly performed regional
anesthetics in children. Both continuous and single
injection techniques (the latter, primarily caudals) are
employed for postoperative analgesia and intraopera-
tive anesthesia. Many of the risks described in SAB’s,
such as hypotension, respiratory function, and postan-
esthetic apnea, are applicable to epidurals. Because
catheter techniques involve the delivery of local anes-
thetics, opioids, and adjunctive agents through cathe-
ters over periods of days, some additional risks must
be considered and which may vary with the type of
agent injected.
The best data on complications to date come from
the prospective epidural audit conducted by the Asso-
ciation of Paediatric Anesthetists of the UK and Ire-
land (4). Ten thousands six hundred and thirty-three
continuous epidurals were prospectively accrued over
5 years, and complications categorized according to
severity and sequelae. Only five incidents were catego-
rized as serious, and of those only one had sequelae
lasting over 12 months, cauda equina syndrome related
to a drug infusion error. Inadvertent intrathecal injec-
tion resulting in spinal anesthesia occurred in two
740
D.M. Polaner and J. Drescher
patients. Persistent dural leak was not described in this
series, but can occur, and rarely may be resistant to
treatment with blood patch (E. Krane, personal com-
munication).
Catheter misplacement may be more common when
threading to more cephalad positions; in these cases, it
is prudent to obtain an epidurogram (38).
Central neuraxis opioids are often administered
through epidural catheters and carry several risks.
These are both dose dependent as well as drug depen-
dent, as the most hydrophilic agents have the greatest
propensity for rostral spread, while lipophilic agents
like fentanyl exhibit more localized binding to opioid
receptors in the spinal cord (39). The untoward effects
of central neuraxis opioids have long been known to be
dose dependent, and the minimum effective dose should
be chosen (40,41). The most serious complication is
respiratory depression, but pruritus and nausea can be
debilitating, and urinary retention may occur in up to
30% of patients. All can be mitigated with low doses of
antagonists such as naloxone (0.25–1 lgÆkg)1Æh)1);
mixed results have been reported with agonist–antago-
nists (nalbuphine, 0.05 mgÆkg)1 per 4 h) (42–44).
Peripheral nerve blocks
There is increasing use of peripheral neural blockade
in pediatrics, in part driven by the use of ultrasound
for localization (45). Claimed advantages include
decreased incidence of side effects compared with other
analgesic modalities, early discharge, site-specific anal-
gesia and reduction in health care utilization and costs,
although current data in children have not confirmed
these observations reported in adults (46). Both single
injection and continuous blockade of virtually all
reported peripheral nerve techniques have been
described in children, and these small series have all
noted a paucity of complications. The PRAN also
found few complications with peripheral blocks,
including none with blocks of the head and neck (6).
Catheter dislodgement is a risk with continuous
peripheral blocks in children. Securing the catheters
seems to need special attention in upper extremity
blocks and might be more problematic in all peripheral
blocks (47).
Ultrasound. Ultrasound guidance may reduce compli-
cations and improve the quality of regional blockade
compared with blind techniques or nerve stimulator
guidance. The greater precision of needle localization
with ultrasound may permit a major reduction in local
anesthetic volume needed to establish a block, thus
reducing the risk for local anesthetic toxicity. Ultra-
Pediatric Anesthesia 21 (2011) 737–742 ª 2010 Blackwell Publishing Ltd
D.M. Polaner and J. Drescher Regional anesthesia safety

sound guidance for ilioinguinal/iliohypogastric nerve
blocks allowed a reduction of anesthetic volume from
0.2 to 0.075 mlÆkg)1 (48). Ultrasound reduced local
anesthetic volumes by 30–50% in sciatic and femoral
nerve blocks in children and increased the duration of
sensory blockade, compared to nerve stimulator
guidance (49).
Outpatient continuous peripheral nerve catheters. There
is only one published report regarding the efficacy and
safety of continuous peripheral nerve catheters in
pediatrics (22). Two hundred and twenty-six peripheral
catheters were placed in 217 patients, of which 112 were
discharged home with their catheters. Complications
were reported in 2.8%: prolonged numbness (>24 h
after cessation of infusion), infection, difficult catheter
removal, and local anesthetic toxicity (tinnitus).
Conclusions
Regional blockade in infants and children appears to
have a very high degree of safety, whether used for in-
traoperative anesthesia or for postoperative analgesia.
Like with any anesthetic, scrupulous attention to
technique and detail and prudent patient selection is
essential to avoid complications. The use of new tech-
nologies, such as ultrasound-guided peripheral nerve
blockade, has shown some promise toward increasing
the safety profile of these already safe techniques.

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