1.1

History

The first publication of pediatric regional anesthesia dates to August 1898, when August Bier attempted spinal anesthesia with cocaine on six patients, two of whom were children. Regrettably, all patients, including Bier himself after undergoing the procedure at the hands of a colleague, experienced postoperative vomiting and headaches. Consequently, Bier concluded that the technique offered little advantage over general anesthesia [ ]. Despite this setback, Bier’s pioneering work laid the foundation for the further development and refinement of pediatric regional anesthesia.

Between 1908 and 1910, Dr. Tyrel Gray conducted a series of surgical procedures on children aged 3 months to 13 years using spinal anesthesia. Interestingly, none of these children received sedation; instead, they were accompanied by trusted nurses during the surgery, and some even enjoyed a slice of cake! Dr. Gray recognized the significant advantages of spinal anesthesia, and he believed it would play a crucial role in pediatric surgery. He acknowledged that any disadvantages associated with its use would likely diminish with further research: “The advantages to be gained by the use of spinal analgesia have so far impressed me that I am convinced it will occupy an important place in the surgery of children in the future. Such disadvantages as are consequent on its use will doubtless be eliminated as more work is done on the subject, but these I have found comparatively trifling when compared with those of general analgesia administered under the same conditions.” [ , ].

1.2

Shift in trends

Apart from one noteworthy exception, Meredith Campbell’s groundbreaking introduction of caudal anesthesia for children at the American Society of Regional Anesthesia in 1933, there was a noticeable decline in interest in regional anesthesia [ ]. Several factors contributed to this waning enthusiasm. Some were related to substantial improvements in general anesthesia, both in terms of technical advancements, such as the widespread adoption of tracheal intubation and mechanical ventilation, and pharmacological developments, particularly the availability of safer volatile agents like halothane [ , ]. In contrast, regional anesthetic techniques and agents saw little change, and information regarding the pharmacology of local anesthetics in children was limited. Moreover, regional anesthesia was perceived to be time-consuming, less reliable, potentially risky (with legal complications), varied in duration, and lacked flexibility (adjusting the depth of anesthesia was difficult). It demanded specialized expertise and the use of custom-designed, often hard-to-sterilize, reusable pediatric equipment. Moreover, most surgeons preferred patients to be under general anesthesia: unconscious and immobile [ ].

The revival of pediatric regional techniques didn’t take place until the 1970s, with Dr. Estela Melman’s description of 200 cases using neuraxial techniques for both general and orthopedic surgery [ ]. Her research substantiated the safety and efficacy of regional anesthesia in pediatric surgery, without morbidity or mortality. Interestingly, this finding stood in stark contrast to an accompanying editorial that expressed skepticism, stating, “I doubt that the types of pediatric regional anesthesia discussed in this paper will gain much acceptance in this country.”

1.3

Present day

Since then, the practice of pediatric regional anesthesia has evolved significantly. One pivotal development was the shift from using regional anesthesia alongside sedation to using it as a supplement to general anesthesia. This shift not only enhanced the safety, but also improved the overall effectiveness of these techniques [ ]. Furthermore, moving from a purely landmark-based practice to incorporating the use of nerve stimulators played a crucial role in encouraging more widespread adoption [ , ]. However, it was the introduction of ultrasound that notably accelerated the widespread use of regional techniques in children [ ].

Additionally, there has also been a paradigm shift away from central techniques. A landmark retrospective study by ADARPEF, of over 24,000 pediatric regional blocks, found that complications were rare, mostly minor, and often preventable with the appropriate equipment. Most notably, the study found zero adverse events among the 9396 peripheral blocks examined [ ]. As a result, the authors advocated a preference for peripheral techniques over central ones. This shift remains a dominant and persistent trend to this day [ , , , ]. Despite widespread preference for peripheral nerve blockade over neuraxial, caudal blocks are fundamentally versatile and remain commonplace within the practice of pediatric anesthesia. Of the 104,393 blocks included in the PRAN database analysis by Walker et al., the most common block was a single-injection caudal [ ].

1.4

Safety of pediatric regional anesthesia

Although the utilization of pediatric regional techniques has gained popularity, it still faces challenges in achieving the same level of widespread acceptance as in adult cases [ ]. One of the biggest identifiable differences between adult and pediatric regional anesthesia is the propensity to perform blocks, both peripheral and neuraxial, after the induction of general anesthesia in the pediatric population, as opposed to awake or with minimal sedation as in adults. Therefore, one of the primary challenges in recent times has been addressing safety concerns, particularly when performing regional techniques in conjunction with general anesthesia. This combination raises concerns about the loss of critical sensory feedback, which typically serves as an alert for unintentional intravascular injection or paresthesias, signaling potential nerve injury.

In fact, this was famously discussed in a case report involving paralysis following epidural placement under general anesthesia in an adult patient. The authors concluded that performing epidurals under general anesthesia should only be considered in life-threatening situations [ ]. In response, prominent figures in pediatric anesthesia argued that the standard of care in medicine is “ultimately determined by the common practice of physicians and by common sense–an element that seemed to be lacking in the case report by Bromage and Benumof.” [ ] They emphasized that performing regional anesthesia in awake or lightly sedated children might be even riskier, and instead recommend that they must be sedated or anesthetized to ensure the safe administration of a regional block while the child remains still and calm [ ]. Nevertheless, no matter how strongly worded the editorials may be, they cannot substitute for actual data.

Given the infrequent occurrence of such events, it remained imperative to rely on comprehensive registries to obtain a more precise risk assessment. In the past two decades, several projects attempted to provide an accurate representation of the incidence of adverse events associated with regional techniques performed in children under general anesthesia. These results consistently reveal that most regional blocks were conducted under general anesthesia ( Table 1 ). The risk for neurologic or severe local anesthetic toxicity was found to be higher for awake or sedated blocks than under general anesthesia, even when adjusted for age [ ]. In fact, Taenzer and colleagues observed more than a sevenfold increase in postoperative neurological symptoms in awake patients [ ]. Only two cases of nerve injury lasting over a year were reported: one due to cauda equina syndrome resulting from a medication error [ ], and the other involving numbness following a sedated popliteal block [ ]. Notably, the two most severe complications, namely nerve injury and Local Anesthetic Systemic Toxicity (LAST), are exceedingly rare, with estimated rates ranging from 0.02% to 0.13% for nerve injury and approximately 0.01%–0.05% for LAST [ , , , , ]. An appropriately conservative interpretation of the data suggests that the risk associated with placing nerve blocks under general anesthesia in children is comparable to that in awake adults [ , , , ].

1.5

The evolution of pediatric anesthesia: Summary points

• ●
  

  Pediatric regional techniques have gained popularity in recent times, but they still face challenges in achieving the same level of widespread acceptance as in adult cases.

  
  
• ●
  

  Safety concerns are one of the primary challenges, particularly when performing regional techniques in conjunction with general anesthesia.

  
  
• ●
  

  These multiple large scale database analyses agree that the routine practice of performing regional anesthesia for pediatric patients while the patient is under general anesthesia is just as safe, if not safer, than awake patients.

3.1

Compartment syndrome

Regional anesthesia and its potential to mask compartment syndrome has been a long-standing controversy. Compartment syndrome is an acute emergency characterized by inter-compartmental tissue pressure >30 mm Hg. This causes tissue ischemia and requires emergent decompression to prevent further damage. Compartment syndrome is often associated with trauma, fractures, malpositioning during surgery or ischemia-reperfusion injury. The abnormally high pressure in a closed, non-compliant muscle compartment leads to decreased circulation, ischemia, and eventually myonecrosis. There is risk to loss of limb if treatment is delayed beyond 4 h from symptom onset [ , ].

This syndrome is not unique to any population and is seen in all age groups. Although, diagnosis may be more challenging in infants and young children due to their level of development and its impact on communicating symptoms to caregivers and healthcare team. Severe pain, that is not explained by the trauma or surgery, is often the most identifying of the common symptoms of compartment syndrome ( Table 2 ) [ ]. Hence, there has been long standing concern that a nerve block, which interferes with the experience of pain, could delay diagnosis. Nevertheless, sudden increase in pain, as measured through validated pain scales, should prompt urgent evaluation of the patient. In fact, some have argued that a comfortable patient with a nerve block who has sudden breakthrough pain would be more easily identified as having early symptoms of compartment syndrome ( Fig. 1 ) [ , ].

Breakthrough pain in acute compartment syndrome [ ].

The European Society of Regional Anaesthesia and Pain Therapy and the American Society of Regional Anesthesia and Pain Medicine Joint Committee released a joint statement that supported the safe use of regional anesthesia in pediatric patients with no evidence that it may increase the risk of acute compartment syndrome or delay its diagnosis [ ]. They also provided several recommendations, which are summarized in Table 3 [ ].

Table 3

Best practice rules to avoid/reduce risk of compartment syndrome in pediatric regional anesthesia.

Local Anesthetic Concentration	Single shot (Peripheral and neuraxial): Use 0.1%–0.25% bupivacaine, levobupivacaine, or ropivacaine concentrations
	Continuous Infusions Use 0.1% of Bupivacaine, levobupivacaine, or ropivacaine concentration
High Risk Surgery for Compartment Syndrome	These include tibial compartment surgery, advised to restrict both volume and concentration in sciatic catheters to avoid overly dense nerve blockade
Local anesthetic additives	Use with caution as additives can increase duration and/or density of block
Monitoring	Patients at higher risk for compartment syndrome who have received a regional anesthetic should be followed by an acute pain service to allow for early detection
Urgent Workup	If compartment syndrome is suspected, compartment pressure should be urgently measured

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