Analgesia in pediatric patients is critical for minimizing discomfort and maximizing satisfaction for both the patients and their caregivers. In the last decade, ultrasound has been shown to be effective in improving the safety and efficacy of regional anesthesia. This issue discusses materials, methods, and monitoring for pediatric patients undergoing nerve blocks in the emergency department, including both ultrasound-guided and landmark approaches. Special considerations for pediatric patients are reviewed, including maximum dosages of local anesthetic and how to perform nerve blocks safely in patients with different developmental abilities and in medically complex children. Recognition and management of local anesthetic systemic toxicity syndrome are also reviewed.
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Following are the most informative references cited in this paper, as determined by the authors.
2.American College of Emergency Physicians. Point-of-care ultrasonography by pediatric emergency medicine physicians. Accessed April 1, 2022. (Policy statement)
3.Scientific American. How does anesthesia work? Accessed April 1, 2022. (Magazine article)
15. Lexi-Drugs. Lexicomp. Accessed April 1, 2022. (Drug database)
22. American Society of Anesthesiologists Committee on Standards and Practice Parameters. Standards for basic anesthetic monitoring. Accessed April 1, 2022. (Practice guideline)
23. emDOCs.net - Emergency Medicine Education2019. Pain profiles - nerve block tips & tricks: sterility, safety, simulation. Accessed April 1, 2022. (FOAM)
24. Lin M. New trick of trade: recent chats on linear U/S probe in peripheral IV placement & tegaderm damaging probe. Slide probe into folded “cuff” of sterile glove. Flat edge and no wrinkles with probe cover. Bonus: glove ? fingers out of way. (Gel goes in first) Accessed April 1, 2022. (FOAM)
26. * Neal JM, Brull R, Horn J-L, et al. The second American Society of Regional Anesthesia and Pain Medicine Evidence-Based Medicine Assessment of Ultrasound-Guided Regional Anesthesia: executive summary. Reg Anesth Pain Med. 2016;41(2):181-194. (Executive summary) DOI: 10.1097/AAP.0000000000000331
27. * Guay J, Suresh S, Kopp S. The use of ultrasound guidance for perioperative neuraxial and peripheral nerve blocks in children. Cochrane Database Syst Rev. 2016;2(2):CD011436. (Systematic review, meta-analysis; 20 studies) DOI: 10.1002/14651858.CD011436.pub2
38. Roberts S. Peripheral nerve blocks for children. NYSORA. Accessed April 1, 2022. (Website, FOAM)
43. * Kriwanek KL, Wan J, Beaty JH, et al. Axillary block for analgesia during manipulation of forearm fractures in the pediatric emergency department a prospective randomized comparative trial. J Pediatr Orthop. 2006;26(6):737-740. (Randomized controlled trial; 41 patients) DOI: 10.1097/01.bpo.0000229976.24307.30
47. * Wathen JE, Gao D, Merritt G, et al. A randomized controlled trial comparing a fascia iliaca compartment nerve block to a traditional systemic analgesic for femur fractures in a pediatric emergency department. Annal Emerg Med. 2007;50(2):162-171. (Randomized controlled trial; 55 patients) DOI: 10.1016/j.annemergmed.2006.09.006
48. * Oberndorfer U, Marhofer P, Bösenberg A, et al. Ultrasonographic guidance for sciatic and femoral nerve blocks in children. Br J Anaesth. 2007;98(6):797-801. (Randomized controlled trial; 46 patients) DOI: 10.1093/bja/aem092
52. * Turner AL, Stevenson MD, Cross KP. Impact of ultrasound-guided femoral nerve blocks in the pediatric emergency department. Pediatr Emerg Care. 2014;30(4):227-229. (Retrospective; 81 patients) DOI: 10.1097/PEC.0000000000000101
53. * Ritcey B, Pageau P, Woo MY, et al. Regional nerve blocks for hip and femoral neck fractures in the emergency department: a systematic review. CJEM. 2016;18(1):37-47. (Systematic review; 9 studies) DOI: 10.1017/cem.2015.75
55. * Heffler MA, Brant JA, Singh A, et al. Ultrasound-guided regional anesthesia of the femoral nerve in the pediatric emergency department. Pediatr Emerg Care. 2022 Jan 10. DOI: 10.1097/PEC.0000000000002607 (Comparative study; 85 cases)
85. * Walker BJ, Long JB, Sathyamoorthy M, et al. Complications in pediatric regional anesthesia: an analysis of more than 100,000 blocks from the pediatric regional anesthesia network. Anesthesiology. 2018;129(4):721-732. (Prospective observation study; 104,393 blocks in 91,701 patients) DOI: 10.1097/ALN.0000000000002372
87. Herring A. Making your own pressure monitor. Highland EM Ultrasound Fueled Pain Management. Accessed April 1, 2022. (FOAM)
90. * Neal JM, Mulroy MF, Weinberg GL. American Society of Regional Anesthesia and Pain Medicine checklist for managing local anesthetic systemic toxicity: 2012 version. Reg Anesth Pain Med. 2012;37(1):16-18. (Practice guideline) DOI: 10.1097/AAP.0b013e31822e0d8a
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Keywords: nerve block, pediatric nerve block, ultrasound-guided nerve block, local anesthetic, regional anesthesia, local anesthetic systemic toxicity, LAST, peripheral nerve blocks, facial nerve blocks, upper extremity nerve blocks, brachial plexus nerve block, forearm nerve block, digital nerve block, lower extremity nerve blocks, femoral nerve block, fascia iliaca plane block, popliteal sciatic nerve block, posterior tibial nerve block, truncal nerve blocks, genitourinary nerve blocks, nerve block complications