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
Local anesthetic systemic toxicity (LAST), which is rare but potentially life threatening, can occur with any local anesthetic through any route of administration. Toxicity is based on ideal body weight, and symptoms of LAST can be divided into 2 main categories: neurotoxicity and cardiovascular toxicity. The symptoms of neurotoxicity include perioral numbness, metallic taste, mental status changes or anxiety, visual changes, muscle twitching, and ultimately, seizures, coma, and respiratory depression. The symptoms of cardiovascular toxicity include tachycardia, hypertension, ventricular arrhythmias, and/or asystole.
Patient risk factors for LAST include extremes of age, decreased muscle mass, renal/hepatic/cardiac disease, metabolic disturbances (eg, acidosis, hypoxia, hypercarbia), and pregnancy. Procedural risk factors for LAST include injection into highly vascular areas (highest incidence in paravertebral injections, followed by upper and lower extremity peripheral nerve blocks) and multiple injections or infusion.
To reduce the risk of LAST, dilute anesthetics with normal saline, allowing for large volume blocks to be performed without risking toxic doses. Vasoconstrictors such as epinephrine can be added to decrease the rate of absorption and therefore decrease toxic doses. Use an ultrasound to confirm needle placement, and aspirate prior to injecting. Monitor the patient for development of symptoms. Using the Local Anesthetic Dosing Calculator on patients undergoing nerve blocks or regional anesthesia to calculate the maximum dose in advance may help reduce the risk of LAST. However, the calculator should not be used as the primary means of dosing. Always double check and err on the side of caution.
If the dose is above the threshold for toxicity, consider lowering the dose of local anesthetic.
Prepare for adverse events by storing a checklist for management as well as intralipid in a nerve block cart (it does not require refrigeration) for easy access if any complications should occur.
When diagnosing LAST, note that it results from sodium channel blockade, which affects the central nervous system and cardiac system. The central nervous system is more sensitive to the effects of local anesthetics than the cardiac system and will generally manifest signs/symptoms of toxicity first.
To manage LAST, stop the infusion of anesthetics, and provide supportive care (advanced cardiovascular life support, benzodiazepines for seizures, airway management). Consider giving intralipid
(see the guidelines from the American Society of Regional Anesthesia and Pain Medicine and the Association of Anaesthetists of Great Britain and Ireland).
Multiple variables may influence a patient's risk of developing LAST. This weight based calculator should be used to generate a rough estimate for toxic doses.
There are no randomized clinical trials involving LAST. Much of the existing evidence is based on case reports, expert opinion, and retrospective anesthesia databases.
Nathan Teismann, MD
Previous versions of Goldfrank’s Toxicologic Emergencies reported an increased maximum allowable dosage due to the vasoconstrictive effects of epinephrine when added to local anesthetics. The most recent version no longer includes this adjustment. While there likely is a higher safe dose when epinephrine is added, that estimate is no longer included in this calculator. As always, dosages should be double-checked and reviewed using local pharmacy practice and policies.
William White, MD; Lilly Bellman, MD, FAAP; Yiju Teresa Liu, MD
Ashkon Shaahinfar, MD, MPH, FAAP; Mark L. Waltzman, MD
May 2, 2022
June 1, 2025
Date of Original Release: May 1, 2022. Date of most recent review: April 1, 2022. Termination date: May 1, 2025.
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