Environmental Conditions for Safe Regional Procedures

Monitoring Procedures

Regional anesthesia is not without consequences. It must be performed by anesthesiologists in the operating room with the same monitoring equipment as used for general anesthesia. An intravenous line must be established before any injection of local anesthetics. As stated by Eyres,^[131] "It may be deemed negligent not to have access to a reliable open vein during administration of significant doses of local anesthetics." Placement of a precordial stethoscope and monitoring of electrocardiographic tracings, blood pressure, temperature, and respiratory rate are the minimal requirements. Evaluation of tidal volume, end-tidal carbon dioxide, and peripheral oxygen saturation by pulse oximetry are desirable especially in infants. All the data should be noted on a complete anesthesia chart.

Sedation of the Patient

Regional blocks can be performed without sedation on cooperative and un-premedicated patients.^[132] During emergency procedures, especially in the presence of a full stomach, general anesthetics and sedatives should preferably be avoided, and it is surprising how well the children accept these techniques when they are in pain. During elective surgery, many children fear needles, and general anesthesia is usually requested by the patient. If not contraindicated for medical reasons, light general anesthesia can be safely used and is widely accepted in pediatrics.^{[1] [133]} Potentially dangerous procedures such as interscalene blocks or thoracic epidurals must not be attempted on unanesthetized patients, even if apparently cooperative, because it cannot be guaranteed that the patient will not panic during the procedure, as has been reported even for adults.^[134] Injection of muscle relaxants must be delayed until the block procedure is fully achieved^[135] because general anesthesia occasionally can be detrimental to the patient in hiding early symptoms of potential complications.

Assessment of the Block

The efficacy and extent of any block must be systematically evaluated for patients of all ages. This evaluation is not easy in children, even when conscious, in the absence of a motor block. It cannot be achieved properly in alert patients unless the anesthesiologist has gained the confidence of the child, disguises what is being done (especially handling of needles), and makes comparative tests in nonblocked areas. Gentle skin pinching is the most dependable technique of sensory testing, especially in lightly anesthetized patients, whereas answers by very anxious alert patients can be misleading. Application of neuroselective electrical stimulation has proved to be suitable in healthy volunteers,^{[136] [137]} but clinical data for pediatric patients are lacking, even though the technique looks promising. In awake patients, eliciting muscle twitches and injecting concentrated local anesthetic to produce a motor block can be helpful in reassuring the child of the effectiveness of the procedure. When the patient is awake, it is important that the anesthesiologist provides psychological support during the first minutes after skin incision to avoid panic until the child is convinced of the success of the block procedure.

Medicolegal Implications

In pediatric practice, the patient and the parents have to be convinced that no malpractice has occurred. The recommendations appearing in Table 45-7 should be followed when possible to avoid irrelevant medicolegal problems.