KEY POINTS

1. Embryologic and physiologic phenomena (or processes) are not achieved at birth; lower epidural approaches, use of lower concentrations of local anesthetics, and particular precautions in the selection of block needles are necessary.
2. Because of psychological immaturity and incomplete acquisition of the body image scheme, sedation or light general anesthesia is recommended during performance of block procedures, especially for those at risk of neurologic damage, to avoid panic attacks.
3. Physical means of location of the anatomic spaces, plexuses, and conduction nerves are required to achieve a block procedure safely in children.
4. Short-acting local anesthetics (e.g., lidocaine, mepivacaine) are not recommended for continuous infusions; ropivacaine has a longer T_max and higher C_max than bupivacaine in infants, but its V_d (distribution volume) and clearance are affected less by continuous infusions, and ropivacaine is therefore preferable for this indication.
5. Sound selection of additives, especially clonidine, considerably improves the duration and quality of postoperative pain relief, making the use of a continuous technique unnecessary in many pediatric patients.
6. Regional procedures are anesthetic techniques, and they must be performed by experienced anesthesiologists in an operative room environment with suitable equipment (e.g., specifically designed block needles of appropriate length) and with full antibacterial precautions.
7. Whatever the procedure, the injection technique is critical, and four safety rules must be followed: aspiration test, evaluation of a test dose with epinephrine when appropriate, slow speed of injection, and immediate cessation if any unusual resistance is felt.
8. Spinal and epidural forms of anesthesia are well tolerated hemodynamically, especially by younger patients. However, their indications should be restricted to major operations or to patients at risk for postanesthetic apneas (e.g., premature infants younger than 60 weeks).
9. Peripheral conduction blocks are preferred over central block procedures whenever they are suitable for the operation; if long-lasting pain relief must be provided, placement of a catheter along the nerve path should be systematically considered because the technique is very effective and carries virtually no risk.
10. Axillary, femoral, and popliteal sciatic blocks are the easiest, safest, and most recommended blocks for use in the daily practice of pediatric anesthesia.