Regional Anesthesia and Analgesia (also see Chapter 45 )

Most regional anesthesia techniques used in adults can be administered safely to pediatric patients as long as strict attention is paid to the dose of local anesthetic, the dose of epinephrine, the route of administration, and the use of proper equipment.^{[239] [365] [366]} Perhaps the greatest advance in pediatric anesthesia has been the development of methods producing postoperative analgesia (also see Chapter 72 and Chapter 73 ). Caudal anesthesia, caudal narcotics, regional blocks, and patient-parent-nurse-controlled analgesia have all been accepted by anesthesiologists and patients. Even pediatric patient-controlled epidural analgesia has been successfully used in children as young as 5 years.^[367] Each institution and practitioner must decide which method works best, given each particular practice setting. Obviously, until dosage guidelines and safety standards for monitoring are well established, some of these techniques must be limited to medical centers familiar with their use in children.^[368]

It is my practice to supplement the analgesia of either opioid or regional techniques with 40 mg/kg rectal acetaminophen at the beginning of the procedure. Several studies have demonstrated that 40 mg/kg rectal acetaminophen will place most patients in the therapeutic range for antipyresis (we do not know the plasma levels associated with analgesia in children) within 60 to 180 minutes, hence the need to insert the suppositories at the beginning of the procedure rather than the end.^{[369] [370] [371] [372]} It should be noted that suppositories should not be cut because the drug is not evenly distributed within the matrix; combinations of suppository doses are the best means of achieving a dose close to 40 mg/kg. Repeat rectal dosing should be approximately 20 mg/kg every 6 hours until transition to oral acetaminophen (total 24-hour limit, ≅100 mg/kg either orally or rectally).^[369]

Regional nerve blocks and direct local infiltration of surgical wounds with long-acting local anesthetics are simple, yet very effective methods of providing pain relief for all children. In most institutions it is now rare for a pediatric patient to awaken from anesthesia without some form of regional block. ^{[239] [372] [373]} This practice has been especially helpful in the outpatient population; parents are encouraged to start analgesics when they observe their child becoming irritable but before complete dissipation of the block. This approach usually provides a smooth transition from general anesthesia and a pain-free patient.

Chapter 43 and Chapter 44 discuss regional anesthesia and analgesia in detail, with Chapter 45 placing special emphasis on pediatrics.