Anaesthesia 2021, 76 (Suppl. 1), 74–88 doi:10.1111/anae.

15283

Review Article

Fundamentals and innovations in regional anaesthesia for

infants and children
G. Heydinger,1 J. Tobias2 and G. Veneziano3

1 Fellow, 2 Professor, 3 Assistant Professor, Department of Anesthesiology and Pain Medicine, Nationwide Children’s
Hospital, Columbus, OH, USA

Summary
Regional anaesthesia in children has evolved rapidly in the last decade. Although it previously consisted of
primarily neuraxial techniques, the practice now incorporates advanced peripheral nerve blocks, which were
only recently described in adults. These novel blocks provide new avenues for providing opioid-sparing
analgesia while minimising invasiveness, and perhaps risk, associated with older techniques. At the same time,
established methods, such as infant spinal anaesthesia, under-utilised in the last 20 years, are experiencing a
revival. The impetus has been the concern regarding the potential long-term neurocognitive effects of general
anaesthesia in the young child. These techniques have expanded from single shot spinal anaesthesia to
combined spinal/epidural techniques, which can now effectively provide surgical anaesthesia for procedures
below the umbilicus for a prolonged period of time, thereby avoiding the need for general anaesthesia.
Continuous 2-chloroprocaine infusions, previously only described for intra-operative regional anaesthesia,
have gained popularity as a means of providing prolonged postoperative analgesia in epidural and continuous
nerve block techniques. The rapid, liver-independent metabolism of 2-chloroprocaine makes it ideal for
prolonged local anaesthetic infusions in neonates and small infants, obviating the increased risk of local
anaesthetic systemic toxicity that occurs with amide local anaesthetics. Debate continues over certain practices
in paediatric regional anaesthesia. While the rarity of complications makes comparative analyses difficult, data
from large prospective registries indicate that providing regional anaesthesia to children while under general
anaesthesia appears to be at least as safe as in the sedated or awake patient. In addition, the estimated
frequency of serious adverse events demonstrates that regional blocks in children under general anaesthesia
are no less safe than in awake adults. In infants, the techniques of direct thoracic epidural placement or caudal
placement with cephalad threading each have distinct advantages and disadvantages. As the data cannot
support the safety of one technique over the other, the site of epidural insertion remains largely a matter of
anaesthetist discretion.

.................................................................................................................................................................
Correspondence to: G. Heydinger
Email: grant.heydinger@nationwidechildrens.org
Accepted: 7 September 2020
Keywords: 2-chloroprocaine; epidural anaesthesia; fascial plane block; regional anaesthesia; spinal anaesthesia;
paediatrics

Introduction emphasis on multimodal anaesthetic recovery protocols

Regional anaesthesia is becoming a familiar, if not essential, and accumulating evidence of improved outcomes. The
component of modern paediatric anaesthesia practice due specialty of paediatric regional anaesthesia continues to be
to the proliferation of ultrasound technology, increased refined, with the application of innovative blocks and

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Heydinger et al. | Regional anaesthesia in paediatrics Anaesthesia 2021, 76 (Suppl. 1), 74–88

techniques, as well as the resurgence of previously advisory committees support this as a standard of
established practices. The expansion of training practice [19]. However, children, particularly neonates and
programmes has led to training focusing on regional infants, are more vulnerable to local anaesthetic systemic
anaesthesia in infants and children. Recent anatomical toxicity (LAST) than adults [20]. Quality and safety reviews
investigations have enhanced our understanding of the and pharmacokinetic studies have established safe
relationships between fascial planes and the peripheral practices for local anaesthetic dosing in this population,
nervous system. The result is an increase in the application during both single shot and continuous infusion
of novel fascial plane techniques, such as the quadratus techniques [10, 21].
lumborum, serratus anterior and erector spinae blocks [1– In this review, we discuss the resurgence of older
3]. Originally applied in adults, fascial plane blocks have techniques, including neuraxial anaesthesia instead of
quickly moved into the paediatric domain [4–6]. general anaesthesia, and the use of 2-chloroprocaine for
Simultaneously, anaesthetic techniques that had become epidural anaesthesia in neonates, review novel techniques
less common over previous decades, such as infant spinal of regional anaesthesia in infants and children, and present
anaesthesia and the epidural administration of 2- updates on important topics, including LAST. Additionally,
chloroprocaine for postoperative analgesia, are being controversial topics, including the performance of regional
adopted with greater frequency in paediatric centres [7, 8]. anaesthesia in the anaesthetised patient, as well as direct vs.
Recent concerns regarding the potential deleterious caudal placement of thoracic epidural catheters are
neurocognitive effects of volatile and intravenous (i.v.) explored.
anaesthetics in young children have further enhanced
interest in regional anaesthesia and prompted its Methods
resurgence in place of general anaesthesia [9]. A systematic search of PubMed was conducted between
Regional anaesthesia is a safe and effective option for February and June 2020 using search terms including
intra-operative and postoperative analgesia in infants and ‘regional anaesthesia’; ‘local anaesthesia’; ‘spinal’;
children, including pre-term neonates. It avoids opioid- ‘epidural’; ‘caudal’; ‘chloroprocaine’; and ‘fascial plane
related adverse effects and facilitates the resumption of block’. Abstracts from publications were reviewed and
spontaneous ventilation and earlier tracheal extubation [7, those pertaining to the paediatric population or noted to
8, 10]. Spinal anaesthesia can reduce the incidence of provide specific insight into topics relevant to this article
postoperative apnoea and respiratory morbidity in high-risk were included for further review. The reference list of these
infants [11]. Spinal anaesthesia avoids airway publications was reviewed to ensure key paediatric reports
instrumentation, allows continuation of spontaneous regarding regional anaesthesia in infants and children were
respiration, and offers enhanced haemodynamic stability in identified. We reviewed neuraxial vs. general anaesthesia in
this fragile population [12]. Continuous epidural analgesia infants and children; continuous chloroprocaine epidurals;
in infants has been associated with numerous benefits, local anaesthetic systemic toxicity; paediatric fascial plane
including decreased time to tracheal extubation, earlier blocks; and controversial topics in paediatric regional
return of bowel function and attenuation of the metabolic anaesthesia.
stress response [13, 14]. Continuous regional analgesia may
also decrease postoperative sedative requirements in Neuraxial anaesthesia instead of
neonates after major surgery, resulting in reduced opioid general anaesthesia
wean times and shorter ICU length of stay [15]. Combined In recent years, there has been increased scrutiny on the
with general anaesthesia, regional anaesthetic techniques effects of anaesthesia on the developing brain. Concerns
decrease requirements for intra-operative volatile regarding the long-term neurobehavioural effects of
anaesthetic agents, opioids and neuromuscular blocking anaesthesia began in 1999 with the demonstration of
agents, thereby limiting their potential impact on accelerated apoptosis in juvenile rats after exposure to
neurocognitive outcomes [16]. specific anaesthetic agents that act through the N-methyl-D-
Audits of multi-institutional prospective databases have aspartate (NMDA) or gamma-amino butyric acid (GABA)
reported a low incidence of serious adverse events with systems [22]. Since then, studies in various animal species
regional anaesthesia in all age groups [17, 18]. The have demonstrated widespread cellular morphological and
incidence of adverse events is unaffected by performance behavioural changes after early exposure to commonly
of regional anaesthetic techniques under general used i.v. and volatile anaesthetic agents [23]. Proposed
anaesthesia or deep sedation in children. National mechanisms for the cellular changes include oxidative

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Anaesthesia 2021, 76 (Suppl. 1), 74–88
stress on mitochondrial pathways and interruption of
normal NMDA and GABA receptor activity [24, 25].
Despite no definitive human data, in 2016 the US Food
and Drug Administration issued a warning regarding the
potential impact of these agents for children aged < 3 years,
especially for procedures lasting more than 3 h or with
repeated exposures. While some retrospective studies have
demonstrated an association between early anaesthetic
exposure and neurodevelopmental deficits in children, other
trials have failed to show a correlation [26]. Recently, an
international, multicentre randomised controlled trial
showed no difference in neurodevelopmental outcomes at 2
and 5 years of age after a single, short-duration general
anaesthetic (60 min) with sevoflurane vs. an awake regional
technique during infancy [27, 28]. While reassuring, this trial
did not address prolonged or repeated exposure to general
anaesthesia, which may still have clinical ramifications, as
preclinical studies have observed neuro-apoptosis to be
dose- and time-dependent [9].
As our knowledge on this subject is incomplete and
many paediatric patients will require multiple anaesthetic
exposures throughout their childhood, consideration has
been given to alternative techniques. Regional anaesthesia
can decrease volatile anaesthetic, sedative or opioid
requirements when used as an adjunct, or alternative, to
general anaesthesia, while providing effective intra-
operative and postoperative analgesia [16, 29–31]. Spinal
anaesthesia in children was first introduced in the early 20th
century as a method of decreasing the significant morbidity
and mortality associated with general anaesthesia. The
modality was commonly employed until mid-century
advances enhanced the safety of general anaesthesia. A
resurgence in spinal anaesthesia occurred during the 1980s
as a technique to prevent postoperative apnoea following
general anaesthesia with halothane in former pre-term
infants with underlying pulmonary pathology [32].
Enthusiasm subsequently waned with the advent of newer
volatile anaesthetic agents (sevoflurane and desflurane),
which were associated with a decreased incidence of
postoperative respiratory events, including apnoea, when
compared with halothane.
Recently, interest in spinal anaesthesia has re-emerged
over concerns of the potential neurotoxic effects of general
anaesthesia on the developing brain, despite a lack of
evidence demonstrating such neurotoxicity. Williams et al.
reported that infants receiving spinal anaesthesia did not
have increased odds of poor academic achievement later in
life [33]. Accordingly, spinal anaesthesia was the control arm
of the largest prospective study examining the effect of
general anaesthesia on neurodevelopment [27, 28].
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Heydinger et al. | Regional anaesthesia in paediatrics
The benefits of spinal anaesthesia in infants extend
beyond avoiding potential neurotoxicity. Spinal anaesthesia
may also be desirable in infants given their higher incidence
of adverse effects with general anaesthesia compared with
the greater paediatric population [34]. In a series of > 1500
infants in which spinal anaesthesia was attempted for
surgical procedures, adverse events were uncommon but
included bradycardia in 1.6% and a ‘high spinal’ in 0.6%
[35]. Only 3.7% of patients required supplementary oxygen
either by nasal cannula or ‘blow by’ and oxygen
desaturation, defined as a pulse oximeter reading of < 90%,
occurred in only 0.6% of patients. A higher than intended
sensory level was observed in 56 out of 1483 patients (3.6%)
in which successful spinal block was obtained. Out of these
56 patients, 5 received bag-valve-mask ventilation and 5
required tracheal intubation. Similar results were found in
another retrospective evaluation of spinal anaesthesia in
1132 children, ranging in age from 7 days to 14 years
(mean age: 5 years 8 months) [36]. Less than 1% of the
cohort experienced oxygen desaturation (oxygen
saturation < 95%) and none required tracheal intubation.
Infants do not experience significant blood pressure
variations with spinal anaesthesia due to the immaturity of
the peripheral sympathetic nervous system. In an
investigation of infants undergoing pyloromyotomy,
changes in mean systolic blood pressure were -8.2  16.8%
and -24.2  17.2% with spinal and general anaesthesia,
respectively, and a difference between the means of 16.2%
(95%CI 9.5–22.9%) [37]. In another study, the relative risk of
moderate hypotension, defined as mean arterial pressure
< 35 mmHg, was increased by a factor of 4.5 (95%CI 2.7–
7.4, p < 0.001) with general anaesthesia compared with
spinal anaesthesia [12].
Improved efficiency and cost savings are also possible
with spinal anaesthesia in children, with procedure finish to
out-of-room time of less than 5 min. Ing et al. and Kachko
et al. reported operating room time reductions of 17.5 and
18.6 min, respectively, following spinal anaesthesia
compared with general anaesthesia for pyloromyotomy [38,
39]. Imbelloni et al. reported anaesthetic cost reductions of
54% after spinal, compared with general anaesthesia in
children [40]. Additionally, patients who do not receive
supplementary sedation may be able to bypass first-phase
post-anaesthesia recovery, thereby increasing cost savings
and facilitating same day hospital discharge.
Various surgical procedures have been successfully
accomplished in children with spinal anaesthesia, including
lower abdominal surgery (urological procedures and hernia
repair); lower extremity orthopaedic surgery; omphalocele
repair; exploratory laparotomy; myelomeningocele repair;
© 2021 Association of Anaesthetists
Heydinger et al. | Regional anaesthesia in paediatrics
and even patent ductus arteriosus closure (Fig. 1).
Achievement of successful spinal anaesthesia with
adequate levels of surgical anaesthesia has been reported
to be as high as 84–95% at experienced paediatric
institutions [35, 41]. Decreased cortical arousal resulting
from the de-afferentation of spinal anaesthesia allows the
majority of infants to sleep through surgical procedures
without the administration of systemic sedative agents,
further increasing the safety of these techniques. Reported
rates of the need for supplementary sedation requirement
are 15–24%, with most infants easily sedated using a
low-dose continuous dexmedetomidine infusion or
intermittent doses of midazolam and/or fentanyl [35, 41].
Complications related to spinal anaesthesia in the
paediatric population are infrequent. Although the
incidence of post-dural puncture headache after spinal
anaesthesia in older children and adolescents may be
similar to adults (4–5%), the symptoms are limited, with only
anecdotal reports of the need for an epidural blood patch
[42]. Backache following spinal anaesthesia is experienced
by approximately 5–10% of patients, whereas 3–4% may
develop transient neurological symptoms, including
paraesthesia [43]. To date, there are no reports of
permanent neurological injuries or fatalities following spinal
anaesthesia in paediatrics.
Spinal anaesthesia in infants is a time-limited technique
that has been historically considered for surgery lasting less
than 60 min. However, the duration of surgical anaesthesia
may be extended by the use of adjuncts such as clonidine. A
2018 retrospective single-centre analysis suggested that the
duration of spinal anaesthesia may be extended to 60–
100 min [44]. All patients in the cohort received intrathecal
1
isobaric bupivacaine 0.5% (1 mg.kg , up to 7 mg) with
clonidine and/or adrenaline. In a controlled, prospective,
1
dose-ranging study, adjunctive use of 1 µg.kg clonidine
(a) (b)
Figure 1 (a) Patient positioning for placement of spinal
anaesthesia; (b) Patient positioned for surgery following
spinal blockade.
© 2021 Association of Anaesthetists
Anaesthesia 2021, 76 (Suppl. 1), 74–88
was found to essentially double the duration of surgical
blockade (from 67 to 111 min) with isobaric spinal
bupivacaine, without deleterious haemodynamic or
respiratory side-effects.
To extend the boundaries of regional anaesthesia to
more complex urological and abdominal surgery, combined
spinal/caudal catheter techniques have been described. In
1996, Williams et al. provided the initial description of 19
infants undergoing major abdominal surgery with spinal
anaesthesia followed by insertion of a caudal epidural
catheter for the administration of a continuous local
anaesthetic infusion after the spinal anaesthesia dissipated
[45]. Duration of surgery varied from 50 to 200 min. All
patients completed surgery without supplementary opioids
or conversion to general anaesthesia. Mild sedation was
required in five patients, with either midazolam or a low-dose
propofol infusion. In 2007, Somri et al. investigated the
combined spinal/caudal technique for 28 high-risk neonates
and infants undergoing major upper abdominal surgery [46].
After spinal anaesthesia was performed, a caudal epidural
catheter was inserted and threaded to the appropriate
thoracic level with radiographic confirmation. Four patients
required conversion to general anaesthesia due to
unsatisfactory analgesia. Twenty infants required i.v.
midazolam for irritability. Intra-operatively, one neonate with
bronchopulmonary dysplasia, and another with neonatal
respiratory distress syndrome, developed a transient
increase in their respiratory effort after receiving midazolam,
and two infants with active apnoea of prematurity developed
apnoea intra-operatively. All four patients were treated easily
by the application of brief bag-valve-mask ventilation. The
authors reported no significant haemodynamic changes with
spinal/caudal epidural anaesthesia. In 2012, Somri et al.
performed a prospective randomised controlled trial to
assess the effect of combined spinal/caudal anaesthesia vs.
general anaesthesia on the return of gastrointestinal
function in infants undergoing elective intestinal surgery [47].
Fifty patients were randomly allocated either combined
spinal/caudal anaesthesia or general anaesthesia. The
spinal/caudal group had a faster recovery of intestinal
function, as well as a lower incidence of postoperative
abdominal distention and pneumonia.
More recently, a retrospective study outlined the
technique for 23 patients, aged 3–44 months, undergoing
complex urological procedures [48]. Twenty patients
successfully completed surgery with combined
spinal/caudal anaesthesia. One hour after intrathecal
injection for spinal anaesthesia, the caudal catheter was
1
dosed with 3% 2-chloroprocaine (1.5 ml.kg bolus
1 1
followed by an infusion of 1 ml.kg .h ) administered via
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Anaesthesia 2021, 76 (Suppl. 1), 74–88
the caudal catheter. A continuous i.v. dexmedetomidine
infusion was employed for sedation. All patients tolerated
surgery that included complex hypospadias repair; ureteric
re-implantation; ureterocele excision/re-implantation;
mega-ureter repair; feminising genitoplasty; and open
pyeloplasty without the need for airway intervention or peri-
operative complications. The average duration of surgery
was 109 min, with the longest lasting 172 min. The report
served as a proof of concept that prolonged urological
procedures can be completed with regional anaesthesia in
children aged up to 3 years. The authors suggested this
technique serves to avoid airway manipulation, which may
be particularly useful in patients with recent upper
respiratory tract infections, congenital airway abnormalities
or parenchymal lung disease. The authors noted that this
technique may also be offered to parents who express
concerns during the pre-operative visit regarding
neurocognitive effects of general anaesthesia.
Continuous epidural infusions in
neonates and infants
Opioids remain a mainstay for providing postoperative
analgesia in infants; however, their intra-operative and
postoperative administration may be associated with
adverse effects, including respiratory depression, the need
for postoperative mechanical ventilation and a delay in
return of gastrointestinal function. Opioid-sparing
anaesthetic techniques such as continuous epidural
analgesia may prevent or mitigate these effects. In 1986,
Ecoffey et al. described 20 infants receiving combined
general-epidural anaesthesia for urological and upper
abdominal surgery with the administration of intermittent
boluses of bupivacaine via the epidural catheter [49]. All
patients had their tracheas extubated at the conclusion of
surgery with none requiring opioids in the first 24
postoperative hours. Murrell et al. described a cohort of 20
term and pre-term neonates that received a combined
technique with general anaesthesia and an epidural infusion
of bupivacaine for major abdominal surgery [50]. Tracheal
extubation was accomplished in all patients at the
conclusion of surgery. Mean duration of postoperative
epidural infusion was 47 h, with effective analgesia and low
pain scores without the requirement for supplementary
analgesia. A much larger cohort was published by
B€
osenberg et al. involving 240 neonates receiving epidural
analgesia during, and following, major surgical procedures
[51]. The investigators reported stable intra-operative
conditions without the need for supplementary opioids or
neuromuscular blocking drugs and with a low incidence of
adverse events. Other authors have reported similar
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Heydinger et al. | Regional anaesthesia in paediatrics
advantages of epidural analgesia in neonates and infants,
including a limited need for parenteral opioids and early
tracheal extubation [8, 30]. In a case-control, matched study,
neonates receiving continuous epidural analgesia had
decreased mechanical ventilation times, improved
intestinal transit time and enhanced gastrointestinal
function after major surgery compared with conventionally
treated patients [14]. Others have reported that continuous
epidural analgesia was more effective in attenuating the
hormonal stress response compared with i.v. opioids after
abdominal surgery in infants [52].
Despite the benefits of continuing the epidural infusion
into the postoperative period, infants present unique
challenges for the provision of continuous epidural
analgesia. Immaturity of the hepatic microsomal enzyme
system and other physiological differences place neonates
and infants at higher risk for LAST. In the early 1990s, the
expanded use of continuous epidural analgesia resulted
in multiple reports of LAST in the paediatric population
[20, 53]. An Anesthesia Patient Safety Foundation
investigation revealed that in all cases, the toxicity was
associated with high-dose bupivacaine infusions above
1 1
0.5 mg.kg .h . Careful dose restriction is needed,
especially in neonates and infants, when using continuous
infusions of epidural bupivacaine or ropivacaine [10, 21].
However, additional pharmacokinetic data provided
even more concerns regarding continuous epidural
bupivacaine infusions in neonates and infants. With
1 1
epidural infusion rates of bupivacaine at 0.2 mg.kg .h ,
increasing serum concentrations were noted at 48 h
leading the authors to caution against infusions beyond
that time period. Other investigators have noted stable
plasma concentrations with epidural infusions of
1 1
ropivacaine at 0.2–0.4 mg.kg .h [10].
Concerns with the variable pharmacokinetics of amide
local anaesthetic agents during prolonged infusions in
neonates and infants have led to a resurgence in the use of 2-
chloroprocaine for postoperative epidural infusions [54, 55].
Chloroprocaine is metabolised by plasma cholinesterases
and has a plasma half-life of seconds to minutes, rather than
hours as with long-acting amide local anaesthetic agents
[56]. Henderson et al. used continuous 2-chloroprocaine
infusions via the caudal route as the sole anaesthetic
technique in a cohort of 10 former pre-term infants
undergoing inguinal hernia repair [57]. The dosing regimen
included 3% 2-chloroprocaine, administered as a bolus dose
in increments of 1 ml.kg 1, followed by an infusion starting at
1 ml.kg 1.h 1. None of the infants required supplementary
anaesthesia, plasma concentrations of 2-chloroprocaine
were minimal, and there were no complications. Continuous
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Heydinger et al. | Regional anaesthesia in paediatrics Anaesthesia 2021, 76 (Suppl. 1), 74–88

caudal epidural infusions with 2-chloroprocaine at an likely responsible for irreversible neurological deficits and
average dose of 2.8  1 ml.kg 1.h 1
(84  30 mg.kg 1.h 1) back pain, respectively [60]. A preservative-free preparation
1
resulted in a plasma concentration of 0.5 pg.ml in one of 2-chloroprocaine is now widely available and paved the
infant and undetectable levels in four others. Tobias et al. way for a resurgence in neuraxial 2-chloroprocaine use, first
described the combination of continuous 2-chloroprocaine in adults and then children.
infusion with general anaesthesia in 25 neonates undergoing More recently, several investigators have published
major abdominal surgery. Chloroprocaine dosing began studies focusing on the use of continuous 2-chloroprocaine
1
with a 1–1.5 ml.kg bolus, followed by a 1–1.5 ml.kg 1.h 1
epidural infusions in infants for postoperative analgesia.
infusion [30]. All patients had adequate intra-operative Ross et al. detailed the postoperative effect of continuous 2-
analgesia without supplementary opioids. Tracheal chloroprocaine epidural infusions in 18 infants after major
extubation occurred at the conclusion of the procedure in 23 thoraco-abdominal surgery [54]. Epidural infusions
1
of 25 neonates and there were no episodes of postoperative consisted of 1% 2-chloroprocaine  clonidine (0.5 µg.ml )
apnoea or bradycardia. In both authors’ reports, the volume starting at 0.35  0.1 ml.kg 1
.h 1
(maximum of 0.42  0.1
1 1
and concentration of local anaesthetic used was remarkable ml.kg .h ). Thirteen patients had their tracheas extubated
1
(bolus doses of 30–45 mg.kg with infusions of 30– 24 h postoperatively. In the first and second postoperative
45 mg.kg 1.h 1) in that an equivalent dose of an amide local 24 h, the average number of opioid medication
anaesthetic agent would not have been possible due to the administrations was 3.8  2.6 and 1.6  2.4 doses,
high probability of LAST (Table 1 ) . respectively. No comparator group was included for
The promising applications of 2-chloroprocaine for evaluation of relative efficacy. Veneziano et al.
neuraxial use in neonates and infants following these two retrospectively evaluated 21 paediatric patients who
initial reports in the 1990s were clouded by ongoing received continuous 2-chloroprocaine epidural infusions for
concerns of adverse effects related to 2-chloroprocaine in postoperative analgesia after major thoracic, abdominal or
adults. Anecdotal reports of serious complications, limb surgery [8]. The reported epidural infusion rates
1 1
including cauda equina syndrome and severe back pain ranged from 0.25 to 1.5 ml.kg .h 2-chloroprocaine
with subdural and epidural use of 2-chloroprocaine, 1.5%. Pain scores in the cohort were low in the first 48 h
diminished its appeal [58, 59]. Also likely impeding the postoperatively, reflected by median FLACC (faces, leg,
increased use of 2-chloroprocaine in infants was the activity, cry and consolability) and N-PASS (neonatal pain
introduction of ropivacaine into clinical practice, which was analgesia sedation score) scores ≤ 2 at all time-points.
shown to have favourable pharmacokinetics in neonates Another study retrospectively compared the efficacy of
following both bolus dosing and continuous infusions when continuous epidural infusions of 0.1% ropivacaine or 1.5%
compared with bupivacaine. During this time, animal 2-chloroprocaine for management of post-thoracotomy
experiments demonstrated that the preservatives, sodium pain in 52 infants [55]. Opioid consumption trended lower
bisulfite and ethylenediaminetetraacetic acid (EDTA), in the 2-chloroprocaine group compared with the
previously included in 2-chloroprocaine solutions, were ropivacaine group in the first 24 h (0.19 mg.kg 1
vs.

Table 1 Commonly used local anaesthetic agents in paediatrics

Bupivacaine Ropivacaine Chloroprocaine
Classification Amide Amide Ester
Metabolism Hepatic Hepatic Plasma esterases
Typical concentration 0.25–0.5% 0.2–0.5% 1.5–3%
PNB duration of actiona 6–12 h 6–12 h Not applicable
a
Epidural duration of action 3–6 h 3–6 h Up to 60 min
Maximum PNB doseb 3 mg.kg 1
3 mg.kg 1
Not applicable
1 1 1 1 1 1c
Epidural rate 0.2–0.3 mg.kg .h 0.2–0.4 mg.kg .h 7.5–15 mg.kg .h
Cardiotoxicity potential +++ + low
PNB, peripheral nerve block.
a
Duration of action may be increased by addition of adjunctive non-opioid agents
b
Maximum PNB dose includes addition of epinephrine.
c
Based on typical dosing regimen at authors’ institution (Nationwide Children’s Hospital, Columbus, OH, USA).

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Anaesthesia 2021, 76 (Suppl. 1), 74–88
1
0.30 mg.kg morphine equivalents, respectively;
p = 0.08) with no differences between the groups in the
second 24-h postoperative period.
A final report regarding the use of 2-chloroprocaine
infusions in neonates and infants described its use in
paravertebral catheters as an alternative to neuraxial
catheters. Bairdain et al. reported on the efficacy of
continuous 2-chloroprocaine paravertebral catheters in
neonates undergoing long-gap oesophageal atresia repair
[15]. A continuous infusion of 1.5% 2-chloroprocaine was
1 1
initiated at 0.5–0.8 ml.kg .h in the ICU. The authors
reported an approximate two-thirds reduction in sedative
and opioid exposure postoperatively and significantly fewer
days spent in the ICU.
Local anaesthetic systemic toxicity in
infants and children
Although the incidence of complications from local
anaesthetic administration in paediatric patients is low (0.76
patients experiencing severe LAST per 10,000 procedures),
accidental systemic injection or inappropriate dosing can
result in life-threatening neurological or cardiovascular
complications [18]. Physiological differences in paediatric
patients compared with adults, as well as the fact that most
blocks are performed under general anaesthesia in this
population, can potentially increase the risk of LAST or delay
its diagnosis.
The two classes of local anaesthetics are the amides
and esters. The amides, which include bupivacaine;
ropivacaine; lidocaine; mepivacaine; prilocaine; and
levobupivacaine, undergo hepatic metabolism. There is an
increased potential for LAST with amide local anaesthetics
in neonates and infants due to their immature microsomal
enzymes and lower plasma levels of a1-acid glycoprotein.
Hepatic cytochrome P450 enzymes may not reach adult
metabolic capacity until the age of 1 year, resulting in
reduced clearance and increased terminal half-life of the
drug, and the potential for local anaesthetic accumulation in
the plasma with prolonged local infusions. The a1-acid
glycoprotein that extensively binds amide local anaesthetic
agents in plasma is significantly decreased at birth,
contributing to an increased free fraction of drug in
newborns, thereby potentiating the risk of toxicity [61]. For
these reasons, a decrease in maximum dose (bolus and
infusion) is recommended for amide local anaesthetic
agents in children aged < 6 months [62]. Plasma a1-acid
glycoprotein levels increase rapidly after the first month of
life [61] and following surgical stress [63], potentially
offering some protection from LAST in the postoperative
period.
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Heydinger et al. | Regional anaesthesia in paediatrics
The esters, which include 2-chloroprocaine, procaine
and tetracaine, undergo metabolism in the plasma by
serum cholinesterases, resulting in a significantly shorter
serum half-life compared with the amides and therefore a
decreased potential for toxicity in patients of all ages
including, neonates and infants [64, 65]. The previously
described resurgence in the use of 2-chloroprocaine for
postoperative analgesia in neonates and infants was largely
driven by the limited potential for toxicity with this ages,
even when used as a continuous infusion [66]. Although two
anecdotal case reports describe the occurrence of
LAST with 2-chloroprocaine after accidental systemic
administration with bolus dosing, the duration was limited
and full resuscitation was achieved for both patients [67, 68].
Many strategies may be utilised to limit the probability
of LAST in the paediatric population. These include careful
consideration of the patient’s age and comorbid conditions;
choice of local anaesthetic agent; addition of adjuvants; and
the use of a safe and proper technique during regional
blockade. Patients who are younger, have a history of
premature birth, low muscle mass or hepatic, renal and
cardiac dysfunction, may be at increased risk of developing
LAST due to differences in pharmacokinetics of the
circulating drug. Maintaining adequate cardiopulmonary
function during blockade is important because low cardiac
output, hypoxaemia and hypercarbia all increase the risk of
toxicity related to these medications. The use of adjuvants
may offer some advantage by imparting equipotent
analgesia with a decreased concentration and volume of the
local anaesthetic. The addition of adrenaline to local
anaesthetic agents results in lower systemic absorption in
many clinical conditions [69]. Protection may also be afforded
by the use of ultrasound guidance during regional techniques.
A study comprising 20,021 paediatric patients undergoing
peripheral nerve blockade found that the use of ultrasound
reduced the risk of LAST [70]. Test dosing of paediatric
regional anaesthetics remains a controversial topic due to the
differences in physiological and clinical conditions under
which regional anaesthesia is performed in children
compared with adults. However, slow and incremental dosing
with intermittent aspiration should be maintained with the
administration of any local anaesthetic agent.
Given the volumes and concentrations required to
achieve effective surgical anaesthesia, dosing of local
anaesthetic agents is frequently close to the maximum
allowed, and strict attention to total doses using mg.kg 1
and
mg.kg .h1 1
is mandatory. A 2016 investigation of the
Pediatric Regional Anesthesia Network (PRAN) database
revealed evidence of a surprising trend in local anaesthetic
dosing practices [71]. In neonates with epidural catheters, a
© 2021 Association of Anaesthetists
Heydinger et al. | Regional anaesthesia in paediatrics
potentially toxic dose was delivered to 6% intra-operatively
and 20% postoperatively. Over nearly 7 years, the proportion
of patients receiving a larger than recommended local
anaesthetic infusion increased over time to nearly half by
2014.
Treatment of LAST is similar in paediatric and adult
populations, but differences in physiological and clinical
conditions must again be considered. All symptoms of
LAST, and clinical signs other than catastrophic
cardiovascular events, can be masked by general
anaesthesia. Volatile agents and certain i.v. anaesthetic
agents may have anticonvulsant effects, increase the seizure
threshold, and therefore delay detection of LAST until
cardiovascular signs manifest. The initial management of
LAST requires cessation of the administration of the local
anaesthetic agent (bolus or continuous infusion) and the
establishment of adequate ventilation and oxygenation to
prevent or reverse hypoxaemia, hypercarbia and acidosis.
Treatment of cardiovascular events should follow Paediatric
Advanced Life Support guidelines. Central nervous system
excitatory activity, including seizures, can be aborted with a
benzodiazepine such as midazolam. Immediate treatment
with intralipid is advisable in the presence of arrhythmias,
prolonged seizures or other rapid clinical deterioration.
Ideal dosing regimens remain speculative in infants and
children, but it is reasonable to follow established adult
1
dosing guidelines of 1.5 ml.kg intralipid 20% infused over
2–3 min, repeated until circulation is restored, followed by a
1 1
continuous infusion of 0.25 ml.kg .min , to a maximum of
1
12 ml.kg in total [72]. Intralipid should be immediately
available wherever regional anaesthesia is performed, as
there are several reports of resuscitation following its use
[73, 74]. Lastly, anecdotal evidence suggests that
extracorporeal membrane oxygenation may be considered
in patients not responsive to intralipid.
New paediatric regional anaesthesia
techniques
The proliferation of ultrasound technology has liberated
anaesthetists to explore a myriad of fascial planes. Many of
these are the targets of a new generation of truncal blocks
that are discretely viewed and no longer defined by tactile
endpoints of ‘pops’ and ‘clicks’. Typically, an isolatable
neural structure is not seen in the fascial plane blocks.
Rather, the blocks rely on the spread of a local anaesthetic
agent across and within the inter-fascial plane to
anaesthetise a splay of small nociceptive fibres. The trend
arguably began with the transversus abdominis plane
(TAP) block, but now encompasses multiple novel fascial
plane blocks covering various sensory distributions. Three
© 2021 Association of Anaesthetists
Anaesthesia 2021, 76 (Suppl. 1), 74–88
that have garnered recent attention in the paediatric
population are the quadratus lumborum block (QLB),
serratus anterior plane block (SAPB) and erector spinae
block (ESB) (Table 2 ).
Quadratus lumborum block was first described in an
abstract in 2007, and was an evolution and expansion of the
TAP block with the realisation that more posterior
approaches to the TAP block resulted in greater
paravertebral infiltration including a lateral (QLB1),
posterior (QLB2) and transmuscular (QLB3) technique
(Fig. 2a). The local anaesthetic target is the inter-fascial
plane between the quadratus lumborum muscle and the
lateral aponeurosis of the abdominal oblique muscles, the
latissimus dorsi muscle or the psoas muscle (QLB1, QLB2
and QLB3, respectively). The QLB has provided successful
analgesia for a variety of surgical procedures in adults,
including caesarean section, exploratory laparotomy and
total hip arthroplasty. Relatively quickly, this promising
technique was applied to the paediatric population for
lower abdominal surgery, including inguinal hernia repair
and stoma closures. Hernandez et al. described their
experience with a series of 15 QLB blocks in 10 children
undergoing various abdominal procedures [4]. Cephalad
extent of sensory blockade was achieved to the T7
dermatome in 6 out of 15 patients (40%), the T8 dermatome
in 10 out of 15 patients (67%) and the T9 dermatome in 14
out of 15 patients (93%). Caudal extension of analgesia was
T12-L1 in all patients.
The QLB may provide specific advantages over other
commonly performed regional anaesthetic techniques in
the paediatric population. A 2017 randomised controlled
€ uz et al. compared QLB with TAP block in 53
trial by Oks€
children, ranging in age from 1 to 7 y, undergoing unilateral
inguinal hernia repair or orchidopexy [75]. Opioid
consumption and pain scores were both lower in the QLB
group during the first 24 h postoperatively. A second
clinical trial by the same group compared the QLB with
caudal block in the same patient population [76]. The QLB
was again superior, resulting in decreased opioid
consumption and pain scores in the first 24 h
postoperatively. A subsequent, prospective randomised
study compared QLB with ilio-inguinal/iliohypogastric
nerve blockade in 40 children, aged 1 to 7 y [77]. The
number of patients who required oral analgesics was
significantly lower in the QLB group, while pain scores were
similar.
The serratus anterior plane block has also been recently
introduced into the paediatric population following its
success in adults. First described by Blanco et al. in adults in
2013, the SAPB involves the deposition of a local
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Anaesthesia 2021, 76 (Suppl. 1), 74–88
TM
RM
ESM
(a) (b)
TP TP
(c) (d)
Figure 2 (a) Ultrasound anatomy for quadratus lumborum
block in a 15-month-old child. Arrows indicate needle tip
position for type 1, 2, and 3 QL blocks; (b) Ultrasound
anatomy for serratus anterior plane block in a 16-year-old
child. Arrow indicates needle tip location for deep serratus
anterior plane block; (c) Ultrasound anatomy for erector
spinae block. Arrow indicates needle tip location for erector
spinae block; (d) Radio-opaque thoracic epidural threaded
from caudal space. QLM, quadratus lumborum muscle; PM,
psoas muscle; TP, transverse process; VB, vertebral body;
QL, quadrates lumborum; LDM, latissimus dorsi muscle;
SAM, serratus anterior muscle, ICM, intercostal muscle; TM;
trapezius muscle; RM, rhomboid muscle; ESM, erector
spinae muscle; TP, transverse process.
anaesthetic agent in the inter-fascial plane between either
the serratus anterior muscle and the latissimus dorsi muscle
(superficial) or the serratus anterior muscle and intercostal
muscles (deep) over the mid-axillary line at the level of the
fifth rib (Fig. 2b) [2]. This block provides reliable
dermatomal anaesthesia at the levels of T2 through T6 of the
ipsilateral hemithorax.
Literature pertaining to SAPB in children is largely
limited to cases series following cardiac or thoracic surgery.
In the context of systemic heparinisation for cardiac surgery,
SAPB has been proposed as a potentially safer alternative to
neuraxial or paravertebral blockade. One case series
described the use of SAPB to provide postoperative
analgesia in three children (aged 3 days, 14 days and
4 years) following thoracotomy and repair of coarctation of
the aorta [5]. All patients underwent tracheal extubation in
the operating theatre. The authors considered the peri-
operative opioid consumption and ICU length of stay to be
shorter in these patients compared with historical averages.
Another case series examined the effects of SAPB in five
paediatric patients, ranging in weight from 9 to 21 kg,
following sternotomy and surgery for congenital heart
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Heydinger et al. | Regional anaesthesia in paediatrics
defects [78]. The patients’ tracheas were extubated by the
6th postoperative hour and additional or rescue analgesia
was not required for the first 12 h postoperatively in any of
the patients. Neither of these case series reported any
complications resulting from SAPB.
Kaushal et al. compared postoperative analgesia in 108
children receiving SAPB, pectoral nerve-2 blockade or
intercostal nerve block for post-thoracotomy pain after
cardiac surgery [79]. Patients who required tracheal
intubation and mechanical ventilation for more than 2
postoperative days were excluded from analysis. The study
demonstrated that objective pain scores were lower in the
SAPB group than the intercostal nerve block group after the
first 4 h following tracheal extubation through the 12-h
evaluation period. Pain scores in the pectoral nerve-2
blockade group were comparable to the SAPB group until
12 h post-tracheal extubation, at which time SAPB was
superior. No adverse events were attributed to any of the
regional anaesthetic techniques.
The novel erector spinae block has gained notable
attention in recent years. Intended to provide analgesia to
the thoracolumbar dermatomes, ESB has been applied to a
heterogeneous group of surgical procedures in children
and adults, including open and minimally invasive
abdominal and thoracic surgery, cardiac surgery, breast
surgery and hip arthroplasty [80]. The ease in identifying
anatomical landmarks, and perceived safety compared with
paravertebral and epidural blocks has helped drive the
increasing popularity of ESB. The block is accomplished by
injection of a local anaesthetic agent beneath the erector
spinae muscle and hydro-dissection of the muscle from the
tissue-fascial plane at the level of the transverse process of
the vertebra (Fig. 2c). Performance of ESB is commonly
described using a parasagittal, in-plane ultrasound-guided
technique. The targeted vertebral level for injection varies
by report and desired area of analgesia based on the
surgical procedure. Cadaveric and contrast studies have
demonstrated multiple vertebral level spread with
infiltration of the paravertebral space as well as dorsal and
ventral rami.
The literature regarding ESB in children comprises
numerous case reports, case series and a select group of
more rigorous studies. Three randomised controlled trials
have been conducted examining ESB in children. Mostafa
et al. compared bilateral ESB with sham blocks in 60
patients, aged 3 to 10 y, undergoing open midline
splenectomy [6]. Pain scores were lower in the ESB group
during the first 8 h of the 24 postoperative hours evaluated.
Patients who received ESB had significantly lower intra-
operative opioid requirement and required less
© 2021 Association of Anaesthetists
Heydinger et al. | Regional anaesthesia in paediatrics
postoperative rescue analgesia. Aksu et al. compared ESB
and QLB in 60 children, ranging in age from 1 to 7 y,
following lower abdominal or urological surgery including
inguinal hernia repair, orchidopexy or hydrocele repair [81].
The trial recorded pain scores for the first 6h
postoperatively, time to first analgesic, and analgesic
requirements for the first postoperative 24 h. All outcome
measures were similar between the ESB and QLB groups.
The authors concluded that the techniques could be used
interchangeably in children for postoperative analgesia
after lower abdominal surgery, based on the clinician’s
preference and experience. El-Emam et al. compared ESB
with ilio-inguinal/iliohypogastric blockade for postoperative
analgesia in 60 children after unilateral inguinal hernia repair
[82]. The ESB was shown to be superior to ilio-inguinal/
iliohypogastric blockade for the primary outcome measure
of time to first analgesic request. The ESB group also had
lower early pain scores and received fewer doses of rescue
medication. In a retrospective analysis of 164 patients, aged
2 days to 19 years, an ESB was placed before various open
and minimally invasive thoraco-abdominal procedures [83].
More than 70% of the patients had a successful block as
determined by heart rate responses (less than a 10%
increase) at skin incision. Using a subset analysis of patients
following placement of a gastrostomy tube, the authors
1
inferred that ESB with 0.5 ml.kg of local anaesthetic
solution achieved blockade of at least five dermatomes.
When considering all of these studies, comprising > 250
patients, there were no reported procedural complications
or adverse events related to the ESB.
Controversies in paediatric regional
anaesthesia
Asleep vs. awake for regional anaesthesia
Few differences between the practice of adult and
paediatric regional anaesthesia are as apparent as the
awake adult vs. the sleeping child. In the adult population,
prevailing thought contends that procedural sedation
during regional anaesthetic techniques should not prevent
Table 2 Comparison of novel fascial plane blocks
Quadratus lumborum
Anatomical distribution T7/T8–T12/L1 (ipsilateral abdomen)
Indications Abdominal surgery
Dosing considerations 1. Consider lower concentration with higher volume to increase dermatomal coverage.
2. Be aware of maximum local anaesthetic dose for bilateral blockade.
Potential complications Kidney puncture,
intraperitoneal injection
© 2021 Association of Anaesthetists
Anaesthesia 2021, 76 (Suppl. 1), 74–88
the patient’s ability to communicate any atypical
sensations to the physician during the procedure. Under
these circumstances, ideally the patient will verbalise a
paraesthesia that may indicate impending neural injury or
changes that will alert the physician to premonitory
symptoms of LAST. However, the long-standing practice in
the paediatric anaesthesia community is to conduct
regional anaesthesia with the patient anaesthetised in
order to maintain a motionless patient who might
otherwise be unco-operative and distressed. The
supposition remains that a calm and immobile child may
avoid accidental needle displacement and puncture of
vital anatomical structures. In addition, any advantages of
patient feedback are lost with young children who are
unable to interpret and report abnormal clinical
phenomena.
The distinction between these practice modalities has
been marked at times by controversy and debate. In the late
1990s, two publications described five patients who
experienced serious complications, including paraplegia
with epidural anaesthesia during general anaesthesia [84].
This led to discussion and concerns regarding the safety of
this practice from experts in the world of adult regional
anaesthesia. The response from leaders in paediatric
regional anaesthesia was to assert that performing regional
blocks in children during general anaesthesia has been, and
remains, the standard of practice, as substantiated by its
widespread general practice. In 2008, the American Society
of Regional Anesthesia and Pain Medicine concluded that
providing regional anaesthesia in an anaesthetised child
may have an acceptable risk-benefit profile. However, a
specific exclusion made in these recommendations
included the performance of interscalene brachial plexus
blockade in children during general anaesthesia based on
anecdotal reports of injury [85].
During this contentious period, there was a lack of
substantial data to either support or refute the safety of
performing regional anaesthesia in anaesthetised children.
For years, the only large-scale prospective data registry of
Serratus anterior Erector spinae
T2-T6 (ipsilateral chest) Ipsilateral abdomen or chest
(depending on vertebral level)
Thoracic surgery Abdominal or thoracic surgery
Pneumothorax, intravascular Pneumothorax
injection
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Anaesthesia 2021, 76 (Suppl. 1), 74–88
regional anaesthesia in children was the French Language
Society of Paediatric Anaesthesiologists (ADARPEF) [86].
Comprising 24,409 regional anaesthetics (89% conducted
under general anaesthesia), from 38 participating centres in
1996, the overall complication rate was 0.9 per 1000 blocks.
There were no permanent injuries or medicolegal actions
recorded. More than 10 years later, the UK Prospective
National Paediatric Epidural Audit published data on
10,633 epidural catheter insertions in children [17]. Every
patient except one had the procedure performed under
general anaesthesia. The authors rated recorded
complications as serious, moderate or minor. Five incidents
were deemed serious with only one of these patients having
sequelae at 12-month follow-up, consisting of neurological
deficits related to a drug infusion error. The 2010 ADARPEF
study revisited the complication rate of paediatric
anaesthesia in 29,870 blocks (96% conducted under
general anaesthesia) from 47 institutions. The complication
rate, similar to the first ADARPEF study, was only 1.2 per
1000 blocks, with no long-term injuries. In 2014, the
multidisciplinary consortium of the PRAN examined the
relative risk of performing regional anaesthesia in over
50,000 children who were awake, sedated or under general
anaesthesia. The PRAN investigators found that
postoperative neurological symptoms occurred at a lower
frequency in children under general anaesthesia (0.93 per
1000, CI 0.7–1.0) than sedated or awake patients (6.82 per
1000, CI 4.2–10.5) with a similar frequency of LAST between
the groups (0.08 per 1000, CI 0.02–0.2 vs. 0.34 per 1000,
95%CI 0–1.9, respectively) [87]. In an address of the 2008
ASRA practice advisory, a group queried the PRAN
database for the incidence of complications in children
receiving interscalene brachial plexus blockade under
general anaesthesia. An evaluation of the cohort of 518
children, 390 under general anaesthesia and 123 sedated
or awake, revealed no serious adverse events in either
group, with an estimated upper-limit complication rate on
a par with awake or sedated adults [88]. More recently, the
PRAN consortium examined the safety of paediatric
regional anaesthesia in a report consisting of over
100,000 regional blocks, the vast majority of which were
performed under general anaesthesia (93.7%) [18]. The
risk of complications was higher for patients sedated or
awake compared with general anaesthesia (OR 2.93; 95%
CI 1.34–5.52; p < 0.01). With no permanent neurological
injuries, a rate of transient neurological deficits of 2.4 per
10,000, and an incidence of LAST of 0.76 per 10,000, the
data support the standard practice of performing
regional anaesthesia during general anaesthesia in the
paediatric population.
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Heydinger et al. | Regional anaesthesia in paediatrics
Direct vs. caudal approaches for placement of an
epidural catheter
Although a significant body of evidence demonstrates that
continuous epidural infusions are a safe and effective
technique in neonates and infants, some studies have
suggested this population remains at higher risk of
complications from this procedure [17]. Given the
anatomical differences in neonates and infants, concern
exists for an increased hazard of neurological injury from
needle trauma during direct lumbar or thoracic epidural
catheter placement. These anatomical differences include a
narrower epidural space and a less dense ligamentum
flavum that could make confirmation of correct needle
position more challenging. Another difference in infants is
the fatty tissue content of the epidural space, which is
gelatinous and loosely packed with fat lobules. This
epidural fluidity allows smooth passage of an epidural
catheter inserted from the more easily accessible caudal
space. The epidural catheter can be advanced cephalad
from the caudal space to the desired lumbar or thoracic
vertebral level, and then confirmed using various
techniques (Fig. 2d). Both the caudal and direct epidural
approach have advantages and disadvantages and debate
remains regarding which is ideal for providing lumbar or
thoracic analgesia in infants.
osenberg et al. first described placement of a thoracic
B€
epidural catheter via the caudal approach in infants [89].
After proof of feasibility in human cadavers and live piglets,
the authors performed the procedure on 20 neonates
and infants undergoing gall bladder surgery. They were
able to thread the catheter to within one vertebral level of
the desired inter-space in 19 of 20 patients following
radiographic confirmation. There were no observed
episodes of haemodynamic instability or neurological
sequelae noted postoperatively. This technique has
continued to grow in popularity since that time, and
multiple studies have confirmed that the procedure is safe
and efficacious [90, 91]. In 2012, the PRAN consortium
examined neuraxial catheters in all age groups and found
an increased incidence of catheter-related problems in
thoracic, compared with lumbar and caudal, epidural
catheters (8%, 5% and 2%, respectively) [92]. Despite these
concerns, in a study from the PRAN consortium involving
307 neonatal neuraxial catheters there was no evidence of
long-term sequelae, persistent neurological problems,
serious infections, spinal cord injuries or epidural
haematomas related to the placement of the epidural
catheters. The incidence of complications did not differ
between the direct lumbar/thoracic versus caudal
approaches (OR 0.83, 95%CI 0.42-1.62, p = 0.6) [71].
© 2021 Association of Anaesthetists
Heydinger et al. | Regional anaesthesia in paediatrics
One possible advantage of direct epidural placement is
attainment of the desired vertebral level without other
means of confirmation. Blindly threading caudal catheters
cephalad in infants leads to a high rate of malposition. A
retrospective study of infants that received caudally placed
thoracic catheters found that 28 of 86 catheters (33%) were
inadequately positioned when confirmed radiographically
[93]. Using external measurement alone to estimate desired
catheter depth can be misleading. A study of 25 patients,
aged 2 days to 5 months, found that the external
measurement consistently underestimated the actual
length required to reach the desired level by an average of
4.28 cm [94]. Multiple techniques have been described to
confirm caudal catheter level, including ultrasound, nerve
stimulation and plain radiography [95–97] but, as recently
as 2012, most caudal catheters were placed without a
confirmation technique [92]. Radiological imaging requires
use of a radio-opaque catheter, injection of a radio-opaque
dye and exposure to ionising radiation. If real-time
placement with fluoroscopy is used, there is significant
exposure to ionising radiation, as well as the added cost and
organisation required for use of fluoroscopy in the
operating room. Although a single postoperative
radiograph is simple to obtain, repositioning of the catheter
is not feasible. Ultrasound imaging allows adequate view
due to incomplete ossification of the vertebral column in
the young infant and may be the guidance technique of
choice given the lack of ionising radiation
widespread availability in the operating room, thereby
allowing real-time observation as the catheter is advanced
cephalad [98].
A frequently cited concern with caudal epidural
catheter placement is procedure site contamination and
infection risk. Due to the location of the catheter, faecal
soiling of the epidural dressing may occur. Several studies
have examined the risk of bacterial colonisation of catheters
placed at the caudal, vs. lumbar, level. A prospective trial in
210 patients showed a similar incidence of gram-positive
colonisation between caudal (25%) and lumbar (23%)
catheters. There was, however, a higher incidence of gram-
negative colonisation found with caudal (16%), compared
with lumbar, catheters (3%). Caudal catheters also had a
higher rate of dressing compromise (20%) compared with
lumbar catheters (3%). Despite these findings, there were
no instances of clinically significant systemic or local
infections reported with either technique
Subcutaneous tunnelling of the catheter away from the
caudal insertion site can decrease the incidence of catheter
contamination or colonisation. Bubeck et al. demonstrated
that tunnelling of caudal catheters decreased colonisation
© 2021 Association of Anaesthetists
Anaesthesia 2021, 76 (Suppl. 1), 74–88
rates from 29% to 11%, which was similar to the rate of
lumbar catheter colonisation (9%) [100].
Local anaesthetic leakage around epidural catheters is
a common problem associated with both direct and caudal
approaches, especially in neonates and smaller infants, due
to the decreased volume accommodated by the epidural
space and the discrepancy in size between the insertion
needle and the epidural catheter. While there is a paucity of
data that directly compares leakage rates between the two
techniques, having the epidural catheter tip further from the
insertion site seems intuitively more likely to reduce the
chance of local anaesthetic leaking. While there are
advantages and disadvantages to each technique, the
caudal approach appears more commonly implemented in
neonates and infants, whereas anatomical changes make
the direct approach more practical in children older than a
year. As both techniques are generally safe, clinicians
should formulate their regional analgesia plan on a case-by-
case basis depending on the clinical scenario, patient
characteristics and professional experience.
Acknowledgements
No competing interests declared.
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