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Introduction
Regional anaesthesia has increased in popularity in recent years (Clergue et al., 1999). This was prompted by two significant events. Firstly, the realisation that children do feel pain and require pain relief like adults; and secondly, that avoiding general anaesthesia in premature babies may have major advantages.
With the increased survival of premature infants in recent years, the number of premature neonates presenting for surgery has increased. These premature neonates present with either chronic or acute defects that urgently need to be corrected. The risk of general anaesthesia is significant in these patients as they are at a greater risk of developing respiratory failure and postoperative apnoea compared to term infants of the same age (Welborn et al., 1986). Recent concerns regarding the deleterious effects of general anaesthesia on the developing brain further justifies the use of regional anaesthesia in this vulnerable age group (Sun et al. 2008).
The use of regional anaesthesia therefore may have considerable advantages not only in premature neonates but also in infants, children and adults. The stages of development can be classified as follows: Stage 1:
Neonate or newborn (0-30 days), Stage 2: Infant or baby (1 month-1 year), Stage 3: Toddler (1-4 years), Stage 4: Childhood (prepubescence) (4-12 years), Stage 5: Adolescence and puberty (12-20 years), and Stage 6: Adulthood (21 years – death), which can be subdivided into early adulthood
(21-39 years), middle adulthood (40-59 years) and advanced adults/senior citizen (older than 60 years) (Jones, 1946).
A brief history of paediatric regional anaesthesia
The 19th century was a time when fundamental changes were made in the concepts regarding medicine. This is especially true for the speciality of regional anaesthesia. It is also the period regarded as the birth of modern regional anaesthesia (Bonica, 1984; Dalens, 1995). The thought that the heart is the centre for pain reception was discounted and Bell in 1811 and Magendie in 1822 showed that both motor and sensory impulses were relayed by the nerve tracts. By 1840, Muller established that the brain is the centre for perception and received all sensory information, including pain stimuli (Dalens, 1995).
August Bier is commonly regarded as the “father of regional anaesthesia” and discovered the “cocainization of the spinal cord”, using a spinal anaesthetic technique (Fortuna & de Oliveira Fortuna, 2000). Since then, the regional anaesthetic techniques of the time included spinal, caudal
epidural and supraclavicular brachial plexus blocks. These procedures gained enthusiastic acceptance by the anaesthesiologists of the time (Bainbridge, 1901; Farr, 1920; Campbell, 1933). However, these procedures gradually fell into disuse and almost came to a complete halt after the Second World War.
This was mainly due to the development of new anaesthetic agents and improved techniques for general anaesthesia, which were safer and more reliable to use. The nineteen seventies saw a re-emergence of paediatric regional anaesthesia. Studies conducted by Lourey and McDonald (1973), Kay (1974) and Melman et al. (1975) caused a resurgence in the popularity of paediatric regional anaesthesia. The concept that regional and general anaesthesia can be used in a complimentary fashion, rather than being in contention with each other, also gained increasing acceptance (Dalens, 1995).
This increase in regional anaesthesia could be attributed to the constant refinement, and/or development of new techniques. Research into newer, safer and better local anaesthetic solutions, as well as the use of continuous infusions through pumps, has offered new ways of providing preand post-operative analgesia to patients scheduled for paediatric surgery (Cook et al., 1995). With the above-mentioned advances in the field of anaesthesiology, the need for a strict protocol for administration, with reliable equipment, well-trained and alert personnel, become even more important (Fortuna & de Oliveira Fortuna, 2000).
CHAPTER 1: INTRODUCTION
1.1) A brief history of paediatric regional anaesthesia
1.2) The importance of clinical anatomy in regional anaesthesia
1.3) Indications and limitations of paediatric regional anaesthesia
1.3.1 General indications of regional anaesthesia
1.3.1.1 Disorders of the respiratory tract
1.3.1.2 Disorders of the central nervous system
1.3.1.3 Myopathy and myasthenia
1.3.2 General contraindications or limitations of regional anaesthesia
1.3.2.1 Patient refusal
1.3.2.2 Local infections at the needle insertion site
1.3.2.3 Septicaemia (presence of pathogens in the blood)
1.3.2.4 Coagulation disorders
1.3.2.5 Neurological diseases involving the peripheral nerves
(neuropathy)
1.3.2.6 Allergy to the local anaesthetic solution
1.3.2.7 Lack of training
1.4) Equipment used for paediatric regional anaesthesia
1.5) Imaging techniques used to aid in regional anaesthesia
1.5.1.1 Basic principles of nerve stimulation
1.5.1.2 Essential features of nerve stimulator
1.5.2 Ultrasound guidance and regional anaesthesia
1.5.2.1 Advantages of ultrasound guidance during regional
anaesthesia
1.5.2.2 Basic principles of ultrasound
1.5.2.3 Ultrasound guided regional anaesthesia:
1.5.2.4 Ultrasound in children
1.5.3 Magnetic Resonance (MR) Imaging
1.6) A survey into paediatric regional anaesthesia in South Africa:
Clinical anatomy competence, pitfalls & complications
CHAPTER 2: LITERATURE REVIEW
2.1) Paediatric caudal epidural block
2.1.1 Introduction
2.1.1.1 History of caudal epidural blocks
2.1.1.2 Advantages of paediatric vs. adult caudal epidural blocks
2.1.2 Indications & contraindications
2.1.2.1 Indications
2.1.2.2 Contraindications
2.1.3 Anatomy
2.1.3.1 The sacrum
2.1.3.2 Abnormalities of the sacrum
2.1.3.3 The sacral hiatus
2.1.3.4 The termination of the spinal cord (conus medullaris)
2.1.3.5 The dural sac
2.1.3.6 The caudal canal and caudal epidural space
2.1.3.7 Vasculature of the spinal cord
2.1.4 Techniques
2.1.4.1 Safety precautions
2.1.4.2 Classic technique: Single-shot caudal epidural block
2.1.4.3 Classic technique: Continuous caudal epidural block
2.1.5 Complications
2.1.5.1 Dural punctur
2.1.5.2 Vascular puncture
2.1.5.3 Systemic toxicit
2.1.5.4 Misplacement of the needle into soft tissue
2.1.5.5 Puncture of the sacral foramen
2.1.5.6 Partial or complete failure of the block
2.1.5.7 Lateralisation of the block
2.1.5.8 Infection due to the placement of a continuous catheter
2.1.5.9 Other complications associated with caudal epidural
blocks
2.1.6 Imaging modalities used for paediatric caudal and lumbar epidural
blocks
2.1.6.1 Radiographic methods
2.1.6.2 Ultra-sound guidance
2.2) Paediatric lumber epidural block
2.2.1 Introduction
2.2.1.1 History of lumbar epidural blocks
2.2.1.2 Advantages of lumbar epidural blocks over spinal
anaesthesia
2.2.2 Indications and contraindications
2.2.2.1 Indications
2.2.2.2 Contraindications
2.2.3 Anatomy
2.2.4 Techniques
2.2.5 Complications
2.3) Paediatric infraclavicular brachial plexus block
2.3.1 Introduction
2.3.2 Indications & contraindications
2.3.3 Anatomy
2.3.4 Techniques
2.3.5 Complications
2.3.5.1 Vascular puncture
2.3.5.2 Systemic toxicity
2.3.5.3 Pneumothorax
2.3.5.4 Phrenic nerve block
2.3.5.5 Horner’s syndrome
2.3.5.6 Nerve injury
2.3.6 Use of nerve stimulation and other imaging modalities
2.3.6.1 Nerve stimulators and infraclavicular blocks
2.3.6.2 Ultrasound guidance for improving infraclavicular blocks
2.4) Paediatric Femoral nerve block
2.5) Paediatric ilio-inguinal/iliohypogastric nerve block
CHAPTER 3: AIMS OF THE THESIS
3.1) Paediatric caudal epidural block
3.2) Paediatric lumbar epidural block
3.3) Paediatric infraclavicular approach to the brachial plexus
3.4) Paediatric femoral nerve block
3.5) Paediatric ilio-inguinal/ iliohypogastric nerve block
CHAPTER 4: MATERIALS & METHODS
4.1) Paediatric caudal epidural block
4.2) Paediatric lumbar epidural block
4.3) Paediatric infraclavicular approach to the brachial plexus
4.4) Paediatric femoral nerve block
4.5) Paediatric ilio-inguinal/ iliohypogastric nerve block
4.6) Sample size and selection
4.7) Ethical considerations
4.8) Statistical analysis
4.9) Limitations of the study
CHAPTER 5: RESULTS
CHAPTER 6: DISCUSSION
BIBLIOGRAPHY
