British Journal of Anaesthesia 111 (S1): i114i124 (2013)

doi:10.1093/bja/aet379

Applications of regional anaesthesia in paediatrics

R. D. Shah and S. Suresh*
Department of Pediatric Anesthesiology, Ann & Robert H. Lurie Childrens Hospital, Feinberg School of Medicine, Northwestern University,
Chicago, IL 60611, USA
* Corresponding author. E-mail: ssuresh@luriechildrens.org; ssuresh@northwestern.edu

Editors key points

Regional anaesthetic techniques are
increasingly used for both acute and chronic
pain management in children.
Advantages in ultrasound guidance and
tailored dosing regimens have facilitated their
widespread use in paediatrics.

Keywords: caudal analgesia;

peripheral; regional anaesthesia

Increased use of regional anaesthesia in infants, children, and

adolescents has significantly improved the scope of paediatric
pain management. Regional anaesthesia is generally accepted
as an integral component of postoperative pain relief in paediatric patients.1 Several regional anaesthetic techniques are
also playing emerging roles in managing chronic paediatric
pain syndromes. Performance of regional anaesthesia can be
safely and effectively applied to paediatric patients, and
these techniques are becoming increasingly popular.2 3
Regional anaesthetic techniques are commonly performed
in paediatric patients4; large prospective databases and expert
opinion have demonstrated the ability to safely perform regional anaesthesia in children with minimal risk of neurological
damage.5 The use of ultrasound guidance and its incorporation
into the practice of regional anaesthesia has dramatically
improved routine paediatric perioperative care.

Safety of regional anaesthesia in children

Most regional anaesthetic techniques in adults are performed
awake or with mild sedation, allowing patients to report paresthesias or pain during block placement, symptoms of local anaesthetic systemic toxicity (LAST), and progression of sensory
or motor block after injection.6 Although several authors
have criticized the practice of performing major neuraxial or
peripheral nerve blocks in adults under deep sedation or
general anaesthesia, this is commonly utilized in infants and
children to facilitate patient cooperation while performing
the block.7
In contrast to adult practice, the majority of regional anaesthesia in children and infants is performed under either deep
sedation or general anaesthesia. Prospective and retrospective
safety studies support the notion that performing regional
anaesthesia under general anaesthesia is safe practice.5 8 9

complications;

paediatric

anaesthesia,

The Pediatric Regional Anesthesia Network (PRAN), a multicentre collaborative effort, has facilitated the collection of
detailed prospective data for research and quality improvement. Polaner and colleagues10 recently reported on the first
3 yr of data registry, giving an overall favourable impression
of the safety of modern paediatric regional anaesthesia practice (Table 1).

Pharmacology and toxicity of local

anaesthetics in infants and children
Safe dosing guidelines and age-related trends in local anaesthetic pharmacokinetics and pharmacodynamics have been
characterized and have facilitated expansion of paediatric regional anaesthesia practice.11 12 Neurologic or cardiac toxicity
related to excessive local anaesthetic blood concentration is
more likely to occur in infants than in adults because of low
protein binding and decreased intrinsic clearance.13
Resuscitation measures must be initiated immediately after
LAST. Neurotoxicity (seizures) can be treated with barbiturates,
benzodiazapines or propopfol. Recent evidence indicates that
the most successful treatment for LAST-related cardiotoxicity
is the administration of a lipid emulsion, which is now considered first-line therapy.14 An emerging number of case reports
demonstrate that rapid bolus injections of lipid emulsion
reverse the toxic effects of local anaesthetics in paediatric
patients.15 Safe dosing limits for lipid resuscitation are important to establish in neonates and children because complications from lipid overload have been reported in neonates
receiving i.v. nutritional support.16 The recommended dose of
20% Intralipidw for paediatric patients is 2 5 ml kg21. This
dose is repeated (up to 10 ml kg21) if cardiac function does
not return (Table 2).17 Although the exact mechanism of lipid

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Evidence supports the safety and efficiency of a

number of regional anaesthetic techniques and
drug combinations.

Summary. Advances in the field of paediatric regional anaesthesia have specific

applications to both acute and chronic pain management. This review
summarizes data regarding the safety of paediatric regional anaesthetic
techniques. Current guidelines are provided for performing paediatric regional
techniques, with a focus on applications for postoperative pain management.
Brief descriptions of relevant anatomy followed by indications for commonly
performed blocks are highlighted along with the potential of adverse sideeffects.

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Paediatric regional anaesthesia

Table 1 Summary of Single-injection blocks and adverse event rates for all centres. Total adverse event rates reported in parentheses. Rates ,1%
reported as decimals and .1% rounded to nearest whole number. Note that in the neuraxial category and the lower extremity category, the total
number of complications are fewer than the cumulative sums of the individual types. This is because there were 3 cases in which 2 blocks were done
in a single patient, 1 successful block after a complication in the other, and because of ambiguity in the data entry, it was impossible to determine
which block was placed first. To assign the most conservative complication rate to the specific block category, the complication was counted
against both blocks, but the total number of complications in that general block type is accurate. See text for more details. There were no serious
complications or sequelae reported in any single-injection group. TAP, transversus abdominis plane. Table reproduced from Polaner and
colleagues10 with permission from Lippincott Williams and Wilkins/Wolters Kluwer Health (&2012)
Total procedures

Total adverse events (%)

No sequelae

No sequelaechange in treatment

Caudal

6011

172 (3)

60

112

Lumbar

103

5 (5)

Thoracic

13

2 (15)

Neuraxial

Subarachnoid
Total neuraxial

83

5 (6)

6210

183 (3)

64

119

6 (4)

4
0

Upper Extremity
Interscalene

80
164

Infraclavicular

40

Axillary

99

2 (2)

Musculocutaneous

Elbow

Wrist

Other

58

Total

455

8 (2)

78

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Supraclavicular

Lower Extremity
Lumbar plexus

6 (8)

Fascia iliaca

221

1 (0.5)

Femoral

872

6 (0.7)

Sciatic

413

11

Popliteal fossa

319

Saphenous

78

14 (3)
2 (0.6)

Other

325

5 (2)

Total

2307

33 (1)

11

22
0

Head and neck

Supraorbital/supratrochlear

58

Infraorbital

139

Greater auricular/superficial cervical

157

Occipital

101

11

Other

89

Total

556

39

Greater palatine

Other block type

Intercostal

Ilioinguinal/iliohypogastric

737

3 (0.4)

Rectus sheath

294

Paravertebral

1 (7)

Penile

230

14

TAP

140

1 (0.7)

Other

395

Total

1849

5 (0.3)

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Shah and Suresh

emulsion therapy is unknown, when administered rapidly after

the diagnosis of LAST, lipid resuscitation can be a life-saving
measure in paediatric patients, as has been reported to the
LipidRescue registry (www.lipidrescue.org).

Regional anaesthesia for paediatric acute

pain management
A substantial body of literature supports the safety and efficacy
of performing regional anaesthetic techniques in children.
Evidence-based literature shows that combined regional
and general anaesthesia can decrease hospital stay and
improve outcomes in paediatric patients.18 Despite some controversy regarding the performance of regional anaesthesia in
sedated children, there is consensus among paediatric anaesthesiologists regarding the importance and feasibility of safely
providing regional anaesthetic techniques under general anaesthesia.8

or ropivacaine (0.1 0.375%) with 1:200 000 epinephrine at a

dose of 11.5 ml kg21 (maximum dosage 30 ml).

Continuous neuraxial catheters

Continuous epidural analgesia is commonly used to manage
post-surgical pain in infants and children.21 Epidural catheters
can be placed in the thoracic, lumbar, or caudal regions. It is
also possible to insert a caudal catheter and thread it cephalad
to the desired dermatomal level. Bupivacaine and ropivacaine
are frequently used local anaesthetic solutions. Common additives include opioids and a2-agonists, including fentanyl, morphine, hydromorphone, and clonidine. It is imperative that
standardized dosing parameters for a single injection, and for
continuous infusion, be used in neonates, infants, and children
to avoid LAST.22 Suggested paediatric dosing regimens are
listed in Table 3.

Central neuraxial techniques

Caudal analgesia
Caudal block is one of the most commonly used paediatric regional anaesthetic techniques for postoperative analgesia.
Caudal block is performed in children undergoing surgery of
the lumbosacral to midthoracic dermatomal levels with anticipated moderate-to-severe postoperative pain. Its popularity
originates in part from easily palpable landmarks and relative
ease of placement. A styletted needle with a blunt tip is
passed through the sacrococcygeal ligament into the caudal
space. A distinct pop is felt when the caudal block space is
entered. Nerve stimulation and ultrasonography have been
described as tools to assist in caudal placement.19 20 Commonly used local anaesthetics include bupivacaine (0.125 0.25%)

Table 2 Treatment of LAST

Dosing guidelines for lipid resuscitation of paediatric
local anaesthetic toxicity
Administer 1 ml kg21 of 20% lipid emulsion i.v. over more than 1 min
Repeat dose every 3 5 min to a maximum of 3 ml kg21
(up to total dose 10 ml kg21)
Maintenance infusion of 0.25 ml kg21 min21 until
circulation restored

Peripheral and truncal nerve blocks are playing an emerging

role in paediatric postoperative pain management.23 Several
peripheral blocks have also been described as effective in
achieving analgesia in paediatric trauma.24 These techniques
are typically performed under general anaesthesia and are
often performed utilizing ultrasound guidance. Head and neck,
transversus abdominis plane (TAP), rectus sheath, ilioinguinal/
iliohypogastric (IL/IH), and upper and lower extremity blocks
are commonly performed.25 35 Common dosing guidelines have
been included as a reference point for practitioners (Table 4).
Peripheral nerve blocks are also increasingly utilized in
paediatric chronic pain management to facilitate physical
therapy while providing sympathectomy; such interventional
approaches have become more plausible with the use of ultrasound guidance.36 Serial peripheral nerve blocks can be performed to treat chronic neuropathic pain in children. In such
circumstances, the pain relief often outlasts the duration of
conduction block, which might be attributable to reduced
central sensitization, and interruption of the circuit established
between nociceptor, central nervous system, and motor unit.37
Concomitant corticosteroid administration can contribute to
this effect via anti-inflammatory action and suppression of
ectopic neuronal discharge.38 We have noted that the majority
of patients with neuropathic pain who undergo serial peripheral nerve blocks experience pain relief that increases in duration after each block.

Table 3 Paediatric epidural dosing guidelines

Medication

Initial bolus

Infusion solution

Infusion limits

Bupivicaine

2.5 3 mg kg21

0.0625 0. 1%

0.4 0. 5 mg kg21 h21

Ropivicaine

2.5 3 mg kg21

0.1 0. 2%

0.4 0.5 mg kg21 h21

Fentanyl

1 2 mg kg21

2 5 mg ml21

0.5 2 mg kg21 h21

Morphine

10 30 mg kg21

5 10 mg ml21

1 5 mg kg21 h21

Hydromorphone

2 6 mg kg21

2 5 mg ml21

1 2.5 mg kg21 h21

Clonidine

1 2 mg kg21

0.5 1 mg ml21

0.5 1 mg kg21 h21

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Peripheral nerve block

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Table 4 Suggested dosing of local anaesthetics for peripheral

nerve blocks
Maximum
volume (ml)

Dose (ml
kg21)

Head and neck

0.1

Axillary

0.1 0.2

10

Infraclavicular

0.2 0.3

15

Intercostal

0.05 0.1

Rectus sheath

0.1 0.2

Ilioinguinal

0.1 0.2

10

Femoral nerve

0.2 0.3

15

Sciatic nerve

0.2 0.3

20

Popliteal fossa

0.2 0.3

15

Lumbar plexus

0.2 0.3

20

Penile

0.1

10

Digital nerve

0.05 0.1

Transversus abdominus plane

(TAP)

0.2 (per side)

5
10 (per side)

Nerve block techniques utilized in adult pain management

have, in some instances, been applied to paediatric patients.
Mesnil and colleagues39 described the suprazygomatic approach to the maxillary nerve block, an effective procedure
for adults with trigeminal neuralgia, as useful to control postoperative pain and facilitate early feeding resumption after
cleft palate repair in infants.

Continuous peripheral nerve block

Continuous peripheral nerve blocks (CPNBs) are increasingly
used in paediatrics as a method of providing extended duration
of pain relief40 and facilitating physical therapy in children
with chronic pain syndromes.41 CPNBs have been reported to
be effective in both reducing pain and enabling participation
in physical therapy in children with CRPS.41 Despite such reports, limited data exist regarding the safety, feasibility, and
efficacy of CPNBs in children.42
Perineural catheters can be placed at various locations to
ensure site-specific analgesia. Brachial plexus catheters are
useful for surgical procedures of the shoulder, elbow, forearm,
and hand. Perineural catheter placement in the axillary region
can provide pain control, but concerns over catheter sterility
and migration exist.43 Catheters placed in the supraclavicular
region are effective and reduce these concerns. Placement of
a catheter into the TAP provides continuous analgesia and
decreases supplemental postoperative systemic opioid requirements.44 In addition, use of continuous TAP catheters in paediatric patients can serve as an alternative to conventional
neuraxial catheters.45 TAP catheters can also provide analgesia
in patients with severe spinal deformities that preclude neuraxial anaesthesia.46
CPNBs are also useful in providing lower extremity analgesia
for extended periods. Femoral catheters have been used safely
and effectively in children.47 Continuous femoral nerve blocks
are commonly used to treat pain from surgery on the distal

Ultrasound-guided peripheral nerve block

techniques
Advances in ultrasonography have expanded the scope of regional anaesthesia practice in paediatrics. Ultrasound guidance improves the ease and safety of peripheral nerve block.
This section reviews some of the more common peripheral
nerve blocks in children and provides a straightforward approach to performing these blocks.

Upper extremity blocks

Brachial plexus block can be performed at various locations and
is applicable to upper extremity surgical procedures. Axillary,
infraclavicular, interscalene, and supraclavicular approaches
are possible, supraclavicular brachial plexus block being the
most common upperextremity block performed in children (personal communication, PRAN database). The use of ultrasound
guidance when performing regional anaesthesia allows performance of brachial plexus blocks at any location safely and effectively by allowing better recognition of brachial plexus
anatomy and improved localization of adjacent structures
during needle placement.

Axillary block
Anatomy and indications

The axillary approach to the

brachial plexus block supplies analgesia to the elbow, forearm,
and hand via the radial, median, and ulnar nerves. The radial
nerve most commonly lies posterior to the axillary artery, and
the ulnar nerve lies anterior and inferior to the artery. The
median nerve is most often located anterior and superior to
the axillary artery. The musculocutaneous nerve is situated
outside of the axillary neurovascular sheath between the
biceps brachii and coracobrachilias muscles, and must be
blocked separately from the radial, median, and ulnar nerves.

Technique Although axillary block techniques are not well

described in the literature, ultrasound-guided axillary techniques
used in adults can be applied in children.49 50 An in-plane technique is utilized with the ultrasound probe positioned transverse
to the humerus (Fig. 1). Multiple injections with needle repositioning facilitate circumferential spread of the local anaesthetic
around each nerve.51 Careful ultrasound-guided needle advancement should be completed because of the superficial depth of
the axillary sheath.

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Block technique

femur and anterior knee and to treat complex regional

pain syndrome and cancer-related pain. Risks associated
with indwelling catheter placement include infection, nerve
damage, and falls as a result of block-induced quadriceps
motor weakness. Continuous sciatic nerve block can also be
used to provide analgesia to the lower extremity in infants
and children, with fewer adverse effects than epidural anaesthesia in children undergoing major foot and ankle surgery.48
CPNBs are evolving as a novel extended analgesic modality in
paediatrics. Ultrasound guidance can facilitate and confirm
placement of the catheter, which can reduce pain and potentially
eliminate the need for opioids and their undesirable side-effects.

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SCM
UN

MN

C5

AA

C6
RN

C7
ASM

MSM

Fig 1 Axillary nerve block sonoanatomy. MN, median nerve; AA, axillary artery; UN, ulnar nerve; RN, radial nerve.

Complications

Interscalene block
Anatomy and indications Analgesia of the shoulder and
proximal humerus is achieved by blocking the brachial plexus
at the level of the interscalene groove. At this site, the trunks
and roots of the brachial plexus lie posterior to the
sternocleidomastoid muscle and are situated between the
anterior and middle scalene muscles. The C5, C6, and C7
nerve roots are easily seen between the anterior and middle
scalene muscles using this approach.
Technique The ultrasound probe is positioned in the transverse
oblique plane at the level of the cricoid cartilage at the lateral
border of the sternocleidomastoid muscle (Fig. 2). The
anterior and middle scalene muscles, which make up the
interscalene groove, lie deep to the sternocleidomastoid
muscle and lateral to the subclavian artery. The hyperechoic
structures that comprise the neurovascular bundle of the C5,
C6, and C7 nerve roots are contained within this groove.
Nerve stimulation can be used to guide local anaesthetic
delivery to the brachial plexus at this level; however,
ultrasound guidance might decrease the required total
amount of local anaesthetic.52 53
Complications

Successful interscalene block is associated

with hemidiaphragmatic paralysis, recurrent laryngeal nerve
block, and Horner syndrome; such side-effects should not be
mistaken for complications.54 The interscalene block should
be used with caution in children because of potential risks of
pneumothorax, vertebral artery injection, and intrathecal
injection.40

Supraclavicular block
Anatomy and indications The supraclavicular approach,
which provides analgesia to the upper arm and elbow, facilitates

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Fig 2 Interscalene block sonoanatomy. SCM, sternocleidomastoid;

ASM, anterior scalene muscle; MSM, middle scalene muscle.

block of the trunks and divisions of the brachial plexus, which

are located lateral and superficial to the subclavian artery.
An important sonographic landmark is the first rib, which is
posterior and medial to the brachial plexus; the cervical
pleura is situated deep to these structures.

Technique Few techniques have been described for paediatric

patients.55 The ultrasound probe is positioned in the coronaloblique plane, just superior to the upper border of the
mid-clavicle. The subclavian artery, which is identified as a
hypoechoic and pulsatile structure, lies adjacent to the
brachial plexus. The needle is advanced medially towards the
brachial plexus, just superior and lateral to the subclavian
artery, using an in-plane approach. Potential risk of
intraneural injection or vascular puncture is minimized by
directing the needle in a lateral-to-medial fashion.
Complications

Pneumothorax, haematoma, infection, and

intravascular injection are possible complications of the
supraclavicular block. The potential for pneumothorax is
present as the lung parenchyma is located just medial to the
first rib. Direct visualization of the needle tip with
ultrasonography might decrease the likelihood of this
complication.

Infraclavicular block
Anatomy and indications

Like the supraclavicular block, the

infraclavicular block provides analgesia to the upper arm and
elbow. This approach to the brachial plexus allows nerve
block at the level of the cords of the plexus that lie medial
and inferior to the coracoid process. The axillary artery and
vein are deep to the cords. The pectoralis major and minor
muscles are superficial to the brachial plexus. The lateral cord
of the plexus is seen on ultrasound as a hyperechoic
structure. The posterior cord is situated deep to the axillary
artery. The medial cord can be difficult to identify because of
its anatomical position between the axillary artery and vein.

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Potential complications include neural injury,

intravascular injection, haematoma, skin puncture site infection, and skin tenderness. Utilization of ultrasound guidance
to facilitate needle advancement can help to reduce the
likelihood of haematoma formation from inadvertent vascular
puncture, intravascular injection, or nerve injury.

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Paediatric regional anaesthesia

Technique A lateral approach for performing the ultrasoundguided infraclavicular block is described in the paediatric
literature.56 The ultrasound probe is positioned in a transverse
orientation below the clavicle to identify the brachial plexus.
The needle is inserted inferior to the probe and advanced
using an out-of-plane technique. The needle is directed lateral
to the cords of the brachial plexus; careful attention is needed
to avoid vascular structures as the local anaesthetic is
deposited into the deeper portions of the neurovascular
sheath. De Jose Maria and colleagues55 described an
alternative technique in which the probe is positioned parallel
to the clavicle in a parasagittal plane, and the needle is
directed cephalad towards the brachial plexus.

EO

IO

TA

Complications

Truncal blocks
The frequent use of ultrasonography has increased the success
and safety of truncal blocks in paediatric regional anaesthesia
practice. The emerging role of minimally invasive surgical techniques in children has expanded the spectrum of patients that
benefit from these blocks.

Transversus abdominus plane block

Anatomy and indications

The TAP block supplies analgesia

to the anterior abdominal wall and facilitates effective
postoperative pain control, but does not provide surgical
analgesia.44 This block is frequently utilized for laparoscopic
procedures to provide analgesia at port placement sites and
for larger abdominal incisions.57 58 Three muscle layers are
identified lateral to the rectus abdominis: the external
oblique, internal oblique, and the transversus abdominis
(Fig. 3). The TAP plane, which lies between the internal
oblique and transversus abdominis muscles, encases the
thoracolumbar nerve roots (T8 L1), which deliver sensory
innervation to the skin and muscles of the anterior
abdominal wall.

Technique An ultrasound-guided in-plane approach is used

to advance the needle into the TAP plane.59 The ultrasound
probe is positioned adjacent to the umbilicus and moved
laterally, away from the rectus abdominus, to facilitate
visualization of the three muscle layers of the abdominal
wall. The needle is advanced in-plane starting from either the
lateral or medial side. Injection of the local anaesthetic
creates an elliptical pocket within the TAP plane.
Complications

Potential complications include infection,

peritoneal, bowel puncture, or both, and intravascular injection.

IL/IH nerve block

Anatomy and indications The IL/IH nerves originate from
T12 and L1 of the thoracolumbar plexus and provide

Fig 3 TAP block sonoanatomy. EO, external oblique; IO, internal

oblique; TA, transversus abdominis.

sensation to the inguinal area and the anterior scrotum. The

IL/IH nerves are blocked medial to the anterior superior iliac
spine where they traverse the internal oblique aponeurosis.
Successful IL/IH nerve block can provide equivalent relief to
caudal block for inguinal surgery with the benefit of
increased duration of postoperative analgesia.60 61

Technique The ultrasound probe is positioned medial to the

anterior superior iliac spine, in-line with the umbilicus (Fig. 4).
Three abdominal muscle layers are identified (internal oblique,
external oblique, and transversus abdominus). At this level,
the external oblique muscle layer can be aponeurotic and
only two muscle layers may be seen.62 The IL/IH nerves
appear as oval structures that lie between the internal oblique
and transverse abdominal muscles. The needle is advanced
in-plane to the IL/IH nerves and the local anaesthetic is
injected. In children, ultrasound-guided block dramatically
reduces the volume of local anaesthetic required to produce
analgesia compared with landmark-based techniques.63 64
Complications

Complications associated with IL/IH nerve

block are rare but include needle-insertion site infection,
intravascular injection, bowel puncture, pelvic haematoma,
and femoral nerve palsy.

Rectus sheath block

Anatomy and indications The rectus sheath block provides
analgesia along the midline of the anterior abdominal wall.
The rectus abdominis muscle, lying on the anterior abdominal
wall, is divided by the linea alba. The thoracolumbar nerves
(T7T11) lie posterior to rectus abdominis, immediately
anterior to the posterior sheath. The rectus sheath block is
commonly utilized to provide postoperative pain relief for
umbilical hernia and single-incision laparoscopic surgery.65

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The infraclavicular block confers risks similar

to those of the supraclavicular block, including the risk of a
pneumothorax because of the close proximity of the cervical
pleura. The close location of the axillary artery and vein make
haematoma because of vascular puncture a potential
complication.

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Shah and Suresh

Anterior

EO
IO

Sartorius
IL/IH
TA

SN
Posterior

Fig 4 Ilioinguinal/iliohypogastric nerve block sonoanatomy. EO,

external oblique; IO, internal oblique; IL/IH, ilioinguinal/iliohypogastric nerves; TA, transversus abdominis.

Fig 5 Saphenous nerve block sonoanatomy. SN, saphenous nerve.

Technique

The ultrasound probe is placed lateral to the

umbilicus and the rectus abdominis is identified. The
posterior rectus sheath lies immediately under the rectus
abdominis and sits above the peritoneum. The needle is
advanced in-plane from lateral to medial, and the local
anaesthetic is placed between the rectus abdominis and the
posterior rectus sheath.66

Complications

Potential complications of the rectus sheath

block include infection, intravascular injection, and bowel
puncture.

Anatomy and indications The saphenous nerve innervates

the knee and the medial portion of the leg below the knee. It
is a branch of the femoral nerve and courses within the
adductor canal, running adjacent to the sartorius muscle
before continuing onto the medial aspect of the knee (Fig. 5).
It can be blocked proximally to provide sensory analgesia to
the anterior knee or can be blocked more distally to provide
analgesia solely to the medial aspect of the lower extremity.

Femoral nerve block

Technique With the patient in the supine position, the leg is

abducted and laterally rotated as the probe is placed on the
medial aspect of the knee. The sartorius muscle is identified;
the saphenous nerve lies adjacent to this structure. The
needle is directed using an in-plane technique towards the
saphenous nerve and the local anaesthetic is injected.

Anatomy and indications

Complications

Lower extremity blocks

The femoral nerve, which
innervates the anterior thigh and the knee, originates from
the L2, L3, and L4 nerve roots and is commonly blocked in
paediatrics for surgical interventions of the knee. The femoral
nerve sits lateral to the femoral artery and vein and is
encased in a neurovascular bundle that is easily seen with
ultrasonography.67 In addition to performing a single-shot
block, a perineural catheter can be safely placed to provide
extended analgesia.

Technique With the patient in the supine position, the

femoral nerve, artery, and vein are located within the
inguinal crease. The femoral nerve is identified lateral to the
artery and the femoral vein is seen just medial to the artery
as a collapsible vessel. An in-plane or out-of-plane approach
can be used to guide the needle towards the lateral portion
of the femoral nerve. The local anaesthetic circumferentially
surrounds the nerve as it is injected.50 Careful needle
visualization with advancement decreases the likelihood of
inadvertent puncture of the femoral vessels.
Complications

Potential complications of the femoral nerve

block include infection, nerve injury, and haematoma
formation secondary to femoral vessel puncture.

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Potential complications of saphenous nerve

block include nerve injury, haematoma formation from
arterial puncture, and infection at the needle-insertion site.

Sciatic nerve block

Anatomy and indications

The sciatic nerve, which

originates from the nerve roots of L4 to S3, innervates the
posterior thigh and the portion of the leg distal to the knee
(excluding the medial component). The nerve exits the pelvis
via the greater sciatic foramen and courses inferior to the
gluteus maximus muscle, travelling distally through the
posterior popliteal fossa, where it splits into the tibial and
common peroneal nerves. The nerve can be blocked via the
subgluteal, anterior thigh, or popliteal approaches in
children. Continuous sciatic nerve block, and a single-shot
technique, can provide extended analgesia in children.68 69

Technique The subgluteal approach to the sciatic nerve

requires the patient to lie either in the lateral decubitus
position, with the hip and knee flexed, or in the prone
position. The ultrasound probe is placed between the greater
trochanter and the ischial tuberosity and the gluteus
maximus muscle is identified; the sciatic nerve is situated

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Saphenous nerve block

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Paediatric regional anaesthesia

Complications

Complications of sciatic nerve block include

skin puncture site infection, haematoma formation from
vessel puncture, and local anaesthetic toxicity.

Paravertebral block
Anatomy and indications

The paravertebral space is a

potential wedge-shaped area that contains intercostal and
sympathetic nerve fibres. Boundaries of the paravertebral
space include the superior costotransverse ligament
posteriorly, the parietal pleura anteriorly, intervertebral discs
medially, and the head and neck of the ribs superiorly.
Paravertebral block has been described as an effective
modality for achieving postoperative analgesia with fewer
adverse effects and fewer contraindications than central
neuraxial block.73 Indications include thoracotomy, breast
surgery, cholecystectomy, renal surgery, and inguinal
herniorraphy.74 Ultrasound-guided paravertebral block has
been utilized for postoperative pain management in children
undergoing thoracic and cardiac surgery procedures.75
Lonnqvist described continuous paravertebral block as a
viable option for extended postoperative analgesia.76

Technique The patient is placed in the lateral or prone

position. A linear array transducer is placed at the appropriate
spinous process and moved longitudinally in the cephalocaudad direction until the corresponding transverse process is
identified. The ultrasound probe is then rotated 908 until it lies
perpendicular to the spinal column. The transverse process
and the pleura can both be seen at this point. A needle is
advanced in-plane until it traverses the intercostal muscles to
a point superficial to the pleural border (Fig. 6). A local
anaesthetic solution can be injected, a catheter placed into
this space, or both.

Lumbar plexus block

Anatomy and indications

The lumbar plexus originates

from the T12 to L5 nerve roots. Its branches, which include
the femoral, genitofemoral, lateral femoral cutaneous, and
obturator nerves, innervate the lower abdomen and the
upper leg. The plexus is located within the psoas muscle,
deep to the paravertebral muscles, and can be blocked with
the ipsilateral sciatic nerve to achieve complete analgesia to
the lower extremity. Lumbar plexus block can be safely
performed in children.72

Technique The patient is positioned lateral decubitus and

the iliac crest and spinous processes are identified. The
ultrasound probe is placed lateral to the midline and the L4
or L5 transverse process is located. The erector spinae and
quadratus lumborum muscles lie deep to the transverse
process, and deep to these, within the psoas major muscle, is
the lumbar plexus. Because of this anatomical location, the
plexus is often difficult to demarcate from the similar
echogenicity to muscle. Nerve stimulation can be used in
conjunction with ultrasonography to confirm needle
positioning near the plexus.

Cephalad

Needle

Transverse process
at T3

Pleura
Paravertebral
space
Superior costotransverse ligament

Complications

Complications include infection, haematoma, and retroperitoneal bleeding because of the location
of the plexus.

Fig 6 Sonoanatomy of the paravertebral space.

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deep to this structure. An in-plane or out-of-plane technique

can be utilized for needle guidance. The local anaesthetic is
injected until it circumferentially surrounds the nerve. A
perineural catheter can also be placed to deliver continuous
nerve block.
An anterior approach to sciatic nerve block can be performed with an ultrasound-guided approach.70 This technique
is ideal for the non-anesthetized patient with lower extremity
discomfort, as the block is performed in the supine position
with the patients leg abducted and laterally rotated. The
probe is placed inferior to the inguinal crease and the femur
is identified; the probe is moved medially to reveal the sciatic
nerve in its location deep and medial to the femur. The nerve
often lies deeper in larger patients, which can make this approach technically challenging to complete in older children.
The sciatic nerve can also be blocked more distally in the
popliteal fossa.71 The patient is positioned prone or can
remain supine and the ultrasound probe is placed in the popliteal crease. The popliteal artery is seen; the tibial nerve, which
lies adjacent to the artery, can be followed proximal to the junction with the common peroneal nerve, merging together to
form the sciatic nerve. The sciatic nerve can be blocked here
or the tibial and common peroneal nerves can be individually
targeted at this location.

BJA
Complications

Potential complications of paravertebral

block include accidental pleural puncture, hypotension from
local anaesthetic spread centrally with sympathetic block,
neurological injury because of intrathecal or epidural entry,
and paravertebral haematoma formation.

Discussion
The practice of paediatric regional anaesthesia has made tremendous strides in recent years. Advances in ultrasonography
and precise dosing regimens have facilitated widespread applications of regional anaesthetic techniques in infants, children,
and adolescents. Prospective studies indicate that these techniques can be safely performed and positively impact on the
outcomes of paediatric patients undergoing painful procedures and those who suffer from chronic pain. Large prospective databases in the USA and Europe will allow ongoing
monitoring of regional techniques in children and allow meaningful decisions regarding their safety and efficacy.

R.D.S. and S.S.: responsible for the conception of this review, interpretation of the data, drafting the review, and final approval
of the published version.

Declaration of interest
None declared.

Funding
None.

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