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Indian J. Anaesth.
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48 (5)ANAESTH
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INDIAN JOURNAL OF ANAESTHESIA, OCTOBER 2004

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REGIONAL ANAESTHESIA IN PAEDIATRIC PATIENTS

Dr. Dilip Pawar
Introduction
In 1898, after introduction of spinal block in adults
by August Bier, this block was extensively used in children.
By the beginning of last century large series were published
primarily by surgeons.1,2,3 The patients in whom it was
often used were sick enough to be refused general
anaesthesia. In 1950s with the introduction of balanced
anaesthesia technique, the blocks were used less frequently.
In 1986, Anand published his work in infants to
demonstrate that pain relief provided in the intra-operative
period decreases morbidity.4,5 This paper changed the
thinking and attitude of anaesthesiologists on pain
management in children from no pain relief at all to
aggressive pain management. Around the same time it
was appreciated that regional anaesthesia (RA) blocks,
produce excellent intraoperative analgesia. They are easy
to perform and safe. In the last two decades their use has
increased dramatically.6,7 In children regional analgesia is
commonly used in conjunction with general anaesthesia.
The advantages of RA are :
a.
It provides complete block of sensory transmission,
hence offers complete pain relief.
b.
The anaesthetic requirement (inhalational agents)
comes down drastically. It has opiate sparing effect.
Hence the recovery from GA is faster and smoother.
c.
It can be extended to the post-operative period
especially after major operation to provide pain relief.
Indications
i.
Whenever possible all children should receive RA in
some form or other, appropriate to the proposed
surgery.
ii.

RA in children is usually administered and practiced

after induction of general anaesthesia except in certain
situations like, premature baby or ex-premature baby
up to a conceptual age of 60 weeks when there is fear
of post operative apnoea.8,9 It is a well-recognized
D.A,M.D., MNAMS,
Prof. Department of Anaesthesiology
All India Institute of Medical Sciences
Ansari Nagar, New Delhi-110029
Correspond to :
Dr. Dilip Pawar
E-mail :dkpawar@hotmail.com

fact that the incidence of post operative apnoea is

least under spinal block as compared to spinal with
sedation or general anaesthesia.10 Whatever technique
is practiced in this group of infants proper monitoring
is a must.
iii.

Children undergoing thoracic and upper abdominal

surgeries those need aggressive pain management in
the post-operative period.

Contra indications
a.
Lack of parental consent
b.

Infection at the site of administration of the block

c.

Any coagulation disorder.

Common regional analgesia techniques

The most commonly practiced RA technique is the
caudal (epidural) block.11,12,13 Other common blocks are ilio
inguinal ilio hypogastric block (hernia) and block of the
dorsal nerve of penis (penile).
Caudal block
The sacral anatomy and caudal block technique
described in the textbooks are extrapolation of adult anatomy
and techniques and are not children specific. Thats the
reason why a high rate of inability to feel the sacrococcygeal ligament and high failure rate of the block is
described.
Anatomy : The sacrum in infants and children is flat
as compared to that of an adult (fig.1). The sacral hiatus
is situated near the natal cleft in adults where as in infants
it is located much higher. In neonates it could be at the
middle of sacrum. The filum terminale terminates at a
lower level than S2, might be S3 or S4. The size of the

Fig. 1 : Anatomical differences in adults and child sacrum.

PAWAR : REGIONAL ANAESTHESIA

vertebrae is so small that little advancement of needle

might reach two or three segments cephalopod.
The sacral hiatus is bordered by spine above, two
laminae and two cornue on the sides. The sacro coccygeal
ligament extends from the posterior aspect of these bony
structures to dip down anteriorly. The depth of the epidural
space is maximum at the apical region of the hiatus (fig.2).
It gradually reduces to negligible space at the level of the
cornue.

395

is not touched). This way there is a overlap between the

site of puncture of skin and the ligament, preventing any
leakage of the drug administered. A 22/23 G hypodermic
needle is advanced at an angle of 70-90o at the apical
region of the hiatus (fig.4). The ligament can be identified
Technique in child
no change of angle,
no advancement

Adult technique

The technique : The approach to the hiatus should be

made from above along the sacral spines and not from the
tip of the coccyx. That makes it easy to identify the
commonly seen sacral anomalies in children.
Cornu
Sacro coccygeal ligament

Fig. 4 : Technique of caudal block in children and adults.

Depth of epidural space

highest at the apex of
the hiatus

Fig. 2 : The sacrococcygeal ligament and depth of epidural space.

An imaginary line is drawn between the two posterior

superior iliac spines. They can be identified as projections
or dimples in chubby kids (fig.3). This line passes thro the

by the loss of resistance or the pop of overcoming the

resistance. The saccro coccygeal ligament is always felt.
Once the needle crosses the ligament, it should be stopped
and drug deposited. Further advancement or change of
direction is not necessary. In case thinner needles are used
it should be disconnected from the syringe to look for any
back flow. The negative pressure generated by aspiration
often collapses the vein over the needle tip. Some people
advice routine use of styletted needle for fear of introducing
dermal plug. However it has been seen that microscopic
plugs or cells is not possible to avoid even in a 26,27G
styletted needle. Some people advocate routine use of test
dose. However we do not practice it and have not had any
complication in our practice of last over twenty years.
Catheter insertion : In patients where post operative
pain relief is necessary for longer duration a catheter might
be inserted through the caudal space and advanced to the
dermatomes involved in incision.14,15 An infusion with more
lipophilic drug like fentanyl is used. When the catheter is
left at the caudal epidural space only hydrophilic opioid
like morphine can be used intermittently. It is effective
even for thoracic and upper abdominal surgery.

Fig. 3 : Surface anatomy of sacral hiatus in relation to sacral spines.

S1-S2 space or S2 spine. Feel the S2 spine and proceed

downwards feeling the spine of S3, S4 till one feels the
hiatus. The hiatus might be at the level of any of these
spinous processes. At higher level chance of puncturing the
dural sac is a possibility. Once the hiatus is identified by
the thumb, it is moved across to feel the laminae. Then the
skin is pulled up to the spinous process (the point of injection

Catheter can be inserted through a Touhy needle

(fig.5). The length of catheter to be advanced has to be
measured prior to insertion. It can also be inserted through
an indwelling cannula. An 18 G catheter easily passes through
18 G cannula. The possibility of catheter not reaching or
kinking or knotting is very high. Hence one should try to
confirm the tip radiologically using a water-soluble dye.
As the sacral hiatus is close to the anus there is possibility
of contamination of the catheter and the puncture site. It
can be prevented by occlusive dressing with a water resistant

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INDIAN JOURNAL OF ANAESTHESIA, OCTOBER 2004

Fig. 5 : Tunneling of caudal epidural catheter.

flap cover or by bringing out the catheter on the lateral

flank by subcutaneous tunneling. The 18G catheter has less
chance of kinking than 20G/22G ones. The catheter
advancement from caudal route has less chance of kinking
than through the lumbar route.
The common drugs used are
a)
Single shot caudal block : Bupivacaine 0.25%. Higher
concentration causes undesirable motor block and
should be avoided. For surgery of various sites different
doses are recommended :

Genital and anal canal

0.5 mlkg-1

Upto T12 (hernia)

0.75 mlkg-1

Upto T10

1.00 mlkg-1

This recommendation is a modification of Armitage

formula used in our patient population.
b)

c)

Intermittent : Morphine 30-50 mgkg-1 in 10 ml for

infants and children weighing more than 5 kg and 5 ml
for less than 5 kg.16 This volume though empirical has
been seen to be effective and safe.
Continuous : Bupivacaine 0.125% with fentanyl
1-2 mgml-1 or bupivacaine 0.0625% with fentanyl
2 mgml-1

The infusion can be started with 1-1.5 mlhr-1. Up to

2 mlkg-1 is good enough for most of the cases.
Other neuraxial blocks
Lumbar Epidural (Fig.6)
The lumbar epidural block is technically similar to
that of an adult. The only differences are :
i)

Depth of the epidural space is small

ii)

The ligaments are thinner, hence difficult to feel the

loss of resistance.

Fig. 6 : The technique of lumbar epidural block.

iii)

The midline approach is preferred as the laminae are

not well developed.

Subarchnoid block17,18
The differences are:
i)
the spinal cord is at a lower level might be L3 or L4
in infants. Hence a lower space L5-S1 or L4-5 is always
preferred.
ii)

The laminae are not well developed hence the midline

approach is preferred.

iii)

The CSF volume is higher and the CSF turn over is

faster hence the drug gets diluted and removed faster.
The duration of action gets reduced.19

The technique : Technically it is the same as that

in adult except that a thinner (25-30G) and smaller needle
are used at a lower space. In these babies spinal in sitting
position has been described but my personal preferences is
lateral position.
Combined Spinal Epidural Anaesthesia (CSEA)
Because of the limitations of single shot subarachnoid
block and epidural block, viz shorter duration of action
and in ability to produce post operative pain relief this
combined thechnique was described by Williams. A variety
of extensive surgical procedures including small bowel
resection and genitourinary procedures were successfully
performed. The post operative analgesia was satisfactorily
maintaned in all the patients. It can be said that CSEA is
a potential option to GA for major abdominal surgery in
infants.20
Ilio Inguinal and Ilio Hypogastric nerve block
(hernia)21,22:
Anatomy : This pair of nerves transverse along the
lateral wall of pelvis. They emerge through the internal

PAWAR : REGIONAL ANAESTHESIA

oblique muscle to lie under external oblique aponeurosis

medial to the anterior superior iliac spine (fig.7).

397

difficult to identify the space and may lead to intra-peritoneal

injection.

L1

Skin
Skin
Exter. obl aponeurosis
ileo inguinal nerve
ileo hypogastric nerve

Int. obl muscle

Int.oblique muscle
Transverse ab. muscle

Ant. Sup. iliac spine

Fig. 7 : Anatomy of ilio inguinal and ilio hypogastric nerves.

Technique : A point, one centimeter medial and

lower to the anterior superior iliac spine is identified (fig.8).
A needle with short bevel is chosen. As the needle is
advanced at this point through skin and subcutaneous tissue
the external oblique aponeurosis offers resistance. A pop
or loss of resistance is felt as the needle penetrates the
external oblique aponeurous. The local anaesthetic injected
here will bathe the nerves and block them.

Fig. 9 : The technique of ilio inguinal and ilio hypogastric nerves block.

Dorsal Nerve of Penis block (Penile)23,24,25

Anatomy : The dorsal nerve of penis emerge from
under the symphysis pubis on the dorsal surface of the
corpora cavernosa. They lie in a triangular compartment
bounded by the symphysis pubis above, the corpora cavernosa
below and the membranous layer of fascia in front (fig.10).
When viewed in the anterior posterior view this space is
divided by the suspensory ligament of the penis derived
from the deep surface fascia. The suspensory ligament then
divides into two sheets, which passes around the shaft of
the penis. The nerves lie deep in the triangular space
formed by the division of the suspensory ligament, and are
accompanied by their arteries and vein.

Membaranous layer of
superficial fascia

Dorsal nerve of penis

Fig. 10 : Anatomy of the dorsal nerve of penis.

Fig. 8 : Site of puncture for II and IH block.

This block is used for hernia repair. Often

manipulation of cords lead to noxious stimulation. This can
be effectively blocked by modification of this classical block.
The needle after initial drug deposit is further advance in
to the internal oblique muscle. If a loaded syringe is used
it will be difficult to inject in to the muscle. The needle
is advanced gradually keeping gentle pressure on the plunger.
Once it crosses the muscle it becomes easy to inject. The
drug is deposited here . It lies between internal oblique and
fascia transversalis and gradually trickle down to bathe the
cord at the inguinal canal (fig.9). In infants it might be

There are potential pear shaped spaces on each side

of the suspensory ligament and it is into these spaces that
the local anaesthetic should be deposited. Any attempt to
get close to the nerves might lead to injury to the vessels.
Techniques : The symphysis pubis is palpated.
A needle (short beveled) inserted at right angles until it
contacts it. The needle is then with drawn and redirected
below the symphysis, through the fascia into the space
above the corpora cavernosa. It has been observed that
single injection most of the times enter the compartment
on one side of the suspensory ligament. It is therefore

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INDIAN JOURNAL OF ANAESTHESIA, OCTOBER 2004

best to inject on both sides by angling the needle by fifteen

degree (fig.11).

blocks. The incidence of serious complications are seen

only with central neuraxial blocks and is 1 in 40000-50000
cases.32
Complications after

Skin
Suspen. lig.

Spinal33
- Total spinal block
- High spinal and respiratory paralysis
- Post dural puncture headache (PDPH)
- Meningitis

Bucks fascia

Fig. 11 : The technique of dorsal nerve of penis block.

The volume needed for an effective block is 1.5-2 ml

on each side in infants and adding 1 ml 10 kg-1 on each side
for bigger boys. Often the ventral branch escapes the block
and may need additional subcutaneous infiltration of the
ventral surface of penis.
Complications
The complications of regional analgesia may be drug
related or technique related.
Drug related26,27,28
The major toxic affect of LA is on the cardiovascular
and central nervous system. The effects depend on total
dose, site and route of administration, rate of degradation,
metabolism and elimination. It can be prevented by use of
recommended doses only. Minimum recommended dose
for lignocaine is 1.5 mgkg-1 and with adrenaline 3 mgkg-1.
Bupivacaine up to 3 mgkg-1 is recommended. For infants
below 6 months the dosage should be reduced by 30%.29,30,31
In case of intravenous injection of bupivacaine,\may
manifest with cardio toxicity. The risk of cardiac toxicity
might increase with concomitant use of inhalational agents.
Though in children CNS toxicity also occurs almost at the
same time, its clinical manifestation might be masked by
general anaesthesia. The treatment is basically symptomatic.
The cardiac toxicity of bupivacaine is difficult to treat.
Technique related
The technique related complications have been
studied both retrospectively as well as prospectively. The
incidence is low and is of minor in nature and transient.
The incidence is practically negligible with peripheral nerve

The incidence of PDPH has been reported to be as

high as in adult. It might be difficult to make a diagnosis.
A crying child in upright position if becomes quiet on lying
down he/she probably is having a headache.
After epidural34
- Dural tap
- Total spinal
- Catheter knotting, kinking.
Conclusion
The regional analgesia techniques are simple and
easy to learn. It has least complications. It is cost effective
and hence has a special place in our country where resources
are limited. It provides complete analgesia intra-operatively,
which can be extended to the post operative period. Regional
analgesia should be practiced more often in our country.
This article describes the common blocks, but the RA in
children has gone beyond caudal. Most RA techniques
suitable for adults can be used in paediatric patients.
References
1. Gray HT. A study of spinal anaesthesia in infants and
children: From a series of 200 cases, Part I. Lancet 1909; 2:
913-917.
2. Gray HT. A study of spinal anaesthesia in children and
infants: From a serious of 200 cases, Part II. A study of the
second series of 100 cases. Lancet 1909; 2: 991-996.
3. Gray HT. A further study of spinal anaesthesia in children
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4. Anand KJ, Sippell WG, Aynsley-Green A. Randomized trial of
fentanyl anaesthesia in preterm babies undergoing surgery:
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5. Anand KJ, Hickey PR. Pain and its effects in the human
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6. Yaster M, Maxwell LG. Pediatric regional anesthesia.
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7. Dalens B. Regional anesthesia in children. Anesth Analg 1989;
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PAWAR : REGIONAL ANAESTHESIA

8. Bailey A, Valley R, Bigler R. High spinal anesthesia in an
infant Anesthesiology 1989; 70: 560.
9. Welborn LG, Rice LJ, Hannallah RS, et al. Postoperative
apnea in former preterm infants: Prospective comparison of
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10. Sartorelli KH, Abajian JC, Kreutz JM, et al. Improved outcome
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11. Ruston FG.Epidural anaesthesia in paediatric surgery L Present
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22. Trotter C, Martin P, Youngson G, et al. A comparison between
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24. Kirya C, Werthmann MWJ. Neonatal circumcision and penile
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14. Pegues DA, Carr DB, Hopkins CC. Infectious complications

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Can J Anaesth 1997; 44(5): 511-514.
21. Hannallah RS, Broadman LM, Belman AB, et al. Comparison
of caudal and ilioinguinal / iliohypogastric nerve blocks
for control of post-orchiopexy pain in pediatric ambulatory
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29. Eyres RL, Hastings C, Brown TCK, Oppenheim RC. Plasma

bupivacaine concentrations following lumbar epidural
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bupivacaine concentrations in children during caudal epidural
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bupivacaine concentrations in children during caudal epidural
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32. Giaufre E, Dalens B, Gombert A. Epidemiology and morbidity
of regional anesthesia in children: A one year prospective
survey of the French Language Society of Pediatric
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33. Kilpatrick ME, Girgis NI. Meningitis: A complication of spinal
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34. Polnar DM, SureshS, Cote C. Pediatric regional anesthesia .In
A practice of anesthesia for infants and children. Ed.Cote C
et al, 3rd Ed. W. B. Saunders, London 2001; 638.

ISA ANNUAL CONFERENCE 2006

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of ISA, to host the 2006 ISA Annual Conference in the proper format available with the Secretary and the
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the decision will be taken during Annual Conference (28th December 2004 at Bhopal).

Secretary, ISA National.