Eur J Anaesthesiol 2015; 32:289–297
REVIEW
Regional anaesthesia in neonates, infants and children
An educational review
Martin Jöhr
Prophylactic analgesia with local anaesthesia is widely used
in children and has a good safety record. Performing regional
blocks in anaesthetised children is a safe and generally
accepted practice. When compared with adults, lower con-
centrations of local anaesthetics are sufficient in children; the
onset of a block occurs more rapidly but the duration is
usually shorter. Local anaesthetics have a greater volume of
distribution, a lower clearance and a higher free (non-protein-
bound) fraction. The recommended maximum dose has to be
calculated for every individual. Peripheral blocks provide
analgesia restricted to the site of surgery, and some of them
have a very long duration of action. Abdominal wall blocks,
such as transverse abdominis plane or ilio-inguinal nerve
Introduction
Current position of paediatric regional anaesthesia
Regional anaesthesia is mainly used to provide post-
operative analgesia. Prophylactic analgesia with local
anaesthetics is an attractive concept, especially in pae-
diatric practice, because the evaluation of pain can be
very challenging in young children. In contrast to opioids,
local anaesthetics can be administered safely, and in
recent guidelines regional anaesthesia is accepted as
the cornerstone of post-operative pain relief in the pae-
diatric patient.1 Surprisingly, in children, there are only
limited data to show that regional anaesthesia really
improves analgesia compared with systemic medication;
this is true for inguinal hernia repair, urological surgery,
cleft lip repair and ophthalmological surgery.2
Regional blocks are usually performed in anaesthetised
children. This is an accepted practice provided the clin-
ician selects and performs the technique carefully and is
appropriately skilled.3–5 Although regional anaesthesia
has a good safety record overall,5–8 the global experience
with paediatric regional anaesthesia is still quite low;
From the Section of Paediatric Anaesthesia, Department of Anaesthesia, Kantonsspital, Luzern, Switzerland
Correspondence to Dr Martin Jöhr, Department of Anaesthesia, Kantonsspital, CH-6000 Luzern 16, Switzerland
Tel: +41 41 205 4908; fax: +41 41 370 5427; e-mail: joehrmartin@bluewin.ch
0265-0215 ß 2015 Copyright European Society of Anaesthesiology
Copyright © European Society of Anaesthesiology. Unauthorized reproduction of this article is prohibited.
block, should be performed with the aid of ultrasound.
Caudal anaesthesia is the single most important technique.
Ropivacaine 0.2% or levobupivacaine 0.125 to 0.175% at
roughly 1 ml kg 1 is adequate for most indications. Clonidine
and morphine can be used to prolong the duration of
analgesia. Ultrasound is not essential for performing caudal
blocks, but it may be helpful in case of anomalies suspected
at palpation and for teaching purposes. The use of paediatric
epidural catheters will probably decline in the future because
of the potential complications.
Published online 16 February 2015
even the most commonly performed procedure, caudal
block, represents only 2.5% of all central neuraxial
blocks performed.9 Determining the risk–benefit ratio
is difficult for techniques that are relatively rarely per-
formed.
Developmental pharmacology
Lower concentrations of local anaesthetics that are
used in adults are clinically effective in children; the
onset of a block occurs more rapidly but the duration is
shorter. However, with the exception of caudal anaes-
thesia, no scientific data exist on the best dose and
concentration for specific regional blocks in different
age groups.
Pharmacokinetics
In infants, local anaesthetics have a greater volume of
distribution,10,11 a lower clearance,12 and a higher free
non-protein-bound fraction.10 The larger volume of
distribution counteracts the increased potential for
toxicity caused by the larger free non-protein-bound
DOI:10.1097/EJA.0000000000000239
 290 Jöhr
fraction. This means that the amount used for single-shot
procedures in terms of ml kg 1 can be the same in
children as for adults.
For a continuous infusion the situation in the developing
organism is much more complex;13 the maturation of the
metabolism has to be taken into account. CYP1A2 which
metabolises ropivacaine is immature before 4 to 7 years of
age, whereas CYP3A4/7, which metabolises levobupiva-
caine, has full enzymatic capacity by the age of 1 year.
Unfortunately, no well designed study compares the two
local anaesthetic molecules.
Pharmacodynamics
In neonates and infants, nerve fibres are thinner, they have
less myelin and the nodes of Ranvier are located closer to
each other. Therefore, a smaller sleeve of local anaesthetic
solution is sufficient to block three nodes of Ranvier or
more, a prerequisite for the blockade of saltatory conduc-
tion. Nerve fibres are more susceptible to the effects of
local anaesthetics, and a shift of the dose–response curve
to the left has been shown in young rabbits.14
Systemic toxicity
In animal experiments, young individuals are more resist-
ant to the toxic effects of local anaesthetics than older
ones.15 But, when using a whole-organ preparation, the
effect of bupivacaine on cardiac contractility was even
greater in neonatal rabbits than in adult rabbits.16
Toxicity occurs when high plasma levels are reached
following the absorption of an excessive dose of local
anaesthetic, or when the drug is inadvertently injected
into the vascular space.
The maximum recommended dose must be calculated for
every individual patient. Although this dose should not lead
to clinically relevant toxicity, provided that the patient is
healthy and the anaesthesiologist adheres to all the tenets of
good practice, signs of toxicity may still occur in sick
patients, or following unintended intravascular injection.17
In paediatric regional anaesthesia, it is a rule of safety to
draw up only the exact amount of drug needed.
It is generally accepted that the amount of bupivacaine
should be limited to 2.5 mg kg 1 for single injections
and to 0.25 mg kg 1 h 1 for continuous infusions. With
Table 1 Maximum recommended doses for various local anaesthetics
Single injection
(mg kgS1)
Bupivacaine 2.5
Levobupivacaine 2.5
Ropivacaine 3 to 4
Lidocaine 7 2 (?)
Prilocaine 7 to 10
These doses are in large part not evidence based and represent experts’ opinion.
Eur J Anaesthesiol 2015; 32:289–297
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levobupivacaine similar limits should probably be fol-
lowed; some experts consider that with ropivacaine
slightly higher doses may be used safely. But for a
continuous infusion, the immature metabolism of the
very young has to be taken into account (Table 1).
Peripheral blocks
Peripheral blocks provide analgesia restricted to the site
of surgery and some of them have a very long duration of
action. Their safety record is good. However, peripheral
blocks are not without risk: needle trauma, compression/
ischaemia and neurotoxicity are mechanisms that can
lead to neurological complications. The recommended
doses are based mainly on experts’ opinion and not on
evidence. When the injections are made with ultrasound
guidance, a very low volume can be seen to provide
adequate spread (Table 2).
Topical anaesthesia
EMLA cream (which contains prilocaine 2.5% and lido-
caine 2.5%) is almost universally used for skin analgesia
before venous puncture in awake children. It works best
with an application time of 60 to 90 min and should be
removed 15 min before the intended procedure in order
to allow regression of the prilocaine-mediated vasocon-
striction. At higher doses, prilocaine can cause methae-
moglobinaemia. Because of the reduced activity of
methaemoglobin reductase in neonates and young
infants, there is an increased risk of methemoglobine-
mia,18 even after moderate doses of prilocaine.19 How-
ever, the use of EMLA cream is safe, even in this age
group, as long as the dose is restricted to 1 to 2 g.20,21
Wound infiltration
Wound infiltration is employed chiefly to provide post-
operative analgesia but it can only be expected to pro-
duce reliable analgesia if the surgery could have been
performed under infiltration anaesthesia alone, in an
awake child - for example superficial skin surgery. When
used after laparotomy22 or for port-site infiltration after
laparoscopic surgery,23,24 it may be only a partial remedy
for post-operative discomfort.
Anaesthesiologists in most cases use a skin wheal
before performing a major conduction block in awake
children. In addition, infiltration is extensively used by
Continuous infusion
(mg kgS1 hS1) Comments
0.25
0.25
1 1
0.4 0.2 mg kg h in the first 6 months of life
Not suitable Not recommended in infants and young children because
of an increased risk of methaemoglobinaemia

Table 2 Dosage of local anaesthetics for peripheral nerve block
Type of the block Dosage (ml kg S1
)
Rectus sheath block 0.1 to 0.2
TAP-block 0.2 to 0.5 (maximum 20 ml)
Ilio-inguinal nerve block 0.1 to 0.3
Penile block 2  0.1
Brachial plexus block 0.3 to 0.75
Femoral nerve block 0.3 to 0.75
Sciatic nerve block 0.3 to 0.75
These doses are mainly based on experts’ opinion and not on evidence. When the
injections are made under ultrasound guidance, a sufficient spread can often be
seen with a very low volume. TAP-block, transversus abdominis plane block.
paediatricians, surgeons and emergency physicians for
the repair of skin lacerations or minor superficial surgery.
With appropriate psychological guidance, infiltration can
be performed with minimal suffering of the child, pro-
vided certain rules are followed (Table 3).25–29 Wound
infiltration is widely used in clinical medicine in adults as
well as in children; nevertheless, it is rarely taught in a
systematic manner in medical schools.
Tonsillar bed infiltration
Initially it was thought that tonsillar bed infiltration was
very desirable because it offered the theoretical
advantage of pre-emptive analgesia. However, local infil-
tration of the tonsillar bed has no demonstrable preemp-
tive effect30 and has only a small impact on post-operative
pain.31 Infiltration of the tonsillar bed can produce
dramatic complications,32,33 although the use of adrena-
line containing local anaesthetic solutions reduces blood
loss.34 Therefore, the management of post-tonsillectomy
pain still relies mainly on systemic medication, opioids
and non-opioid analgesics, as well as corticosteroids.
Abdominal wall blocks
There is growing consensus that abdominal wall blocks
should be performed with the aid of ultrasound, because
otherwise imprecise administration of the local anaesthetic
and even intra-peritoneal injections commonly occur.
A rectus sheath block consists of an injection between the
rectus muscle and the posterior rectus sheath. Its main
indication is analgesia after umbilical hernia repair or,
depending on the site of incision, after open pyloromyot-
omy. It provides more reliable and longer analgesia than
surgical wound infiltration,35 and the absorption kinetic
of the local anaesthetic seems to be quite slow.36 The
Table 3 The rules for an injection of local anaesthetics with minimal pain, for example, for a skin wheal before performing a conduction block
Factor Comments
Needle size Thin needles cause less pain
Speed of injection A slow injection is far less painful
Site of injection Infiltration from inside of the wound is less painful compared with an injection through the intact skin
Local anaesthetic Alkalinised lidocaine causes less pain compared with a plain solution
Impact of order A second injection is perceived more painfully compared with the first one
Eur J Anaesthesiol 2015; 32:289–297
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Paediatric regional anaesthesia 291
ideal volume of injection has not yet been defined, but
0.2 ml kg 1 on each side are often used.
A transversus abdominis plane block (TAP-block) con-
sists of an injection into a plane between the internal
oblique and transversus abdominis muscle (Fig. 1).37,38 It
provides unilateral analgesia of the abdominal wall,39 and
is an alternative to central neuraxial blocks, when these
techniques are not possible, for example, in spinal dys-
raphism or other anomalies of the spinal canal.40 In
addition, the TAP-block technique seems to be useful
for analgesia after bone harvesting at the iliac crest.41
Whereas a mid-axillary injection covers the segments
T10 to L1, higher segments can be reached with a
sub-costal TAP-block.42 The clinical duration of the
block and the best volume of injection have not yet been
defined in children, but, higher doses seem to improve
the duration of analgesia.43 Bilateral TAP-blocks need
careful observation of the total local anaesthetic dose
because rapid absorption and high plasma levels have
been reported in adults.44 Realistically, with a long-acting
local anaesthetic and a volume of 0.3 ml kg 1, a duration
of 5 to 10 h can be expected. TAP-block is a safe tech-
nique, provided the dose is correctly calculated and an
intra-peritoneal injection is avoided.45
An ilio-inguinal nerve block provides post-operative pain
relief after inguinal incisions, such as herniotomy or orch-
idopexy. It may not prevent the intra-operative perception
of noxious stimuli caused by, for example, traction on the
peritoneal sac. In addition, in the case of orchidopexy, ilio-
inguinal nerve block does not cover the scrotal incision,
which surprisingly does not seem to contribute to a major
extent to post-operative pain. An additional pudendal
nerve block could cover this location but in younger
children, a caudal block would provide more reliable
and more complete analgesia. With ultrasound guided
ilio-inguinal block the typical complications of a land-
mark-based technique46 such as femoral nerve block47
and intestinal puncture48–50 can be avoided. Finally, the
ilio-inguinal nerve block scores better than a TAP-block
for inguinal hernia repair.51 A volume of 0.1 to 0.3 ml kg 1
is often used; however, in children, the clinical duration as
well as the optimal volume is largely unknown.
Penile block
Anaesthesia of the dorsal nerve of the penis is considered
the standard for analgesia after penile surgery. A variety
References
Palmon et al.25
Scarfone et al.26
Bartfield et al.27
Palmon et al.25
Bartfield et al.28
Bartfield et al.29
 292 Jöhr
Fig. 1
Anterior Posterior
External oblique
Internal oblique
Transversus
Abdominal cavity
3,3
Transversus abdominis plane block consists of an injection into a plane
between the internal oblique and transversus abdominis muscle. The
arrow shows the path of the needle.
of techniques are available such as the classical sub-pubic
puncture or a sub-cutaneous ring block; the latter pro-
vides analgesia of shorter duration,52 but offers more
complete intra-operative analgesia than the sub-pubic
injection.53 Sub-cutaneous infiltration of the perineal
nerves is required for analgesia of the ventral aspect of
the penis to allow pain-free awake surgery.54
Sub-pubic penile block, as described by Dalens et al.,55
consists of the injection of local anaesthetic below the
superficial fascia – before it becomes Buck’s fascia – into
the fat-filled sub-pubic space, wherein the dorsal nerves
of the penis run and give off their branches. Penile block
is easy to learn.56 The penis is fixed between the thighs
with tape, and the needle, a 25-gauge spinal needle,
penetrates the skin 0.5 to 1.5 cm lateral to the mid-line
and is directed slightly medially (10 to 208) and slightly
distally (10 to 208) until a marked ‘give’ is felt as the
superficial fascia is crossed and the tip of the needle
enters the sub-pubic space. Two paramedian injections
of 0.1 ml kg 1 (up to 2  4 ml) bupivacaine 0.5 to 0.75%
without adrenaline are given. This provides prolonged
pain relief for up to 24 h. The use of ultrasound has been
reported to increase the success rate,57 but in the view of
the author, it is not a prerequisite for this block. Sub-
pubic penile block is virtually free of complications.58 It
has been suggested that the intrinsic vasoconstriction of
ropivacaine could cause penile ischaemia59; however,
ropivacaine has been extensively used for this indication
in some countries,60 and in any case, similar cases have
also been reported with plain bupivacaine.
Extremity blocks
Brachial plexus blocks, as well as sciatic and femoral
nerve blocks, are widely used in clinical practice. The
Eur J Anaesthesiol 2015; 32:289–297
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choice of the needle size and the injected volume differ
between the adult and the paediatric surgical patient; but,
in other respects, the indication and the techniques are
identical so they are not discussed in detail in this review.
The ease of diffusion of local anaesthetics in children
compared with adults makes it easier to achieve an
excellent block.
Continuous catheter techniques are also used in paedia-
tric patients61,62 but they are mostly restricted to special
patient groups with chronic pain.63,64 This may be related
to technical difficulties with paediatric catheters that
include leakage of local anaesthetic solution along the
catheter, and also the fact that complete pain relief often
does not lead to a satisfied and comfortable child, and
sedative effects of opioids are needed anyway.
Miscellaneous blocks
A large variety of peripheral nerve blocks are feasible and
their use is mainly dependent on the experience of
the practitioner.
An infra-orbital nerve block can be used for analgesia
after cleft lip repair.65,66 In skilled hands, an infra-orbital
nerve block can also be used for the repair of upper lip
lacerations under deep sedation. For this indication, the
author prefers to approach the site of exit of the infra-
orbital nerve from within the mouth. In contrast, for
analgesia after cleft lip surgery the percutaneous
approach is usually preferred.
A supra-zygomatic maxillary nerve block using a volume
of 0.15 ml kg 1 ropivacaine 0.2% has been described for
analgesia after cleft palate repair.67 The needle is
inserted at the upper edge of the zygomatic arch until
contact with the greater wing of the sphenoid is felt; then
the needle is redirected in a 208 forward and 108 down-
ward direction into the pterygopalatine fossa. Real-time
ultrasound allows the spread of the local anaesthetic to be
followed.68 The clinical anatomy has been recently
reviewed,69 but no large case series of this technique
have yet been reported.
Central neuraxial blocks
Anatomical and physiological properties
The dura and the spinal cord reach lower levels in the
spinal canal in infants (spinal cord L3 at birth, L1-L2 at
1 year; dura S4 at birth, S2 at 1 year) than in children and
adults. The loose epidural fat enhances a more even
spread of local anaesthetics, up to the thoracic region.
It is widely believed that central blocks in awake infants
and young children have limited haemodynamic effects.
However, studies measuring cerebral blood flow (by
transcranial Doppler) have reported a decrease in blood
flow after both spinal and caudal block.70,71 In the context
of combined general and regional anaesthesia, hypoten-
sion can be observed, although this is not widely reflected
in the literature.72

Caudal epidural anaesthesia
Caudal anaesthesia is the single most important regional
anaesthesia technique in children. Compared with neur-
axial techniques in adults, it can be easily learned.73 The
puncture is usually performed with the child in a lateral
position, the upper hip flexed at 908, the lower one at 458.
The sacral hiatus is identified by palpation.74 The dural
sac shifts significantly cephalad when the hips and the
spine are in a flexed position.75 Alternatively, in the fully
awake neonate, according to the author’s opinion, a
caudal block can be performed best with the baby in
the prone position.
Different types of cannulae are currently in use. Normal
hypodermic needles have a long tradition, but some
authorities argue that this practice should be abandoned
because of the risk of spreading epidermal cells into the
spinal canal.76 This has been shown to be a problem in
the case of lumbar puncture,77 but no such reports have
been published yet after epidural injections. With mod-
ern needles, the amount of tissue coring seems to be
identical among the different types of needles.78
Specially designed caudal needles with a short bevel
and a stylet are available and perhaps reduce the risk
of vascular puncture.79 Plastic intravenous cannulae or
lumbar puncture needles are also used. The use of short
intravenous cannulae has two advantages: first, if coring of
some skin occurs, it is irrelevant because it remains in the
stylet; second, easy catheterisation is a good sign that the
catheter is indeed in the spinal canal. The choice of the
needle size depends on the clinician’s preference; larger
needles, such as 23 G, give a more clear sensation of the
tissues, but the thinner the needle, the less the trauma to
the tissues. In the author’s opinion, the needle used
should not be larger than 25 G.
Ultrasound is not essential for performing a caudal block.
On the contrary, it may make a simple procedure more
complex and more prone to infection, but it can help in
cases of suspected anomalies at palpation and also for
teaching purposes. In addition, it has given new insight
into the mechanism of caudal anaesthesia. It seems that
there is an inverse relationship between age, weight, and
height and the number of segments covered by a caudal
injection of 1.5 ml kg 1 of ropivacaine 0.2%.80 The
injected volume has a surprisingly small impact on the
anatomical spread 81 and the anatomical spread is much
smaller compared with the clinical spread (Fig. 2).82
A dose of roughly 1 ml kg 1 ropivacaine 0.2% or levobu-
pivacaine 0.125 to 0.175% is adequate for most indica-
tions. The volume is usually restricted to 25 ml. Caudal
injections using local anaesthetics are not recommended
for abdominal incisions in children weighing more than
25 kg. The volume needed for a clinically functioning
block depends also on the surgical site, and many prac-
titioners still follow the recommendations given by
Armitage83 (Table 4).
Eur J Anaesthesiol 2015; 32:289–297
Copyright © European Society of Anaesthesiology. Unauthorized reproduction of this article is prohibited.
Paediatric regional anaesthesia 293
Fig. 2
Cranial Caudal
T12 L1 L2
Local anaesthetic
Spinal cord
Caudal block in a 3.5-kg neonate. Ultrasound picture taken immediately
after injection. Typically the anatomical spread goes up to a spinal level
around T12; the clinical spread for analgesia is much higher.
Additives to local anaesthetics are widely used. Adrena-
line (5 mg ml 1) allows the detection of intra-vascular
needle placement 84 and should be used, in the author’s
opinion, at least for the test dose. In preschool children,
the intra-vascular injection of adrenaline is recognised
not only by the tachycardia, but also by an impressive
T-wave elevation (Fig. 3).85 On the contrary, some
practitioners prefer to inject plain solutions because
the addition of adrenaline to the local anaesthetic offers
an additional source of error. Clonidine prolongs the
duration of analgesia by around 4 h,86 but it should be
avoided in young infants, as post-operative apnoea can
occur.87–90 Morphine provides long-lasting analgesia91
but side-effects, such as nausea, urinary retention, prur-
itus and respiratory depression, are common,92 and the
role of caudal opioids has recently been questioned.93
Importantly, the more lipophilic opioids, such as fenta-
nyl,94 sufentanil,95 pethidine,96 diamorphine,97 or trama-
dol98 cause side-effects, but do not prolong the duration
of analgesia in a clinically relevant way. Ketamine pro-
longs analgesia,99 but its use should be discouraged,
because of potential neurotoxicity100; magnesium,101
dexamethasone102 and dexmedetomidine103 are not yet
ready for clinical use.
Epidural catheters
Epidural catheters in children are well reported.104 The
incidence of permanent damage is probably close to
1 : 10 000, that of severe complications 1 : 1000, and pres-
sure sores occur in 1 : 300. Reports of severe unexplained
complications raise concern105 and consequently the
value of epidural catheters is fervently discussed, especi-
ally for neonates and infants.106 The likelihood is that the
use of paediatric epidural catheters will decline in the
near future.107
 294 Jöhr
Table 4 Dosage of local anaesthetics (ropivacaine 0.2% or
bupivacaine/levobupivacaine 0.125 to 0.175%) for caudal
anaesthesia
Site of incision Dosage (ml kgS1)
Penile or anal surgery 0.5 to 0.75
Lower extremity 1.0
Abdominal incision 1.0 to 1.25
It is technically easy to insert a catheter via the sacral
hiatus. The proximity of the anal region raises concerns
about the risk of bacterial contamination,108 and special
precautions have to be taken. In larger series, no severe
infections have been reported,109 and the method seems to
be safe. However, an increased incidence of colonisation of
caudal catheters with Gram-negative bacteria has been
described.108,110 Also, most of the reported septic111–113
and technical114 complications in connection with paedia-
tric epidural anaesthesia have occurred with catheter tech-
niques and not with single-shot caudal injections. The
feasibility of inserting caudal catheters up to a high thoracic
level (caudo-thoracic anaesthesia) was mentioned by Paolo
Busoni, then described by Bösenberg et al.115 and was
subsequently confirmed by others.116 However, this tech-
nique is only reliably successful when large-bore
catheters115 or catheters with a stylet116 are used, and
mal-positioning can occur.117 Recent animal data suggest
that manipulations with large-bore catheters in the epi-
dural space can cause detectable damage to the spinal
cord.118 Therefore, the author of this review is convinced
that this technique should be abandoned or only used in a
few selected patients.
A thoracic epidural puncture allows more precise catheter
placement for thoracic or upper-abdominal incisions.
Loss of resistance to 0.9% normal saline is almost uni-
versally recommended for the identification of the epi-
dural space and there is consensus that none at all or only
minimal air should be injected. Nevertheless, some
Fig. 3
(a)
1 mV
(b)
1 mV
Accidental intra-vascular injection of bupivacaine 0.25% with
adrenaline 5 mg ml 1 during attempted caudal anaesthesia in a 2.2-kg
neonate observed by the author. ECG tracing at baseline (a) and 15 s
after the injection of approximately 0.2 ml kg 1 (b).
Eur J Anaesthesiol 2015; 32:289–297
Copyright © European Society of Anaesthesiology. Unauthorized reproduction of this article is prohibited.
experts, including the author, still prefer air but try to
avoid its injection. However, the use of thoracic epidural
puncture should be restricted to cases of severe illness
and extensive thoraco-abdominal surgery, as relevant
complications have been reported.119–121 It should be
performed only by very experienced operators.
Spinal anaesthesia
Since the late 1980s, spinal anaesthesia has been used as a
sole anaesthetic, especially in the group of high-risk ex-
premature babies.122 In babies below 5 kg, a dose of
1 mg kg 1 plain bupivacaine 0.5% is usually recom-
mended.123 But, even in skilled hands, spinal anaesthesia
seems to have a measurable failure rate,124 and the
duration of analgesia is short. Compared with spinal
anaesthesia, awake caudal anaesthesia has a slower onset
of action, the blockade is less dense and potentially toxic
doses of local anaesthetics, 3 mg kg 1 bupivacaine 0.25%
or 4 to 5 mg kg 1 ropivacaine 0.375%, are needed.
Spinal anaesthesia seems a good theoretical choice for
avoiding the potential risk of neurotoxicity of general
anaesthesia agents; however, the author of this review is
convinced that awake regional anaesthesia should only be
used in very selected cases, and that the combination of
light general anaesthesia and a regional block is currently
the best technique for inguinal hernia repair in these
high-risk patients.
Systemic administration of local anaesthetics
The beneficial systemic effects of local anaesthetics are
frequently discussed in the anaesthetic community. In
adults, the use of intravenous lidocaine leads to less pain
and faster recovery; an observation that has been sup-
ported by several meta-analyses.125,126 Surprisingly, up to
now, no comparable experiences in paediatric patients
have been published. But it seems unlikely that these
positive effects would not be observable in a paediatric
population.
Conclusion
Regional anaesthesia plays a major role in post-operative
pain relief in children, and the classical techniques, such
as caudal anaesthesia, wound infiltration and penile
block, have an excellent safety record.
Acknowledgements relating to this article
Assistance with the review article: the author wishes to thank Prof.
Thomas M Berger (Kantonsspital Luzern, Luzern, Switzerland) for
his help in editing the manuscript.
Financial support and sponsorship: none.
Conflicts of interest: none.
References
1 Association of Paediatric Anaesthetists of Great Britain and Ireland. Good
practice in postoperative and procedural pain management. 2nd edition.
Paediatr Anaesth 2012; 22 (Suppl 1):1–79.

2 Suresh S, Schaldenbrand K, Wallis B, De Oliveira GS Jr. Regional
anaesthesia to improve pain outcomes in paediatric surgical patients: a
qualitative systematic review of randomized controlled trials. Br J Anaesth
2014; 113:375–390.
3 Krane EJ, Dalens BJ, Murat I, Murrell D. The safety of epidurals placed
during general anesthesia (editorial). Reg Anesth Pain Med 1998;
25:433–438.
4 Dalens B, Albert N. Asleep or awake: rethinking ‘‘safety’’. Reg Anesth Pain
Med 2014; 39:267–268.
5 Taenzer AH, Walker BJ, Bösenberg AT, et al. Asleep versus awake: does
it matter?: pediatric regional block complications by patient state: a report
from the pediatric regional anesthesia network. Reg Anesth Pain Med
2014; 39:279–283.
6 Ecoffey C, Lacroix F, Giaufré E, et al. Epidemiology and morbidity of
regional anesthesia in children: a follow-up one-year prospective survey of
the French-Language Society of Paediatric Anaesthesiologists
(ADARPEF). Paediatr Anaesth 2010; 20:1061–1069.
7 Giaufré 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 Anesthesiologists. Anesth Analg 1996;
83:904–912.
8 Polaner DM, Taenzer AH, Walker BJ, et al. Pediatric Regional Anesthesia
Network (PRAN): a multiinstitutional study of the use and incidence of
complications of pediatric regional anesthesia. Anesth Analg 2012;
115:1353–1364.
9 Cook TM, Counsell D, Wildsmith JA. Major complications of central
neuraxial block: report on the Third National Audit Project of the Royal
College of Anaesthetists. Br J Anaesth 2009; 102:179–190.
10 Mazoit JX, Denson DD, Samii K. Pharmacokinetics of bupivacaine
following caudal anesthesia in infants. Anesthesiology 1988; 68:387–
391.
11 Ecoffey C, Desparmet J, Maury M, et al. Bupivacaine in children:
pharmacokinetics following caudal anesthesia. Anesthesiology 1985;
63:447–448.
12 Aarons L, Sadler B, Pitsiu M, et al. Population pharmacokinetic analysis of
ropivacaine and its metabolite 2’,6’-pipecoloxylidide from pooled data in
neonates, infants, and children. Br J Anaesth 2011; 107:409–424.
13 Holford N, Heo YA, Anderson B. A pharmacokinetic standard for babies
and adults. J Pharm Sci 2013; 102:2941–2952.
14 Benzon HT, Strichartz GR, Gissen AJ, et al. Developmental neurophysiology
of mammalian peripheral nerves and age-related differential sensitivity to
local anaesthetic. Br J Anaesth 1988; 61:754–760.
15 Badgwell JM, Heavner JE, Kytta J. Bupivacaine toxicity in young pigs is
age-dependent and is affected by volatile anesthetics. Anesthesiology
1990; 73:297–303.
16 Simon L, Kariya N, Edouard A, et al. Effect of bupivacaine on the isolated
rabbit heart: developmental aspect on ventricular conduction and
contractility. Anesthesiology 2004; 101:937–944.
17 Rosenberg PH, Veering BT, Urmey WF. Maximum recommended doses
of local anesthetics: a multifactorial concept. Reg Anesth Pain Med 2004;
29:564–575.
18 Guay J. Methemoglobinemia related to local anesthetics: a summary of
242 episodes. Anesth Analg 2009; 108:837–845.
19 Frey B, Kehrer B. Toxic methaemoglobin concentrations in premature
infants after application of a prilocaine-containing cream and peridural
prilocaine. Eur J Pediatr 1999; 158:785–788.
20 Essink-Tebbes CM, Wuis EW, Liem KD, et al. Safety of lidocaine-
prilocaine cream application four times a day in premature neonates: a
pilot study. Eur J Pediatr 1999; 158:421–423.
21 Brisman M, Ljung BM, Otterbom I, et al. Methaemoglobin formation after
the use of EMLA cream in term neonates. Acta Paediatr 1998; 87:1191–
1194.
22 Edwards TJ, Carty SJ, Carr AS, Lambert AW. Local anaesthetic wound
infiltration following paediatric appendicectomy: a randomised controlled
trial: Time to stop using local anaesthetic wound infiltration following
paediatric appendicectomy? Int J Surg 2011; 9:314–317.
23 Møiniche S, Jørgensen H, Wetterslev J, Dahl JB. Local anesthetic
infiltration for postoperative pain relief after laparoscopy: a qualitative and
quantitative systematic review of intraperitoneal, port-site infiltration and
mesosalpinx block. Anesth Analg 2000; 90:899–912.
24 Loizides S, Gurusamy KS, Nagendran M, et al. Wound infiltration with
local anaesthetic agents for laparoscopic cholecystectomy. Cochrane
Database Syst Rev 2014; 3:CD007049.
25 Palmon SC, Lloyd AT, Kirsch JR. The effect of needle gauge and lidocaine
pH on pain during intradermal injection. Anesth Analg 1998; 86:379–
381.
26 Scarfone RJ, Jasani M, Gracely EJ. Pain of local anesthetics: rate of
administration and buffering. Ann Emerg Med 1998; 31:36–40.
Eur J Anaesthesiol 2015; 32:289–297
Copyright © European Society of Anaesthesiology. Unauthorized reproduction of this article is prohibited.
Paediatric regional anaesthesia 295
27 Bartfield JM, Sokaris SJ, Raccio-Robak N. Local anesthesia for
lacerations: pain of infiltration inside vs outside the wound. Acad Emerg
Med 1998; 5:100–104.
28 Bartfield JM, Crisafulli KM, Raccio-Robak N, Salluzzo RF. The effects of
warming and buffering on pain of infiltration of lidocaine. Acad Emerg Med
1995; 2:254–258.
29 Bartfield JM, Pauze D, Raccio-Robak N. The effect of order on pain of local
anesthetic infiltration. Acad Emerg Med 1998; 5:105–107.
30 Molliex S, Haond P, Baylot D, et al. Effect of pre vs postoperative tonsillar
infiltration with local anesthetics on postoperative pain after tonsillectomy.
Acta Anaesthesiol Scand 1996; 40:1210–1215.
31 Stuart JC, MacGregor FB, Cairns CS, Chandrachud HR. Peritonsillar
infiltration with bupivacaine for paediatric tonsillectomy. Anaesth
Intensive Care 1994; 22:679–682.
32 Weksler N, Nash M, Rozentsveig V, et al. Vocal cord paralysis as a
consequence of peritonsillar infiltration with bupivacaine. Acta
Anaesthesiol Scand 2001; 45:1042–1044.
33 Kang PB, Phuah HK, Zimmerman RA, et al. Medial medullary injury during
adenoidectomy. J Pediatr 2001; 138:772–774.
34 Strub KA, Tschopp K, Frei F, et al. Local infiltration of epinephrine and
bupivacaine before tonsillectomy. HNO 1996; 44:672–676.
35 Gurnaney HG, Maxwell LG, Kraemer FW, et al. Prospective randomized
observer-blinded study comparing the analgesic efficacy of ultrasound-
guided rectus sheath block and local anaesthetic infiltration for umbilical
hernia repair. Br J Anaesth 2011; 107:790–795.
36 Wada M, Kitayama M, Hashimoto H, et al. Brief reports: plasma
ropivacaine concentrations after ultrasound-guided rectus sheath block in
patients undergoing lower abdominal surgery. Anesth Analg 2012;
114:230–232.
37 Lissauer J, Mancuso K, Merritt C, et al. Evolution of the transversus
abdominis plane block and its role in postoperative analgesia. Best Pract
Res Clin Anaesthesiol 2014; 28:117–126.
38 Suresh S, Chan VW. Ultrasound guided transversus abdominis plane
block in infants, children and adolescents: a simple procedural guidance
for their performance. Paediatr Anaesth 2009; 19:296–299.
39 Mai CL, Young MJ, Quraishi SA. Clinical implications of the transversus
abdominis plane block in pediatric anesthesia. Paediatr Anaesth 2012;
22:831–840.
40 Taylor LJ, Birmingham P, Yerkes E, Suresh S. Children with spinal
dysraphism: transversus abdominis plane (TAP) catheters to the rescue!.
Paediatr Anaesth 2010; 20:951–954.
41 Tanaka M, Mori N, Murakami W, et al. The effect of transversus abdominis
plane block for pediatric patients receiving bone graft to the alveolar cleft
(in Japanese). Masui 2010; 59:1185–1189.
42 Benz-Wörner J, Jöhr M. Regional anaesthesia in children: caudal
anaesthesia and trunk blocks (In German). Anasthesiol Intensivmed
Notfallmed Schmerzther 2013; 48:272–277.
43 Suresh S, Taylor LJ, De Oliveira GS Jr. Dose effect of local anesthetics on
analgesic outcomes for the transversus abdominis plane (TAP) block in
children: a randomized, double-blinded, clinical trial. Paediatr Anaesth
2014; (in press).
44 Torup H, Mitchell AU, Breindahl T, et al. Potentially toxic concentrations
in blood of total ropivacaine after bilateral transversus abdominis
plane blocks: a pharmacokinetic study. Eur J Anaesthesiol 2012;
29:235–238.
45 Long JB, Birmingham PK, De Oliveira GS Jr, et al. Transversus abdominis
plane block in children: a multicenter safety analysis of 1994 cases from
the PRAN (Pediatric Regional Anesthesia Network) database. Anesth
Analg 2014; 119:395–399.
46 Weintraud M, Lundblad M, Kettner SC, et al. Ultrasound versus landmark-
based technique for ilioinguinal-iliohypogastric nerve blockade in
children: the implications on plasma levels of ropivacaine. Anesth Analg
2009; 108:1488–1492.
47 Lipp AK, Woodcock J, Hensman B, Wilkinson K. Leg weakness is a
complication of ilio-inguinal nerve block in children. Br J Anaesth 2004;
92:273–274.
48 Amory C, Mariscal A, Guyot E, et al. Is ilioinguinal/iliohypogastric nerve
block always totally safe in children? Paediatr Anaesth 2003; 13:164–
166.
49 Frigon C, Mai R, Valois-Gomez T, Desparmet J. Bowel hematoma
following an iliohypogastric-ilioinguinal nerve block. Paediatr Anaesth
2006; 16:993–996.
50 Jöhr M, Sossai R. Colonic puncture during ilioinguinal nerve block in a
child. Anesth Analg 1999; 88:1051–1052.
51 Fredrickson MJ, Paine C, Hamill J. Improved analgesia with the ilioinguinal
block compared to the transversus abdominis plane block after pediatric
inguinal surgery: a prospective randomized trial. Paediatr Anaesth 2010;
20:1022–1027.
 296 Jöhr
52 Holder KJ, Peutrell JM, Weir PM. Regional anaesthesia for circumcision.
Subcutaneous ring block of the penis and subpubic penile block
compared. Eur J Anaesthesiol 1997; 14:495–498.
53 Lander J, Brady-Fryer B, Metcalfe JB, et al. Comparison of ring block,
dorsal penile nerve block, and topical anesthesia for neonatal
circumcision: a randomized controlled trial. JAMA 1997; 278:2157–
2162.
54 Serour F, Mori J, Barr J. Optimal regional anesthesia for circumcision.
Anesth Analg 1994; 79:129–131.
55 Dalens B, Vanneuville G, Dechelotte P. Penile block via the subpubic
space in 100 children. Anesth Analg 1989; 69:41–45.
56 Schuepfer G, Jöhr M. Generating a learning curve for penile block in
neonates, infants and children: an empirical evaluation of technical skills in
novice and experienced anesthetists. Paediatr Anaesth 2004; 14:574–
578.
57 Faraoni D, Gilbeau A, Lingier P, et al. Does ultrasound guidance improve
the efficacy of dorsal penile nerve block in children? Paediatr Anaesth
2010; 20:931–936.
58 Soh CR, Ng SB, Lim SL. Dorsal penile nerve block. Paediatr Anaesth
2003; 13:329–333.
59 Burke D, Joypaul V, Thomson MF. Circumcision supplemented by dorsal
penile nerve block with 0.75% ropivacaine: a complication. Reg Anesth
Pain Med 2000; 25:424–427.
60 Ecoffey C, Becel M. Penile block with ropivacaine. Ann Fr Anesth Reanim
2009; 28:104–105.
61 Dadure C, Capdevila X. Peripheral catheter techniques. Paediatr Anaesth
2012; 22:93–101.
62 Gurnaney H, Kraemer FW, Maxwell L, et al. Ambulatory continuous
peripheral nerve blocks in children and adolescents: a longitudinal 8-year
single center study. Anesth Analg 2014; 118:621–627.
63 Burgoyne LL, Pereiras LA, Bertani LA, et al. Long-term use of nerve block
catheters in paediatric patients with cancer related pathologic fractures.
Anaesth Intensive Care 2012; 40:710–713.
64 Anghelescu DL, Harris BL, Faughnan LG, et al. Risk of catheter-
associated infection in young hematology/oncology patients receiving
long-term peripheral nerve blocks. Paediatr Anaesth 2012; 22:1110–
1116.
65 Prabhu KP, Wig J, Grewal S. Bilateral infraorbital nerve block is superior to
peri-incisional infiltration for analgesia after repair of cleft lip. Scand J Plast
Reconstr Surg Hand Surg 1999; 33:83–87.
66 Bösenberg AT, Kimble FW. Infraorbital nerve block in neonates for cleft lip
repair: anatomical study and clinical application. Br J Anaesth 1995;
74:506–508.
67 Chiono J, Raux O, Bringuier S, et al. Bilateral suprazygomatic maxillary
nerve block for cleft palate repair in children: a prospective, randomized,
double-blind study versus placebo. Anesthesiology 2014; 120:1362–
1369.
68 Sola C, Raux O, Savath L, et al. Ultrasound guidance characteristics and
efficiency of suprazygomatic maxillary nerve blocks in infants: a
descriptive prospective study. Paediatr Anaesth 2012; 22:841–846.
69 Prigge L, van Schoor AN, Bosman MC, Bösenberg AT. Clinical anatomy
of the maxillary nerve block in pediatric patients. Paediatr Anaesth 2014;
24:1120–1126.
70 Bonnet MP, Larousse E, Asehnoune K, Benhamou D. Spinal anesthesia
with bupivacaine decreases cerebral blood flow in former preterm infants.
Anesth Analg 2004; 98:1280–1283.
71 Lundblad M, Forestier J, Marhofer D, et al. Reduction of cerebral mean
blood flow velocity and oxygenation after high-volume (1.5 ml kg(-)(1))
caudal block in infants. Br J Anaesth 2014; 113:688–694.
72 Jöhr M, Berger TM. Caudal blocks. Paediatr Anaesth 2012; 22:44–50.
73 Schuepfer G, Konrad C, Schmeck J, et al. Generating a learning curve for
pediatric caudal epidural blocks: an empirical evaluation of technical skills
in novice and experienced anesthetists. Reg Anesth Pain Med 2000;
24:385–388.
74 Lees D, Frawley G, Taghavi K, Mirjalili SA. A review of the surface and
internal anatomy of the caudal canal in children. Paediatr Anaesth 2014;
24:799–805.
75 Koo BN, Hong JY, Kim JE, Kil HK. The effect of flexion on the level of
termination of the dural sac in paediatric patients. Anaesthesia 2009;
64:1072–1076.
76 Broadman LM. Where should advocacy for pediatric patients end and
concerns for patient safety begin. Reg Anesth 1997; 22:205–208.
77 Batnitzky S, Keucher TR, Mealey J, Campbell RL. Iatrogenic intraspinal
epidermoid tumors. JAMA 1977; 237:148–150.
78 Guldogus F, Baris YS, Baris S, et al. Comparing tissue coring
potentials of hollow needles without stylet and caudal needles
with stylet: an experimental study. Eur J Anaesthesiol 2008;
25:498–501.
Eur J Anaesthesiol 2015; 32:289–297
Copyright © European Society of Anaesthesiology. Unauthorized reproduction of this article is prohibited.
79 Dalens B, Hasnaoui A. Caudal anesthesia in pediatric surgery: success
rate and adverse effects in 750 consecutive patients. Anesth Analg 1989;
68:83–89.
80 Lundblad M, Lönnqvist PA, Eksborg S, Marhofer P. Segmental distribution
of high-volume caudal anesthesia in neonates, infants, and toddlers
as assessed by ultrasonography. Paediatr Anaesth 2011; 21:121–
127.
81 Brenner L, Marhofer P, Kettner SC, et al. Ultrasound assessment of cranial
spread during caudal blockade in children: the effect of different volumes
of local anaesthetics. Br J Anaesth 2011; 107:229–235.
82 Lundblad M, Eksborg S, Lönnqvist PA. Secondary spread of caudal block
as assessed by ultrasonography. Br J Anaesth 2012; 108:675–681.
83 Armitage EN. Caudal block in children. an 1979; 34:396.
84 Veyckemans F, Van Obbergh LJ, Gouverneur JM. Lessons from 1100
pediatric caudal blocks in a teaching hospital. Reg Anesth 1992;
17:119–125.
85 Mauch JY, Spielmann N, Hartnack S, Weiss M. Electrocardiographic and
haemodynamic alterations caused by three different test solutions of local
anaesthetics to detect accidental intravascular injection in children. Br J
Anaesth 2012; 108:283–289.
86 Schnabel A, Poepping DM, Pogatzki-Zahn EM, Zahn PK. Efficacy and
safety of clonidine as additive for caudal regional anesthesia: a
quantitative systematic review of randomized controlled trials. Paediatr
Anaesth 2011; 21:1219–1230.
87 Breschan C, Krumpholz R, Likar R, et al. Can a dose of 2microg.kg(-1)
caudal clonidine cause respiratory depression in neonates? Paediatr
Anaesth 1999; 9:81–83.
88 Bouchut JC, Dubois R, Godard J. Clonidine in preterm-infant caudal
anesthesia may be responsible for postoperative apnea. Reg Anesth Pain
Med 2001; 26:83–85.
89 Fellmann C, Gerber AC, Weiss M. Apnoea in a former preterm infant after
caudal bupivacaine with clonidine for inguinal herniorrhaphy. Paediatr
Anaesth 2002; 12:637–640.
90 Galante D. Preoperative apnea in a preterm infant after caudal block with
ropivacaine and clonidine. Paediatr Anaesth 2005; 15:708–709.
91 Krane EJ, Jacobson LE, Lynn AM, et al. Caudal morphine for postoperative
analgesia in children: a comparison with caudal bupivacaine and
intravenous morphine. Anesth Analg 1987; 66:647–653.
92 Krane EJ. Delayed respiratory depression in a child after caudal epidural
morphine. Anesth Analg 1988; 67:79–82.
93 Lönnqvist PA, Ivani G, Moriarty T. Use of caudal-epidural opioids in
children: still state of the art or the beginning of the end? Paediatr Anaesth
2002; 12:747–749.
94 Campbell FA, Yentis SM, Fear DW, Bissonnette B. Analgesic efficacy and
safety of a caudal bupivacaine-fentanyl mixture in children. Can J Anaesth
1992; 39:661–664.
95 Erol A, Tavlan A, Tuncer S, et al. Caudal anesthesia for minor subumbilical
pediatric surgery: a comparison of levobupivacaine alone and
levobupivacaine plus sufentanil. J Clin Anesth 2008; 20:442–446.
96 Kumar TPS, Jacob R. A comparison of caudal epidural bupivacaine with
adrenaline and bupivacaine with adrenaline and pethidine for operative
and postoperative analgesia in infants and children. Anaesth Intens Care
1993; 21:424–428.
97 Kelleher AA, Black A, Penman S, Howard R. Comparison of caudal
bupivacaine and diamorphine with caudal bupivacaine alone for repair of
hypospadias. Br J Anaesth 1996; 77:586–590.
98 Prosser DP, Davis A, Booker PD, Murray A. Caudal tramadol for
postoperative analgesia in paediatric hypospadias surgery. Br J Anaesth
1997; 79:293–296.
99 Schnabel A, Poepping DM, Kranke P, et al. Efficacy and adverse effects of
ketamine as an additive for paediatric caudal anaesthesia: a quantitative
systematic review of randomized controlled trials. Br J Anaesth 2011;
107:601–611.
100 Lönnqvist PA, Walker SM. Ketamine as an adjunct to caudal block in
neonates and infants: is it time to re-evaluate? Br J Anaesth 2012;
109:138–140.
101 Albrecht E, Kirkham KR, Liu SS, Brull R. The analgesic efficacy and safety
of neuraxial magnesium sulphate: a quantitative review. Anaesthesia
2013; 68:190–202.
102 Kim EM, Lee JR, Koo BN, et al. Analgesic efficacy of caudal
dexamethasone combined with ropivacaine in children undergoing
orchiopexy. Br J Anaesth 2014; 112:885–891.
103 Bharti N, Praveen R, Bala I. A dose-response study of caudal
dexmedetomidine with ropivacaine in pediatric day care patients
undergoing lower abdominal and perineal surgeries: a randomized
controlled trial. Paediatr Anaesth 2014; 24:1158–1163.
104 Llewellyn N, Moriarty A. The national pediatric epidural audit. Paediatr
Anaesth 2007; 17:520–533.

105 Meyer MJ, Krane EJ, Goldschneider KR, Klein NJ. Case report: neurological
complications associated with epidural analgesia in children: a report of 4
cases of ambiguous etiologies. Anesth Analg 2012; 115:1365–1370.
106 Bösenberg AT, Jöhr M, Wolf AR. Pro con debate: the use of regional vs
systemic analgesia for neonatal surgery. Paediatr Anaesth 2011;
21:1247–1258.
107 Moriarty A. Pediatric epidural analgesia (PEA). Paediatr Anaesth 2012;
22:51–55.
108 McNeely JK, Trentadue NC, Rusy LM, Farber NE. Culture of bacteria from
lumbar and caudal epidural catheters used for postoperative analgesia in
children. Reg Anesth 1997; 22:428–431.
109 Strafford MA, Wilder RT, Berde CB. The risk of infection from epidural
analgesia in children: a review of 1620 cases. Anesth Analg 1995;
80:234–238.
110 Kost-Byerly S, Tobin JR, Greenberg RS, et al. Bacterial colonization and
infection rate of continuous epidural catheters in children. Anesth Analg
1998; 86:712–716.
111 Emmanuel ER. Postsacral extradural catheter abscess in a child. Br J
Anaesth 1994; 73:548–549.
112 Larsson BA, Lundeberg S, Olsson GL. Epidural abscess in a one-year-old
boy after continuous epidural analgesia. Anesth Analg 1997; 84:1245–
1247.
113 Meunier JF, Norwood P, Dartayet B, et al. Skin abscess with lumbar
epidural catheterization in infants: is it dangerous? Report of two cases.
Anesth Analg 1997; 84:1248–1249.
114 De Armendi AJ, Ryan JF, Chang HM, et al. Retained caudal catheter in a
paediatric patient. Paediatr Anaesth 1992; 2:325–327.
115 Bösenberg AT, Bland BA, Schulte-Steinberg O, Downing JW. Thoracic
epidural anesthesia via caudal route in infants. Anesthesiology 1988;
69:265–269.
Eur J Anaesthesiol 2015; 32:289–297
Copyright © European Society of Anaesthesiology. Unauthorized reproduction of this article is prohibited.
Paediatric regional anaesthesia 297
116 Gunter JB, Eng C. Thoracic epidural anesthesia via the caudal approach
in children. Anesthesiology 1992; 76:935–938.
117 van Niekerk J, Bax Vermeire BM, Geurts JW, Kramer PP. Epidurography in
premature infants. Anaesthesia 1990; 45:722–725.
118 Gamble JJ, Ambros B, Seguin P, et al. Stimulating thoracic epidural
placement via a lumbar approach causes significant spinal cord damage
in a porcine model. Can J Anaesth 2014; 61:306–311.
119 Kasai T, Yaegashi K, Hirose M, Tanaka Y. Spinal cord injury in a child
caused by an accidental dural puncture with a single-shot thoracic
epidural needle. Anesth Analg 2003; 96:65–67.
120 Aldrete JA, Ferrari H. Myelopathy with syringomyelia following
thoracic epidural anaesthesia. Anaesth Intensive Care 2004;
32:100–103.
121 Allison CE, Aronson DC, Geukers VG, et al. Paraplegia after thoracotomy
under combined general and epidural anesthesia in a child. Paediatr
Anaesth 2008; 18:539–542.
122 Abajian JC, Mellish RW, Browne AF, et al. Spinal anesthesia for surgery in
the high-risk infant. Anesth Analg 1984; 63:359–362.
123 Jöhr M. Kinderanästhesie, 8th edition München: Elsevier; 2013;
pp. 154–156.
124 Hoelzle M, Weiss M, Dillier C, Gerber A. Comparison of awake spinal with
awake caudal anesthesia in preterm and ex-preterm infants for
herniotomy. Paediatr Anaesth 2010; 20:620–624.
125 Marret E, Rolin M, Beaussier M, Bonnet F. Meta-analysis of intravenous
lidocaine and postoperative recovery after abdominal surgery. Br J Surg
2008; 95:1331–1338.
126 Vigneault L, Turgeon AF, Coté D, et al. Perioperative intravenous lidocaine
infusion for postoperative pain control: a meta-analysis of randomized
controlled trials. Can J Anaesth 2011; 58:22–37.