Neuraxial blocks for anaesthesia and analgesia in children

The use of regional techniques in paediatric anaesthesia has increased dramatically. Our aim is to produce a comprehensive review of the recent literature on neuraxial blockade in infants and children, focusing on three topics: choice of local anaesthetic and adjunct drugs, technical aspects and complications.

The current literature shows a trend towards using the single isomers (levobupivacaine or ropivacaine) rather than racemic bupivacaine. In addition, opioids as adjuncts are being challenged by clonidine and ketamine, which have more benign side effects. The spread of radiopaque dye within the epidural space (which may mimic that of local anaesthetic solutions) appears to be highly variable, although distribution is related to the volume injected. Recent techniques (e.g. ultrasound or stimulating catheters) have been developed to accurately identify the position of epidural catheters. In contrast to adults, neuraxial blockade using local anaesthetic solutions is associated with stable cardiovascular variables, even in children with congenital heart disease. Although the incidence of complications associated with paediatric neuraxial blockade is low, the potential risks must always be considered.

It is likely that the use of epidural ketamine or clonidine as adjuncts to local anaesthetics will grow. Alternatives, such as midazolam, may offer advantages in particular circumstances, although rigorous evaluation of the safety of these solutions when injected along the neuraxis and the development of formulations without preservatives are needed. The use of stimulating caudal catheters or ultrasound-guided techniques appears to offer promising options for the future to more accurately position catheters.