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Regional anaesthesia in overview
Introduction
Regional anaesthesia in paediatric patients
Over the past several years, a renewed interest has been observed in the field of regional anaesthesia for paediatric patients (Giaufré et al., 1996). This is due to the increased survival of extremely premature infants, and infants with congenital malformations and life-threating conditions. However, this was achieved by exposing these infants to multiple stressors in the neonatal period (Grunau et al., 2006). Berde and colleagues (2005) echo this statement by affirming that neonates can often undergo urgent intervention during their initial days and weeks of life.
Several studies on the effects of neonatal pain have been published. In a study conducted by Taddio and co-workers (1995), the pain response of male infants who underwent neonatal circumcision, was evaluated during routine vaccinations. They conclude that male infants, who had previously undergone circumcisions, exhibited a greater pain response than those who did not. In a similar study, they state: “This initial analysis raised concerns about the possible long-term effects of untreated pain in infants, especially those who have repeated experience of pain”.
Simons and collaborators (2003) make the following comment in their research study on pain inflicted on newborn babies: “In sharp contrast of the accumulating evidence that repetitive pain is harmful in newborns, and despite major clinical advances over the past 10 years, neonates experience up to 14 painful procedures per day, and, remarkably, more than 65% of the patients in this study did not receive appropriate analgesic therapy”.
Parry (2008) confers that it is widely known that neonates experience pain based on their cortical awareness, as well as their incomplete development of inhibitory pathways. Short-term and long-term detrimental effects will occur due to the changes in the developing nervous system, should neonatal pain be inadequately managed (Simons et al., 2003; Parry, 2008). This is concerning, especially in light of the statement by Ranger et al. (2007) that crying, especially in fragile newborns, can be detrimental to their health due to the increased intracranial pressure, as well as the high energy consumption.
This debate is well summarised in the statement made by Derbyshire (2008): “There is now enough evidence that clinical benefits outweigh risks from anaesthetic or analgesic intervention during procedures on neonates and infants, regardless of whether evidence supports or denies neonatal pain”.
Parry (2008) concluded in a study that “the purpose of pain management is to resolve or reduce pain whilst minimizing the side effects of treatments”. Shah and Suresh (2013) advocate that the scope of paediatric pain management has significantly improved due to the increased use of regional anaesthesia in the paediatric population. They also accentuate that the literature supports the safet and efficacy of the use of regional anaesthesia on this specific group of patients.
Berde and co-workers (2005) mentioned that, due to the use of opioids and other agents, and management of adverse effects there-of, more local anaesthetics are being used in infants and neonates.
Rochette et al. (2009) compared two studies by the French language paediatric anaesthetists society (Association des Anesthésistes Réanimateurs Pédiatriques d’Expression Française: ADARPEF). The first study was conducted in 1994, while the second was a prospective survey over a period of one year between 2005 and 2006. The most significant difference observed between these two studies is the 200 – 500% increase in the performance of peripheral nerve blocks.
One factor that can explain the increased performance of peripheral nerve blocks is captured in a statement by Lyon (2005), in which he mentions that general anaesthesia should only be administered to infants after four months of age, due to the immaturity of their haemoglobin.
Another factor in the consideration of regional anaesthesia in paediatric patients, is safety. In a large multicentre prospective study conducted by Giaufre and co-workers (1996), more than 24 000 nerve block procedures in paediatric patients were evaluated. Only 23 adverse reactions, with no long-lasting side effects, were observed.
Ivani and De Negri (2001) list the following factors for the increased use of regional anaesthesia in paediatric patients:
Realisation and awareness of experienced pain and the use of analgesics;
Evidence on the efficacy of regional anaesthesia;
Increased information being made readily available;
Safety of the use of regional anaesthesia in a population group.
Dalens (2006) makes the following statement: “With sound judgment and appropriate scientific knowledge, regional anaesthesia represents in many instances the best technique to provide adequate intraoperative and postoperative pain relief in paediatric patients.”
