co beyond the caudal: truncal blocks an alternative option

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REVIEW

CURRENTOPINION Beyond the caudal: truncal blocks an alternative

option for analgesia in pediatric surgical patients

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www.co-anesthesiology.com

Jodi-Ann Oliver and Lori-Ann Oliver

Purpose of review

To discuss and compare the more commonly used truncal blocks with neuraxial techniques in childrenundergoing a variety of thoracic, abdominal and urological procedures.

Recent findings

Owing to the advent of ultrasonography and its increasing use in regional anesthesia, there has been arenewed interest in implementing these techniques in children for intraoperative and postoperative painmanagement.

Summary

The use of regional anesthesia particularly with ultrasound guidance is an integral part of painmanagement during the intraoperative and postoperative period in children who undergo surgery. Its use isessential in improving patient pain control and overall satisfaction as well as decreasing hospital stay andreducing hospital admission after surgery. Truncal blocks serve as an excellent alternative to neuraxialblockade, in patients who have a contraindication to neuraxial blockade, patients undergoing a unilateralprocedure and those in an outpatient ambulatory setting undergoing routine procedures, wherein theadverse effects of neuraxial blockade such as motor weakness, difficulty ambulating, urinary retention,increased nausea and vomiting, may delay same day discharge.

Keywords

neuraxial anesthesia in children, pediatric regional anesthesia, peripheral nerve blocks, truncal blocks

INTRODUCTION abdominal, thoracic and orthopedic procedures.

Department of Anesthesiology, Yale New Haven Hospital, New Haven,Connecticut, USA

Correspondence to Jodi-Ann Oliver, MD, Yale-New Haven Children’sHospital, 1 Park Street, 3rd Floor, New Haven, CT 06510, USA. Tel: +1(203) 785 2802; fax: +1 (203) 785 6664; e-mail: [email protected]

Curr Opin Anesthesiol 2013, 26:644–651

DOI:10.1097/ACO.0000000000000021

The use of regional anesthesia is now at the forefrontof management of intraoperative and postopera-tive pain in pediatric patients undergoing a varietyof surgical procedures. This renewed interest inpediatric regional techniques is largely because oftwo reasons: improvement in postoperative painscores and improvement in safety of these pro-cedures. Firstly, regional anesthesia has beenassociated with a reduction in postoperative painscores, improvement in overall patient satisfaction,decreased opioid use and associated side-effects,reduction in hospital length of stay and remissionrates for uncontrolled postoperative pain [1

&

].Secondly, the advent and use of ultrasonographyhas improved visualization of needle placementand vital structures, which has improved the safetyprofile of these invasive procedures and significantlyreduced procedure-related complications [2

&

].Despite the increased use of peripheral nerve

blocks in pediatric surgical patients, the caudal,a form of neuraxial block, still remains the goldstandard and is the most widely used regional tech-nique for this patient population for a variety of

iams & Wilkins. Unautho

However, the use of neuraxial blocks has beenassociated with side-effects such as urinary reten-tion, nausea, vomiting and difficulty ambulat-ing, which can delay hospital discharge especiallyfollowing routine outpatient ambulatory procedures[3]. As a result, peripheral nerve blocks particularlytruncal blocks have been used more in this patientpopulation with equivalent if not superior analgesiaand minimal side-effects. The aim of this review is tocompare the use of truncal blocks with the currentgold standard, neuraxial blockade especially thecaudal block, in pediatric patients undergoingabdominal and thoracic surgery.

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Volume 26 � Number 6 � December 2013

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mailto:[email protected]

KEY POINTS

� In children, neuraxial anesthesia has been the mainstay for intraoperative and postoperative analgesia fora variety of abdominal, thoracic and orthopedicprocedures, but has been associated with significantside-effects that may delay discharge especially in theambulatory setting.

� With the advent of ultrasonography, there is anincreased interest and utilization of peripheral nerveblock techniques in children.

� Truncal blocks such as transversus plane block (TAP),rectus sheath block and ilioinguinal/ iliohypogastricblocks have been shown to provide equivalent if notsuperior analgesia in comparison with neuraxialblockade for surgeries involving the anterior abdominalwall and urologic procedures.

� Paravertebral blocks (PVBs) have been used for avariety of surgical procedures because of their lowercomplication rates, longer duration of analgesia,decreased side-effects and reduction in opioidconsumption when compared with neuraxial blocks.

Beyond the caudal: truncal blocks an alternative option for analgesia in pediatric surgical patients Oliver and Oliver

The truncal blocks can be divided into twocategories: anterior and posterior, with the anteriordivision consisting of TAP, rectus sheath block, andilioinguinal and iliohypogastric blocks (IL/IH). Theposterior truncal blocks consist of paravertebral(PVB) and intercostal blocks. In this article, we willfocus on the most widely used truncal blocks forintraoperative and postoperative analgesia in thepediatric surgical population: TAP block, rectussheath block, ilioinguinal and iliohypogastric blocksand paravertebral block.

TRANSVERSUS ABDOMINIS PLANEBLOCK

TAP block has been increasingly used to providepostoperative analgesia that is comparable withthe gold standard, caudal epidural analgesia, inchildren undergoing abdominal procedures, withnone of the side-effects such as urinary retention,limited mobility and increased opioid use oftenassociated with neuraxial blockade. TAP block there-fore serves as a viable alternative to neuraxial block-ade in children who have a contraindication to theuse of neuraxial blockade and it can be performedunder ultrasound guidance after the induction ofgeneral anesthesia with minimal risk to the patients.

FIGURE 1. Transversus abdominis plane block. Theultrasound image shows the anatomy of the abdominal wallwith the external oblique muscle (top), internal obliquemuscle (middle) and transversus abdominis muscle (bottom)above abdominal viscera.

ANATOMY AND TECHNIQUES

The TAP block was first described as a landmarktechnique by Rafi in 2001 involving placement ofblunt needle in the triangle of Petit, an area bounded

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posteriorly by the latissimus dorsi muscle, anteriorlyby external oblique muscle and the iliac crestinferiorly [4]. The abdominal wall consists of threemuscle layers: external oblique, internal oblique andtransversus abdominis muscles, from superficialto deep, respectively. Sensory innervation for theanterolateral abdominal wall is provided by theanterior rami of T6–L1 and intercostal nerves(T7–11), the subcostal nerve (T12), iliohypogastricand ilioinguinal nerves (L1), which travel in thisplane between the transversus abdominis andinternal oblique muscles (Fig. 1) [5,6].

A blunt needle is advanced perpendicular to theskin until a single pop or tactile sensation of lossof resistance was felt, indicating proper needleplacement, and local anesthetic is then injected.McDonnell et al. in 2006 ascribed the double poptechnique in which loss of resistance is notedby needle penetration first through the externaloblique fascia and internal oblique muscles withfinal entry into the plane between internal obliqueand transversus abdominis muscles [7,8]. The use ofultrasound guidance using a high-frequency linearprobe is now the preferred technique for TAP blockplacement under general anesthesia. The needle isvisualized with real-time ultrasound with in-planetechnique, in which the probe is placed in theaxial plane of the triangle of Petit or lateral to theumbilicus following visualization of the rectussheath [9

&&

]. The needle is then inserted in theplane between the internal oblique and the trans-versus abdominis muscles and local anesthetic isincrementally injected (Fig. 2) [10].

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FIGURE 2. Transversus abdominis plane (TAP) block. Theultrasound image shows the needle injecting locating localanesthetic between the internal oblique muscle andtransversus abdominis muscle during TAP block placement.

Ambulatory anesthesia

INDICATIONSTAP blocks have been used in children for a varietyof urologic and abdominal procedures [11] and insituations, in which neuraxial procedures are con-traindicated or considered too risky [12]. Visoiu et al.[13

&&

] showed in a small retrospective study thatTAP catheters could be effectively used to provideadequate postoperative analgesia in infants with lowbody weight and in which neuraxial techniqueswere contraindicated or with difficult placementsecondary to sacral-spinal abnormalities. Bielskyet al. [14] also demonstrated the efficacy of TAPblock in two case reports involving two infantsweighing 2.5 and 3.1 kg, respectively, in whichTAP blocks were used to effectively manage painafter urgent colostomy; one patient had congenitalanomalies that included imperforated anus withclub feet and seventh cranial nerve paralysis,whereas the other had only anal atresia. TAP blockscan also be used in cases, in which there are relativecontraindications to neuraxial blockade such asbleeding disorders, in patients after laminectomiesand in patients with potential bony anatomicalabnormalities such as VATER syndrome [15,16].

TAP blocks have been shown to provide post-operative analgesia in children undergoing abdomi-nal surgeries with reduced postoperative opioiduse. Sahin et al. [17

&&

] demonstrated, in a random-ized comparative study, involving 60 patients, ages2–8 years, that ultrasound-guided TAP blocks pro-vided superior postoperative analgesia when com-pared with wound infiltration performed by thesurgeons. Patients in the TAP block group hadlonger intervals before the need for breakthroughanalgesia and a significantly lower cumulative doseof total analgesics when compared with those in the

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wound infiltration group. Though a greater volumeof local anesthetic was used for patients undergoingTAP block, the results are consistent with otherstudies that show that TAP blocks provide a longerduration of analgesia in comparison with woundinfiltration, and wound infiltration is only effectivein the immediate postoperative period, whereas TAPblock remains effective for up to 24 h [17

&&

].

COMPLICATIONS

The TAP block is associated with perforation ofabdominal viscera, peritoneal puncture and intra-vascular injection, which is of particular concern insmall infants and children [18]. These risks are signi-ficantly reduced with the use of ultrasound guidanceand in fact a review of the literature indicates thatthese complications are relatively rare, when theblock is performed under ultrasound guidance [9

&&

].

RECTUS SHEATH BLOCK

Schleich [19] first described the use of the rectussheath block in 1899 in adult patients, to providerelaxation of the anterior abdominal wall. Rectussheath blocks have also been used for women under-going open and laparoscopic gynecological pro-cedures [20–22] and to augment postoperativeanalgesia in patients after midline laparotomy[23,24]. Ferguson et al. in 1996, then Courregeset al. in 1997 [25,26], described the use of the rectussheath block for providing analgesia for childrenundergoing umbilical hernia repair. This block hasbeen used not only for umbilical hernia repairs, butalso for pyloromyotomies and procedures withmidline laparoscopic incisions [27].


The umbilical area is innervated by the right and leftthoracoabdominal intercostal nerves, derived fromthe anterior rami of spinal roots T8–T12. The nervespass from behind the costal cartilage and travel inthe plane between the transversus abdominismuscle and internal oblique muscle. The rectussheath has an anterior and a posterior wall, withthe tendons of the internal and external obliquemuscles forming the anterior wall and the tendon ofthe transversus muscle forming the posterior wall.The nerves run between the sheath and the posteriorwall of the rectus abdominis muscle, innervating themuscle and ending as the anterior cutaneous branchsupplying the cutaneous area of the umbilicus.Anatomical variations have been identified, withthe nerves either coursing beneath or on top ofthe rectus abdominis muscle before ending at theumbilicus (Fig. 3) [28

&&

].



FIGURE 3. Rectus sheath block. The ultrasound image showsthe abdominal wall with the rectus abdominis muscle withthe linea alba at the level of the umbilicus.


Traditionally, the rectus sheath block has beenperformed using landmarks, in which a 23-gaugeneedle is placed above or below the umbilicus about0.5 cm medial to linea semilunaris. The anteriorrectus sheath is identified by moving the needleback and forth until a scratching sensation or clickis felt [25,26]. Because of the inaccuracy of thistechnique, most rectus sheath blocks are performedtoday using ultrasonography. Willschke et al. [29]demonstrated, using ultrasonography, that therewas a poor correlation between the depth of therectus sheath and the height, weight and body sur-face area of children and effectively argues the pointthat the use of ultrasonography is a more reliableand superior technique. A high frequency probe isplaced perpendicular to the umbilicus and the lineaalba is identified in the midline with the rectusmuscles laterally. The needle is then inserted usingthe in-plane technique and local anesthetic isinjected in a potential space between the rectusabdominis muscle and posterior sheath just superiorto the peritoneum [30

&&

,31].

INDICATIONS

Rectus sheath block has been used to provide intra-operative and postoperative analgesia in childrenundergoing procedures involving the midlineabdominal wall and umbilical areas as well as pro-cedures with a single incision through the umbilicussuch as laparoscopic appendectomies [28

&&

,29,30&&

,31,32]. Rectus sheath blocks have also been usedsuccessfully in pediatric patients with chronic abdo-minal pain caused by abdominal cutaneous nerveentrapment, iatrogenic peripheral nerve injury,myofascial pain syndrome or of unknown cause [33].



COMPLICATIONS

The rectus sheath block has been associated withbowel perforation and damage to abdominal organsbecause of the close proximity of the needle to theperitoneum. There have also been reports of intra-vascular injection involving the inferior epigastricartery and retroperitoneal hematoma [34]. Thesecomplications have significantly been reduced withthe use of ultrasonography [35]. Polaner et al. con-ducted a multicenter study, which reviewedpediatric regional blocks and their associated com-plications. Based on his database, 294 rectus sheathblocks were performed in which 256 (87%) of theseblocks were performed with the use of ultrasoundand no adverse events or complications were noted[36

&&

].

ILIOINGUINAL AND ILIOHYPOGASTRICNERVE BLOCKS

The ilioinguinal/iliohypogastric block is a com-monly used peripheral nerve block technique usedfor children undergoing groin or urologic surgeries.It has been shown to be equivalent or better thancaudal block and is associated with minimal side-effects and complications.


The ilioinguinal and iliohypogastric nerves (T12–L1) travel below the internal oblique within itsaponeurosis 1–3 cm medial to the anterior superioriliac spine (ASIS). This block can be performed withthe use of landmarks or ultrasonography. The land-mark technique involves identifying the ASIS and amark is made 2 cm medial and 2 cm superior to theinitial mark and the needle is inserted perpendicularto skin; two pops are appreciated after the needlepasses first through the external oblique muscle andthen the internal oblique muscle; local anesthetic isthen injected [37]. Another landmark techniqueinvolves placing the needle one-third of the waybetween the ASIS and the umbilicus and injectinglocal anesthetic after feeling a pop or click when theneedle passes through the internal oblique and isthe space between the internal oblique and trans-versus abdominis muscle [38

&&

]. This block is morecommonly performed with the use of a high-frequency linear probe placed at ASIS facing theumbilicus; the layers of the abdominal musclesare identified and the nerves are located betweenthe internal oblique and transversus abdominismuscle; local anesthetic is injected in this potentialspace (Fig. 4). The use of ultrasound is associatedwith a higher success rate compared with landmarktechnique as demonstrated by Weintraud et al. [39].



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FIGURE 4. Ilioinguinal/iliohypogastric nerve block. Theultrasound image shows the muscle layers of the abdominalwall at the level of anterior superior iliac spine with nervebundle between the internal oblique muscle and transversusabdominis muscle.


INDICATIONS

Ilioinguinal/iliohypogastric nerve blocks are com-monlyused toprovide analgesia for surgery involvingthe inguinal region and groin area such as inguinalhernia repair, orchiopexy and hydrocelectomy.Abualhassan et al. performed a randomized prospec-tive study in which 50 children ages 1–6 yearsscheduled for unilateral groin surgery were random-ized into either use of a caudal or an ultrasound-guided ilioinguinal/iliohypogastric nerve block.Those in the ilioinguinal/iliohypogastric nerveblock group were noted to have a longer time to firstrescue analgesia 253�102.6 min compared with219.6�48.4 min in the caudal group and more chil-dren in the caudal group required rescue medicationsin a day-stay unit or at home compared with theilioinguinal/iliohypogastric nerve group [40

&&

]. Healso noted that the use of ultrasound allowed forlower doses of local anesthetic solution comparedwith caudal block and significant reduction in com-plications. Willschke et al. clearly demonstrated in aprospective study that ultrasound-guided techniquewas superior to landmark technique in accuracy andhad a higher success rate [41]. These findings wereconfirmed by Bhatpara et al. who showed that IL/IHnerve blocks provide longer postoperative analgesiaand better safety margin, as lower doses of localanesthetic can be used compared with caudal blockin children undergoing herniotomy [42].

COMPLICATIONS

As with the other anterior trunk blocks, theilioinguinal/iliohypogastric block has minimal



complications especially when ultrasound is uti-lized. Most complications include bowel punctureor intravascular injection [43]. Other complicationssuch as pelvic hematoma [44], femoral nerve palsy[45] and quadriceps muscle paresis [46] haveoccurred during ilioinguinal/iliohypogastric blockplacement when utilizing the conventional land-mark technique.

PARAVERTEBRAL NERVE BLOCKS

PVBs were first described in 1905 by Hugo Sellheimbut were not utilized extensively until the last15 years when the block was felt to be a viablealternative to epidural or caudal blockade in certainpatient populations. PVBs have been shown to notonly be safer but also to provide similar analgesicbenefits for managing postoperative pain as well asdelaying the recurrence of tumors and metastaseswhen compared to epidurals [47

&&

]. This techniquewas first utilized in children undergoing surgery byLonnqvist in 1992 and has been subsequently usedto provide postoperative pain control in childrenundergoing thoracic, abdominal or urogenital pro-cedures with postoperative pain control equivalentto or superior to neuraxial blockade with fewer side-effects [48

&&

].


The paravertebral space is a potential space thatexists lateral to the spinous process, which con-tains the intercostal and sympathetic nerves and isbordered anteriorly by the parietal pleura, mediallyby the posterolateral aspect of the vertebra and theintervertebral foramen, laterally by the parietalpleura and posteriorly by the costotransverse liga-ment. The paravertebral space has been estimatedto be 1 cm caudal to the transverse process and2.5 cm lateral to the spinous process in most adultsand is affected by multiple factors [49

&

]. Naja et al.[50] measured the paravertebral space using nervestimulation technique and showed that the dis-tance from skin to the paravertebral space wasinfluenced by BMI, which significantly affectedthe paravertebral space depth at upper (T1–3)and lower (T9–12) thoracic levels but had no effectat the mid (T4–8) thoracic level. Chelly et al. [51]further showed that the depth of the paravertebralspace is also influenced by factors other thanweight (BMI) such as age, height and thoraciclevel.

In children, identifying the correct location anddepth of the paravertebral space is of utmost import-ance in decreasing complications such as pneumo-thorax or pleural puncture, which are rare but



FIGURE 5. The paravertebral nerve block. The ultrasoundimage shows the needle during placement of T9–10paravertebral nerve block with low-frequency curvilinearprobe in a teenager undergoing thoracic surgery.


often catastrophic. A variety of different techniquesincluding 2D echocardiography, ultrasonographyand computed tomography guidance have beenemployed to predict the location and depth of theparavertebral space by determining the lateral dis-tance from the spinous process to the paravertebralspace and the skin to paravertebral space depth ofthe paravertebral space. Lonnqvist and Hesser [52]first used thoracic and upper abdominal computertomography to derive these equations for estimatingthe spinous process to paravertebral space (SP-PVS)depth (0.12�body weight (kg)þ10.2) and skin toparavertebral space (S-PVS) (0.48�body weight(kg)þ18.7) in millimeters in children and adoles-cents. Ponde and Desaie [53

&&

] used echoguidance todetermine the optimal point from needle insertionas well as the depth of the paravertebral space ininfants ranging in age from 2 days to 60 monthsof age.

The paravertebral nerve block can be performedusing landmark, loss of resistance, neurostimulationor ultrasound guidance. The classic or landmarktechnique involves identifying the spinous processand marking the skin laterally at the level of trans-verse process and using a Tuohy needle to contactthe posterior surface of the transverse process [54

&

].Once the transverse process is contacted, the dis-tance from the skin to transverse process is measuredand the needle is withdrawn to skin and angled at15 to 60 degrees and advanced 1 cm caudally beyondthe transverse process and local anesthetics can beinjected slowly following a negative drop technique.Chelly [55

&&

] describes the drop technique in whicha drop of fluid is injected on the top of the needle tocheck for respiratory variations before catheterplacement. Loss of resistance technique is similarto the classic technique but employs the use of a lossof resistance syringe or pressure transducer that isfilled with saline and connected to the Tuohy needleand advanced until there is a notable loss of resist-ance. The neurostimulation technique employs theuse of an insulated Tuohy needle, which is con-nected to a nerve stimulator, and a motor responsein the intercostal or abdominal muscles is elicited[56]. The ultrasound can also be utilized to visualizethe paravertebral space using a high-frequencylinear 10–15 MHz probe placed perpendicular(lateral or intercostal approach) or parallel (sagittalapproach) to the spinous process and has becomethe standard technique utilized in children under-going surgery under general anesthesia [57

&&

]. Inlarger children and adolescents, the use of a low-frequency curvilinear 2–5 MHz probe may offerbetter visualization of the paravertebral space incomparison with the high-frequency linear probe(Fig. 5).



INDICATIONSThe PVB is a versatile technique, as it can be per-formed at every spinal level and has been increas-ingly used as an alternative to neuroaxial blockadefor a variety of reasons. Koyyalamudi et al. [58] useda continuous cervical (C5) PVB with a continuousthoracic (T5) PVB to provide postoperative analgesiafor a 10-year-old child undergoing a forequarteramputation for an osteosarcoma of the left hume-rus, where a brachial plexus block would have pro-vided ineffective postoperative analgesia. Visoiuand Yhang [59] used ultrasound-guided bilateralthoracic paravertebral catheters to treat postopera-tive pain following bowel resection in an opioidtolerant and mildly coagulopathic pediatric patient,in which epidural placement was contraindicated.Berta et al. showed that a single-injection PVB atT10–12 level was as efficacious in controlling post-operative pain when compared with continuousparavertebral catheters for children undergoingmajor renal surgery [60].

PVBs have also been used in outpatient ambu-latory settings, in which faster postoperative recov-ery and same-day discharges are essential. In thisspecific patient population, the single shot caudalhas been the gold standard but has been associatedwith short duration of analgesia, requiring the use ofsupplemental analgesia in the immediate postsur-gical period as well as unwanted side-effects such asurinary retention and motor weakness, which candelay patient discharge. PVBs have been associatedwith prolonged analgesia that exceeds the expectedduration of the local anesthetics administered whencompared with caudals or epidurals. Tug et al.showed in a small prospective study involving



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70 children from ages 3–7 that a single L2 paraver-tebral injection provides analgesia that is superiorto caudal placement in children undergoinginguinal surgery. Patients in the paravertebralgroup had decreased need for supplemental analge-sics (11.4 vs. 34.3%) because of increased duration ofanalgesia with a mean duration of 1300 min (range:120–1440 min), lower block failure rates (5.7 vs.11.4%) and higher parental satisfaction scores(74.3 vs. 40%) [61].

COMPLICATIONS

PVBs are rarely associated with complications,which include pneumothorax and pleural puncture,bleeding, epidural or intrathecal spread, infection,nerve injury, hypotension and spinal headache[62

&&

]. Naja et al. conducted a prospective trial with662 patients including 42 children in which PVBswere placed using neurostimulation technique. Hereported a 6.1% failure rate in the adults withcomplications such as hypotension, inadvertentvascular puncture, epidural and intrathecal spread,pleural puncture, hematoma and pneumothorax inthe adults with no failures or complications noted inthe children [63]. Berta et al. also reported a com-plication rate of 8.3% involving two inadvertentintravascular injections in a small study group of24 patients [60].

SUMMARY

The use of regional anesthesia techniques in childrenhas increased, largely in part because of the advent ofultrasonography, which has improved the efficacyand the safety profile of these blocks. Also peripheralnerve blocks provide excellent intraoperative andpostoperative pain control, by reducing the use ofopioids and its associated adverse effects. Truncalblocks offer an excellent alternative to neuraxialblockade in patients with contraindications as wellas in outpatient ambulatory procedures, in which theadverse effects of neuraxial blockade such as motorweakness, difficulty ambulating and urinary reten-tion may delay same day discharge. The use of per-ipheral nerve blocks in children will continue toincrease and it is imperative for pediatric anesthesi-ologists to embrace and master these techniques, asthey offer immense benefits to improving the peri-operative pain management of their patients.

Acknowledgements

None.

Conflicts of interest

There are no conflicts of interest.



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30.&&

Bhalia T, Sawardekar A, Dewhirst E, et al. Ultrasound-guided trunk and coreblocks. J Anesth 2013; 27:109–123.

This article is a review of the available literature regarding core and trunk blocks ininfants and children and specifically focuses on the TAP, ilioinguinal/iliohypogas-tric nerve, rectus sheath, lumbar plexus, and paravertebral and intercostal nerveblockade. This article also includes the common indications, complications,anatomy and techniques for the above-stated blocks.31. Johnson CM. Rectus sheath block in children. Tech Regional Anaesth Pain

Manage 1999; 3:189–190.32. De Maria BJ, Gotzens V, Madbrok M. Ultrasound-guided umbilical nerve block

in children: a brief description of a new approach. Pediatr Anesth 2007;17:44–50.

33. Skinner AV, Lauder GR. Rectus sheath block: successful use in the chronicpain management of pediatric abdominal wall pain. Paediatr Anaesth 2007;17:1203–1211.

34. Yuen PM, Ng PS. Retroperitoneal hematoma after a rectus sheath block. J AmAssoc Gynecol Laparosc 2004; 11:448.

35. Dolan J, Lucie P, Geary T, et al. The rectus sheath block: accuracy of localanesthetic placement by trainee anesthesiologists using loss of resistance orultrasound guidance. Reg Anesth Pain Med 2009; 34:247–250.

36.&&

Polaner DM, Taenzer AH, Walker BJ. Pediatric Regional AnesthesiaNetwork (PRAN): a multiinstitutional study of the use and incidence ofcomplications of pediatric regional anesthesia. Anesth Analg 2012; 6:1353–1364.

The Pediatric Regional Anesthesia Network is a multicenter study, which obtaineddata on practice patterns and complications involving the use of regional anesthe-sia in infants and children. This article highlights a low rate of complications in theUnited States, which is comparable with the data from large multicenter Europeanstudies.37. Hadzic A. Regional anesthesia for pediatric surgery. In: Hadzic A, editor.

Textbook of Regional Anesthesia and Acute Pain Management. First edition.,1st Ed New York: McGraw Hill companies; 2007. pp. 763–767.

38.&&


This article is a review of the available literature regarding core and trunk blocks ininfants and children and specifically focuses on the TAP, ilioinguinal/iliohypogas-tric nerve, rectus sheath, lumbar plexus, and paravertebral and intercostal nerveblockade. This article also includes the common indications, complications,anatomy and techniques for the above-stated blocks.39. Weintraud M, Marhofer P, Bosenberg A. Ilioinguinal/iliohypogastric blocks in

children: where do we administer the local anesthetic without direct visualiza-tion? Anesth Analg 2008; 106:89–93.

40.&&

Abualhassan AA. Ultrasound-guided ilioinguinal/iliohypogastric nerve blocksversus caudal block for postoperative analgesia in children undergoingunilateral groin surgery. Saudi J Anaesth 2012; 6:367–372.

This study was designed primarily to determine whether ultrasound-guided ilioin-guinal/iliohypogastric nerve blocks could provide comparable postoperative an-algesia to blind technique caudal block in children undergoing unilateral groinsurgery, with secondary endpoints such as analgesic consumption, parentalsatisfaction, and postoperative complications. They were able to show thatultrasound-guided IL/IH nerve blocks provide ideal postoperative analgesic forunilateral groin surgery in children and are as effective as caudal block, with a lowervolume of local anesthetics used.41. Willschke H, Bosenberg A, Marhofer P, et al. Ultrasonographic-guided

ilioinguinal/iliohypogastric nerve block in pediatric anesthesia: what is theoptimal volume? Anesth Analg 2006; 102:1680–1684.



42. Bhattarai BK, Rahman TR, Sah BP, Tuladhar UR. Analgesia after inguinalherniotomy in children: combination of simplified (single puncture) ilioinguinaland iliohypogastric nerve blocks and wound infiltration vs. caudal block with0.25% bupivacaine. Kathmandu Univ Med J (KUMJ) 2005; 11:208–211.

43. Johnr M, Sossai R. Colonic puncture during ilioinguinal nerve block in a child.Anesth Analg 1999; 88:1051–1052.

44. Vaisman J. Pelvic hematomas after an ilioinguinal nerve block for orchialgia.Anesth Analg 2001; 92:1048–1049.

45. Ghani KR, McMillan R, Paterson-Brown S. Transient femoral nerve palsyfollowing ilioinguinal nerve blockade for day case inguinal hernia repair. J RColl Surg Edinb 2002; 47:626–629.

46. Erez I, Buchumensky V, Shenkman Z, et al. Quadriceps paresis in pediatricgroin surgery. Pediatr Surg Int 2002; 18:157–158.

47.&&

Chelly JE. Paravertebral blocks. Anesthesiol Clin 2012; 30:75.

This article provides a comprehensive review of paravertebral nerve blocks: theanatomy, techniques, indications and complications associated with these blocks.48.&&


This article is a review of the available literature regarding core and trunk blocks ininfants and children and specifically focuses on the TAP, ilioinguinal/iliohypogas-tric nerve, rectus sheath, lumbar plexus, and paravertebral and intercostal nerveblockade. This article also includes the common indications, complications,anatomy and techniques for the above-stated blocks.49.&

Greengrass RA, Duclas R Jr, et al. Paravertebral blocks. Int Anesthesiol Clin2012; 50:56–73.

This is a review article about PVB, focusing on indications as primary anesthetic,analgesia, use in acute pain associated with trauma, use in chronic pain, variousblock techniques, contraindications, distribution of block, choice of local anes-thetics and complications of the block.50. Naja MZ, Gustafsson AC, Ziade MF, et al. Distance between the skin and the

thoracic paravertebral. Anaesthesia 2005; 60:680–684.51. Chelly JE, Uskova A, Merman R, et al. A multifactorial approach to the factors

influencing determination of paravertebral depth. Can J Anaesth 2008;55:587–594.

52. Lonnqvist PA, Hesser U. Location of the paravertebral space in children andadolescents in relation to surface anatomy assessed by computed tomogra-phy. Paediatr Anaesth 1992; 2:285–289.

53.&&

Ponde VC, Desaie AP. Echo-guided estimation of formula for paravertebralblock in neonates, infants and children till 5 years. Indian J Anaesth 2012;56:382–386.

The purpose of this study was to use echosonography to determine an equationfor determining the paravertebral space in neonates, infants and children up to5 years’ old.54.&

Moawad HE, Mousa SA, El-Hefnawy AS, et al. Single-dose paravertebralversus epidural blockade for pain relief after open renal surgery: a prospectiverandomized study. Saudi J Anaesth 2013; 7:61–67.

This article compared the effectiveness of a single injection PVB to epiduralblockade in patients undergoing major renal surgery and was able to show that thatthe single-injection PVB resulted in similar analgesia but with greater hemody-namic stability than the epidural blockade and may be recommended for patientswith coexisting circulatory dysfunction.55.&&


This article provides a comprehensive review of paravertebral nerve blocks: theanatomy, techniques, indications and complications associated with these blocks.56. Naja ZM, Raf M, Rajab ME, et al. Nerve stimulator-guided paravertebral

blockade combined with sevoflurane sedation versus general anesthesia withsystemic analgesia for postherniorrhaphy pain relief in children. Anesthesio-logy 2005; 103:600–605.

57.&&

Chelly JE. Paravertebral blocks. Anesthesiol Clin 2012; 30:81–83.

This article provides a comprehensive review of paravertebral nerve blocks: theanatomy, techniques, indications and complications associated with these blocks.58. Koyyalamudi VB, Elliot C, Gibbs CP, Boezaart AP. Perioperative analgesia for

forequarter amputation in a child: a dual paravertebral approach. Anesth Analg2010; 110:761–763.

59. Visoiu M, Yhang Y. Ultrasound guided bilateral paravertebral continuous nerveblocks for a mildly coagulopathic patient undergoing exploratory laparotomyfor bowel resection. Pediatr Anesth 2011; 21:459–462.

60. Berta E, Spanheil J, Smakal O, et al. Single injection paravertebral block forrenal surgery in children. Paediatr Anaesth 2008; 18:593–597.

61. Tug R, Ozcengiz D, Gunes Y. Single level paravertebral versus caudal block inpaediatric inguinal surgery. Anaesth Intensive Care 2011; 39:909–913.

62.&&


This article provides a comprehensive review of paravertebral nerve blocks: theanatomy, techniques, indications and complications associated with these blocks.63. Naja Z, Lonnqvist PA. Somatic paravertebral nerve blockade: incidence of

failed block and complications. Anesthesia 2001; 56:1184–1188.



co beyond the caudal: truncal blocks an alternative option

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