SPECIAL ARTICLE

The European Society of Regional Anaesthesia and Pain

Therapy and the American Society of Regional Anesthesia
and Pain Medicine Joint Committee Practice Advisory on
Controversial Topics in Pediatric Regional Anesthesia
Giorgio Ivani, MD,* Santhanam Suresh, MD,† Claude Ecoffey, MD,‡ Adrian Bosenberg, MB, ChB, FFA(SA),§
Per-Anne Lonnqvist, MD,|| Elliot Krane, MD, FAAP,** Francis Veyckemans, MD,††
David M. Polaner, MD, FAAP,‡‡ Marc Van de Velde, MD,§§ and Joseph M. Neal, MD||||

Background and Objectives: Some topics in the clinical management

of regional anesthesia in children remain controversial. To evaluate and
T he American Society of Regional Anesthesia and Pain Medicine
(ASRA) and the European Society of Regional Anaesthesia and
Pain Therapy (ESRA) are the primary societies for regional anesthe-
come to a consensus regarding some of these topics, The European Society sia in the world, and one of their goals is to create recommendations/
of Regional Anaesthesia and Pain Therapy (ESRA) and the American So- guidelines through the collaboration of their experts.
ciety of Regional Anesthesia and Pain Medicine (ASRA) developed a joint The first result was in 2009, the publication of “The
committee practice advisory on pediatric regional anesthesia (PRA). American Society of Regional Anesthesia and Pain Medicine
Methods: Representatives from both ASRA and ESRA comprised the and the European Society of Regional Anesthesia and Pain Ther-
joint committee practice advisory on PRA. Evidence-based recommenda- apy Joint Committee Recommendations for Education and Train-
tions were based on a systematic search of the literature. In cases where ing on Ultrasound-Guided Regional Anesthesia.” 1
no literature was available, expert opinion was elicited. Experts selected The 2 societies worked again together to create The Euro-
controversial topics in PRA. pean Society of Regional Anesthesia and Pain Therapy and the
Results: The performance of PRA under general anesthesia or deep American Society of Regional Anesthesia and Pain Medicine
sedation is associated with acceptable safety and should be viewed as the Joint Committee Practice Advisory on Pediatric Regional Anes-
standard of care (Evidence B2 and Evidence B3). Because of the diffi- thesia (PRA). Experts from both societies discussed important
culty interpreting a negative test dose, the use of test dosing should remain and controversial topics in PRA and provide guidance, wherever
discretionary (Evidence B4). The use of either air–loss of resistance or possible, from an evidence-based perspective and on the basis of
saline–loss of resistance techniques is supported by expert opinion, but the expert opinion when conclusive evidence is lacking in the litera-
literature supporting one technique over the other is sparse and controversial; ture. Four topics were selected by participant consensus according
when used appropriately, each technique may be safely used in children. to the current main areas of PRA controversy: 1) the performance
There are no current evidence-based data that the use of RA increases the risk of regional nerve blocks under deep sedation (DS) or GA, 2) the
for acute compartment syndrome or delays its diagnosis in children. value of a test dose, 3) the use of air versus normal saline for loss
Conclusions: High-level evidence is not yet available for the topics eval- of resistance (LOR) for epidural space detection, and 4) regional
uated, and most recommendations are based on Evidence B studies. The anesthesia and the risk of obscuring compartment syndromes.
ESRA/ASRA recommendations intend to provide guidance for the safe We are unaware of any previous practice advisories that spe-
practice of regional anesthesia in children. cifically addressed controversial topics in PRA. The ASRA and
(Reg Anesth Pain Med 2015;40: 526–532) the ESRA hope that this article will be useful not only to those
who work every day in pediatric hospitals but also to all anesthe-
siologists who care for children less frequently. In addition, we in-
From the *Department of Anesthesiology, Regina Margherita Children’s Hospi- tend to provide guidance and reflection on current controversial
tal, Turin, Italy; †Ann & Robert H. Lurie Children’s Hospital of Chicago, Northwest- clinical issues in PRA practice.
ern University, Chicago, IL; ‡Pôle Anesthésie-SAMU-Urgences-Réanimations,
Hôpital Pontchaillou, Université Rennes 1, Rennes, France; §University of
Washington and Seattle Children’s Hospital, Seattle, WA; ||Section of Anaesthesiol-
ogy and Intensive Care, Department of Physiology and Pharmacology, Karolinska
Institutet; and Paediatric Anaesthesia/PICU/ECMO Services, Karolinska University METHODS
Hospital, Stockholm, Sweden; **Departments of Pediatrics, and Anesthesiology,
Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, Representatives from both ASRA and ESRA comprised the
CA; ††Cliniques Universitaires St Luc, Catholic University of Louvain Medical joint committee practice advisory on PRA. Committee members
School, Brussels, Belgium; ‡‡Departments of Anesthesiology and Pediatrics, Uni- met in workgroups, and decisions on topics to be addressed were
versity of Colorado School of Medicine and Children’s Hospital Colorado, Aurora,
CO; §§Department of Cardiovascular Sciences, KULeuven; and Department of
made through consensus. The committee used similar methodol-
Anesthesiology, UZLeuven, Leuven, Belgium; and ||||Department of Anesthesi- ogy on the generation of practice advisories previously described
ology, Virginia Mason Medical Center, Seattle, WA. by the American and European anesthesiology societies.2,3 In
Accepted for publication May 5, 2015. brief, an evaluation of availability and strength of the evidence
Address correspondence to: Santhanam Suresh, MD, Ann & Robert H. Lurie
Children’s Hospital of Chicago, 225 E Chicago Ave, Chicago, IL 60611
was systematically performed. Scientific evidence was obtained
(e‐mail: ssuresh@[Link]). by performing a systematic search of literature. All committee
Identification of institution(s) where work is attributed: Ann & Robert H. Lurie members participated in the expert opinion decisions because all
Children’s Hospital of Chicago Northwestern University , Chicago, IL. involved have had extensive experience (>20 years) on the topic.
The authors declare no conflict of interest.
Copyright © 2015 by American Society of Regional Anesthesia and Pain Medicine
No other clinician outside of the committee was consulted.
ISSN: 1098-7339 Published reports evaluating the practice of RA for pediatric
DOI: 10.1097/AAP.0000000000000280 patients were searched using the National Library of Medicine’s

526 Regional Anesthesia and Pain Medicine • Volume 40, Number 5, September-October 2015

Copyright © 2015 American Society of Regional Anesthesia and Pain Medicine. Unauthorized reproduction of this article is prohibited.
Regional Anesthesia and Pain Medicine • Volume 40, Number 5, September-October 2015 Advisory: Pediatric Regional Anesthesia

PubMed database, the Cochrane Database of Systematic Reviews, In response to those concerns, thought leaders in pediatric
and Google Scholar inclusive to December 9, 2014. Free text and anesthesiology opined that it was safe and consistently stated that
MeSH terms “block,” “regional,” “children,” “surgery,” “anesthe- it was acceptable care to perform PRA under GA/DS in chil-
sia,” “local,” and “pediatric” were used individually and in various dren.11,12 Nevertheless, objective data were lacking, and the dis-
combinations. No language restriction was used. No date limit cussion about the safety of PRA during GA/DS was largely based
was used. The search was limited to articles in subjects younger on opinion and anecdote.12 A 2008 ASRA practice advisory guide-
than 18 years. We reviewed the reference lists from identified line acknowledged the need for performance of regional blockade
studies to identify additional studies not found during our primary under GA or DS in children.13
search. No search was performed for unpublished studies. The sci-
entific evidence was classified according to the quality of research
design as presented in Table 1, similar to what has been previously Current Evidence Base for the Safety of PRA
described in other practice advisories.2,3 Performed During GA/DS
When the literature search revealed a lack of published stud- Apart from reports of single-center experiences with regard
ies or when the only evidence was generated from studies with in- to PRA,14,15 there are currently 4 major large-scale (>10,000 pa-
sufficient quality because of methodological constraints, it was tients per study) multicenter studies available that specifically
deemed as “insufficient literature” and expert opinion from the have focused on the incidence of complications after PRA.16–19
ESRA/ASRA joint committee was considered. A summary of these seminal studies is provided below. None of
the studies reported any cases of paralysis after the use of neuraxial
anesthesia/analgesia, leading to an incidence (95% confidence in-
RESULTS terval [95% CI]) of 0 (0%–0.004%) for paralysis.
The first large-scale effort focused on the complications
associated with the use of PRA was published by the French-
Performance of Regional Anesthesia Under Language Society of Paediatric Anaesthesiologists (ADARPEF)
General Anesthesia or DS in 1996.16 At the 38 participating centers, all use of regional anes-
Soon after the first description by August Bier of spinal an- thesia was prospectively registered during 1 year (May 1993–
esthesia in 1898, this regional anesthesia technique became pop- April 1994), with a special focus on safety issues. There were
ular for use in children on both sides of the Atlantic Ocean.4,5 24,409 regional anesthetics included in the study, of which 89%
This was later followed by the seminal publication by Campbell were performed under GA. Neuraxial blocks were the most com-
in 1933, which reported the use of caudal blockade for pediatric mon; caudal blockade was by far the most common individual
urologic procedures.6 However, with the many advances in the de- block performed. Peripheral blocks and local anesthesia tech-
velopment of general anesthesia (GA) between 1940 and 1960, niques were used in only 38% of the registered cases. The overall
PRA was used only in a few specialized centers until the 1980s. complication rate was found to be very low (0.9 per 1000 blocks),
At that time, a resurgence of interest in PRA took place, per- but neuraxial blocks were found to have a higher complication rate
haps best exemplified by the description of epidural anesthesia in compared with peripheral techniques (1.5 and 0 per 1000 blocks,
pediatric patients by Ecoffey et al7 and Murat et al.8 Epidural an- respectively). None of the observed complications resulted in
esthesia rapidly became a common modality of regional anesthe- long-term disability or medicolegal action (follow-up period of
sia in infants and children and was most often performed under 12 months) (Evidence B2).
GA. A case report of a devastating neurological complication The second large-scale effort focused on the complications
resulting from multiple attempts at a thoracic epidural blockade associated with the use of PRA was conducted by the 2007 UK
performed under GA in an adult, however, provoked controversy Prospective National Pediatric Epidural Audit.17 To quantify the
about the safety of this practice in children.9 The contention was risk associated with the use of pediatric epidural analgesia, the As-
based on the supposition that improper needle placement could sociation of Paediatric Anaesthetists of Great Britain & Ireland
be detected in the awake patient by paresthesia, pain on injection, undertook a prospective audit within its membership, with the
or unexpected motor responses—warning signs that would not be aim to include 10,000 epidural infusions. The audit was per-
detectable under GA or DS (GA/DS) in children. This concern formed from 2001 to 2005. If an individual patient complication
was further increased by a European publication describing seri- was recorded, a more detailed 12- month follow-up was under-
ous complications after attempted epidural block placement under taken. An expert panel adjudicated complications and graded the
GA in 4 pediatric patients.10 severity. A total of 10,633 epidurals in all pediatric age groups
were included in the study. All but one were placed under GA.
Overall, 96 incidents were reported, with the large majority being
TABLE 1. Classification of Scientific Evidence classified as minor (1:189). Only 5 incidents were recorded as se-
rious (1 of 2000) and an additional 9 as major (1:1100). One child,
Evidence Class Study Design who had a drug infusion error, experienced persistent paresthesia
Category A1 Sufficient number of randomized controlled still present at the 12-month follow-up (1:10,000). Four patients
trials to conduct a meta-analysis developed compartment syndrome, but the expert panel judged
Category A2 Several randomized controlled trial but not that there was no delay in diagnosis because of the epidural infu-
sufficient to conduct sion (Evidence B3).
Category A3 Single randomized controlled trial The third large-scale effort focused on the complications as-
Category B1 Observational comparisons between sociated with the use of PRA was the 2010 ADARPEF study.18 In
clinical interventions for a specific outcome this prospective 1-year study (November 2005–October 2006) in-
Category B2 Observational studies with associative statistics cluding 47 different institutions, a total of 29,870 regional blocks
Category B3 Noncomparative observational studies with were performed under GA and 1262 regional blocks without con-
descriptive statistics comitant GA. Compared with the earlier ADARPEF study, pe-
Category B4 Case reports ripheral nerve blocks were used with increasing frequency (66%
peripheral vs 34% neuraxial). However, in children younger than

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Copyright © 2015 American Society of Regional Anesthesia and Pain Medicine. Unauthorized reproduction of this article is prohibited.
Ivani et al Regional Anesthesia and Pain Medicine • Volume 40, Number 5, September-October 2015

3 years, the use of neuraxial and peripheral blocks was similar, (LA) test doses in children. The epinephrine-containing test dose
whereas, in older children, peripheral nerve blocks were performed initially was designed to be used in awake adults who were not re-
4 times more frequently than neuraxial blocks. The authors did ceiving β-blocking agents to detect accidental intravascular injec-
not analyze differences in complications under GA/DS. Only tion during epidural anesthesia.26 In an awake adult, the injection
41 complications were recorded in this study (1.2:1000), and none of 3 mL of an LA solution containing 15 μg epinephrine produces
resulted in long-term sequelae. Similar to the 1996 ADARPEF hemodynamic effects (mainly tachycardia) if injected intravascu-
study, neuraxial blocks were associated with a 6-fold higher inci- larly. Most children, however, have their regional blocks placed
dence of complications (Evidence B3). while under GA/DS, making the recognition of accidental intra-
The fourth large-scale effort focused on the complications as- vascular injection of LA with epinephrine more difficult.
sociated with the use of PRA was the 2014 Pediatric Regional An- To detect accidental intravascular injection of an LA solution in
esthesia Network (PRAN) report.19 To allow for prospective and children, some practitioners add epinephrine to the LA solution at a
continuous audit of practice trends as well as the incidence of concentration of 2.5 or 5 μg/mL, a concentration of 1/400,000 or
complications, 6 academic centers in the United States pioneered 1/200,000, respectively. However, a small child’s increased
an Internet-based PRAN database in 2006.20 They reported on resting heart rate, combined with the fact that most regional
53,564 cases of PRA prospectively collected between 2007 and blocks are performed under GA/DS, means that the utility and
2012.19 They were able to demonstrate that performing a PRA un- accuracy of test dosing remain a matter of controversy among
der GA (with or without neuromuscular blockade [NB]) did not pediatric anesthesiologists.
increase the risk of immediate or late complications. The inci- The volume of a pediatric test dose was empirically defined
dence of neurological complications (all of which were minor with as a volume of 0.1 mL/kg of an LA solution containing 5 μg/mL
1 exception that resolved) in patients under GA without NB was of epinephrine, that is, a dose of 0.5 μg/kg epinephrine.27 This
lower than that seen in any other group: 0.62 of 1000 (CI 0.4– was thought to be sufficient to induce an easily detectable hemo-
0.92) compared with 2.4 of 1000 (CI, 1.6–3.6) in patients under dynamic change but also small enough to avoid complications and
GA with NB, 8.3 of 1000 (4.9–13.3) in sedated and 3.4 of 1000 is supported by a dose-response study.28
(CI, 0.7–10.0) in awake patients (Evidence B2). Pediatric regional
anesthesia was performed in awake patients most commonly in Incidence of Accidental Intravenous Injection of LA
neonates and infants younger than 6 months (n = 290) and teen- During Regional Anesthesia in Children
agers (n = 515); those in which sedation was used included mainly In the first prospective study of ADARPEF, 6 of the 25 com-
teenagers (n = 2060). plications observed were caused by the accidental intravascular
injection of the LA16 (Evidence B3). The second ADARPEF
Cautionary Case Reports study reported 15 cases of LA toxicity, of which 6 had a nega-
A strong evidence base exists supporting the safety of PRA tive test dose18 (Evidence B3). In a prospective study of 1100
performed under GA/DS. However, this does not ensure that seri- caudal blocks, the incidence of unintentional vascular puncture
ous complications cannot occur under certain circumstances. was 6.9% and 8 (0.7%) accidental intravascular (IV) injections,
Thus, if PRA is performed with the wrong type of equipment or all occurring in infants weighing less than 10 kg, were observed29
without basic safety precautions, if the operator has insufficient (Evidence B4).
training and/or skills, or if PRA is used in particularly vulnerable In another prospective study including 742 epidural caudal
patient categories, serious complications may still occur, a fact or lumbar blocks, a 5.6% incidence of unintentional vascular in-
that may be especially true in association with the use of epidural jections was observed. In addition, in 12 cases out of 36, aspira-
blockade.21–24 Furthermore, there is always a risk of rare compli- tion for blood had been negative before the injection of the
cations, often of obscure or unknown etiology, that are unrelated epinephrine-containing LA30 (Evidence B3). In an audited cohort
to operator expertise and will not be an adequately identified event from the PRAN database composed of a total of 26,949 blocks
in large-scale studies25 (Evidence B4). using a test dose, there was a 0.21% incidence of positive test
doses, almost all of which occurred during caudal or epidural
Evidence-Based Conclusions and Clinical Advice placement20 (Evidence B3). There were no positive test doses in
• The performance of PRA under GA/DS is associated with ac- other blocks, with the exception of 1 single-injection truncal block,
ceptable safety and should be viewed as the standard of care although test doses were less frequently used in non-neuraxial
(Evidence B2 and Evidence B3). blocks when ultrasound guidance was used.
• The overall risk for complications is 0.66% (95% CI, 0.6%– All the aforementioned studies attested to the importance of
0.7%), whereas the risk of paralysis is estimated at 0 (95% CI, dose calculation and staying below the maximum recommended
0%–0.004%) (Evidence B2 and Evidence B3). LA dose to avoid complications related to LA toxicity.
• Despite the reassuring safety of PRA performed under GA/DS, Possible Interfering Factors Specific to Efficacy of the
serious complications may still occur. In the event of an unex- Test Dose in Children
pected clinical outcome, especially unanticipated motor block-
ade during continuous postoperative regional block after the One of the main problems is interpreting the hemodynamic
use of PRA, a high index of suspicion for neurological injury response induced by an IV injection of LA mixed with a small
is warranted and appropriate diagnostic and therapeutic mea- dose of epinephrine.31,32 The following factors have been demon-
sures must be performed without delay (Evidence B4). strated or theorized to alter the reliability of a test dose: 1) the gen-
eral anesthetic agent used and its dose at the time of injection of
the test dose; 2) a higher basal heart rate in infants and small chil-
dren; 3) a possible age-dependent variation of the reactivity of the
Test Dose and Intravascular Injection cardiovascular system to epinephrine; 4) the premedication re-
Because differences exist in both the physiological and clin- ceived; 5) the LA used; and 6) the GA technique used.32–36
ical conditions under which regional anesthetics are administered In children under sevoflurane anesthesia, the IV injection of
in children compared with adults, there is considerable contro- 0.1 mL/kg of an LA solution containing 5 or 2.5 μg/mL epineph-
versy and disparity of practice regarding the use of local anesthetic rine produces (Evidence B3):

528 © 2015 American Society of Regional Anesthesia and Pain Medicine

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Regional Anesthesia and Pain Medicine • Volume 40, Number 5, September-October 2015 Advisory: Pediatric Regional Anesthesia

1) An early modification (within 20–40 seconds) of the T wave those in favor of saline-LOR and those who prefer to use air-LOR.
morphology on the electrocardiogram (ECG): the increase in T Recently, a third option has been advocated as a “compromise”—
wave amplitude is more pronounced in younger children.28 In use of a combination of air and saline.44
older children, adolescents, and adults, inversion of the T wave
is observed.35 These modifications are best observed in leads I, Air-LOR
II, III, or V5 on the ECG.37 The pathophysiology of this modi-
fication of the T wave is unknown: it can be observed after the Several complications related to the air-LOR technique have
accidental IV injection of a large dose of a mixture of lidocaine been published (nerve root compression, pneumocephalus, incom-
and bupivacaine without epinephrine but also when a small plete analgesia, and venous air embolism)8,10,45–48 (Evidence B4).
dose of epinephrine is injected IV without any LA.38 However, all these complications were associated with the total
2) A change in heart rate: this is most often manifested as a heart amount of air injected (eg, multiple attempts, large injection
rate increase of more than 10 beats/min observed somewhat volume). Thus, expert consensus is that the amount of air in the
later than the T wave changes. However, bradycardia or other syringe should be limited to a maximum of 0.5 to 1 mL and used
dysrhythmias may be observed, too, and about 25% of patients only to detect the change of resistance, releasing the pressure on
may not demonstrate any change in rate. the plunger immediately on entry into the epidural space. Re-
3) A transient increase in systolic blood pressure: this can be stricting the volume of air that is/can be injected will on theoretical
missed during intermittent noninvasive measurement of grounds substantially limit the risk for any air-related complica-
blood pressure, as is usually the case in routine pediatric an- tions. The use of air-LOR is currently the preferred choice in some
esthesia cases. countries.49
4) In children receiving GA with propofol and remifentanil- Other gases have been tried as alternatives to air for LOR.
based total intravenous anesthesia, the Twave amplitude changes From a theoretical point of view, CO2 may offer some theoretical
are highly inconsistent—elevation is seen in only 25% of cases, advantages.50 Carbon dioxide is extremely soluble in blood and
whereas no change or depression is seen equally in the remain- therefore will mitigate the risk of air embolism; in addition, CO2
der.39 Other hemodynamic criteria need thus to be defined in this may possess bactericidal properties. However, the availability of
context. Diastolic blood pressure elevation, measured between 1 CO2 is limited in most operating rooms and may therefore be an
and 2 minutes after injection, was reported to be a highly sensi- impractical alternative as compared with either air or saline.
tive indicator and was observed in all cases studied.
Saline-LOR
The use of saline avoids most of the issues related to the use
Evidence-Based Conclusions and Clinical Advice of air. However, as with air, it is essential to limit the volume of
• Because of the difficulty interpreting a negative test dose, the the injectate because excessive amounts of saline may dilute sub-
use of test dosing should remain discretionary. In clinical prac- sequently injected LA, may make the identification of uninten-
tice, if a test dose is used, there may be false-negative results, es- tional dural puncture more difficult, and can together with the
pecially when the test dose is only partially administered volume of LAs cause transient reduction in cerebral blood flow
intravenously or when the general anesthetic agents can blunt in small infants.51 Despite these issues associated with the use
the hemodynamic effects of epinephrine. A negative result after of saline-LOR, the exclusive use of saline has been recommended
the injection of a test dose therefore is reassuring but does not by some experts and has become the general practice in some
rule out vascular placement of needle or catheter. Any injection countries.52,53
of an LA solution should be performed slowly, in small aliquots
(0.1–0.2 mL/kg) and with intermittent aspiration and observa- Air/Saline-LOR
tion of the ECG tracing (Evidence B4).
One publication involving 500 pediatric epidural blocks de-
• In all experimental studies using the deliberate IV injection of
scribed the use of saline with a bubble of air in the syringe44
an LA solution containing epinephrine to model accidental IV
(Evidence B3). This was reported to permit easy detection of the
injection, no false-positive results were observed: any modifica-
epidural space with a lower incidence of dural puncture (0.5%)
tion of the T wave or of the heart rate within 30 to 90 seconds
than what has been reported for exclusive use of air or saline.50
after the injection of a test dose should thus be interpreted as
an accidental IV injection until disproven (Evidence B3).
• Imaging modalities (ultrasound, fluoroscopy) may help to avoid
or visualize accidental intravascular needle placement in periph- Evidence-Based Conclusions and Clinical Advice
eral blocks, but data are lacking in PRA to determine the value • The use of either air-LOR and saline-LOR techniques are sup-
of these techniques (expert opinion).40,41 ported by different international experts, and the literature
supporting 1 technique over the other is sparse; as long as either
technique is used appropriately, each may be safely used in in-
fants and children. The combination of air and saline may repre-
Loss of Resistance sent a better alternative that will minimize the risk of injecting
Despite the introduction of ultrasound guidance as a comple- air and reduce the volume of saline injected. This method is also
ment to regular LOR, the traditional LOR techniques using air or associated with a low risk for unintentional dural puncture (ex-
saline still remain the most widely used techniques for detecting pert opinion).
needle placement in the epidural space.42,43 • There are insufficient data in children to determine if using LOR
In 1995, a case series was published reporting a serious com- to air or saline to detect needle entry into the epidural space will
plication after the use of air-LOR in children, which immediately result in clinically significant differences regarding safety, ac-
triggered an intense discussion regarding whether saline-LOR is a curacy, and subsequent efficacy of the injected LA (Evidence
safer option and therefore should be the only recommended tech- B3 and Evidence B4). Thus, both the aforementioned alterna-
nique10 (Evidence B4). This discussion has since been ongoing tives are acceptable if care is taken to keep the injected volume
and has divided the pediatric anesthesia community into 2 camps, at a minimum.

© 2015 American Society of Regional Anesthesia and Pain Medicine 529

Copyright © 2015 American Society of Regional Anesthesia and Pain Medicine. Unauthorized reproduction of this article is prohibited.
Ivani et al Regional Anesthesia and Pain Medicine • Volume 40, Number 5, September-October 2015

• In neonates and infants, the volume of air contained in the sy- Evidence-Based Conclusions and Clinical Advice
ringe should be limited to less than 1 mL and air injections • There is no current evidence that the use of regional anesthetics
should not be repeated if multiple attempts are made to enter increases the risk for ACS or delays its diagnosis in children.
the epidural space (expert opinion). • A comprehensive preoperative discussion with the patient’s
• Although the committee recognizes that an air embolism family and the surgical team should be performed to inform
with hemodynamic consequences is rare when LOR-air is them of this rare but serious complication.
used, enough evidence is lacking regarding the brain safety • As with many controversies linked to PRA, it is almost impos-
even for small amounts of air in the presence of a right-to- sible to give unequivocal statements or recommendations. We
left cardiac shunt. suggest the following “best practice rules ” to reduce or avoid
the risk of compartment syndrome in children undergoing sur-
gery with perioperative PRA: 1) single shot for both periph-
Compartment Syndrome eral and neuraxial blocks: use 0.1% to 0.25% bupivacaine,
Acute compartment syndrome (ACS) of a limb is caused by levobupivacaine, or ropivacaine concentrations because they
high pressure in the closed noncompliant muscle compartment, are less likely to mask ischemic pain and/or produce muscle
which leads to compromised circulation, ischemia, and, if unrec- weakness than more concentrated solutions (Evidence B4);
ognized, to motor and sensory impairment, neuronal death, and 2) for continuous infusions, bupivacaine, levobupivacaine, or
myonecrosis.53 Therefore, the time to diagnosis of ACS is essen- ropivacaine concentrations should be limited up to 0.1%; 3) in
tial because a delay in treatment of more than 4 hours can lead to cases of patients having tibial compartment surgery or other
irreversible limb damage and possible limb loss. high-risk surgeries for compartment syndrome, restricting both
Both adults and children develop this syndrome, which is gen- volume and concentration in sciatic catheters is advisable;
erally associated with trauma, fracture with subsequent casting, 4) the use of LA additives should be with caution because they
prolonged malpositioning during surgery, or ischemia-reperfusion can increase the duration and/or density of the block; 5) high-
injury.54–61 External or internal compression creates excessive pres- risk patients should have appropriate follow-up by acute pain
sure in a closed fascial compartment and leads to excruciating services to allow early detection of potential signs and symp-
pain that cannot be ascribed to the trauma or surgery. A compart- toms; and 6) if ACS is suspected, compartment pressure mea-
ment pressure greater than 30 mmHg is the commonly accepted surements should be urgently assessed.
trigger for emergency intervention.62
The hypothesis that RA delays diagnosis and treatment of
ACS is one that continues to generate debate. Only isolated case CONCLUSIONS
reports describe this event, and any evidence-based conclusion is Notwithstanding the evidence of the value, safety, and effi-
difficult. Moreover, in children, especially in preverbal or nonver- cacy of PRA, some aspects of it remain controversial. The ASRA
bal children, the recognition of ACS is more difficult because of and the ESRA have worked together on the main controversies
its unreliable warning signs (Evidence B4). Furthermore, several and present their conclusions. High-level evidence is not yet avail-
case reports suggest that breakthrough pain in a patient with a able for these controversies, and most recommendations are based
previously well-functioning continuous block may be an early on Evidence B–level studies.
warning sign of ACS and enhance its detection if caregivers are A practice advisory based on consensus should only be con-
vigilant (Evidence B4). sidered within its inherent limitations. First, it may become obso-
Epidural infusions and peripheral single-dose and continu- lete as new information becomes available from future studies. It
ous LA infusions have been stated to be responsible for delayed is, therefore, likely that this practice advisory will need to be re-
diagnosis in children, but without convincing evidence of viewed and updated periodically. It is possible that anesthesio-
causation63–65 (Evidence B4). In many cases, the main root cause logists practicing PRA may encounter system and individual
was not caused by the regional anesthetic technique but because of barriers to implement the proposed recommendations. Neverthe-
inadequate observation or to surgical malposition of the patient. less, the ESRA/ASRA joint commission hopes that barriers to im-
Kanj and colleagues,66 evaluating 23 children undergoing fas- plementation will be overcome with the publication of this
ciotomy for ACS of the upper limb, showed that pain and swelling international practice advisory.
were the main symptoms of excessively high compartment pres-
sure (>30 mmHg) in all but 2 patients, and that diagnosis in chil- REFERENCES
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Johnson et al67 reviewed 12 pediatric cases of ACS associ-
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Regional Anesthesia and Pain Medicine • Volume 40, Number 5, September-October 2015 Advisory: Pediatric Regional Anesthesia

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