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blocks are performed under general anaesthesia in children, but there is no clear evidence
that this obscures early signs of systemic local anaesthetic toxicity (Bernards et al, 2008).
Lipid emulsion infusion has been shown to be of value in managing acute CV toxicity due to
accidental intravascular injection of local anaesthetics (Ludot et al, 2008) and is recommended
as an early intervention. See Section 5.1.
Neurological damage attributable to paediatric regional analgesia is rare, and the benefit of
ensuring a cooperative and immobile infant or child may outweigh the risk of performing
regional anaesthesia under general anaesthesia in children (Bernards et al, 2008). Prolonged
blockade and immobility may result in nerve compression accompanied by neurological deficit
or neuropathic pain (Symons & Palmer, 2008). A retrospective review of 24 005 cases of regional
block revealed five serious adverse outcomes, including three deaths, associated with difficult
epidural insertions in young infants (Flandin‐Blety & Barrier, 1995 Level IV). A prospective study
including 15 013 central blocks (predominantly caudal blocks) reported 1.5 minor
complications per 1000 (Giaufre et al, 1996 Level IV). An audit of 10 633 paediatric epidurals
performed in the United Kingdom and Ireland reported five serious incidents: two epidural
abscesses, and one each of meningism, severe postdural puncture headache requiring
autologous blood patch, and a drug volume error resulting in cauda equina syndrome (which
was the only case associated with residual symptoms at 12 months). Peripheral or nerve root
damage was reported in six cases: three resolved spontaneously, two required chronic pain
referral and gabapentin but resolved by 12 months, and one had residual symptoms at 1 year.
Compartment syndrome was reported in four children, but symptoms were not masked by the
epidural infusion (Llewellyn & Moriarty, 2007 Level IV).
Bacterial colonisation of catheters is more commonly associated with caudal than lumbar
catheters (Kost‐Byerly et al, 1998 Level IV), but epidural space infection is rare in the absence of
prolonged or repeated insertion or immunodeficiency syndromes (Strafford et al, 1995 Level IV).
Intrathecal opioids
Following cardiac surgery, intrathecal morphine 20 mcg/kg prolonged time to first analgesia
and decreased postoperative morphine requirements but did not alter time to discharge from
intensive care (Suominen et al, 2004 Level II). Addition of intrathecal tetracaine and morphine to
IV remifentanil decreased pain scores and analgesic requirements after early extubation
(Hammer et al, 2005 Level II).
CHAPTER 10 (but not lower doses) to intrathecal local anaesthetic prolonged the duration of analgesia and
In infants undergoing lower abdominal and urological surgery, addition of fentanyl 1 mcg/kg

reduced supplemental analgesic requirements (Batra et al, 2008 Level II).
Spinal fusion
Low‐dose intrathecal opioids given preoperatively, reduced blood loss and provided good
analgesia in the immediate perioperative period (Eschertzhuber et al, 2008 Level II). Epidural
infusion of local anaesthetic and opioid via a catheter placed prior to wound closure provided
comparable (Cassady et al, 2000 Level II; O'Hara et al, 2004 Level II) or improved analgesia (Sucato et
al, 2005 Level IV) compared with morphine PCA. Dual catheter techniques improved
dermatomal spread and may be more effective (Ekatodramis et al, 2002 Level IV), improving
analgesia at rest and on movement (Blumenthal et al, 2005 Level II; Blumenthal et al, 2006 Level II).
PCEA was effective with a high level of patient satisfaction in selected cases (Saudan et al, 2008
Level IV).

360 Acute Pain Management: Scientific Evidence