?? s????te?a efa?

1
?? s????te?a efa?µ???µe??? pe??fe????? ?e??????
ap???e?sµ?? sta pa?d??

• ?. ???SO??
• ?p??. ?a?. ??a?s??s??????a?
• ?? ?a?/?? ??????? ??a?s?/??a?
• ?G? ???????

2
?? p?? s???? ???s?µ?p????µe??? pe??fe?????
?e?????? ap???e?sµ?? sta pa?d??

• ?a?d?? 4-7 et??
• ?. ?p???e?sµ?? ?a????ß??ß??????
  ?a?????p???st???? ?e????
• ?e???? ?e?????? ap???e?sµ??
• ?a?d?? gt 7et??
• ?e?????? ap???e?sµ?? ?????
• Pediatric regional anesthesia update. Curr
  Opin Anaesthesiol. 200720232-5
• Pediatric regional anesthesia. Miner Anestesiol
  200975577-83
• Peripheral nerve blocks in paediatric
  anaesthesia. Srp Arh Celok Lek 2009 137497-501

3
?e??fe????? ?e?????? ?p???e?sµ?? (???)sta ?a?d??
???? ?

• ??e??e???t??? a?a???s?a
• ?ete??e???t??? a?a???s?a
• ??t?µet?p?s? O???? p????
• ??t?µet?p?s? ??????? p????

4
?e??fe????? ?e?????? ?p???e?sµ?? (???)sta ?a?d??

• ?p???te? a?te?de??e??
• ????s? pa?d??? ? ??????
• F?e?µ??? st?? pe????? efa?µ????
• ???e???a sta t?p??? a?a?s??t???
• S?et???? a?te?de??e??
• ??ata?a??? p??t???t?ta?
• ?e???µ????? pa??se??

5
?e??fe????? ?e?????? ?p???e?sµ?? (???)sta ?a?d??
?OS ?

• ?p? Ge???? ??a?s??s?a, epe?d? ta pa?d??
• d?a?at????ta? ap? needle phobia
• de? ep???µ??? t? d?at???s? t?? s??e?d?t?t?ta?
  ?at? t?? ep?t??es? pa?eµßat???? te??????
• de? s??e??????ta?
• Regional techniques as an adjunct to general
  anesthesia for pediatric extremity and
• spine surgery. J Pediatr Orthop. 2006 26801-4

6
?e??fe????? ?e?????? ?p???e?sµ?? (???)sta ?a?d??
?F????G?
???a? ?????? ?a? asfa??? ? efa?µ??? ??? se ??a
a?a?s??t?p???µ??? pa?d? ?

• NAI, d??t? ap?te?e? t? µ??? ef??t? ??s?
• ?? ??? e?asfa?????? ??a??p???t??? d?e??e???t???
  ?a? µete??e???t??? a?a???s?a ?a? pe????????? t?
  ??????s? t?? ?p??e?d??
• An opioid-free anaesthetic using nerve blocks
  enhances rapid recovery after minor hand surgery
  in children.
• Eur J Anaesthesiol. 201027521-5

7
?p?d?µ??????a ??s???t?ta t?? ??? sta pa?d??

• ????pt??? µe??t? ? 11/2005 - 10/2006
• 47 ??s???µe?a
• 29870 ?e?t????? pe??fe????? ap???e?sµ?? ?p?
  ?e???? a?a?s??s?a
• ?e?t????? ap???e?sµ?? 44
• ?e??fe????? ap???e?sµ?? 66
• ?a?d?? ?????a? lt3 et?? ? ?e?t????? / pe??fe?????
  ap???e?sµ?? 45 vs 55
• ?a?d?? gt 3 et?? ? 4 f???? s????te??? ??
  pe??fe????? ap???e?sµ??

Epidemiology and morbidity of regional
anesthesia in children a follow-up one-year
prospective survey of the French-Language
Society of Pediatric Anesthesiologists
(ADARPEF). Pediatr Anesth 2010 20106110
8
?p?d?µ??????a ??s???t?ta t?? ??? sta pa?d??

• ?? ep?p????? t?? pe???????? a?a?s??s?a? de? e??a?
  s????? sta pa?d??
• µ?s? s??????? s????t?ta 0.12, CI 95
  (0.090.17)
• ?µfa?????ta? p?? s???? sta ß??f? lt6 µ????
  s?????t??? µe ta µe?a??te?a pa?d??
• (0.4 vs 0.1)
• ?? ??? pa???s?????? µ????te?? s????t?ta ep?p?????
  s?????t??? µe t??? ?e?t?????? ap???e?sµ??? (6
  f???? µ????te??)
• ?? ep?p????? t?? ??? µp??e? ?a s?et????ta? µe
• ? t?? te????? (t?a?µat?sµ?? ?e????, a?µ?t?µa,
  p?e?µ????a?a?)
• ? t??? ?a?et??e? s??e???? ????s??
• ? t?? t?????t?ta t?? t?p???? a?a?s??t????

Epidemiology and morbidity of regional
anesthesia in children a follow-up one-year
prospective survey of the French-Language
Society of Pediatric Anesthesiologists
(ADARPEF). Pediatr Anesth 2010 20106110
9
?fa?µ??? ??? sta pa?d??
??????T?S??S ?SF?????S

• ?at??????? e??p??sµ??
• ?pa???? monitoring
• ??pa?de?s? ?µpe???a
• G??s? t?? a?at?µ???? - f?s????????? -
  fa?µa????????? d?af????

Safety in pediatric regional anesthesia.
Pediatric Anesthesia 2012 22 2530
10
??at?µ???? F?s????????? d?af???? sta pa?d??

• Sta ß??f? ?a? µ???? pa?d??
• ?te??? µ?e????p???s?
• ?e?????? ??e? e??a? ?ept?te?e? µe µ????te??
  µ????
• ?????te?? ap?stas? µeta?? ??µß?? Ranvier
• ? ?? ?NA ep?t???????ta? ta??te?a ?a? p????ste?a
• Sta ß??f?
• ?te??? a??pt??? t?? e?d??e????? ? ?
  d?ape?at?t?ta t?? t?p???? a?a?s??t???? ??? p???
  t?? d?? ?ate????se??
• ? ? ?e?????? ap???e?sµ?? e??a??stata? p?? ??????a
  a??? d?a??e? ????te??
• ?? pe??t???e? e??a? ?ept?? ? ? a?s??s? ap??e?a?
  t?? a?t?stas??

11
Fa?µa????????? d?af???? sta pa?d??

• ?? fa?µa????????? d?af???? sta pa?d?? af?????
  pe??ss?te??
• ta ?e???? ?a? ta ß??f?

Toxicity of local anesthetic drugs a pediatric
perspective. Paediatr Anaesth 20122239-43
12
??s?????a t?p???? a?a?s??t???? (??) se ??? sta
pa?d??
???pe? ?a s???p????????ta? mg/kg ?a? OXI MONON
ml/kg

• ????st? ef?pa? d?s?
• ?e???? ???f? 2 mg/kg
• ?a?d?? 2.5 mg/kg
• ? ?d?a d?s? s???st?ta? ??a ???e ??a ap? ta t?p???
  a?a?s??t???
• bupivacaine, levobupivacaine, ropivacaine

Safety in pediatric regional anesthesia.
Pediatric Anesthesia 2012 22 2530
13
?fa?µ??? ??? sta pa?d??

• S???st?ta?
• ?a ???s?µ?p?????ta? short beveled needles.
• ???ta t??p?te t? d??µa a?asp??ta? t?, ??a ?a µ??
  ???eta? ? a?s??s? t?? ?p??e?µe??? pe??t???a?.
• ?p?????sµ?? ????? ?a? µ???st?? d?s?? t?? t?p????
  a?a?s??t????.
• ??ade?a ????s? t?p???? a?a?s??t???? s????
  a?a???f?s?.
• G??s? a?at?µ???? ?d???? s?µe???.
• ???s? ?e???d?e???t? (??? µ?????as?)
• (???s?µ?p????µe 1-1.2 mAmps µ???? ?a ??ß??µe
  µ???? ap??t?s? ? e??tt?s?
• 0.2-0.5 mAmps e?? s??e???e? ? ap??t?s? ?
  ????s? t?p???? a?a?s??t????)
• ???s? ?pe?????

14
??? sta ?a?d?? ???s? ?pe?????

• ? ?pe??????af??? ape?????s? t?? ?e???? sta pa?d??
  e??a? ?????? p???t?ta?, d??t? ta ?e??a ß??s???ta?
  p?? ep?fa?e?a?? se s??s? µe t??? e?????e?
  ep?t??p??ta? t? ???s? ?????te??? s????t?ta?
  µetat??p??? (probes).
• ? S????t?ta 8-14 MHz
• ? ????? pa?d?? 25 mm
• ? ?e???a pa?d?? 38 mm

Interest of ultrasonographic guidance in
paediatric regional anaesthesia.  Ann Fr
Anesth Reanim. 200928878-84
15
?e??fe????? ?e?????? ?p???e?sµ?? (???)sta ?a?d??
???s? ?pe?????

• ? ???s? ?pe????? ??a t?? ep?t??es? ??? sta
  pa?d??
• ? t? p?s?st? ep?t???a?
• ep?ta???e? t?? ??a??? d??s??
• ? t?? apa?t??µe?? ???? t?? t?p???? a?a?s??t????
• ? t?? asf??e?a ? e?att??e? t?? ep?pt?s? t??
  µa????? e?da??e?a??? ????s??
• ?
  pe??????e? t?? ???d??? t?a?µat?sµ?? t?? ?e????
• Evidence-based medicine Assessment of
  ultrasound imaging for regional anesthesia in
  infants, children,
• and adolescents. Reg Anesth Pain Med 201035(2
  Suppl)S47-54
• The use of ultrasound for nerve block in
  children seems beneficial. Ugeskr Laeger.
  20111732257-61

16
?e??fe????? ?e?????? ?p???e?sµ?? (???)sta ?a?d??
???s? ?pe?????

• Sta pa?d?? sta ß??f? s???st?ta? ? ???s?
  ?pe????? ??a t?? ep?t??es? ap???e?sµ?? t??
  ???µ??.
• Ultrasound-guided trunk and core blocks in
  infants and children.
• J Anesth 201327109-23

17
?. ?p???e?sµ?? ß?a??????? p???µat??

• ? µas?a??a??? ap???e?sµ?? t?? ß?a???????
  p???µat?? ap?te?e? t? s????te?? p??sp??as? t??
  ß?a??????? p???µat?? sta pa?d?? ?a? s???st?ta? se
  epeµß?se?? t?? ??? ????? (s??da?t???a,
  e?ada?t???a, e?te??ass?µe??? a?t??e??a?, µetaf???
  te???t??, ....).
• ??S???G??
• ? ???????µe?a ??p??? ??a?s??t???
• ß??p?ßa?a??? ? ?eß?ß??p?ßa?a??? 0.25 0.5 ?
  ??p?ßa?a??? 0.2-0.5
• ? ??s? 0.3-0.5 mL/kg, max 17.5 mL
• (max dose 2.5 mg/kg, ?e???? ???f? 2 mg/kg)
• ?p?p?????
• ? ???d???? a?µat?µat??
• ? ??? pa?at????e? t??s? t?? µas?a??a?a? a?t???a?
  s???st?ta? efa?µ??? sta?e???
• p?es?? t??????st?? ??a 5 minutes, ?ste ?a
  ap?t?ape? ? s??µat?sµ?? a?µat?µat??.

18
?. ?p???e?sµ?? ß?a??????? p???µat??
? ????f?s? µas?a??a?a? a?t???a? ?a? p?????s? t??
ße????? t?? ?e???d?e???t?? p??? ap? t?? a?t???a
µe ????a 30-45 µ???e? p??? t? µ?s? t?? ??e?da?. ?
?p??e? ?a ?p???e? a?s??s? pop ?a??? d?ape???ta?
t? µas?a??a?? ???t??. ? Se ????t??? ap??t?s? t??
???a? ?e???? se ?e???d???e?s? 0.4 mA, e???eta? t?
?.?. ? ?? µ??de?µat??? ?e??? ap???e?eta? µe ?µes?
e?s?d? t?? ße????? st? ?ast??a t??
???a??ß?a??????? µ??? ?a? ep?ßeßa???eta? µe t??
p???a???µe?e? s?sp?se?? t?? d??ef???? µ???.
19
?. ?p???e?sµ?? ß?a??????? p???µat??

• S???st?ta? ? ???s? ?pe??????af???? ?a??d???s??

Axillary approach to the brachial plexus AA,
axillary artery MN, median nerve UN, ulnar
nerve RN, radial nerve MCN, divided
musculocutaneous nerve
Ultrasound-guided upper extremity blocks - tips
and tricks to improve the clinical practice.
Paediatr Anaesth 20122265-71
20
?. ?p???e?sµ?? ????a??? ?e????

• ??de????ta? ??a
• ??a???s?a t?? µe?a??te??? tµ?µat?? t?? µ???? se
  epeµß?se?? p??? ap? t? ???at?.
• ??a???s?a t?? ?s? ep?f??e?a? t?? ?ast?????µ?a?
  ?a? t?? ast?a?????.
• ß??p?ßa?a??? ? ?eß?ß??p?ßa?a??? 0.25 0.5 ?
  ??p?ßa?a??? 0.2-0.5
• ? 0.5 mL/kg, max 20 mL
• (max dose 2.5 mg/kg, ?e???? ???f? 2
  mg/kg)
• ?p?p?????
• ? ???d???? a?µat?µat??
• ? ??? pa?at????e? t??s? t?? µ???a?a? a?t???a?
  s???st?ta? efa?µ??? sta?e??? p?es??
• t??????st?? ??a 5 minutes, ?ste ?a ap?t?ape?
  ? s??µat?sµ?? a?µat?µat??.

21
?. ?p???e?sµ?? ????a??? ?e????

• ?pt?a ??s?
• ??s?d?? ße???a? ???eta st? ?d??? s?µe??
• 0.5 1 cm ??t??e? t?? ß??ß?????? s??d?sµ??
• 0.5 1 cm ep? ta e?t?? t?? µ???a?a? a?t???a?
• 2 clicks
• 1 ?ta? d?ape???ta? ? p?at?? pe??t???a
• 2 ?ta? d?ape???ta? ? ?a?????? pe??t???a
• ????? t?? ep????at?da? sa? ????t??? ap??t?s?
  st? ?e???d???e?s?.

22
?. ?p???e?sµ?? ????a??? ?e????

• S???st?ta? ? ???s? ?pe??????af???? ?a??d???s??

Ultrasound guided lower extremity blocks.
Paediatr Anaesth 20122272-80
23
?. ?p???e?sµ?? ????a??? ?e????
Femoral nerve (FN), femoral artery (FA), femoral
vein (FV)
24
?. ?p???e?sµ?? t?? ??aµe??sµat?? t?? ?a????a?
?e??t???a?

• T?s? ?pt?a.
• ??s?d?? ße???a? ???eta 0.5 1 cm ??t??e? t??
  s?µe??? ???s?? t?? ??? 1/3 µe ta ?s? 2/3 t??
  ??aµµ?? t?? ß??ß?????? s??d?sµ??.
• 2 clicks
• 1 ?ta? d?ape???ta? ? p?at?? pe??t???a
• 2 ?ta? d?ape???ta? ? ?a?????? pe??t???a
• (a??????e? a?s??s? ap??e?a? t?? a?t?stas??)
• ????? ?? 0.5 -1 ml/kg, max 25 ml
• (max dose 2.5 mg/kg, ?e???? ???f? 2 mg/kg)
• ?p?t???a
• ? µ???a?? ?. 100
• ? p????? µ???de?µat??? ?. 90
• ? ????e?d?? ?. 80

25
?. ?p???e?sµ?? ?s??a??? ?e????

• ??de????ta? se epeµß?se?? t?? ?p?s???? µ????, t??
  p????a? ep?f??e?a? t?? ???µ??, t?? ast?a????? ?a?
  t?? ????? p?d??.
• ???s?µ?p?????ta? d??f??e? p??spe??se?? t??
  ?s??a??? ?. sta pa?d??
• (??????, ? ?p?s??a ? p????a p??sp??as?)
• ????? ?? 0.7-1 ml/kg, max 27.5 ml
• (max dose 2.5 mg/kg, ?e???? ???f? 2 mg/kg)
• ?p?p?????
• ? ???ß? ?e????
• ? ?p??????? s?µe??? s??d??µ?? d?aµe??sµat??

26
?. ?p???e?sµ?? ?s??a??? ?e????

• ???ST?? ???S????S?
• modification of Labats technique developed by
  Dalens and others (1990)
• ??a??a ??s?
• ??d? se ????a 90 µ?????
• ??s?d?? ße???a? ???eta st? µ?s?? µeta?? ???a???
  ????? ???????? µe????a t???a?t??a

27
?. ?p???e?sµ?? ?s??a??? ?e????

• ???ST?? ???S????S?
• the Raj block was developed in 1975
• ?pt?a ??s?
• ??d? s???µ??? ?a? ????sµ??? st? ?s??? st?
  ???at?
• ??s?d?? ße???a? ???eta st? µ?s?? µeta?? ???a???
  ?s??a??? ???t?µat?? µe????a t???a?t??a
• ??de????ta? se pa??sa??a pa?d?? se ef?ß???.

28
?. ?p???e?sµ?? ?s??a??? ?e????

• ???G?? ???S????S?
• Sta pa?d?? ? p????a p??sp??as? t?? ?s??a???
  ?e???? ap?te?e? t?? e?????te?? ?a?
• asfa??ste?? te?????. B. Dalens, A. Tanguy, G.
  Vanneuville. Anesthesia and Analgesia 1990.

29
?. ?p???e?sµ?? ?s??a??? ?e????
S???st?ta? ? ???s? ?pe??????af???? ?a??d???s??
F femur SN sciatic nerve
Sciatic nerve block lateral approach (Probe and
needle position)
Ultrasound guided lower extremity blocks.
Paediatr Anaesth 20122272-80
30
?. ?p???e?sµ?? st?? ????a?? ?????

• S??????, se p?a??a ? p???? ??s?
• ??d?a se ????a 30 µ?????
• ??s?d?? ße???a? st? d??asµ? t?? ?s??a??? ?e????
  se ????? pe????a?? ?a? ???µ?a?? ?e??? (µe
  ?efa???? ?ate????s?, ?p? ????a 45 µ?????)
• ?d??? S?µe?a
• ??? ????a t?? ????a??? ß?????
• ep? ta e?t?? t?? ????a??? a?t???a?
• p????a t?? µ?s?? ??aµµ?? t?? ????a??? t???????
• ?a ?e??a p??e???ta? se ß???? 7-18 mm ap? t? d??µa
  
• ????e?s? ?????? pe????a??? ?. ? ?a??a?a ??µ??
  t?? p?d??
• ????e?s? ???µ?a??? ?. ? pe?µat?a?a ??µ?? t??
  p?d??
• ????? ?? O.3 0.5 ml/kg, max volume 12 ml
• (max dose 2.5 mg/kg, ?e???? ???f? 2
  mg/kg)

31
?. ?p???e?sµ?? st?? ????a?? ?????

• ? ap?stas? ap? ????a?? pt??? s?µe?? e?s?d??
  ße???a? ?p??????eta? ß?se? t?? ß????? s?µat??.
• ?Slt10 kg ap?stas? ? 1 cm
• ?S 10 - 20 kg ap?stas? ? 2 cm
• G?a ???e a???s? ?at? 10 kg t?? ?S
• ? p??pe? ? ße???a ?a µeta???e?ta? ?efa???? st?
  ????a?? t?????? pe??p?? ?at? 1 cm
• (Konrad and Johr, 1998)

32
?. ?p???e?sµ?? ?a????ß??ß??????
?a?????p???st???? ?e????

• ??de????ta? se epeµß?se?? ß??ß????????,
  ????????a?, ?d???????
• ??at?µ?a
• ?a 2 ?e??a p???????ta? ap? t? ?sf???? p???µa
  (T12-?1)
• ?a? ?e?t??ta? µeta?? t?? ?s? p?????? ?a? t??
  e????s??? ?????a??? µ??? st? ep?ped? t?? p??s??a?
  ??? ?a????a? ??a??a? (????)
• ?pe??????af???? µe??te? sta pa?d?? de?????? ?t?
• ?a ?e??a ß??s???ta? p??s??ste?a st?? ????,
• ap? ?t? ?? pa?ad?s?a??? te?????? ?p??eta?
• ? µ?s? ap?stas? ?e????- pe??t??a??? e??a? 3-7 mm

33
The relative position of ilioinguinal and
iliohypogastric nerves in different age groups of
pediatric patients. Acta Anaesthesiol Scand 2010
May54566-70.

• ?e?et????a? ?pe??????af??? 200 pa?d??
• (probe t?p??et????e se µ?a fa?tast??? ??aµµ?,
• ? ?p??a s???dee t?? ???? µe t?? ?µfa??).
• ?????a 1-82 µ??e?.
• ??a????st??a? se 3 ?µ?de?
• lt12 µ???? (n84)
• 12-36 µ??e? (n80)
• 37-82 µ??e? (n36)
• ?e?et????a? ?? ap?st?se??
• ???? ?G? (?G? ?a????ß??ß????? ?e???)
• ???? ?G? (?G? ?a?????p???st??? ?e???)
• ?G? ?G?
• ?????-?G?
• ?????-?G?
• ?G?-?e??t??a??

34
The relative position of ilioinguinal and
iliohypogastric nerves in different age groups of
pediatric patients. Acta Anaesthesiol Scand 2010
May54566-70
?? ap?st?se?? ???µa - ?G?, ???µa - ?G?, ?G?
?e??t??a??, ?G? - ?e??t??a?? ? ?ta?
pa??µ??e? ?a? st?? 3 ?µ?de?
35
?. ?p???e?sµ?? ?a????ß??ß??????
?a?????p???st???? ?e????

• ??p???t?s? pa?d??? se ?pt?a ??s?.
• ??????µe t? ??aµµ? p?? s??d?e? t?? ???? µe t??
  ?µfa??.
• ?? d?a???????µe se t??a µ???.
• S?µe?? e?s?d?? ße???a? t? s?µe?? ???s?? t?? ???
  t??t?µ????? µe ta ?s? 2/3.
• ??s??s? e??? pop ?a??? ? ße???a d?ape??? t???
  p??????? µ??.
• ????s? t?? d?a??µat?? t?? t?p???? a?a?s??t????
  µet? ap? p??se?t??? a?a???f?s?.
• ???s?µ?p??e?ta? at?a?µat??? ße???a 22 ? 25 G.

36
?. ?p???e?sµ?? ?a????ß??ß??????
?a?????p???st???? ?e????

• ??s?????a
• Ropivacaine 0.2 ? ?eß?ß??p?ßa?a???
  0.25
• se d?s? 0.25 0.5 mL/kg e????µe?a
  ß?ad???.
• (max dose 2.5 mg/kg, ?e???? ???f? 2
  mg/kg)
• ?p?p?????
• ?p???e?sµ?? µ???a??? ?e???? se p?s?st? 11.
• ???s? e?t???? (Johr Sossai1999, Amory et
  al2003, Frigon2006).
• S???st?ta? ? ???s? ?pe?????.

Pediatric regional anesthesia abdominal wall
blocks. Paediatr Anaesth 20122288-92
37
?. ?p???e?sµ?? ?a????ß??ß??????
?a?????p???st???? ?e????

• ?e t?? ?pe??????af??? ?a??d???s? ß?????e
• ? ta??te?? ap????f?s?
• ? ?????te?? s?????t??s? st? p??sµa t??
  ??p?ßa?a????
• Ultrasound versus landmark-based technique for
  ilioinguinal-iliohypogastric nerve blockade in
  children the
• implications on plasma levels of ropivacaine.
  Anesth Analg 2009 108 14881492
• ?e t?? pa?ad?s?a?? te????? t? 85 t?? t?p????
  a?a?s??t???? ?????e?ta? e?d?µ????
• Ilioinguinal/iliohypogastric blocks in children
  where do we administer the local anesthetic
  without direct
• visualization? Anesth Analg 2008 106 8993
• ?pa?te?ta? e??tt?s? t?? ???????µe??? d?s??,
  ?ta? ???s?µ?p??e?ta? ?pe??????af?a

38
?. ?p???e?sµ?? ?a????ß??ß??????
?a?????p???st???? ?e????

• ????????S??S
• Se epeµß?se?? ????????a?
• ?ta? ep?te?e?ta? ?aµ??? t?µ? st? ?s?e?, p??pe? ?a
  s?µp?????eta? ? ?e?????? ap???e?sµ?? t??
  ?a????ß??ß?????? ?a?????p???st???? ?e???? µe
  d????s? t?? t?µ?? ? µe a?d????? ?e?????
  ap???e?sµ?.
• ?? ß???? a?a?s??s?a? p??pe? ?a a????eta? µ???? ?a
  ???????????? ?? ?e???sµ?? t?? pe??t??a???, t??
  spe?µat???? p???? ?a? t?? ???e??, d??t? ?
  e?e??sµ?? ap? t??? ?e???sµ??? de? ?a??pteta? ap?
  t?? ?e????? ap???e?sµ? t?? ?a????ß??ß??????
  ?a?????p???st???? ?e????.

39
Transversus Abdominis Plane Block

• Ta te?e?ta?a ?????a pa?at??e?ta? a???µ???
  efa?µ??? t?? ap???e?sµ?? st?
• ep?ped? t?? e????s??? ?????a??? µ??? ? Transverse
  abdominal plane (TAP) block
• Ipsilateral transversus abdominis plane block
  provides effective analgesia after appendectomy
  in children a
• randomized controlled trial. Anesth Analg.
  2010111998-1003
• Ultrasound guided transversus abdominis plane
  block in infants, children and adolescents a
  simple procedural
• guidance for their performance. Paediatr Anaesth
  2009 19296-299
• Ultrasound-guided bilateral transversus
  abdominis plane block in a 2-month-old infant.
• J Anesth 2009 23643-644
• Ultrasound-guided transversus abdominis plane
  block for neonatal abdominal surgery.
• Anaesth Intensive Care 2009 37469-472
• Ultrasound-guided transversus abdominis plane
  block for reversal of ileostomy in a 2-kg
  premature neonate.

40
Transversus Abdominis Plane Block
Transversus Abdominis Plane Block
? ????s? t?? t?p???? a?a?s??t???? ???eta? µeta??
t?? e????s??? ?a? t?? ?s? ????? ?????a???
µ???, ?p?? p??e???ta? ??e? (T6-?1) p?? pa??????
a?s??t???t?ta st? p??s??? ?a? p????? ?????a??
t????µa
41
Transversus Abdominis Plane Block

• Surface anatomy of the 'Petit' triangle
• LD lattisimus dorsi muscle
• EO external oblique muscle

42
Ipsilateral transversus abdominis plane block
provides effective analgesia after appendectomy
in children a randomized controlled trial.
Anesth Analg. 2010111998-1003

• 22-gauge 25-mm or 50-mm at?a?µat??? ße???a
  pe???????? a?a?s??s?a? (Plexufix B.Braun,
  Germany)
• ?? pa?d? t?p??ete?ta? se ?pt?a ??s? (? ?at??? p??
  efa?µ??e? t?? ap???e?sµ? st??eta? st?? a?t??et?
  p?e???)
• ???af?ta? t? t?????? t?? Petit
• (µeta?? p??s???? ?e????? t?? p?at?
  ?a??a??? µ?, ?p?s???? ?e????? ??? p?????? ?a?
  ?a?????? a?????f?a?)
• ??s?d?? st? d??µa ?a? p?????s? t?? ße???a? ?p?
  (??) ????a µe t? µet?p?a?? ep?ped? µ???? t?? 1?
  a?s??s? a???µ???? a?t?stas?? (pe??t???a ???
  p??????).
• ???se?t??? p?????s? t?? ße???a? µ???? t?? a?s??s?
  ap??e?a? t?? a?t?stas?? ?a??? ? ße???a
  e?s???eta? a??µesa st?? pe??t???e? t?? ??? ?a?
  t?? ?s? p?????? µ?.
• ?e?a?t??? p?????s? µ???? t?? 2? a?s??s?
  a???µ???? a?t?stas?? ?a? t?? epa???????? ap??e???
  t??
• (e?s?d?? st? ?AP).
• ???se?t??? a?a???f?s? ??a ?a ap???e?s?e? ?
  e?da??e?a?? ????s?.
• ????s? 1 ml d?a??µat??. ??? pa?at??e?ta? ?
  a?t?stas? ? ????? ??s? ? ??a p??sp??e?a
  e?t?p?sµ??
• ??s?????a 0.3 mL/kg ropivacaine 0.75
  (???gt 2 - 2.5 mg/kg S???????? ????? ???
  gt20 ml)

43
Suresh S, Chan VW. Ultrasound guided transversus
abdominis plane block in infants, children and
adolescents a simple procedural guidance for
their performance. Paediatr Anaesth 200919296-9

• (5-10 mHz) ultrasound probe
• St? µ?s?? t?? ap?stas?? ?a?????? a?????f?a
  ?at?te?? p?e????? ?e????
• ??a?????s? t?? 3 µ????? st?ß?d??
• ????s? 1 ml d?a??µat?? ??a ep?ßeßa??s? t?? s?st??
  ??s??
• ?????µa bupivacaine 0.25 µe 1200.000
  epinephrine
• ??s?????a 0.4 mL/kg
• ??? gt 2 mg/kg S???????? ????? ???
  gt20 ml

• Ultrasound view after 1 ml injection of local
  anesthetics.
• S skin
• SC subcutaneous tissue
• EOM external oblique muscle
• IOM internal oblique muscle
• TAM transverse abdominis muscle
• P peritonial cavity

44
?e???? ?e?????? ap???e?sµ??

• ? ß?s? t?? p???? ?e????ta? ap? t? ?a????ß??ß?????
  ?a? t? µ????e???t??? ?e???.
• ?a ?a??a?a ?e??a t?? p???? (?2-4) ?e??????? t?
  ?p????p? p???.
• ?a ?a??a?a ?e??a t?? p???? pe????? ??t? ap? t??
  ?ß??? ???d? µ?sa st? ?p??ß??? d??st?µa.
• ?? ?p??ß??? d??st?µa d?a?????eta? µe t??
  ??eµast??a s??desµ? se a??ste?? ?a? de???
  d?aµ???sµa.
• ?? p??s??? ???? t?? ?p??ß???? d?ast?µat??
  s??µat??eta? ap? t?? pe??t???a t?? Scarpa.
• ?? ?a??a?e? a?t???e? t?? p???? ?a? ?? ep?p????
  e? t? ß??e? f??ße? ß??s???ta? st? µ?s? ??aµµ?. ?a
  ?a??a?a ?e??a t?? p???? p??e???ta? st? p??? t??
  a??e???.
• ?e???? ?e?????? ap???e?sµ??
• ??de????ta? se epeµß?se?? f?µ?s?? d?????s??
  ?p?spad?a.
• ?p?p????? ? a?µ?t?µa
• ?pa???e?eta? ? ????s? ad?e?a?????.
• ? ???????
• ?p??ß??? p??sp??as?
• ? ???????
• ?p?d???? ring block

45
?e???? ?e?????? ap???e?sµ??

• ?? ???????
• ?p??ß??? p??sp??as?
• ????s? st?? ?p??ß??? ???a
• ?pt?a ??s?
• ??t?p?sµ?? µ?s?? ??aµµ?? ?ß???? s?µf?s?? (?G?S)
• ??s?d?? ße???a? 0.5 -1 cm p?a???? t?? ?G?S s?ed??
  ???eta (???? ???a?a p??? ta µ?sa)
• ??t??? pop µ???? ? ße???a d?ape??se? t??
  pe??t???a t?? Scarpa se ß???? 8-30 mm.
• ?? ß???? e?s?d?? e??a? a?e???t?t? t?? ?????a? ?
  t?? ß?????.
• ?p?s????µe t? ße???a ??? ??t? ap? t? d??µa ?a?
  t?? epa?a?ate??????µe st?? ???? p?e???.

46
?e???? ?e?????? ap???e?sµ??
? ???????

• ?p??ß??? p??sp??as?
• ??s?????a
• 0.25 ?eß?ß??p?ßa?a??? 0.1 ml/kg se ???e
  p?e???, max 5 ml se ???e p?e???
• ??e????t?µa e?att??eta? ? p??a??t?ta ß??ß?? t??
  ?e????, t?? a??e??? ?a? t?? s??a???d??? s?µat??

47
?e???? ?e?????? ap???e?sµ??
? ???????

• Penile block - Subcutanous ring block
• ?????te?? d????s? t?p???? a?a?s??t???? µe
  at?a?µat??? ße???a st? ß?s? t?? p????.

48
S??e?e?? ?.?.?. sta pa?d??

• S?????? efa?µ??eta? se ß?a??????, µ???a??,
  ?s??a?? ? ?. ap???e?sµ? st?? ????a?? ß????.
• ? ?a?et??a? p????e?ta? 3-4 cm p?? µ?sa ap? t??
  ???? ße???a?.
• S???st?ta? ? ???s? t?? ?pe?????
• ??s?????a 0.1 - 0.2 mL/kg/hour (bupivacaine ?
  levobupivacaine 0.125 - 0.25 ? ropivacaine 0.1
  -0.2)

Peripheral catheter techniques. Paediatr
Anaesth 20122293-101
49
S??e?e?? ?.?.?. sta pa?d??

• ??s?????a 0.1 - 0.2 mL/kg/hour
• bupivacaine ? levobupivacaine 0.125 - 0.25 ?
  ropivacaine 0.1 to 0.2
• S???st?µe?e? maximum d?se?? ??a S??e?e?? ??? sta
  pa?d??
• ?e???? ???f? lt 6 µ???? 0.2 mg/kg/h
• ?a?d?? 0.4 mg/kg/h
• ? ? ?d?a d?s? s???st?ta? ??a ???e ??a ap? ta
  a??t??? t?p??? a?a?s??t???

Continuous peripheral nerve blocks for
postoperative analgesia in children feasibility
and side effects in a cohort study of 339
catheters. Can J Anaesth 200956843-50
50
? ????????? ????ST?S?? S?? ??????

• Pediatric Regional Anesthesia Network (PRAN)
• a multi-institutional study of the use and
  incidence of
• complications of pediatric regional anesthesia.
• Departments of Anesthesiology and Pediatrics,
  Children's Hospital Colorado, USA
• Anesth Analg 20121151353-64

51
? ????????? ????ST?S?? S?? ??????

• ????pt??? µe??t? ? 4/2007 - 3/2010
• 13725 pa?d??
• 14917 ?e?t????? pe??fe????? ap???e?sµ?? ?p?
  ?e???? a?a?s??s?a
• (95 t?? ap???e?sµ?? ?p? ?e????
  a?a?s??s?a)
• ?e?t????? ap???e?sµ?? 65 (40 ?
  Single-injection caudal blocks)
• ?e??fe????? ap???e?sµ?? 35
• (83 ??? ??? ????? 69 ??? ??t? ????? µe US
  ?a??d???s?)
• ? p?s?st? ep?p?????
• ?a???a? ???at??
• ?aµ?a ep?p???? µe d????e?agt 3 µ??e?
• ????te?a s?µß?µata st??? single-injection ??? vs
  s??e?e?? ???
• 33 t?? s?µßaµ?t?? st??? s??e?e?? ??? ?
  p??ß??µata t?? ?a?et??a

Anesth Analg 20121151353-64
52
?e??fe????? ?e?????? ?p???e?sµ?? sta pa?d??

• ?? pe??fe????? ?e?????? ap???e?sµ?? ? p???t?µ?
  e??a?e?? sta ????a t?? pa?d?a?a?s??s???????

Anesth Analg 20121151353-64
Epidemiology and morbidity of regional
anesthesia in children a follow-up one-year
prospective survey of the French-Language
Society of Pediatric Anesthesiologists
(ADARPEF). Pediatr Anesth 2010 20106110
53
Oh pain, pain, go awayGo ruin someone elses day
! Rivian Bell