Practice advisory on the prevention and management of complications of pediatric regional anesthesia

Study objectives: To develop evidence-based recommendations for prevention and management of infections, bleeding, and local anesthetic toxicity in children undergoing regional anesthesia. Design: A joint committee of the European Society of Regional Anesthesia and Pain Therapy (ESRA) and the American Society of Regional Anesthesia and Pain Medicine (ASRA) studied electronic literature databases of pediatric regional anesthesia to construct evidence-based recommendations. Main results: For epidural anesthesia lumbar or thoracic placement is preferred. Skin preparation prior to block placement with chlorhexidine is preferred to povidone iodine. A tunneled catheter technique is suggested when using the caudal route or if the epidural catheter placement is kept in situ for more than 3 days. Inspection of the epidural catheter insertion site should be performed at least once a day as part of the postoperative management. When medical and physical examination is normal, coagulation tests are usually unnecessary but if coagulation tests are abnormal, neuraxial and deep peripheral nerve blocks are contraindicated. For patients receiving Low Molecular Weight Heparin thromboprophylaxis, a safety interval of two half-lives plus the time required for heparin to reach maximal levels is considered an adequate compromise between bleeding risk and thrombosis risk when removing epidural catheters. Ultrasound-guided peripheral nerve blocks reduce the risk of vascular puncture and thus the risk of local anesthetic toxicity is reduced. Conclusions: In children undergoing regional anesthesia the incidence of infection, hematoma, and local anesthetic toxicity is low. The ASRA/ESRA joint committee proposes a practice advisory to prevent and treat these complications.