الفهرس 
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Abstract
Since the development of pediatric regional anesthesia in the early 1900s, there has been progression in techniques, equipment, and knowledge. This is especially true after renewed interest in the field since the 1980s. We have touched on the majority of pediatric regional anesthesia that is commonly practiced today and the role of ultrasonography.
Adequate knowledge of the anatomy of the area along with appropriate indications and knowledge of complications will facilitate the use of peripheral nerve blocks in children. Pediatric practitioners are now utilizing regional anesthesia in all anatomical areas to provide a minimally painful surgical experience to their patients.
The fear of use of peripheral nerve blocks in children under general anesthesia is not unfounded but techniques with the use of ultrasound technology can facilitate better placement of nerve blocks.
Regional anesthesia, with or without general anesthesia, offers multiple benefits compared with general anesthesia alone. These benefits include reductions in morbidity and mortality, superior postoperative analgesia, and enhanced cost-effectiveness.
When properly performed, regional anesthesia is a safe, clinical practice with risk profiles similar to general anesthesia. The availability of better equipment and safer local anesthetic agents has also improved the safety of regional anesthetic techniques.
There is a lot of benefits of regional anesthesia in children which include hemodynamic stability and a reduction in minimum alveolar concentration, less need for muscle relaxants, the absence of respiratory depression with some evidence of respiratory stimulation, less need for postoperative ventilatory support after major surgery (particularly thoracotomy), an earlier return of gut function and subsequent feeding, enhanced suppression of the metabolic stress response and less immunodepression, in addition to the economic benefits of a shorter intensive care unit and hospital stay.
Despite its well-known benefits, clinical failures can occur during the application of regional anesthetic technique. Neurovascular anatomy is highly variable, and currently available nerve localization techniques provide little or no information regarding the anatomical spread of local anesthesia; furthermore, traditional nerve localization techniques (nerve stimulation) rely on anatomical assumptions that may be incorrect.
Recently, the use of ultrasonography has led to an increased number of blocks being performed in pediatric patients due to increased visibility of both needle location and surrounding structures, Lower dose of local anesthetics are required for a given block due to deposition of local anesthetic at the site of the nerve. Compared to nerve stimulator or anatomic landmark techniques, the use of ultrasound has several advantages including Shorter block performance time, Higher success rate, Shorter onset time, longer block duration and increase visibility of neuraxial structures.
A balance between the efficacy of an anesthetic block and patient safety remains a major challenge for pediatric regional anesthesia. Ultrasound guidance is the main tool we have at our disposal and we need to disseminate the need for this fundamental technique.
In order to prolong the duration of analgesia without increasing the dose of local anesthetic and the possible risk of toxicity, multimodal analgesia can be adopted which involves the administration of adjuvants like Epinephrine (adrenaline), Morphine and its related drugs, Clonidine are the most commonly used adjuvants in children.
Complications with ultrasound guidance are rare: the most frequent is the execution of an inadequate block; less frequent is nerve damage, which can be caused by a blunt needle of the correct size, but also by pressure injection of local anesthetic. A high injection pressure means that the needle is in an intraneural position, with high risk of severe and/or persistent neurological injury.
Complications of pediatric regional anesthesia must not be underestimated even though their overall incidence is low. Most of these adverse effects can be prevented by a sound evaluation of the patients preoperatively, safe selection of the techniques and block needle.
Some complications cannot be avoided but their potentially detrimental consequences can be attenuated or even prevented by early detection and adequate emergency management of the patient. If these safety precautions are strictly followed and the postanesthetic follow up of the patient is adequate, the overall morbidity rate compares very favorably with that of general anesthesia with parenteral administration of opioids.