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An Ounce of Prevention Is Worth a Pound of Cure: Regional Anesthesia in Children

Section Editor(s): Saidman, LawrenceGurnaney, Harshad MBBS; Stricker, Paul MD; Ganesh, Arjunan MBBS

doi: 10.1213/ane.0b013e31818fa416
Letters to the Editor: Letters & Announcements

Department of Anesthesiology and Critical Care Medicine; The Children’s Hospital of Philadelphia and University of Pennsylvania School of Medicine; Philadelphia, Pennsylvania;

Dr. Malinovsky does not wish to respond.

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To the Editor:

We commend Ludot et al. on the use of 20% lipid solution to successfully resuscitate a 13-year-old patient after local anesthetic toxicity was diagnosed.1 Although the authors discuss the importance of prompt resuscitation, very little was mentioned about prevention and we have several concerns regarding the choices made for regional analgesia in this patient. First, a lumbar plexus block was utilized for a patient undergoing meniscectomy. A femoral nerve block has been shown to be appropriate for intra and postoperative analgesia in patients who undergo procedures on the knee.2 Lumbar plexus block has a greater incidence of complications (as the authors state) than femoral nerve block and is technically more challenging to perform.3

Second, because this patient also received a general anesthetic, it was not necessary to use the large amount of local anesthetic (0.375% ropivacaine in addition to 0.5% lidocaine) to obtain intraoperative and postoperative analgesia. We now routinely perform a femoral nerve block (with ultrasound guidance enabling us to use lower volumes4) using ropivacaine 0.15% to 0.2% (with or without clonidine 1 mcg/kg) for this procedure (usually performed as a day surgery procedure).5 A reduced dose of the ropivacaine could have decreased the likelihood of local anesthetic toxicity in this instance.

In conclusion, we believe that by using an appropriate dose (concentration and volume) of local anesthetic and by selecting regional anesthesia techniques associated with lower risk of complications, one can decrease the incidence of local anesthetic toxicity.

Harshad Gurnaney, MBBS

Paul Stricker, MD

Arjunan Ganesh, MBBS

Department of Anesthesiology and Critical Care Medicine

The Children’s Hospital of Philadelphia and University of Pennsylvania School of Medicine

Philadelphia, Pennsylvania

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1. Ludot H, Tharin JY, Belouadah M, Mazoit JX, Malinovsky JM. Successful resuscitation after ropivacaine and lidocaine-induced ventricular arrhythmia following posterior lumbar plexus block in a child. Anesth Analg 2008;106:1572–4
2. Kaloul I, Guay J, Cote C, Fallaha M. The posterior lumbar plexus (psoas compartment) block and the three-in-one femoral nerve block provide similar postoperative analgesia after total knee replacement. Can J Anaesth 2004;51:45–51
3. Capdevila X, Coimbra C, Choquet O. Approaches to the lumbar plexus: success, risks, and outcome. Reg Anesth Pain Med 2005;30:150–62
4. Marhofer P, Schrogendorfer K, Wallner T, Koinig H, Mayer N, Kapral S. Ultrasonographic guidance reduces the amount of local anesthetic for 3-in-1 blocks. Reg Anesth Pain Med 1998;23:584–8
5. Cucchiaro G, Ganesh A. The effects of clonidine on postoperative analgesia after peripheral nerve blockade in children. Anesth Analg 2007;104:532–7
© 2009 International Anesthesia Research Society