• Most US techniques in children are performed under general anaesthesia. Large studies have demonstrated that this is safe practice, and it is the recommendation from ESRA/ASRA. However, awareness that this could potentially mask complications, like intraneural injection, is important
• Large prospective databases have shown a low complication rate in paediatric regional anaesthesia. Nevertheless, there is less literature exploring regional techniques in children or detailing paediatric anatomy, particularly in children with congenital disorders or neuromuscular conditions, when compared to adults.
• Following a nerve block, some children may experience a patch of skin exhibiting a prolonged  numbness or a tingling sensation. Typically, this is self-limiting and tends to improve within a few weeks, though it might persist for up to one year. Permanent nerve damage is exceptionally rare and precise numbers are not known. In adults it is estimated to occur in 1 out of 2,000-5,000 nerve blocks. A recent study examining over 100,000 blocks in children demonstrated a temporary nerve damage incidence of 2.4 per 10,000 patients, with no cases of permanent nerve damage identified.

• Be aware that a general anaesthesia might conceal the early (neurological) signs of LAST
• Neonates and infants are particularly vulnerable to the risk of LAST. The physiological immaturities of the neonatal liver in association with a relatively high cardiac output produce pharmacological differences that combine to increase the risk of local anaesthetic toxicity in neonates. 
• Most common when performing blocks in a highly vascularised area (brachial plexus, caudal, penile block) or when combined with local infiltration by the surgeon (ensure the total concentration of local anaesthetic administered, does not exceed the maximal safe dose )

• Maintain strict adherence to sterility protocols when performing a nerve block
• Risk increases with prolonged use of catheters (> 3 days)

NB: Studies have demonstrated an increased overall risk for complications when performing central blocks in children compared to peripheral block, but the use of ultrasound reduces risks for complications.

CONTRAINDICATIONS

Absolute contraindications

• Patient or parent refusal
• Local anaesthetic allergy
• Infection at the proposed needle insertion point

Relative contraindications

• Coagulopathy or on anticoagulants – block dependent (see EJA guidelines 2022)
• Challenging anatomy at site of the block

Block specific contraindications (see individual block sections)

CONSIDERATIONS

• Pre-existing nerve damage
• Compartment syndrome: the concern is that blocks could mask the pain associated with compartment syndrome and thus delay diagnosis. However, there is no evidence to support NOT doing a block in children. 

Recommendations regarding compartment syndrome (See also ESRA/ASRA guidance 2015):

• Discuss with the surgical consultant to identify high risk cases
• Discuss with parents/child, discuss risks and benefits of the block and symptoms of compartment syndrome
• Use low concentration of LA (e.g.0.125% of levobupivacaine or 0.1% of ropivacaine)
• Don’t use any additives (not even dexamethasone)
• The surgical consultant needs to consider inserting a compartment pressure monitoring device
• Postoperative vigilance