Regional Block Area Setup, Equipment, and Monitoring

Fig. 1.1

Equipment storage cart with clear identification of equipment, supplies, and medication

The following outlines the contents of this cart:

1.2.1 General Equipment

Sterile skin preparation solution.
Sponges/gauze.
Drape.
Marking pen and ruler for landmark identification.
Selection of different sizes of syringes.
A variety of needles with a selection of gauges for skin infiltration, drawing up 5 % dextrose, local anesthetics, sedation, or induction of general anesthetic.
In pediatric patients, most regional blocks are performed under general anesthesia without a muscle relaxant. However, selections of sedatives and hypnotics can be used for cooperative mature pediatric patients as follows:
- Midazolam (IM/IV: 0.1–0.15 mg/kg up to 0.5 mg/kg, IV infusion with loading dose of 0.05–0.2 mg/kg over 2–3 min. Continuous infusion initiated at a rate of 0.06–0.12 mg/kg/h)
- Propofol (IV: 1–2 mg/kg for sedation, then 100–150 μg/kg/min infusion)
- Short-acting opioids:
  
  Fentanyl (IV sedation: 1–2 μg/kg, then 0.5–1 μg/kg/h IV infusion).
  
  Remifentanil (IV: 2–18 years: 1 μg/kg over 30–60 s, then 0.05–0.1 μg/kg/min IV infusion). All sedation medication should be titrated to response.
- Several commonly used local anesthetics with different concentrations, as well as 50 mL bags or ampules of normal saline for drug dilution if necessary.
- All local anesthetics should be stored separately from the intravenous drugs.

1.2.2 Emergency Drugs and Resuscitating Equipment

Although the use of ultrasound allows reduced volumes of local anesthetic to accomplish a successful nerve block, it is pertinent to have resuscitation equipment and drugs available.
Children have a higher tolerance to local anesthetic on a weight-dependent basis owing to a greater volume of distribution; this increases the threshold in reaching the toxic dose. However, in newborns less than 6 months, the threshold in reaching the toxic dose is reduced due to the lower concentration of serum protein for local anesthetic binding, namely, alpha-1 acid glycoprotein. This results in a higher plasma concentration of unbound local anesthetic.

1.2.3 Resuscitation Equipment

Oxygen supply, nasal prongs, and face masks.
A selection of different sizes of Guedel airways, face masks, laryngeal masks, and endotracheal tubes.
Laryngoscopes (Macintosh and Miller blades) and gum elastic bougie.
Ambu^® bag (bagger).
Suction.
Selections of various sizes of intravenous cannulae.
Defibrillator should also be accessible.

1.2.4 Resuscitation Drugs (Intravenous Doses)

Atropine (0.02 mg/kg)
Epinephrine (0.01 mg/kg)
Suxamethonium (2 mg/kg)
Ephedrine (1–12 years: 0.2–0.3 mg/kg; 12–18 years: 2.5–5 mg)
Glycopyrrolate (5–10 μg/kg)
Intralipid® 20 % (1.5 mL/kg bolus over 1 min followed by 0.25 mL/kg/min infusion; bolus dose can be repeated at 5-min intervals if there is no return of spontaneous circulation) (see Chaps. 7 and 8).

1.2.5 Monitoring

Routine monitoring should be applied before sedation or general anesthetic is induced. This includes:
- Electrocardiogram
- Noninvasive blood pressure
- Pulse oximetry
- Capnography
- End-tidal gas monitoring

1.2.6 Nerve Block and Catheter Equipment

There is a variety of different needles for single-shot nerve blocks and Tuohy needles for peripheral nerve catheter insertion. The needles for single-shot nerve blocks usually have a female attachment for the nerve stimulator and another extension to facilitate aspiration and injection of 5 % dextrose or local anesthetics. Extension tubing is also available to facilitate flexible attachment of a syringe to the Tuohy needle for catheter insertions.

1.2.7 Needles

1.2.7.1 Needle Tip Design

A blunt needle (Fig. 1.2) reduces the risk of nerve damage and provides a better feel for the “pop” of puncturing through the fascia. However, if the needle is too blunt, the user may have to apply extra pressure to perforate the fascia, which can result in “overshooting” the nerve.