Paediatric regional anaesthetic procedures: clinical anatomy competence, pitfalls and complications

Abstract

Clinical procedures are an important part of the daily work of doctors of various specialities, including the practice of regional anaesthetic procedures on paediatric patients. The competency that a doctor displays in clinical procedures is an important aspect of their overall clinical competence and the successful performance of regional blocks demands a working and yet specific knowledge of the anatomy underlying each procedure, especially knowledge regarding the relative depth or specific positions of certain key structures in paediatric patients, as it is known that the anatomy of children differ to a greater or lesser degree from that of adults. Precise information on epidemiology and morbidity of paediatric regional anaesthesia, especially from a clinical anatomy perspective, remains scarce. The aim of this study was therefore: (1) to determine, through means of a questionnaire, the scope of regional anaesthetic techniques performed on paediatric patients in South Africa, as well as, determine the competence of anaesthesiologists to perform these procedures based on their clinical anatomy knowledge regarding each nerve block; (2) select 5 problem procedures based on the anatomical competence that anaesthesiologists display when performing each nerve block; and (3) develop an extensive, referenced clinical anatomy knowledge base regarding each of the 5 problem procedures. A list of 18 regional anaesthetic procedures common in paediatric practice was compiled and a detailed questionnaire was completed by a randomly selected sample of anaesthesiologists (n=80) working in both government institutions and in private practice. The problem procedures chosen were those that were performed most often; ranked important; encountered most difficulties and complications; where anaesthesiologists felt uncomfortable performing the procedures and where the influence of clinical anatomy knowledge on the safe and successful performance of the procedure was ranked highest. The 5 problem procedures selected are the following: caudal epidural block, lumbar epidural block, the axillary approach to the brachial plexus, femoral nerve block and the ilioinguinal/ iliohypogastric nerve block. A referenced clinical anatomy knowledge base was developed by an extensive literature review of the selected procedures under the following headings: Indications, contraindications, step-by-step technique, anatomical pitfalls, anatomically related complications and references.