1. UGRA in pedriatric anesthesia
Markus F. Stevens
Academic Medical Center Amsterdam

2. UGRA in pediatric anesthesia
Practice Advisory of ESRA/ASRA
Neuraxial anesthesia
UGRA for caudal anesthesia?
UGRA extremity blocks
Inguinal hernia: caudal or TAP or IL/IH
Umbilical hernia: caudal or TAP or rectus sheath
Things I do NOT recommend
Take home message

3. UGRA in pediatric anesthesia
Practice Advisory of ESRA/ASRA
Ivani G RAPM 2016

4. UGRA in pediatric anesthesia
Practice Advisory of ESRA/ASRA
PRA under GA/DS = acceptable safety (B2)
Incidence complications low (0.66%) (B2)
Incidence of paralysis is estimated % (B3)
Use of epinephrine test dose questionable (C)
Saline-LOR or Air-LOR ( < 1ml) (C)
No evidence against PRA with risk of compartment (C)
But low concentration, no additives ….. (C)
Ivani G RAPM 2015

5. UGRA in pediatric anesthesia
PRAN: retrospective study with > 50,000 RA
Incidence of (transient) neurologic symptoms:
0.6/1000 (CI, 0.4–0.92) GA without NMB
2.4/1000 (CI, 1.6–3.6) GA with NMB
8.3/1000 (CI, 4.9–13.3) sedation
3.4/1000 (CI, 0.7–10.0) awake
Taenzer AH RAPM 2014

6. UGRA in pediatric anesthesia
PRAN study – use of localizing technique
Polander DM AA 2012

7. UGRA in pediatric anesthesia
Neuraxial anesthesia: spinal

8. UGRA in pediatric anesthesia
Neuraxial anesthesia: epidural

9. UGRA in pediatric anesthesia
Neuraxial anesthesia: epidural

10. UGRA in pediatric anesthesia
Neuraxial anesthesia: epidural catheter

12. UGRA in pediatric anesthesia
Neuraxial anesthesia
Hermanns H BJA 2006

13. UGRA in pediatric anesthesia
UGRA for caudal anesthesia?

14. UGRA in pediatric anesthesia
UGRA for caudal anesthesia?

15. UGRA in pediatric anesthesia
Extremity blocks

16. UGRA in pediatric anesthesia
Extremity blocks

17. UGRA in pediatric anesthesia
Inguinal hernia: caudal or TAP or IL/IH
Baird D
J Paediatr Surg 2013

18. UGRA in pediatric anesthesia
Umbilical hernia: caudal or TAP or rectus sheath

19. UGRA in pediatric anesthesia
Umbilical hernia: caudal or TAP or rectus sheath

20. UGRA in pediatric anesthesia
Umbilical hernia: caudal or TAP or rectus sheath
Dingeman RS
JAMA Surg 2013

21. UGRA in pediatric anesthesia
Things I do NOT recommend

22. UGRA in pediatric anesthesia
Things I do NOT recommend
Glover CD
J Pediatr Orthop B 2015

23. UGRA in pediatric anesthesia
Things I do NOT recommend

24. UGRA in pediatric anesthesia
Take home messages:
Performing RA under GA is safe
Neuraxial US extremely helpful in baby’s
Ultrasound not standard for caudal
For Limb blocks UGRA is extremely helpful
Caudal ≥ TAP ≥ pararectal/II/IH ≥ local infiltration
Careful indication

25. Thank you for your attention