Complications of Regional Anaesthesia

Renewed interest in the paediatric application of regional anaesthesia was the result of increased concern for postoperative pain management and the recognition that the benefit of regional techniques adequately combined with sedation or light general anaesthesia exceeded the limitations of each technique per se. Mastering the technique of different blocks by paediatric anaesthesiologists and the better understanding of the developmental pharmacology of local anaesthetics both contributed to overall success. The favourable outcome observed in children undergoing combined general anaesthesia and epidural analgesia for both urology and thoracic surgery, the routine practice of caudal or peripheral nerve blocks to provide smooth painless emergence for infraumbilical procedures and the effectiveness of chronic implanted epidural catheters for pain relief in oncology patients were, at our Institution, key factors in encouraging further the widespread use and acceptance of regional techniques. This apparently uncomplicated horizon was supported by extensive clinical experience with caudal and lumbar epidural blocks. The first published analysis of large series included several hundred patients (Busoni & Andreuccetti 1986) without complication except a very low incidence of postoperative vomiting and urinary retention. On the other hand, McGown (1982) recognized severe complications in 500 caudals in children younger than ten years. In this issue of Paediatric Anaesthesia, FlandinBl6ty & Barrier (1995) report a retrospective multicentre study on the complications in 24005 blocks performed in ten French and Belgian institutions. The survey reveals that three infants died as a consequence of grave neurological damage and two others remained respectively paraplegic and tetraplegic after extradural anaesthesia for abdominal procedures. The authors of this study provide critical information which may be helpful in preventing unfavourable outcomes in other patients. They point out that all five accidents have common features: infants age (6-1 1 weeks), gender (male), predominance of black babies, absence of any preexisting neurological abnormality, and a clinical pattern of life threatening central nervous system (CNS) damage with fatal complications or permanent neurological sequelae. Also, the clinical setting complied with accepted standards for paediatric surgical procedures. However, the sequence of events suggests more the implication of several mechanisms rather than a unique pathophysiological interpretation.