Pediatric Anesthesia for Orthopedic Surgery

  • Kathryn R. DelPizzoEmail author
  • Naomi Dong
  • Carrie Rowe Guheen


Pediatric patients undergoing orthopedic procedures warrant unique considerations compared to adults. Providers should understand these differences before caring for children in the operating room. The use of regional anesthesia in children, particularly ultrasound-guided, has proven beneficial and is therefore increasingly recommended. Evidence-based data regarding the use of regional anesthesia and its safety is being compiled on a more routine basis due to the creation of the Pediatric Regional Anesthesia Network (PRAN.) As congenital syndromes are common in pediatric orthopedic patients, providers should be familiar with their anesthetic implications. This chapter provides an overview of anesthetic practice and common challenges encountered by anesthesiologists as well as perioperative physicians when caring for children undergoing orthopedic procedures.


Pediatric regional anesthesia Pediatric Regional Anesthesia Network (PRAN) Transient neurological deficit Enhanced recovery after surgery (ERAS) IPACK block Local anesthetic systemic toxicity (LAST) 


  1. 1.
    Slikker W Jr, Zou X, Hotchkiss CE, Divine RL, Sadovova N, Twaddle NC, et al. Ketamine-induced neuronal cell death in the perinatal rhesus monkey. Toxicol Sci. 2007;98:145–58.CrossRefPubMedPubMedCentralGoogle Scholar
  2. 2.
    Briner A, Nikonenko I, De Roo M, Dayer A, Muller D, Vutskits L. Developmental stage-dependent persistent impact of propofol anesthesia on dendritic spines in the rat medial prefrontal cortex. Anesthesiology. 2011;115:282–93.CrossRefPubMedPubMedCentralGoogle Scholar
  3. 3.
    Jevtovic-Todorovic V. Anesthesia and the developing brain: are we getting closer to understanding the truth? Curr Opin Anaesthesiol. 2011;24:395–9.CrossRefPubMedPubMedCentralGoogle Scholar
  4. 4.
    Jevtovic-Todorovic V, Hartman RE, Izumi Y, Benshoff ND, Dikranian K, Zorumski CF, et al. Early exposure to common anesthetic agents causes widespread neurodegeneration in the developing rat brain and persistent learning deficits. J Neurosci. 2003;23:876–82.CrossRefPubMedPubMedCentralGoogle Scholar
  5. 5.
    Lin E, Lee J, Lee C, Deng M, Loepke AW. Do anesthetics harm the developing human brain? An integrative analysis of animal and human studies. Neurotoxicol Teratol. 2017;60:117–28.CrossRefPubMedPubMedCentralGoogle Scholar
  6. 6.
    Davidson A, Disma N, de Graaf J, Withington DE, Dorris L, Bell G, et al. Neurodevelopmental outcome at 2 years of age after general anaesthesia and awake-regional anaethesia in infancy (GAS): an international multicentre, randomized controlled trial. Lancet. 2016;387:239–50.CrossRefPubMedPubMedCentralGoogle Scholar
  7. 7.
    Sun L, Li G, Miller T, Salorio C, Byrne MW, Bellinger DC, et al. Association between a single general anesthesia exposure before age 36 months and neurocognitive outcomes in later childhood. JAMA. 2016;315(21):2312–20.CrossRefPubMedPubMedCentralGoogle Scholar
  8. 8.
    Davidson AJ. Anesthesia and neurotoxicity to the developing brain: the clinical relevance. Paediatr Anaesth. 2011;21:716–21.CrossRefPubMedPubMedCentralGoogle Scholar
  9. 9.
    Hansen T. Use of anesthetics in young children Consensus statement of the European Society of Anaesthesiology (ESA), the European Society for Pediatric Anaesthesiology (ESPA), the European Association of Cardiothoracic Anaesthesiology (EACTA), and the European Safe Tots Anaesthesia Research Initiative (EuroSTAR.). Pediatr Anesth. 2017;27(6):558–9.CrossRefGoogle Scholar
  10. 10.
    Davidson A, Sun L. Clinical evidence for any effect of anesthesia on the developing brain. Anesthesiology. 2018;128:840–53.CrossRefPubMedPubMedCentralGoogle Scholar
  11. 11.
    Disma N, O’Leary J, Loepke A, Brambrink AM, Becke K, Clausen NG, et al. Anesthesia and the developing brain: a way forward for laboratory and clinical research. Pediatr Anesth. 2018;28:758–63.CrossRefGoogle Scholar
  12. 12.
    US Food and Drug Administration [Internet]. FDA Drug Safety Communication: FDA review results in new warnings about using general anesthestics and sedation drugs in young children and pregnant women. United States 2016 [updated 2018 March 8 cited 2019 Jan 4]. Available at:
  13. 13.
    Bosenberg A. Benefits of regional anesthesia in children. Paediatr Anaesth. 2012;22:10–8.CrossRefPubMedPubMedCentralGoogle Scholar
  14. 14.
    Ecoffey C, Lacroix F, Giaufre E, Orliaguet G, Courreges P. Epidemiology and morbidity of regional anesthesia in children: a follow-up one-year prospective survey of the French-Language Society of Paediatric Anaesthesiologists (ADARPEF). Paediatr Anaesth. 2010;20:1061–9.CrossRefPubMedPubMedCentralGoogle Scholar
  15. 15.
    Giaufre E, Dalens B, Gombert A. Epidemiology and morbidity of regional anesthesia in children: a one-year prospective survey of the French-Language Society of Pediatric Anesthesiologists. Anesth Analg. 1996;83:904–12.CrossRefPubMedPubMedCentralGoogle Scholar
  16. 16.
    Rochette A, Dadure C, Raux O, Troncin R, Mailhee P, Capdevila X. A review of pediatric regional anesthesia practice during a 17-year period in a single institution. Paediatr Anaesth. 2007;17:874–80.CrossRefGoogle Scholar
  17. 17.
    Dalens BJ. Pediatric regional anesthesia. CRC: Boca Raton; 1990.Google Scholar
  18. 18.
    Hadzic A, editor. Hadzic’s textbook of regional anesthesia and pain medicine. 2nd ed. New York: McGraw-Hill; 2017.Google Scholar
  19. 19.
    Walker B, Long J, Sathyamoorthy M, Birstler J, Wolf C, Bosenberg AT, et al. Complications in pediatric regional anesthesia: an analysis of more than 100,000 blocks from the Pediatric Regional Anesthesia Network. Anesthesiology. 2018;129(4):721–32.CrossRefGoogle Scholar
  20. 20.
    Polaner D, Taenzer A, Walker B, Bosenberg A, Krane EJ, Suresh S, et al. Pediatric Regional Anesthesia Network (PRAN): a multi-institutional study of the use and incidence of complications of pediatric regional anesthesia. Anesth Analg. 2012;115(6):1353–64.CrossRefGoogle Scholar
  21. 21.
    Taenzer M, Walker B, Bosenberg A. Asleep versus awake: does it matter? Regional block complications by patient state: a report from the Pediatric Regional Anesthesia Network. Reg Anesth Pain Med. 2014;39:279–83.CrossRefGoogle Scholar
  22. 22.
    Koumbourlis AC. Scoliosis and the respiratory system. Paediatr Respir Rev. 2006;7:152–60.CrossRefPubMedPubMedCentralGoogle Scholar
  23. 23.
    DelPizzo K, Zayas VM. Scoliosis. In: Yao F, Fontes ML, Malhotra V, editors. Anesthesiology: problem-oriented patient management. 8th ed. Philadelphia: Lippincott Williams & Wilkins; 2016. p. 1072–93.Google Scholar
  24. 24.
    Hardacker DM, Tolley JA. Postoperative neuraxial pain relief in the pediatric patient. Semin Pediatr Surg. 2004;13:203–9.CrossRefPubMedPubMedCentralGoogle Scholar
  25. 25.
    Wolf AR. Effects of regional analgesia on stress responses to pediatric surgery. Paediatr Anaesth. 2012;22:19–24.CrossRefGoogle Scholar
  26. 26.
    Finkel JC, Boltz MG, Conran AM. Haemodynamic changes during high spinal anaesthesia in children having open heart surgery. Paediatr Anaesth. 2003;13:48–52.CrossRefPubMedPubMedCentralGoogle Scholar
  27. 27.
    Humphreys N, Bays SM, Parry AJ, Pawade A, Heyderman RS, Wolf AR. Spinal anesthesia with an indwelling catheter reduces the stress response in pediatric open heart surgery. Anesthesiology. 2005;103:1113–20.CrossRefPubMedPubMedCentralGoogle Scholar
  28. 28.
    Lee TW, Grocott HP, Schwinn D, Jacobsohn E. High spinal anesthesia for cardiac surgery: effects on beta-adrenergic receptor function, stress response, and hemodynamics. Anesthesiology. 2003;98:499–510.CrossRefPubMedPubMedCentralGoogle Scholar
  29. 29.
    Wolf AR, Doyle E, Thomas E. Modifying infant stress responses to major surgery: spinal vs extradural vs opioid analgesia. Paediatr Anaesth. 1998;8:305–11.CrossRefPubMedPubMedCentralGoogle Scholar
  30. 30.
    Marhofer P. Regional blocks carried out during general anesthesia or deep sedation: myths and facts. Curr Opin Anesthesiol. 2017;30:621–6.CrossRefGoogle Scholar
  31. 31.
    Llewellyn N, Moriarty A. The national pediatric epidural audit. Paediatr Anaesth. 2007;17:520–33.CrossRefGoogle Scholar
  32. 32.
    Flack S, Anderson C. Ultrasound guided lower extremity blocks. Paediatr Anaesth. 2012;22:72–80.CrossRefPubMedPubMedCentralGoogle Scholar
  33. 33.
    Tsui B, Suresh S. Ultrasound imaging for regional anesthesia in infants, children, and adolescents: a review of current literature and its application in the practice of extremity and trunk blocks. Anesthesiology. 2010;112:473–92.CrossRefPubMedPubMedCentralGoogle Scholar
  34. 34.
    Tsui BC, Suresh S. Ultrasound imaging for regional anesthesia in infants, children, and adolescents: a review of current literature and its application in the practice of neuraxial blocks. Anesthesiology. 2010;112:719–28.CrossRefPubMedPubMedCentralGoogle Scholar
  35. 35.
    Lonnqvist PA. Is ultrasound guidance mandatory when performing paediatric regional anaesthesia? Curr Opin Anaesthesiol. 2010;23:337–41.CrossRefPubMedPubMedCentralGoogle Scholar
  36. 36.
    Ecoffey C. Safety in pediatric regional anesthesia. Paediatr Anaesth. 2012;22:25–30.CrossRefPubMedPubMedCentralGoogle Scholar
  37. 37.
    Rubin K, Sullivan D, Sadhasivam S. Are peripheral and neuraxial blocks with ultrasound guidance more effective and safe in children? Paediatr Anaesth. 2009;19:92–6.CrossRefPubMedPubMedCentralGoogle Scholar
  38. 38.
    Dillane D, Tsui BCH. Is there still a place for the use of nerve stimulation? Paediatr Anaesth. 2012;22:102–8.CrossRefGoogle Scholar
  39. 39.
    Suresh S, Ivani G, Tsui BCH, et al. Regional anesthesia in pediatric patients. In: Hadzic A, editor. Textbook of regional anesthesia and acute pain management. New York: McGraw-Hill; 2007.Google Scholar
  40. 40.
    Patel D. Epidural analgesia for children. Cont Educ Anaesth Crit Care Pain. 2006;6:63–6.CrossRefGoogle Scholar
  41. 41.
    Berde CB. Toxicity of local anesthetics in infants and children. J Pediatr. 1993;122:S14–20.CrossRefGoogle Scholar
  42. 42.
    Kokki H. Spinal anaesthesia in infants and children. Baillières Clin Anaesth. 2000;14:687–707.Google Scholar
  43. 43.
    Borgeat A. Peripheral nerve block in patients with preexisting neurologic disease. Period Biol. 2011;113:147–50.Google Scholar
  44. 44.
    Lirk P, Birmingham B, Hogan Q. Regional anesthesia in patients with preexisting neuropathy. Int Anesthesiol Clin. 2011;49:144–65.CrossRefPubMedPubMedCentralGoogle Scholar
  45. 45.
    Bosenberg A, Larkin K. Syndromic vignettes in anaesthesia. Anaesthesia and Charcot-Marie-Tooth disease. South Afr J Anaesth Analg. 2006;12:131–3.CrossRefGoogle Scholar
  46. 46.
    Hebl JR, Horlocker TT, Schroeder DR. Neuraxial anesthesia and analgesia in patients with preexisting central nervous system disorders. Anesth Analg. 2006;103:223–8.CrossRefPubMedPubMedCentralGoogle Scholar
  47. 47.
    Walco GA, Dworkin RH, Krane EJ, LeBel AA, Treede RD. Neuropathic pain in children: special considerations. Mayo Clin Proc. 2010;85:S33–41.CrossRefPubMedPubMedCentralGoogle Scholar
  48. 48.
    YaDeau JT, Liguori GA, Zayas VM. The incidence of transient neurologic symptoms after spinal anesthesia with mepivacaine. Anesth Analg. 2005;101:661–5.CrossRefPubMedPubMedCentralGoogle Scholar
  49. 49.
    PDPH Incidence is Higher in Teenagers than Adults. DelPizzo K, Luu T, Fields K, et al. 42nd annual ASRA conference April 6–8 2017, San Francisco, abstract no 3947.Google Scholar
  50. 50.
    DelPizzo K, Cheng J, Dong N, Edmonds CR, Kahn RL, Fields KG, et al. Post-dural puncture headache in uncommon in young ambulatory surgery patients. HSS J. 2017;13:146–51.CrossRefPubMedPubMedCentralGoogle Scholar
  51. 51.
    Puncuh F, Lampugnani E, Kokki H. Use of spinal anaesthesia in paediatric patients: a single centre experience with 1132 cases. Paediatr Anaesth. 2004;14:564–7.CrossRefPubMedPubMedCentralGoogle Scholar
  52. 52.
    Kokki H, Turunen M, Heikkinen M, Reinikainen M, Laisalmi M. High success rate and low incidence of headache and neurological symptoms with two spinal needle designs in children. Acta Anaesthesiol Scand. 2005;49:1367–72.CrossRefPubMedPubMedCentralGoogle Scholar
  53. 53.
    Imbelloni LE, Vieira EM, Sperni F, Guizellini RH, Tolentino AP. Spinal anesthesia in children with isobaric local anesthetics: report on 307 patients under 13 years of age. Paediatr Anaesth. 2006;16:43–8.CrossRefPubMedPubMedCentralGoogle Scholar
  54. 54.
    Wee LH, Lam F, Cranston AJ. The incidence of post dural puncture headache in children. Anaesthesia. 1996;51:1164–6.CrossRefPubMedPubMedCentralGoogle Scholar
  55. 55.
    Oliver A. Dural punctures in children: what should we do? Paediatr Anaesth. 2002;12:473–7.CrossRefPubMedPubMedCentralGoogle Scholar
  56. 56.
    Kachko L, Platis CM, Livni G, Tarabikin E, Michowiz S, Katz J. Spinal anesthesia in infants with ventriculoperitoneal shunt: report of five cases and review of literature. Paediatr Anaesth. 2006;16:578–83.CrossRefPubMedPubMedCentralGoogle Scholar
  57. 57.
    Kokki H. Spinal blocks. Paediatr Anaesth. 2012;22:56–64.CrossRefPubMedPubMedCentralGoogle Scholar
  58. 58.
    Littleford JA, Brockhurst NJ, Bernstein EP, Georgoussis SE. Obstetrical anesthesia for a parturient with a ventriculoperitoneal shunt and third ventriculostomy. Can J Anaesth. 1999;46:1057–63.CrossRefPubMedPubMedCentralGoogle Scholar
  59. 59.
    Tobias JD. Caudal epidural block: a review of test dosing and recognition of systemic injection in children. Anesth Analg. 2001;93:1156–61.CrossRefPubMedPubMedCentralGoogle Scholar
  60. 60.
    Mossetti V, Ivani G. Controversial issues in pediatric regional anesthesia. Paediatr Anaesth. 2012;22:109–14.CrossRefPubMedPubMedCentralGoogle Scholar
  61. 61.
    Berde CB. Convulsions associated with pediatric regional anesthesia. Anesth Analg. 1992;75:164–6.CrossRefGoogle Scholar
  62. 62.
    Berde C. Regional anesthesia in children: what have we learned? Anesth Analg. 1996;83:897–900.CrossRefPubMedPubMedCentralGoogle Scholar
  63. 63.
    Hu D, Hu R, Berde CB. Neurologic evaluation of infant and adult rats before and after sciatic nerve blockade. Anesthesiology. 1997;86:957–65.CrossRefGoogle Scholar
  64. 64.
    Ludot H, Tharin JY, Belouadah M, Mazoit JX, Malinovsky JM. Successful resuscitation after ropivacaine and lidocaine-induced ventricular arrhythmia following posterior lumbar plexus block in a child. Anesth Analg. 2008;106:1572–4.CrossRefPubMedPubMedCentralGoogle Scholar
  65. 65.
    Shah S, Gopalakrishnan S, Apuya J, Shah S, Martin T. Use of Intralipid in an infant with impending cardiovascular collapse due to local anesthetic toxicity. J Anesth. 2009;23:439–41.CrossRefPubMedPubMedCentralGoogle Scholar
  66. 66.
    Roberts S. Regional anesthesia in pediatric patients: general considerations. In: Hadzic A, editor. Hadzic’s textbook of regional anesthesia and pain medicine. 2nd ed. New York: McGraw-Hill; 2017.Google Scholar
  67. 67.
    Suresh S, Ecoffey C, Bosenberg A, Lonnqvist PA, de Oliveira GS Jr, de Leon Casasola O, et al. The European Society of Regional Anesthesia and Pain Therapy/American Society of Regional Anesthesia and Pain Medicine Recommendations on local anesthetics and adjuvants dosage in pediatric regional anesthesia. Reg Anesth Pain Med. 2018;43(2):211–6.PubMedGoogle Scholar
  68. 68.
    Canale ST. Osteochondrosis or epiphysitis and other miscellaneous affections. In: Canale ST, editor. Campbell’s operative orthopaedics. 13th ed. Philadelphia: Elsevier; 2017.Google Scholar
  69. 69.
    Warner WC, Sawyer JR. Scoliosis and kyphosis. In: Canale ST, editor. Campbell’s operative orthopaedics. 13th ed. Philadelphia: Elsevier; 2017.Google Scholar
  70. 70.
    Warner WC, Beaty JH. Paralytic disorders. In: Canale ST, editor. Campbell’s operative orthopaedics. 13th ed. Philadelphia: Elsevier; 2017.Google Scholar
  71. 71.
    Warner WC, Sawyer JR. Neuromuscular disorders. In: Canale ST, editor. Campbell’s operative orthopaedics. 13th ed. Philadelphia: Elsevier; 2017.Google Scholar
  72. 72.
    Alman BA, Howard AW. Metabolic and endocrine abnormalities. In: Morrissy RT, Weinstein SL, editors. Lovell and Winter’s pediatric orthopaedics. 6th ed. Philadelphia: Lippincott Williams & Wilkins; 2006.Google Scholar
  73. 73.
    Alman BA, Goldberg MJ. Syndromes of orthopaedic importance. In: Morrissy RT, Weinstein SL, editors. Lovell and Winter’s pediatric orthopaedics. 6th ed. Philadelphia: Lippincott Williams & Wilkins; 2006.Google Scholar
  74. 74.
    Odding E, Roebroeck ME, Stam HJ. The epidemiology of cerebral palsy: incidence, impairments and risk factors. Disabil Rehabil. 2006;28:183–91.CrossRefPubMedPubMedCentralGoogle Scholar
  75. 75.
    Nolan J, Chalkiadis GA, Low J, Olesch CA, Brown TC. Anaesthesia and pain management in cerebral palsy. Anaesthesia. 2000;55:32–41.CrossRefPubMedPubMedCentralGoogle Scholar
  76. 76.
    McCarthy JJ, D’Andrea LP, Betz RR, Clements DH. Scoliosis in the child with cerebral palsy. J Am Acad Orthop Surg. 2006;14:367–75.CrossRefPubMedPubMedCentralGoogle Scholar
  77. 77.
    Frei FJ, Haemmerle MH, Brunner R, Kern C. Minimum alveolar concentration for halothane in children with cerebral palsy and severe mental retardation. Anaesthesia. 1997;52:1056–60.CrossRefPubMedPubMedCentralGoogle Scholar
  78. 78.
    Specchio N, Carotenuto A, Trivisano M, Cappelletti S, Vigevano F, Fusco L. Prolonged episode of dystonia and dyskinesia resembling status epilepticus following acute intrathecal baclofen withdrawal. Epilepsy Behav. 2011;21:321–3.CrossRefPubMedPubMedCentralGoogle Scholar
  79. 79.
    Watve SV, Sivan M, Raza WA, Jamil FF. Management of acute overdose or withdrawal state in intrathecal baclofen therapy. Spinal Cord. 2011;50:107–11.CrossRefPubMedPubMedCentralGoogle Scholar
  80. 80.
    Mohamad F, Parent S, Pawelek J, Marks M, Bastrom T, Faro F, et al. Perioperative complications after surgical correction in neuromuscular scoliosis. J Pediatr Orthop. 2007;27:392–7.CrossRefGoogle Scholar
  81. 81.
    Abu-Sneineh K, Lipton GE, Gabos PG, Miller F. Dysfunction of a ventriculoperitoneal shunt after posterior spinal fusion in children with cerebral palsy: a report of two cases. J Bone Joint Surg Am. 2003;85-A:1119–24.CrossRefGoogle Scholar
  82. 82.
    Hahn F, Hauser D, Espinosa N, Blumenthal S, Min K. Scoliosis correction with pedicle screws in Duchenne muscular dystrophy. Eur Spine J. 2008;17:255–61.CrossRefGoogle Scholar
  83. 83.
    Muhly WT, Sankar WN, Ryan K, Norton A, Maxwell LG, DiMaggio T, et al. Rapid recovery pathway after spinal fusion for idiopathic scoliosis. Pediatrics. 2016;137(4):e20151568.CrossRefGoogle Scholar
  84. 84.
    Leeds IL, Boss EF, George JA, Strockbine V, Wick EC, Jelin EB. Preparing enhanced recovery after surgery for implementation in pediatric populations. J Pediatr Surg. 2016;51(12):2126–9.CrossRefPubMedPubMedCentralGoogle Scholar
  85. 85.
    Alajmi T, Saeed H, Alfaryan K, Alakeel A, Alfaryan T. Efficacy of tranexamic acid in reducing blood loss and blood transfusion in idiopathic scoliosis: a systematic review and meta-analysis. J Spine Surg. 2017;3(4):531–40.CrossRefPubMedPubMedCentralGoogle Scholar
  86. 86.
    Murat I. Latex allergy: where are we? Paediatr Anaesth. 2000;10:577–9.CrossRefGoogle Scholar
  87. 87.
    Karila C, Brunet-Langot D, Labbez F, Jacqmarcq O, Ponvert C, Paupe J, et al. Anaphylaxis during anesthesia: results of a 12-year survey at a French pediatric center. Allergy. 2005;60:828–34.CrossRefPubMedPubMedCentralGoogle Scholar
  88. 88.
    De Queiroz M, Combet S, Berard J, Pouyau A, Genest H, Mouriquand P, et al. Latex allergy in children: modalities and prevention. Paediatr Anaesth. 2009;19:313–9.CrossRefPubMedPubMedCentralGoogle Scholar

Copyright information

© Springer Nature Switzerland AG 2020

Authors and Affiliations

  • Kathryn R. DelPizzo
    • 1
    Email author
  • Naomi Dong
    • 2
  • Carrie Rowe Guheen
    • 3
    • 4
  1. 1.Department of Anesthesiology, Critical Care, and Pain ManagementHospital for Special Surgery, Weill Cornell MedicineNew YorkUSA
  2. 2.Hospital for Special Surgery, Weill Cornell MedicineNew YorkUSA
  3. 3.Hospital for Special Surgery, Department of Anesthesiology, Critical Care, and Pain ManagementNew YorkUSA
  4. 4.Weill Cornell Medicine, Department of AnesthesiologyNew YorkUSA

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