In this video, a bilateral ultrasound-guided pudendal nerve block is demonstrated on a 15-month-old healthy child undergoing circumcision and penoscrotal fusion repair. After the induction of general anesthesia, a nerve block time-out is conducted. Subsequently, the patient is positioned in the frog-leg stance by an assistant, and the perineum is cleaned using chlorhexidine. Using a high-frequency linear ultrasound probe, the ischiorectal fossa is identified between the ischial tuberosity and the anus at the 3 and 9 o’clock positions relative to the anus. A 22-gauge, 50-millimeter-long Pajunk needle is then inserted using an out-of-plane technique, advanced 1-2 cm deep and medial to the ischial tuberosity, until a subtle change in resistance or “pop” is felt, confirming the correct placement below the sacrospinous ligament. The local anesthetic (0.3 to 0.5 mL/kg of 0.2% Ropivacaine or 0.25% Bupivacaine on each side) is then incrementally injected, observed as spreading medially and beneath the ischial tuberosity. The block is then repeated on the other side. Our patient tolerated the procedure well and did not require any opioids intraoperatively, postoperatively in the post-anesthesia care unit, or at home following discharge.
Keyword: pediatric anesthesia
Ultrasound-Guided Arterial Catheterization in a Pediatric Patient
This video demonstrates an overview of radial arterial cannulation in a pediatric patient using real-time ultrasound (US) guidance. Ultrasound imaging is a useful tool in the armamentarium for guiding arterial line placement, and its use has become commonplace due to increased accessibility and improved technology. Ultrasound imaging facilitates the detection of abnormal anatomy and abnormal findings (e.g. thrombosis). It also allows for real-time guidance for arterial cannulation, which is especially valuable during difficult insertions such as in neonates or small infants, patients with weak or absent pulses or landmarks, and those with multiple prior cannulations. There is evidence of higher success rates with first attempts and decreased complications compared to the traditional landmark and palpation techniques.
Ultrasound-Guided Insertion of Pediatric Central Venous Catheter
This video demonstrates the placement of a central venous catheter (CVC) in the internal jugular vein (IJV) in an infant using real-time ultrasound (US) guidance. Traditionally, the landmark approach has been the technique used to guide CVC placement. Presently, the use of ultrasound (US) for guiding placement has become commonplace due to increased accessibility, improved technology, and evidence of increased first-attempt success rates and decreased complications. Real-time US-guided central venous cannulation is now the recommended technique over the landmark technique by professional organizations. The experienced use of US allows for the detection of abnormal anatomy or findings (e.g. vein thrombosis) and allows for real-time visualization, which is especially helpful during difficult insertions, absence of landmarks, and in challenging patient groups such as in small infants.
Pediatric Lumbar Epidural Catheter Placement via the Landmark Technique.
This video demonstrates an epidural catheter placement on a 2-year-old, 12kg male patient presenting for left hip osteotomy. His past medical history was remarkable for congenital heart defects, bilateral congenital hip dislocations, and a sacral dimple which is sometimes associated with neurologic spinal canal abnormalities. In this case, no neurologic anatomical abnormalities were demonstrated on the neonatal spine ultrasound. The patient was placed in a left lateral decubitus position. Using anatomical landmarks like Tuffier’s line or the intercristal line corresponding to L4-L5 level, the target level for needle placement was identified and marked. The patient’s skin was sterilized and draped under sterile conditions. An 18-gauge, 5 cm length Tuohy needle was used to encounter the epidural space. A general guideline for the depth to the epidural space from the skin is approximately 1mm/kg of body weight¹. Subsequently, a 20-gauge catheter was placed through the needle to a depth of 4.5 cm at the level of the skin. Negative aspiration of blood or CSF was confirmed. A test dose was calculated at 0.5 mcg/kg epinephrine or 0.1ml/kg of lidocaine 1.5% with epinephrine 1:200,000. In this case, a 1.2 mL test dose of lidocaine 1.5% with epinephrine 1:200,000 was given without any observed cardiovascular changes (e.g. ≥ 25% increase or decrease in T wave amplitude, HR increase ≥ 10 bpm, or SBP increase ≥ 15 mmHg)¹. Finally, the catheter was secured to the back of the patient. Parental consent was obtained for the publication of this video.