In this video, a bilateral ultrasound-guided rectus sheath nerve block is demonstrated on a 7-year-old male child undergoing umbilical hernia repair. After the induction of general anesthesia, nerve block time-out is conducted. Following this, the periumbilical area is cleansed using chlorhexidine. A high-frequency linear ultrasound probe is then placed in a transverse orientation lateral to the umbilicus to identify the rectus muscle and its posterior rectus sheath. The three lateral abdominal wall muscles—internal oblique, external oblique, and transversus abdominis—are also visualized lateral to the rectus muscle.
Using an in-plane technique, a 22-gauge, 50-millimeter-long Pajunk needle is inserted from lateral to medial direction. The needle is advanced through the subcutaneous tissue and the body of the rectus muscle until it reaches the target plane between the rectus muscle and the posterior rectus sheath. Correct needle placement is confirmed through hydro dissection with normal saline, where proper spread is indicated by separation of the rectus sheath from the muscle or by the rectus muscle lifting up.
Next, 0.2% Ropivacaine, a local anesthetic, is incrementally injected. The procedure is then repeated on the opposite side with total drug volume typically ranging from 0.05 ml/kg to 1.0 ml/kg up to a maximum total volume of 10 to 20 ml. The patient tolerates the procedure well and does not require any opioids intraoperatively or postoperatively in the post-anesthesia care unit.
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.
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.
