Eur J Anaesthesiol 2015; 32:289–297

REVIEW

Regional anaesthesia in neonates, infants and children

An educational review
Martin Jöhr

Prophylactic analgesia with local anaesthesia is widely used block, should be performed with the aid of ultrasound.
in children and has a good safety record. Performing regional Caudal anaesthesia is the single most important technique.
blocks in anaesthetised children is a safe and generally Ropivacaine 0.2% or levobupivacaine 0.125 to 0.175% at
accepted practice. When compared with adults, lower con- roughly 1 ml kg 1 is adequate for most indications. Clonidine
centrations of local anaesthetics are sufficient in children; the and morphine can be used to prolong the duration of
onset of a block occurs more rapidly but the duration is analgesia. Ultrasound is not essential for performing caudal
usually shorter. Local anaesthetics have a greater volume of blocks, but it may be helpful in case of anomalies suspected
distribution, a lower clearance and a higher free (non-protein- at palpation and for teaching purposes. The use of paediatric
bound) fraction. The recommended maximum dose has to be epidural catheters will probably decline in the future because
calculated for every individual. Peripheral blocks provide of the potential complications.
analgesia restricted to the site of surgery, and some of them
have a very long duration of action. Abdominal wall blocks,
such as transverse abdominis plane or ilio-inguinal nerve Published online 16 February 2015

Introduction
Current position of paediatric regional anaesthesia even the most commonly performed procedure, caudal
Regional anaesthesia is mainly used to provide post- block, represents only 2.5% of all central neuraxial
operative analgesia. Prophylactic analgesia with local blocks performed.9 Determining the risk–benefit ratio
anaesthetics is an attractive concept, especially in pae- is difficult for techniques that are relatively rarely per-
diatric practice, because the evaluation of pain can be formed.
very challenging in young children. In contrast to opioids,
local anaesthetics can be administered safely, and in Developmental pharmacology
recent guidelines regional anaesthesia is accepted as Lower concentrations of local anaesthetics that are
the cornerstone of post-operative pain relief in the pae- used in adults are clinically effective in children; the
diatric patient.1 Surprisingly, in children, there are only onset of a block occurs more rapidly but the duration is
limited data to show that regional anaesthesia really shorter. However, with the exception of caudal anaes-
improves analgesia compared with systemic medication; thesia, no scientific data exist on the best dose and
this is true for inguinal hernia repair, urological surgery, concentration for specific regional blocks in different
cleft lip repair and ophthalmological surgery.2 age groups.

Regional blocks are usually performed in anaesthetised Pharmacokinetics

children. This is an accepted practice provided the clin- In infants, local anaesthetics have a greater volume of
ician selects and performs the technique carefully and is distribution,10,11 a lower clearance,12 and a higher free
appropriately skilled.3–5 Although regional anaesthesia non-protein-bound fraction.10 The larger volume of
has a good safety record overall,5–8 the global experience distribution counteracts the increased potential for
with paediatric regional anaesthesia is still quite low; toxicity caused by the larger free non-protein-bound

From the Section of Paediatric Anaesthesia, Department of Anaesthesia, Kantonsspital, Luzern, Switzerland
Correspondence to Dr Martin Jöhr, Department of Anaesthesia, Kantonsspital, CH-6000 Luzern 16, Switzerland
Tel: +41 41 205 4908; fax: +41 41 370 5427; e-mail: [email protected]

0265-0215 ß 2015 Copyright European Society of Anaesthesiology DOI:10.1097/EJA.0000000000000239

Copyright © European Society of Anaesthesiology. Unauthorized reproduction of this article is prohibited.

 290 Jöhr

fraction. This means that the amount used for single-shot levobupivacaine similar limits should probably be fol-
procedures in terms of ml kg 1 can be the same in lowed; some experts consider that with ropivacaine
children as for adults. slightly higher doses may be used safely. But for a
continuous infusion, the immature metabolism of the
For a continuous infusion the situation in the developing
very young has to be taken into account (Table 1).
organism is much more complex;13 the maturation of the
metabolism has to be taken into account. CYP1A2 which
Peripheral blocks
metabolises ropivacaine is immature before 4 to 7 years of
Peripheral blocks provide analgesia restricted to the site
age, whereas CYP3A4/7, which metabolises levobupiva-
of surgery and some of them have a very long duration of
caine, has full enzymatic capacity by the age of 1 year.
action. Their safety record is good. However, peripheral
Unfortunately, no well designed study compares the two
blocks are not without risk: needle trauma, compression/
local anaesthetic molecules.
ischaemia and neurotoxicity are mechanisms that can
lead to neurological complications. The recommended
Pharmacodynamics doses are based mainly on experts’ opinion and not on
In neonates and infants, nerve fibres are thinner, they have evidence. When the injections are made with ultrasound
less myelin and the nodes of Ranvier are located closer to guidance, a very low volume can be seen to provide
each other. Therefore, a smaller sleeve of local anaesthetic adequate spread (Table 2).
solution is sufficient to block three nodes of Ranvier or
more, a prerequisite for the blockade of saltatory conduc- Topical anaesthesia
tion. Nerve fibres are more susceptible to the effects of EMLA cream (which contains prilocaine 2.5% and lido-
local anaesthetics, and a shift of the dose–response curve caine 2.5%) is almost universally used for skin analgesia
to the left has been shown in young rabbits.14 before venous puncture in awake children. It works best
with an application time of 60 to 90 min and should be
Systemic toxicity removed 15 min before the intended procedure in order
In animal experiments, young individuals are more resist- to allow regression of the prilocaine-mediated vasocon-
ant to the toxic effects of local anaesthetics than older striction. At higher doses, prilocaine can cause methae-
ones.15 But, when using a whole-organ preparation, the moglobinaemia. Because of the reduced activity of
effect of bupivacaine on cardiac contractility was even methaemoglobin reductase in neonates and young
greater in neonatal rabbits than in adult rabbits.16 infants, there is an increased risk of methemoglobine-
mia,18 even after moderate doses of prilocaine.19 How-
Toxicity occurs when high plasma levels are reached ever, the use of EMLA cream is safe, even in this age
following the absorption of an excessive dose of local group, as long as the dose is restricted to 1 to 2 g.20,21
anaesthetic, or when the drug is inadvertently injected
into the vascular space.
Wound infiltration
The maximum recommended dose must be calculated for Wound infiltration is employed chiefly to provide post-
every individual patient. Although this dose should not lead operative analgesia but it can only be expected to pro-
to clinically relevant toxicity, provided that the patient is duce reliable analgesia if the surgery could have been
healthy and the anaesthesiologist adheres to all the tenets of performed under infiltration anaesthesia alone, in an
good practice, signs of toxicity may still occur in sick awake child - for example superficial skin surgery. When
patients, or following unintended intravascular injection.17 used after laparotomy22 or for port-site infiltration after
In paediatric regional anaesthesia, it is a rule of safety to laparoscopic surgery,23,24 it may be only a partial remedy
draw up only the exact amount of drug needed. for post-operative discomfort.
It is generally accepted that the amount of bupivacaine Anaesthesiologists in most cases use a skin wheal
should be limited to 2.5 mg kg 1 for single injections before performing a major conduction block in awake
and to 0.25 mg kg 1 h 1 for continuous infusions. With children. In addition, infiltration is extensively used by

Table 1 Maximum recommended doses for various local anaesthetics

Single injection Continuous infusion

(mg kgS1) (mg kgS1 hS1) Comments
Bupivacaine 2.5 0.25
Levobupivacaine 2.5 0.25
1 1
Ropivacaine 3 to 4 0.4 0.2 mg kg h in the first 6 months of life
Lidocaine 7 2 (?)
Prilocaine 7 to 10 Not suitable Not recommended in infants and young children because
of an increased risk of methaemoglobinaemia

These doses are in large part not evidence based and represent experts’ opinion.

Eur J Anaesthesiol 2015; 32:289–297

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 Paediatric regional anaesthesia 291

Table 2 Dosage of local anaesthetics for peripheral nerve block ideal volume of injection has not yet been defined, but
Type of the block Dosage (ml kg S1
)
0.2 ml kg 1 on each side are often used.
Rectus sheath block 0.1 to 0.2 A transversus abdominis plane block (TAP-block) con-
TAP-block 0.2 to 0.5 (maximum 20 ml)
Ilio-inguinal nerve block 0.1 to 0.3
sists of an injection into a plane between the internal
Penile block 2  0.1 oblique and transversus abdominis muscle (Fig. 1).37,38 It
Brachial plexus block 0.3 to 0.75 provides unilateral analgesia of the abdominal wall,39 and
Femoral nerve block 0.3 to 0.75 is an alternative to central neuraxial blocks, when these
Sciatic nerve block 0.3 to 0.75
techniques are not possible, for example, in spinal dys-
These doses are mainly based on experts’ opinion and not on evidence. When the raphism or other anomalies of the spinal canal.40 In
injections are made under ultrasound guidance, a sufficient spread can often be addition, the TAP-block technique seems to be useful
seen with a very low volume. TAP-block, transversus abdominis plane block.
for analgesia after bone harvesting at the iliac crest.41
Whereas a mid-axillary injection covers the segments
paediatricians, surgeons and emergency physicians for
T10 to L1, higher segments can be reached with a
the repair of skin lacerations or minor superficial surgery.
sub-costal TAP-block.42 The clinical duration of the
With appropriate psychological guidance, infiltration can
block and the best volume of injection have not yet been
be performed with minimal suffering of the child, pro-
defined in children, but, higher doses seem to improve
vided certain rules are followed (Table 3).25–29 Wound
the duration of analgesia.43 Bilateral TAP-blocks need
infiltration is widely used in clinical medicine in adults as
careful observation of the total local anaesthetic dose
well as in children; nevertheless, it is rarely taught in a
because rapid absorption and high plasma levels have
systematic manner in medical schools.
been reported in adults.44 Realistically, with a long-acting
local anaesthetic and a volume of 0.3 ml kg 1, a duration
Tonsillar bed infiltration of 5 to 10 h can be expected. TAP-block is a safe tech-
Initially it was thought that tonsillar bed infiltration was nique, provided the dose is correctly calculated and an
very desirable because it offered the theoretical intra-peritoneal injection is avoided.45
advantage of pre-emptive analgesia. However, local infil-
tration of the tonsillar bed has no demonstrable preemp- An ilio-inguinal nerve block provides post-operative pain
tive effect30 and has only a small impact on post-operative relief after inguinal incisions, such as herniotomy or orch-
pain.31 Infiltration of the tonsillar bed can produce idopexy. It may not prevent the intra-operative perception
dramatic complications,32,33 although the use of adrena- of noxious stimuli caused by, for example, traction on the
line containing local anaesthetic solutions reduces blood peritoneal sac. In addition, in the case of orchidopexy, ilio-
loss.34 Therefore, the management of post-tonsillectomy inguinal nerve block does not cover the scrotal incision,
pain still relies mainly on systemic medication, opioids which surprisingly does not seem to contribute to a major
and non-opioid analgesics, as well as corticosteroids. extent to post-operative pain. An additional pudendal
nerve block could cover this location but in younger
children, a caudal block would provide more reliable
Abdominal wall blocks and more complete analgesia. With ultrasound guided
There is growing consensus that abdominal wall blocks ilio-inguinal block the typical complications of a land-
should be performed with the aid of ultrasound, because mark-based technique46 such as femoral nerve block47
otherwise imprecise administration of the local anaesthetic and intestinal puncture48–50 can be avoided. Finally, the
and even intra-peritoneal injections commonly occur. ilio-inguinal nerve block scores better than a TAP-block
A rectus sheath block consists of an injection between the for inguinal hernia repair.51 A volume of 0.1 to 0.3 ml kg 1
rectus muscle and the posterior rectus sheath. Its main is often used; however, in children, the clinical duration as
indication is analgesia after umbilical hernia repair or, well as the optimal volume is largely unknown.
depending on the site of incision, after open pyloromyot-
omy. It provides more reliable and longer analgesia than Penile block
surgical wound infiltration,35 and the absorption kinetic Anaesthesia of the dorsal nerve of the penis is considered
of the local anaesthetic seems to be quite slow.36 The the standard for analgesia after penile surgery. A variety

Table 3 The rules for an injection of local anaesthetics with minimal pain, for example, for a skin wheal before performing a conduction block

Factor Comments References

Needle size Thin needles cause less pain Palmon et al.25
Speed of injection A slow injection is far less painful Scarfone et al.26
Site of injection Infiltration from inside of the wound is less painful compared with an injection through the intact skin Bartfield et al.27
Local anaesthetic Alkalinised lidocaine causes less pain compared with a plain solution Palmon et al.25
Bartfield et al.28
Impact of order A second injection is perceived more painfully compared with the first one Bartfield et al.29

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 292 Jöhr

Fig. 1 choice of the needle size and the injected volume differ
between the adult and the paediatric surgical patient; but,
in other respects, the indication and the techniques are
Anterior Posterior
identical so they are not discussed in detail in this review.
The ease of diffusion of local anaesthetics in children
compared with adults makes it easier to achieve an
External oblique excellent block.
Continuous catheter techniques are also used in paedia-
Internal oblique tric patients61,62 but they are mostly restricted to special
patient groups with chronic pain.63,64 This may be related
Transversus to technical difficulties with paediatric catheters that
include leakage of local anaesthetic solution along the
catheter, and also the fact that complete pain relief often
does not lead to a satisfied and comfortable child, and
Abdominal cavity sedative effects of opioids are needed anyway.
3,3
Miscellaneous blocks
Transversus abdominis plane block consists of an injection into a plane A large variety of peripheral nerve blocks are feasible and
between the internal oblique and transversus abdominis muscle. The their use is mainly dependent on the experience of
arrow shows the path of the needle.
the practitioner.
An infra-orbital nerve block can be used for analgesia
of techniques are available such as the classical sub-pubic after cleft lip repair.65,66 In skilled hands, an infra-orbital
puncture or a sub-cutaneous ring block; the latter pro- nerve block can also be used for the repair of upper lip
vides analgesia of shorter duration,52 but offers more lacerations under deep sedation. For this indication, the
complete intra-operative analgesia than the sub-pubic author prefers to approach the site of exit of the infra-
injection.53 Sub-cutaneous infiltration of the perineal orbital nerve from within the mouth. In contrast, for
nerves is required for analgesia of the ventral aspect of analgesia after cleft lip surgery the percutaneous
the penis to allow pain-free awake surgery.54 approach is usually preferred.
Sub-pubic penile block, as described by Dalens et al.,55 A supra-zygomatic maxillary nerve block using a volume
consists of the injection of local anaesthetic below the of 0.15 ml kg 1 ropivacaine 0.2% has been described for
superficial fascia – before it becomes Buck’s fascia – into analgesia after cleft palate repair.67 The needle is
the fat-filled sub-pubic space, wherein the dorsal nerves inserted at the upper edge of the zygomatic arch until
of the penis run and give off their branches. Penile block contact with the greater wing of the sphenoid is felt; then
is easy to learn.56 The penis is fixed between the thighs the needle is redirected in a 208 forward and 108 down-
with tape, and the needle, a 25-gauge spinal needle, ward direction into the pterygopalatine fossa. Real-time
penetrates the skin 0.5 to 1.5 cm lateral to the mid-line ultrasound allows the spread of the local anaesthetic to be
and is directed slightly medially (10 to 208) and slightly followed.68 The clinical anatomy has been recently
distally (10 to 208) until a marked ‘give’ is felt as the reviewed,69 but no large case series of this technique
superficial fascia is crossed and the tip of the needle have yet been reported.
enters the sub-pubic space. Two paramedian injections
of 0.1 ml kg 1 (up to 2  4 ml) bupivacaine 0.5 to 0.75% Central neuraxial blocks
without adrenaline are given. This provides prolonged Anatomical and physiological properties
pain relief for up to 24 h. The use of ultrasound has been The dura and the spinal cord reach lower levels in the
reported to increase the success rate,57 but in the view of spinal canal in infants (spinal cord L3 at birth, L1-L2 at
the author, it is not a prerequisite for this block. Sub- 1 year; dura S4 at birth, S2 at 1 year) than in children and
pubic penile block is virtually free of complications.58 It adults. The loose epidural fat enhances a more even
has been suggested that the intrinsic vasoconstriction of spread of local anaesthetics, up to the thoracic region.
ropivacaine could cause penile ischaemia59; however,
It is widely believed that central blocks in awake infants
ropivacaine has been extensively used for this indication
and young children have limited haemodynamic effects.
in some countries,60 and in any case, similar cases have
However, studies measuring cerebral blood flow (by
also been reported with plain bupivacaine.
transcranial Doppler) have reported a decrease in blood
flow after both spinal and caudal block.70,71 In the context
Extremity blocks of combined general and regional anaesthesia, hypoten-
Brachial plexus blocks, as well as sciatic and femoral sion can be observed, although this is not widely reflected
nerve blocks, are widely used in clinical practice. The in the literature.72

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 Paediatric regional anaesthesia 293

Caudal epidural anaesthesia Fig. 2

Caudal anaesthesia is the single most important regional

anaesthesia technique in children. Compared with neur- Cranial Caudal
axial techniques in adults, it can be easily learned.73 The
puncture is usually performed with the child in a lateral
position, the upper hip flexed at 908, the lower one at 458. T12 L1 L2
The sacral hiatus is identified by palpation.74 The dural
Local anaesthetic
sac shifts significantly cephalad when the hips and the
spine are in a flexed position.75 Alternatively, in the fully Spinal cord
awake neonate, according to the author’s opinion, a
caudal block can be performed best with the baby in
the prone position.
Different types of cannulae are currently in use. Normal
hypodermic needles have a long tradition, but some
authorities argue that this practice should be abandoned
because of the risk of spreading epidermal cells into the Caudal block in a 3.5-kg neonate. Ultrasound picture taken immediately
after injection. Typically the anatomical spread goes up to a spinal level
spinal canal.76 This has been shown to be a problem in around T12; the clinical spread for analgesia is much higher.
the case of lumbar puncture,77 but no such reports have
been published yet after epidural injections. With mod-
ern needles, the amount of tissue coring seems to be
identical among the different types of needles.78
Specially designed caudal needles with a short bevel Additives to local anaesthetics are widely used. Adrena-
and a stylet are available and perhaps reduce the risk line (5 mg ml 1) allows the detection of intra-vascular
of vascular puncture.79 Plastic intravenous cannulae or needle placement 84 and should be used, in the author’s
lumbar puncture needles are also used. The use of short opinion, at least for the test dose. In preschool children,
intravenous cannulae has two advantages: first, if coring of the intra-vascular injection of adrenaline is recognised
some skin occurs, it is irrelevant because it remains in the not only by the tachycardia, but also by an impressive
stylet; second, easy catheterisation is a good sign that the T-wave elevation (Fig. 3).85 On the contrary, some
catheter is indeed in the spinal canal. The choice of the practitioners prefer to inject plain solutions because
needle size depends on the clinician’s preference; larger the addition of adrenaline to the local anaesthetic offers
needles, such as 23 G, give a more clear sensation of the an additional source of error. Clonidine prolongs the
tissues, but the thinner the needle, the less the trauma to duration of analgesia by around 4 h,86 but it should be
the tissues. In the author’s opinion, the needle used avoided in young infants, as post-operative apnoea can
should not be larger than 25 G. occur.87–90 Morphine provides long-lasting analgesia91
Ultrasound is not essential for performing a caudal block. but side-effects, such as nausea, urinary retention, prur-
On the contrary, it may make a simple procedure more itus and respiratory depression, are common,92 and the
complex and more prone to infection, but it can help in role of caudal opioids has recently been questioned.93
cases of suspected anomalies at palpation and also for Importantly, the more lipophilic opioids, such as fenta-
teaching purposes. In addition, it has given new insight nyl,94 sufentanil,95 pethidine,96 diamorphine,97 or trama-
into the mechanism of caudal anaesthesia. It seems that dol98 cause side-effects, but do not prolong the duration
there is an inverse relationship between age, weight, and of analgesia in a clinically relevant way. Ketamine pro-
height and the number of segments covered by a caudal longs analgesia,99 but its use should be discouraged,
injection of 1.5 ml kg 1 of ropivacaine 0.2%.80 The because of potential neurotoxicity100; magnesium,101
injected volume has a surprisingly small impact on the dexamethasone102 and dexmedetomidine103 are not yet
anatomical spread 81 and the anatomical spread is much ready for clinical use.
smaller compared with the clinical spread (Fig. 2).82
Epidural catheters
A dose of roughly 1 ml kg 1 ropivacaine 0.2% or levobu- Epidural catheters in children are well reported.104 The
pivacaine 0.125 to 0.175% is adequate for most indica- incidence of permanent damage is probably close to
tions. The volume is usually restricted to 25 ml. Caudal 1 : 10 000, that of severe complications 1 : 1000, and pres-
injections using local anaesthetics are not recommended sure sores occur in 1 : 300. Reports of severe unexplained
for abdominal incisions in children weighing more than complications raise concern105 and consequently the
25 kg. The volume needed for a clinically functioning value of epidural catheters is fervently discussed, especi-
block depends also on the surgical site, and many prac- ally for neonates and infants.106 The likelihood is that the
titioners still follow the recommendations given by use of paediatric epidural catheters will decline in the
Armitage83 (Table 4). near future.107

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 294 Jöhr

Table 4 Dosage of local anaesthetics (ropivacaine 0.2% or experts, including the author, still prefer air but try to
bupivacaine/levobupivacaine 0.125 to 0.175%) for caudal
anaesthesia avoid its injection. However, the use of thoracic epidural
puncture should be restricted to cases of severe illness
Site of incision Dosage (ml kgS1) and extensive thoraco-abdominal surgery, as relevant
Penile or anal surgery 0.5 to 0.75 complications have been reported.119–121 It should be
Lower extremity 1.0
Abdominal incision 1.0 to 1.25
performed only by very experienced operators.

Spinal anaesthesia
It is technically easy to insert a catheter via the sacral Since the late 1980s, spinal anaesthesia has been used as a
hiatus. The proximity of the anal region raises concerns sole anaesthetic, especially in the group of high-risk ex-
about the risk of bacterial contamination,108 and special premature babies.122 In babies below 5 kg, a dose of
precautions have to be taken. In larger series, no severe 1 mg kg 1 plain bupivacaine 0.5% is usually recom-
infections have been reported,109 and the method seems to mended.123 But, even in skilled hands, spinal anaesthesia
be safe. However, an increased incidence of colonisation of seems to have a measurable failure rate,124 and the
caudal catheters with Gram-negative bacteria has been duration of analgesia is short. Compared with spinal
described.108,110 Also, most of the reported septic111–113 anaesthesia, awake caudal anaesthesia has a slower onset
and technical114 complications in connection with paedia- of action, the blockade is less dense and potentially toxic
tric epidural anaesthesia have occurred with catheter tech- doses of local anaesthetics, 3 mg kg 1 bupivacaine 0.25%
niques and not with single-shot caudal injections. The or 4 to 5 mg kg 1 ropivacaine 0.375%, are needed.
feasibility of inserting caudal catheters up to a high thoracic Spinal anaesthesia seems a good theoretical choice for
level (caudo-thoracic anaesthesia) was mentioned by Paolo avoiding the potential risk of neurotoxicity of general
Busoni, then described by Bösenberg et al.115 and was anaesthesia agents; however, the author of this review is
subsequently confirmed by others.116 However, this tech- convinced that awake regional anaesthesia should only be
nique is only reliably successful when large-bore used in very selected cases, and that the combination of
catheters115 or catheters with a stylet116 are used, and light general anaesthesia and a regional block is currently
mal-positioning can occur.117 Recent animal data suggest the best technique for inguinal hernia repair in these
that manipulations with large-bore catheters in the epi- high-risk patients.
dural space can cause detectable damage to the spinal
cord.118 Therefore, the author of this review is convinced Systemic administration of local anaesthetics
that this technique should be abandoned or only used in a The beneficial systemic effects of local anaesthetics are
few selected patients. frequently discussed in the anaesthetic community. In
A thoracic epidural puncture allows more precise catheter adults, the use of intravenous lidocaine leads to less pain
placement for thoracic or upper-abdominal incisions. and faster recovery; an observation that has been sup-
Loss of resistance to 0.9% normal saline is almost uni- ported by several meta-analyses.125,126 Surprisingly, up to
versally recommended for the identification of the epi- now, no comparable experiences in paediatric patients
dural space and there is consensus that none at all or only have been published. But it seems unlikely that these
minimal air should be injected. Nevertheless, some positive effects would not be observable in a paediatric
population.
Fig. 3
Conclusion
(a) Regional anaesthesia plays a major role in post-operative
pain relief in children, and the classical techniques, such
as caudal anaesthesia, wound infiltration and penile
block, have an excellent safety record.
1 mV
Acknowledgements relating to this article
(b) Assistance with the review article: the author wishes to thank Prof.
Thomas M Berger (Kantonsspital Luzern, Luzern, Switzerland) for
his help in editing the manuscript.
Financial support and sponsorship: none.
1 mV
Conflicts of interest: none.

Accidental intra-vascular injection of bupivacaine 0.25% with

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 Paediatric regional anaesthesia 295

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